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In the article I found relating to civil law, A 58 year old male was seeking monetary compensation from the health service, after he claims contracting Hepatitis C as a result of receiving a contaminated blood transfusion in the 1980’s. The result was that there wasn’t sufficient evidence to give validity to his claims as the disease could have easily been contracted before or after the transfusion.
Civil law is brought by the individual looking for some kind of supposed wrongdoing and seeks to establish responsibility. In this case the individual sort compensation for contracting a disease through professional negligence from the health service.
The article I found relating to criminal law involved a man charged with murder after stabbing a man to death following a road rage incident. Criminal cases are brought by the state, prosecuting the individual and giving punishment for heir action. It seeks to prevent harmful behaviour through prosecution and punishments.
Law reflecting precedent
In 1982 Mrs Victoria Gillick took her local authorities to court to prevent her children who where under the age of 16 from being given contraceptive advice or treatment without parents consent. The case went to the high court where the judge Mr. Justice Woolf dismissed Mrs. Gillick’s claims.
"...whether or not a child is capable of giving the necessary consent will depend on the child’s maturity and understanding and the nature of the consent required. The child must be capable of making a reasonable assessment of the advantages and disadvantages of the treatment proposed, so the consent, if given, can be properly and fairly described as true consent." (Gillick v West Norfolk, 1984)
The case was reviewed by Lord Fraser who agreed with justice Woolf’s decision he went on to provide guidelines relating specifically to contraceptive advices, stating a doctor could give advice or treatment providing
That the girl (although under the age of 16 years of age) will understand his advice;
That he cannot persuade her to inform her parents or to allow him to inform the parents that she is seeking contraceptive advice;
That she is very likely to continue having sexual intercourse with or without contraceptive treatment;
That unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer;
That her best interests require him to give her contraceptive advice, treatment or both without the parental consent." (Gillick v West Norfolk, 1985)
This case set a precedent in common law meaning all future child consent issues could be referred to the ruling in this case. As a result the gillick competencies where established that allow professions to access capacity of under 16’s allowing them to make their own decisions if capacity can be established.
There are many laws and legislation that govern and influence the ambulance service and paramedic practice. Some of these influence our everyday practice and action such as the health and safety at work act 1974, Data protection act 1998, Control of substances hazardous to health regulation 2012, driving regulations and blue light driving exemption and medicines management. Theses are just a few the list is extensive.
One important statute that governs my everyday practice is consent and capacity. Patients have a fundamental right in deciding what happens to them and their bodies. Gaining Valid consent to treatment is key in providing any form of healthcare from delivering personal care to invasive treatment such as surgery.
Valid consent must be given freely and voluntarily and this must be a continual process given to each particular healthcare task such as exemption and treatment, Consent is only valid when a person has been appropriately informed of all relevant facts and risk and has the capacity to understand a particular treatment. Consent remains valid unless the patient withdraws it, which they have a right to do at any time, if circumstances change the patient must be informed and consent regained.
According to JRCALC guidelines there are 3 basic questions or tests a clinician should perform in order to ensure consent is valid
A, Does the patient have capacity? –Is the patient able to comprehend and retain information material to the decision, believe it and use that information in making a decision while bearing the full consequences in mind?
B, Is consent given voluntarily- consent is only valid if given freely with no pressure or undue influence to accept or refuse treatment
C, Has the patient received sufficient information? – The patient must, in broad terms, the nature and purpose of the procedure as well as the potential consequences of consenting to it or refusing to consent
JRCALC (2006) ‘ethical issues’ pg1
In the prehospital setting this can often be problematic, Adults that normally would have capacity may temporarily be incapable of giving valid consent. Pt may be under the influence of drugs or alcohol, unconscious or incapacitated in some way or there medical condition may prevent them from having the capacity to give freely their informed consent. In these circumstances it is permitted to apply treatments that are necessary acting in the best interests of that patient until such a time that the patient regains capacity and valid consent can be given.
What if a patient withdraws or refuses to give their consent? A patient is entitled to refuse or withdraw their consent at any time and we must respect that decision providing that capacity is established and the patient is fully informed of the possible consequences of that refusal.
Consent in children and young people differs somewhat from adults particularly in refusal of treatment. In the case of those under the age of 16 the Gillick competencies can be applied to assess a Childs capacity to make a decision
Activity 2.4 You and practice law 1
A patient admitted into your care area has a clearly displayed ‘Do Not Resuscitate’ instruction on the care notes. Soon after arriving, the patient complains of chest pain and becomes very cyanosed. The doctor in the work area arrives and requests the collection of the defibrillator and drawing up of drugs related to resuscitation. You the DNR notice to the doctor but he refuses to withdraw treatment and carries on with the resuscitation.
Where does the doctor’s decision to resuscitate leave you? Can the DNR be over-ridden and in what circumstances, and is the law clear on this issue?
There is no specific law relating to DNR instruction, they are regarded as an advanced decision by the patient or the patients doctor and vary greatly depending on the individual. When considering if a person should be resuscitated or not a clinician should ‘follow a good decision-making process that complies with all relevant legislation, including laws relating to capacity, discrimination and human rights’ resuscitation council 2015
Some DNAR relate specifically to the patient’s long-term conditions some are more general. If the doctor feels the patient has a reasonable chance of recovery and is acting in the patient’s best interest then he is well within his rights and ethics to override the DNAR in these circumstances.
The resuscitation council has published guidance with the British medical association and the Royal college of nursing on DNAR, New guidance means that DNAR or being phased out and new Treatment escalation plans (TEP) are being put into place that are a lot more expansive they cover what treatments would be appropriate as well as resuscitation advice.
You arrive at the scene of an incident where a child has been injured. As you approach the property, an obviously agitated individual leaves via the front door, slamming it on their departure. Upon entering the house you see that the environment is very dirty, there is evidence of animals living in the property, and there is a large amount of unwashed clothing, crockery and personal items lying around. The story recounted to you by the family does not match the child’s injuries and the child is behaving in a withdrawn manner and saying very little. Once you get the child in the ambulance, with an adult as escort, your colleague tells you that they know the family and asks you not to say anything about the state of the house in case the authorities jump to conclusions and take the child away from the family, who are struggling.
What would be your professional duty and to whom? How would you deal with your colleague and their approach to the family? What other professional(s) might you engage with in this matter and what documentation would you complete?
This is a child protection issue laws relating to the children’s Act 2004 apply, The NSCPP website can be consulted for advice.
My duty of care is to the child and to them alone. The child is showing signs of abuse and this must be investigated immediately.
I would speak to my colleague and inform them of my concerns and that I would have to report my concerns.
I would refer this child to the safeguarding team, completing my EPCR and a safeguarding referral form and also highlight my concerns immediately to the receiving staff at the hospital if I though that the child was in immediate risk I would also contact the police.
A colleague that you work with constantly uses the employer’s internet facilities to log onto personal emails. Also, they access clinical data about their family and friends and print the information in the department.
Has this person done any wrong? What harm can come of their actions? Are any laws being broken, if so which ones and finally, what should you do?
The colleague is abusing his position and is misusing the trust facilities for is own person. The colleague has accessed information about friends and relatives that they may not and should not be privy too. As such they have broken quite a few laws and legislation. This breaks the Data protection act (1998), the freedom of information act (2000), it also potential breeches the human rights of the individuals whom they have accessed their information.
It is a difficult situation to be in but the colleague must be reported to your line manger, as you would be in danger of being an accomplice if you failed to do so.
You arrive at the scene of an accident; the patient has sustained injuries that lead you to suspect there may be a severe cervical or spinal injury. Your instinct and training tell you to treat the patient where they are to stabilise them and wait for more advanced extraction equipment and personnel. You are ordered by an individual in authority, from another agency, to move the patient immediately; there appears to be no immediate danger to you or the patient.
What is your initial response to the request and what is the legal and ethical view of this scenario? On whose authority should the move be carried out and who is responsible for the care of the patient in multi agency situations?
My initial response is to refuse the request and explain my position and duty of care to my patient. It is my responsibility to protect my patient from harm and provide the best care for the patient that I can.
I would carry out a dynamic risk assessment taking into account the health and safety at work act 1974 and the views of the other agency as they may have greater understanding of the risks involved in the current situation.
The ambulance service has overall responsibility to save life through effective management of the casualties at scene, I would only move the patient on the authority of the ambulance on scene Bronze commander. Initially that is the first ambulance clinician on scene until a duty officer arrives.
Activity 3.1 Examining you own sense of ethics
I think the most admirable qualities in a person are honesty, treating people as equals and altruism as well as intelligence and humility.
I think I do aspire to live my life through these values and when I asked a loved one they describes my values as
Honesty, treating people with respect and as equals. Being non judgemental.
I generally do things and live my life by what I feel is right even if at times his can leave me frustrated. I think I generally care for people and not just about creating a ‘good name’ for myself, However I can be on occasion arrogant thinking I know what is ‘right’ better than another person, which is wrong, as it is often just a different perspective, this is a trait I try to work on, if at times I fail.
Activity 4.1 Getting informed consent
In the prehospital setting getting informed consent can de difficult at times pt may be under the influence of drugs or alcohol which may mean they are temporally unable to give informed consent.
If the patient is unconscious they also cannot give informed consent.
Pt may also have medical conditions such as learning difficulties or conditions such as dementia, which may mean they cannot fully understand what is being explained to them so they will not be able to give informed consent.
In these situations the clinician must work in the best interest of the individual in question.
Activity 4.2 Keeping information confidential
It is easy in inadvertently leak information to the public ‘behind the cotton curtain’. Personally I have been asked by a sister in charge to lower my voice while behind the ‘cotton curtain’. This happened when handing over on a quite ward, a non-emergency patient. Often as clinicians we handover in a busy emergency department where this ‘cotton curtain’ does not exist, we are taught to be confident and speak clearly. This is very different from the quite ward so our delivery must also change. It may be necessary to move to another place for handover where we cannot be overheard.
Activity 4.4 Whistle blowing
It is difficult to know if I would have reported my colleague to the police as describes in the activity, It would depend on circumstance and his response to me challenging him, I wouldn’t have allowed him to continue at work and would have reported the incident to my line manager. If he either refused to leave or admit to having a problem and if the public was at risk I would then report him to the police.
High profile cases such as high death rates after cardiac surgery at Bristol royal infirmary should be viewed with scepticism, they could be legitimist reasons for these high rates such as the consultants operating on patients that other surgeons would not in order to give hem a chance, in this case the doctor should have highlighted his concerns trough the proper channels before contacting the media who can sensationalise the case. It does not reflect well on health professionals, it gives the impression of poor or even malpractice to the public. The fact that other professional are highlighting their concerns through the media may lead the public to think that poor practice is covered up within the health service and brings the entire NHS into disrepute as opposed to one surgical procedure carried out by a few surgeons in one hospital, that may be risk surgery but the alternative would be death for the patient regardless.
Looking at the policy within my trust it seeks to provide a balance between protecting the individual and the trust.
The trust states the policy is intended to enable employees
Evidence based practice
Activity 1.1 what EVP means to you
Evidence based practice should govern everything we do clinically as paramedics. Procedures and treatments given to patients should have valid research to support their implementation and practice. It also means a clinician should be up to date on current best practice supported by this evidence base. Research should be assessed and evaluated, it should be reliable and systematical reviewed.
When asking a colleague about EBP he suggested that it is used to drive best practice as paramedic through change by evaluating current methods and new research, it should be patient centered and always be about delivering the best possible care to the patient.
From what I know of EBP it will be fundamental in my practice and my studies with the OU. It should form the basis of all the academic work I carryout. I should also reflect on my practice, reviewing the way I carryout tasks and manage situation to assess current methods and seek evidence to develop my practice.
Activity 2.1 Finding useful sources
Meier, Curtis AIRWAY MANAGEMENT IN PATIENTS WITH BRAIN INJURY.
Emergency Nurse. Dec2013, Vol. 21 Issue 8, p18-23. 6p. 1
Keir J. Warner, BS⁎, , Sam R. Sharar, MD†, Michael K. Copass, MD‡, Eileen M. Bulger, MD⁎ Prehospital Management of the Difficult Airway: A Prospective Cohort Study The Journal of Emergency Medicine Volume 36, Issue 3, April 2009, Pages 257–265
Activity 4.1 Medline and back pain
I used the database PubMed to carryout this search, it returned 132,655 results.
Looking at the first 20 there are articles that have no relevance to the nature of the information I require, ‘advice to a young man experiencing back pain’ many sources where reviewing data, some for middle aged women, children and older people. To narrow the search I used the term ‘back pain in young males’ this reduced the search somewhat but still to over 3000 articles I then narrowed it using filters, published in the last 5 years and reviewed articles, this gave me 47 results which was much more manageable and looking through most had some relevance.
Activity 4.2 Using PICO
Activity 4.2 was carried out on the OU website, using the PICO formula has helped me to understand how to search for articles and narrow the search by use of bracket and quotation marks as well as identify key terms.
Activity 4.3 The Cochrane Library
The Cochrane library is a collection of six databases that gathers trusted evidence for a range of fields, so healthcare professionals can make informed decisions and deliver better care to the patient.
The people who produce the Cochrane library are a global independent network of researchers, professionals, patients and carers working together to produce credible, accessible health information, free from commercial sponsorship and other conflicts of interest.
This database I think has great value in development of my practice, it gives me free access to reliable sources of current up to date information, on which to develop my practice and make informed decision on the delivery of care to my patients. I did find from carrying out this activity that the evidence base for specific reviews related to paramedics when compared to nursing is comparatively small and much more high quality research needs to be carried out within my field.
I found the Cochrane website easy to use and particularly liked that current highlighted reviews about current hot topics. I also thought that the podcast could be of particular interest to me, as I would be able to listen to them while driving the ambulance.
This website I feel will be fundamental in my studies with the OU. I will be able to use it to find reliable sources of information on the topics I need to cover and understand in order to become a paramedic. I will be able to use reliable sources of information I can trust to develop my practice.
Activity 4.4 Research evidence
I carried out the Activity 4.4 on the OU website. It highlighted different types of research such as Radom control trials including blind studies, systematic reviews and their benefits to health professionals and case control studies. I found the activity useful in highlighting to me different types of research and evidence and the benefits of each.
Activity 4.5 Choosing the right sources
I carried out activity 4.5 on the OU website however I couldn’t find a writing task as asked in this activity there was a quiz however at the end my answers where as follows
NICE-Clinical guidelines about the management of hip fracture in adults.
Cochrane Library-A systematic review on the use of music therapy to treat depression.
PubMed-A research article about the use of reflexology to treat back pain.
UK DUETs-Recommendations for research to address known knowledge gaps.
Activity 5.1 Your experience of sources
The sources of information I use in my everyday practice form various categories ones provided by the trust in the form of Guidelines, these include JRCALC, Trust clinical guidelines and PGD’s (patient group directives), OU resources internet resources such as Cochrane library and my open Athens account. Medical books such as Nancy Caroline ‘emergency care in the streets’ and anatomy and physiology books and my collogues particularly my mentor.
Personally I feel all sources have their own value, I prefer to base my practice on evidence base using guidelines as well as current up to date research and systematic reviews on the benefits of particular treatments while also respecting my colleagues clinical expertise and experience, I find is works best for practical applications of knowledge as well as theoretical.
I find the biggest conflict comes when current research may challenge the experience and knowledge of long standing clinicians. When this happens I often discuss the job afterwards with the clinician, asking why they did a task or carried out a treatment that particular way, talking through research, their knowledge and experience, to reflect and improve my own practice. I feel it is of the upmost importance, to respect a colleague experiences, as well as current research in evaluating and delivering the best care for the patient.
Activity 5.2 What counts as evidence?
Having carried out this activity on the OU website I think Sarah could use current guidelines, a systematic review or a randomized control trail to have the relevant information to make an informed decision on how to advise her patient on if she is ok to eat oats.
Other sources are available such as websites, unpublished work and newspaper articles but great care should be taken in establishing the reliability of such sources.
She could also ask fellow senior colleagues their advice, as they may have been in a similar situation themselves
Activity 7.1 looking for evidence
In this activity I had to find research to answer if compression garments where more or less effective at preventing delayed onset muscle, then doing warm up or warm down exercises, in order to advise a patient.
I used the PICO formula to separate exactly how I would go about obtaining research t answer this question,
Patient- Runner / athlete
Intervention- Compression garments
Comparison- Warm up/cool down exercises
Outcome- Prevention of DOMS
I used the Cochrane library and OU library resources to obtain evidence. First I searched compression garments and exercise and obtained 20 results, looking through there was quite a lot of useful articles I choose 2 that seamed the most appropriate. I found evidence to suggest that compression garments have been effective at helping to reduce DOMS.
I then for comparison searched for evidence regarding stretching and reduction of DOMS, I found less results but still found good evidence which showed little effect in reduction of DOMS, including a META analysis of different treatment that confirmed the effectiveness of compression garments when compared to warm-up/down exercises.
Most of the evidence I collected came from reputable sources and seemed fairly reliable, In particular the meta-analysis and evidence from the journal of sports medicine, however the reviews on the studies carried our revealed that some studies showed inconclusive results and other conducted with a degree of bias or not ideal conditions. However there was evidence from various sources to suggest that compression garments did help in reducing DOMS and little evidence to suggest that warm up/ warm down exercises has any real beneficial effect.
My answer to the patients would be, having researched the possible treatments for DOMS compression garments have been shown to have moderate effect in the prevention or reduction of DOMS, research indicates that compression garments are effective in enhancing recovery from muscle damage
Stretching and warm up/ warm down exercises by comparison has shown to have little effect. The studies have produced very consistent findings. They showed there was little or no effect of Stretching to prevent or reduce muscle soreness after exercise
I would recommend the use of compression garments in this case but also warn them that although studies suggest that they may show benefits to wearing compression garments, the effects are moderate and far from conclusive, prevention is better than cure and prolonged intense exercise should be avoided.
Compression garments and recovery from exercise-induced muscle damage: a meta-analysis.
British Journal of Sports Medicine. Sep2014, Vol. 48 Issue 18, p1340-1346
Beliard, Samuel. Compression Garments and Exercise: No Influence of Pressure Applied.
Journal of Sports Science & Medicine. 2015, Vol. 14 Issue 1, p75-83. 9p. .
Robert D Herbert, Marcos de Noronha, stretching to prevent or reduce muscle soreness after exercise. Cochrane Bone, Joint and Muscle Trauma Group
Published Online: 6 JUL 2011 available at
Compression Garments and Exercise Garment Considerations, Physiology and Performance.
Research Methods in Health Sciences
Activity 2.1 Evaluating a website
Online activity completed on PROMPT regarding ‘Evaluating a website’
Activity 3.1 Finding research methods in use
Activity 3.4-Focus Groups
Focus groups are qualitative research methods that seek to gather a large amount of data on a selected groups perception, beliefs or attitudes to a particular topic.
Focus group research can be defined as ‘a group of individuals selected and assembled by researchers to discuss and comment on, from personal experience, the topic that is the subject of the research’. (Powell and single 1996) this group is guided by a moderator or interviewer and the group discuses issues the moderator raises.
Focus groups should consist of between 4-10 people, each group is classed as a single unit, and 2-4 units are needed. Groups need not be randomized and should have a key characteristic in common key to the study. The trained facilitator must be impartial and the setting interactive.
This type of research method has been used across many different fields such as marketing, organizational research and social sciences but is increasingly popular in health research. Health researchers have used this method in a variety of ways. Traditionally it was used to test hypothesis by developing questionnaires. Current research has shown that focus group study to be useful in its own right. They can be used to explore current medical practices and education, response to new initiatives, highlight attitude to health of hard to reach groups and identify problematic medical practices.
A large amount of qualitative data is produced as a result of this method and careful analysis is important. This can be a time consuming process and can be difficult to interpret and present as meaningful results when compared to quantitive data.
Careful design is important, paying particular attention to the problems focus and what the objectives of the study are, how the individuals are selected and on what basis they are chosen, the setting and role of the moderator is key in order to facilitate and focus the discussion on key elements the discussion raises. A poor design will lead to poor results.
Focus groups are important as they allow us to understand not just what a particular group of people think about a particular subject but can also why they think that way. They are considered relatively cheap to produce and provide a large amount of quantative data. The group dynamics often allow key areas to be highlighted and people can feel more comfortable to express their real opinions on a subject
However care must be taken when selecting this method the discussion is assisted by a moderator, the quality of the discussion can relay on the skill of this moderator and care must be taken to be impartial, they should preferably not be affiliated with the research. Participants are self selected, discussions can be led by strong individuals opinions, Results are often difficult to appraise critically and generalise to larger groups.
The study I choose that uses this method is:
Identifying barriers and facilitators to ambulance service assessment and treatment of acute asthma: a focus group study (Shaw D, Siriwardena A N 2014)
They conducted three group interviews with paramedics in a regional UK ambulance trust. Seventeen participants were identified which included paramedics, specialist paramedics and operational officers.
The study ‘aimed to identify factors which might prevent or enable adherence to asthma guidelines through exploration of the attitudes, perceptions and beliefs of ambulance clinicians’ (Shaw D, Siriwardena A N 2014)
Throughout the group discussions five key themes were established that identified problems in training and adhering to ambulance guidelines. The author goes on to explore these themes and why paramedics treat and think in this way. Then suggests possible implications and improvement that could be made to guidelines and best practice
As a result of this research they conclude that the findings provide opportunities to ‘strengthen clinical support, patient communication, information transfer between professionals and pathways for prehospital care of patients with asthma’.
Barbour, R. S. (2005), Making sense of focus groups. Medical Education, 39: 742–750
Focus groups as a tool for critical social research in nurse education. Nurse Educ Today. 2001 May;21(4):323-33.
Leung, F.-H., & Savithiri, R. (2009). Spotlight on focus groups. Canadian Family Physician, 55(2), 218–219.
Robinson N (1999), The use of focus group methodology — with selected examples from sexual health research. Journal of advanced nursing, Vol. 29 Issue 4, p905-913.
Rosaline S. Barbour, & Kitzinger, J (eds) 1999, Developing Focus Group Research, SAGE Publications Ltd, London, England, viewed 11 December 2015, doi:
Powell RA, Single HM (1996), Focus groups, International Journal for Quality in Health Care, Vol 8, No. 5 pp 499-504, Oxford University Press
Shaw D, Siriwardena AN (2014)
Identifying barriers and facilitators to ambulance service assessment and treatment of acute asthma: a focus group study. BMC Emerg Med. 2014; 14: 18. Available at
Acidosis in diabetes
People with diabetes can suffer from high blood glucose levels known as hyperglycaemia with little or absolute insulin deficiency. That leads to a condition known as diabetic ketoacidosis characterised by hyperglycaemia, hypoketoaemia and metabolic acidosis.
Lack of insulin production combined with the release of stress hormones in particular glucagon leads to the overproduction of glucose and ketones. Without insulin the body cannot utilise glucose, Ketones began the process of breaking down fat to use as fuel called lipolysis. The by-products known as ketones bodies called acetoacetic acid and hydroxybutyric acid are acidic and contribute to the acidosis.
Hyperglycaemia causes osmotic diuresis, glucose is excreted in the urine, which carries sodium, and potassium ions with it, this also causes symptoms polyuria, dehydration and excessive thirst.
Insulin deficiency further increases sodium depletion as it decreases sodium reabsorbtion. These processes mean that the normal bicarbonate ion buffering system quickly becomes saturated and can no longer cope with the change in equilibrium and as a result hydrogen ions build causing the blood to become acidic.
Willims G, Pickup j.c, 2004, Handbook of Diabetes, Third edtion, Blackwell publishing pg118-119
Activity 3.1 Inherited conditions
Huntington’s disease is an inherited genetic condition caused by a fault in the IT-15 gene on chromosome 4 known as the huntintin gene as in encodes for the protein huntingtin. It is autosomal dominant meaning a child with an affected parent has a 50% chance of inheriting the condition. It is a neurodegenerative condition causing the progressive breakdown of nerve cells within the brain.
Symptoms usually begin to manifest between the ages of 30-50 and once diagnosis has been made the average life expectancies is 15-20 years with gradual physical, mental and behavioural decline.
The gene contains a repeating sequence of three base pairs CAG named a triplet repeat, the fault causes an excess number of CAG repeats which results in the gene containing an excess of glutamine units. Huntingtin protein encoded by the abnormal gene collects in the nucleus of the cell causing an inclusion body. Currently how this then causes a neurogenic condition is not fully understood but neurons become dysfunctional causing progression degeneration and then dies. In Huntington’s certain neurons such as basal ganglia cells are more affected than other causing different areas of the brain to be effected first that is characterised by the symptoms and progression of the disease.
The disease causes motor, cognitive and psychiatric symptoms: -
Motor function is affected and is characterised by both involuntary movements and loss of voluntary movements. This can cause loss of manual dexterity, slurred speech, swallowing difficulties and problems with balance as the disease progresses patients lose all ability to control voluntary movements and become rigid and cannot care for themselves.
Cognitive problems can include difficulty in multi tasking, poor memory and concentration, a need for routine, inability to read facial expressions, lack of awareness and repetition.
Psychiatric symptoms can be devastating for the individual and the most common is depression, it also causes mood swings, mania and inappropriate behaviour. Other symptoms include irritability, anxiety, apathy, obsessive and social isolation.
Unfortunately there is currently no cure for the disease. Treatments is focussed on slowing the progress and management of symptoms.
Medications include antidepressants, mood stabilisers and medications to suppress involuntary movements. Speech and language therapy combined with occupational therapy are used to el pith day to day living and regular exercise is recommended which has shown to improve coordination and patients feel better physically and mentally.
Huntington’s disease NHS choices assessed on 12-2-16
Rosenblatt¨. A, Nance M.A, Ranen N.G, Paulsen J.S. 2009 ‘A Physician’s Guide to the Management of Huntington’s Disease’ The Huntington’s Disease Association available at www.hda.org.uk
Treating Alzheimer’s disease
Alzheimer’s is a degenerative cerebral disease that adversely affects cortical functions including memory, orientation, comprehension, language and judgment.
There is currently no cure for dementia. Treatment involves the management of cognitive, behavioural and physiological symptoms, using both medications and social support.
Drug treatment falls into two main categories; acetylcholinesterase inhibitors and NMDA receptor antagonists. Both work in different ways to help alleviate symptoms and slow the progress of the condition.
Acetylcholinesterase inhibitors include drugs such as Doneprezil, Rivastigmine and Galanamine. A person with Alzheimer’s disease has low levels of acetylcholine, which acts as a neurotransmitter. These drugs prevent the enzyme acetylcholinesterase from breaking down aceylcholine in the brain thus raising levels of acetylcholine. This should help alleviate symptoms such as anxiety, improves motivation, memory, concentration and improve a person’s ability to continue with their daily lives. The effect however is short lived often lasting between 6-12 months.
NMDA receptor antagonist currently used is Memantine. Alzheimer’s disease causes damage to cells that causes an excess of the neurotransmitter glutamate to be produced, which then causes further damage to neurons. Mematime works by blocking the effects of glutamate. It can slow the progress of symptoms and also has positive effects on behavioral problems such as delusions, aggression and agitation.
Current research points towards a possible cure for Alzheimer’s disease, there is currently a clinical trail ongoing that uses a drug that targets TAU tangles that clumps together causing plaques and damage to cells. The hope is that it will slow their progress or remove them altogether.
Another area of promising research involves the use of stem cells. Used to regrow brain neurons that are damaged by the progression of Alzheimer’s. However currently this poses a challenge, as brain stem cells are not easy to access and the use of stem cells in bone marrow already used in other medical treatments don’t mature into brain cells.
A current meta-analysis of treatments and new research suggest that currently successful treatment of Alzheimer’s will require a combination of treatments to target not only cognitive and behavioral symptoms but focus on the rescue of damaged neurons, to regenerate neurons and stop nuerodegeneration. Experimental drug named M30 uses three classes of multi target ligands (Keap1–Nrf2 regulators, endogenous neurogenic agents, and HIF-1 activators). These drugs trigger numerous processors that function together to increase their efficacy, called network medicines. This approach has proved extremely effective in treating conditions such as AIDS, cancer and depression.
Dr McShane R , Bishara D , Jones R, Dr Mann J (2014)
Drug treatments for Alzheimer’s disease Factsheet 407LP alzheimers.org.uk
Zheng, H., Fridkin, M., & Youdim, M. (2015). New Approaches to Treating Alzheimer’s Disease. Perspectives in Medicinal Chemistry, 7, 1–8.
NICE Guidance 2011 ‘Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease’
NICE technology appraisal guidance [TA217]
Composition and structure of the plasma membrane
The major component of a plasma membrane is a phospholipids bi-layer. Phospholipids are formed from fatty acids, glycerol and a phosphorous component. The tail of phospholipids is formed from fatty acid chains and are hydrophobic, the head formed from glycerol and the phosphorus component is hydrophilic. This structure means that the phospholipids naturally form a bi-layer with the water hating tails facing inward and water loving heads outward. The phospholipids molecules are able to move freely within their membrane layer resulting in the membrane having a fluid structure. Mechanical support is provided to the cell by another fat molecule known as cholesterol. Also attached to the inner surface of the membrane are cytoskeleton filaments, forming the cytoskeleton which helps cells maintain their shape.
The membrane is semi permeable which allows some substances to pass through; also along the membrane are membrane proteins and protein channels that allow movement of larger molecules and ions through facilitated diffusion and active transport mechanism. Along the surface of the membrane are chains of sugars that can bond with proteins and lipids to form glycoprotein’s and glycolipids. The glycoproteins are receptors, responding to and receiving signalling molecules such as hormones.
Drugs acting at the plasma membrane
Morphine- Morphine is an opioid and used for its analgesic properties. It works on Mu opoid receptors located in the brain and spinal column. Morphine binds to receptor sites located at terminal axons of neurons, this then has an inhibitory response effectively reducing the activation of descending pathways lowering neuron activity and reducing pain.
Atenolol- this is known as a Beta-blocker, more specifically a beta 1 antagonist. It works by acting on receptor sites located at the postsynaptic neurons that usually respond to adrenalin and noradrenalin blocking their action. These cells are mainly found in cardiac muscle and the beta antagonist works by blocking these sites. This will reduce heart rate and the force at which the heart contacts which lowers blood pressure. Their primary use is in treating hypertension.
Nifedipine-Is a calcium channel blocker, it inhibits the movement of calcium ions across the membrane. It mainly acts on the myocardium and vascular smooth muscle. Blocking the movement of calcium ions across the membrane in these tissues inhibits the contraction of these muscles resulting in the vasodilatation of the coronary and systemic arteries. This means that the drug can be used to treat angina and hypertension.
Veramipril- Is also a calcium channel blocker. It acts in the same way as nifedipine inhibiting the movement of calcium ions across the membrane, it has the same effects and is used to treat angina and hypertension in the same way. However Veramipril also has an effect on the electrical conductivity of the heart. It blocks the Calcium influx slow channel, affects the AV node of the heart. Slowing AV conduction and repolarisation reducing heart rate. It is used effectively to treat arrhythmias of the heart specifically effecting the atria, such as atrial fibrillation, atrial flutter and supra ventricular rhythms.
Minoxidil- Is a potassium channel agonist. It opens potassium channels causing a hyperpolisation of cell membranes. It directly affects the arterioles causing them to dilate increasing blood flow to the capillary bed and reducing blood pressure. Initially it was used to treat hypertension but doctors using this treatment found an increase in hair growth in patients and as such it is now used to treat premature balding. The exact reason is unknown but it is thought that the increased blood flow to capillary bed helps to slow premature balding.
Propofol is the most widely used general aesthetic. It chemical structure is shown above and molecular formula is
https://pubchem.ncbi.nlm.nih.gov/search/C12H18O. Its molecular weight is 178.27 g/mol. Its usual application is for induction of anesthesia in patients requiring a procedure such as general surgery. It is administer intravenously.
Etomidate is a drug used for the induction of general anaesthesia. Its chemical structure is shown above and its formula is
https://pubchem.ncbi.nlm.nih.gov/search/C14H16N2O2. It molecular weight is 244.2 g/mol. It is used intravenously.
Isoflurane is an inhalation anaesthetic, it chemical structure is shown above and its formula is
https://pubchem.ncbi.nlm.nih.gov/search/C3H2ClF5O, It has a molecular weight of 184.49 g/mol. Used in the induction of anaesthesia. It has a rapid effect and is short acting. The level of anaesthesia can be quickly changed and is administered by vaporising. It’s the preferred inhalation anaesthetic in obstetrics
Neuromuscular blocking agents are muscle relaxants. They enable light anesthesia with adequate relaxation of the muscles of the stomach and diaphragm as well as the relaxation of the vocal chords to enable the passage of an endotracheal tube.
There are two different groups of Neuromuscular blocking agents non-depolarising and depolarising neuromuscular blocking drugs.
Non-depolarising drugs can be reversed and have a slower onset. Drugs within this class have varying degrees of duration. They include atrcurium, cistracurium, Mivacurium, Pancuronium, Rocuronium and vecurium. Each has its own use but the most commonly used is Atracuronium due to its shorter duration of action and its use for patients with hepatic and renal impairment.
The most widely used depolarising neuromuscular agent is Suxamethonium. It has a rapid onset and brief duration and if commonly used during rapid sequence induction. Unlike non-depolarising drugs its effects cannot be reversed and recovery is spontaneous.
Other drugs used as premedication are benzodiazapam. Drugs include diazepam, lorazapam, midazolam and temazapam. They are used for their effects in reducing anxiety, for sedation and their amnesia effect. They are often given the night before an operation to ease anxiety and just before for there sedative and amnesic effects.
Drugs.com. (2016). Isoflorane. Retrieved febuary 20, 2016, from http:/www.drugs.com/pro/isoflurane.html
Joint Formlary commitee. (2012). British National Formulary (64 ed.). BMJ Group.
Open chemistry database. (n.d.). PubChem Propofol. Retrieved febuary 12, 2016
Open chemistry database. (n.d.). PubChem Isoflurane Retrieved febuary 12, 2016
Open chemistry database. (n.d.). PubChem Etomidate Retrieved febuary 12, 2016
Blood glucose and diabetes
Diabetes is a condition in which blood glucose is chronically raised. There are two types; type 1 diabeties where the insulin producing
Introduction to enzymology
1 day post MI the most sensitive indicator of MI indication would be the enzyme essay CK-MB as the levels in the blood would be at its highest at this point.
2 day post MI the most sensitive indicator of MI indication would be the enzyme essay AST as the levels in the blood would be at its highest at this point.
3 day post MI the most sensitive indicator of MI indication would be the enzyme essay LDH as the levels in the blood would be at its highest at this point.
Tropnium T and Tropnium I are the most common and most sensitive enzyme essays used in the detection of myocardial infarction showing significant changes in enzyme levels four hours after onset of symptoms. Troponium T and I testing is a useful enzyme essay as it is the most specific test for damage to heart muscle alone and remains elevated for a longer time frame.
The kit e use is called CodeFree blood glucose monitoring kit. It is manufactured by SD biosensor based in Korea
The test strips and kit should be kept at room temperature between 2-32 C, The test strip slot should be kept free from dust and the strips stored in a dry cool environment. After removing a test strip from the container it should be resealed to protect the other strips. The strips should only be used for 6 months after opening the container.
The kit uses a test strip and monitor to record blood glucose, this gives a digital numerical reading to indicate blood glucose levels it utilizes Glucose oxidase and potassium Ferricyanide. Blood mixes with the enzymes and creates an electrical current that is read by the meter, the strength of which indicates blood glucose levels.
The meter reads blood glucose between 10 – 600 mg/dl or 0.6- 33.3 mmol/l if above this value Hi will be shown and below 0.6 low.
The kit doesn’t need to be calibrated but should be checked regularly with a control solution to ensure it is working effectively.
The kit is suitable for capillary blood only.
Thrombokinase as a target for anticoagulants
Warfarin acts by inhibiting the synthesis of Vitamin K dependent clotting factors. This inhibits the conversion prothrombin to thrombin, interrupting the clotting cascade, therefore preventing the conversion of fibrinogen to fibrin and clot formation.
Clotting factor X is a vitamin K dependent serine protese (Medscape 2016). It is an enzyme that forms the initial pathway for thrombus formation converting prothrombin into thrombin. A lack of Factor X causes excessive bleeding and it is thought a complete lack of factor X is incompatible with life. Acquired factor X can be caused by severe liver failure as Factor X is synthesized in the liver. A lack of the protein causes acquired factor X deficiency as well as Vit K deficiency, which is also associated with other clotting factors.
Open university. (2006). Sk277 Human biology. In Book 3 Body Systems (pp. 94-95). milton keynes: open university.
Robert A Schwartz, M. M., & Chief Editor: Perumal Thiagarajan, M. (2015, 2 10). Factor x Deficienacy. Retrieved 03 15, 2016, from Medscape.
Enzyme inhibition in the treatment of gout
Gout in the most common form of inflammation arthritis. It is caused by the build up of urate that then is deposited and forms crystals in the joints, particularly affecting the hands and feet. Left untreated it can result in irreversible joint damage. Symptoms include very painful hot, red and swollen joints that often have a shiny appearance.
Gout is a chronic disease that has acute attacks therefore treatment involves management of acute symptoms and urate lowering therapy to manage the condition. Acute treatment uses NSAID’s such as Naproxen and predinisalone to reduce inflammation as well as colchaine, which ‘inhibits leucocytic phageocytosis of monosodium urate crystals’ (BMJ 2014). Long-term treatment employs the use of drugs such as Allopurinol. Allopurinal is a Xanthine oxidase inhibitor, it lowers the level of uric acid in the plasma and urine by inhibiting the enzyme Xanthine oxidose responsible for converting xanthine to uric acid. This results in the lowering of urate levels, less crystal deposits in the joints, reducing further acute attacks.
Roddy Edward, Mallen Christian D, Doherty Michael. Gout BMJ 2013; 347 :f5648
Nursing Standard 2014, April vol 28 no 31
Medicines.org.uk Allopurinal accessed on 11-4-2016
Introduction to pharmacology
Drug formulation 1
Instant hit of nicotine, also distracting due to chewing motion
Helps ease craving throughout day as steady stream of nicotine
Instant nicotine hit as quickly dissolved
Slow release, also distracting
Help as mimic a cigarette inhaling the nicotine as you would a cigarette
Instant sift does to ease immediate craving.
Medication to help withdrawal from cravings doesn’t replace nicotine therefore completely rids you of the addiction
Help the body respond less to the effects of nicotine thereby stopping you smoking.
Drug Formulations 2
Fentanyl is an opioid analgesic used in the management of pain. Searching the BNF website I have found various presentations including Fentenyl for IV injection, IV infusion, Transdermal patch, sublingual tablet, lozenge, nasal spray and sublingual buccel.
Transdermal application is used for chronic intractable pain not currently treated with strong opioid analgesic (BNF 2015) and is often used in palliative care.
IV injection or IV Infusion is used in Analgesia and enhancement of anesthesia during an operation or used in analgesia in intensive care.
Buccel lozenges and films, Intranasal sprays and sublingual tablet are all used in breakthrough pain in patients receiving opioid therapy for chronic cancer pain.
Currently this drug is not used by the ambulance service however studies have shown its successful application for trauma such as NOF in the form of fentenyl lollys for acute pain management, we also come across transdermal patches that are prescribed to patients we are treating.
BNF 2015, Fentanyl accessed on 13-4-16
Activity 4.3 Pharmacokinetic indices
The plasma biding being measured in vitro, Meaning ‘in glass’, the measurement was done in a testube or in an artificial environment.
In a clinical pharmacological study 40mg levobupivacaine was given by IV administration. The Cmax Value recorded was 1.4± 0.2 µg/ml and the AUC 70 ± 27 µg min/ml.
Cmax value was higher after intravenous dosing with a lower dose when compared to epidural dosing as absorption by body tissues is influenced by the site of injection and Cmax value are usually measured in the blood. IV dose is given directly into the vein (into circulation) so is systemic, rapidly distributed and absorbed by the tissues, so c-max will be achieved quickly and concentrations in the blood high. Epidural dosing is given into the epidural space located in the spine, although this may show immediate effects in the local area, C-max value is lower as the route means the drug is absorbed locally, so the concentration levels are lower when measured in the blood, as they have to pass through interspinal fluid, into the plasma and blood. Therefore C-max value will be lower for a higher dose as the drug is absorbed locally before systemically.
The half life for intravenous dosing of l evobupivacaine is 1.3 hours the volume of distribution was 67 liters
Codeine- Codeine is an opiate and is mainly used in the treatment of mild to moderate pain but can also be used in the treatment of diarrhoea. It is used in children over 12 years and adults.
To treat Acute diarrhoea the dose is given by mouth. In Adults and children aged 12-17 30mg 3-4 times a day is given.
To treat Mild to moderate pain in Adults 30-60mg can be given ever 4 hours to a maximum dose of 240mg either by mouth or intramuscular injection.
In children in can be used to treat short-term moderate pain either given by mouth or intramuscular injection 30-60mg ever 6 hours to a maximum of 240mg per day for no more than 3 days.
Codeine is contraindicated in children under 12, in all children up to 18 who have had their tonsils or adenoids removed, children with neuromuscular disorder respiratory problems, multiply trauma or extensive surgery. It is also contraindicated in people with ultra rapid metabolic disorder and pregnant and breast feeding mothers. All opoids should not be used in patients with acute respiratory disorders, comatose patients, head injuries, and raised intracranial pressure and with risk of paralytic iteus.
A reduced dose should be used in patients with Adrenocorticical insufficiency, debilitated patients, diseases of billary tract, the elderly, those with hypotension, hypothyroidism, impaired respiratory function and bowel diseases. They should also be avoided in asthmatic particularly during an attack and COPD patients. They should also be avoided in patients with hepatic or renal impairments.
Promethazine- is an antihistamine that can be used for allergic reaction, anaphylaxis in adults, sedation and treatment of nauseas, vomiting, vertigo, labyrinthitistis and motion sickness. Dose regimes vary greatly depending on application and age.
For symptomatic allergy relief it is to children 2-4 mg twice a day, 5-9 years 5-10mg twice daily, 10-17 years 10-20mg 2-3 times daily and in adults 10-20 mg 2-3 times a day. Alternatively Adults can be given intramuscular injection of 25-50 mg up to a maximum of 100 mg.
In Anaphylactic reaction in can be given to adults only, by slow IV injection. For sedation and treating other condition the dose also varies relating to age.
Children below the age of 6 should not be given over the counter medicines containing promethazine.
They should be avoided in patients with liver disease and used with caution in pt with renal impairment and pregnant and breast feeding women. Patients should also be aware that the sedation effects can be comparative to the effects of alcohol so complex task and driving should be avoided.
Alcohol has a potentially serious interaction with Mirtazapine increasing the sedative effect. Mirtazapine is used in patients with severe depression, as such the risk of overdose may be increased. In my practice if a patient has taken mirtazapine combined with alcohol which could be common in depressed individuals then care should be taking in monitoring these patients when taking them to hospital due to the sedative effects and possible implication on the CNS, with possible airway compromise.
Aspirin and NSAID’s have potentially serious interactions as they increase the side effects associated with aspirin, these include blood disorders, bronchospasm hemorrhages and skin interaction. Therefore the concomitant uses of Aspirin and NSAID’s should be avoided. In my practice patients are often on aspirin following a stoke or MI, If I attend a patient prescribed Aspirin I should not recommend the use of NSAID’s such as Ibuprofen for muscle problems and pyrexia without contacting their GP.
Activity 3.1 Urine test analysis
Glucose present in urine is termed glycosuria. A positive test results for glucose could indicate that a person is suffering from diabetes, When blood glucose levels in the blood become too high, glucose can no longer be reabsorbed by the kidney so is excreted in the urine. Glucose can also be present in urine if a woman is pregnant.
Ketones present in urine termed ketonuria indicates that a person is no longer producing energy from carbohydrates but instead is breaking down stored fats to produce energy a waste product of which is ketone bodies, common reasons for this is a patient suffering a hyperglycaemic episode and going into a state called diabetic ketoacidosis other causes can be starvation, sever exercise, vomiting and pregnancy.
Billirubin present in urine could indicate liver disease such as hepatitis.
Protein present in urine termed proteinuria is often a sign of kidney disease as proteins should be too large to pass through the glomerous so should not enter the urine. Conditions include diseases of the glomeruli including glomerulonenephritus and diabetes, can indicate urine infections and are a warning of other medical conditions such as congestive heart failure and eclampsia in pregnancy.
Blood in urine termed haematuria can be indicative of many conditions including tubulointersitial nephritis, polycystic kidney disease, renal cell carcinoma, sickle cell diseases, tumors, stones and infections as well as others.
Urinalysis is commonly used to diagnose Urinary tract infections, kidney diseases and track the effects of diabetes but can also be used with other diagnostic tests to give indications of other disease such as congestive heart failure. Within my role as a paramedic currently we do not carryout, analyse or interpret urine tests however it is commonly used by Emergency care practitioners (ECP) in the presence of other symptoms to detect and treat Urinary tract Infections (UTI) and assist in treating diabetics checking for ketoacidosis as well as aiding diagnosis and admittance of patients with kidney problems. I am sure that in the near future paramedics will be asked to perform reanalysis in order to treat patients within the community setting and during this course and on placements I have seen and carried out urinanalysis and feel confident that I would be able to use this skill effectively.
Book 3 Body systems. (2006). 2nd ed. Milton Keynes: Open university, pp.18-28.
Lerma, E.V. (2016) Urinalysis: Reference range, interpretation, collection and panels. Available at: http://emedicine.medscape.com/article/2074001-overview#a2 (Accessed: 7 July 2016).
Activity 4.1 summery of the nervous and endocrine systems
Method of communication
Generation of action potentials (electrical signals)
Hormones released into the blood stream
Speed of communication
Rapid, Conduction in myelinated axons 100 ms-1
Dependent on blood flow and distance between endocrine tissue and target cell (slower that nervous system)
Location of response
Along axons, Dependent on source of response, Motor neurons, sensory neurons, Central nervous system Peripheral nervous system
Dependent of release of hormone by endocrine tissue and its target cell
Signalling molecules between cells
Neurotransmitter molecules of various types released into synaptic cleft
Hormones molecules released by endocrine tissues into bloodstream
Motor neurons, sensory neurons, Autonomic and somatic system
Hypothalamus, pituitary, adrenal gland axis. Pancreases
Activity 4.2 The kidneys role in homeostasis
The kidney plays a vital role in many homeostatic processes including fluid balance, sodium levels, excretion of unwanted substances, regulation of PH and production and activation of specific hormones. An important function of the kidney is the control of simple inorganic substances water and salts that are essential for life. Water is the main constitute of both intracellular and extracellular fluids and forms the basis of all body fluids, the kidney controls the body fluid volume and therefore directly influences blood pressure.
The kidney removes unwanted substance and controls the amount of water in the body through the formation of urine that is then excreted by the individual. The main processes involved in the formation of urine is through glomerular filtration, tubular reabsorbtion and tubular secretion.
Blood travels through the renal artery into the afferent arterioles into the glomurous where initial filtration occurs, the filtrate then passes through proximal convoluted tubule where reabsorbtion of glucose, amino acids and water occurs, loop of henle where the passive movement of water and ions occurs by osmosis, the filtrate then flows into the collecting ducts where the final control of urine compositions occurs via reabsorbtion and secretion. urine is formed and passes out through the renal pelvis.
Glomerular Filtration directly effects blood volume and blood pressure. This is controlled by detection of sodium levels by macula densa cells and rennin production by juxtaglomerular cells.and the production of alodestrone by the liver. . This causes an increase or decrease of the width of afferent and efferent arteriole controlling blood flow and filtration rate. Effecting sodium levels and therefore water levels. A reduction in blood volume will cause a reduction in filtration rate an increase in reabsorbtion of sodium and the passive movement of water by osmosis out of the tubule.
(Open University 2006)
Changes in the amount of water in the body will effect the osmolarity of the intracellular and extracellular fluids this is detected by neurons in the hypothalamus called osmoreceptors, when these cells detect an increase in the osmolarity of fluids that surround them they signal hypothalamic neurons to secret hormones called anti diuretic hormone or ADH.
ADH directly affects the amount of water excreted in the urine by stimulating changes in the membranes that are found in the collecting ducts of the kidney where urine is concentrated. It effects a membrane protein called auqaporins specifically one named AQP2, increasing the amount of AQP2 pores that increase the amount of water that can be reabsorbed by the luminal membrane of epithelial cells in the collecting ducts. Water is then reabsorbed into the blood and urine is more concentrated.
ADH release is also stimulated by changes in blood volume detected by stretch receptors located where venous blood enters the heart and bararecptors located in arteries that responds to changes in blood volume, a decrease in blood pressure results in a decrease in the firing of these neurons which effects the release of ADH at the pituitary gland.
Book 3 Body systems. (2006) Chapter 1 the kidney. 2nd ed. Milton Keynes: Open university, pp. 7-48.
Activity 5.1 The cellular pathophysiolology of necrosis
Heart attack- Myocardial infarction is the loss of blood flow to cardiac muscle causing irreversible damage to cardiac tissue through ischemia and hypoxia, which results in the death of cardiac muscle and necrotic tissue damage. MI is caused by a blockage to the coronary arteries usually through the development of atherosclerotic plaques, which ruptures causing a blood clot. Blood flow is then disrupted. Without a flow of blood to tissues below this point it lacks oxygen and nutrients firstly becoming ischemic, triggering cellular inflammation, then becomes hypoxic, then causing cell death.
Gangrene- two main types, Infectious gangrene and ischemic gangrene.
Infectious gangrene is caused by clostridium spores. Infection begins with the contamination of a post traumatic or postoperative wound by these clostridium spores, Tissue that is already become necrotic due lack of blood flow causing ischemia during period of trauma provides an environment for the bacteria to grow, This then causes spreads local necrosis of muscle and fatty tissue and compromising of blood vessel due to oedemas as a result of infection, further increasing the environment for bacteria to grow.
Ischemic gangrene is causes by poor blood flow, Atherosclerosis causes peripheral arterial diseases that causes a reduction in blood flow to the feet, This causes tissue to become ischemic, The atherosclerotic plaques contain a necrotic core covered by a protective cap, due to narrowed vessels forces exerted on theses can sheer of this cap causing a thrombus to develop within the vessels this then completely block blood flow, causing tissue necrosis. Chronic ischemia to the legs caused for example by diabetes can mean that small wounds to the feet are able to become infected easier due to lack of blood flow to the area and also become gangrenous.
MRSA methicillin-resistant Staphylococcus aureus (MRSA) is found commonly in communities and people often carry it without their knowledge. It causes skin infections that are difficult to treat because the bacteria have become resistant to antibiotic treatment. MRSA bacteria carry a cytoxtic gene that produces a toxin that destroys body tissue and white blood cells. Abscesses are produced that contain pus composed of dead white blood cells and a necrotic core, these abscess can become deep and due to the nature of the bacteria difficult to treat causes Necrotizing fasciitis as the infection spreads and can become life threatening.
Activity 6.1 Myocardial infarction diagnosis-cell pathophysiology
A Myocardial infarction (MI) is defined as irreversible tissue death of myocardial cells as a result of ischemia. There are two main types a STEMI and a NSTEMI and this relates to changes in the ST segment of an ECG. Generally the main cause of an MI is the development of a clot in a coronary artery supplying an area of the heart with blood and therefore oxygen and nutrients. This results in acute heart failure meaning the heart cannot pump effectively and can no longer pump with sufficient force to supply the body’s tissues with blood to meet the metabolic need of the body. Cardiovascular diseases encompass a wide range of conditions, all of which affect the heart and cause an MI to occur. The main causes for development of MI is he hardening of the arteries called atherosclerosis and furring of the arteries athroma. This causes the vessel to come under more pressure due to the narrowing, less elastic arteries. This can causes damage to a fatty plague lining the arteries causing a part to sheer off, this initiates the bodies clotting mechanism and a blood clot is formed causing a blockage within the artery. Risk factors of developing an MI is being overweight, high cholesterol, high blood pressure, stress, and conditions such as Diabetes, Angina and arrhythmias of the heart such as Arterial fibrillation.
ECG- when someone is having an MI changes can occur within an ECG, This test is carried out by placing leads on a patient’s test that then gives 12 views of the heart from different directions producing what is known as a heart trace. A detailed examination of the ECG can determine if damage has occurred and where it has occurred. However an ECG is not foolproof and may appear normal even if the patient has had a MI.
An ECG produces a waveform that specific parts are labelled PQRST. An ECG can determine different things that are happening within the heart as each complex represent one heart beat and each part of that represent a different stage of the cardiac cycle. In a person having an MI changes are often detected in the Q wave which is inverted and large, the R wave is small and the ST segment is raised not returning to the baseline resulting of what is known as a ST elevation myocardial infarction or STEMI. This change is what we as clinicians look for in a patient having chest pain, it is a life threatening condition, it indicates the person is having a MI and requires emergency treatment in a cath lab to remove the clot and restore blood flow.
Blood tests can be carried out to determine if a patient has had an MI. Damage that occurs within a blood vessel causes enzymes to be released into the bloodstream. This can be detected by blood tests a couple of hours after damage has occurred. Different enzymes are produced by different tissue within the body when damage occurs to that tissue. When heart muscle is damaged various enzymes are released but the most useful is Troponin-T or Troponin-I . Troponin is a protein released from myocytes when irreversible myocardial damage occurs (patient.co.uk). Levels are taken at two, six and twelve hour intervals and raised Troponin levels when combined with cardiac symptoms and ECG finding, indicating ischemia, are a positive indication of a cardiac event. Other Enzymes are Creatine Kinase, which is present in 90% of MI’s but is also present in skeletal muscle and Creatine phosphokinase that is more specific to heart muscle. Raised levels of proteins myoglobin and lactate dehydrogenase are also present.
Angiogram- An angiogram also known as cardiac catheterization is a technique used to image the blood flow through the coronary arteries. A contrast medium is injected into the coronary arteries at the aorta, immediately after injection of the contrast medium a series of x ray are taken which shows the movement of blood through the coronary arteries. This is done by passing a catheter through the left femoral artery and feeding it through to the heart. The technique allows a clinician to visualize the vascular network inside the heart, it can determine exactly where a blockage has occurred as well as accessing the narrowing of vessels within the heart. Different catheters can access different chambers of the heart.
Activity 6.2 Circulatory shock
The two types of shock I have chosen to research are hypovolaemic shock and anaphylactic shock
Hypovolaemic shock is caused by the loss of fluids that causes inadequate circulating volume, causing poor perfusion and leading to multiply organ failure.
The main cause of hypovolaemic shock is through the loss of blood through hemorrhage also known as hemorrhagic shock. The main cause is through external hemorrhage often the result of penetrating trauma or through blood loss from GI bleeding. Internal blood loss also occurs through organ injury and aortic aneurysm. Other causes of hypovolaemic shock can be through burns and gastroenteritis.
The body reacts to initially hemorrhage by activating the clotting cascade, contracting blood vessels, forming a fibrin clot over damaged vessels. The body’s stress response is activated, triggering the release Adrenalin and noradrenalin. The cardiovascular system increases heart rate, contractility of myocardium and contracting peripheral blood vessels. Blood is redistributed to the brain, lungs, heart and vital organs and away from GI tract and non-essential systems. The renal system reacts, releasing renin that causes angiotensin to be converted to angiotension II by the lungs and liver, which contracts arterial smooth muscle. Aldosterone is also released which acts on sodium reabsorbsion in the kidney, so conserves water, to attempt to maintain blood pressure. The endocrine system releases anti diuretic hormone (ADH) from the posterior pituitary gland, in response to lowering blood pressure. As part of the stress response the immune system prepares for possible infection with the release of cytokines, triggering of compliment cascade, T cell proliferation and an inflammatory response in an attempt to prepare and promote healing and site of injury.
Stage 1 shock/ class 1 haemorrhage (loss of 0-15%)- little symptoms body is able to compensate for loss, slight tachycardia may be seen and a delayed capillary refill time as blood loss head onwards 15% mark.
Stage 2/ class 2 haemorrhage (15-30%)- Symptoms include tachycardia, tachyponea, lowering of pulse pressure and delayed capillary refill time. Pt will appear cool and clammy and may be anxious
Stage 3/class 3 haemorrhage- further increased tachycardia and tachypnoea with decreased blood pressure and marked delayed capillary refill time. Pt will be confused have a sense of impending doom and a lowering GCS.
Stage 4/ class 4 haemorrhage – Immediately life threatening, very tachycardia and tachypnoea with lowered BP narrowing of pulse pressure diastolic unreadable, PT skin will be cold and pale often unconscious or very low GCS. Impending cardiac arrest.
Anaphylactic shock- Anaphylaxis is a multiorgan system reaction, where a person has a violent reaction to a substance they have previously been exposed and become sensitive too. No blood loss occurs pt instead causes a widespread vasodilatation of blood vessels, which results in hypovolaemia due to the increased space, this causes poor circulation and poor perfusion that can be fatal.
On exposure to the allergen, excessive histamine is released and various immunological mechanisms triggered that cause the sudden and mass degranulation of mast cells and basophil. This causes a physiological response to various systems causing severe bronchoconstriction, utricarcia and mass vasodilatation causing fluid to leak into intestinal spaces resulting in hypovoleamia, swelling and oedema. The swelling can be severe may occlude upper airway becoming life threatening.
Anaphylaxis doesn’t follow the same pattern as other types of shock and as such I cannot list it in stages. Symptoms can develop suddenly and evolve rapidly or onset can be delayed even up to 24 hours after initial exposure. Initial allergic reaction could be mild with flushing of skin and development of hives.
If Anaphylaxis occurs symptoms will include
-Itchy skin or a raised, red skin rash
-Swollen eyes, lips, hands and feet
-Feeling lightheaded or faint
-Swelling of the mouth, throat or tongue, which can cause breathing and swallowing difficulties
-Abdominal pain, nausea and vomiting
-Collapse and unconsciousness
Hypovolemic shock clinical presentation: History, physical, causes (2016) Available at: http://emedicine.medscape.com/article/760145-clinical#b4 (Accessed: 1 August 2016).
Caroline, N.L., Nancy Caroline’s emergency care in the streets (Nancy Caroline’s). 6th edn. Chapter 18 Hemorrhage and shock Pg 18.14-18.19 Sudbury, MA: Jones and Bartlett Publishers.
S Shahzad Mustafa, MD (2016) Anaphylaxis. Available at: http://emedicine.medscape.com/article/135065-overview (Accessed: 1 August 2016).
Multiply organ dysfunction syndrome is a systemic, sustained inflammatory response that results in multiply organ failure. It is the most frequent cause of death in ICU and is a complication of systemic insults to the body such as burns, severe infection and trauma. It has an extremely high mortality rate varying from 27-100% depending on the organs involved (EL-Menyar 2012).
When hypovolemic shock occurs MODS is often the result, Rapid fluid loss results in multiply organ failure due to inadequate circulating volume and subsequent inadequate perfusion (Kolecki 2014) to vital tissues and organs. Common causes of rapid fluid loss, that cause hypovalemic shock are, external blood loss due to trauma or GI bleeding, internal loss due to acute injury or rupture of aortic aneurysm or fluid loss due to gastroenteritis or burns.
In order for the body to function correctly the body must maintain its various systems within strict limits, via negative feedback mechanisms, to maintain homeostasis. When blood/fluid loss occurs, the body responds by initiating a cascade of pathways, if blood loss continues, homoeostasis can not be maintained, Causing tissue damage, poor perfusion, chronic inflammation and septic complications, which results in organ dysfunction that then leads to MODS.
Shock occurs when these mechanisms can no longer compensate for the amount of blood loss. Cardiovascular decompensation occurs, this causes impaired cellular metabolism due poor perfusion and oxygenation that affects all body systems.
The inflammatory response triggered by this major insult to the body’s system can cause MODS to develop. The activation of the immune system with the release of pro and anti inflammatory cells including cytokines, adhesion molecules, compliment, protease, reactive oxygen species and nitric oxide, play a significant role in the pathogenesis of multiply organ failure (El-Menya 2012). A dysregulated immune response, or immuneparalysis, in which the homeostasis between pro-inflammatory and anti-inflammatory reaction is lost is thought to be key in the development of MODS (Ramírez 2013) These cells which initially attempt to protect the body can cause significant harm to the hosts own cells, if the degree of injury is severe, surgery s prolonged and with different interventions and therapy for trauma, this then can develop into systemic inflammatory response syndrome (SIRS) triggering septic markers, Hyper inflammation and the development of MODS.
MODS develops in stages, Patients that present with significant trauma, often results in a hyper inflammation reaction and the development of SIRS. This can be beneficial in the initial stages, if the response is mild to moderate, resolving as patients recover. This is often termed the first hit. If this response is massive however it can overwhelm the body’s systems and early MODS can develop. This happens quickly usually within 3 days effecting respiratory and cardiac systems and associated with a high mortality rate. If injury is significant enough and shock that develops severe. The inflammatory response is sustained and a second hit can develop, usually as a result of sepsis. This often affects liver and kidneys. This is known as late MODS and is associated with less mortality but is still the major cause of death to the trauma patient once initial injury has been treated, through the development of these sepsis complications. It is thought that the initial first hit, even if moderate, primes the body and opens it up to susceptibility for a second hit from even mild insult or injury, resulting in tissue damage and development of MODS.
MODS is hard to predict and treat, currently the pathway in development and cause for MODS is still under debate, It is thought that many factors influence the development of MODS these include Patients factors (Age, gender, BMI and comorbidities), Injury factors (severity, blunt trauma, contaminated injury time factors organ ischemia) and Treatment factors (depth of shock, surgery, fluid resuscitation, ventilation, sepsis) all contribute to the development and severity of MODS, current research focuses on development of markers to predict the pathway to MODS in a hope to develop treatments and strategies to treat and prevent MODS occurring.
A, A.-K. (2015). Multiple Organ Dysfunction Syndrome in Sepsis. Retrieved june 12, 2016, from http://emedicine.medscape.com/article/169640-overview
Anderson, M. w. (2013). Traumatic shock: The Fifth Shock. Journal of truauma Nursing , 20 (1), 37-43.
El-Menyar. (2012). Multiple Organ Dysfunction Syndrome (MODS): Is It Preventable or Inevitable? International Journal of Clinical Medicine , 3, 722-730.
M, R. (2012). Multiple Organ Dysfunction Syndrome. Current Problems in Pediatric and Adolescent Health Care , Volume 43, Issue 10 273-277.
Maag M. (2003). Trauma, Shock, Multiple Organ Dysfunction. University of San Francisco.
medscape. (2015 йил 16-febuary). atenolol. Retrieved 2015 йил 16-febuary from medscape : referance.medscape.com
P, K. (2014, febuary 27). Medscape. Retrieved June 10, 2016, from http://emedicine.medscape.com/article/760145-overview
Wessem K, L. L. (2014). The effect of evolving trauma care on the devolpment of multiple organ dysfunction syndrome. European Journal of Trauma and Emergency Surgery , 1.
Yao Y, R. H. (1998). The Inflammatory basis of trauma/shock-associated multiple organ failure. Inflammation Research , 201-210.
Patient Assessment 1
Activity 4.1 Communication basics
Good communication involves being an active communicator, including active listening. You must be aware of both verbal and non-verbal communication and fully engage with the individual you are communicating with.
Good communication with patients includes using clear language, avoiding using medical jargon, be aware of non verbal communication, including body posture and eye contact, establish a dialogue with the individual, adapting your communication style to the person and situation, Empathises and listen, trying to establish a rapport with the patient.
Activity 4.2History taking the basics
Table 4.1 for use with Activity 4.2: template for taking a history
History of presenting complaint
Pt developed chest pain after breakfast 1 hour ago while walking upstairs. Pain is described as a pressure as if someone is sat on patient’s chest. It radiates to jaw and has a pain score of 6/10. It eases when at down. Pt is a little nauseous but does happen when takes paracetamol.
Past medical history
Parents died of heart attacks in their 60’s
Lives alone and normally independent. Does have a dog that he walks regularly. Neighbours can look after.
No system review was carried out in this clip
I think it does provide a good template for history taking however personally I would include On examination instead of system review, Impression, Treatment and Plan.
Left sided Abdominal pain with PV bleeding
2/7 Hx of left sided abdominal pain. Worse today with PV bleeding that started today that prompted 999 call.
Past medical history
Asthma, Seen GP 2 months ago everything fine. Is sexually active with no contraception being used
No regular medication mentioned, Pt taken 2 Ibuprofen for pain.
None of note
Lives with family, Main carer for 3 year old child
Heavy PV bleed with period cramp like pain but much worse. Pain 10/10. Pain is localised to left side of abdo. Does not radiate nothing changes pain. Pt reports urine and bowels normal, Other symptoms include feeling faint.
No full examination carried out in this video clip
Abdo pain? cause. ? Miscarriage
Non required currently
Convey ED for further investigations
Activity 4.3 Learning how to take histories
I have worked in the ambulance service for 10 years now, Frontline for the past 7 so have been taking histories from patients for a long time. I feel this activity is a bit redundant but will reflect on it as described.
Key question to ask patients varies according to presenting condition but history taking should begin with
-Asking the patients name and introducing oneself.
-Asking why they called an ambulance today
Questions will then vary according to pt answers. Pain for example would need questions such as what type of pain is it? Does anything make it worse or better? Does it go anywhere else? Pain scoring between 1-10. Any other symptoms?
Other key questions include
-Have you any past medical history?
-What medications do you take?
_Whats your mobility like?
-Do you live alone? Are you independent or do you have any care in place?
Discussing these details with my mentor he is happy with my ability to take a history and feels I communicate well adapting my style to fit, the only thing that I have been told I need to work on occasionally is formulating an opinion before entering the patients address based on information given by control.
I feel I can communicate well with people and use open questions well, allowing pt the time to speak about what troubling them. I also can focus my history taken quickly if the patient is time critical. Occasional I have gotten frustrated slightly with patients when given information completely irrelevant to the reason for then calling. Overall though I feel I can illicit information well and am fairly comprehensive in taking a good history.
Activity 4.4 Achieving competence in history taking
Six pieces demonstrating histories from EPCR
Activity 5.2-Practicing examination skills
Inspection- the uses of the senses to inspect a patient by what we can see, hear, feel and smell. This skill is often carried out without thinking about it by clinicians, just by looking at a patient from across a room clinicians often have an instinctive feeling that a patient is unwell. This is because immediately a clinician is accessing a patients appearance, colour breathing and general demeanour this skill can take a number of years to develop, The ambulance service I work for have tried to use a tool within the patients assessment to explain this in the form of the patient assessment triangle encompassing level of alertness, efficacy of breathing and colour this goes part way into helping clinicians understand this skill. I feel over the years of practice with the OU and previously with other roles in previous ambulance service I have become competent at this skill and can quickly determine if a patient is really ill by looking at them, by the feel of their skin and their demeanour.
Another part of inspection is being confident in anatomy and physiology and an understanding how body systems work and how illnesses present. This is an obvious skill when assessing a broken limb for example recognising the signs of fracture but can be more subtle for example the identifications of different types of rashes, blanching and non blanching, which may be indicative of serious illness (meningitis) and what is a simple heat rash. I feel that through my years of experience I have come to understand my anatomy and physiology and a range of diseases and conditions and continue to build on this knowledge all the time however I feel it is important to recognise the limited scope of my experience in comparison to a doctor and care should all ways be taken and guidance sort in order to best treat my patients.
Smells can also be indicative of illness and this is apparent in a variety of illness examples include gangrene, ulcers, melena, infectious diarrhoea, these are smells that once one has experienced t is not forgotten and I have gained experience in these and would be confident in recognising them in the future.
Overall I feel I am growing in confidence all the time with my ability to carryout this skill and feel confident in my practice.
Auscultation-Listening to the chest, abdomen heart and bruits to determine illness and conditions.
I have developed this skill over a number of years, when I first learnt this skill I found it extremely difficult to determine the difference between various sounds and knowing what a particular sound indicated and I am still developing this skill now.
When listening to the chest I first learnt where to listen and what area or lobe of the chest I was listening too. The importance of different sounds and what they meant. Initially I used this skill to recognise a possible chest infection and one of the first sounds I grew confident in hearing was crackles in the chest, another was the recognising a wheeze in a person with asthma or COPD in order to treat them. As well as medical patients we utilise this skill in trauma patients and look for abnormal air entry to indicate possible pneumothorax and heamathorax I have seen this in a patient recently recognised the reduced breath sounds myself prior to air ambulance arrival reported my finding s to the Critical care paramedic who performed a finger thoracotomy. This was confirmed as correct when he got a hissing sound as air was released from the plural space allowing the lung to inflate. I am growing in confidence all the time in my ability to recognise chest sound in order to aid my deferential diagnosis of a possible patient condition I feel I now have a level of competency in this skill and can utilise it well
Other area we use this skill is in bowel sounds which I am still developing my skill in, I can recognise the different sounds or absence of sounds knowing that a lack of bowel sounds could indicate a blockage but am still developing my skills to determine other patient conditions and differential diagnosis.
Heart sounds I am still developing but can recognise various conditions such as murmurs or possible valve problems by deviations away from the normal lub dub. Bruits I know what to look for but have never heard one in the field and so this is a skill I can look to develop further.
Percussion –This is a skill I have found difficult and am still trying to achieve a level of competency in, I feel as a service and as paramedics it is not a skill I have seen carried out routinely.
Personally I have only rally practiced indirect percussion when assessing a chest. I find that when performing this skill it is very difficult to do wearing gloves so always remove them if I am going to perform this skill which can pose issues. I am still developing this skill and so far only carry it out in inspection of the chest. I known the difference between hypo-resonant a dull sound indicating fluid or consolidation in the lung, Normal sounds and hyper-resonant which is loud high pitched drum like sound that is indicative or excesses air in the lungs/chest i.e. in asthma or pneumothorax. This is a useful skill that can be performed in trauma and in medical patients to determine different patient conditions and I must work to develop my knowledge and skills in this area. I am confident in recognising the limited sounds I know and what they could indicate but still under confident in fully utilising this skill. I am also aware that percussion can be carried out on other body structures to help determine different patient conditions but have never seen this performed for example in an abdominal exam. This is an area I will look to develop in the future
In reflection this is a skill I am under confident in using and will seek advice from my colleagues in its correct use and appropriateness in my practice.
Palpation- This is the skill of feeling the body to determine possible illness or conditions. This skill is vital as my role as a paramedic when assessing various body systems for injury and illness. This is a skill we carryout routinely in a variety of different ways to determine different things and I am confident in my ability to carry out this skill but my knowledge base is still developing.
This skill is particularly important in carrying out an abdominal exam and utilising deeper palpation to tell us about possible problems with abdominal organs. Pain in different places can indicate conditions such as appendicitis, gallstones and kidney stones and urine infections to name a few. We must check for masses particularly pulsating ones to indicate AAA and a hard and distended abdomen can indicate bleeding. An abdominal assessment is difficult and there a lot of different reasons for the development of abdominal pain and tenderness when palpating but as clinician’s it is important we recognise possible immediately life threatening ones such as AAA and act appropriately as well as minor ones associated with simple illness such as UTI which may be treated in the community. I feel that this is a skill I have been developing over the years but through my work with the OU with my increased knowledge of anatomy and physiology it is a skill I am becoming increasing confident in carrying out but again also recognise my limited scope of practice and recognise care must be taken. I have previously attended a patient that had just been discharged from hospital following a UTI that was still experiencing lower abdominal pain who I referred to his GP only to find a few days later he had been admitted with a femoral aneurysm which highlighted to be my limited knowledge and showed I still need to work on my patient assessment skills and differential diagnosis.
Palpation is also used throughout the body to assess injury this can e from broken limbs assessing the injury, pulses below site of injury and skin tone to examining the chest for frail segments broken ribs and subcutaneous emphysema. It can be used from head to toe to assess various injuries and palpate areas of concern. Pain is often an indication that further assessment is required. This is a skill I have developed over many years and again I feel confident in carrying out a top to toe exam feeling for deformity and abnormalities again I would say that when I first learnt this skill my lack of understanding of body systems and anatomy may have limited my practice but feel much more confident now after learning with the OU.
Activity 5.3 Abnormal expansion of the chest
Plural effusion-Is the build up of fluid in the plural space that results in pressure on the lung, abnormal chest expansion and shortness of breath as well as other associated symptoms. Normally there is a small amount of fluid in-between the parietal plural that covers the inner surface of the thoracic cavity and the visceral pleura that cover lung surfaces, this is to facilitate movement during respiration, If there I a change in homeostatic function that manages this fluid either excess fluid can be produced or is not drained off resulting a build up of fluid within this space, this leads to a flattening of the diaphragm and a restriction o movement during respiration. This leads to progressive dyspnoea, chest pain and cough. A pleural effusion is usually a result of another underlying condition such as pneumonia, cancer or asbestosis.
Pneumothorax- is the presence of air in the pleural space. This impairs respiration, as it doesn’t allow the lung on the effected side to full expand resulting in impaired gaseous exchange and cellular oxygenation. The degree to which this affects the body depends on how much air has entered the plural space and how much the lung has collapsed on the effected side. In trauma this can often lead to a tension pnemonthorax which causes a shift of the mediastinum and is seen through tracheal deviation it is immediately life threatening and must be addressed quickly. Spontaneous pneumothorax can occur and this usually is in patients who are tall and thin or with underlying lung conditions such as COPD.
Symptoms include abnormal chest expansion, chest pain, respiratory distress, tachypnoea, and tachycardia hypotension.
Flail chest- causes paradoxical movement of a segment of the chest wall as a result of fractures of 3 or more ribs anterior ally or posterior in 2 or m0re places in each rib resulting in a free moving flail segment. It is caused by significant blunt trauma and if observed it is likely that there will be damage to underlying structure, if a person has osteoporosis significantly less force may be required to cause the injury. Symptoms include paroxdical breathing, chest pain, tachypnoea and impaired oxygenation
Which is often a result due to underlying injury rather that flail segment
Asthma-Is a disease that effects the small airways, usually a trigger can cause an acute attack to develop which causes a narrowing of the airways as a result it becomes increasingly difficult to breath in and out, this causes wheezing, shortness of breath, cough and as it progresses dizziness, tachycardia tachypnoea. Due top the mechanism of how we breath expiration requires effect from the muscles within the body whereas inspiration is a passive process. As someone suffering from an acute asthma attack symptoms progress and they become tired it becomes increasingly difficult to expel air from the lungs, the patient becomes tired muscles weaken and over inflation of the chest occurs with little movement of air in or out, this then is life threatening an immediate action with adrenalin and bronchodilators and steroids is necessary.
Emedicine.medscape.com. (2016). Asthma: Practice Essentials, Background, Anatomy. [online] Available at: http://emedicine.medscape.com/article/296301-overview [Accessed 10 Aug. 2016].
Emedicine.medscape.com. (2016). Flail Chest: Background, History of the Procedure, Problem. [online] Available at: http://emedicine.medscape.com/article/433779-overview [Accessed 10 Aug. 2016].
Emedicine.medscape.com. (2016). Pleural Effusion: Background, Anatomy, Etiology. [online] Available at: http://emedicine.medscape.com/article/299959-overview [Accessed 10 Aug. 2016].
Emedicine.medscape.com. (2016). Pneumothorax: Practice Essentials, Background, Anatomy. [online] Available at: http://emedicine.medscape.com/article/424547-overview [Accessed 10 Aug. 2016].
Activity 5.7 Terminology for the abdomen
Rigidity-R igidity is the involuntary tightening of the abdominal muscles that occurs in response to underlying inflammation
Guarding-A patient who contracts their abdominal muscles, can be voluntary in response to pain or involuntary
Boarding- hard distended often-bruised abdomen indicating internal bleeding
Ascites-A collection of fluid within the peritoneal cavity
Rebound - initial pressure does not cause pain but when the examining hand is released, pain is felt). Rebound tenderness suggests peritoneal irritation.
Caroline, N. (2006.). Emergency care in the streets. Chapter 13 Physical examination
Ferguson, C. (1990). Inspection, Auscultation, Palpation, and Percussion of the Abdomen. Butterworths. [online] Available at: http://www.ncbi.nlm.nih.gov/books/NBK420/ [Accessed 10 Aug. 2016].
Activity 5.8 Listening to the bowel
I have found listening to bowel sounds and extremely difficult exercise in my patient assessment and find it difficult to establish the difference between normal bowel sounds and abnormal bowel sounds. I have also found the literature on the subject contradictory some argue that it is irrelevant and the varying degrees at which clinicians perform it confusion.
When listening to the bowel sounds of my volunteer a found an irregular pattern of gurgling bowel sounds at around 15 per minute, which is considered normal in textbooks. Auscultation should cover all four quadrants and absent bowel sounds over 60 sec should be noted indicating a lack of intestinal activity that could be associated with obstruction as well as other diseases, High pitched frequent bowel sounds could indicate a small bowel obstruction and abdominal bruits large vascular problems. Other than recognising these clinical presentations of immediate need for admit to ED I find abdominal auscultation to be a poor indication of possible dieses and injury, bowel sounds can vary a lot from person to person and dependent on time of day and food intake also I find that determining normal bowel sounds can be very subjective.
In conclusion having found out more about bowel sound during the course of this activity and through examination I am now more confident in my knowledge of what I need to know and what this could indicate i.e. lack of or decreased bowel sounds, hyper-resonance and bruits. This will help me in developing my practice and differential diagnose.
Activity 5.10 Appendicitis
The person I talked to who had their appendix removed said they initially felt like they had the flu, began to vomit then experienced the worst pain in their entire life. I asked if they had ever heard of mcburney's point and they said they hadn’t but had sever pain in the right side of their abdomen. I asked them if this was in their lower right and they said this was were the worse pain was particularly when pressed but it also went to the upper right as well, this does indicate they did have pain at mcburney's point. They were given antibiotics and a few days later had an appendectomy.
Activity 5.11 Detecting masses in the abdomen
There was 41,112 new cases of bowel cancer in the UK in 2013 (cancer research UK) estimated 30.2 new cases per 100,000 adults and the lifetime risk of developing bowel cancer is 1 in 14 for men and 1 in 19 for women.
In India there were an estimated 6.09 new cases of bowel cancer per 100,000 adults in 2012, and an estimated 64,332 new cases in total.
Activity 5.12- Using the Glasgow coma scale
Mental status is the prime indicator of how sick a patient is. The quickest way of assessing this is through the use of AVPU. Is the patient alert, respond to voice, pain or unresponsive. It is also important to assess if they are first alert then orientated to person, place, day and event. However the most reliable way of assessing mental status is through the use of the Glasgow coma scale, GCS, this is shown in the table below
Changes in level of consciousness are the single most important observation in assessing the severity of head injury.
Papillary assessment is important, as the pupils are very sensitive to a raise in intra cranial pressure ICP. Sluggish pupils are an early sign of increased ICP whereas blown unequal pupils or bilaterally fixed pupils are a more ominous sign of raised ICP. These changes are due to the pressure placed on the ocular motor nerves. Raised ICP cannot be quantified in the pre-hospital setting but treatment decisions are based on signs such as hypotension or hypertension, posturing and papillary response. Therefore serial assessments of both GCS and pupil signs are important in the pre-hospital setting.
Pt with a reduced level of consciousness can often require an ABC approach, there airway needs to be managed, the trigeminal, glossopharyngeal and hypoglossal nerves are responsible for airway control, In the unconscious pt particularly if head injury has occurred these nerves can be effected, they are responsible for control of the tongue swallowing and that the hypopharnyx is slightly contracted if these muscles relax the airway can become occluded, Trismus can also occur where the muscles clamp down closing the airway this is an indication of head injury or cerebral hypoxia.
Breathing rate also needs to be evaluated deviations away from normal rate indicate effected nervous system.
Circulation needs to be assessed checking peripheral and central pulses looking for signs of shock. Blood pressure is important and can indicate shock but also raised ICP. A patient with raised ICP will show increasing blood pressure, reduced heart rate and reduced respiratory rate, know as crushing’s triad.
Aphonia- means no sound, It is the inability of an individual to produce a voice, it is caused by an injury or condition of the vocal cords meaning hey do not function correctly
Dysphonia- knows as a horse voice, it is the difficulty in producing a voice from the vocal cords, normally caused by the inability of the vocal cords to vibrate normally
Dysarthria- difficulty in speaking, caused by problems controlling the muscles used in speech
Aphasia-Difficulty in speaking caused by a damage to a specific area of the brain results in an inability to comprehend and formulate language.
Activity 2.2 Reflecting on your experiences of major wounds
I attended an incident in which a person had been stabbed in the leg. On arrival at scene we found the patient on the floor with a pool of blood around him with a reduced level of consciousness. We quickly cut of his clothes while talking to people on scene that informed us that he had been stabbed, they thought in the leg. It was quickly established that the patient had a stab wound to the upper leg, it was approx 4 cm wide but was arterial, the wound had severed the femoral artery and the blood loss was significant with the patient already in hypovalemic shock.
This incident happened a long time ago when I was working for another ambulance trust I was relatively new to the emergency service working as an assistant practitioner supporting a paramedic. I remember the incident vividly so it must have affected me. At the time the focus was on trying to save the patients life, I remember thinking oh my god at the amount of blood present and following orders issued by the paramedic and hoping to everything right and save the mans life. It is only in reflection that I really felt any real emotion, I felt sad and frustrated as although we got the patient to hospital he later died due to the amount of blood loss and extent of the injury. I often think back to the incident wondering if we could have done anything differently, now with improvements in patient care we may have saved his life. In reflection at the time we did everything we could have done and the outcome was inevitable at the time only with changes in practice now issued to us could we have changed anything.
We applied direct pressure to the wound, applying a pressure dressing and elevated it, We carried out a full top to toe assessment finding only one wound, We did the mans observation, Gained IV access, administered fluids, assisted the patients breathing as his respiration rate had begun to slow, provided an ATMIST to the hospital and conveyed under blue light conditions. At the time that was the only treatment we could give to the patient. In my current ambulance trust we wound have used a CAT tourniquet to staunch the wound and tranexamic acid to aid the clotting process, these treatment may have saved his life.
Management of Hostile and Major Incidents
Activity 2.2 Are assaults on paramedics increasing?
Personally I believe this question is difficult to answer and I would say it depends on where you work and your own experience. I have been assaulted while working for the service but it was minor I did report it and the person was prosecuted and found guilty. I have worked both in cities and country and do find that the risk is increased in an inner city environment mainly due to the increased misuse of drugs and alcohol. So I believe that is anti social behaviour and the misuse of substances increases and more of these jobs being dealt with by ambulance staff as oppose to the police as previously may have been, so will assaults on ambulance staff.
Talking to colleagues however may have highlighted a different picture on the issue
‘It’s always been like this, people just report it more’
‘Depends on what you class as an assault, People are less tolerant now, the older generation would have dealt with it in there own unique way’
‘People are now encouraged to report incidents’
Maybe then Assaults haven’t increased just we have become less tolerant to abuse and are encouraged to report incidents and deal with them officially rather than in our own ‘unique’ way.
It appears that the facts and figures do support the view that assaults on ambulance staff are increasing across the whole of the UK. A simple web search produced many numbers of newspaper report detailing the raise in assaults on ambulance staff.
‘Attacks on London ambulance workers jump by 23%’ Evening standard 31 March 2014.
It is reported that in 2013, there were 582 assaults on London ambulance service staff up 23% on the previous year and that 4 staff members a day are victims of abuse that includes physically violence, spitting and verbal abuse.
It is reported much the same in the midlands.
‘Physical assaults on ambulance staff in west midlands up by 30%’ BBC News 16 NOV 2015.
Where staff members have been kicked, punched and threatened with knifes.
Within my own trust there has been an increase in assaults. ‘Between February 1st 2013 and 31st January 2014 there have been 104 reports of physical abuse to front line crews. The type of injuries staff have received range from cuts and bruising and sprains through to the more serious injuries such as dislocations and fractures, (SWAST)
Ken Wenman, Chief Executive of SWASFT, added: “The Trust takes incidents of assaults on staff extremely seriously and any abuse, verbal or physical, will not be tolerated. Every member of Trust staff plays a vital role in serving the community by helping to deliver the right care in the right place at the right time and staff should be able to fulfil their life-saving role without fear of abuse or assault.”
I think that the figures suggest that not only are assaults increasing but the severity and type of assaults are increasing in the past ambulance staff may have got a little verbal abuse at times but where not faced with the increase physical assaults they now deal with on a day to day basis. From my own experience I have heard of in recent years a couple of very violent assaults on staff that left them hospitalised.
Does this reflect the NHS as a whole?
‘Physical attacks and assaults against NHS staff have increased to 163 per day with fears waiting times and workforce cutbacks are to blame’. The telegraph 30 Nov 2012
‘Figures reveal 9% hike in violent assaults on NHS staff in a year’ Nursing standard 25 November, 2014
The NHS statistics and figures suggest it does with a variety of reason suggested for this. This suggests that staff must remain vigilant and protect themselves.
Activity 2.3 Conflict Resolution Training
I participated in a group section for conflict resolution training and was given a work book to go through and submit my answers too.
The book talked about the importance on verbal communication, attitude and how to deescalate a possible confrontation situation. It talked about the importance of professionalism and trying to remain objective an impartial. It told us about safety aspects, lone working and the importance of knowing ones exit from a situation and to not get trapped.
In the group session we then talked about the workbook, important aspects of it and were then allowed to talk about our own personal experience of conflict, how we dealt with it and if it was good or bad. We than went through physical technique to protect oneself if conflict should arise for example how to get a person off you if you are grabbed.
The experience was a good one and the session went well, the workbook was a little tedious but having completed it gave us more time to talk about real life scenarios. The training on how to remove oneself from a situation was at time a little unrealistic but did provide us with basic techniques to protect ourselves.
Activity 3.2 National Guidelines and legislation on emergencies
The Security Service (MI5) is responsible for protecting the UK against threats to national security. It is the domestic counter intelligence and security service and is responsible for keeping us safe from national threats. It is directed by the joint intelligence committee and is bound by the security service act of 1989. MI5 is headed by the Director General, currently Andrew Parker.
The Office for Security and Counter-Terrorism coordinates the government’s response in case of a terrorist incident. The National Counter Terrorism Security Office (NaCTSO) is a police unit that supports the 'protect and prepare' strands of the government’s counter terrorism strategy.(Gov.uk) Thy form part of the The national police chiefs council and works directly with the home office.
There main responsibilities are to provide help, advice and guidance to both private and public sectors on how to deal with and prevent and protect from the terrorists threat mainly on
-crowded places throughout the UK
-hazardous sites and dangerous substances
-the critical national infrastructure (working with the Centre for Protection of National Infrastructure (CPNI)
Centre for the protection of national infrastructure (CPNI) It provides protective security which is 'putting in place, or building into design, security measures or protocols such that threats may be deterred, detected, or the consequences of an attack minimised'.
In this Part “emergency” means—
-an event or situation which threatens serious damage to human welfare in a place in the United Kingdom,
-an event or situation which threatens serious damage to the environment of a place in the United Kingdom, or
-war, or terrorism, which threatens serious damage to the security of the United Kingdom.
Activity 4.1 Major incident Report
We received a job over the MDT regarding a multi vehicle collision on the motorway. Having booked mobile and proceeded on lights and sirens to the incident we received a radio communication from control, informing us we would be the first crew on scene, that there were reports of many vehicles involved and they were expecting multiply patients.
We were told that a duty officer had been dispatched to the incident but was approx. 10 mins behind us. They also informed us the helicopter was available, HART had been informed about the incident and if we could give a situation report on arrival at scene.
On arrival at scene we were confronted with what was obviously a serious incident with a lot of vehicles involved including large good vehicles and cars. We parked as close to the incident as possible, police were already on scene so took direction from them. My colleague the Paramedic on scene first assumed the role of operational command until he could be relieved by the duty officer.
We applied our PPE and approached the scene, at this point we do not treat or rescue patients instead a rapid scene assessment must take place and we generated a METHANE report.
We declared an Major incident, confirmed the Exact location, gave the Type of incident with estimate od number of vehicles involved, Identified possible Hazards , determined best Access and egress points conferring with police and fire on scene, estimated Number of casualties, identified Emergency services and resources required. We conveyed this to control. Informed police and fire on scene and began liaising with there officers, I then began a log following the incident commander recording communications made and decisions made.
We assessed that air support and HART team would be required as it was expected that patients would have suffered major traumatic injuries and entrapment likely. Some vehicles were on fire so the risk of burns and safety of staff and patient was a concern.
At this point the duty officer arrived on scene and he took over the role as incident commander, we briefed him on what had happened so far and that we had declared a major incident. He took command and then in liaison with other emergency servicers present began to organise the incident establishing a control point, casualty triage, clearing station and patient collection , ambulance parking and loading points. He also established an inner and outer circle around the scene of operations, also creating an equipment dump to keep the area clear
We were then asked to begin the process of triage. This involves the use of a triage sieve, labelling patients according to priorities for treatment with categories from P1, P2, P3 and dead. This is done in pairs and a flow chart is used as shown below
This tool is only used in adults though and paediatric triage utilises a different tool.
Once this task was completed we reported it to the officer who had already established a clearing station, more ambulance resources had begun to arrive and we were able to start treating and stabilising patients. We began treating P1 patients.
At this point it is important to consider the capability of receiving hospitals, the local hospital was only able to except a number of casualties and other hospitals needed to receive others. The availability of other types of transport for patients for example PTS vehicles, St Johns and Red Cross for walking wounded and Air ambulance for worse cases to fly to major trauma centers.Burns was a consideration in this incident so casualties with significant burns were taken to a burns unit in Bristol. Also a local hotel was used and ECP and nurse practitioners used to treat minor wounds.
A major incident can be defined as ‘An event or situation requiring a response under one or more of the emergency services major incident plans. A significant incident or emergency can be described as any event that cannot be managed within routine service arrangements. Each require the implementation of special procedures and may involve one or more of the emergency services, the wider NHS or a local authority’. (SWAST major incident plan) A major incident standby can be declared until the extent of the situation can be established. This can be a result of many different situations including winter pressures, CBRN incident, a bid bang, mass casualties and many more.
In this incident a major incident was declared because of the amount of vehicles involved, the number of injured and the amount of resources that would be required by the ambulance service and the receiving hospitals as such normal working would be affected and normal service could not be run.
A MIC or medical incident commander is described a medical advisor to the on scene ambulance command, they provide medical advice with the overall responsibility for medical recourses deployed on scene and the provision appropriate lifesaving interventions, they work closely with officers on scene to provide and deploy specialist advanced care team to the scene.
Legislation that governs how my ambulance trust works and operates a major incident include
-NHS England Core Standards for Emergency Preparedness, Resilience and Response (2015).
-National Resilience Planning Assumptions (Cabinet Office, 2015) and the Community Risk Registers which cover the Trusts area.
As well as more general guidance based on
-The Civil Contingences Act (2004)
- NHS Act 2006 (as amended)
- The Health and Social Care Act (2012)
- NHS Standard Ambulance Contract
- NHS England EPRR Core Standardise general guidance
This guidance provides the trust with its responsibilities an expectations in order to deliver quality care to the patients at all times.
In this incident we liaised with officer in command about priorities for treatment were allowed to load our patient into our vehicle were told which hospital we would be conveying our patient to and followed the route out of the incident.
South West Ambulance Service (2013) Major Incident Plan. Available at: http://www.swast.nhs.uk/Downloads/SWASFT%20Board%20papers/January2013Board.pdf (Accessed: 19 September 2016).
Activity 4.2 Reading of Nancy Caroline chapter 47
I think the most acute problem in scaling up triage in a major incident would be to have enough staff to carryout triage and to make them continue to triage patients until all patients are labelled with categories before treatment can occur.
Having searched the internet I came across accounts from paramedics who had attended the London 7/7 bombing recounting their experience of triaging patients in his account the paramedic describes how he entered the train and was confronted with four patients two P3 patients who appeared to have hearing loss from the incident as they were shouting at each other with a women laid across their laps and another patient on the floor, he described how he quickly assessed the patient across their laps and found her to be not breathing and no pulse, he opened her airway she still didn’t breath and had to labelled her as dead. He moved onto the women on the floor who was unconscious but breathing labelled her as P1 and began treating her. He describes how difficult he found this knowing that in other circumstances the dead women would have been resuscitated and given a chance, he also comments on how the experience still affects him today even though he seems reluctant to admit it
"I can't honestly say that this one event has had a greater impact on me than others I've been involved in, but my wife says it changed me dramatically – I often suffer from insomnia (paramedic Craig Cassidy).
I couldn’t find an after action review of a recent major incident. I searched mainly for ones regarding terrorist incidents so I am unsure if these have become classified in order to prevent possible terrorist exploiting weakness in emergency service. I also think that services would not wish this information to be part of the public domain. I was able to find reviews and accounts into what happened at incidents but the majority of information was already within public domain and not specific to emergency service response and good and bad points.
Activity 5.1 Dealing with terrorist acts
1, As a first responder to a terrorist incident, where my immediate aim is to treat patients I would first have to hold off, Bronze command needs to be established, a account of the incident begun, Other emergency services consulted and health and safety considerations met, before triage can begin. Once these key elements have been established a triage officer can be appointed and a triage sieve can begin. This involves labelling patients in different categories depending on priority of treatment. P1-imeddiate-(red) P2-Uregnt-(yellow) P3- Delayed (green) and P4- expectant (green with red corners, this category can only be evoked by strategic medical command) and dead. Having been appointed to triage I would go from patient to patient labelling them appropriately before treatment can begin, this process is shown in the table below
After all patients have been labelled the triage officer can begin mobilising resources to treat and extract different patients based on this priority, I could then begin treatment and extraction of a patient assigned to me before moving to casualty clearing station where a triage sort can occur as shown below.
Having read about major incident triage I have also experienced this myself on a small scale at an RTC, where my paramedic colleague held off treating patients and established command first to organise resources, I found this extremely difficult at the time, knowing patients needed help but having to wait in order to establish structure and mange patients efficiently.
(b) The training I have received to deal with major incidents include
1 days training on my initial ECA training
4 hours mandatory training last year
Work undertaken with the O.U in management of hostile and major incidents
My paramedic training which has taken 4 years of part time study in order to qualify as a paramedic, this includes assessment of theory through tests and essays as well as OU portfolio. I have also undergone simulations multiply RTC environments as well having gained practical experience. This prepares me for my role as a paramedic and incidents I may encounter. More detailed training within the trust of major incidents and management roles requires you to be a paramedic and carryout extra training in your own time.
Gunshot wounds-Gunshot wound varied in there devastation on what type of gun is used, the type of projectile and the area that is damaged and tissues involved.
The least devastating injury is a simple gunshot wound to the extremity’s that has no bony injuries or neurovascular compromise this would be treated in hospital with splinting and antibiotics.
The degree of injuries than changes depending on various factors and tissues involves. The entry wound characterised by the initial contact and implosion pushes inwards forcing energy into surrounding tissues clothing fragments can be taken inwards increasing chance of infection, the amounts of deformity and tissue destruction depends upon the initial path of destruction of the projectile, crushing tissues as it passes through, this can be irregular as the bullet may be deflected as its hits other tissues, shockwaves can then occur within tissues causing tissues cavity’s to develop this can have varying effects dependent of which tissues it effects. Fragmentation can occurs either from the projectile itself or from bone as it passes through causing further damage to surrounding tissues. Exit wounds as the projectile leaves the body also can be larger than entry wounds dependent on the energy dissipated as it travels through causing further complication and bleeding.
A shotgun fires shot which are many fragments designed to spread out as it travels decreasing velocity fairly rapidly. Shot guns cause the most devastation when fired at close range with multiply fragments effecting multiply tissues also the risk of infection is greatly increased as multiply clothing fragments are carried inside, this would be the worst injury I would expect to treat. I would apply a pressure dressing to the wound in attempt to control bleeding use a CAT tourniquet where appropriate, canulate, give IV tranasamic acid, IV Fluids and transport rapidly to the emergency department.
Another wound would be from a bullet from a high velocity rifle, this is likely to be a straight pathway exiting the body and devastation will depend on tissues involved. This could be minor as described in the first injuries are if a major vessel is cut deadly.
All gunshot wounds have the potential to be catastrophic; a single low projectile that injures the aorta is likely to be fatal.
Bomb blast injuries-There are four classes of injury from explosions, Primary blast injuries this is from the blast itself, damage is caused by the pressure wave generated from the explosion, secondary blast injuries- injuries sustained from flying debris and shrapnel from the device, tertiary blast injuries caused by the patient being thrown by the force of the explosion onto a stationary object and quaternary injuries which include burn injuries sustained from hot gasses or fires caused by the blast. It is expected that the vast majority of patients who survive and explosion will have some combination of all four types (Caroline N 2008)
The least critical type of injury I would expect to see would be loss of hearing from damage to tympanic membrane as a result of the shock wave generated this is caused as air containing organs are much more susceptible to damage due to pressure changes created by the shock wave. Pain hearing loss and bleeding can occur in the prehospital setting there is little treatment for this injury, reassurance must be given to patient and other injuries suspected.
Injuries then vary in there destructive nature dependent of tissues involved, Head injuries are the most fatal either from penetration or bleeding from blunt trauma in the prehospital setting we can look for and assess head injuries, checking GCS, Pupils vital signs and neurological exams but treatments require specialist teams within a trauma hospital. Basic intervention such as IV access and high flow 02 given followed by an ATMIST and rapid transport.
Other common and concerning injuries effecting patients in blast injuries are lung injuries due to the air containing space being more susceptible to pressure changes, pneumothorax is common requiring needle decompression in the prehosptal setting. Anyone with suspected lung injury should be given high dose 02, IV access gained and rapid transport to ED.
As with gunshot wound the range of injuries that can occur in blast injuries varies considerable, the devastation of the injury to the individual will depend on its location and severity, in blast injuries shrapnel from the device or projectiles such as metal glass and wood fragments from the blast can injure a v variety of tissues, the shock wave can cause blunt force trauma and widespread burns can be fatal, so it is very difficult to give a single most serious wound as the smallest wound could be fatal.
Caroline, N. (2008). Emergency care in the streets. 6th ed. jones and barlett, pp.17.23-17.26.
Smith, W. (2012). Triage in mass casualty situations. Continuing Medical Education, [online] 30(11), pp.413-415. Available at: http://www.cmej.org.za/index.php/cmej/article/view/2585/2645 [Accessed 30 Aug. 2016].
Activity 5.2 The 2005 London bombing
The London 7/7 terrorist bombing was a mass acuity incident across multiple locations. There were 775 casualties and 56 deaths, 53 at scene. 55 patients were triages as P1 or P2 patients of which 20 were critical injured. 667 were categorised as P3 walking wounded and two patients triaged as expectant.
It was recommended by the coroner in her report in 2011 that
‘London Ambulance Service and London Air Ambulance must review training of their staff for triage, or assessment, at incidents with multiple casualties. Particularly, staff should be told that performing triage does not prevent them giving immediate or basic medical treatment’
The rapid process of triage sieve does not encourage treatment however the packs provided by ambulances service containing an aide memoire clearly states that selection of dressings and devices for keeping the airway open and preventing catastrophic haemorrhage and that the unconscious patient should be placed in the recovery position and airway maintained.
It was found that during the initial process of triage that some basic manoeuvres and possible treatments may have been missed as paramedics were reluctant to get drawn into treating patients before the initial triage sieve was completed. The coroners concluded that it is important to remember that carrying out initial triage does not preclude immediate or basic medical intervention.
The standard P1-P4 triage sieve has limitation and only takes into account basic respiratory rates and pulse rates, the patients must then go through the process of triage sort for a more detailed triage to excess further issues such as blood pressure and GCS. However even this is limited in its scope and both system have a tendency to over triage victims. Over triage can also occur in paediatric cases when the rate tools are not used (paediatric triage tape) for assessing correct respiratory rate.
However the study by Lockey suggest that the triage system employed by London ambulance service which was a simplified version of the p1-p4 system categorising patients into two groups, seriously injured P1 and P2 and walking wounded P3 although has a tendency to over triage is possible better than the standard P1-P4 system as it ‘is slow to effect and does not take into account subsequent injury evolution and physiological deterioration’. It suggests that re-triage is then more effective in the hospital environment.
I also think over triage can occur when confronted with a devastating scene where a lot of damage has occurred to surrounding environment leading paramedics to assume injuries to be severe. A need to rapidly clear scene due to a dangerous environment may also lead to over triage.
I think under triage may occur when confronted with multiply causalities without the staff to deal with the number of patients for example all walking P3, all conscious but unable to walk P2, all unconscious P1 without fully carrying out triage. It may also occur where rapid assessment has been carried out but re-triage and assessment is slow. Due to the nature of these mass casualty incidents and how injuries from these circumstances can evolve, many injuries may be slow to develop as such many lower priority patients injuries may quickly become life-threatening if not treated in a timely manor and closely monitored.
In the London bombing there was a tendency to over triage. Over triage can be costly to patients meaning non critical injured patients are given a higher priority for evacuation and treatment , it can impairs treatment as already constrained resources have a greater number of patients to deal with meaning the most critically injured receive less prompt treatment. In part this was due to the simplified triage system employed by London ambulance service. 775 people where injured, 56 people died, 53 at scene, as described earlier they where categorised into two main groups seriously injured (P1+P2) and walking wounded (P3). 55 patients were categorized as seriously injured 667 walking wounded. Overall 20 of the 55 categorised as critical injured where found to be so and 349 of the walking wounded treated in field units or transferred to hospitals for further treatments (Aylywin 2005). The overall over triage rate was found to be 63%. (Lockey 2005)
However this does not give the whole picture. The London bombings where complex with multiply locations, a confusing scene with varying reports. There were four sites in total three underground and one on a bus, initial report from underground with patients emerging from both sides of the tunnel meant there was ‘eight separate incident scenes declared all requiring a full emergency response’( Aylwin 2005).
Due to this different emergency response teams reached different locations at different times meaning that over triage from some of the location was reported to be as high as 85% whereas scenes where HEMS were dispatched has a over triage rate as low as 33%.
However this over triage didn’t man that patients suffered, In London the over triage rate of 65% would mean that when compared with similar incidents the critical mortality rate would be expected to be of 25-30%. In London this was much lower at 15% but in London this ‘seems unrelated to over triage but rather to the deployment of trained, skilled , medical and paramedical staff working within their normal environment an scope of practice, providing rapid scene assessment and clearance while providing effective triage’ (Alywin 2005).
Overall the Response by London ambulance service was deemed successful and over triage was not seen as a detrimental to treatment of patients, it was shown immediate mortality can be reduced by rapid access, assessment and evacuation by an effective prehospital trauma system. (Alywin 2005) and that critical mortality is London was less than all previous mass casualty events.
(b) In the london bombing communications were extreamly difficult, The amount of conflicting information being received by the public was difficult to sort and manage, with multiply locations for incidents and varying amount of reported causilties made getting a clear picture of the incident difficult. The mobile phone networks then failed causing confusion amongst the public and further increasing difficulties in communication between service personal.
The AIRWAVES system used by the emergency services had only one AIRWAVE base radio stations at priority sub-surface tube stations maning that communication could be quickly become overloaded with traffic meaning failures in communications. It was also seen that there was a need for structure in the way communications are managed in a major incident situation, bronze commanders needing to take control rather than individual paramedics to reduce the amount of traffic and confusing information. Also control room response needs to manged effectively as the amount of information received by call takers and the responses initiated and manged by indervidual dispatches can be confusing making communication between staff on the ground and thoses in control difficult.
(c) Having accessed various sources of information including news reports corners’ inquest and testimonials by ambulance and fire staff the response by London ambulance staff was considered too slow, with poor communications and a lack of organisation.
There was a 52 minute delay in a response being sent to the Tavistock square incident were 13 people died as a result of a bomb blast on a bus. Paramedics were sent to the wrong location than waited a further 30 min for another resource. Half off London’s ambulances were not sent to the incident and kept back for further possible attacks, paramedics recalling how they watched events unfolding on television and were told not to respond. Paramedics were criticised by the coroner for a lack of basic life saving actions being carried out while performing triage and were hampered further by a lack of basic medical supplies to deal with causalities. Also the delay to incident involving possible live tracks should have not been an issue as this should have been dealt with instantly. Control room organisation and communications were heavily criticized for a lack of training, untrained staff being utilised in GOLD command roles, vital information being wrote on scraps of paper and the use of other private and volunteer ambulance staff being utilised who lacked any training in how to respond to a major incident hindering the response and trained staff sitting on ambulance stations.
I think that some of this criticism is justified a 52 minute response to a major incident scene is not acceptable and communication should and could have been better, both by paramedics on scene but in particular control rooms organisation of communications. It highlighted a need for further major incident training for staff particularly those first on scene and initiating a command role which has now been dealt with country wide with regular training and aid memoir major incident plans issued on every vehicle. I also agree that carrying out triage does not stop paramedics performing basic lifesaving manoeuvres such as open airway and apply CAT tourniquets. However the overall response by London ambulance service was considered good with people working extremely hard in difficult circumstances. The statistics shows a far lower critical mortality rate than was expected for such an incident and that highly trained individuals saved lives that day. The criticism of ambulances not being sent that were available to respond is a difficult one for the public and media to understand but I can see from LAS perspective that as well as the possibilities for further attacks other Londoners will still get ill from accidents and emergencies and they couldn’t commit all resources in one go. They will always be criticisms at such incident but LAS response was generally good lessons have been learnt and improvements implemented.
Activity 5.3 Scrutiny of emergency plans
The London Emergency services liaison panel plan is an overview and structure to highlight the responsibilities of agency’s working together in a major incident, In London these include the Metropolitan police, Fires service, London ambulance service City of London police, British transport police, HM coast guars and the port of London authority.
The plane breaks down the responsibilities into sections these include;
Major incident ( definition),Functions of emergency services, working together, scene management, command and control, co-ordinating groups, communicating systems, Casualties clearance, helicopter, Investigation, safety, other assistance,media liaison and public information, occupier response, debrief , welfare of responders
Having read through the various sections this provides an overview of what is expected of various agency throughout a response , It doesn’t go into specific detail how this should be implemented and seems a guidance to trust at a command level to then produce there own polices and instructions.
The report in its mantra, mythology and doctrine is very family to me. The trust I work for South western ambulance service utilise the same information in development of there own major incident plan. The structure of which is very similar to the one produced above with a focus on the trust responsibilities in providing healthcare. Both plans utilise the joint emergency service interoperability program JESIP, which is a common way of working to reduce harm and save life. It is categorised as an event or situation that requires a response under one or more emergency service major incident plans to operate. It has various key principles including Principle for joint working which include an agreed command structure (gold, silver and bronze), the joint decision model meaning commanders of different agencies work together and the use of METHANE as a common way of passing information.
The report also talks about triage and triage sieve and sort, the way communication should be handeld, the need for casualty clearing and evacuation and the resources that can be utilised to achieve this. However again it provides an overview and dictates what should be done but doesn’t discuss how this can be achieved and what this means for paramedics.
Where this information differs are key responsibilities as health care providers representing the NHS and our key strategic goals as health care providers which is
-Instigate command and control structure for NHS assets
-communicate information to hospitals
-transport to receiving hospitals
The London plan does not provide detail of what is expected of staff and how this will be achieved but the major incident plan from my trust does and references actions need to be taken by paramedic at scene with a aid memoire provide on each vechicle. The trust plan goes in much more depth about what is expected of indeviduals, how triage is achieved, the importance of correct command structure and the setting up of inner and outer cordons with various commanders in each post. Overall the trust policy is much more detailed in all aspects covered by the London plan but specific to ambulance responsibilities
Activity 6.1 Exploring the HPA site
This activity asked be to explore the HPA website. Unfortunately the website has been replaced by Public Health England and the link on the OU website redirects us to this site. The information is longer presented in the format suggested by the activity and I can no longer find all relevant information, However I did find the document ‘Initial investigation and management of outbreaks and illnesses of unusual illnesses-a guide for health care professionals’’ as such this activity is based on this.
STEP 1-2-3, When approaching a scene consider first action One patient treat as normal, Two patients have a low index of suspicion and approach with caution, Report to control on arrival at scene and keep them informed. Three or more patients treat as high index of suspicion, do not approach scene, withdraw, report to control, isolate oneself and send for specialist help
Key issues in response to a HAZMAT or CBRN incident
Ensure personal safety
Tell, and seek advice from, the HPA
Triage casualties and contaminated persons
Communicate with other emergency services and with other health professionals
Keep comprehensive records, in line with ambulance service usual practice
(Public Health England 2010)
Use of CHALETS or METANE assessment to pass information regarding incident to control, METHANE may be considered more detailed and appropriate in a HAZMAT or CBRN incident but it is important to remember that METHANE is the standard method in a major incident for joint working with other services.
Full PPE should be worn by trained staff when entering, what is considered as the warm and hot zone. No unprotected personal should cross the inner cordon of an incident. If a staff member comes into contact with a contaminated person, unprotected, they also must be considered a casualty.
Within the ambulance service we have the Hazardous area response team (HART) that are trained to deal with CBRN and HAZMAT incidents, they provide an enhanced ambulance response to the incident.
MERIT- Medical Emergency Response Incident Team. This is a team of multi agency trained medical professionals asked to attend an incident by the ambulance service to help deal with a CBRN incident usually provided by the local acute trust hospital.
Public Health England (2010) Initial investigation and management of outbreaks and incidents of unusual illness: Version 5.0 July 2010. Available at: http://webarchive.nationalarchives.gov.uk/20140714084352/http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1201265888951 (Accessed: 19 September 2016).
Activity 6.2 Reading of nancy caroline Chapter 48
Biological weapons are weapons that utilise microorganisms or toxins and include viruses and bacteria and neurotoxins to ‘deliberately inflict disease among people, animals and agriculture’. The use of these weapons is not new and various cases in history are evident one dating back as far as 14 centuries before Christ. With the use of diseased cattle to inflict disease on an opposing army.
However the current threat from biological warfare is very real with increasing understanding of infectious diseases and the devastation this can cause to the human population and a countries infrastructure, the likelihood of an attack continues to rise. The development of biological weapons with the freely available medical information is relatively easy when compared to nuclear technology. Even when ill conceived attacks with minimal causalities occur such as the anthrax attacks in the US in 2001, the ability of this to strike terror and fear into the population alone would be considered successful by terrorist groups.
How as Paramedics can we prepare?
Safety is paramount. There should be a high index of suspicion when dealing with any mass casualty event and if WMD is suspected paramedic must not rush to scene and must stand off ‘ uphill and upwind’ (Caroline 2007) The correct personal must be present to deal with such a threat. The greatest treat to a paramedic in such an event are from ‘contamination and cross-contamination’ (Caroline 2007) meaning you are now a casualty yourself and can no longer help the public.
The most important actions to be taken y a first responder is to establish communication with control, provide a METHANE report, trigger a major incident, establish a command structure and await specialist response from trained individual such as the HART team and SORT who are trained specifically in how to deal with CBRN incidents.
The biological threat
Biological weapons can be grouped into virus, bacteria and neurotoxins, they can be difficult to grow and maintain and many break down quickly when exposed to the environment some however can remain inactive for years such as anthrax. They can be spread by aerosols spraying into the air which could carry the agent for miles spreading across a large number of people and animals that when inhaled causes disease. Animals can be used as a vector to carry the disease such s mosquitoes and fleas. The water and food supply can be poisoned and of course the disease can be spread from person to person.
Viruses and bacteria require an incubation period and may take a period of hours or weeks for symptoms to develop, neurotoxins some of the most dangerous substances known to man can kill instantly but cannot replicate themselves and spread like bacteria or viruses.
Examples of biological weapons
-Anthrax-gram positive bacteria known as Bacillus anthracis, Naturally occurring it is found in soil and mainly effects animals but can cause disease in humans if contaminated animal meat is ingested however the weaponised version is in the form of a powder that when inhaled causes Pulmonary anthrax and causes severe respiratory distress and are ‘associated with a 90% death rate if untreated. Antibiotics can be used to treat anthrax infection and a vaccine is also available. It is not contagious.
-Plague- an infection caused Yersinia pestis, a gram-negative coccobacillus (medscape 2016) caused by fleas which feed on infected host, bacteria multiply eventually blocking the fleas foregut wit bacteria that when it attempts to feed again regurgitates clotted blood and bacteria into the victims bloodstream the person then becoming infected and the next host. Plague is characterized by high fevers and swollen and painful lymph nodes, If left untreated septicemia develops and a secondary disease known as pneumonic plague can develops which is much more contagious and means it can spread from human to human by respiratory route this has a mortality rate of 100 if left untreated. Patients should be isolated for this reason and treatment with antibiotics commenced. There is currently no vaccine.
-Smallpox a viral agent that is highly contagious and was a high cause of morbidity and mortality until recently due to vaccination it is an airborne virus that is environmentally stable and can remain infective for long periods. T multiplies in the respiratory tract. Symptoms include high fever headache, rigors malaise vomiting and abdominal and back pain, and pustules then develop. Death usually occurs within two weeks due to toxaemia. This is a high likelihood of being used as a biological weapon due to its infectious nature. A vaccine does exist was successful in eradicating smallpox from society. Treatments are mainly supportive.
-Viral haemorrhagic fever (Ebola, rift valley, yellow fever,) the most common being Ebola with recent outbreaks in West Africa. It is highly infectious and spreads by aerosol so are a likely biological weapon of choice. It is associated with a 52%-92% mortality rate. Characterised by general febrile illness and malaise, they target ‘vascular beds, causing micro vascular damage’ (medscape 2015) manifestations are diverse but can cause capillaries to leaks and massive oedema to occur. T can cause damage to al body systems and lead to death. Treatment is largely supportive and vaccines remain a current area of research and testing. Isolation and strict barrier nursing with full protective equipment is necessary
-Ricin- A plant protein toxin derived from the castor plant. It is one of the most toxic and easily produce plant toxin in the world, which makes it highly likely to be used as a biological weapon. Ricin is extremely toxic to cells as it inhibits protein synthesis. Route of admission is key to toxicity Inhalation is the most toxic and causes sudden onset nasal and throat congestion, coughing, chest tightness and dyspnoea after 24 hours it causes sever respiratory distress and death within 48 hours. Treatment is supportive and no vaccine is available.
-Botulinum Toxin, A gram-positive bacteria Clostridium botulinum produces the botulinum toxin and is one of the most lethal toxins known to man. Only a small level of exposure results in death. These toxins ‘bind to the presynaptic nerve terminal at the neuromuscular junction and cholinergic autonomic sites. This prevents the presynaptic release of acetylcholine and blocks neurotransmission’ (medscape 2015) this results in muscle weakness and paralysis, symptoms progress through descending paralysis and lead to respiratory failure. Treatment is positive and with proper respiratory support and ventilation the mortality rate is only 5% but complete recover is prolonged.
These agents can cause large-scale mortality, morbidity and can incapacitate a large number of people in the shortest possible time and have adverse effects on human health (Thavaselvam and Vijayaraghavan, 2010)
The world health organisation (WHO) continuously monitors disease outbreaks through the Global Outbreak Alert and Response Network
The Network has four main tasks:
(1) Disease intelligence and detection
(2) Verification of rumours and reports
(3) Immediate alert
(4) Rapid response
"Infectious disease intelligence, gleaned through sensitive surveillance, is the best defence" (Heymann and Rodier, 2001)
Science has potential for creating even more effective and horrific biological weapons. ‘Biological warfare events (BW) is widely regarded as the absolute perversion of medical science ‘(Onyenekenwa 2012). Knowledge on the production of biological weapons is freely available and experts in this field are not rare meaning terrorist networks could find them easier to replicate. There is a serious concern locally and globally at the likelihood of use of biological weapons by non-state-sponsored groups. ‘The threat that biological agents will be used on military forces and civilian populations is now more likely than at any point in all of history’ (Dire)
The impact of a CBR attack would depend heavily on the success of the chosen method and the weather conditions at the time of the attack. The first indicators of a CBR attack may be the sudden appearance of powders, liquids or strange smells within the building, with or without an immediate effect on people (Gov.uk 2015)
The current UK threat level is SEVERE which means an attack is highly likely
2016, C.C. (2016b) THREAT LEVELS. Available at: https://www.mi5.gov.uk/threat-levels (Accessed: 15 October 2016).
Caroline, N.L., Elling, B., Smith, M., American Academy of Orthopaedic Surgeons (AAOS) and American Academy of Orthopaedic Surgeons (2007) Nancy Caroline’s emergency care in the streets (Nancy Caroline’s). 6th edn. Sudbury, MA: Jones and Bartlett Publishers.
Chemical & biological weapons (2016) Available at: http://www.wmdawareness.org.uk/the-facts/chemical-weapons/ (Accessed: 15 October 2016).
Dire, MD, D.J. (2016) CBRNE - biological warfare agents: Historical aspects of biological warfare agents, delivery, dissemination, and detection of biological warfare agents, bacterial agents. Available at: http://emedicine.medscape.com/article/829613-overview?pa=GqL2fTKsVeTBSUO%2B61N1yUjEV5yMsk1NgNgtOJjmItxxnIS%2FSJrLqZTH9CrwdL2C56MI7dGTgNawPfsOtJla9Q%3D%3D (Accessed: 15 October 2016).
Heymann, D.L. and Rodier, G.R. (2001) ‘Hot spots in a wired world: WHO surveillance of emerging and re-emerging infectious diseases’, The Lancet Infectious Diseases, 1(5), pp. 345–353. doi: 10.1016/s1473-3099(01)00148-7.
Recognising the terrorist threat (2015) Available at: https://www.gov.uk/government/publications/recognising-the-terrorist-threat/recognising-the-terrorist-threat#chemical-biological-and-radioactive-threats (Accessed: 15 October 2016).
Onyenekenwa Cyprian Eneh , 2012. Biological Weapons-agents for Life and Environmental Destruction. Research Journal of Environmental Toxicology, 6: 65-87.
Recognising the terrorist threat (2015) Available at: https://www.gov.uk/government/publications/recognising-the-terrorist-threat/recognising-the-terrorist-threat#chemical-biological-and-radioactive-threats (Accessed: 15 October 2016
Thavaselvam, D. and Vijayaraghavan, R. (2010) ‘Biological warfare agents’, Journal of Pharmacy and Bioallied Sciences, 2(3), p. 179.
Patient assessment 2
Activity 3.1 More on 12 lead ECG’s
Correct lead placement is essential for correct analysis of a 12 lead ECG. A lead takes a specific view of the heart from a particular vantage point. It consists of six limb leads and 6 precordial leads. The limb lead takes views from the side and from the feet, the precordial from the front and left side of the heart.
ECG placement is critical not only to these views but also when comparing ECG’s.
When a current is moving towards a lead it creates a positive deflection on the ECG tracing for that lead. For that reason lead 2 should always be positive and AVR negative due to the opposite picture they impose.
When taking an ECG the patient should be: -
-Comfortable and not shivering
-Skin should be prepared, freeing it of hair and free from oil etc
-Limb leads connected ensuring correct placement
-Place precordial lead again ensuring correct placement
Rules regarding ECG include: -
-Lead 2 should always be positive and aVR negative
-ST segment starts isoelectric except in V1 and V2 were 1mm is acceptable
-PR interval should be between 120-200ms
-QRS complex should not exceed 110ms
-QRS and T waves have the same direction in the standard leads
-The R wave in the precordial leads grows from V1 to at least V4
The QRS is upright in lead 1 and 2
-The P wave is upright in lead 1 and 2 and V2-V6
-There is no Q wave in leads 1, 2 V2-V6
-The T wave is upright 1,2 and V2-V6
The most important aspect in prehospital care of 12 lead ECG finding is identification of AMI, For this reason the most important aspect of the ECG for us to focus on is The ST segment, the Q wave and the T wave. The 12 lead ECG however cannot fully determine if a patient is suffering from AMI, changes may take hours to develop and for that reason clinical presentation is key.
Activity 3.3 Understanding lead 2 ECG’s
-Normal appearance of cardiac ccle
-slow rate below 45b/min
-waves appear normal
ECG appears normal just increased rate above 100 b/min
P wave before every QRS unless rate so fast ir hides it
PR interval shortend
QT interval shotenened
Also known as narrow complex tachycardia
Regular but fast rate 150-250 bpm
P wave merged with T wave
P waves are absent
QRS and T wave normal
QRS complexes are Irregular Ireggular due to random timimng od impulses reaching AV node
Rate and Rthym normal
P wave replaced by F waves
2-4 F waves before QRS complex giving saw tothed apprearence
First degree heart block
Prolonged P-R interval above 0.20 sec
Rate and rhythm of heart normal
Every P wave is followed by QRS complex
QRS and T waves are normal
Second degree heart block
Not every P wave is followed by a QRS complex
Wveforms usally normal shape ad duration
Mobitz type 1-PR interval lethens until a QRS complex is dropped, then repeats
Mobitz type 2-Tere is a constinant prlonged PR interval in QRS complex, and QRS is dropped in a regular pattern.
Third degree heart block
Complete dissosiation between P waves and QRS complex
P waves are normal
Slow ventricular rate but regular
Decresed blood pressure
Chotic electric activity
No contraction of ventricles
No cardiac output
Leads to Death
Left bundle branch block
QRS complexes are prolonged and bizarly shaped
Abnormal T wave
Amplitude of qrs complex increased
Noraml PR interval
Normal rate and rhythm
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ECG appears normal