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The best way to determine effective Paramedic prac- so on, for support of paramedic practice. tices is to look at those practices from a scientifi c vantage. A literature search for research pertaining to shared prac- Use of the scientifi c method, the acquisition of knowledge tice issues (e.g., safety in medication administration) may through objective observation and considered reasoning, cor- reveal previous clinical research on the subject that could rects previous misconceptions and integrates new conceptual potentially be applied to the practice of paramedicine. frameworks for Paramedic practice.2 The application of the Similarly, Paramedics can look to the research of other scientifi c method will lead to the improvement of patient professions, such as business and education, for evidence- care. based practices. For example, operational issues, such as For example, scientifi c research created the paradigm effective human resource allocation, have already been shift in trauma care that concludes that limited resuscitation researched by hospital administrators and major businesses. (i.e., permissive hypotension) may be more advantageous Unfortunately, these studies can suggest solutions that to the patient than previously thought. Also, in the past it are impractical in the out-of-hospital setting or are cost pro- seemed logical that survival chances for trauma patients were hibitive for EMS. Furthermore, the practice of out-of-hospital increased by replacing blood loss with intravenous solutions care is unique in many cases and there may be no analogous in a 3:1 ratio. Well-designed studies have demonstrated the studies from other allied health professions to draw upon. fallacy of that thinking and Paramedics have adjusted their The best support for Paramedic practice is research done in trauma care accordingly—saving lives in the process.3,4 the prehospital setting, by Paramedics, physicians, and others While every EMS call can be unique, the purpose of sci- interested in advancing prehospital patient care. Details on entifi c EMS research is to establish a Paramedic practice that how to start EMS research follows shortly. 58 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Performing a Literature Search Most medical libraries, and many university libraries, The fi rst step in utilizing research to create evidence-based have a reference librarian. The reference librarian is trained practice is to ask key questions. These key questions should in research techniques and can help the Paramedic develop a focus on topics that are important to the Paramedics’ practice. search strategy to identify which articles will be most helpful. An example of a question is: “Does pediatric intubation by Paramedics improve patient outcomes?” Reviewing the Literature After deciding on the question, the Paramedic should After obtaining relevant research articles, the Paramedic perform a search of the current literature that is available on needs to identify the kind and type of research that was per- the topic of interest. By reviewing the published reports of formed in the study. research, called the literature, the Paramedic may fi nd stud- Currently, the most common kind of EMS research in the ies on the topic or studies that ask a question that is similar to literature is retrospective research. A question is raised and the question at hand. Paramedics look at past practice patterns, typically from doc- High-quality EMS research, when completed, is pub- umentation on the patient care reports, to determine effective lished in various academic journals or works. Unlike the versus ineffective practice. popular press, these journals are peer reviewed.8–11 Retrospective data analysis is often used in performance A peer-reviewed journal accepts submissions for publi- improvement. The danger of retrospective studies are the cation and circulates them to other experts in the fi eld for numerous variables involved in the particular patient sce- inspection and critical analysis. This process is called refer- narios that could account for the patient changes and which eeing. This intradisciplinary review provides readers with a are not controlled. For example, if the rate of ventilation in a degree of confi dence that what they are reading meets the cardiac arrested patient treated by Paramedics is being mea- profession’s standards and is a scholarly work. sured, how does the researcher know that every Paramedic However, even when a work has been properly vetted counts respirations the same way or that every Paramedic there may still be some errors. In medicine the saying goes, even counts respirations, perhaps leaving out the respiratory “One study does not make a practice.” It is important that a rate in the documentation by stating that manual ventila- Paramedic carefully read the entire study to see if the same tion was performed with a bag-valve-mask assembly? As a conditions exist in his or her system such that the study results result, randomness could be an explanation for the results. can reasonably be applied to that practice. Data dredging (data mining) is conducting research The most effective means of performing a literature search without a scientifi c question in mind (i.e., without a pre- is a computerized search. The most inclusive search engine for defi ned hypothesis). The application of mathematical tests of medicine is the electronic search engine called MEDLINE, “statistical signifi cance” to data and trying to observe pat- formerly the paper “Index Medicus®.” MEDLINE provides a terns in that data, and then attempting to form a cause and list of most published medical research that is searchable by effect conclusion, is not scientifi c research.16 key words or medical subject headings (MeSH).12–15 The most scientifi cally valid research is prospective Other research search engines that can also be used include research. In prospective research, an attempt is made to PubMed, a search engine of the National Library of Medicine account for all predictable or known confounding variables, (http://www.ncbi.nlm.nih.gov/pubmed/); the Cumulative to control those variables, and then add a treatment. If change Index to Nursing and Allied Health (CINAHL – http://www occurs then it may be reasonable to conclude that the treat- .ebscohost.com/cinahl/); as well as the Educational Resources ment may have caused that change. Information Center (ERIC – http://www.eric.ed.gov/). Even a The gold standard for research is the double-blinded ran- search of popular search engines like Google® scholar can be domized clinical trial (RCT).17,18 This technique is a prospec- helpful. tive scientifi c study that controls known and unknown variables Hypothetically, a Paramedic could fi nd dozens of cita- (which could result in spurious results), leaving only one vari- tions on a subject, especially if the key words have broad able to be manipulated. Subjects are then chosen at random to application, like the subject of pediatric intubation. be included in either the experimental treatment group or in To separate the “wheat from the chaff,” the Paramedic the control group (the control group receives standard treat- should review the research study’s abstract. The abstract ment). The key is that the treatment group, those who receive is an abbreviated “executive” summary that hits a study’s the experimental treatment, are subjects chosen at random.19 highlights. The results of the treatment of the experimental group After reading the abstracts, and eliminating non-related subjects is then compared to the results of the control group. articles, the Paramedic should take the reduced list of studies Ultimately a conclusion is drawn. and review the studies directly. With the reference informa- The use of statistically equivalent groups (i.e., patient pop- tion (i.e., author’s name, journal name, journal volume num- ulations having all the same characteristics [variables] except ber, and research title) in hand, the Paramedic may elect to the one being tested) lends credence to the claim that the pro- either go directly on-line to read the article or proceed to a cedure/medication/and so on worked as predicted and did not medical library. occur as a result of random chance or some other variable. Research and EMS 59 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Clinical Trials utility in a case study may be the development of theories of In a clinical trial (i.e., experimental medical research), sub- causation, leading to further research. jects are assigned at random to either the treatment group or There is precedent for case reports, such as case law. Case to the non-treatment group (i.e., those receiving standard care law has been used for hundreds of years to support decisions [control group]). which are based on decisions made by an earlier court. Like To limit bias, the participants may not be aware of which case law, case reports may be used in a court of law, or by a treatment group they are in. In a single-blind study, the sub- Paramedic in front of a medical director, to defend a decision ject does not know which group he is in. In a double-blind in a highly unusual circumstance.27 study, both the researcher and the participants are unaware of In dealing with instances of rare diseases, such as Ebola which group the subject is in.17,20,21 virus, or an exceptional event, such as a plane crash, the case Research often uses inactive drugs, called placebos, report may be the only means of educating other Paramedics or ineffective devices, called shams, that appear similar to as to the nature and scope of the atypical problem. the actual drug or device in order to create blinding for the Another example of descriptive research is a cross- participants.22–24 sectional survey. The cross-sectional survey is essentially a snapshot of a certain aspect of a population at a given moment Statistical Evidence in time that the researcher is interested in. It is obtained by means of observation, usually utilizing a written tool such The key to utilizing experimental research is to understand as a survey. A cross-sectional survey can look at a specifi c the statistical methods used to either confi rm the hypothesis population and a specifi c disease, for example. or reject it. The National Health and Nutrition Examination Survey Classical hypothesis testing compares the results of two (NHANES) conducted by the Centers for Disease Control treatment groups, statistically, in order to obtain a degree of and Prevention has established the prevalence of obesity in confi dence that the treatment actually caused the effect. the United States and might be used to help support the deci- Always skeptical, the researcher’s fi rst assumption is that sion to purchase a bariatric ambulance. By using an analysis the effect was not caused by the treatment but rather by ran- of a cross-sectional survey, Paramedics can use the preva- dom chance. With this assumption that the null hypothesis lence of certain diseases, conditions, and so on, to determine is true (i.e., the treatment did not cause the desired effect but operational, medical, and educational priorities. rather random chance could account for the change), the prob- The results of a cross-sectional survey of one popula- ability is calculated. The probability of random chance causing tion may not be applicable to another patient population. the changes, rather than the treatment, is called the p value. Furthermore, any descriptive study, like the cross-sectional An acceptable p value is arbitrarily assigned by the researcher survey, does not prove a cause and effect relationship between prior to the start of the study and is symbolized as . various variables. The calculated p value is then compared to the selected . The fi nal descriptive study is the ecological study, also If the p value is less than the value, the alternative hypothe- sis is accepted, and is considered “statistically signifi cant.”25 called a correlational study. This type of research design serves to provide information about trends and rates of dis- Traditionally, in the medical community values of 0.05 ease within a population. Often cited
as X number of cases are considered the standard for probabilities.26 In other words, of Y disease per 1,000 or per 100,000 of Z population, the if the p value in a study is less than 0.05 then this result may ecological study results are often quoted to emphasize the be considered to mean that the treatment caused the intended prevalence of a disease and therefore the need for research effect and that the researcher is willing to accept the notion grants or funding for special projects. that there is a 5% chance that the improvement in outcome occurred by random chance. Observational Studies The observational study, in contrast to the descriptive study, Types of Research asks a question and poses a simple explanation or hypothesis. To have a scientifi cally valid result from an observational Generally, research can be broken down into three types: study, it is necessary to control extraneous confounding vari- descriptive studies, observational studies, and experimental ables that could account for the desired change. studies. One such method of observational study is the case- control study. In the case-control study, the Paramedic would Descriptive Studies compare the cases—those patients with the disease—to The descriptive study simply states the prevalence of a con- the controls—those patients without the disease—and then dition and is often illustrative of a problem, without trying to examine the procedures performed on both to see if there was offer an explanation. an association between outcomes. A case report or case series is an example of a descriptive For example, a case-control study might look at both study. By reporting interesting or unique cases, Paramedics patients who died and those who survived a cardiac arrest to can help other Paramedics gain insight into a problem. The see if there was a difference in the medications administered 60 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to the surviving patients that could have made a statistical For example, an ST segment elevation on an electro- difference (i.e., not attributed to chance). cardiogram (ECG) tracing suggests myocardial infarction. Similar to a case-control study, a cohort study examines However, some African Americans have naturally occur- patients who have been exposed to a treatment and compares ring ST segment elevations on their ECG tracing. To state to them to a group that was not exposed to the same treatment. an African American male that this elevated fi nding was sug- The patients are followed to determine outcomes. gestive of a myocardial infarction would be a false positive. For example, a group of patients (such as pediatric One cause of a false negative is the limitations that a study patients) would be divided into two groups—intubated ver- group’s size places on the experiment. The number of partici- sus not intubated—and then a review of outcome data (i.e., pants in a treatment group, abbreviated N, may not be large the patient care report) would be analyzed to determine if one enough for the statistical difference to become evident and sup- group had a statistically better outcome. port the alternative hypothesis. This should not be interpreted to mean that the opposite is true (i.e., that the null hypothesis Experimental Studies is true). Instead, the evidence may have been inconclusive. Classic research starts with a suggested explanation why The results of small studies should be viewed as suspect something occurs or could occur. For example, a hypothesis and lacking power. The power of study (i.e., the ability to might be that administration of oxygen to cardiac patients attribute the changes to the treatment rather than chance) is improves long-term survival for cardiac patients. increased whenever there is an increase in the number of sub- With the hypothesis in mind, the researcher uses the jects (i.e., sample size) in the study. experiment to test, under controlled conditions, if a treatment created the predicted change. Meta-Analysis When considering the results of the research, the In some cases it is diffi cult to obtain a large population of researcher understands that there can be two plausible expla- study subjects, or the event being studied is relatively rare. To nations why the change occurred. The fi rst explanation is overcome the problem of reduced statistical power, a meta- that the treatment did not create changes (i.e., any changes analysis may be performed. are purely random and coincidental). This hypothesis is In a meta-analysis, the results of several similar small called the null hypothesis. An alternative hypothesis, that studies are combined and a statistical hypothesis test is the treatment is a plausible explanation for a change, is also applied. Of course, differences in subjects and methods used considered. in the individual studies must be taken into account before a Then a statistical test is applied to the outcome data to conclusion can be made.29 For the results of a meta-analysis to determine which hypothesis is most likely correct. The results be considered valid, it is important that the original research of the statistical analysis either support the null hypothesis or studies are methodologically sound. the alternative hypothesis. Prehospital Research Errors in Research Contributing to prehospital research can be as easy as being A common error made in an experiment is to reject the null willing to participate in the study. While the person doing the hypothesis and accept the alternative hypothesis when in fact lion’s share of the data collection and analysis is usually cited it is not supported. This is called a type I error. as the lead author, it takes a team to accomplish the goal. A type I error, also called a false positive, assumes a treat- Studies can be as simple as a descriptive study or as ment effect where none exists. An example of a false positive complex as a double-blinded randomized clinical trial. would be the assumption that the administration of oxygen In every case participants in a study should carefully con- to a patient with carbon monoxide poisoning increased the sider the study’s hypothesis before committing to making a patient’s oxygen saturation. contribution. Alternatively, incorrectly failing to reject the null hypoth- At its core, every research project should minimally “do esis is called a type II error, or a false negative. A type II no harm” and should reasonably be expected to improve error is a failure to observe the change created by the treat- the patient’s condition.30 If it is lacking either of these two ment when one did occur.28 qualities, the study should be considered suspect and perhaps An example of a type II error might be ascertaining a unethical. patient’s blood sugar was low and concluding that treatment Such a critical review of every clinical trial is consistent is required and subsequently administering glucose, when in with the Paramedic’s ethical responsibility for benefi cence fact the glucometer is out of calibration and producing erro- toward patients.31–33 neous low readings. In terms of patient care and test results, a false nega- Ethical Concerns tive would give patients false reassurance that treatment was The world was witness to the atrocities carried out in Nazi effective while a false positive may either lead to a wrong concentration camps, including the inhumane medical stud- conclusion or may ignore that the patient’s condition could ies that were performed, allegedly in the name of science. have an alternative explanation. Following the exposure of these medical studies, during the Research and EMS 61 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Nuremberg trials at the end of World War II, the world scien- is comprised of individuals who are not directly involved in tifi c community adopted a set of ethical research rules called the research and who can make an objective decision based the Nuremberg code. on the merits of the data. The Nuremberg code is a set of guiding principles that limit the scope and nature of experiments using human subjects.34–36 The United States government, using the Institutional Review Board 10 principles of the Nuremberg code, created the National To protect the rights of patients, and to protect patients from Research Act of 1974. This act, found in the Code of Federal unscrupulous researchers, proposals for research are typi- Regulations Title 45 Volume 46, speaks to three themes. cally evaluated by an Institutional Review Board (IRB). An The fi rst theme is the respect for the person’s freedom IRB is an independent ethics committee that is tasked with and dignity as manifested by informed consent. Implicit in ensuring that human rights are not violated and the standards that respect is the patient’s right to make an informed choice of medical research are upheld. as to whether to participate.37–39 An IRB review is mandatory for any federally funded In the past, some convicted criminals would be granted research. The activities of these IRBs are monitored by the privileges or even amnesty if they were willing to partici- Offi ce of Human Rights Protection of the Department of pate in questionable research. By the nature of incarceration, Health and Human Services (HHS).43,44 these individuals could not reasonably be expected to make an informed decision that was free of coercion. Emergency Circumstances The second principle actually speaks to the problem of In some cases, such as during an emergency, it would be imprac- diminished autonomy. Any person who is mentally incapable tical to obtain informed consent from either the patient or a of making an informed decision (e.g., by virtue of age or infi r- legally authorized representative (such as a healthcare proxy, mity) could not willingly consent to participate in research if one was available). Recognizing this problem, the United (21 CFR 50.24). For example, a child could not consent to States Code has an emergency exception (21 CFR 50.24). participate in a study by virtue of age. However, a parent may This exception for patient consent has been applied to make the decision whether the child can participate. This is numerous clinical trials. If a patient is incapable of consent- known as substituted judgment. The concept is that a respon- ing due to the medical condition, a form of consent similar to sible person is substituting her judgment for the child. The implied consent may be utilized. parent might determine that if the child had the ability to con- Regulations currently require that the public be informed, sent and understood the potential good that could come from through various mechanisms of disclosure such as newspa- such research, the child would agree to participate. per advertisements or television spots, of clinical trials. This The third principle of ethical research deals with disclosure attempts to establish informed consent before the the question of justice. In other words, one group of people emergency and advise the population of their right to refuse should not bear all the risks of research when the benefi ts to participate in the research. of said research would benefi t all persons in the larger society. The Tuskegee syphilis project would be an example of injustice in research.40–42 In the Tuskegee research, poor Professional Paramedic African American males who contracted syphilis were observed to determine how the disease progresses. This con- The professional Paramedic should read more about tinued even after antibiotics were developed that could have cured the participants and prevented signifi cant complications these concepts in the Belmont Report, written by the of syphilis. National Commission for the Protection of Human Research should not be permitted to begin or continue if Subjects of Biomedical and Behavioral Research in researchers reasonably believe that death or permanent dis- ability could occur. In every
instance, sensible safeguards 1979 (available at http://ohsr.od.nih.gov/guidelines/ should be in place to prevent injury and protect the patient. belmont.html). Part of this obligation is a willingness to terminate the clinical trial if it can be shown that continuation of the experi- ment could cause more death or disability than pre-existing standard treatments. Economic Research Conversely, if patients receiving the experimental treat- Some professional practice questions do not directly involve ment are showing marked improvement over those receiving patient care but rather matters of operational effi ciency or standard treatment then standard treatment must be stopped cost. Again, research can help to answer the questions. and the new experimental treatment offered. These research designs are called economic analysis. To ensure this last standard, many clinical trials have a The classic economic analysis is the cost-benefi t ratio. A Data and Safety Monitoring Board (DSMB). The DSMB simple cost-benefi t analysis asks the question of whether it is 62 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. advantageous (i.e., cost-effective) to take a particular action encourages introspection and courage—the courage to or make a change in a procedure. accept change. Business has many statistical methods of determining By questioning current practices, the Paramedic avoids cost-effectiveness. These same methods can often be applied paradigm blindness. Paradigm blindness can be summed to EMS. up by the phrase “because we have always done it this way.” Paradigms can sometimes become barriers to innovation Absence of Research and improvement. Lacking good research to support a practice or procedure, Best practices, by defi nition, speak to improvement— Paramedics often turn to what is referred to as best practice. improvement of self and the profession. This concept, A best practice, a term borrowed from business, suggests continual self-improvement, is best represented by the that one method of delivering care is the most effective, and Japanese concept of kaizen. Kaizen is not only a business therefore a superior, means of providing care.45 principle but a professional attitude for Paramedics. The use of best practices has two distinct advantages. Kaizen emphasizes process and system thinking. Kaizen First, it requires a comparison of one Paramedic’s practice is evident when Paramedics participate in performance against the practice of others. This head-to-head comparison improvement committees and multi-agency planning. Research and EMS 63 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. For Paramedics to attain and maintain professional status in the healthcare industry, it is important to continually ask the question, “Does what we do really help?” Paramedics must be prepared to change fi eld practice as evidence, borne of research, demonstrates new and improved means to improve patient care. Key Points: • Paramedic practice, protocols, and procedures research examines past practice patterns originated from anecdotal experience. By relying to determine effective versus ineffective solely on pattern recognition or “common practices. Though useful, the reliability of sense,” Paramedics ultimately practiced retrospective studies is limited due to the defensive medicine. The use of the scientifi c numerous variables that may be present but method to acquire scientifi c-based information are not accounted for. has helped to correct previous misconceptions and integrate new conceptual frameworks into • By accounting for predictable or confounding Paramedic practice. variables, prospective research is the most scientifi cally valid type of research. The gold • Paramedics and medical directors are moving standard for research methodology is the double- forward from anecdotal-based procedures and blinded randomized clinical trial. This method protocols toward evidence-based practices. provides a high degree of scientifi c validity These practices are proven to be logical, because only one variable is manipulated. independently evaluated, applicable to a number of same or similar circumstances, and • In clinical trials, the control group is given a are the most effective means of delivering placebo or sham, while the experimental group improved patient outcomes. Advantages of is given the actual treatment. A statistical evidence-based practice include more cost- analysis can then be applied to the data to effective practices by quantifying how effective evaluate whether the treatment caused the certain practices are in delivering patient care. desired effect or if the effect occurred by The fi rst step in moving toward evidence-based chance. The p value is assigned to provide practice is searching existing research of other statistical evidence that a treatment had the allied health professions by performing a literature desired effect(s). search. • Generally, research can be broken down into • In performing a literature search, the fi rst step three types of research: descriptive studies, is to ask a question important to the Paramedic observational studies, and experimental practice. Reviewing abstracts can narrow your studies. search for a specifi c topic. Because “one study does not make a practice”, it is important that • Descriptive studies are studies that involve several studies relating to a topic be reviewed. close or focused examination of a condition or A computerized search of peer-reviewed academic problem that exists. Though not critical of asking journals provides the greatest access to past “why,” or offering an explanation, descriptive research as well as the most current information studies work to gather valuable and relevant available. information about the condition or problem at hand. Found in case law, case reports offer insight • Retrospective studies are the most common type into a problem through discussion of a particular of research found in EMS literature. This type of event or occurrence. 64 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • Further descriptive studies include cross-sectional several similar studies and applying a statistical surveys. Often utilizing a written tool, such as a hypothesis test for the variable being studied. survey, data is collected to investigate a specifi c idea. Cross-sectional surveys have the benefi ts of • Outlined in the National Research Act of 1974, the examining specifi c populations or diseases that can U.S. government established three principles that be applied to a local or national level. address ethical concerns of scientifi c research. The principles exist to protect participants against • Often called a correlational study, an ecological inhumane and unethical practices. study serves to provide information by objectively examining trends and rates. By gathering and • The fi rst principle outlines the importance for any analyzing data or reports, both cross-sectional and study participant to be informed about the study’s ecological studies can provide powerful statistics to hypothesis so as to make an informed choice as to support a scientifi c question. whether to participate or not. • Observational studies ask a simple question or • The second principle addresses the problem of hypothesis and account for variables in the diminished autonomy or the ability to consent. topic of study. Normally in a case-control study, A participant may not be able to willingly consent two or more specifi c groups are compared (for example, due to age, infi rmity, or mental and analyzed. A researcher would examine ability). the procedures (for example, to identify any • The third principle speaks to maintaining justice similarities or differences that can be associated for the participants. The idea of fair treatment between group outcomes regarding a particular for both the control and experimental groups is situation or condition). A cohort study is similar in outlined. To ensure justice is upheld, many methodology; however, instead of examining the clinical trials have Data and Safety Monitoring treatment or procedures used in specifi c cases, Boards. These boards take an objective approach a specifi c population is analyzed for statistical to evaluating the merit of experimental signifi cance of treatment. methodology and data collected. In the case • of any federally funded research and for most All scientifi c studies essentially begin with a other research projects, even before research question. In an experimental study the investigation begins a proposal must be submitted to an is focused on answering why something occurs or Institutional Review Board. This independent could occur. Null and alternative hypotheses are ethics committee reviews the proposal for any always formed and variables are limited to the one violations of ethics. variable being manipulated. • • Professional practice questions do not always If the alternative hypothesis is accepted but is not involve patient care, but can be used to perform supported with suffi cient scientifi c evidence, a type economic research. This research provides I error or false positive result occurs. In contrast, valuable information through cost-benefi t a failure to observe a change may lead to a false analysis. negative or type II error. This may be caused by a limited sample size or may occur in a study that has • In the absence of research, Paramedics turn to best a low statistical power. practice as a way of determining the best method • or most effective way of providing patient care. To be confi dent the data represents changes due to the manipulated variable, (for example, • Best practice encourages the comparison of treatment) and not simply because of chance, practices against others as well as encouraging the a larger sample size must be studied. One way examination and constructive criticism of current researchers overcome this is by performing a meta- practices. Questioning one’s own practice helps analysis. This is done by combining the results of one avoid paradigm blindness. Research and EMS 65 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. What are the three origins of EMS practice? 8. What are type I and type II errors in 2. What are the steps to the scientifi c method? experimental research? 3. Describe the process of creating an evidence- 9. Explain the ethical concerns and what should based practice. be done to safeguard participants of clinical 4. Explain how to perform a literature search. trials. 5. What are the types of research and how do 10. Describe the advantages of a double-blinded they differ? randomized clinical trial. 6. What are the pitfalls of retrospective data analysis? 11. How can researchers overcome the problem 7. What type of information is discovered by a of reduced stat power? researcher from descriptive studies? 12. What is best practice and what are its advantages? Case Study Questions: Please refer to the Case Study at the beginning in favor of an MFI protocol for diffi cult airway of the chapter and answer the questions below: management. However, after several months an 1. Looking back at the task given, investigating the important question was brought up about the effectiveness of MFI in the prehospital setting, use of one of the medications in an MFI as it was would retrospective or prospective research not statistically used very much. How would you studies be more helpful? design a research proposal for an experimental 2. Contacting other agencies and speaking with study that would evaluate this question? personnel is much different than gathering 5. What
is the argument behind the statement, information via published reports. What is the “One study does not make a practice”? difference between the two? 6. What are some questions that you should have in 3. What errors in research would you have to be mind when evaluating the validity or reliability of aware of when researching to ensure reliability a research study? and validity? 7. Evaluate the importance of obtaining an 4. You presented your research and both the objective review of research studies methodology medical director and QA/QI committee are concerning ethics. References: 1. Theodoridis S, Koutroumbas K. Pattern Recognition (3rd ed.). 4. Dubick MA, Atkins JL. Small-volume fl uid resuscitation for the Boston: Academic Press; 2006. far-forward combat environment: current concepts. J Trauma. 2. Gauch H. Scientifi c Method in Practice. Cambridge: Cambridge 2003;54 (5 Suppl):S43–S45. University Press; 2003. 5. Johnston S, Brightwell R, et al. Paramedics and pre-hospital 3. Mackinnon MA. Permissive hypotension: a change in thinking. management of acute myocardial infarction: diagnosis and Air Med J. 2005;24(2):70–72. reperfusion. Emerg Med J. 2006;23(5):331–334. 66 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 6. Mason S, Knowles E, et al. Effectiveness of Paramedic 29. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control practitioners in attending 999 calls from elderly people in Clin Trials. 1986;7(3):177–188. the community: cluster randomised controlled trial. BMJ. 30. Department of Health and Human Services’ Part 46 Protection of 2007;335(7626):919. Human Subjects [see 46.116, (a),(3)]. 7. Davis DP, Peay J, et al. The impact of aeromedical response to 31. Pitkin RM, Branagan MA. Can the accuracy of abstracts be patients with moderate to severe traumatic brain injury. Ann improved by providing specifi c instructions? A randomized Emerg Med. 2005;46(2):115–122. controlled trial. JAMA. 1998;280(3):267–269. 8. Gitanjali B. Peer review—process, perspectives and the path 32. Pitkin RM, Branagan MA, et al. Accuracy of data in abstracts of ahead. J Postgrad Med. 2001;47(3):210–214. published research articles. JAMA. 1999;281(12):1110–1111. 9. Van Rooyen S, Godlee F, et al. Effect of blinding and unmasking 33. Al-Marzouki S, Evans S, et al. Are these data real? Statistical on the quality of peer review: a randomized trial. JAMA. methods for the detection of data fabrication in clinical trials. 1998;280(3):234–237. BMJ. 2005;331(7511):267–270. 10. Jefferson T, Wager E, et al. Measuring the quality of editorial 34. Weindling P. The origins of informed consent: the peer review. JAMA. 2002;287(21):2786–2790. International Scientifi c Commission on Medical War 11. Jefferson T, Rudin M, et al. Editorial peer review for improving Crimes, and the Nuremburg code. Bull Hist Med. 2001; the quality of reports of biomedical studies. Cochrane Database 75(1);37–71. Syst Rev. 2007;2:MR000016. 35. Marrus MR. The Nuremberg doctors’ trial in historical context. 12. http://www.nlm.nih.gov/medlineplus/ Bull Hist Med. 1999;73(1):106–123. 13. http://www.ncbi.nlm.nih.gov/sites/entrez 36. Annas GJ, Grodin MA. The Nazi doctors and the Nuremberg 14. http://scholar.google.com/ code: relevance for modern medical research. Med War. 15. http://www.emedicine.com/ 1990;6(2):120–123. 16. Smith GD, Ebrahim S. Data dredging, bias, or confounding. BMJ. 37. Fisher JA. Procedural misconceptions and informed consent: 2002;325(7378):1437–1438. insights from empirical research on the clinical trials industry. 17. Lachin JM, Matts JP, et al. Randomization in clinical trials: Kennedy Institute of Ethics Journal. 2006;16(3):251–268. conclusions and recommendations. Control Clin Trials. 38. Palmer BW, Savla GN. The association of specifi c 1988;9(4):365–374. neuropsychological defi cits with capacity to consent to 18. Eddy DM. Practice policies: where do they come from? JAMA. research or treatment. J Int Neuropsychol Soc. 2007; 1990;263(9):1265, 1269, 1272 passim. 13(6):1047–1059. 19. Rosenberger W, Lachin J. Randomization in Clinical Trials. New 39. Evans K, Warner J, et al. How much do emergency healthcare York: Wiley-Interscience; 2002. workers know about capacity and consent? Emerg Med J. 20. Day SJ, Altman DG. Statistics notes: Blinding in clinical trials 2007;24(6):391–393. and other studies. BMJ. 2000;321(7259):504. 40. Thomas SB, Quinn SC. The Tuskegee Syphilis Study, 1932 to 21. Friedman L, Furberg C, Demets D. Fundamentals of Clinical 1972: implications for HIV education and AIDS risk education Trials. Berlin: Springer; 1998. programs in the black community. Am J Public Health. 22. Weihrauch TR. Placebo effect in clinical trials. Med Klin 1991;81(11):1498–1505. (Munich). 1999;94(3):173–181. 41. Katz RV, Kegeles SS, et al. The Tuskegee Legacy Project: 23. Kienle GS, Kiene H. The powerful placebo effect: fact or fi ction? willingness of minorities to participate in biomedical J Clin Epidemiol. 1997;50(12):1311–1318. research. J Health Care Poor Underserved. 2006;17(4): 24. Harrington A. The Placebo Effect. Cambridge: Harvard 698–715. University Press; 1999. 42. http://www.cdc.gov/tuskegee/timeline.htm 25. Weinberg CR. It’s time to rehabilitate the p-value. Epidemiology. 43. Belmont Report: Ethical Principles and Guidelines for the 2001;12(3):288–290. Protection of Human Subjects of Research. Federal Register 26. Whitley E, Ball J. Statistics review 4: Sample size calculations. Document 79-12065. Crit Care. 2002;6(4):335–341. 44. Bankert E. Institutional Review Board. Boston: Jones & Bartlett 27. Sinclair M. Precedent, super-precedent. George Mason Law Pub; 2005. Review (14 Geo. Mason L. Rev. 363), 2007. 45. Bodmer W. Principles of scientifi c management. FASEB J. 28. Singh G. A shift from signifi cance test to hypothesis test 1993;7(9):723–724. through power analysis in medical research. J Postgrad Med. 2006;52(2):148–150. Research and EMS 67 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. As a Paramedic, the public as a whole and each individual patient and family entrusts us with their lives to care for them appropriately. Some situations provide dilemmas for the Paramedic, whether it is with a patient, family member, partner, supervisor or medical director. A strong sense of ethics as well as following accepted ethical and legal practices helps allow the Paramedic to maintain the trust and privilege that is placed in us by society. • Chapter 5: Ethics and the Paramedic • Chapter 6: The Law and Paramedics 69 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Conduct and responsibility derived from guiding principles as well as cultural and religious beliefs • Duty-based ethics founded on principles, not consequences • Bioethics and their application to day-to-day decision making • The idea of what is “right” • Awareness of patient dignity, privacy, and autonomy • Understanding how ethical principles, and their proper application, can help resolve ethical dilemmas Case Study: The Paramedics were called to the home of a 43-year-old man with a history of lung cancer. He was semiconscious with labored breathing. His ex-wife produced an advanced directive stating that he did not want extraordinary means to keep him alive. His mother produced a handwritten will that stated he would accept oxygen and pain medication and any means to deliver them. Many family members were present and they began taking sides and telling the Paramedics what to do. 70 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Ethics and the Paramedic 71 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Although it is easy to think that the Paramedic operates solely on protocols and guidelines, without thought to real human consequences, a Paramedic’s clinical decision making also has a strong ethical component. This chapter evaluates the question of what is “right,” versus what is “correct” and draws from two ethical models of decision making. The Paramedic’s decisions must also follow established human and legal rights and moral obligations. Paramedics may be asked to apply ethical principles to real life ethical concerns such as end-of-life decisions. To make educated and responsible clinical decisions, the Paramedic should have a well-rounded understanding of the EMS code of ethics. Ethics Defi ned exist. The ethics of a Paramedic entering into either one of these two workplaces can be affected by the culture present. Ethics, from the Greek “ethos” meaning character, is a sys- James O. Page, founding editor of the Journal of tem of guiding principles that govern a person’s conduct. Emergency Medical Services, spoke to the problems of a neg- Paramedics use ethical principles to help guide them to ative EMS culture in his article entitled “A Call for a Cultural make the right decision in a specifi c situation such as the one Revolution,” written after he witnessed the care provided to depicted earlier. his family.1 Mr. Page emphasized that the problem, as he saw Factors that can affect a person’s ethics are cultural infl u- it, was not just with the individuals whose behaviors were ences and religious beliefs. Religion provides people with a unprofessional, but in an EMS system that permitted—even description of what is right and what is wrong. Broadly, these encouraged—this type of behavior, thereby creating an EMS religious beliefs can be applied to a Paramedic’s practice. system with a negative culture. Many Paramedics obtain personal direction from these reli- Some Paramedics’ personal code of conduct, their moral- gious beliefs when confronted with an ethical dilemma. ity, is a mere refl ection of the culture where they work. The The culture in which a person lives can also have a great infl uence of others, a so-called worldview, has a signifi cant impact on that person’s ethics. In this context, culture means impact upon most people’s decision making and can replace those unique activities and symbols that make one group’s the individual Paramedic’s ethics. condition different from another’s. Culture can include the Alternatively, other Paramedics have carefully considered way a group of people dress, as well as their unique language and adopted a personal system of beliefs (i.e., professional and special rituals. ethics) which is based upon higher principles, discussed When discussing the concept of culture, images of shortly. It takes a strong personal belief system and a strong exotic places and people with strange customs may come sense of morality to withstand the ethical challenges from a to mind. However, a workplace can also have a culture. For negative culture. example, EMS has a distinctive culture. Paramedics who wear distinctive uniforms separate themselves from the rest of the public. Paramedics also develop phrases and termi- Medical Ethics nology that is often only understood by another Paramedic. Medical ethics pertains more specifi cally to how Paramedics Paramedics have certain special rituals
and rites of passage, behave in regard to patients. The term bioethics was originally often marked by educational achievement, such as obtaining coined by Van Rensselaer Potter. When speaking of bioethics clinical privileges. he was referring to a set of guiding principles for the medi- In some EMS organizations, the prevalent culture cal practitioner. Bioethics is a form of applied ethics—that is, includes a sense of a higher purpose. For example, the job ethics applied to the medical situation. Bioethics is used in is viewed as performing a valuable service to the commu- day-to-day decision making by Paramedics in the fi eld. nity which is manifested by a positive regard for the patient. Bioethics came to prominence during the 1960s when These Paramedics obtain positive meaning from their jobs, questions about health care and the implications of medical thus enriching their own lives. The culture of the workplace advances, such as in vitro fertilization and abortion, were could be said to be a positive one. forcing theologians, physicians, lawyers, and legislators to Alternatively, if the prevalent attitude among a group of consider the morality of certain medical procedures. Paramedics is that EMS is just a “job” and patient care is an Bioethics holds that an unconsidered decision that onerous task to be endured, then a more negative culture may results in harm to the patient is unethical. However, the 72 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. answers to questions regarding patient care are often not as be necessary to perform a painful needlestick. Teleologically clear as they might fi rst appear. Topics of great controversy, speaking, the benefi t of the medication far outweighs the such as pediatric intubation, have advocates on both sides, harm of the needlestick. each with valid arguments supporting their position. The Generally speaking, the intrinsic good of acts performed role of bioethics is to help guide the Paramedic to make an by Paramedics should prevent and control disease, relieve ethical decision. pain and suffering, and generally prolong life. These acts One means of coming to the answer is to have Paramedics should clearly outweigh any suffering, pain, or inconvenience come to a consensus. When the majority of Paramedics to the patient. agree to a specifi c conduct or course of action, determining However, when the decision to perform a procedure is that it does more good than harm, then the act is considered complicated then the Paramedic should weigh the outcomes to be ethical. This ethical relativism is in play at all times. or consequences of performing the act against not performing Ethical decisions change over time as new conditions, tech- the act and then make a decision that maximizes the intrinsic nologies, and knowledge alter the situation’s fundamental good. This approach to ethical decision making is called act- conditions. utilitarianism. In a number of situations, there is already a consensus Underlying this foundation is an implicit understanding as to the ethics concerning a certain conduct. For example, that the Paramedic cannot increase her own happiness at the Paramedics agree that diverting drugs for personal use is patient’s expense. For example, starting an intravenous access unethical. In instances when that conduct occurs, the profes- on the basis of some future good, such as the Paramedic can sion has a responsibility to take action. Action must be taken keep profi cient with obtaining intravenous access by practice, against the offender to prevent a reoccurrence. would be an ethical violation. If the conduct has risen to the level of criminality then Paramedics have a responsibility to report that crime to the proper authorities. If the conduct is less egregious, but still unethical, then the Paramedic may have a duty to report the Street Smart conduct to management and/or civil authorities, such as a state EMS offi ce. The decision to withhold a treatment in favor of Foundations for Value Judgments transporting the patient to an emergency When confronted with an ethical confl ict the Paramedic must department where a more experienced physician make a decision as to what action to take. He must make a can perform the skill could be seen as a utilitarian judgment as to which course of action is the correct course of action in terms of right or wrong. That decision mak- act, provided no harm came to the patient due ing requires that the Paramedic make a value judgment. to the delay. Several models are available to help the Paramedic make that decision. Deontological Model of Ethics Other Paramedics maintain that the consequences of an act Street Smart are relatively unimportant. Their position is that it is more important that decisions be driven by principles. Some Paramedics, in order to avoid controversy, This approach, the deontological approach, acknowl- may elect to not make a decision, deferring to edges that harm may occur but that Paramedics must perform their duty. Deontology is duty-based ethics in which the deci- medical direction or to another Paramedic. Even a sion as to whether an action is right or wrong is based on non-decision is a decision—the same ethical dilemmas principles and not upon the consequences. still exist. A situation that demands action by any person in that situation, as a matter of duty, is called a universal law. An example of a universal law would be for one Paramedic to stop another Paramedic from committing an act of violence Teleological Model of Ethics to a patient in restraints. The teleological model of ethics simply states that the end There are some universally agreed upon principles to justifi es the means. This approach implies that, even though which Paramedics and physicians alike subscribe; for exam- some harm may occur, in the end if the outcome is good then ple, the duty to “fi rst, do no harm;” primum non nocere. the behavior is ethical. For example, Paramedics do not want Observance of this rule would be an example of a deontologi- to hurt their patients, yet to reverse a drug reaction it may cal approach to ethical decision making. Ethics and the Paramedic 73 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. as privilege in another. An example is the difference in the Professional Paramedic freedom of speech in the United States versus the People’s Republic of China. Human rights are easier to understand than natural or Almost all religions and cultural systems refer to a personal rights as they are based on a commonly desired belief that is commonly called the “golden rule.” human condition (i.e., freedom from want, freedom from Also referred to as the ethic of reciprocity, this pain, and freedom from suffering). Human rights involve concept speaks to a basic human right to be treated universally accepted standards of justice. A patient’s human rights cannot be abridged by a with decency. Key to the golden rule is that a person Paramedic without risk of severe social repercussions. These attempting to live by this rule treats all people, not societal remedies are usually in the form of substantial civil just members of one’s own group, with consideration. penalties or criminal prosecution. Patients also enjoy some legal rights. These are rights afforded them by the government in the form of laws, stat- utes, ordinances, and regulations. These legal rights can be Virtue Ethics affi rmative rights in which the person can do something. For example, in the patient’s bill of rights the patient has a right A somewhat middle ground approach, virtue ethics, does not to self-determination, such as the right to choose treatment or depend on consequence-driven decisions or duty-driven deci- choose not to have treatment. sion making, but upon virtues. These legal rights can also take the form of a prohibition Virtue ethics suggests that a “right-thinking” person will which prohibits others from performing an action affecting make the best decision for the patient based upon a predeter- the individual. For example, a person has the right to be free mined set of virtues. The fundamental quality of a virtuous from unreasonable searches. The Bill of Patient Rights was person is to act without regard to the consequences to oneself recently adopted by the U.S. Congress (Table 5-1). or to some abstract duty, but rather to act altruistically for the sole benefi t of the patient.2 Mores and Paramedics The source of one’s virtues can be intrinsic, meaning that What some individuals might argue is a human right is more the virtues come from within the person. Examples of virtues of a social norm. A social norm is a rule of conduct that include compassion and kindness. These internalized values regulates the interaction between people but is not specifi c are often the result of values instilled in a child by a parent to one individual. Mores are a social custom rather than a during the child’s upbringing. They are considered by some to universally accepted standard of justice and do not rise to the be innate qualities for a Paramedic. level of a right. Generally a more is a collective agreement An extrinsic source of virtues comes from external among a group of people on how they will behave in a group sources such as religion. Sometimes called divine command and with one another. A more can be thought of as a social ethics, extrinsic ethics can be based upon the Bible’s Ten contract that states the involved parties will all act in a similar Commandments or Buddha’s Four Noble Truths and Eight way, or face the condemnation of the collective. Paths to Righteousness. In both cases, a higher authority has Professional groups, including Paramedics, may adopt predetermined what qualities a virtuous person would have certain mores, or moral obligations, that go beyond the and calls upon the person to display those virtues through basic human rights which every patient enjoys. For example, correct action. if an off-duty Paramedic fails to stop at the scene of a serious motor vehicle collision to offer aid, the action or omission Personal Rights and Moral Obligations may not be illegal, but other Paramedics might consider such The defi nition of a personal right can be somewhat nebu- an act immoral. Some would assert that the Paramedic has a lous and hard to defi ne. However, an individual knows when moral obligation to stop. However, the patient does not have he or she has been deprived of that right. A right could be a right to care from an off-duty Paramedic. loosely defi ned as something to which a person is entitled based on the society’s sense of fair play. Rights are not social Foundations of Bioethics expediencies that can change as conditions change. Rights The Hippocratic Oath has stood as the foundation for bioeth- are not privileges because privileges depend on the goodwill, ics for over 2,500 years.3–5 The Hippocratic Oath defi ned those or cooperation, of others. Rights are immutable and universal ethical principles that a physician was to follow. Inherent in to all people who are designated as possessing them. Some the Hippocratic Oath are the concepts of benefi cence and people refer to them as natural rights. Natural rights are a non-malfeasance. function of existing in the societal group. Because rights are Over time, various philosophers, such as Immanuel Kant, defi ned by the society, the existence of rights will vary. An have refi ned the subject of medical ethics. In the eighteenth example of a natural right in the United States is the freedom century, Thomas Percival developed the fi rst medical code of expression. What is a right in
one country may be seen of ethics, which was adopted by the American Medical 74 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 5-1 Patient Bill of Rights The ideal of human dignity suggests that every Paramedic also has a duty to be nonjudgmental. To be nonjudgmental, • The Right to Information. Patients have the right to receive accurate, the Paramedic must resist coming to a decision about some- easily understood information to assist them in making informed one based on an artifi ciality such as poverty or race. Prejudice decisions about their health plans, facilities, and professionals. has no place in paramedicine. • The Right to Choose. Patients have the right to a choice of health In support of this concept, the National Association care providers that is suffi cient to assure access to appropriate high-quality health care including giving women access to qualifi ed of EMT code of ethics states, “The Emergency Medical specialists such as obstetrician-gynecologists and giving patients with Technician provides services based upon human need, with serious medical conditions and chronic illnesses access to specialists. respect for human dignity, unrestricted by consideration of nationality, race, creed, color or status.”7 • Access to Emergency Services. Patients have the right to access emergency health services when and where the need arises. Health plans should provide payment when a patient presents himself/ Patient Autonomy herself to any emergency department with acute symptoms of Another tenet central to bioethics is the concept of patient suffi cient severity “including severe pain” that a “prudent layperson” autonomy, the patient’s ability to control her person and her could reasonably expect the absence of medical attention to result personal destiny through decision making. Followed to its in placing that consumer’s health in serious jeopardy, serious logical conclusion, patient autonomy implies that patients impairment to bodily functions, or serious dysfunction of any bodily organ or part. could decide to do nothing about a fatal illness, a decision that might lead to their own demise. This would be accept- • Being a Full Partner in Health Care Decisions. Patients have the right to fully participate in all decisions related to their health care. able provided that the patient is capable of understanding and Consumers who are unable to fully participate in treatment decisions understood the ramifi cations of such a decision. have the right to be represented by parents, guardians, family Paramedics might otherwise intervene in the previously members, or other conservators. Additionally, provider contracts described case, objectively for the good of the patient, if it should not contain any so-called “gag clauses” that restrict health were not for the respect that all medical professionals have for professionals’ ability to discuss and advise patients on medically patient autonomy. It is understood that the patient’s wishes, necessary treatment options. even without the power to act upon them, would be hollow if • Care Without Discrimination. Patients have the right to considerate, it were not for a Paramedic’s respect for autonomy. The sanc- respectful care from all members of the health care industry at all tity of patient autonomy is foundational to medicine. times and under all circumstances. Patients must not be discriminated against in the marketing or enrollment or in the provision of health Privacy care services, consistent with the benefi ts covered in their policy and/ or as required by law, based on race, ethnicity, national origin, religion, Privacy, a condition of being secluded from the view, opinion, sex, age, current or anticipated mental or physical disability, sexual or intrusion by others, is another foundation of the patient– orientation, genetic information, or source of payment. physician relationship. All healthcare providers zealously pro- • The Right to Privacy. Patients have the right to communicate with tect their patients’ privacy so that patients may feel at liberty health care providers in confi dence and to have the confi dentiality to discuss their medical conditions with health professionals. of their individually-identifi able health care information protected. If a Paramedic was to violate a patient’s privacy, then Patients also have the right to review and copy their own medical the patient might not be forthcoming with needed medical records and request amendments to their records. information in the future. Such an unauthorized disclosure • The Right to Speedy Complaint Resolution. Patients have the would not only compromise present patient care but also have right to a fair and effi cient process for resolving differences with a chilling effect on future patient care. their health plans, health care providers, and the institutions that serve them, including a rigorous system of internal review and an The issue of a patient’s right to privacy in an electronic independent system of external review. age where personal information can be transmitted to others • Taking on New Responsibilities. In a health care system that at the speed of light has become one of national concern, as affords patients rights and protections, patients must also take evidenced by HIPAA federal regulations.8–10 Paramedics must greater responsibility for maintaining good health. remain vigilant and attempt to prevent disclosure of private medical information, whether accidental or intentional, in order to maintain the trust of patients. Association in 1846.6 That code of ethics still stands and Veracity includes such corollary concepts as respect for human dig- nity, patient autonomy, privacy, and justice. Veracity is not just about truth but an adherence to truth- fulness. When a Paramedic practices being truthful with all Respect for Human Dignity of her patients, making it a habit to be truthful, then that It almost goes without saying that Paramedics must fi rst have Paramedic can be said to have veracity. This truthfulness is a respect for human dignity. Human dignity is not just about essential if the Paramedic wants to establish a therapeutic patient autonomy and the patient’s right to self-d etermination. relationship with the patient. For the purpose of treatment, Human dignity addresses the right of every person to be patients reveal facts about themselves that they would not treated respectfully, regardless of his or her station in life. reveal to anyone else. Ethics and the Paramedic 75 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. These revelations are so critical to the physician–patient rare medicine or allocating limited resources on the scene of relationship that the courts, without extraordinary reason, a multiple casualty incident (MCI). cannot ask the physician to willingly violate that trust. The In some of these instances, a random selection criterion courts have reasoned that if such a trust was violated then is applied, while in others a standard such as likelihood of a patient might not confi de essential aspects of medical his- medical benefi t is applied. In every situation, a recognized tory to the physician. Without that trust patients might not standard has to be applied in order to be fair and just. ever seek medical attention. The fallout of a violation of such a fundamental aspect of the physician–patient relationship EMS Code of Ethics could lead to widespread illness and untreated injury. Many healthcare professions, including EMS, have adopted A devotion to the truth, a physician’s veracity, burdens a code of ethics. A code of ethics serves as a standard for the physician with a duty to maintain this relationship until the profession and a basis by which practitioners facilitate the patient’s death—and perhaps beyond. This duty creates a resolution of ethical dilemmas. Many associations, such as legal bond (a fi duciary relationship) between the physician the National Association of EMT (NAEMT), have a code of and the patient. ethics (Table 5-2). Fidelity Inherent within the concept of veracity is the idea of fi del- Moral Rules ity. Fidelity is the obligation of the physician, and therefore and Particular Circumstances the Paramedic, to keep the promises that are made to the patient. Infi delity leads to mistrust and a general deteriora- Certain trying situations (for example, end-of-life decisions tion of veracity that is counterproductive to the therapeutic and triage) call upon a Paramedic’s morals and ethics. Using relationship. the framework of ethical decision making, described earlier, the Paramedic can come to an ethical decision. Benefi cence The other pillar of a physician–patient relationship is the con- Ethical Obligation cept of benefi cence. Benefi cence implies that the physician’s The public has come to expect that its emergency medical actions are acts of mercy and charity, a good act performed services system is its “public health safety net.” As such, it for people at a time of need. has placed the ethical burden on EMS systems to respond to The quintessential model of benefi cence is the Good all calls for help. Samaritan. The story of the Good Samaritan is that the Good The response to these calls should be immediate and not Samaritan cared for another who was injured on the roadside, complicated by concerns of fi nances. While fi nancial limi- not out of obligation but out of compassion. tations may affect a community’s ability to sustain an EMS Non-malefi cence system, the individual Paramedic should not be burdened with these fi nancial concerns. The Paramedic’s duty should Included in every act of benefi cence is the idea of non- be simple: respond to all calls for help. malefi cence. While similar, these two concepts are not the same. Benefi cence means that an act of good is performed whereas Allocation of Scarce non-malefi cence means that no act of harm will be done. The medical concept of “fi rst, do no harm” is an exam- Medical Resources ple of the application of the principle of non-malefi cence.11,12 Physicians and bioethicists have had many discussions regard- Harm (for example, in the form of a fever) which results from ing the distribution of limited resources. An example of an the physician’s inaction is not the physician’s responsibility. allocation of a scarce medical resource is allocation of organs The patient understands this. Although the patient depends for transplantation. Paramedics are similarly confronted with on the physician’s mercy and charity to prevent this harm, it the same ethical issues when they are on-the-scene of a MCI is understood that this can only be asked for, not demanded. and must allocate the scarce medical resources. However, the Paramedic, like the physician, is responsible Most Paramedics rely on the concept of medical utility for any harmful acts performed and can be held liable (malfea- to resolve this ethical dilemma. Simply put, medical utility sance). It is therefore important that the Paramedic be p rudent, assumes that those with the best prognosis should be treated relying on tested or proven methods of treatment when caring with the limited resources. Those with a likelihood of medi- for a patient, rather than risk creating harm. There is a greater cal benefi t are treated fi rst, whereas those who are expected duty not to injure others than there is to benefi t them. to succumb to their injuries and for whom medical treatment would be futile are left to be treated last.13–17 Justice In this situation, medical utility, a form of act- Justice, the application of the concept of fairness, implies utilitarianism, provides suffi cient guidance for Paramedics impartiality in the administration of rewards. In the case of to act. A problem arises, however, when a fellow emergency medicine, justice might be involved in the distribution of a responder, such as a fi refi ghter, is injured (Figure 5-1). 76 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in
part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 5-2 National Association of Emergency Medical Technicians Code of Ethics EMT Code of Ethics As adopted by the National Association of EMTs Professional status as an Emergency Medical Technician and Emergency Medical Technician-Paramedic is maintained and enriched by the willingness of the individual practitioner to accept and fulfi ll obligations to society, other medical professionals, and the profession of Emergency Medical Technician. As an Emergency Medical Technician-Paramedic, I solemnly pledge myself to the following code of professional ethics: A fundamental responsibility of the Emergency Medical Technician is to conserve life, to alleviate suffering, to promote health, to do no harm, and to encourage the quality and equal availability of emergency medical care. The Emergency Medical Technician provides services based on Figure 5-1 Firefi ghter with injuries on-scene. human need, with respect for human dignity, unrestricted by consideration of nationality, race creed, color, or status. transportation would improve operational effi ciency and there- The Emergency Medical Technician does not use professional fore serve a greater good. Others might argue that treating knowledge and skills in any enterprise detrimental to the public well being. and transporting the fi refi ghter represents a problem of bias The Emergency Medical Technician respects and holds in confi dence and, perhaps more importantly, a breakdown of the concept of all information of a confi dential nature obtained in the course of medical utility. The key to such ethical problems is to balance professional work unless required by law to divulge such information. The Emergency Medical Technician, as a citizen, understands and benefi ts with burdens and determine the moral behavior. upholds the law and performs the duties of citizenship; as a professional, the Emergency Medical Technician has the never-ending responsibility Ethics and EMS Research to work with concerned citizens and other health care professionals in Following the discovery of the Nazi atrocities of human promoting a high standard of emergency medical care to all people. experiments that were exposed during the Nuremberg tribu- The Emergency Medical Technician shall maintain professional nals following World War II, there was a strong call for a competence and demonstrate concern for the competence of other members of the Emergency Medical Services health care team. formal code of ethics for medical researchers. In 1947 the An Emergency Medical Technician assumes responsibility in defi ning Nuremberg code for the ethical conduct in the use of humans and upholding standards of professional practice and education. for experiments was advanced and accepted by many coun- The Emergency Medical Technician assumes responsibility for tries. Enhancements to this original landmark document were individual professional actions and judgment, both in dependent and passed in the Helsinki Declaration of 1964 and in subsequent independent emergency functions, and knows and upholds the laws guidelines passed by the World Health Organization. which affect the practice of the Emergency Medical Technician. Currently, all medical research, including EMS research, An Emergency Medical Technician has the responsibility to be aware of and participate in matters of legislation affecting the Emergency is governed under the federal regulation 45 CFR 46.111 as Medical Service System. well. Medical research is monitored by the U.S. Department The Emergency Medical Technician, or groups of Emergency Medical of Health and Human Services. The Department of Health Technicians, who advertise professional service, do so in conformity with and Human Services requires that all medical research be the dignity of the profession. presented to an Institutional Review Board (IRB) for accep- The Emergency Medical Technician has an obligation to protect the tance. An IRB consists of experts from the fi elds of theology, public by not delegating to a person less qualifi ed, any service which sociology, psychology, and medicine.18 The IRB is respon- requires the professional competence of an Emergency Medical Technician. sible for reviewing all aspects of a proposed research project The Emergency Medical Technician will work harmoniously with and sustain confi dence in Emergency Medical Technician associates, the in terms of the potential psychosocial impact and ensure that nurses, the physicians, and other members of the Emergency Medical all human subject research is ethical. Services health care team. Before any research is accepted by an IRB, the researcher The Emergency Medical Technician refuses to participate in unethical must demonstrate that the risks to the subjects are minimized procedures, and assumes the responsibility to expose incompetence or and any risks are proportional to the potential gain or benefi t, unethical conduct of others to the appropriate authority in a proper and that subject selection is unbiased, and that informed consent professional manner. is obtained from each subject. Written by Charles Gillespie M. D. Adapted by the National Association of Emergency Medical Technicians, 1978. End-of-Life Decisions End-of-life decisions are complicated by the defi nition of Some Paramedics would argue that triaging a fellow emer- death. Is death the absence of a heartbeat and breathing (clin- gency responder to the highest classifi cation serves a social ical death), as the ancients believed? Or is death the absence utility, since the presence of an injured fi refi ghter on-scene of life; that is, those factors that make us uniquely human, would be disruptive to operations. The fi refi ghter’s immediate such as consciousness, wakefulness, and awareness. Ethics and the Paramedic 77 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Current technologies permit a patient to be in a persistent Ethics Committees vegetative state (PVS), a permanent state of unconsciousness, Many healthcare organizations have established an ethics with an intact brainstem that still produces a heartbeat and committee, a committee which can help individuals, including breathing. Most medical authorities agree that biological death Paramedics, deal with common ethical concerns. An example (death of the human) occurs when the brain is dead. To estab- of when an ethics committee might help a Paramedic would lish death, most physicians apply the Harvard Medical School be with the development of palliative care protocols that pro- criteria: unresponsiveness, lack of movement, no refl exes, and vide for appropriate comfort and pain relief at the end-of-life a fl atline EEG. without hastening the patient’s death. Also, guidance could Paramedics encounter patients who are near-death and be provided as to whether it is appropriate to administer oxy- are sometimes confronted with the question of end-of-life gen to a patient with a Do-Not-Resuscitate (DNR) order. decisions. Without guidance from the patient, in the form An ethics committee typically has the same make-up as of advanced directives, or the presence of a healthcare proxy, an IRB. Generally its mission is to foster awareness of ethi- the Paramedic may be called on to make the decision to cal concerns that might arise during patient care and to guide start CPR. practitioners, including Paramedics, with decision making. Under the conditions described, and barring the presence Other organizations that deal with issues of medical ethics of signs of death (i.e., signs that would indicate medical futil- include the Institute of Society, Ethics and the Life Sciences, ity, such as rigor mortis or rigor lividity), the Paramedic is formed in 1969 and based in Hastings-on-the-Hudson, and generally compelled to perform CPR and leave the end-of- the Kennedy Institute of Ethics, established at Georgetown life decision to the family and the physician at a later time. University in Washington, DC. 78 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Paramedics are confronted with ethical dilemmas and with health-related questions which raise ethical issues. An understanding of ethical principles, and their proper application, can help the Paramedic to resolve these ethical dilemmas and allow the Paramedic to continue to provide care without hesitation. Key Points: • Ethics is defi ned as a system of guiding principles inalienable, such as the freedom of expression. that govern a person’s conduct. Cultural and Human rights involve universally accepted standards religious beliefs can strongly affect a person’s of justice, such as freedom from pain and suffering. ethics. There are even workplace cultures in EMS, Legal rights come in the form of laws, statutes, which can have a positive or negative infl uence on ordinances, and regulations. Moral obligations may how Paramedics view their responsibility. It takes a go beyond the basic human rights of the patient, strong personal belief system and a strong sense of such as the obligation for an off-duty Paramedic to morality to withstand the ethical challenges from a stop at the scene of an accident and offer assistance. negative culture. • Human dignity addresses the right of every person • Bioethics is a form of applied ethics (i.e., ethics to be treated respectfully, regardless of his or her applied to the medical situation) and is used in day- station in life. Paramedics must respect human to-day decision making by Paramedics in the fi eld. dignity, and therefore be nonjudgmental. When the majority of Paramedics agree to a specifi c conduct or course of action, saying that it does • The sanctity of patient autonomy is foundational more good than harm, then the act is considered to to medicine. Patients have the ability to control be ethical. their personal destiny through decision making, given that they are capable of understanding the • Generally speaking, the intrinsic good of acts ramifi cations of their decision. performed by Paramedics should prevent and control disease, relieve pain and suffering, and • The patient’s privacy must be maintained in order generally prolong life and clearly outweigh any to sustain patient trust. suffering, pain, or inconvenience to the patient. • When Paramedics practice being truthful with all • Deontology is duty-based ethics where the decision of their patients, making it a habit to be truthful, if an action is right or wrong is based on principles then those Paramedics can be said to have veracity. and not upon their consequences. A situation that This truthfulness is essential if there is to be a demands action and for which all persons, as a therapeutic relationship between the Paramedic matter of duty, should act unconditionally is called and the patient. To maintain patient trust, the a universal law. Paramedic must also practice fi delity, keeping the promises made to the patient. • Virtue ethics suggest that a “right-thinking” person will make the best decision for the patient based • Benefi cence assumes an act of good is performed, upon a predetermined set of virtues. This person whereas non-malefi cence means that no act of harm will be able to act altruistically for the sole benefi t will be done. It is important that the Paramedic be of the patient. prudent, relying on tested or proven methods of treatment, when caring for a patient, rather than • The defi nition of what is “right” can vary. Generally, risk creating harm. There is a greater duty not to a right is a sense of fairness. Natural rights are injure others than to benefi t them. Ethics and the Paramedic 79 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it. • In the case of medicine, justice—the application • Paramedics are sometimes confronted with the of the concept of fairness—might be involved in question of end-of-life decisions. Without guidance the distribution of a rare medicine, or to ration from advance directives or a healthcare proxy, and out limited resources on the scene of a multiple unless there are signs of death (i.e., rigor mortis casualty incident (MCI). The concept of medical or rigor lividity), the Paramedic generally performs utility assumes that those with the best prognosis CPR and leaves the end-of-life decision to the family should be treated with the limited resources. and physician at a later time. • A code of ethics serves as a standard for the • An ethics committee’s mission is to foster awareness profession and a basis by which practitioners of ethical concerns that might arise during facilitate resolution of ethical dilemmas. patient care and to guide practitioners, including • Paramedics, in their decision making. There is a formal code of ethics for medical researchers. An Institutional Review Board • An understanding of ethical principles, and their reviews proposed research projects, ensuring proper application, can help the Paramedic to they meet certain ethical criteria before they resolve ethical dilemmas and allow the Paramedic can be carried out. to continue to provide care without hesitation. Review Questions: 1. What infl uences a person’s ethics? 8. How is benefi cence different than 2. What encompasses the term “bioethics,” coined non-malefi cence? by Van Rensselaer Potter? 9. What concept is demonstrated when limited 3. What is necessary for an act to be considered resources are applied to select people? ethical or unethical? 10. Explain the role of ethics in EMS research. 4. How does the teleological foundation of ethics 11. What professions make up an ethics committee differ from the deontological model? and what is its overarching purpose? 5. How can the defi nition of what is “right” vary? 12. When confronted with an end-of-life decision, 6. What are the foundations of bioethics? when is it appropriate for the Paramedic not to 7. What is veracity, and how is it related to fi delity? perform CPR? Case Study Questions: Please refer to the Case Study at the beginning of the 3. Many educational programs for healthcare chapter and answer the questions below: providers require a course in ethics. Should 1. How would you decide what care to provide for Paramedics be required to complete such a the patient in the case study? course? Why or why not? 2. What model of ethics supports your decision? 80 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. References: 1. Page JO. The Paramedics: An Illustrated History of Paramedics 10. Buppert C. Safeguarding patient privacy. Establish department in Their First Decade in the U.S.A. Kfar Sava: Backdraft compliance with new federal regulations on individually Publications; 1979. identifi able health information. Nurs Manage. 2002;33(12):31–35. 2. Miller DG, Pellegrino ED, Thomasma DC. The Christian Virtues 11. Meskin LH. Non-malefi cence: do no harm! J Am Dent Assoc. in Medical Practice. Washington DC: Georgetown University 1992;123(6):8, 11. Press; 1996. 12. Hoyt D. Prehospital care: do no harm? Ann Surg. 3. Yeager AL. On Hippocrates. Either help or do not harm the 2003;237(2):161–162. patient. Bmj. 2002;325(7362):496. 13. Marco CA, Schears RM. Prehospital resuscitation practices: 4. Doherty DJ. Contemporary medical ethics. Would Hippocrates a survey of prehospital providers. J Emerg Med. 2003;24(1): approve—or even understand? Postgrad Med. 1985;77(3): 101–106. 212–216. 14. Van der Hoeven JG, Waanders H, Compier EA, van der Weyden 5. Cameron NM. Bioethics and the challenge of the post-consensus PK, Meinders AE. Prolonged resuscitation efforts for cardiac society. Ethics Med. 1995;11(1):1–7. arrest patients who cannot be resuscitated at the scene: who is 6. Baker et al.The American Medical Ethics Revolution: How the likely to benefi t? Ann Emerg Med. 1993;22(11):1659–1663. AMA’s Code of Ethics Has Transformed Physicians’ Relationships 15. Battistella FD, Nugent W, Owings JT, & Anderson JT. Field triage to Patients, Professionals, and Society. Baltimore: The Johns of the pulseless trauma patient. Arch Surg. 1999;134(7):742–745; Hopkins University Press; 1999. discussion 745–746. 7. http://www.naemt.org/about_us/emtoath.aspx 16. Hawkins ML, Treat RC, Mansberger AR, Jr. Trauma victims: 8. Ouellette A, Reider J. Practical, state, and federal limits on the fi eld triage guidelines. South Med J. 1987;80(5):562–565. scope of compelled disclosure of health records. Am J Bioeth. 17. Sharma BR. Triage in trauma-care system: a forensic view. J Clin 2007;7(3):46–48. Forensic Med. 2005;12(2):64–73. 9. Banks DL. The Health Insurance Portability and Accountability 18. Garvin C, Landrum RE. (Ed.). Protecting Human Subjects: Act: does it live up to the promise? J Med Syst. 2006; Departmental Subject Pools and Institutional Review Boards. 30(1):45–50. New York: American Psychological Association; 1999. Ethics and the Paramedic 81 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The origins of case law • Civil and tort laws and the elements of a lawsuit • The complexity of patient consent (both legal and ethical concerns) • Understanding of patient rights • Principles of advanced directives • Acts and laws that impact the Paramedic as an employee Case Study: A Paramedic has been subpoenaed to give an affi davit as part of a pretrial investigation into the death of a 45-year-old man. The plaintiff is suing the hospital for malpractice and the untimely death of the patient. The patient was brought to the emergency department by EMS with the complaint of chest pressure and shortness of breath. It is claimed that the patient had to wait 15 minutes to be seen by a physician and had gone into sudden cardiac arrest and died. The lawyers for the plaintiff are looking into the prehospital care given by the Paramedic. The Paramedic’s assessment, diagnostic workup, and course of treatment all followed standard protocols. However, despite the Paramedic’s best efforts to inform the patient of the necessity for intravenous access, the patient refused, insisting on hospital personnel to perform such treatments. The prehospital care given by the Paramedic was found to have been within the Paramedic’s scope of practice despite the patient’s unresolved symptoms upon arrival at the emergency room (ER). 82 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Law and Paramedics 83 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW The Paramedic is expected to have a commanding knowledge of human physiology, symptomology, and pharmacology, but there is a more sobering side to paramedic practice that even the most knowledgeable Paramedic cannot overlook; the legal side. The legal side of EMS affects almost every Paramedic action from their duty to act to how Paramedics conduct themselves in the fi eld. This chapter examines the origins of case law and the divisions between criminal and civil law. The Paramedic must train for the unknown, and should not wait to be caught in the middle of a legal case before becoming familiar with the legal side of the profession. Paramedics should not have a defensive approach, living in fear of being sued; rather, they should develop a preventative approach through a sound understanding of the law. Often the Paramedic’s focus is placed on roles and responsibilities; however, in an almost reverse way of thinking the complexity of patient rights must also be examined and understood. Paramedics must also have an understanding of the legal basis of their actions when managing the day-to-day situations of patients with mental health issues, as well as patients who refuse care. Origin of Law Government units or departments have also been formed, under statutory authority, and charged with various functions In the past, when a transgression occurred against a king, the to carry out the business of government. These departments, accused would be brought before the king and be allowed during the performance of their duties, often fi nd it necessary to plead his case. The king would then make a decision, to regulate the conduct of citizens pursuant to their rule- pronounce sentence, and issue an edict (i.e., a public making authority through the establishment of rules. These declaration equivalent to law that prohibited others from rules, or regulations, while not being statutory law, carry the performing similar acts under certain penalty for such acts).1 same force as law. It was in this manner that the rule of law began. Any reported violation of a regulation would need to be Over time, when the numbers of cases became too investigated and then determined, or adjudicated, in a court numerous for the king, the king would appoint a magistrate having authority (i.e., jurisdiction). When a regulation is (i.e., his majesty’s administrator) to handle the minor cases. violated an administrative court generally has jurisdiction. These magistrates would judge the worthiness of a case When a violation of a departmental regulation occurs, the and render judgment. They would also make a notation of department (the petitioner) brings charges against the alleged the resolution to report to the king as well as to preserve the wrongdoer (the respondent). The respondent is notifi ed to appear decision for future reference. in administrative court and respond to the charges. A hearing Over time a considerable number of these judicial cases would then be conducted before an administrative law judge were documented and became case law. These case laws (ALJ) to discuss the merits of the case. A decision would then be were arranged in order of date and jurisdiction (i.e., codifi ed) rendered by the ALJ. While serious, these cases frequently held for ease of reference. When another magistrate came across less severe penalties for the individual, as opposed to criminal a similar case and needed guidance or wished to render a penalties, because it was a violation of a regulation rather than similar judgment, the magistrate would refer to this case law. of a statute. However, the penalty may have a signifi cant impact By using case law in this manner, the courts helped to assure upon the respondent’s job or profession. fairness under the law.2 Without a king to issue edicts or a dictator to impose his decrees, democracy required a new means of establishing Criminal Law versus Civil Law public policy. Duly elected legislators representing the people of a particular area of the governing state would create new Criminal Law laws, called statutes. Using these statutes, the government One of the purposes of criminal law was to replace personal could govern the population and offenders of the law could vendettas and blood feuds between groups of people with be prosecuted under a judicial system. This is the general a general condemnation of an act by a sympathetic public. structure of the government in the United States today.3 By removing the aggrieved victim from the process, and 84 Foundations of
Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. replacing her with the state as prosecutor, successive acts of A tort is a civil or private wrongful act, other than a vengeance were prevented and order was maintained. breach of contract, resulting in some type of injury or harm A crime could therefore be defi ned as an act done in (not necessarily physical injury).4 A tort involves some type of violation of a person’s duties to the community and for which duty which arises by law. Duties and responsibilities relating the written law requires the person to provide satisfaction, often to contracts arise from the relationship as a result of the in the form of restitution and loss of liberty, to the community. agreement or contract. Those contract issues are not torts. Crimes were defi ned and codifi ed in the criminal law. The Several different types of torts are relevant to a Paramedic. outraged community would rise up and, in its capacity as the An intentional tort occurs when the Paramedic intentionally state, demand prosecution of the individual. Therefore, when and affi rmatively performs an act which causes harm to a person is charged with a crime the prosecutor is the state the patient. An assault (a threat of violence) or a battery (e.g., the State of Montana v. Joe Citizen), and the person is (unwanted touching) are examples of intentional torts. tried in a criminal court. (Depending on the severity of the act, an assault and battery Dependent on the severity of the crime, a citizen could can separately constitute a crime and be prosecuted under the be tried in a local city or town court before a justice, for a criminal law.) Another example of a claim of intentional tort violation or infraction of the law, or before a judge in a county that has been lodged against a Paramedic is the charge of false or state court, for a misdemeanor or felony charge. imprisonment (a restriction of movement or a confi nement There are two separate criminal court systems; one for that abridges the patient’s right to freedom, such as by the use the states and one for the federal government. The federal of restraints). government has courts to adjudicate crimes involving federal Paramedics have certain public expectations placed upon laws. In addition, each state has state courts to adjudicate them in regard to their conduct and behavior. This public crimes involving violations of state laws. trust involves an understanding between the patient and Each state also has courts which determine appeals from the Paramedic that the patient will be treated with dignity the decisions of trial level state courts. An appeal is a request and respect in the same manner a physician would treat the for the appellate court to change the decision issued by the patient. If the Paramedic violates that trust, then the patient trial level court. The federal court system also has courts may bring a lawsuit against the Paramedic for any damages which determine appeals from trial level federal courts. In sustained. some situations, due to the type of issue presented, decisions Lawsuits against Paramedics more frequently involve of state courts may additionally be challenged in the federal carelessness and an allegation of negligence, a failure of the appeals courts. The highest court in the United States is the Paramedic to exercise the degree of care that a prudent person U.S. Supreme Court. Thus, U.S. Supreme Court is the last would exercise. court of appeal. Negligence is further divided into simple negligence, the lack of ordinary care that a reasonably prudent person under the same or similar circumstances would exercise, and gross negligence. Gross negligence involves intent on the part Street Smart of the Paramedic to willfully, or with reckless disregard for the patient, cause harm to the patient. Separately, egregious Many insurance providers/carriers will not protect or conduct of this type might also give rise to criminal charges pay claims for Paramedics whose conduct rises to the which might be leveled against the Paramedic by the district attorney, acting on behalf of the state. level of criminality. Negligence, either simple or gross, that occurs during patient care can give rise to a charge of malpractice, a variation of negligence. Examples of malpractice are discussed later in Civil Law the chapter. In order to resolve confl icts between individuals and to help maintain the peace, the states and the federal government Elements of a Tort Action have provided a forum in which persons and businesses can adjudicate allegations of civil wrongs which are not of a For a tort of malpractice to be actionable (i.e., to be the basis criminal nature. Every state, as well as the federal government, for a lawsuit), it must have the four elements of a tort. The has civil courts to provide for resolution of disputes involving elements of a tort are described in the following text. civil law. Common matters of civil law include contracts (an Duty to Act agreement between parties that is alleged to have been The fi rst element of a tort is a duty to act. Generally speaking breached), torts (claims involving a duty and allegations of a Paramedic has a duty to act whenever the Paramedic is injury, often due to negligence), estates, trusts, wills, real called to perform patient care (i.e., the Paramedic is “on estate matters, commercial matters, and grievances against duty”). The duty arises from her employment or volunteer the government. status as a Paramedic. Generally, a citizen does not have a The Law and Paramedics 85 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. duty to act toward a patient requesting assistance, regardless of training, unless that person is acting in the capacity as an Street Smart EMS provider or there is an expectation of the person to act in that role by virtue of job description. However, once a duty has been undertaken, or an Every state in the United States has enacted either a assignment accepted, then the patient can reasonably expect Good Samaritan law or volunteer protection act that that the Paramedic will continue care until care can be turned protects those who, in good faith, attempt to render over to another patient care provider with the same or higher aid to the sick or injured when off-duty. Of course, training.5 If the Paramedic were to prematurely terminate the Paramedic–patient relationship before the other provider there is an assumption that the patient wants the care assumed responsibility for patient care, thus interrupting being provided. patient care and resulting in harm to the patient, the patient could charge the Paramedic with patient abandonment. Abandonment occurs as a result of an overt action—for example, when a Paramedic walks away from the patient Breach of Duty without turning over care to another provider who has the Assuming that the Paramedic has a duty to act, the next same or higher level of training. However, if a Paramedic element to determine in the lawsuit would be if the Paramedic were to stop and render aid and then left the patient in order to committed a breach of duty. A breach of duty occurs when summon further assistance, this would not be abandonment as a Paramedic fails to perform patient care in conformance the Paramedic is attempting to make reasonable arrangements with the standard of care. The standard of care is that to provide for continued patient care. care and treatment that another Paramedic with the same or Finally, it would not be abandonment if a Paramedic similar training would have rendered in the same or a similar were to render aid, such as CPR, until becoming physically situation. exhausted and incapable of providing further aid. The standard of care is established in court during a lawsuit by the testimony of expert witnesses who would explain the standard of care as relating to the situation Good Samaritan Act in question. The expert would refer to local or regional Most Paramedics have no duty to respond to medical treatment protocols, authoritative textbooks and perhaps, emergencies when off-duty. However, in an effort to encourage quality assurance standards. healthcare professionals such as physicians, nurses, and Once the standard of care is established, the plaintiff ’s Paramedics to render aid during public emergencies, many lawyer would then establish that there was a material breach state legislatures have created Good Samaritan statutes.6 of that standard. The Bible story of the Good Samaritan is found in the A Paramedic may make an error in one of two ways. An Gospel according to Luke (10:25–27). The biblical parable error of commission is the performance of an act which is tells of an injured traveler who is cared for by a well-meaning alleged to be improper or wrong. An error of omission is a stranger. The Good Samaritan doctrine was established from failure to do something which she should have done. If the this story. Paramedic performed an inappropriate procedure (e.g., gave In the spirit of the Good Samaritan, legislatures have a fl uid bolus to a head-injured patient), then the charge would enacted laws that protect well-meaning healthcare providers be malfeasance. who, having no duty to respond, do nonetheless come to If the Paramedic performed the correct procedure but the aid of an injured person. These laws protect them from did so incorrectly, then the charge would be misfeasance. liability for negligent acts which are performed in the course For example, if a Paramedic performed an endotracheal of providing such assistance. intubation on an apneic patient and the endotracheal tube Good Samaritan laws do not provide immunity (exemption was placed in the esophagus instead of the trachea, then from being sued) from lawsuits. Rather, the Good Samaritan the plaintiff would make an allegation of misfeasance. acts provide the Paramedic with a legal defense to counter Finally, a Paramedic can fail to perform the correct or a complainant’s claim of negligence. The Paramedic is still required procedure, which would be an error of omission. required to go to court and demonstrate that he or she was For example, defi brillator batteries are typically checked on acting in the capacity of a Good Samaritan. a routine basis. If a Paramedic were to arrive on-scene of a Good Samaritan laws also may not apply when the cardiac arrest and the defi brillator failed because of a dead Paramedic involved created the situation. For example, if an battery, the family of the deceased could make an allegation off-duty Paramedic was to be involved in a motor vehicle of nonfeasance. collision he would likely not be considered a Good Samaritan In every instance, in order to fi nd negligence the and might be liable if he does not provide assistance, minimally Paramedic must have performed incorrectly.8 The Paramedic calling for rescue.7 He might not enjoy the protections of the must have either affi rmatively committed an error or failed to Good Samaritan act if he was expected to render fi rst aid. act appropriately (omission). 86 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Damages act to the injury, the patient, as plaintiff, cannot prove that the Paramedic is
negligent. It is not enough that a mistake was made. For the mistake to be actionable, the patient must have experienced some injury or harm from the error. The legal concept de minimis non curat et lex is applied to frivolous lawsuits where the patient Street Smart did not experience any substantial injury. The term translated means: “the law has not a cure for trifl es.” One eight-year study of lawsuits against EMS providers Damages are compensation for having suffered some injury or loss. Compensatory damages include both economic in an urban 9-1-1 system indicated that the majority and non-economic damages. Economic damages are concrete of lawsuits involved negligent operation of an and can easily be calculated. In other words one can put a emergency response vehicle. fi xed price on the loss. Economic damages include such things as the cost of repair, reimbursement for lost wages, and medical expenses. Non-economic damages are compensation for intangibles that one cannot put a fi xed price on. These Borrowed Servant Doctrine include compensation for pain and suffering, loss of life, injury to a part of the body, and loss of companionship. EMS practice dictates that the Paramedic with the highest Another type of damages are punitive damages, which level of education or experience is responsible for patient can also be levied by the court against the Paramedic. care. Therefore, the Paramedic is responsible for directing Punitive damages are akin to a civil fi ne that is intended as and supervising any patient care performed by any other a punishment for egregious conduct or to send a message to EMS providers on the team with lower levels of training. others so as to deter such conduct by others in the future. In those circumstances, called the borrowed servant doctrine, the Paramedic is not only accepting assistance from Proximate Causation those EMS providers but is also accepting responsibility for the actions and the errors of those providers. Therefore, the The saying goes that bad things happen to good people and Paramedic’s failure to supervise a subordinate, who in turn it is unfortunate that patients are forced to endure hardships makes an error and causes harm to befall the patient, leaves as a result of misfortune. But the presence of an injury and the Paramedic liable for the assistant’s actions. the commission of an error do not always equal cause and This legal principle, respondeat superior, Latin meaning effect.9 “let the master answer,” is well established in case law. A tort requires that there be a duty, a breach of that duty, Whenever a Paramedic permits another EMS provider and an injury as a proximate result. Thus, the plaintiff must to care for a patient, the Paramedic assumes vicarious prove that the Paramedic’s actions were the proximate cause liability for the actions of that provider. Take the case where of the injury.10 the Paramedic, while caring for a minor injury, allows the This is often diffi cult to prove. In many instances, the ambulance driver to drive at high rates of speed with lights injury may already have been present. For example, a patient and siren on. If the ambulance was to have a collision and who experienced a spinal cord injury during a motor vehicle harm the patient, the public, or the occupants of the other collision may have experienced that injury at the moment vehicles, the courts might hold the Paramedic vicariously of impact (i.e., primary injury). However, the patient may liable for the harm caused because the Paramedic did not complain that the injury did not occur at the moment of instruct the driver to turn off the warning lights and siren or impact but as a result of rough or inappropriate handling of slow to a reasonable speed. the patient by the Paramedic. The plaintiff would assert that the Paramedic’s actions may have caused the injury. Alternatively, the patient may assert that the injury The Process of a Civil Lawsuit occurred at the time of the collision but the injury was made When a patient feels that he has been harmed by the worse (i.e., secondary injury) by the Paramedic. In those Paramedic’s actions (i.e., an actionable cause), the patient cases, the patient might argue that the Paramedic should share generally approaches an attorney. The attorney initiates the responsibility for damages with the patient or the individual legal proceedings in hopes of obtaining a payment for the who caused the accident. This is called contributory damages the patient sustained. negligence. In this situation, the Paramedic would only be The attorney would serve (cause to be delivered) papers, responsible for a percentage of the damages that were levied called a summons and complaint, on the Paramedic. The by the court. summons and complaint identifi es some of the specifi cs of In other instances, there may be no way to prove that the matter and asks the defendant (the Paramedic being sued) the Paramedic’s actions created the harm, despite the fact to respond to the allegation contained in the complaint. it can demonstrated that the Paramedic erred and that the Attorneys usually hire a person, called a process server, patient is injured. Without proximate causation linking the to deliver the summons and complaint to the defendant. In The Law and Paramedics 87 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. the situation where a reasonable effort has been made to recognized by the court, verify the Paramedic’s identity. The serve the defendant, and the defendant refuses to accept the Paramedic then swears that the copy of the PCR is a true papers, then the courts can rule that the papers be served in a and accurate copy of the original. If using a notary public is different manner. permitted, then it may not be necessary for the Paramedic Once the matter is pending in court, the plaintiff or to appear in court to authenticate the document. defendant could then ask the court to make a decision based As a part of the pretrial investigation, the Paramedic may on the facts asserted only in the papers that had been fi led in be requested to give a sworn written statement, called an court. The judge, acting as fact fi nder, might then arrive at a affi davit, which attests to facts involving the case. fi nding in favor of the plaintiff and grant the plaintiff ’s request In a more formal proceeding prior to the trial stage, for damages. Alternatively, it is also possible the judge might the Paramedic may also be called to a deposition, which determine that judgment should be awarded to the defendant usually occurs in an attorney’s offi ce. During a deposition, Paramedic and dismiss the lawsuit. This determination by the the Paramedic swears to an oath. Then the plaintiff ’s attorney judge solely on the papers without conducting a trial is called asks questions while a stenographer takes minutes of the summary judgment. proceedings. A judge is generally not present during a It is in the Paramedic’s best interests to accept the papers deposition. The deposition allows the plaintiff ’s attorney to and contact his own attorney to avoid being in default. Failing obtain testimony in an out-of-court setting that will assist in to appear in court or to contest the lawsuit can result in a preparing the case. The testimony given at the deposition may summary judgment being entered against the Paramedic. or may not be presented later during the trial. Most malpractice insurance carriers require that any The purpose of the pretrial discovery phase is to provide Paramedic served with papers contact the insurance carrier both parties with suffi cient information to decide how to within a specifi ed period of time. This allows the insurance proceed with the case. It is possible that the attorney will carrier to contact an attorney to represent the insured learn that the Paramedic is not a party who should be sued. Paramedic. If the Paramedic’s employer is providing the Paramedics have been removed as a named party in a lawsuit insurance coverage, then the insurance company seeks to during this phase. protect the interests of both the Paramedic’s employer and If the case has merit, the defendant (i.e., the Paramedic) the insurance company. In some cases, the Paramedic may and the Paramedic’s attorney may decide that a trial would have his own malpractice insurance coverage. In that case, be counterproductive, inordinately diffi cult or expensive and the Paramedic must contact that insurance carrier. agree to pay the plaintiff a sum of money, called a settlement, to the plaintiff in order to conclude the matter. Pretrial Discovery Quality Assurance and Discoverability In an effort to determine the truth in a matter, the defendant’s attorney (the Paramedic’s lawyer) and the plaintiff ’s attorney Atypical patient presentations and/or differences in the (the patient’s lawyer) will undertake specifi c prescribed legal knowledge base of individual Paramedics can lead to less than proceedings. desirable practice in the fi eld on occasion. Quality assurance/ One action may be to issue a subpoena, which is a improvement (QA/QI) is an effort to improve patient care legal command or direction issued by the court to appear at through uniformity and reliability with the standard of care. a certain place, such as the offi ce of the plaintiff ’s attorney QA/QI is often accomplished through retrospective or the courthouse, at a particular time. The subpoena may analysis of the PCR. Disclosure of any defi ciencies in the direct the Paramedic to appear personally and it can also PCR, in a court of law, would have a chilling effect upon the demand that certain pertinent fi les and records be brought QA/QI process. with the Paramedic. Failure to respond to a subpoena may In an effort to encourage EMS care, vis-á-vis through the subject the Paramedic to legal sanctions including a charge QA/QI process, many states have adopted laws that protect of contempt of court. these QA/QI results from disclosure during the discovery In some instances, the patient may simply authorize, process. through a written release of information, that the Paramedic’s patient care report (PCR) be released to the attorney. If this Immunity and Defense report is released, the Paramedic is not required to appear at Immunity is a special privilege which, as used in the civil law, that time. means that the person or entity with immunity is exempt or Every report must be authenticated before it can be cannot be sued or held responsible for torts. The idea is that entered into the court’s record as evidence. To authenticate it is in the public interest that these entities not be sued. The the PCR, for example, the Paramedic may be given a copy practice of governmental immunity stems from old case law in court and asked to testify that the item is a true and that essentially stipulates that a citizen of the crown cannot accurate copy or that it is the original document. Another sue the king. means of authenticating the PCR that may be acceptable in Governmental immunity (also called sovereign some instances is to have a notary public, a person who is immunity) means that the government is exempt from liability 88 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. for torts committed by its employees except to the extent that water in the drug vial. Later a patient in pain received the it has consented by statute to be sued. substituted sterile water and suffered harm (pain) because As is relevant to the Paramedic, immunity
is usually there was no drug in the vial. granted when the Paramedic is required by law to report a The incidences of summary dismissal and summary crime, called mandatory reporting, and the Paramedic does judgment are both low because there are usually issues of so in good faith. Paramedics may be required to report child fact to be decided at trial. Judges also tend to prefer that each abuse, sexual assaults, gunshot wounds, certain communicable party has its opportunity to present its case in court. diseases, and animal bites. In fact, the failure to report these The best defense against a successful lawsuit is to conditions, as required by law, may leave the Paramedic with practice within the Paramedic’s scope of practice, to practice some personal liability for failing to report. to the standard of care within the EMS system, to observe States have limited or restricted their immunity over the the patient’s rights, and to document one’s actions completely years. It is more infrequent that EMS employees of state, local, and thoroughly.12 or federal government are granted governmental immunity. Patient Consent Motions in Court Paramedics have both an ethical and legal responsibility to During a trial, both the plaintiff and the defendant can request preserve the patient’s right to self-determination. In 1914 that the judge accept a motion. A motion is a request to the Supreme Court Justice Benjamin Cardozo said “every human judge for some action (i.e., dismiss the case, order a party to being of adult years and sound mind has a right to determine do something, postponement, cease and desist orders, etc.). what shall be done with his own body.”13 When a Paramedic A motion can be verbal, but is most often a written request helps to preserve this right it encourages patient autonomy, that contains pertinent points for the judge to consider. which in turn can lead to a more open dialogue and more For example, the attorney for the defendant, the rational decision making by the patient. Paramedic, may make a motion for summary dismissal based The importance of preserving patient autonomy cannot be upon the facts in the case, stating that the facts of the case are overstated. One of the leading causes of lawsuits by patients clear and without dispute. A lawsuit may also be dismissed against physicians, as reported in a National Academy of if the time from the occurrence of the incident to the time of Sciences study, was the lack of rapport between patient and fi ling the lawsuit has exceeded the statute of limitations. The physician leading to increased mutual mistrust. statute of limitations simply states that a plaintiff (usually the Patient-oriented medical care has not always been the patient) cannot commence a lawsuit after a certain amount of policy in medicine. In the past, physicians, in a form of time has passed. benevolent paternalism, expected patients to comply with The statute of limitations is handled differently in the case their instructions without question and to leave the medical of a child. Typically, the state permits the child to reach an age decisions to them. of majority, between 18 and 21 years of age, and then adds The landmark 1972 case Canterbury v. Spence may have the additional time to permit the lawsuit to be commenced. changed the nature of the physician–patient relationship. Therefore, in a pediatric case, it may take 10 years or more During that case the judge decided “it is the prerogative of before a case is commenced and more time for it to be fi nally the patient, not the physician, to determine for himself the resolved.11 direction in which his interests seem to lie . . .” The defendant’s attorney may also request summary Implicit in this statement is the concept of patient dismissal, claiming that the court does not have jurisdiction education and self-disclosure.14 The trend in medicine is now in the matter. Jurisdiction is usually established early in the toward more patient involvement in decisions that directly case. If there is a jurisdictional problem in that the plaintiff affect the patient. This is now viewed as a matter of right. commenced the lawsuit in the wrong place, then the case may be dismissed in that court. However, a new case would likely then subsequently be commenced in a different court or court Disclosure system which would have jurisdiction. One of the fundamental precepts of patient consent is The plaintiff ’s attorney may request a summary judgment disclosure. Disclosure is an open dialogue between patient awarding judgment to the patient based solely on the papers and provider in which the provider tells the patient about the submitted to the court. The concept of negligence per se is procedure, including its attendant risks, and recommends a case where summary judgment might be granted for the the procedure to the patient. It is therefore implicit that the plaintiff. Negligence per se occurs when the Paramedic Paramedic will get the patient’s consent, or authorization, committed a criminal act, and the patient was injured as a result before continuing with the procedure. of that criminal act. The assumption is that the Paramedic’s An issue crucial to disclosure is the extent of the negligence fl ows from the criminal act. An example of information required to be disclosed. The Paramedic should negligence per se might be the case where a Paramedic was provide the patient with information that is material to the diverting narcotics for personal use and substituting sterile situation at hand. For example, the patient should be informed The Law and Paramedics 89 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. how the procedure will help the patient. As an example, before Voluntariness starting an intravenous access, the Paramedic could explain The patient’s consent must be voluntary and the patient cannot to the patient that having an intravenous access allows the be coerced into consenting. However, a limited explanation Paramedic to administer drugs more quickly. of the procedure by the Paramedic, without an offer to ask The patient should also be told of the risks that can questions or to withdraw permission, might be construed to reasonably be expected as a result of the procedure. This is be coercion. The patient in the back of an ambulance is left called foreseeable harm. It is not necessary to provide the with few options. For example, the patient cannot get up and patient with an exhaustive explanation of the risks of the leave when the ambulance is moving and may feel compelled procedure or medication. The patient should be provided a to agree with the Paramedic. The Paramedic should make short list of the most common reactions or consequences every effort to ensure that the patient is comfortable with the (e.g., pain at the insertion site of an IV). decision made. Immediately following the explanation, the Paramedic should offer to answer any questions the patient may have. The Paramedic should also advise the patient that he or Permission she can withdraw permission, or withdraw consent, for the Following the explanation and an opportunity for the patient to procedure at any time. ask questions, the Paramedic should then ask for permission to proceed. In most cases the permission is going to be verbal. Understanding Every effort should be made to have the permission confi rmed by another person, a witness, who can attest to the patient’s For a valid legal consent to occur, the patient must be of capacity, the explanation’s content, and the patient’s consent. sound mind (possess the intelligence and presence of mind) to The Paramedic would then follow-up the verbal understand what is being said to her.15 An explanation offered permission with a notation on the PCR. to an incoherent patient who then consents is not informed consent. Inherent in the concept of informed consent is that BARNACLE the patient must have the capacity to understand what is being offered. Some Paramedics use the mnemonic BARNACLE to ensure If the patient is under the infl uence of drugs or alcohol, that they have completed all of the necessary steps in obtaining that patient may not have the capacity to consent. A question an informed consent (Table 6-1). arises when a patient has had a few drinks but is not The (B) in BARNACLE stands for benefi ts. Were the intoxicated. In those situations, the Paramedic is advised to benefi ts of the procedure explained to the patient? Next, contact medical control for direction before proceeding. were the alternatives (A)—for example, that consent can Other medical conditions can also impair a person’s ability be withdrawn—explained to the patient? Then, were the to think, and therefore consent. Fever-induced delirium, acute reasonably foreseeable risks (R) explained to the patient as stress reaction, medication-facilitated impairment, and organic well as the nature (N) of the procedure? Then, was the patient brain syndromes are just a few of the medical conditions that given satisfactory answers (A) to the patient’s questions? The can preclude a patient from making an informed decision. patient should be advised that he can withdraw his consent The patient must also have the legal capacity to (C) at any time. If the patient does withdraw consent, what understand what is being offered.16 Therefore, capacity is not are the reasonable consequences if he lacks (L) the treatment? only a matter of the patient’s mental state but age as well. Finally, were all explanations (E) offered in terms that the In general, the patient must be of legal age (i.e., the age patient could understand? of majority) in order to consent. In most states the age of majority is 18 years of age, though some states have set the Emergency Exception age of majority at 21 years old. In some cases, the delay created by a lengthy explanation There are some notable exceptions to the age of majority might compromise the patient’s health. In those cases it is and ability to consent.17 Adolescents below the legal age of majority can consent to limited health care. For example, they can consent to treatment for venereal diseases, drug Table 6-1 BARNACLE abuse, and birth control. Otherwise, these youths must have B Benefi ts of procedure parental permission, discussed further in the chapter, before A Alternatives to procedure they can receive health care, including EMS. The reasoning R Risks of procedure for these special exceptions is that laws provide for them due N Nature of procedure to societal determinations that they are in the best interest of A Answers to patient questions C Consent to rights of patient a greater public good: fewer teenage pregnancies, a decrease L Lack of treatment consequences in sexually transmitted disease (STD), and decreased drug E Explanations understood addiction. 90 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. understood that, provided the Paramedic is practicing to the decisions about health care. Even if the decision is poor, in standard of care, the patient would want that care. An example terms of negative consequences, the patient still has the right would be intravenous access. Intravenous access, seen on to make that decision. television and in the hospital, is so commonplace that patients can reasonably expect to understand that an IV will be started Types of Consent by a Paramedic, and that the patient understood the benefi ts Expressed Consent and risks of such a procedure when 9-1-1 was called. While an emergency exception may clearly be of benefi t In a typical medical environment, such as a hospital or to the patient during a crisis, not every call for EMS
is an doctor’s offi ce, before performing any medical procedure emergency. Therefore, a Paramedic should practice obtaining the physician must provide a complete verbal explanation, or informed consent whenever possible and reasonably practical. written justifi cation, to the patient and then obtain a written or verbal consent from the patient. Obviously, this takes time Therapeutic Privilege as well as requires an alert and aware patient. Thus, it is not always practical during an emergency. In rare instances, it is acceptable to withhold information During an emergency, a patient allows a Paramedic to from a patient for the patient’s benefi t. For example, it may initiate care and indicates consent by either gesture or verbal be inappropriate to disclose unhappy news to a depressed acknowledgment. Or, if the patient does not object to receiving patient who has threatened suicide. The case of Canterbury care, then expressed consent is assumed.18 v. Spence established that when the disclosure poses a threat When practical, a Paramedic is well-advised to try or detriment to the patient, then disclosure is contraindicated and obtain a verbal consent for specifi c procedures, such from a medical point of view. as starting an intravenous access, and particularly for At fi rst glance, this may appear to be a form of parentalism, uncommon procedures such as elective cardioversion. A discussed earlier, but the key difference is that the deception request for permission, accompanied by a simple explanation, has a therapeutic value to the patient in and of itself. Examples can improve patient compliance and decrease the risk of of the use of therapeutic privilege include the use of placebos, misunderstanding. medically inert drugs and shams, and procedures performed The essential aspect of patient consent is the fact that the that are not helpful or harmful to the patient. patient is informed of the benefi ts and risks of the procedure and then makes a rational decision based on that information. Waiver of the Right to Consent Whenever a patient can make an informed consent it Some patients will summarily waive their right to consent, strengthens the physician–patient relationship. permitting the Paramedic to treat the patient’s condition to the standard of care. A statement such as “do what you think Implied Consent is best” is an example of a waiver of the right to consent. This When a patient is unconscious and unable to speak for himself, waiver should be noted in the PCR, verbatim if possible, and then Paramedics can treat the patient under the doctrine of witnessed by another EMS provider. implied consent. Under implied consent, it is assumed that the patient would consent if awake and capable of consenting. Advantages of Consent Implied consent is assumed even if the patient was Consent protects the patient’s right to choose (autonomy) and refusing care moments before going unconscious because it thereby strengthens the trust between provider and patient. is thought that the patient, suddenly faced with the reality of When important patient care decisions are made jointly, it his mortality, would have changed his mind. increases the patient’s responsibility as well as protects the Implied consent is not applicable if there is a healthcare proxy Paramedic’s tolerability for a poor outcome. or an advanced directive available; both are discussed later in the Informed consent, as opposed to no consent, also chapter. In those cases, the consent from the healthcare proxy decreases the danger of complaints about fraud, deception, or must be obtained. Otherwise, the express wish of the patient, duress. These charges, once levied, are hard to deny without outlined in the advanced directive, is to be honored. the presence of an informed consent. Perhaps more importantly, consent can also have a Involuntary Consent therapeutic benefi t in and of itself. Patients naturally fear the When a law enforcement offi cer (LEO) places a person in unknown; informed consent provides them with reassurance, custody, that person no longer has the freedom of movement. decreasing their anxiety of the unknown in the process. The This condition makes the person necessarily dependant upon therapeutic impact of knowledge to an anxious patient can the offi cer for his or her safety and welfare, including health reduce some of the negative physiological consequences of care, while in custody. sympathetic stimulation generated by fear. During a life or limb emergency an offi cer can provide Finally, the American Hospital Association’s Patient’s consent for the person in custody (e.g., a prisoner). This Bill of Rights states that the patient has the right to make type of consent is called involuntary consent.19 Involuntary The Law and Paramedics 91 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. consent is usually reserved for true emergencies; the police adults who have children entrusted to their care can, and are power to provide consent is not generally invoked for minor expected to, seek medical attention for the injured or ill child emergencies or elective procedures. in an emergency. This status is called loco parentis. The patient who is under the control of mental health If there is no parent, relative, guardian, or duly- offi cials is in a similar circumstance. Some, but not all, empowered adult present, then the child can be treated in mental health patients are admitted involuntarily; that is, they a modified form of implied consent called the emergency are mandated into treatment. In those cases, permission for doctrine. The emergency doctrine holds that if the parent treatment is obtained from mental health offi cials, not the was present the parent would want the child treated and patient, in another form of involuntary consent.20 transported to the hospital. The emergency doctrine is usually invoked only in cases of life or limb-threatening Emancipated Minors emergencies. Every effort should be made to contact the In some special circumstances patients who are below the age parent, guardian, or responsible adult to obtain consent. of majority are permitted to give informed consent, provided In rare cases, a parent may refuse treatment and they are capable of understanding the consequences of their transportation for a child. The diffi culty lies when the parent decisions and that they are not impaired by alcohol or drugs. refuses care beyond reason and the child is in obvious need This special class of youths is called emancipated minors. of such care. Paramedics should not become confrontational In some states youths under the age of 18 may get married with the parents but continue to gently, but fi rmly, insist that with parental permission. Once married, the husband and a physician see the child. If the parent still refuses, it may be wife are considered to be adults and are treated, for purposes necessary to involve a law enforcement offi cer and invoke of health care, as emancipated minors. A similar situation is child protective laws. created when adolescents under 18 years of age enlist in the In these limited cases, the offi cer may take protective armed forces. custody of the child, citing child protective laws, and the In the majority of states, once an adolescent female is a offi cer will give permission to treat and transport the child mother she is treated as an adult. These teen-aged mothers pursuant to a form of involuntary consent. In this case, are capable of consenting for treatment for both themselves the parents may be charged with child abuse or neglect by and their children and are considered emancipated minors. appropriate authorities. However, every effort should be An adolescent, living away from home and without made to reason with the parent before such a heavy-handed support from the family, may also petition the court for status approach is taken. as an emancipated minor. Once the court decree is issued the adolescent can consent to health care. Medical Restraint Pediatric Consent Paramedics may encounter a patient experiencing a behavioral emergency, abnormal or bizarre behavior Children, by virtue of their age, are usually unable to consent, that may include violence or threats of violence. except for the very limited healthcare services that were Paramedics, unsure of the cause of the behavior (e.g., discussed earlier. A parent or legally appointed guardian must drug intoxication,toxicological emergency, or psychiatric provide consent for them. emergency), may need to institute a medical restraint Obtaining consent from a parent to treat a child is the and treat and transport the patient against his or her will. same as obtaining consent to treat an adult. The parent must Each state usually has a mental health law which be capable of understanding the consequences of a decision provides for the involuntary restraint and transportation to accept the treatment, the risk/benefi t, as well as the of a mentally disturbed person to a medical facility for consequence if treatment is refused. treatment. The applicable law may provide for whether or However, the Paramedic must be prepared to answer not a law enforcement offi cer can or must be present. When more questions about the procedure and may need to confronted with such a situation, the Paramedic should use include the child in the discussion, depending on the child’s every persuasion to encourage the patient to go voluntarily: developmental age. a “talk ’em down before taking ’em down” approach. In a situation in which the patient does not want to go Pediatric Consent without a Parent voluntarily, it may be necessary for either the Paramedic or Problems occur when a child is hurt and no parent is the offi cer to invoke the mental health law and to restrain a immediately available to consent to the child’s treatment and patient in order to protect the patient from himself or herself transportation. or to protect others from the patient. If the child has been left in the custody and care of another The American College of Emergency Physicians (ACEP), adult (e.g., a schoolteacher) then that adult has the authority in their position paper on the use of restraints, states that to provide consent. Parents are frequently asked to complete these emotionally disturbed patients, who are usually either permission slips, slips that permit the school’s agents (e.g., homicidal or suicidal, need to be treated with respect while teachers, coaches, and aides) to act in the parent’s stead. These under these trying situations and afforded as much dignity as 92 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 6-1 Proper use of extremity restraints in opposing directions. possible. Furthermore, restraints should be applied humanely with only the minimum amount of force needed to effect the medical restraint. In some instances it is better to leave the actual act of physical restraint to police offi cers who are trained in restraint procedures. Once restrained, handcuffs and other police restraint devices should be removed as soon as is practical. They should be replaced with other more humane restraint devices, such as padded-leather restraints, wide-band cravats, and the like. Regardless of the restraint device used, the Paramedic should be trained in the use of that device. Following restraint, it is imperative that the Paramedic periodically reassess the patient and document the continued need and use of restraints. The least restrictive, but effective, restraint should be used (Figure 6-1). Positional Asphyxia Sometimes during a restraint a patient will become so agitated and combative that he will enter a state of excited delirium. When in excited delirium the patient will be tachycardic, hypertensive, and have hyperpyrexia. In some instances, the condition is worsened by the presence of sympathomimetic drugs such as methamphetamine or cocaine. Patients in a state of excited delirium who have been restrained and then placed face down
rapidly tire from the restricted breathing. They become hypoxic, a process called positional asphyxia, and then subsequently go into cardiac arrest. While positional asphyxia is uncommon, there have been “in-custody” deaths of patients who have been physically restrained and placed face down. This is especially so if the patient has been “hog-tied” (ankles and wrists tied together behind the back) (Figure 6-2). Figure 6-2 Patients should NOT be “hog-tied.” The Law and Paramedics 93 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. While the exact etiology of this cardiac arrest has been be taken will ultimately rescind their refusal when the patient debated, most healthcare providers agree that restraining senses the genuine concern on the part of the Paramedic. a patient face down poses a signifi cant risk of positional Many EMS agencies have a standard refusal of care form, asphyxia and subsequent cardiac arrest. Whenever possible, crafted by attorneys, for use in the fi eld (Figure 6-3). To be the restrained patient should be placed face up or supine and effective as a form of notifi cation, the patient should receive a not “hog-tied.” copy of the RMA form. Most agencies also require a witness to the patient’s signature. Refusal of Medical Assistance While any adult can serve as a witness, the best witnesses are those who are not interested parties (i.e., someone who Every patient has a right to refuse care. Inherent in the right does not stand to benefi t fi nancially from a lawsuit). A witness to refuse medical care is the understanding that the patient is essentially assuring that the refusal was obtained without must fi rst be able to consent to care before he or she can duress and that the signature is authentic, not that the patient refuse care.21 In the case where the patient can consent, understood the explanation offered. and yet still refuses care, the Paramedic needs to carefully proceed with a refusal of medical assistance (RMA). Against Medical Advice An exploration of the reason for refusal can sometimes reveal issues or problems that can be easily resolved. For Some patients refuse care in opposition to all logic when example, some patients lack insurance and are concerned confronted with a clear and immediate danger to their health. about their ability to pay for the services they need. It is These patients are deciding, against medical advice (AMA), important that they understand that their health supersedes to not go to the hospital.22 In those cases the Paramedic is any fi nancial considerations and arrangements can always be advised to contact medical control for direction and advice. made to ensure that the patient can get the help that is needed. In some instances, the patient may still be permitted to Most hospitals and many EMS services are obligated, by refuse care but the input of the physician often provides the federal law, to provide free service to impoverished people. patient with the incentive to accept care and transportation.23, 24 If the patient remains resistant, the Paramedic should Also, the Paramedic then has the knowledge that he or she did proceed with a complete description of the illness or injuries all that could be done to convince the patient to seek medical that he or she has sustained and the potential complications care immediately. that could arise if the illness or injuries are not treated. However, the situation is different in the case of children. A seriously ill or injured child needs to be seen by a physician. If the parents refuse to permit the child to be seen, and it is clearly a life-threatening situation, then a police offi cer Street Smart should be summoned to the scene. The offi cer may have to take the child into protective custody in order to get the child In many cases, an injury or illness, unchecked, can to treatment. lead to permanent disability and even death. Some agencies require that Paramedics list the foreseeable Destination complications, including death, on the PCR. The Generally, patients are transported to the closest appropriate Paramedic must then ask the patient to read the PCR medical facility. If there are several reasonable options within out loud and then sign it. The “death warrant,” as approximately the same distance, then the patient is often given the choice of hospitals. it is commonly known, serves several functions. For Increasingly, hospitals are becoming more specialized one, the patient must be able to read and understand and the appropriate medical facility may not be the closest or the English language. Asking for the text to be read the patient’s choice. Under a restricted set of circumstances or aloud establishes that the patient both read and conditions, a patient may be diverted from the closest hospital to a hospital equipped to handle the patient’s particular understands the foreseeable consequences of refusal. emergency. The fi rst example of a specialty center may have been the trauma center. A trauma center has some very unique capabilities If the patient remains adamant in her refusal of treatment which permit it to provide the highest level of care for certain and/or transportation, then the Paramedic should advise the traumatic injuries. In general, Paramedics are permitted to divert patient of alternatives. Alternatives may include seeking to these trauma centers based upon authority granted within a set private medical care and calling EMS again if desired. of state, regional, or local protocols. Finally, it is important that Paramedics offer assistance With the likely future development of specialty care to the limit that the patient will accept. Frequently, patients centers, at some point Paramedics may divert to such who initially accept a bandage and then permit vital signs to specialty hospitals as cardiac care centers, with interventional 94 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Rensselaer County Emergency Medical Services REFUSAL OF MEDICAL CARE, TREATMENT, AND/OR TRANSPORTATION PCR NUMBER: ________________ DATE: ________________ TIME: ________________ PATIENT: I understand that competent persons maintain the right to refuse medical care, treatment and/or transportation. I, ________________________________________________, hereby acknowledge that I have been advised by members of the ___________________________________________[AGENCY], that they recommend that I receive medical care, treatment and/or transportation to a hospital emergency department for further evaluation by a physician. I further understand that I may refuse medical care, treatment and/or transportation, but do so at my own risk. I do not have any known physical or mental condition that would prohibit me from making an informed, competent, and intelligent decision to refuse the medical care, treatment and/or transportation that has been offered and recommended. THE RISK ASSOCIATED WITH REFUSAL MAY INCLUDE POSSIBLE LOSS OF LIMB OR LIFE I HAVE ALSO BEEN ADVISED THAT IF I DEVELOP ANY MEDICAL COMPLAINTS OR SYMPTOMS, I SHOULD IMMEDIATELY CONTACT AN AMBULANCE, HOSPITAL EMERGENCY DEPARTMENT, OR MY PHYSICIAN. I hereby release ________________________________________[AGENCY], its, offi cers, agents, personnel, and employees from any and all claims, causes of action or injuries, of whatsoever kind or nature, arising out of or in connection with my refusal of medical care, treatment and/or transportation. Patient’s Signature: ________________________________________________ Date: _________________________ Patient’s Name (print): ______________________________ Patient’s Age: _______ Patient refused signature: _______ FOR MINORS OR PERSONS WHO HAVE GUARDIANS: I am the patient’s legal guardian. My relationship to the patient is _________. I am hereby acting on behalf of the patient, ________________________________________[PATIENT’S NAME]. I have read the above information and refuse medical care, treatment and/or transportation on behalf of the patient. Guardian’s Signature: ____________________________________________ Date: _________________________ Guardian’s Name (print): ______________________________ Guardian’s Full Address: ___________________________ ___________________________ WITNESS: I, _________________________________________, witnessed members of the ______________________ ___________________________[AGENCY] recommend to the patient medical care, treatment, and/or transportation to a hospital emergency department for further evaluation and attention. I further witnessed the above-named patient (or patient’s guardian) decline such medical care, treatment, and/or transportation. Witness Signature: _____________________________________ Date: _________________________ Witness Name (print): ___________________________________ Witness’ Full Address: ___________________________ Occupation: _____________________________ ___________________________ EMS PROVIDER: I, ___________________________________________[EMS PROVIDER], have offered and recommended to __________________________________________[PATIENT’S NAME OR GUARDIAN’S NAME], emergency medical care and treatment, including transportation to a hospital. The patient (or patient’s guardian) has refused my recommendation for medical care, treatment, and/or transportation. I have fully explained the reasons for medical care, treatment, and/or transportation to the patient (or patient’s guardian). I have also explained this form to the patient (or patient’s guardian) and have requested that he/she personally read it. The patient (or patient’s guardian) has expressed to me an understanding of the information contained herein and did not have any questions regarding the content of this form. The patient (or patient’s guardian) did not appear to me to be suffering from any illness or injury nor any condition that would affect his/her ability to refuse medical care, treatment, and/or transportation. The patient (or patient’s guardian) is alert and oriented to person, place, time, and situation. EMS Provider Signature: ______________________________________ Date: _________________________ Provider Certifi cation Level / NYS ID Number: ______________________ Police Agency Present: NO _____ YES _____ Police Offi cer’s Name: ____________________________ Police Agency Name: ______________________________ Figure 6-3 An example of a refusal of medical assistance form. (Reprinted with permission of Rensselaer County Emergency Medical Services) The Law and Paramedics 95 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. cardiology capabilities, and stroke centers, with rehabilitation The state of Missouri interceded, stating there was no facilities, for example. “clear and convincing evidence” that Ms. Cruzan did not Diversion should only occur under express authority of want to live this way. The appeals for this decision went all medical control and when the patient has been fully appraised the way to the U.S. Supreme Court, who upheld the lower of the risks associated with refusing to go to the specialty courts’ decision. hospital. Subsequently, several of Ms. Cruzan’s friends came forward and testifi ed, under oath, that they had had conver- Advanced Directives sations with Ms. Cruzan in the past and that she indicated she would not want to live in a persistent vegetative state. The development of new life-saving technologies is accom- Had Ms. Cruzan made her intentions known to others panied by questions about the quality of life in terminal earlier, or in a more defi nite manner (e.g., in a written letter), illness and prolongation of suffering.25 These advances have the controversy would have been averted. coincidentally occurred at a time when patient autonomy The Cruzan case helped to establish the concept of is increasingly being asserted. Together, the two trends have advanced directives, a central tenant in the right to die combined to create a confl ict between paternalistic physicians movement. Advanced directives, written declarations of who have always had dominion over life and death decisions patient intent during specifi c circumstances, are designed and the patient’s wishes regarding the quality of his or her life. to provide guidance when a patient is threatened with an Several landmark cases have had a tremendous impact existence in a persistent vegetative state or affl icted with a upon these decisions, changing the entire fabric of medical terminal illness. decision making in the process. Case of Karen Ann Quinlan Principles of Advanced Directives Four core principles are included within the concept of Karen Ann Quinlan was found unconscious following advanced directives. These principles
provide a foundation suspected ingestion of barbiturates and alcohol at a party. which sustains an advanced directive. Following mouth-to-mouth resuscitation, Ms. Quinlan The fi rst principle is that competent people can refuse recovered but remained in a persistent vegetative state (PVS). medical treatment, even at their own peril. This statement Her family, witnessing her body waste away and given no affi rms the patient’s right to self-determination. hope for a recovery to a meaningful life, requested that the Next, the interests of the state are subordinate to the will mechanical ventilator supporting her be removed and that of a competent patient. If the competent patient, meeting Ms. Quinlan be allowed to die peacefully, in other words, all of the conditions of consent described earlier, makes a “death with dignity.” decision about his or her health care, then that decision is The state took the position that such an act, removal of inconvertible. the ventilator, would cause her death and therefore constitute The third principle supports making healthcare decisions criminal homicide. The state sought to prevent the family in a healthcare setting as opposed to a court room. The idea is from removing Ms. Quinlan from the ventilator. that the best patient care decisions are made by a partnership The family felt that Ms. Quinlan, a devout Catholic, of physician and patient and that the courts are used only would not want to live by these extraordinary means, and when an impasse is reached. that decisions on her behalf were a private family matter. The The fourth principle states that if a patient lacks the family also felt the state’s position constituted an invasion of ability to make decisions, then the patient may assign privacy (i.e., the patient’s right to self-determination). a surrogate decision maker in her stead. A surrogate The New Jersey Supreme Court ruled in favor of the decision maker has the responsibility to know the patient’s family, stating that the family’s right to privacy extends to preferences and must place the patients’ wishes before the matters of life and death. Ms. Quinlan was removed from the surrogate’s wishes. This level of understanding usually ventilator, started to breathe spontaneously, and survived for involves a personal dialogue between the two individuals almost a decade. and frequently results in a written statement that helps to The importance of the Quinlan case was that it recognized support the decision maker. the patient’s right to make life and death decisions and If the surrogate decision maker knows the patient’s preserved the patient’s autonomy. That case helped initiate wishes, then, in certain situations, the surrogate makes the right to die movement. the decision in a process called substituted judgment. If the surrogate decision maker does not know the Case of Nancy Cruzan patient’s wishes for the specifi c situation that he or she is Nancy Cruzan was a young woman left in a persistent vegetative being presented with, but does know the patient’s wishes state (PVS) following head injuries sustained in a motor for similar situations, then the surrogate must make a vehicle collision. Faced with the prospect of a bleak future, decision on the presumption of what is in the patient’s best the family wanted Ms. Cruzan’s tube feedings stopped.26 interest. 96 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Patient Self-Determination order (sometimes called a Do-Not-Attempt-Resuscitation Act of 1990 (DNAR) order). Paramedics are expected to honor a DNR order and In 1990, following the public’s growing insistence that the not commence cardiopulmonary resuscitation (CPR), patient should control the personal healthcare decisions, defi brillation, or other advanced life support measures when Congress passed the Patient Self-Determination Act presented with a DNR. (PSDA).27 The confusion lies in which treatments are life-sustaining Regulations within the act required hospitals to provide versus life-prolonging. The provision of supplemental oxygen notice to all patients that they have several rights. First, the (e.g., via a partial rebreather mask) is generally considered to patient has a right to participate in and direct her own health be life-sustaining and therefore acceptable. However, assisting care. Next, the patient has the right to refuse medical and/ ventilations with a bag-valve-mask assembly is thought to be or surgical treatments, up to and including the use of life- life-prolonging and therefore unacceptable. saving or life-preserving technologies. The patient also has It is important that Paramedics establish with their a right to prepare an advanced directive, and the hospital medical directors, beforehand, which treatments are life- should assist the patient with preparing an advanced sustaining and which are life-prolonging. directive. Finally, the hospital has a duty to assist the patient There is general agreement that the provision of pain with those decision-making activities such as preparation of medication, for the purpose of palliative care, is life-sustaining advanced directives, designation of a healthcare proxy, and and therefore acceptable. All forms of comfort measures assistance with the institution’s policies on how to utilize (i.e., palliative care, including suctioning, repositioning, and those rights. analgesia) are considered humane and merciful. Types of Advanced Directives Physician’s Order The intention of an advanced directive is to give the patient of Life-Sustaining Treatment control over her own body and to provide guidance to others Physician’s Order of Life-Sustaining Treatment (POLST) on how to proceed with healthcare decisions. In addition, is a more detailed description of the patient’s wishes, placed these advance directives afford healthcare providers some in the form of a physician’s order. This program was started in immunity from criminal or civil prosecution for making Oregon in 1991 as an answer to the issues that routinely occur decisions or taking actions on the patient’s behalf. in patients who may have a DNR order, but who have not yet There are several advanced directive instruments which progressed into cardiopulmonary arrest. Most states in the meet these objectives. The fi rst, and perhaps original, United States only allow Paramedics to honor DNR orders advanced directive instrument is the living will. The living once the patient has become pulseless and apneic. They will, drawn up by a patient, and perhaps an attorney, details also do not allow Paramedics to honor living wills or other the patient’s wishes regarding specifi c healthcare decisions. advanced directives. The advantage of the POLST program A living will might preclude certain treatments using is the forms that are generated through a discussion between terms such as “extraordinary treatment,” “heroic measures,” the patient and their physician that address specifi c situations and “artifi cial life support.” The use of these imprecise including utilizing artifi cial hydration, nutrition, intubation, terms has led to confusion and are ineffective if death is antibiotics, and other medical therapies. Many states that not imminent. The states of New York, Massachusetts, and have instituted POLST programs allow Paramedics to follow Michigan have rejected the use of living wills as the language these orders. therein was not “precise and convincing.” These states and many others preferred the creation of a durable power of attorney for health care (DPAHC). A DPAHC is a surrogate Confi dentiality decision maker, one who uses substituted judgment to guide the patient’s healthcare decisions. An aspect of patient trust and provider veracity is the patient’s The healthcare proxy, the title for the person who has assumption of confi dentiality. Inappropriate disclosure of a DPAHC, has a responsibility to review the medical record, sensitive patient information would be a failure on the part of to consult with healthcare providers, and to give consent to the Paramedic and may well have a chilling effect on future either initiate or to refuse care. Paramedic–patient relations. For this reason Paramedics share patient information only with those on a need-to-know basis. The duty of maintaining patient confi dentiality stems Do-Not-Resuscitate Orders from a person’s right to privacy. In the past, this was more of At some stage during the progression of a terminal disease a professional duty than a legal right. However, current laws the patient, or healthcare proxy, may decide that any artifi cial protect a patient’s confi dentiality to a greater extent. life support would be futile and that death is inevitable. In A breach of confi dentiality should not be confused those cases, the physician, after consultation with the patient with libel or slander. Libel occurs when a falsehood which or healthcare proxy, will issue a Do-Not-Resuscitate (DNR) is damaging to a person’s reputation is written or printed The Law and Paramedics 97 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. and then disseminated to the public. Slander occurs when Health Insurance Portability defamatory lies about a person are told to others. Libel and and Accountability Act slander involve the telling of an un-truth, whereas a breach of confi dentiality is an act of unauthorized disclosure of private The U.S. Congress passed the Health Insurance Portability and personal patient information. Both libel and slander are and Accountability Act (HIPAA) in 1996.28, 29 HIPAA provides actionable in a court of law. for criminal penalties for inappropriate disclosure of patient information. It also establishes a number of protections for Breaches of Patient Confi dentiality the patient’s right to privacy. HIPAA was enacted, in part, to stem the electronic transmission of patient information to A patient’s confi dentiality can be broken under some very unauthorized parties. specifi c circumstances. The American Medical Association HIPAA restricts the distribution of confi dential patient (AMA) acknowledged this in a position paper which says information to only those with a legitimate interest, such that a physician may breach a patient’s confi dentiality when as consulted healthcare professionals, those providing required to do so by law. patient treatment, coding and billing offi ces, and specifi c As stated earlier, the courts hold the physician–patient managerial functions, such as quality assurance and relationship in high regard. Before making a decision to utilization review.30 Patient information may be used abridge a patient’s rights to privacy, the courts weigh the good for training and education provided that all identifying of the community and the protection of the physician–patient information is removed or the patient consents. relationship versus the individual’s rights. The disclosure is HIPAA also requires that every healthcare agency, then limited to that which is necessary to the issue so as to including EMS, appoint a privacy offi cer. The privacy offi cer protect the patient’s privacy rights. is responsible for patient record security, record security Situations in which a Paramedic might be compelled by awareness training of all employees, as well as implementing law to disclose confi dential patient information may include a privacy protection plan within the agency. gunshot wounds, contagious diseases, and/or child abuse and In the future, Paramedics may be required to provide those cases where it is necessary to protect the welfare of patients with a notice of privacy practices for the EMS agency. another individual or the community. Laws in each state or That may include information about what confi dential patient jurisdiction may vary and the Paramedic should be familiar history is considered to be protected health information with applicable statutes that may impact him or her. (PHI). Limited Disclosure Disclosure to Law Enforcement The number of people who are directly, or indirectly, On occasion, law enforcement offi cers will request specifi c connected to the care of one patient is incredible. Literally information about a patient. In most cases, the disclosure dozens of people, from bedside caregivers to support services, of confi dential patient information to another could be a to utilization review, billing, and quality assurance, all have violation of the HIPAA regulations. Generally, the offi cer access to
a patient’s confi dential record. should be provided with information which is required by law. The concept of legitimate interest comes into play when The patient’s name and address can be shared but all other deciding if patient information should be shared. A Paramedic requests for information should be denied until the patient should only provide confi dential patient information to those signs a release of information or a subpoena is served.31 who have a need to know, and then only to the extent that that is needed. For example, an admission clerk does not need to know the patient’s HIV status, yet does need to know if the Employment Law patient has been previously admitted. A notable portion of The Paramedic, whether career or volunteer, is an employee people in the medical chain will need confi dential patient of the EMS agency. As such, the Paramedic is afforded certain information (Table 6-2). protections as a result of Congressional acts. The following is a gross overview of those laws which may pertain to the Table 6-2 Information Dissemination Paramedic. Other laws, both local ordinances and state statutes, may also apply to the Paramedic. Therefore, every • Paramedic Paramedic is advised to become aware of the relevant legal • ER MD and RN environment and seek legal counsel when appropriate. • Billing clerk • Utilization reviewer Americans with Disabilities Act • Infectious disease RN Congress passed the Americans with Disabilities Act • Public health service (ADA) to protect those citizens who had suffered hardship • CDC or discrimination from employers. The ADA prohibits • Media—reporting outbreak discrimination based on disability in hiring, promoting, training, and retiring. To be included in the class of protected 98 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. persons, the individual must have a permanent disability process. Most complaint processes start with an internal which limits full participation in the activities of daily living investigation of the inappropriate conduct and end with a (ADL). resolution that can vary from counseling and reassignment The ADA does not imply that, for example, the hearing- to termination. impaired person must be hired as a Paramedic. Clearly, some jobs require specifi c skills and capabilities. These skills and Amendments to Title VII capabilities are generally described in the position’s functional Since its passage through Congress, Title VII has had several job description. The tasks described therein are those that are amendments added. One of them, the Age Discrimination in needed to perform the function and exclude rare or marginal Employment Act (ADEA), prohibits the discrimination of job functions. those over the age of 40. Another, the Equal Pay Act, requires Perhaps more importantly, the ADA establishes that that pay be based on seniority or merit and not personal reasonable accommodations must be made, whenever preference. possible, which would permit the disabled person to function. EMS and the Fair Labor Standards Act (FLSA) have New technologies are ever increasing the capacity of disabled come into confl ict from time to time. The FLSA is intended citizens to perform varied and vital functions, many within to guarantee that all employees are paid the minimum wage EMS. as well as receive overtime for working extended hours past the normal workweek. Title VII Over the years, employers have created a large number Title VII, the Civil Rights Act, provides the employee with of work patterns and arrangements in order to meet the certain rights (e.g., freedom of religious expression, etc.). public’s demand for round-the-clock EMS coverage. These Recently, a great deal of notoriety has been given to the right arrangements include on-call pay, per diem pay, stipends, and of employees to be free of sexual harassment. the like. Some of these arrangements had to be modifi ed to Sexual harassment can be as blatant as demands of sex meet the requirements of the FLSA. in exchange for career advancement, a quid pro quo. In many cases, the charge of sexual harassment stems from a Family and Medical Leave Act perception of a “hostile working environment.” A hostile The Family and Medical Leave Act (FMLA) requires working environment is one that is intended to humiliate that employers with more than 50 employees provide or intimidate the worker because of gender. Examples of a their employees 12 weeks of unpaid leave for purpose of hostile working environment include displays of sexually childrearing. explicit pictures, uninvited kissing or embracing, or fl agrant Many employers have embraced the FMLA by creating sexual humor. family leave policies, believing that employees who are Every EMS agency should have a policy forbidding afforded the opportunity to establish their families and then sexual harassment and that policy should include a complaint return to work will be happier and more productive. The Law and Paramedics 99 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The acts, laws, and regulations which affect a Paramedic are intended to either protect the Paramedic or to provide for the patient’s protection. Careful attention to these laws, both in letter and in spirit, will help the Paramedic provide safe and effective care. Key Points: • Case law is developed from compiled case decisions • Good Samaritan laws protect healthcare providers and assures fairness through consistent application from liability for negligent acts that are performed of the law. in the course of providing assistance when there • is no duty to act or respond. Although these laws Different units or departments carry out various do not provide immunity from lawsuits, the Good functions of government. Each department may Samaritan acts do provide the Paramedic with be regulated by rules or regulations that are not legal defense to counter a complainant’s claim of statutory laws but carry the same force. negligence. • Criminal law is a violation of a person’s duties to • Standard of care is the care and treatment that the community; therefore, the prosecutor is the another Paramedic with the same or similar state and the case is tried in a criminal court. training would have rendered in the same or similar • An appeal is a request for the appellate court to situation. change the decision issued by the trial level court. • Malfeasance is the performance of an inappropriate • Civil law is the system of law concerned with private procedure. disputes between members of the community. • Misfeasance is the situation when a Paramedic • A tort is a civil or private wrongful act, other than a performs the right procedure but performs it breach of contract, resulting in some type of injury incorrectly. or harm (not necessarily physical injury). • Nonfeasance is the failure to perform the correct • Simple negligence is the Paramedic’s failure to or required procedure, which would be an error of exercise the degree of care that a prudent person, omission. under the same or similar circumstances, would • Damages are compensation awarded to the patient exercise. for some injury or loss. • Gross negligence involves intent on the Paramedic’s • The Paramedic is responsible for directing and part to willfully or with reckless disregard cause the supervising the patient care performed by any other patient harm. EMS providers on the team with less training than • For a tort of malpractice to be actionable against the Paramedic. a Paramedic, it must have the four elements of • The process of a civil lawsuit begins with the tort. First, the Paramedic must have a duty to Paramedic being served papers by a process server. act. Second, it must be shown that the Paramedic breached his duty (standard of care). Third, there • The purpose of the pretrial discovery phase is to is actual harm or damages as a result. Fourth, provide both parties with suffi cient information to proximate cause of harm must be shown. decide how to proceed with the case. 100 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • Immunity is usually granted when the Paramedic • If the child has been left in the custody and care is required by law to report a crime, called of another adult, that adult has been given loco mandatory reporting, and the Paramedic does so in parentis and has the authority to provide consent. good faith. • In rare cases, a parent may refuse treatment and • A motion is a request to the judge for some action. transportation for a child. If the parent still refuses • to give consent after attempts to convince him care The best defense against a successful lawsuit is to is needed, it may be necessary to involve a law practice within the Paramedic’s scope of practice, enforcement offi cer and invoke child protective laws. to practice to the standard of care within the EMS system, to observe the patient’s rights, and to • Paramedics may encounter a patient experiencing completely and thoroughly document one’s actions. a behavioral emergency. In a situation in which the • patient does not want to go voluntarily, it may be The signifi cance of patient consent is that the necessary for either the Paramedic or the offi cer patient makes a rational decision based on to invoke the mental health law and to restrain the information that the Paramedic provides. patient in order to protect the patient from himself • To obtain a valid legal consent, the patient must be or herself or to protect others from the patient. of sound mind and have the capacity to understand what is being offered. • Following restraint, it is imperative that the Paramedic periodically reassess the patient and • The patient’s consent must be voluntary and the document the continued need and use of restraints. patient cannot be coerced into consenting. The least restrictive, but effective, restraint should be used. • In rare instances disclosure is contraindicated from a medical point of view if the disclosure poses a • In the case where the patient can consent, and yet threat or detriment to the patient. still refuses care, the Paramedic needs to carefully proceed with a refusal of medical assistance (RMA). • Consent protects the patient’s right to choose, The Paramedic should proceed with a complete decreases legal charges against providers, and can description of the illness or injuries that he or she have a therapeutic benefi t in and of itself. has sustained and the potential complications that • could arise if the illness or injuries are not treated. A law enforcement offi cer can provide involuntary consent during a life or limb emergency when a • Paramedics should offer assistance to the limit that patient is in custody. Similar circumstances apply to the patient will accept. patients who are under the control of mental health offi cials. • Generally, patients are transported to the closest • appropriate medical facility. Circumstances may Emancipated minors are those youths under the age occur necessitating diversion from the closest of 18 who are married, enlisted in the armed forces, hospital to a hospital equipped to handle the or have petitioned and have legal documentation of patient’s particular emergency. emancipation. Also, once an adolescent female is a mother she is capable of consenting for treatment • High-profi le
cases such as the Quinlan case for herself and her children. emphasized a patient’s right to self-determination, • while the Cruzan case showed that written Similar to consent for an adult, obtaining consent directives would have provided guidance when in a for a child requires the parent to be capable of vegetative state. understanding the consequences of the decision to accept the treatment, the risk/benefi t, as well as • Types of advanced directives include the living will, the consequence if treatment is refused. healthcare proxy, and DNR order. The Law and Paramedics 101 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • In cases of a terminal disease, the patient, or • The Americans with Disabilities Act (ADA) prohibits healthcare proxy, may decide that any resuscitation discrimination based on disability in hiring, efforts should not be performed. A physician promoting, training, and retiring. The ADA also can issue a Do-Not-Resuscitate (DNR) order or a asserts that reasonable accommodations must be Do-Not-Attempt-Resuscitation order (DNAR). made, whenever possible, which would permit the • disabled person to function. Confi dentiality is the nondisclosure of sensitive patient information and stems from a patient’s right • Some jobs require specifi c skills and capabilities to privacy. Libel occurs when a falsehood, which that are generally described in the position’s is damaging to a person’s reputation, is written functional job description. or printed and then disseminated to the public. Slander occurs when defamatory lies about a person • The Civil Rights Act, Title VII, provides employees are told to others. the right to be free of sexual harassment in the workplace. Amendments to Title VII include the Age • A Paramedic should only provide confi dential Discrimination in Employment Act that prohibits patient information to those who have a need to the discrimination of those over the age of 40 and know to the extent that that is needed. the Equal Pay Act that requires pay to be based on • seniority or merit, not personal preference. The Health Insurance Portability and Accountability Act (HIPAA) established a number of protections for • The Family and Medical Leave Act provides employees the patient’s right to privacy. 12 weeks of unpaid leave for purposes of childrearing. Review Questions: 1. Explain the difference between criminal and 9. Identify the elements of a valid refusal of civil law. medical assistance. 2. What are tort laws and how do they pertain to 10. What is the difference between the refusal of the Paramedic? medical assistance and refusal against medical 3. Identify the four elements of a lawsuit. advice? 4. How does the Good Samaritan law protect 11. What are the origins of advanced directives? Paramedics? 12. Describe a DNR order and what care a 5. Describe the three levels of damages. Paramedic can still render. 6. Defi ne four types of consent. 13. Why is patient confi dentiality important and 7. What issues are associated with pediatric what is limited disclosure? consent? 14. What acts and laws have been established that 8. How do the elements of the mnemonic impact the Paramedic as an employee? BARNACLE ensure the Paramedic has completed all of the necessary steps in obtaining an informed consent? 102 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Case Study Questions: Please refer to the Case Study at the beginning of the 3. What argument can be made for the Paramedic chapter and answer the questions below: in regard to being held liable for proximate 1. Assess whether the patient had the right to refuse cause of death? intravenous therapy. 4. What should the Paramedic have done to 2. What indications would require the Paramedic to prepare for a situation like this? initiate intravenous access by implied consent? References: 1. Pennington K. The Prince and the Law, 1200–1600: Sovereignty 18. Ayres RJ, Jr. Legal considerations in pre-hospital care. Emerg and Rights in the Western Legal Tradition (A Centennial Book). Med Clin North Am. 1993;11(4):853–867. Berkeley: University of California Press; 1993. 19. Grant JR, Southall PE, Fowler DR, Mealey J, Thomas EJ, 2. Irons P. A People’s History of the Supreme Court. New York: Kinlock TW. Death in custody: a historical analysis. J Forensic Viking Adult; 1999. Sci. 2007;52(5):1177–1181. 3. http://www.supremecourtus.gov 20. Wobeser WL, Datema J, Bechard B, Ford P. Causes of death 4. Cockburn T, Madden B. Intentional torts claims in medical cases. among people in custody in Ontario, 1990–1999. Cmaj. J Law Med. 2006;13(3):311–335. 2002;167(10):1109–1113. 5. Wiggins CO. Ambulance malpractice and immunity. Can a 21. Moss ST, Chan TC, Buchanan J, Dunford JV, Vilke GM. Outcome plaintiff ever prevail? J Leg Med. 2003;24(3):359–377. study of pre-hospital patients signed out against medical advice 6. Good Samaritan protection. Ann Emerg Med. 2000;35(6): by fi eld Paramedics. Ann Emerg Med. 1998;31(2):247–250. 640–641. 22. Cone DC, Kim DT, Davidson SJ. Patient-initiated refusals of 7. Wilson A. On scene, off duty. Jems. 1991;16(7):29–30. pre-hospital care: ambulance call report documentation, patient 8. Augustine J. Can we leave the scene? Emerg Med Serv. outcome, and on-line medical command. Prehosp Disaster Med. 2005;34(2):44. 1995;10(1):3–9. 9. Williams K. Medical Samaritans: Is there a duty to treat? Oxf J 23. Stuhlmiller DF, Cudnik MT, Sundheim SM, Threlkeld Leg Stud. 2001;21(3):393–413. MS, Collins TE, Jr. Adequacy of online medical command 10. Kelly GC. Patient privacy lawsuit results in judgment for patient. communication and emergency medical services documentation Emerg Med Serv. 2003;32(8):26. of informed refusals. Acad Emerg Med. 2005;12(10):970–977. 11. Colwell CB, Pons P, Blanchet JH, Mangino C. Claims against a 24. Knight S, Olson LM, Cook LJ, Mann NC, Corneli HM, Dean JM. Paramedic ambulance service: a ten-year experience. J Emerg Against all advice: an analysis of out-of-hospital refusals of care. Med. 1999;17(6):999–1002. Ann Emerg Med. 2003;42(5):689–696. 12. Weaver J. Surviving a lawsuit. Emerg Med Serv. 2007;36(9):47– 25. La Puma J, Orentlicher D, Moss RJ. Advance directives on 48, 50, 52 passim. admission. Clinical implications and analysis of the Patient Self- 13. Goldberg RJ, Zautcke JL, Koenigsberg MD, Lee RW, Nagorka Determination Act of 1990. Jama. 1991;266(3):402–405. FW, Kling M, et al. A review of pre-hospital care litigation 26. Ashley RC. How can I best protect my family from a Schiavo/ in a large metropolitan EMS system. Ann Emerg Me. Schindler situation? Crit Care Nurse. 2005;25(3):60–61. 1990;19(5):557–561. 27. Kring DL. The Patient Self-Determination Act: has it reached 14. Graham DH. Documenting patient refusals. Emerg Med Serv. the end of its life? JONAS Healthcare Law Ethics Regul. 2001;30(4):56–60. 2007;9(4):125–131. 15. Bedolla M. The Patient’s Bill of Rights of the American Hospital 28. Garner JC. Final HIPAA security regulations: a review. Manag Association: a refl ection. Linacre Q. 1990;57(3):33–37. Care Q. 2003;11(3):15–27. 16. Schyve PM. Patient rights and organization ethics: the 29. Ludwig GG. HIPAA takes effect. Emerg Med Serv. Joint Commission perspective. Bioethics Forum. 1996;12(2): 2003;32(5):46. 13–20. 30. Wirth S. Privacy matters. Jems. 2002;27(11):191–193. 17. Selbst SM. Medical/legal issues in pre-hospital pediatric 31. Schulman R. HIPAA privacy and security implications for fi eld emergency care. Pediatr Emerg Care. 1988;4(4):276–278. triage. Prehosp Emerg Care. 2006;10(3):340–342. The Law and Paramedics 103 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Since September 11, 2001, the Emergency Services community recognizes that there is a strong link between EMS and public health. In some areas of the United States, Paramedics are utilized to augment the public health system, whether as part of a response to a public health emergency or to augment day to day public health activities in areas of need. These chapters provide a foundation in the fi eld of public health and illness and injury prevention to allow the Paramedic to fulfi ll these important roles in the healthcare system. • Chapter 7: Public Health and the Paramedic • Chapter 8: Illness and Injury Prevention 105 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Improvement of a community’s health status—the broad mission of public health • The international issues relating to public health • EMS as a “safety net” in public health • EMS roles in healthcare access and disaster management Case Study: The local Paramedic agency had been called upon to assist in a mass fl u inoculation program. Several of the inexperienced Paramedics said that while fl u inoculation was important, they didn’t see the relevance to EMS. Weren’t nurses supposed to be doing this? A senior Paramedic overheard them and suggested that after the program had concluded, they might want to research the relationship of fl u immunization programs, public health, disaster management, and EMS. He offered to assist them in their research. 106 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Public Health and the Paramedic 107 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Public health extends farther than just the measurement of a community’s absence of disease and infi rmity. Rather, its broad mission is carried out through prevention and active response to improve the public health of communities. Many organizations exist, both internationally and in the United States, that contribute to the overall goal of public health. These organizations are beginning to recognize the value of EMS and the need to strengthen it as a “safety net” for public health. The growing role of EMS as an integrated part of today’s public health system is discussed throughout the chapter. What Is Public Health? health services in order to fully appreciate their mission and cooperate with their efforts for injury and illness prevention Health is defi ned by the World Health Organization as well as disaster response. (WHO), the most prominent and infl uential international public health agency, as “a
state of complete physical, mental, and social well-being and not merely the absence of disease Public Health in History and infi rmity.”1 This state of well-being applies to not only The concept of community-based disease prevention reaches individuals, but extends also to large groups, communities, far back into antiquity. The practice of quarantine (isolating and nations. Public health, therefore, is defi ned as the practice diseased individuals from the larger community) can be traced and discipline of improving the health of communities, and back to biblical times when lepers were forced to live outside is focused primarily on prevention of illness and injury, city limits and maintain their distance from non-lepers. discussed in detail in Chapter 8. As a secondary mission, The ancient Romans understood the importance of public health agencies respond to disease outbreaks and sanitation in preventing the spread of disease throughout the disasters. In these instances, public health will work closely empire and developed separate sewers and water delivery with Paramedics to prevent such occurrences from reaching systems. Many of these aqueducts can still be seen throughout catastrophic proportions. Thus, it is important for Paramedics Europe, reminding us of the Romans’ accomplishments in to have an understanding of the organization of public public health and disease prevention (Figure 7-1). Figure 7-1 Roman aqueduct in Pont du Gard, France. Aqueducts like this one, built circa 19 B.C., would have carried water to supply an entire city. (Image copyright Riekephotos, 2009. Used under license from Shutterstock.com) 108 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 7-1 Multidisciplinary Public Health Team Koch’s Postulates 1. The organism must be found in all animals suffering from a disease, • Biologists but not in healthy animals. • Sociologists 2. The organism must be isolated from a diseased animal and grown • Social anthropologists in pure culture. • Engineers 3. The cultured organism should cause disease when introduced into • Politicians a healthy animal. • Health educators 4. The organism must be reisolated from the experimentally infected • Industrial hygienist animal. • Health reporter Figure 7-2 Koch’s postulates. • Sanitarians (Environmental health specialist) • Physicians • Nurses The practice of quarantine was even more prominent • Paramedics during the period of the bubonic plague (i.e,, Black Death), in fourteenth century Europe. During those times dead bodies were removed from the towns and cities in an attempt and contributions to the overall well-being of communities to eradicate the spread of the plague, another example of a and populations are each unique. public health practice. Despite these early attempts at prevention, communicable Epidemiology/Biostatistics diseases continued to spread largely unchecked. This was Public health’s mission has been to monitor, identify, and primarily due to a misunderstanding of the origins of disease. prevent outbreaks of disease. That mission is accomplished In the late nineteenth century, the germ theory of disease through epidemiology. Epidemiology is defi ned as “the branch emerged, largely due to the work of the German physician of medical science that deals with the incidence, distribution, Robert Koch (1843–1910).2 Koch developed four “postulates” and control of disease in a population.”3 Epidemiologists to establish that an organism is the cause of a particular are engaged in the surveillance of disease outbreaks and disease (Figure 7-2). This landmark theory permitted public how particular diseases are spread within and between offi cials the opportunity to incorporate the ancient principles various populations. Based on these observations and the of quarantine while allowing physicians and scientists information gained from their research, recommendations to identify, isolate, and inoculate the population. This can be made regarding public health intervention. The combination of public health medicine and clinical medicine ongoing investigations in HIV are one example in which started to have an impact on mortality and morbidity from epidemiologists have been able to track which population infectious disease. groups are at greatest risk of contracting HIV and have assisted in developing prevention programs for these Traditional Public Health Missions groups. Biostatistics is the application of statistical analysis The traditional focus of public health has been on women and to biological data, and is the mathematical component of children’s health, substance abuse prevention, and workplace epidemiology. safety, including environmental safety. Accomplishing these public health missions requires the efforts of both healthcare Environmental Health providers such as physicians and nurses, as well as individuals and organizations from many disciplines. Table 7-1 lists some Environmental health is considered the physical, chemical, of the individuals involved in public health. biological, and psychosocial well-being of a person as it is Challenges to the public’s health (e.g., the H1N1 outbreak related to the natural environment. It considers whether the and the looming threat of cross-species infection) have placed environment is healthy for that person. Perhaps the most a growing emphasis on public health medicine, spotlighting common subject in the fi eld of environmental health is its ability to quickly identify infectious disease and prevent pollution. While pollution control has been practiced for further progression of that disease through immunization. centuries, it is only in the past 50 years that signifi cant public health agendas have been aimed at reducing environmental pollution. Among these agendas have been programs to reduce Public Health Organization noise, air, and light pollution, as evidenced in motor vehicle Within public health there are several different subdivisions. production standards. Sanitation, specifi cally human and These include epidemiology, environmental health, social consumer waste, is a branch of environmental health directed and behavioral health, occupational health, and disaster at preventing waste from polluting the soil and water. Finally, planning and response. While there is considerable overlap industrial and other toxic waste disposal is an important between these individual subdivisions, their responsibilities concern of environmental public health. Strict standards, Public Health and the Paramedic 109 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. such as the federal clean air act, have been established in 1. The promotion and maintenance of the highest degree of physical, an effort to contain such harmful waste and prevent it from mental, and social well-being of workers in all occupations. contaminating soil, water, and air resources. 2. The prevention amongst workers of departures from health caused by their working conditions. Social and Behavioral Health 3. The protection of workers in their employment from risks resulting While social and behavioral health issues may initially from factors adverse to health. seem out of place in the public health sector, addressing 4. The placing and maintenance of the worker in an occupational these issues is very important to a population’s overall well- environment adapted to his physiological and psychological being. An example of a problem that affects social health is capabilities. overpopulation. Overcrowding is a signifi cant public health 5. The adaptation of work to man and of each man to his job. problem in some urban parts of the United States as well as many countries throughout the world, notably China and Figure 7-3 Goals of occupational health as India. Having a high concentration of people in a small area developed by the Joint Committee of WHO/ILO increases the risk of disease and raises public health concerns in 1950 (revised 1995). over sanitation and safety. Recently this issue has been addressed in the prison systems, a microcosm of overcrowding, where there are for predictable public disasters, public health planners can barriers to healthcare access. The European section of the mitigate the resultant harm from these disasters. WHO has undertaken a project to improve the conditions in Pandemics, outbreaks of diseases that spread throughout European prisons. Although signifi cant progress has been a country or a region, are a constant threat to public health.5–9 made, there is still much to be done.4 These outbreaks of infectious disease may reach disaster Other social and behavioral health issues to address proportions if not prevented or controlled in an appropriate include adolescent sexual activity, sexually transmitted fashion. Recent scares have included SARS and H1N1 fl u. In diseases, substance abuse, and mental health. addition to these natural disasters, large-scale accidents and mass casualties pose a threat not only for injury, but also for Occupational Health exposure to chemical and other environmental toxins. Witness In the past, workplace injury was commonplace. As a result, the increase in asthma among responders to the World Trade productivity suffered and the taxpayer’s burden to support Center attack of September 11, 2001. persons injured and out of work via worker’s compensation Public health offi cials and researchers are involved in was staggering. The fi eld of occupational health is responsible planning escape routes, resource mobilization, and response for helping to maintain safety within workplaces, to decrease policies for such disasters, and continue to work with EMS worker injury, and as a result to reduce health-related providers in order to be prepared for these events if and when expenses. they occur. In 1995, the International Labor Organization (ILO) and the WHO established goals for occupational health (Figure 7-3). Common workplace hazards identifi ed included Public Health Management biological or chemical exposure, high noise levels, physical Several organizations exist to conduct public health research hazards such as falls and dangerous machinery, long hours, and implement public health law and policy. From international and sexual harassment. According to the ILO, the primary organizations such as the WHO to local health departments, purpose of promoting occupational health is to decrease these organizations work together to meet the goal of public worker injury and to improve worker morale (i.e., a worker well-being. Since each nation’s public health structure is should not have to expect to risk life or limb by going to unique, it is not possible to describe the “typical” structure work). The ILO and the WHO, along with many professional worldwide. Therefore, the remainder of the discussion, aside organizations, are trying to develop a “culture of safety” where from an introduction to the international bodies, is based on foreseeable risks are eliminated and injuries prevented. the confi guration in the United States. Disaster Planning/Response International Within the past 10 years the world has witnessed numerous The World Health Organization (WHO) is the most prominent disasters, both natural and manmade. Natural disasters such and infl uential international public health agency. Founded in as hurricanes, fl oods, tornados, and tsunamis have garnered April 1948 as a specialized health agency under the United international attention, as have the emergency services Nations, the WHO lists as its primary constitutional objective responses to these disasters. Since these disasters cannot be the “attainment by all peoples of the highest possible level prevented, the quick and coordinated response to such events of health.”1 Based in Geneva, Switzerland, the WHO is is crucial to prevent death and disability. Through preplanning governed by 193 member nations and is managed by the 110 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. World Health Assembly, its international decision-making and decrease infant mortality. One of the earliest pioneers in body. The WHO focuses efforts on monitoring disease the American public health movement was Dr. Sara Josephine outbreaks such as SARS, infl uenza, and HIV/AIDS, as well Baker. Dr. Baker concerned herself with infant mortality. as assisting individual governments with the development and Dr. Baker worked tirelessly in
the ghettos of New York City, administration of vaccines. Largely through the efforts of the particularly Hell’s Kitchen, and helped to decrease the infant WHO, smallpox was declared eradicated in 1979, and polio mortality rate through public education of proper maternal is on the horizon to follow suit in the next several years. In health practices. addition to infectious disease research, the WHO is actively The Federal Public Health Service involved in dozens of other areas of medical and public health interest. These include chronic diseases such as hypertension Another early origin of public health was the federal Public and diabetes, as well as more indolent disorders such as Health Service (PHS). The origin of the PHS was preceded blindness and birth defects. Further information about WHO by the Marine Hospital Service (MHS). At that time, if a sailor can be obtained from their website: http://www.who.int got sick away from home he had nowhere to turn to for help. The World Federation of Public Health Associations But if a sailor paid 20 cents a month to the Marine Hospital (WFPHA) is an international nongovernmental organization Service fund, the MHS would provide him with medical established in 1967 to bring together multiple international care if he should get sick away from home at a distant port public health workers for professional exchange, collaboration, of call. and action. There are currently 70 member organizations, The MHS, and then the PHS, would later became including the American Public Health Association, who meet a key portion of the Department of Health and Human annually to discuss partnerships and collaborative efforts Services (DHHS). The current United States Public Health in public health research and policy, share information and Service (US PHS) has 5,700 commissioned health services publications, and assist each other in the implementation offi cers and 51,000 civilian employees, all led by the of these policies in their respective countries. The WFPHA Surgeon General. THE US PHS provides logistical support has an offi cial liaison to the WHO, and they work in to local, county, and state public health departments. It also close cooperation. Current WFPHA projects include an provides direct patient health care to medically underserved international hand-washing campaign, global tobacco control areas in the United States. and smoking cessation programs, HIV/AIDS research, and Eight agencies comprise the current United States persistent organic pollutants eradication. Public Health Service. These include the National Institutes for Health (NIH), the Food and Drug Administration The American Public (FDA), the Agency for Toxic Substances and Disease Registry (ATSDR), and the Centers for Disease Control and Health Movement Prevention (CDC). In the early 1800s American cities were being ravaged by The Centers for Disease Control and Prevention (CDC) epidemics of smallpox, yellow fever, and cholera. Quarantines is the leading U.S. governmental agency for public health and in-house confi nement were the only effective means study. According to the CDC website, “since it was founded of preventing the spread of these diseases at the time. As a in 1946 to help control malaria, CDC has remained at the result, industry suffered from massive sick calls, leading to forefront of public health efforts to prevent and control declines in productivity.10–12 infectious and chronic disease, injuries, workplace hazards, In response to these epidemics, and in an effort to get disabilities, and environmental health threats.”14 workers back to work, a few wealthy patrons hired graduate Although offi cially under the auspices of the U.S. nurses to care for the poor in Boston, Cincinnati, and Department of Health and Human Services, the CDC is Washington, DC. These nurses were referred to as community recognized independently worldwide for its signifi cant nurses. They worked in the ghettos and tenements of major contribution to public health and safety. Similar to the WHO, cities to improve the public health and reduce the incidence the CDC focuses research and policy efforts on emerging of disease by teaching simple hygienic practices such as infectious diseases as well as chronic medical conditions and washing food as a part of its preparation. environmental health and safety. Like modern day Paramedics, these public health nurses Through its various publications, including the Morbidity would leave the safety of their homes to go to workplaces, and Mortality Weekly Report (MMWR) and Emerging public houses, street corners, and clinics to meet with and Infectious Disease Journal, the CDC is able to communicate teach the public about basic sanitary practices. Ms. Lillian to federal, state, and local governments important relevant Wald, RN, who was credited with coining the term “public topics on an up-to-date basis. Furthermore, the CDC health nurse,” opened the Henry Street Settlement, a famous is regarded as an expert panel and its opinions on various public health clinic, in New York City in 1793.13 public health issues within the United States are frequently Another signifi cant problem at the time was infant cited in public reports and in the news media. Further mortality, particularly in the inner city. Many early public information about the CDC can be obtained from its website: health efforts were meant to improve maternal–child health http://www.cdc.gov. Public Health and the Paramedic 111 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. As described earlier, the American Public Health This role is just one of many roles that Paramedics Association (APHA) is one of the member associations in could become involved with in public health. This fact was the WFPHA. As a separate, distinct American organization, recognized in the report produced by the National Academy’s the APHA works to promote the health of American citizens Institutes of Medicine (IOM) entitled, “Emergency Medical through preventive efforts, research, and public health Services at the Crossroads.” In that report, the IOM spoke practice and policy.15 While many of the projects are similar of the EMS’s evolving role in health care and the need for in scope and purpose to the CDC, the APHA exists as a public health and EMS to cooperate. nongovernmental agency within the United States and works The IOM made specifi c reference to EMS as the “safety with individual states and other individual organizations to net” of the public’s health, referring to the juncture where reach their goals. public health and clinical medicine meet. EMS is there, The Occupational Safety and Health Administration treating and transporting sick and injured patients, when (OSHA) is the federal government’s effort to promote the efforts of public health to prevent illness and injury occupational health. Founded in 1971 to reduce and prevent have been unsuccessful. The IOM report also recognizes work-related injuries, illness, and death, OSHA is responsible the complexity of the public health system and the need for for developing and enforcing various standards of safety in different factions of health care to form strategic alliances in the workplace. Included within these workplace standards order to accomplish the mission to serve the common good. are standards for permissible exposure levels to chemicals With this renewed emphasis, the mission of EMS is now and dusts, personal protective equipment, confi ned space seen as being more in-step with the PHS than previously conditions, and bloodborne pathogen exposure guidelines, thought. A relationship between public health’s physicians, the latter of which is of particular importance to EMS and nurses, scientists, and sanitarians and Paramedics is other healthcare workers. More recently, OSHA has been growing. developing prevention strategies to prevent pandemic The potential intersections between Paramedics and infl uenza outbreak in workplaces. public health care are numerous. For example, Paramedics could share demographic information on symptom patterns State and Local which are commonly associated with certain infectious State and local governments are the primary source of diseases. With this information, public health departments public health policy and regulation. In addition, state and could identify potential outbreaks by identifying groups, or local health departments are involved in the enforcement of clusters, of patients. Paramedics could also cooperate with these regulations. Although national public health and safety public health’s prevention education programs, advocate guidelines are developed at the federal level (i.e., OSHA and for healthcare changes, and lobby for legislative changes other similar organizations), the state and local governments that improve the public’s safety. are responsible for developing and enacting the majority of public health laws in accordance with these accepted Healthcare Access international and national standards. Frequently governed by a state’s Department of Health, these agencies outline such Another focus of public health is healthcare access. Public policies as public smoking policies and laws, vaccination health is concerned with accessibility of health care to an schedules, and restaurant and food service inspection. Many individual and to a population. Without access to physicians are also responsible for investigating outbreaks of illnesses and nurses, the public cannot receive immunizations, health within the state or local communities. EMS personnel education, and other preventive measures. will have the most contact with these local public health For many patients who do not have primary care agencies and, as described in the following text, the greatest physicians, the emergency department (ED) serves as a site cooperative impact on health care and safety. for preventive (primary) medical care.17–23 Although this arrangement is not ideal for either the patient or the ED, it Public Health and EMS nevertheless is a safety net for those patients who would otherwise have no medical care at all. In December 2001, a very important paper was published In addition to serving as a safety net for the underserved in the Annals of Emergency Medicine that outlined the joint populations, the ED also operates in its primary function as efforts of public health and emergency medicine.16 As an a treatment center for acute medical and surgical conditions, extension of the emergency department, EMS is considered providing a necessary service which complements the role crucial to delivering the highest quality care in both public of the primary medical provider as the manager of chronic health surveillance and response. conditions. The role of EMS providers in assisting these Because Paramedics are primarily a community-based persons in transport to ED facilities in times of medical health organization, they are in a position to assist public need is obviously an important link in the overall chain of health offi cials with identifi cation of infectious diseases and healthcare access. Furthermore, the strategic location of mass immunization of the public. EMS vehicles and personnel in various rural, suburban, and 112 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. urban communities, an aspect of public health planning, sessions—whether through drills, didactics, or tabletop allows Paramedics to be in the appropriate location at the exercises—allow individuals from each organization to meet appropriate time for optimal response. and become familiar with each other and one another’s roles. The development of specialized response teams, escape Disaster Response routes, shelter management, and quarantine strategies can The partnership between EMS providers and public health be planned and implemented utilizing both public health and offi cials in preparation for and response to pandemics, EMS resources. Additional cooperation of other governmental natural disasters, and mass casualties is vital to reducing and private relief agencies further strengthens the response morbidity and mortality in these situations. Joint preparation network and provides greater preparation for an actual event. Public Health and the Paramedic 113 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the
right to remove additional content at any time if subsequent rights restrictions require it. Health is defi ned as a state of complete physical, mental, and social well-being. Public health is the practice of maintaining and improving the health of a community, and is focused on primary and secondary prevention of illness and injury. In addition, public health agencies are involved in providing a response to disease and disaster, working closely with EMS personnel to provide the necessary public services when these events occur. It is important for EMS providers to understand the organization and workings of public health on the international, national, state, and especially local levels in order to cooperate and participate in the various prevention and response operations they will collectively encounter. Key Points: • Public health is defi ned as the practice and • The fi eld of occupational health is responsible for discipline of improving the health of communities. helping to maintain safety within workplaces. Although the primary focus is prevention of illness and injury, public health agencies work closely with • Disaster planning and response begins with the Paramedics when responding to disease outbreaks examination of predictable public disasters such as and disasters. natural disasters, outbreaks of infectious disease, large-scale accidents and mass casualties, and • Public health had its roots in community-based exposure to chemical and other environmental toxins. practices of quarantine and improved water sanitation, but communicable diseases continued to • The partnership between EMS providers and public spread largely unchecked until the development of health offi cials is vital to reducing morbidity and germ theory of disease. mortality in disaster situations. • The public health team is made up of both • The World Health Organization (WHO) focuses healthcare providers and individuals and efforts on monitoring disease outbreaks, developing organizations. Within public health there are and administering vaccines, researching infectious several different subdivisions. These include diseases, and managing chronic diseases and disorders. epidemiology, environmental health, social and • The public health movement was fi rst started by behavioral health, occupational health, and public health nurses and other individuals who disaster planning and response. worked to reduce the incidence of disease and • Epidemiology is the branch of medical science that infant mortality through public education of proper deals with the incidence, distribution, and control health practices. of disease in a population. • Led by the Surgeon General, the U.S. PHS provides • Environmental health is considered the physical, logistical support to local, county, and state chemical, biological, and psychosocial well-being of public health departments as well as direct patient a person as it is related to the natural environment. health care to medically underserved areas in the United States. • Social and behavioral health addresses issues that are important to the overall well-being of • The Centers for Disease Control (CDC) focuses a population, such as adolescent sexual activity, research and policy efforts on emerging infectious sexually transmitted diseases, substance abuse, and diseases as well as chronic medical conditions and mental health. environmental health and safety. 114 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • The Occupational Safety and Health Administration infectious diseases and mass immunization of (OSHA) is the federal government agency that is the public. responsible for developing and enforcing various standards of safety in the workplace. OSHA’s • Public health is also concerned with the public’s policies aim at reducing and preventing work- access to health care, such as immunizations, related injuries, illness, and death. health education, and other preventive measures. EMS assists with patient access by responding • One of the many roles that Paramedics may become and transporting patients to the ED to receive involved with in public health is the identifi cation of appropriate care. Review Questions: 1. Other than prevention, what is the focus of 7. What state and federal departments are public health? responsible for public health programs? 2. How did germ theory affect the treatment of 8. Describe how the Centers for Disease Control disease? and the Occupational Safety and Health 3. What are the fi ve subdivisions of public health? Administration work to improve public health. 4. How can offi cials better plan for and respond to 9. Explain how the mission of EMS is in-step with predictable public disasters? the Public Health Service. 5. What is the World Health Organization’s role in 10. How does EMS help to improve public access to public health? health care? 6. How did the public health movement begin in the United States? Case Study Questions: Please refer to the Case Study at the beginning of the arise from EMS participation in a mass fl u chapter and answer the questions below. immunization program? 1. In addition to increasing the number of people 2. How is an immunization program related to the immunized against the fl u, what other benefi ts mission of EMS? References: 1. http://www.who.int/en/ 5. Smolinski MS, Hamburg MA, Lederberg J. Microbial Threats to 2. Brock T. Robert Koch: A Life in Medicine and Bacteriology. Health: Emergence, Detection & Response. Washington DC: Natl Berlin, NY: Science Tech Publishers; 1999. Academy Pr; 2003. 3. http://www.merriam-webster.com/ 6. Brundage JF. Cases and deaths during infl uenza pandemics in the 4. Gatherer A, Moller L, Hayton P. The World Health United States. Am J Prev Med. 2006;31(3):252–256. Organization European Health in Prisons Project after 10 years: 7. Sloan FA, Berman S, Rosenbaum S, Chalk RA, Giffi n RB. persistent barriers and achievements. Am J Public Health. The fragility of the U.S. vaccine supply. N Engl J Med. 2005;95(10):1696–1700. 2004;351(23):2443–2447. Public Health and the Paramedic 115 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 8. Webby RJ, Webster RG. Are we ready for pandemic infl uenza? of the defi nition of the “primary care patient” in the Science. 2003;302(5650):1519–1522. emergency department. Emerg Med Australas. 2005; 9. Spicuzza L, Spicuzza A, La Rosa M, Polosa R, Di Maria G. 17(5-6):472–479. New and emerging infectious diseases. Allergy Asthma Proc. 18. Wise M. Inappropriate attendance in accident and emergency. 2007;28(1):28–34. Accid Emerg Nurs. 1997;5(2):102–106. 10. Bourdelais P. Epidemics Laid Low: A History of What Happened 19. Hamlin C, Sheard S. Revolutions in public health: 1848, and in Rich Countries. Baltimore: The Johns Hopkins University 1998? Bmj. 1998;317(7158):587–591. Press; 2006. 20. Byrne M, Murphy AW, Plunkett PK, McGee HM, Murray A, 11. Steel J. Inappropriate—the patient or the service? Accid Emerg Bury G. Frequent attenders to an emergency department: a study Nurs. 1995;3(3):146–149. of primary health care use, medical profi le, and psychosocial 12. Lee PR. Health policy and the health of the public. A two characteristics. Ann Emerg Med. 2003;41(3):309–318. hundred year perspective. Mobius. 1984;4(3):95–113. 21. Richardson S. Emergency departments and the inappropriate 13. Wald L. The House on Henry Street (Philanthropy and Society). attender—is it time for a reconceptualisation of the role New Brunswick: Transaction Publishers; 1991. of primary care in emergency facilities? Nurs Prax N Z. 14. http://www.cdc.gov/ 1999;14(2):13–20. 15. http://www.apha.org/ 22. Richman IB, Clark S, Sullivan AF, Camargo CA, Jr. National 16. Pollock DA, Lowery DW, O’Brien PM. Emergency medicine study of the relation of primary care shortages to emergency and public health: new steps in old directions. Ann Emerg Med. department utilization. Acad Emerg Med. 2007;14(3):279–282. 2001;38(6):675–683. 23. Young GP, Sklar D. Health care reform and emergency medicine. 17. Bezzina AJ, Smith PB, Cromwell D, Eagar K. Primary care Ann Emerg Med. 1995;25(5):666–674. patients in the emergency department: who are they? A review 116 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Impact of public health prevention programs • Decision making based on surveillance of injury • The Haddon matrix and injury countermeasures • The 4-E’s of injury prevention strategy • Evaluating an injury prevention program • Recognizing teachable moments for the Paramedic Case Study: For the fourth time this month, the Paramedics went to the same address for the same man with the same complaint . . . exacerbation of his chronic obstructive lung disease. The man was a heavy smoker all of his life. Even though he said he had quit, you could still see the yellow on his fi ngers and smell the smoke on his clothing. The Paramedics wondered about the numerous stop smoking campaigns that were available. Which ones worked? How could they assist in getting people to quit or, better yet, never start? 118 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Illness and Injury Prevention 119 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Because the Paramedic’s goal is to help others, it becomes the Paramedic’s mission to help prevent injury as well. Public health promotion programs have proven themselves time and time again. EMS, as a profession, has therefore evolved to include these programs in its mission. Decisions on how to develop public health promotion programs arose from observations, or surveillance of injuries. The Haddon Matrix represents the many opportunities for change and injury countermeasures that can be implemented. Although any of the 4-E’s of the injury prevention strategy can be used in a public health program, education is perhaps the best vehicle for making a difference. Public Health Public Health Prevention Initiatives The focus of public health is to promote the wellness of a Currently public health is involved in many illness and injury community or a people in order to improve the health of prevention initiatives including family planning, smoking the population. The tenants of public health medicine are cessation programs, workplace safety, and motor vehicle consistent with the concepts of primary care. Primary care safety (Table 8-1). These initiatives were all chosen because medicine states that it is easier to prevent disease or injury they represented an area of signifi cant mortality for the in an individual rather than treat it.1,2 However, public public. health differs from primary care because public health The success of these initiatives can be seen in the efforts treats communities whereas
primary care treats individuals. of public health to infl uence family health and planning. Because of its community focus, public health concentrates Through education, promotion of well-baby visits, childhood on the detection of community-wide disease and the creation immunization programs, and freestanding clinics, infant of programs for injury prevention. mortality has dropped 90% from 1900 to the present and Public health helps to reduce the cost of health care, maternal mortality has dropped 99%.4,5 through prevention and/or reduction of injury and illness, Paramedics may recognize the effects of these efforts over and therefore provides signifi cant economic benefi ts to the decades in terms of injury from motor vehicle collisions. the community. Many people believe that public health Improvements in motor vehicle safety through improved is rightfully a function of government. Governments, in motor vehicle engineering (e.g., seat belts and airbags) and general, are formed to secure the people’s welfare and help improved road design (e.g., civil engineering) have resulted ensure a population’s prosperity. Therefore, public health can in a marked decrease in mortality and morbidity in motor be viewed as a matter of national security in that the country’s vehicle collisions. health provides for that country’s social stability. Injury Surveillance Impact of Public Health Injury and illness detection is the fi rst step in injury and Prevention Programs illness prevention. Based upon research and statistical data concerning the incidence of a disease or the prevalance In the past, the spread of infectious diseases (such as of an injury, public health offi cials can make judgments smallpox and the plague) was rampant and mortality from about the need for new prevention programs or the revision these diseases was very high.3 In some instances, public of an existing prevention program. Therefore, for public offi cials would attempt to enforce public health measures, such as quarantine, in an attempt to halt the transmission of these diseases, with varying degrees of success. However, Table 8-1 Examples of Paramedic Public the result of these “after the fact” measures was premature Health Initiatives death, evidenced by an average life expectancy of 30 years. Pedestrian safety Bicycle lanes and sidewalks In the last century, the average life expectancy in the Bicycle safety Helmet patrols (ice cream tickets) western world has steadily increased to the point where it is over SIDS Back to sleep programs 70 years in most industrialized countries. This improvement Drowning prevention Pool inspections can be attributed to a combination of improvements in Child passenger safety Childseat inspections preventive medicine and to broad public health measures such as sanitation systems and water purifi cation plants. Food safety Health inspections 120 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. health offi cials to make good decisions they need accurate Table 8-2 National Centers for Injury information (surveillance). This process, surveillience and Prevention Programs prevention, is consistent with the “plan-do-check-act” cycle of quality improvement. 1. University of Alabama 2. University of California at Los Angeles (UCLA) Early Efforts at Injury Surveillance 3. University of California at San Francisco One of the early champions for public safety and injury 4. Harvard School of Public Health prevention was Ralph Nader. Nader and his associates, 5. University of Iowa referred to as Nader’s raiders, would investigate and report 6. Johns Hopkins University School of Hygiene and Public Health to the public items and goods that they deemed unsafe. 7. University of North Carolina These early efforts amounted to surveillance of a problem 8. University of Washington, Harborview Medical Center and a recommendation for action to reduce or eliminate the 9. University of Pittsburgh, Center for Injury Research and Control problem. One problem Nader was concerned about was the 10. Colorado State University high incidence of mortality caused by ejection from a motor vehicle. Largely as a result of Nader’s vigorous lobbying of the the pressing trauma conditions at that time.This information government and industry, cars were required to have case- is also used to create injury prevention programs focused on hardened steel pins, later called Nader pins, installed in car the specifi c trauma issues encountered in a given region. door locks. These Nader pins prevented passengers from being ejected during a motor vehicle collision, and have therefore saved countless lives. Nader’s infl uence in injury EMS and Injury Prevention prevention serves as an example of one group’s ability to have As a part of an approach to provide comprehensive prehospital a positive impact on the community’s health through injury care, Paramedics have been increasingly involved in public surveillance and action. health efforts. Injury prevention programs, in particular, have involved Paramedics. Trauma Surveillance In 1996, the National Highway Safety and Traffi c While Dr. “Deke” Farrington’s article “Death in a Ditch” and Administration (NHSTA) helped to create a consensus the 1966 white paper “Accidental Death and Disability: The statement regarding EMS and injury prevention. That Neglected Disease of Modern Society” brought the problem statement, “Role of EMS in Injury Prevention,” affi rmed the of trauma to the forefront, it took another white paper, position of EMS as a legitimate source for injury prevention “Injury in America: A Continuing Public Health Problem” to education.8 It was hoped that the consensus paper, sent out emphasize the lack of injury prevention.6,7 for peer-review to some 300 leaders in the EMS community, Written by the National Academy of Sciences in 1983, would help to shift some of the focus of EMS toward injury “Injury in America” emphasized that injury prevention is more prevention and health promotion. cost-effective than injury treatment. As a result, Congress EMS was specifi cally identifi ed as a vehicle for this injury dedicated funding to injury surveillance and prevention. prevention campaign because of its unique advantages. EMS Subsequently, the federal Centers for Disease Control was agencies are, at their essence, community-based organizations tasked with injury surveillance and created the Division of which blend public safety with public health to provide a Injury Control, which is now called the National Centers for service, EMS.9–11 In their role as EMS providers, Paramedics Injury Prevention and Control and the name of the federal enjoy the public’s respect. This high-credibility affords them Centers for Disease Control was changed to the Center for an effective platform from which to educate and to support Disease Control and Prevention. changes, especially regarding injury prevention. There are 10 national injury prevention and control Injury Prevention Theory centers across the country (Table 8-2), each with a focus on regional injury interests, and all are a part of a national and the Haddon Matrix network of injury prevention programs. Starting in 1963, William Haddon, Jr., the fi rst director of the Injury statistics are also compiled in the National Trauma NHSTA, started work on an injury prevention matrix, an easily Registry, which is maintained by regional trauma centers. This understood concept map of injury casuation and prevention. registry is an invaluable source of data regarding trauma and Using a model similar to one used for disease, Haddon plotted trauma trends. Selected data fi elds, called a data set, are gleaned the factors that cause injury across a horizontal X-axis and the from the patient care record (PCR) produced by Paramedics. stages of an injury process along the Y-axis. The result was an High-performing EMS agencies typically consult the injury prevention matrix. trauma registry for valuable information regarding topics for Each square in the Haddon matrix represents an continuing medical education and professional development opportunity to intervene and either prevent or mitigate the in order to keep current and ensure Paramedics are prepared for effects of traumatic injury. The matrix helps people recognize Illness and Injury Prevention 121 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. that the Paramedic is not limited to affecting traumatic injury The fi rst intervention point for prevention would be only after an injury occurs. It emphasizes that there are other elimination of the offending agent. While in some cases, such opportunities to affect traumatic injury. The horizontal X-axis as handguns, this may appear unreasonable, consider the case contains the elements host, agent, and environment, taken that was made for nuclear disarmament. That is, the ability from the Public Health Model. In the case of injury, the host to possess the weapons exists but there is a decision not to is the patient and the host’s characteristics are those human possess them. factors, such as alcohol intoxication, which come into play If the agent (i.e., the hazard) cannot be eliminated, then during an injury. perhaps it can be reduced to a non-lethal level. For example, The agent is the source of the injury. In broadest terms, it a pharmacist is only allowed to fi ll a limited prescription is the source of the mechanical (kinetic), chemical, electrical, of tricyclic antidepressants. This limited number of pills thermal, or radiation energy that, when infl icted on someone, dispensed helps to ensure that less than lethal doses are readily causes trauma. For example, a handgun would be the agent of available to the potentially suicidial patient with depression. injury in a pediatric gunshot wound. If the hazard cannot be eliminated or reduced, then The fi nal X-axis component is the environment. The perhaps the hazard can be contained in order to prevent its environment consists of those circumstances which have release or use. For example, pools have long been recognized an impact on the trauma. The environment can be further as an attractive nuisance to children. Many accidental subdivided into social environment and physical environment. drownings have occurred in unsupervised pools. An example The physical environment, in the case of pediatric gunshot of containment of this hazard would be to assemble fences, wounds, would be the presence of a handgun in the home. with padlocked gates, around pools. This containment The social environment would be the combination of the measure is mandated by law in many communities. adult’s attitude regarding handgun ownership, laws pertaining If the hazard cannot be eliminated, nor reduced, nor to handgun registration, and the child’s innate curiosity. contained, then perhaps the rate of release can be slowed, and/ Marked along the Y-axis are the stages of injury: pre- or distributed over time, in order to decrease the impact of the event, event, and post-event. These stages correspond with the event. Airbags and padded steering wheels are designed to three levels of medicine: primary care, secondary care, and dissipate the energy in a collision across both a larger area as tertiary care. Table 8-3 illustrates a Haddon matrix, using the well as over a longer time. problem of accidental shootings in the pediatric population If the hazard cannot be eliminated, nor reduced, nor and interventions as an example. These interventions are only contained, nor slowed, then the only alternative is to eliminate theoretical. The appeal of the Haddon matrix is that it allows— the target (i.e., the host). A case in which the host, the patient, and almost encourages—free-thinking (i.e., “thinking outside is eliminated is highways are closed during snow emergencies. of the box”) about solutions to public health problems. A declared snow emergency, enforced with the force of law, prevents motorists from even being on the highway under Injury Countermeasures potentially dangerous conditions. In 1970, Haddon produced another paper on injury prevention, In some cases, if the host can be removed, then protecting entitled “On the Escape of Tigers: An Ecological Note.” The the host is the best option. Safety engineers have created paper precisely detailed the 10 levels of countermeasures many barrier devices, ranging from simple gloves to soft that could be effective in reducing
injury. Starting from pre- body armor, to protect the host (people) from injury. incident (i.e., preventative medicine) and proceeding through If contact between the agent and the host is inevitable, to post-incident or clinical medicine, Haddon lays out the then modifi cation of some basic quality of the agent could logical points for effective intervention in injury prevention. be considered. For example, enlarging the size of baseballs Table 8-3 Haddon Matrix for Accidental Pediatric Shootings Problem Statement: CDC reports, in the year 2000, that there was a 58% increase in the number of gun accidents in the pediatric population aged 0–4 years of age, or 1,200 accidental pediatric shootings. Host Agent Physical Environment Social Environment Children age 0–4 Handguns loaded Home bedside United States Right to bear arms Pre-incident Gun safety education Trigger locks Gun lock boxes Gun regulation Incident Pediatric shooting Restriction Gun alarms Gun ownership Body armor Fully automatic Education classes Post-incident Pediatric GSW EMS Automatic confi scation Trauma systems Community statistics Pediatric GSW education 122 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to what we now call the softball decreased the incidence of on injury prevention is seat belt safety seminars. Following orbital fractures in children playing baseball. public education campaigns about the importance of seat In addition, modifying the host (the patient) to be more belt use, the use of seat belts remains highest in younger resilient to injury can help to decrease the injury’s incidence or drivers. Older drivers, taught to drive when seat belts were severity. For example, many healthcare plans offer employee not mandatory, have been more resistant to change. exercise programs to improve the health of their participants The third E, law enforcement, is actually a form of learning. and increase the participants’ resilence to injury and illness, Law enforcement provides punishment for nonconformance thereby diminishing the effect of the hazard/agent. with safety regulations, a form of operant conditioning. If injury cannot be prevented and yet is foreseeable, then Enforcement of safety regulations, such as speed limits, and systems for the rapid detection, treatment, and evacuation the resultant punishment of fees and fi nes provide the host to defi nitive treatment need to be in place. This essentially with a powerful incentive to change behavior. describes the mission of EMS. The fourth and fi nal E is economic incentives. It is also However, improvement in these systems can increase the a form of education—positive operant conditioning. Efforts effi ciency and the effectiveness of EMS. An example of an to behave safely or to correct behaviors are encouraged by improved means of detection is the addition of technology positive feedback, in the form of economic reward. For for location identifi cation of cellular telephone users. This example, some EMS systems distribute tickets for ice cream can improve the communications specialist’s ability to send cones to children seen wearing bicycle helmets. Another needed help. OnStar® is one system available in motor vehicles example might be a rebate after the purchase of a child’s car that detects and reports—through impact sensors, cellular seat or a smoke detector. technology, and global positioning systems—the location and extent of a motor vehicle collision back to a public safety Assessment access point (PSAP). Finally, efforts to improve tertiary care and rehabilitation Whenever Paramedics or an agency become involved in will diminish the long-term impacts of injury. Prostethetics, primary injury prevention, using any of the previous strategies, used to treat wounded soldiers of the Irag war, have improved they are improving the quality of health in their jurisdiction. tremendously and offer an improved quality of life to these Therefore, like all EMS activities, injury prevention is veterans. included in the quality improvement cycle. The fi rst portion of the PDCA cycle of quality improvement is planning. Several key questions should be answered before Injury Prevention Strategies implementation of the initiative as the answers may affect Injury prevention strategies are ways to go about the decision-making process. Every suggested improvement, implementing Haddon’s countermeasures.12 These can whether it is implementing an educational program or include engineering safety into products or processes, purchasing a product with an engineered safety feature, needs educating people about the dangers, increasing or improving to be weighed in a cost-benefi t analysis. The cost, whether enforcement of laws and regulations which promote safety, fi nancial or otherwise, must be considered in light of the and providing economic incentives for people to use safer potential benefi t to be gained from the proposed change. products or processes. For instance, is the cost of the product (for example, a self- Paramedics, when trying to brainstorm injury prevention protecting intravenous catheter) worth the benefi t of reduced strategies for inclusion in Haddon’s countermeasures, needlestick injuries which can cost, by some estimates, can consider four basic strategies, the “4-E’s,” of injury as much as $5,000 per incident? Would one potentially prevention. preventable needlestick injury pay for the increased costs of The fi rst E, engineering, refers to the addition of safety the new intravenous catheters? devices during the engineering phase of product design that Intrinsic within the cost-benefi t analysis is the question will prevent injury. The creation of needleless intravenous of acceptance by the user. A safer device that is not used administration sets is an example of safety engineering. In offers no benefi t. For example, workers must use the safer this case, the injury, accidental needlesticks, is eliminated device in order to prevent injuries. OSHA recognized this fact through a pre-incident intervention which affects the agent. when it required the participation of nonmanagerial front-line The next E, education, requires that the educator change employees in the decision-making process for utilization of the behavior of the host, the population, in a substantial personal protective equipment (29 CFR 1910.1030(c)(1)(v). manner. To affect such change, educators usually must Also taken into consideration during planning is the energize learners, through motivational speaking, to change concept of equity. Safety changes (e.g., workplace routines) behaviors that may have already been engrained into their lives. must be equitable. Equity is a concept of fairness or Understandably, the impact of injury prevention is greatest evenhandedness. To be accepted, any change must appear to when the learner has not already learned the behavior and be equitable to all parties concerned. is just initially learning the “correct” behavior, the one that Changes that are broadly applied to all individuals would will decrease injury. An example of the impact of education be said to have horizontal equity. For example, the blood Illness and Injury Prevention 123 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. alcohol level of 0.08 is considered the limit in most states for Teaching Injury Prevention driving while intoxicated. This legal limitation is an example of an effort to prevent alcohol-related collisions by reducing Paramedics appreciate that every call for an injured person the threshold for law enforcement. The change is then applied has the potential for being a moment to refl ect on the activity to everyone. that caused the injury and consider how to prevent that injury However, in some instances it is more appropriate in the future. That moment is called the teachable moment. to provide an injury prevention program to one group A teachable moment might be defi ned as the time when of people who are unduly affected by a problem. This the patient has a heightened awareness of a problem and is unequal treatment, preferential or targeted treatment, tends receptive to information.The positive impact which prevention to improve the health of that specifi c group. However, it can have to prevent future injury can be mentioned. also tends to reduce the burden carried by the rest of Use of this opportunity to teach, to change the behavior the population in the form of higher taxes or insurance of another person, must be carefully considered. Ill-chosen premiums. This type of injury prevention program would words can sound accusatory and produce an effect opposite create vertical equity. For example, if statistics demonstrate of the intended effect. The patient may perceive the well- a higher number of accidental shootings among children in intentioned words of a Paramedic as victim blaming. Victim low-income households, then public health programs could blaming is counterproductive to the goal at hand, preventing be justifi ably organized to emphasize prevention within a similar occurrence in the future, and tends to cause hostile that population. feelings. For example, lecturing a patient with emphysema When Paramedics are planning injury prevention about the ill effects of smoking at a time when the patient programs, they should be sensitive to the problem of stigma. is short of breath is both ill-advised and counterproductive Stigma is a negative connotation attached to participation in to the goal of smoking cessation. It would be better if the a program, such as labeling and public embarassment. For Paramedic were to offer supportive and nonjudgmental care example, a prevention program that asks drug abusers to to the patient at the present time and then leave the card of a come forward and be identifi ed before participation in a drug smoking cessation program with a family member. treatment program may not meet with much acceptance by the intended benefi ciaries. The potential participants may be concerned about persecution and public ridicule as well as labeling. The success of Alcoholics Anonymous is owed, in Professional Paramedic part, to the anonymity that participants are provided while they recover. Many behaviors are culturally related. The The fi nal question concerns the feasibility of any proposed professional Paramedic should recognize that changing changes. In some instances, prevention programs require the reallocation of scarce resources, including personnel and a behavior may be better accomplished through funds. The reallocation of essential resources requires the Paramedic cultural or religious networks. The goal is enlightened thinking of EMS leaders who can see the long- assisting the patient, not the Paramedic’s glory. term benefi t of such programs. Unfortunately, the realities of politics often interfere with these programs. As a result, many prevention programs—both local and federal—have fallen EMS Injury Prevention Programs due to budget cuts and other immediacies. Some Paramedics may still be hesitant about getting involved in public education for injury prevention, citing concerns Implementation about this “new” role. But these Paramedics should be aware To lead successful injury prevention programs, EMS leaders that other Paramedics have been remarkably successful with must fi rst get Paramedics to invest, intellectually and public education campaigns in the past. A model for EMS spiritually, in these programs. The changing safety paradigm success in injury prevention is the EPIC medic program in in EMS, placing personal safety above all else, is helping San Diego.13 The San Diego Paramedics created an injury Paramedics see the benefi ts of injury prevention programs. prevention project entitled Eliminate Preventable Injuries Chapter 3 on personal well-being emphasized the impor- of Children (EPIC). Using a combination of home safety tance of safety and injury prevention. Paramedics, cognizant assessments, pool safety inspections, child passenger of their roles as models for their community, may minimal- seat safety education, and several other initiatives, these ly demonstrate those safety habits that they would have the Paramedics have strived to make their community a safer public emulate. For example, passing motorists who see a environment for children. Paramedic wearing a seat belt, driving with headlights on The success of programs like the EPIC medic program during the daytime, or using headlights along with windshield has not gone unnoticed by their peers and the community wipers, may imitate the Paramedic’s action. These injury
alike. For example, the EPIC Paramedics were awarded the prevention efforts can have a positive impact. Nicholas Rosecrans Award, a national award recognizing 124 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 8-1 The EPIC team receiving the Nicholas Rosecrans Award for excellence in injury prevention. (Courtesy of EPIC medics; photo by Jeff Lucia) excellence in injury prevention in EMS (Figure 8-1). The or process evaluation, includes statistics on attendance, Nicolas Rosecrans Award is given to agencies or individuals among other items, and explains how the program was for community work with injury prevention. Specifi cally, this implemented. This information is vital to a later analysis prestigious award may be given to those agencies or persons of cost versus benefi t. In some cases, the outcome may be who have either established or expanded a comprehensive acceptable even though more effi cient or effective means of injury prevention program, promoted injury prevention achieving that goal are available or possible. within the EMS community, improved the delivery of EMS The measurement of ends, or outcomes evaluation, is to injured patients, or successfully created collaborations or a matter of comparing the level of injury or illness before partnerships with other public safety organizations to advance and after the program. The initiative is evaluated to determine injury prevention. whether the program made a difference. For example, data about rates of injury in motor vehicle collisions following a seat belt campaign can be obtained from patient care records (PCR) Outcomes or trauma registry statistics. Statements about the success or Action without refl ection cannot be said to be effective, for failure of injury prevention programs rest on the result of the there is no measurement of the change. Statements about outcomes evaluation. For example, Pinellas County EMS in the effectiveness of an injury prevention program require Florida established a pool safety campaign after a series of verifi cation. A process of evaluation, the checking portion in drownings. Kicking off with a media campaign to announce the PDCA cycle, is an integral part of any injury prevention the campaign, the Paramedics of Pinellas County performed program. public education programs, pool safety inspections, and the The measurement of any success, including success in like. Following the campaign, Pinellas County EMS was able injury prevention, is typically data-driven. The measurement to show a 43% reduction in drowning.14 These kinds of hard should involve both the means and the end. Measuring means, numbers tend to impress the public and politicians alike. Illness and Injury Prevention 125 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. With the specter of Avian fl u, the epidemic in obesity, and the proliferation of drug-resistant diseases, there will be many opportunities for Paramedics to work with public health in a strategic alliance that can be synergistic and provide the best outcome for the public. Key Points: • Public health is based on the premise that, as a • The fi rst director of the NHSTA developed an injury community, it is easier to prevent disease or injury prevention matrix based on the factors that cause than provide treatment. With public health, the injury and the stages of an injury process. The concentration lies on the detection of community- matrix emphasized that there is an opportunity for wide disease and the creation of programs for the Paramedic to affect traumatic injury before injury prevention. injury occurs. • Current public health prevention initiatives include • In another paper on injury prevention, Haddon family planning, smoking cessation programs, detailed 10 logical points or countermeasures for workplace safety, and motor vehicle safety. These effective intervention in injury prevention. An initiatives are areas of focus because they have example of Haddon’s logic that is pertinent to been shown to result in signifi cant mortality for the paramedicine is that, if injury cannot be prevented public. and yet is foreseeable, then systems for the rapid • detection, treatment, and evacuation of defi nitive In order for public health offi cials to make treatment need to be in place. good decisions, they need accurate information or surveillance. Ralph Nader pioneered early • The “4-E’s”—engineering, education, law surveillance efforts by investigating and reporting enforcement, and economic incentives—are basic to the public about items and goods that were strategies that the Paramedic can use when deemed unsafe. The Paramedic can appreciate brainstorming injury prevention strategies for improvements on motor vehicle safety that resulted inclusion in Haddon’s countermeasure of injury in the marked decrease in mortality and morbidity prevention. in motor vehicle collisions. • Injury prevention is included in the quality • Stemming from several documents that emphasized improvement cycle. For each suggested the lack of injury prevention and the notion improvement, a cost-benefi t analysis should that prevention is more cost-effective than be made. Equity should also be taken into injury treatment, the National Centers for Injury consideration, as well as any stigma that may be Prevention and Control were established. These associated with the program. The feasibility of any centers, along with the National Trauma Registry, proposed changes should be assessed. gather data regarding injury interests. • Implementation and the success of injury prevention • The National Highway Safety and Traffi c programs depend on how much the Paramedic invests Administration (NHSTA) helped to increase intellectually and spiritually into the program. The the Paramedic’s involvement in public health changing safety paradigm in EMS, placing personal efforts. This is in part because EMS agencies are safety above all else, is helping Paramedics see the community-based organizations, which affords benefi ts of injury prevention programs. them an effective platform for community education and injury prevention. • An appropriate teachable moment might be defi ned as the time when the patient has a heightened 126 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. awareness of a problem and is receptive to evaluation. These statements about the success or information given by the Paramedic. failure can be used to determine how effi cient or • effective the process was and how effective the An evaluation process is an integral part of any program was overall. injury prevention program. The measurement should include the process evaluation and the outcomes Review Questions: 1. Why is EMS an excellent vehicle for injury 7. Identify the four components of the quality prevention programs? improvement cycle. 2. What agencies compile injury statistics and why? 8. What do EMS providers need to invest into 3. What does the Haddon matrix emphasize? an injury prevention program for it to be 4. What is the fi rst point of injury prevention? successful? 5. What injury prevention point is similar to the 9. Describe a teachable moment. mission of EMS? 10. Why should the evaluation of an injury 6. How are the 4-E’s used in brainstorming injury prevention program measure both the means prevention strategies? and the end? Case Study Questions: Please refer to the Case Study at the beginning of the 2. Identify where the patient in the case study chapter and answer the questions below. currently is and brainstorm ideas for assisting 1. Using the Haddon matrix, identify the host, him in quitting/reducing his smoking. agent, and environment in the case study. Also identify the pre-event, event, and post-event. References: 1. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The 5. Garrett E, ed.,et al. Infant Mortality: A Continuing Social burden and costs of chronic diseases in low-income and middle- Problem. Aldershot: Ashgate Pub Co; 2007. income countries. Lancet. 2007;370(9603):1929–1938. 6. Council N, Sciences D, Sciences N. Accidental Death 2. Novick L. Public Health Administration: Principles for and Disability: The Neglected Disease of Modern Society. Population-Based Management. Sudbury, MA: Jones and Bartlett Washington, DC: National Academies Press; 2000. Publishers; 2004. 7. Council N, Medicine I. Injury in America: A Continuing Public 3. Bollet A. Plagues and Poxes: The Impact of Human History on Health Problem. Washington, DC: National Academies Press; Epidemic Disease. New York: Demos Medical Publishing; 2004. 1985. 4. Thompson JB. International policies for achieving safe 8. Garrison HG, Foltin G, et al. Consensus Statement: The Role of motherhood: women’s lives in the balance. Health Care Women Out-of-Hospital EMS in Primary Injury Prevention, Consensus Int. 2005;26(6):472–483. Illness and Injury Prevention 127 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Workshop on the Role of EMS in Injury Prevention. Arlington, 12. Christoffel T, Gallagher S. Injury Prevention and Public Health: VA: Final Report; 1995. Practical Knowledge, Skills, and Strategies. New York: Jones & 9. Garrison HG, Foltin GL, Becker LR, Chew JL, Johnson M, Bartlett Pub; 2005. Madsen GM, et al. The role of emergency medical services 13. Krimston J, Griffi ths K. EMS champions of injury prevention. in primary injury prevention. East Carolina Injury Prevention Highlights from some of the best injury-prevention programs in Program. Prehosp Emerg Care. 1997;1(3):156–162. the United States. Jems. 2004;29(11):80–84, 86, 88 passim. 10. Griffi ths K. Best practices in injury prevention: National award 14. Kirkwood HA. Before the call comes in. EMS and injury highlights programs across the nation. Jems. 2002;27(8):60–74. prevention. Jems. 1995;20(6):21, 23. 11. Kinnane JM, Garrison HG, Coben JH, Alonso-Serra HM. Injury prevention: is there a role for out-of-hospital emergency medical services? Acad Emerg Med. 1997;4(4):306–312. 128 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The four chapters in this section provide a basic foundation in lifespan development, physiology, pathophysiology, and medical terminology. These areas again help lay a solid foundation for the Paramedic to build upon in the later technical and clinical chapters. • Chapter 9: Lifespan Development • Chapter 10: Basic Human Physiology • Chapter 11: Principles of Pathophysiology • Chapter 12: Medical Terminology 129 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Human development from conception to childbirth • The psychosocial theories of nature vs. nurture • The continuous state of physical, cognitive, and psychosocial development from young to old • The impressionable time of middle childhood and the health concerns that face adolescents • Moral development and
facing adult responsibilities • A greater understanding of acceptance of the stages of dying Case Study: The Paramedics were called to the home of a 13-year-old male with diffi culty breathing. When they arrived they were introduced to Erik. His cold had worsened and he was having some diffi culty breathing. While one of the Paramedics began interventions, the other planned to obtain a history. As he began with questions about allergies and medication, he realized he didn’t know much about what 13-year-olds can do. He made a mental note to review human growth and development. It was like being back in Paramedic school. . . . 130 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Lifespan Development 131 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW The Paramedic may encounter patients ranging in age from newborns to over a hundred years of age. The Paramedic’s emphasis is often placed on how to treat the patient medically. This chapter discusses human development. Knowing the patient’s age can dictate a Paramedic’s approach to assessment and care (for example, the difference between a fussy 3-year-old and an elderly person who is making an end-of-life decision). This chapter discusses the physical, cognitive, and psychosocial development of people from birth to death. Personal Development it. Each theorist has brought a unique perspective to the study of psychosocial development. Paramedics will encounter patients of all ages. Understanding the patient’s developmental stage will help the Paramedic Psychosexual Theory adjust his approach accordingly and to connect more therapeutically with the patient. Sigmund Freud advanced one of the fi rst psychosocial A person’s development can be divided into three developmental theories in the late 1800s.1 Freud attached great components. The fi rst and outwardly most evident is the patient’s importance to sexuality and linked a person’s psychosocial physical development, those bodily changes that occur not just development to sex. Freud suggested that human psychic during one’s youth but throughout life. The second change is development was linked to physical growth, specifi cally where the person’s mental or cognitive development and includes the the sexual energy was centered, and that human development development of reasoning, the ability to think, and memory. was therefore biologically controlled. Freud suggested that Cognitive development also includes language acquisition, during childhood a person’s sexual energy shifted from the that human characteristic which permits communication. The oral to the anal to the genital regions as each become a focus third aspect of personal development is a person’s emotions, in the person’s personal life. the affective self. This aspect of development is the result Fundamental to Freud’s theory are the ideas of id, ego, and of internal psychological dynamics and external societal superego. A person’s id consisted of the person’s biological infl uences. The affective portion of the person represents the needs, such as water and food. A person’s id also contained psychosocial aspect of a person’s development. the will to live and the drive to reproduce, the libido. Inherent The changes in a person’s patterns of thinking, feeling, in the id is the concept of pleasure; that is, people will do and physical growth are all part of the person’s development. what is pleasurable and avoid what is not pleasurable. Each of these elements affect the person, to varying degrees, Eventually a person would develop an ego, a conscious over the course of a lifetime. These changes, coupled with state that controls the id. The ego is that personal sense of self life experience, combine to create the person that he or she as a physical being interacting in the world. The ego tempers has become. the id with reality. For example, while sex is pleasurable (a function of the id), if it were to be pursued to the exclusion of all other social interaction then the ego would prevent that. Theories of Personal Development Finally, in early childhood the person would develop a superego, those societal values that run counter to the id. Several theories have been advanced over the years to explain The superego works to suppress the id and forces the ego human development over a lifespan. These theories take into to consider moral behavior. Freud postulated that it was account the physical, mental, and psychosocial aspects of a the ego that kept the confl ict between id and superego to a person and try to provide a meaningful explanation of the minimum. changes that commonly occur. Psychosocial Theory Theories of Psychosocial Erik Erikson, a student of Freud’s psychosexual theory, dismissed the centrality of sexuality in favor of the effect Development of social infl uences on the person. Erikson felt that people The fi rst and most widely known theorist of psychosocial develop because of social pressures to conform and co-exist. development was Sigmund Freud. Having laid a framework Erikson’s view of psychosocial development stressed the for understanding the human psyche, others—such as role of the ego in direct confl ict with Freud’s theory, which Erikson, Skinner, and Piaget—have sought to improve upon stressed the role of the id. 132 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. In essence, Freud’s theory stressed the physical of theories, and an even greater abundance of debate, the developments and supported the idea that nature controlled argument lives on. one’s development. Erikson stressed the social infl uences and supported the idea that nurturance had a greater impact upon personal development.2 This is the classic nature vs. nurture Conception to Childbirth argument. At the moment of sexual climax, millions of spermatozoa are Erikson’s theory was also more comprehensive and deposited into the vaginal vault and begin the journey through included eight stages. Erikson’s theory takes into account the cervix and into the fallopian tubes. When the spermatoza the entire span of a person’s lifetime, adding three stages reach the egg, called an ovum (Figure 9-1), one will penetrate of adulthood to Freud’s fi ve stages of psychosexual and fertilize the ovum. development. The fertilized ovum, now called a zygote, starts to divide Confl ict is the pivotal event that moves people through the repeatedly. During this early stage the zygote will form various stages of Erikson’s psychosocial development. Each a hollow, fl uid-fi lled ball or blastocyst. The cells inside of stage is represented by the critical confl icts. For example, the blastocyst will form the human, whereas the cells on Erikson believed that the young person must resolve confusion the outside will form a protective covering that eventually over one’s role in life to form a personal identity. develops into the placenta. Behaviorism While this development has been occurring, the zygote has been traveling down the fallopian tubes and into the While Pavlov’s experiments with dogs, where he was able uterus. At the end of the fi rst week, the zygote implants into to condition dogs to salivate when a bell was rung, set the the uterine lining. The amnion, which makes amniotic fl uid, stage for a new developmental theory called behaviorism, and the chorion, which will make the placenta, start to form B. F. Skinner’s operant conditioning took center stage. along with the zygote. The placenta will provide the infant Skinner believed that human behavior is simply a function with nutrition through the umbilical cord, which connects of an interaction, positive and negative, with the social the mother and child (Figure 9-2). environment. In about 30% of pregnancies, the zygote fails to implant Expanding on behaviorism, Albert Bandura, another and the pregnancy is spontaneously aborted.5–7 This is referred American psychologist, suggested that people learn in to as spontaneous abortion. three ways: by direct instruction, direct experience, and In the weeks following the implantation, the zygote, now observation. Bandura’s social learning theory suggested that called an embryo, is rapidly dividing and laying down the people developed through learning. foundations for all of the major organ systems. During this All three of these theorists—Pavlov, Skinner, and period of time, from conception to the end of the ninth week, Bandura—took the approach that life experiences (nurturance) the infant is at greatest risk for fetal malformation. Potential are the dominant infl uence in a person’s psychosocial causes of fetal malformation are toxic substances or agents, development.3,4 called teratogens. Examples of teratogens include illegal drugs such as cocaine, alcohol, and infections such as rubella Cognitive Development Theory (measles) and toxoplasmosis. Women who drink alcoholic Cognitive development theorists looked at how the mind was beverages while pregnant can potentially cause a number developed. Jean Piaget, an early cognitive theorist suggested of birth defects, collectively referred to as fetal alcohol that people develop in a building block fashion, one learned syndrome.8–14. behavior building upon another. Piaget suggested that people learn schemes (ways to deal with the world) upon which Genetics and Human Development they build new schemes. The earliest schemes are primitive refl exes. A person’s intelligence is a function of the ability to Every person alive is the result of the union of two sex create new schemes to successfully adapt to the environmental gametes: a spermatozoa and an ovum. Each gamete brings conditions in which a person fi nds himself. This process of 23 chromosomes, a double helix of DNA, into the mix. assimilation (integrating new information into a preexisting Together, these chromosomes provide an individual’s genetic matrix) along with accommodation (the changing of make-up, the genotype. The subsequent division of the cell, preconceptions to allow for new information) was the source called mitosis, continues until a person is created. The visible of human development over a lifespan. outward expression of the chromosome, the phenotype, is therefore the result of the genetic infl uences of both the Topics in Human Development parents. If the gametes each bring an X-chromosome to Central to all discussions of lifespan development is the the union, then the individual will be female. If one of the argument of whether genetics are dominant in a person’s spermatozoa brings a Y-chromosome to the union, then the development or whether the environment and society play a person will be a male. Each chromosome provides genes. greater role in human development. Despite the abundance These genes determine the physical characteristics which Lifespan Development 133 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Acrosomal (head) cap Sperm Acrosome Head Polar body Condensed Zona nucleus pellucida Neck Cell membrane Mitochondria Cytoplasm Nucleus Middle piece Nucleolus Corona radiata made up of epithelial cells Ovum (1/125 of an inch in diameter) Flagellum Principal piece End-piece Figure 9-1 The sperm and fertilized ovum. Placenta Some genetic diseases are linked to the sex chromosomes Umbilical Intrauterine cord cavity (i.e., sex-linked transmission). If both parents contribute that abnormal chromosome, then the child will have the disease. Examples of sex-linked diseases include sickle- cell disease, Brugada syndrome, Huntington’s disease, and Marfan syndrome. If the child has one sickle-cell disease gene,
then the child will be a carrier but will not have the disease. If the child has both genes, then the child will have the disease. Pregnancy After the ninth week, the pregnancy is generally viable. Amniotic Amniotic The embryo, called a fetus, will come to term in about the fluid sac ninth month. The stages of a pregnancy are evenly divided into trimesters, each of which has specifi c characteristics. Figure 9-2 Fetus in utero attached to placenta by The fi rst trimester, the germinal period, is a period of the umbilical cord. high hazard. The second semester sees rapid growth in the fetus and the fi rst signs of life, fetal movements called comprise the individual. If one parent’s genes control the quickening. During the fi nal trimester, at the twenty- child’s characteristics, then that gene is said to be dominant. sixth week, the pregnancy reaches the point where, if the If one parent’s chromosome is not dominant, but instead pregnancy were to terminate prematurely, the infant would is recessive, then the recessive gene will not control the be viable. characteristic. For example, if a blue-eyed mother mates A number of other factors also combine to increase infant with a brown-eyed father and brown eyes are dominant, mortality, including advanced maternal age (greater than 35), then the child will have brown eyes; note eye coloring is not domestic violence (approximately 8% of pregnant women are that simple. battered), and poor health, including a lack of prenatal care 134 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Amniotic cardiac shunts (the foramen ovale and the ductus arteriosus) fluid to reverse blood fl ow and then close.15–17 Amniotic sac Internal os Cavity Street Smart of cervix External os Before labor Early effacement In the fi rst few minutes to one hour after birth, the infant is referred to as newly born. Thereafter, the child is referred to as a neonate for the remainder of the fi rst 28 days of life; this defi nition somewhat changes depending on the source. After the neonatal period, and through the fi rst year, the child is called an infant. The term “baby” is generally considered a Complete effacement Complete dilation lay term. Figure 9-3 Childbirth. Street Smart and poor nutrition. As a result, the most dangerous time in any human’s existence is the time from the moment of conception Less than 10% of the newly born require some form of until birth. active resuscitation. Simple techniques, such as drying the infant, are usually suffi cient to stimulate the Childbirth newly born to breathe. Childbirth, the culmination of nine months of growth and development, begins when the uterus starts to contract in a process called labor (Figure 9-3). These strong rhythmic contractions begin to push the fetus into the birth canal and The Infant dilate the cervix through a process of widening and thinning. This process takes approximately 12 hours on average. It The fi rst year of an infant’s existence revolves around eating, can range from one hour, called a precipitous delivery, to 24 sleeping, and growing. Initially, the infant spends eight hours hours or more. in full rest (non-REM sleep), another eight hours in REM The infant, with its head engaged in the birth canal, sleep (dreaming), and the rest of the time in varying amounts begins a rapid passage down the birth canal in the second of quiet alertness, drowsiness, and distress. stage of delivery. The delivery of the infant may take upwards At about the fourth month, the infant’s sleep/wake cycle of an hour, barring any complications. starts to approximate that of an adult and the child’s response The third and fi nal stage of the delivery is the delivery to the environment starts to become more determined. of the placenta, which marks the end of the pregnancy. Initially, the infant has only primitive survival refl exes, such as the sucking refl ex and the swallowing refl ex. The Newly Born At the moment of delivery the newly born must undergo Physical Development dramatic physiological changes in order to adapt to The average newborn weighs between 3 to 3.5 kg at birth and extrauterine life. During this transition period, the newly will almost triple that weight in the fi rst year of life. Most born’s cardiopulmonary system switches from dependence newborns typically drop between 5% to 10% of their birth on the mother, via the placenta, to independence. weight in the fi rst week due to a combination of fl uid loss During the fi rst minute of life the umbilical blood and consumption of brown fat; brown fat is special baby fat fl ow diminishes, raising carbon dioxide levels, which in used to generate heat. Normally, if the newborn is feeding turn stimulate the newly born’s fi rst breath. The increase in properly, the newborn should regain this weight and surpass intrathoracic pressure, from the air-fi lled lungs, causes the the birth weight by the end of the second week of life.18,19 Lifespan Development 135 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 9-1 Comparison of Vital Signs Between Newborn and 1-Year-Old Infant Street Smart Vital Signs Newborn 1-Year-Old Heart rate (BPM) 120–160 100–120 The common cold could be potentially deadly to an Respirations (BPM) 40–60 20–30 infant as most infants breathe through their nose, i.e., Blood pressure (mmHg) 60 70–100 obligate nose breathers. With stuffy nasal passages the infant must struggle to breathe.24,25 Fortunately, At the moment of birth, the newborn is challenged to most infants obtain passive immunity, passed on adapt to the world outside of the womb. At that moment from the mother, for the fi rst six months. Respiratory the newborn’s heart is racing, between 100 and 160 beats infections are minimized during this critical period.26 per minute, but soon settles to a sustained tachycardia around 120 beats per minute. In like fashion, the newborn’s respirations are between 40 and 60 breaths per During the fi rst six months of life, the infant experiences minute but become increasingly slower over the first year dramatic neuromuscular development. The primitive refl exes until they stabilize at about 20 to 30 breaths per minute (e.g., the Babinski refl ex) start to wane at about six months as (Table 9-1). the motor neurons within the spinal cord mature (Figure 9-4). This neurological development starts in a head-to-toe (i.e., cephalocaudal) fashion and from an inward-to-outward (i.e., proximodistal) fashion. During the assessment of the infant, the Paramedic Street Smart should be attentive to the presence of infantile refl exes.27–29 Upon observation of a healthy infant’s general appearance, the Newborns are very prone to hypothermia because of a Paramedic should note an infant who is interactive with the combination of a large head and a large body surface environment, whose limbs move when stimulated, and who has a strong sucking and gagging refl ex. An infant in trouble area to weight ratio, which encourages more radiant has limp extremities and a “Raggedy Ann” appearance. heat loss. Newborns have a special reserve of brown Most infants, when the Paramedic claps his hands, will startle fat, about 5% by body mass, which helps the newborn and extend both of their arms. This is called the Moro refl ex. An absent Moro refl ex on one side may indicate a neurological generate heat. Premature newborns do not have this disorder, such as hemiplegia, or perhaps a fractured clavicle. brown fat and are more prone to hypothermia than Other primitive or infantile refl exes include the rooting full-term newborns.20-23 refl ex, in which the infant turns toward the cheek that is stroked, and the sucking refl ex. Both of these refl exes are present at birth and help the infant with breastfeeding. The next refl ex is the palmar grasp refl ex. The palmar Maintaining ventilation represents one of the greater grasp refl ex is seen when the infant’s hands grasp an object challenges for an infant. The combination of a narrower pressing against the palm. Another refl ex is the tonic neck airway, which is more easily obstructed, and the fact that an refl ex, in which turning the infant’s head to the side causes infant is an obligate nose breather (i.e., primarily breathes the ipsilateral arm to straighten and the contralateral arm to through the smaller nasal passages) makes partial airway bend, in the classic fencing posture. Both of these refl ex tests obstruction more likely and breathing more diffi cult. are tests of the motor neurons of the upper nervous system. Once air has passed the upper airway into the lungs, The Babinski refl ex, a fanning of the toes and extension of there are fewer alveoli to exchange oxygen to meet the high the great toe caused by stroking the lateral soles of the feet, is metabolic rate and oxygen demand of the infant’s body. To a test of the lower motor neurons. compensate for the mismatch between demand and capacity, the infant increases the respiratory rate. This is not an effective mechanism yet because of the combination of horizontal Street Smart ribs, which decrease expansion, and weak accessory muscles which force the diaphragm to act as the primary muscle of When a person is in a coma, these primitive refl exes respiration. The diaphragm is limited in its ability to sustain a may reappear. Thus, when a family member holds the rapid respiration. Compounding the problem is the increased hand of the unconscious patient she may think that heat loss, from rapid respiration, which in turn increases the metabolic demand upon the body to produce heat. The infant the patient is intentionally grasping the hand when in can quickly fatigue and then experience respiratory distress fact it is a primitive refl ex. and failure. 136 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 9-4 Infant refl exes. Lifespan Development 137 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. At about the time the posterior fontanel closes, at three A smile is often an indication of a person’s affect. Until to four months, these primitive refl exes start to wane. By the around three months of age, infants smile refl exively, meaning time the anterior fontanel closes, in nine months to a year, all they smile randomly and without apparent provocation. The of these refl exes should be gone. infant older than three months will start to demonstrate The infant experiences the greatest amount of growth emotional expressivity through a social smile. A social during this period of time. Bones grow, infl uenced by factors smile is a refl ective smile (in response to someone smiling such as growth hormone, genetics, and the infant’s general at the infant). It is not a refl exive smile caused by an external health. The infant becomes physically stronger
as the muscle stimulus (e.g., the proximity of a person’s face). Often social mass increases correspondingly. smiling is accompanied by vocalizations such as cooing or by As the infant gains control over the larger muscle groups, lip movements called mouthing. the infant will raise the chest off the fl oor and then crawl. The continued social interaction between infant and Later the infant will stand and move about, grasping objects parents is the start of the process of socialization. As the to help with balance while walking. This is called cruising. infant becomes more connected, psychoemotionally, to Eventually, the child will walk unassisted. the mother, the infant is learning behaviors which will affect Each new skill represents another objective the infant the child’s social competence later in life. Further parent–child has accomplished while moving toward maturity. Taking an interaction, such as assistance with simple psychomotor tasks age-related average, Arnold Gesell distributed these different (a process called scaffolding), helps to further develop both tasks across a timeline, called developmental milestones. the infant’s psychomotor skills and the infant’s social skills. The developmental milestones represent a typical child’s A test of an infant’s social skills is the ability to development and are used to gauge an individual child’s withstand parental separation. During a medical emergency development against a norm. the Paramedic may need to examine the child at a location separate from the mother. This tends to elicit separation Cognitive Development anxiety in the infant.30,31 The infant may be observed to reach An infant obtains knowledge of the world through sensory out to the mother, or to grasp the mother fi rmly and resist input, which the infant brain tries to make sense of. Initially, separation. One theory suggests that the infant has no concept the newborn uses his primitive refl exes as building blocks. of time. Thus, when a mother leaves the child for even a Then, future experiences are assimilated into the old schemes, minute, the child—who depends on the mother for survival— thus building all new schemes. feels abandoned and instinctively cries for the mother. As the During this phase, the infant begins to acquire language infant develops, the infant will be comforted by memories of skills. Starting with cooing (simple vowel sounds), the infant the mother and self-soothing activities such as thumb sucking proceeds to preverbal gestures (e.g., pointing). The child then during periods of isolation. utters his or her fi rst words at about 12 months. From that During this early period of socialization, autism is often point, and for the remainder of the fi rst two years, speech discovered. Autism is a developmental disorder which includes develops rapidly and the infant’s vocabulary expands to over impaired social interactions, an absence of separation anxiety, 200 words, mainly consisting of labels of people or things. and problems with both verbal and nonverbal communications. Failure to manifest early signs of socialization, such as refl ective Psychosocial Development smiling, may be indicative of autism. The fi rst psychosocial task encountered by an infant is bonding. Bonding is a process that establishes a lasting nurturing relationship between a mother and child. While bonding may begin during pregnancy, it is a reciprocal Street Smart relationship that involves both mother and child. Many factors can infl uence bonding including physical While an infant’s crying is distressing to most, the separation from the infant, diffi culty in delivery, and absence Paramedic understands that this is the infant’s way of of breastfeeding. The Paramedic can be witness to this communicating. Infants cry because they are angry, bonding behavior, such as mutual gazing, refl ective smiling, and response to touch. Absence of these bonding behaviors in pain or discomfort, or have a basic need which is (i.e., poor bonding) may be refl ective of poor maternal care unfulfi lled. The cry of an infant in pain occurs without and even child abuse. any moaning and is followed by breath holding.32–34 During this formative year, an infant’s temperament becomes manifest. For example, the infant may be easy, diffi cult, or slow-to-warm-up. The majority of infants are cheerful and adapt to change readily. The slow-to-warm-up Parent–Child Relationships infant appears inactive, maybe even in a negative mood, and The importance of a Paramedic understanding the parent– adjusts slowly to changes. The diffi cult infant does not accept child relationship can be pivotal to a positive therapeutic changes and is demonstrative in his disapproval of change. encounter. Dr. Diana Baumrind has suggested in her typology 138 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. of parenting that there are four styles of parenting, each with Preschool Children: a different impact on a child’s psychosocial development. The child development literature has suggested that the impact of Early Childhood these parenting styles, both negative and positive, is evident The early childhood years, from age 2 to 5, are a period of as early as the preschool years. extraordinary growth. For each year of growth the child, Each of these parenting styles will have an impact upon now called a toddler, will add fi ve pounds and three inches the child’s social competence and psychosocial development. of height. The spinal column starts to lengthen and the In some cases, the parenting style is predictive of the problem internal organs start to ascend under the protection of the behaviors. Each of these parenting styles revolves around the thoracic cage. emphasis, or de-emphasis, of nurturance. Nurturance is the The toddler’s pulmonary system continues to grow as quality of caring and concern. A nurturing parent provides terminal airways continue to branch, alveoli develop, and clarity of communication, makes demands for maturity, and hemoglobin levels climb to near adult levels. Perhaps most maintains parental control. The last element, parental control, remarkably, the toddler’s nervous system is almost completed seems to be pivotal in describing a parenting style. in its development. The peripheral nervous system is myeli- Permissive, or indulgent, parents tend to give control over nated, allowing for the development of fi ne motor skills, and to the child by not establishing boundaries or routines. While the brain has attained almost 90% of its adult mass. these parents tend to display affection to their children, they While such factors as genetics and wellness can affect fail to consistently enforce or clarify rules, presenting the child a child’s height and growth, all children should become with mixed messages. Permissive parents tend to accept all larger and taller. Those who fail to grow, exhibiting failure of a child’s behaviors, both good and bad, without judgment. to thrive, may be under severe psychosocial pressures or Children of permissive parents tend to perform poorly in the have nutritional defi cits. Paramedics need to identify these structured environment of the school and have problems with toddlers and encourage the parent to seek medical attention authority. However, they have higher self-esteem and better for the child. social skills than children of other parenting styles. In contrast, the authoritarian parent always needs to be in Physical Development control and tends to demand high levels of maturity. Strict rules are the norm and the display of affection is rare. Authoritarian During these early preschool years, a child learns to run, parents tend to focus on negative behaviors. Children of jump, hop, and throw. These complex motor activities are an authoritarian parents tend to be anxious and withdrawn, with outward manifestation of the growing neuromuscular system poor social skills, but perform moderately well in school. (Figure 9-5). Children of authoritarian parents also tend to have higher At or about 3 years of age, children will learn how to levels of depression. As a result of their upbringing, the toilet themselves. Within another year, children learn how to interaction between Paramedic and child can be diffi cult as dress themselves. The 6-year-old child should have developed these children are generally mistrustful of adults. enough motor dexterity to be able to tie a shoe. The authoritative parent, sometimes referred to as At this age, the impact of sex can be fi rst noted. Males the democratic parent, has all four qualities in balance. tend to be slightly better at skills emphasizing force or power Authoritative parents establish rules, hold children responsible whereas females tend to be better at fi ne motor skills, such for adhering to those rules, and provide explanations of as balancing and foot movements. Most toddlers, because expectations to the child. Authoritative parents focus on of improved eye-to-hand coordination, enjoy games such positive behaviors. They try to catch their children being as puzzles or coloring with crayons. These activities can good. Children of authoritative parents tend to be happy, self- be solitary or enjoyed in groups. When engaged in group confi dent, and independent, to the point of genuine openness activities, toddlers tend to identify with other same sex to other adults. children and begin to model their behaviors based on the The last parenting style could almost be called a non- behaviors of others of the same sex. parenting style: the uninvolved parent. These indifferent The play “pals” that toddlers are often placed with are parents have little commitment to parenting. Children of other siblings. It is during this play period that sibling rivalry indifferent parents tend to have low tolerance for frustration will be seen. Sibling rivalry is a form of competition, for and exhibit problems with impulse control. This group of parental approval or attention, between brothers and/or sisters. children is a particular problem for Paramedics as they also Sibling rivalry can, at times, involve unacceptable behaviors tend to be aggressive, to the point of committing violence. such as aggression or “acting out.” In general, sibling rivalry From a Paramedic’s perspective, it may seem reasonable should be viewed as the toddler’s effort to establish herself to withdraw from a situation in which a child is aggressive. as a person and to establish her place within the family However, the more constructive approach is to remain hierarchy. While not entirely preventable, toddlers can be steadfast. The Paramedic can acknowledge the behavior as taught that violence is not an acceptable means of resolving being unacceptable, without becoming aggressive in either disagreement and that there are other more positive ways to words or action, and all the while remain authoritative. get attention. Lifespan Development 139 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 9-5 Motor skill development: Child. Cognitive Development Here again, the differences between the sexes become The early childhood individual is in a preoperational stage of more evident. Females tend to ask questions and make cognitive development, as per Piaget’s studies. The thinking is requests more indirectly than males, while maintaining more concrete and the child cannot think in terms of abstracts. The eye contact. Females also tend to use more nonverbal cues result is that these children will take what the Paramedic says such as body language. literally. Therefore, the Paramedic should carefully construct statements in order to avoid misinterpretation and confusion. Psychosocial Development As time progresses, the children develop more symbolic Play has a pivotal role in human development at this age. thought, which helps them remember experiences. Psychoanalytic theory suggests that play provides children an As symbolic thought develops, so does mathematical opportunity to gain mastery and demonstrate autonomy for reasoning. Young children understand that the numbers, the purpose of self-satisfaction. names, and objects in a set are related (i.e., 1 one a dog). Cognitive theory suggests that play develops in readily Young children struggle to learn concepts such as ordinality identifi able stages, starting with functional play. Functional (that
numbers occur in an order) and cardinality (that the last play is focused on performance, usually of a simple repeated number represents the sum of the set of objects). movement, such as dribbling a ball or shooting a basket. Also critical at this point in a young child’s development The next level of play is constructive play. In constructive is language acquisition. Going beyond the 300 or 400 play, the child takes common objects and attempts to build learned earlier, the young child now learns how to apply things. Construction of objects permits the child to move into syntax, the rules of grammar, and semantics, the meaning the next phase of play, pretend play. Pretending to substitute of words. The focus of this language development is upon oneself into another character or role permits the child the the practical application of language to social and personal opportunity to expand horizons without threat; lines like relationships. “after all, it wasn’t me, it was my dolly,” might be heard. 140 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Eventually, children become involved in games with rules A person’s language skills (many children are—or learn to at about the fi fth year. Games encourage an understanding of be—bilingual at this age), musical skills (such as playing an interpersonal relationships as well as the relation of abstract instrument), logical skills (manifest in math or chess), and concepts to the real world. kinesthetic skills (such as demonstrated in Figure 9-6) may become apparent. Perhaps the most important intelligence a child learns at this age is the ability to form close human bonds School-Aged Children: as well as a social self (personal and interpersonal skills). Middle Childhood Psychosocial Development Middle childhood is centered on education, the school years, and The stage of middle childhood can be one of great upheaval for personal development. The infl uence of family starts to wane in the individual. There are many challenges to the psychosocial the face of growing social involvement and peer pressure. self such as knowing who the child is. The child develops a Physical Development sense of self and a desire to succeed and achieve. Peers, school, and family are modifi ers of the child’s sense School age signals a slowing in physical growth for a child. of self and often come into confl ict with one another. Erikson’s Girls may grow to be taller than their male counterparts for a psychosocial theory states that middle childhood is a time in time until boys enter puberty. Mortality is traditionally lower which children are concerned about their capacity to do good during this time, with viral illnesses being the largest source work (industry versus inferiority) and show initiative. of sickness. Children often manifest their differences in achievement motivation during this period. Some are learning oriented, Cognitive Development and are focused on attaining competence in an area of study. During middle childhood, children are more interactive with These children are intrinsically motivated. Other children are their environment. They experiment, test, and generally assess more interested in pleasing others (extrinsically motivated) their life condition and developing concepts about it. and have a performance orientation. During this time, the child starts to focus on objects and events. The child is able to focus on and comprehend the complexity Peer Relations of multifaceted problems. Piaget refers to this as the concrete According to Piaget, children in middle childhood overcome operational stage.35 Children in this stage are able to understand their egocentrism (i.e., focus on oneself) and start to relate to such concrete operational concepts as spatial relations, nature of others more in terms of common interests, goals, and so on. time, and the sequential nature of certain activities. Parents have a lesser infl uence in this matter, as they are not Gardner advances the theory by stating that the multiple viewed as peers, and friends start to take on a greater role in intelligences of a person become evident during this stage. shaping the person’s personality. Figure 9-6 Children learn balance and coordination by riding bicycles. Lifespan Development 141 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 9-7 Children tend to gravitate to same sex friendships. Initially, these children are interested in same-sex friends, Gender Identity almost to the exclusion of the opposite sex, and form close During the school-age years, children start to attach a friendships (Figure 9-7). Females tend to form close and intimate gender-role identity to themselves; that sense of being a friendships of one other same-sex friend at this age (dyads) male or a female. It is diffi cult to establish which factor has while males tend to include a larger circle of acquaintances. a greater infl uence on a child’s gender-role identity—genetic A child who forms friendships easily is viewed as popular. infl uences, hormonal factors, or social factors—but it can In addition, popular children are seen as confi dent, good- be a confusing time for a child. In some cases the child’s natured, and energetic. Physical traits that support athleticism psychological assignment of gender may be in confl ict with help a child gain popularity and social acceptance. the child’s biological sex assignment. A child may attempt to Conformity to the group is stressed during this time and maintain androgyny for a time (having both masculine and peer pressure can cause children to make rash decisions which feminine qualities), in an effort to understand the mental and run counter to their personal values or the values taught to physical changes within themselves, while others experiment them by their parents. This experimentation can be healthy, if with one and then the other gender role. not taken to extremes, as it encourages independent thought Regardless of a child’s gender-role identity, it is important about values and morals. that the Paramedic remain nonjudgmental in this matter and Divorce focus on the patient’s medical condition. Dr. Judith Wallerstein, in her landmark work entitled “The Unexpected Legacy of Divorce,” described the problems Adolescence of trust and intimacy that children experience because of Adolescence could best be described as a stormy transition divorce.36 Divided loyalties, inconsistent discipline, and long from childhood to adulthood. Societal concerns, such as periods of tension and discord can come together to produce educational preparation versus industry, have culminated a fear of intimacy, lowered expectations of authority fi gures, in child labor laws, compulsory education, and a separate and a sense of powerlessness in a child. judicial system for juveniles. Each is a response to an issue These fears can be problematic if the Paramedic is treating faced by adolescents. a child with divorced parents. Confl icts may arise during even routine physical assessments and a war of wills may occur. Despite the Paramedic’s good intentions, the child may not be Physical Development willing to accept care and will resent efforts to provide that The most remarkable changes in the human physique, the care, to the point of becoming violent. The Paramedics can body habitus, occur in adolescence. Entering into puberty, only resort to tact and diplomacy and a willingness to accept males and females see dramatic sexual changes in their what the child will permit. physical bodies. 142 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. For males, the development of facial hair, enlargement “comfort” foods, instead of healthier choices, leading to of the penis, and the fi rst ejaculation represent milestones in weight gain beyond growth. They then become obese. their passage to manhood. The United Nation’s World Health Organization (WHO) For females, the development of breasts, the widening of called obesity the “global health epidemic” in 1998 and the hips, and the fi rst menarche (period) represent milestones stated that at that time the health of 6 million children was in in their passage to womanhood. jeopardy because of obesity. The health risks associated with The timing of puberty is widely variable, with some obesity are impressive: type 2 diabetes mellitus, secondary females experiencing menarche at age 12 while some males hypertension, accelerated coronary artery disease, and do not experience ejaculation until age 18. stroke. Females who are early maturing are very concerned At the other extreme of teenage weight problems is about their physical appearance and are often confronted anorexia nervosa. Anorexia nervosa is a psychiatric illness with social situations for which they are not, psychosocially involving problems with self-image and is characterized by speaking, prepared. self-starvation and bulimia, binge-eating and then purging Late maturing males may appear immature and therefore via laxatives or vomiting. Anorexia nervosa affects about 1 lack social grace and self-confi dence, but are actually at more in 1,000 young women or 1% of adolescent girls. If untreated, liberty to develop a unique personality, unfretted by social anorexia nervosa can be fatal.41 pressures. Teenage Suicide Adolescent Health Concerns At increased risk for premature death from trauma, secondary The opportunities for freedom, and the accompanying to increased risk-taking behaviors and a false sense of experimentation, coupled with the use of inhibition-reducing invulnerability, teenagers are also at higher risk of death from drugs, such as alcohol, can potentially create unhealthy suicide. situations for adolescents. The Paramedic should keep these While death from motor vehicle collisions and homicide health concerns in mind when treating adolescent patients. are still competing for the distinction of most common cause of death for young people age 12 to 22, suicide is still Sex and the Adolescent in the top three causes of teenage death. Teenage suicide is frequently the result of a high-stress event (e.g., death of a The advent of sexuality brings the risk of sexually transmitted peer) and/or inadequate coping mechanisms. About 20% to diseases. It has been estimated that 25% of adolescents leaving 25% of adolescents report signs of depression at one time or high school will have, or have had, a sexually transmitted another during adolescence. Among adolescents, 8% report disease. A combination of early sexual maturing, early sexual suffering from debilitating or clinical depression. Suicide is activity, drug and/or alcohol use (lowering inhibitions), and the third leading cause of death for teenagers age 15 to 19.42–44 inadequate instruction about the use of contraceptives results Therefore, Paramedics should take all teenage depression and in a high rate of teenage pregnancy and an epidemic of suicide attempts seriously. sexually transmitted diseases (STD) in adolescents.37–39 Over the last two decades, the number of cases of chlamydia has risen almost 300% and it is estimated that there Cognitive Development will be one million new cases of genital herpes simplex virus The cognitive development of the adolescent revolves around type 2 (HSV-2) each year. It is thought that young women using logic to solve problems, seeing the possibilities rather are more susceptible to STDs because epithelial cells, which than the realities, and engineering new ideas. To turn a phrase, are more susceptible to infection by STDs, extend over the adolescents start to see problems as “less black and white and vaginal surface of the cervix and the cervix is unprotected by more as gray.” cervical mucosa. These epithelial cells later retract in an adult Piaget referred to this stage of intellectual development woman, exposing the cervical mucosa. as the formal stage. Formal thinking
involves the application Genital human papillomavirus (HPV), genital warts, of logic to abstract ideas to solve problems. This formal is the most common sexually transmitted disease among thinking allows the individual to fi nd meaning in seemingly sexually active adolescents. Genital human papillomavirus confusing data and to apply problem-solving techniques to has been connected to the incidence of cervical cancer.40 resolve confl ict. There is currently a vaccine for HPV and it is hoped that its use will decrease the number of cervical cancer cases. Psychosocial Development Adolescents return to egocentrism, a stage previously Obesity encountered in early childhood. Impressed with their Chaotic schedules, the ease and availability of “junk foods,” newfound abilities to reason logically and think abstractly, and peer pressure contribute to poor teenage nutrition. On they formulate idealisms without regard for practical reality. one extreme is the national epidemic of teenage obesity. During this time, adolescents turn their attention to Adolescents seeking solace in food eat carbohydrate-high morality and their own moral development. Kohlberg divided Lifespan Development 143 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 9-8 Adolescence is a time of growth and experimentation. the process of moral development into six stages and three The highest level of moral development, and the sixth levels. stage, is principle-based morality. Having developed a strong The fi rst level is preconventional morality. This is the set of internal principles (e.g., guiding missions), these fi rst stage of moral development and is simply avoidance adolescents conform to their principles rather than face self- of pain. To a person at this level, the morality of an act is condemnation. defi ned by the positive or negative outcome (i.e., pain and Teenagers are challenged to develop their social self, punishment). Notably, obedience is a function of punishment. their intellectual self, their moral self, and their sexual self Advancing to the next stage, the hedonistic phase, the person into a socially acceptable personage (Figure 9-8). conforms less to avoid punishment but more to attain or gain an advantage. Level two is simply conventional morality. Stage three, Early Adulthood conventional morality, involves being seen as a “good person” by Early adulthood is a period of striving and accomplishment. friends and family at its lowest stage. Conduct is geared toward It is punctuated with peak life events such as marriage and that goal. The advanced version of conventional morality, stage childbirth. four, is also called a “law and order” morality. People at this A fundamental decision made by most young adults is stage conform to the rules for the sake of the rules. whether to go to college or to start work. Women are more The third level of moral development is postconventional likely to go to college and more likely to complete college morality. People at the lowest stage of postconventional within the traditional four-year cycle. Men are more likely to morality are concerned with abstract concepts such as justice go to work or start college but not complete it. and democratic principles. Their moral beliefs tend to be more The young adult immediately entering the workforce fl exible, in concert with the society in which they exist. will fi rst enter a period of self-exploration, in preparation for 144 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. work, then try to fi nd an organization or business to enter same-sex friend, and then expect that confi dence to be shared into. Unions, like the guilds before them, offer these young exclusively. Young men tend to establish same-sex friendships adults opportunities to train as apprentices. Apprentices have based on common activities, such as sports. the advantage of gaining competence on the job as well as Regardless of sexual orientation, most young people are learning organizational rules and mores. seeking a monogamous relationship with a signifi cant other person. According to Dr. Robert Sternberg, love has three Physical Development aspects or components: intimacy, passion, and commitment. The majority of people, both male and female, reach Utilizing these three components, Sternberg has described their peak height in their early twenties, and their health seven combinations, each a variation of love: friendship, is generally at its peak as well. Unfortunately, obesity—a infatuation, empty love, romantic, companionate, fatuous, growing problem to children and adolescents—is also more and consummate love. common in young adults, with over one-half of all adults For example, intimacy without either passion or being overweight. commitment is friendship. Infatuation, on the other hand, As an adolescent reaches maturity, and the age of is passion without intimacy and commitment. Arranged consent, unhealthy decisions can be made regarding such marriages are an example of empty love, where there is potentially devastating behaviors as tobacco smoking, alcohol commitment but no intimacy or passion. Sternberg goes on to consumption, and unprotected sex. These behaviors may be describe romantic love, companionate love, and fatuous love. seen as outlets from the stress of everyday pressures. Some The greatest and deepest love has all three components— stress can be negative, such as distress or stress caused by intimacy, passion, and commitment—and is a complete form creditors trying to collect on unpaid bills. Other stress can be of love. positive (eustress), such as the birth of a child. Regardless of the type of stress, all stress can be seen as Marriage either a chance for harm or as a challenge and the body responds accordingly. The sympathetic nervous system responds by an Hypothetically, marriages are an equal partner relationship adrenaline release which leads to hypertension and tachycardia. in which shared concerns and responsibilities help form the Persistent or sustained stress eventually takes a toll on the body bond. In a conventional relationship, the male is the head and the mind, resulting in effects such as hypertension, immune of the household and sole provider, whereas the woman system disorders, and mental disorders. is the homemaker and mother. This form of relationship is rapidly waning in the face of growing single-parent Cognitive Development households and equal partner relationships, in which both parties work and make the home together. It should be Young adults tend to explore the world and seek out new noted that one-third of men and one-fi fth of women are experiences which engender questions about themselves, the single by choice and that singlehood is a viable alternative people with whom they associate, and the world in general. for some people. Young people explore their world through interaction with While marriage is a relative constant in a young adult others, engaging in dialectical thinking (i.e., discovering the person’s life, so is divorce. Divorce occurs in about 50% of truth through dialogue and appreciating that there may be fi rst marriages and most divorces occur in early adulthood.45 multiple perspectives). And while 82% of divorced people eventually remarry, Psychosocial Development with about one-half of those marriages ending in divorce, there is a growing lack of commitment in the institution of Entering young adulthood, many people are engaged in fi nding marriage. the “ideal mate,” that special someone with whom to share common goals and aspirations. Erikson refers to this stage as the choice between intimacy and isolation. Inherent in this Parenthood process is a social clock. A social clock can be thought of as In general, most young adults have less preparation for a set of expectations, placed on the individual by society, to parenthood than they did for their livelihood. The resulting complete certain tasks (e.g., marriage and childbirth) within strain between the expectations of happiness from parenting a predetermined time (young adulthood). Young adults who and the reality of parenting (felt largely by the mother) fail to accept the social norm are seen as outcasts and tend to places an additional burden upon the relationship. As a become self-absorbed in isolation. result, many mothers become single parents and have to depend upon extended families for support and assistance. Love and Friendship Paramedics should understand that single mothers may The differences between the sexes become more evident have limited resources and that EMS is one of the few when it comes to how they look at friendship and love. Young social supports readily available during a time of acute women are inclined to reveal deep personal feelings to a distress. Lifespan Development 145 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to have hormone replacement therapy. While hormone Cultural / Regional differences replacement therapy can help to reduce menopausal symptoms as well as the incidence or severity of osteoporosis (a loss of calcium from the bones secondary to a decrease in Paramedics should be sensitive to the fact that 5% hormones), hormone replacement therapy also increases the of married adults cannot, or do not want to, have risk of cancer, particularly breast cancer.46–48 children. Prying questions, in an effort to make pleasant conversation about what a Paramedic may think is a neutral topic, may be met with anger or silence, affecting the Paramedic–patient rapport. Street Smart A younger woman may undergo a hysterectomy or oophorectomy, for medical reasons, and will then have a surgically induced menopause. Thereafter, Middle Adulthood these women will not only be incapable of Middle adulthood could be characterized as a period of producing offspring, but are at an increased risk of maximal productivity as well as a period of readjustment and realignment. Middle adulthood is also a period of physical cardiovascular disease. decline and changes in interpersonal focus. Physical Development The impact of aging, which commenced in young adulthood, Cognitive Development begins to manifest in more obvious ways. Changes related Dr. K. Warner Schaie’s sequential studies have indicated that to age include a decrease in strength, which peaked in the while intelligence (the ability to think) peaks at different person’s thirties, and a loss of muscle mass. The most outward ages for both men and women, all intellectual abilities show signs of aging—graying of the hair; loss of hair; weight gain, decline at about age 68. The declines are modest in most called the “middle-aged spread”; and wrinkled skin—all cases. Signifi cant loss of intellectual capacity does not occur signal the onset of aging. until age 80. Perhaps more disconcerting to the middle-aged adult, and What is different between the intellect of a young of importance to Paramedics, is the loss of sensory acuity. adult and a middle-aged adult is information processing. Most adults by age 50 will need to wear corrective lens, as the Young adults have the ability to process new information in lens within the eye thickens and is less able to accommodate novel situations (a fl uid intelligence) whereas middle-aged for vision. Reading documents, such as permission forms and adults begin to solidify their understandings (crystallized consents, is more diffi cult without glasses. Hearing loss is intelligence). Crystallized intelligence is the person’s ability also reported in middle-aged adults. to use long-term memory (experiences and skills) to resolve problems. This dichotomy is represented in the comments of Climacteric young adults who claim middle-aged adults are “too rigid in their thinking” and middle-aged adults who complain young Climacteric is an age-related decrease in sex hormone adults do not take advantage of their “wisdom,”—that is, the production that occurs in both men and women. While men middle-aged person’s
intelligence and experience. experience a gradual decline in the number and the viability The rapidly changing complexity of the world has forced of sperm as a result of decreased testosterone production, adults, in record numbers, to return to school. These adult men have been known to sire children at age 80. learners are either changing careers, to meet the demands of Women experience a more dramatic decline in their repro- an overchanging market, or reinforcing their present career ductive capabilities. A decline in sex hormone production— choice through life-long learning. Schools that understand estrogen and progesterone—results in menopause, the the difference between fl uid and crystal intelligence are inability to conceive. By defi nition, menopause is the able to respond appropriately to the learning needs of each cessation of a woman’s menses for an entire year. However, population of students. many women go through a prolonged period of intermit- tent and irregular menstrual periods until hormone levels stabilize. Psychosocial Development The symptoms which often accompany these fl uctuating The quintessential milestone of middle age is the “mid-life hormone levels—such as hot fl ashes, night sweats, vaginal crisis.” The mid-life crisis is in actuality a readjustment from dryness, and insomnia—are distressing. Some women elect young adulthood, with marriage and children, to middle-aged 146 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. existence. Central to the concerns of a middle-aged adult is active and vivacious senior citizens. Most Americans ranging the idea of legacy. Legacy implies that life had meaning—that from age 65 to 84 years of age have suffi cient health to allow the dream of young adulthood has come to fruition. Erikson them to perform their activities of daily living independently, characterized this stage of life as an issue of generativity including dressing, feeding, and caring for themselves. versus stagnation. Middle age is therefore a time of reassessment and Life Expectancy realignment. If the person is at ease with the progress, then The National Center for Health Statistics and the United States the person may choose to reprioritize, rededicate, and renew. Bureau of the Census reports that, on average, a person who Other persons, overwhelmed by the failure of their dreams, has reached the age of 65 in 2000 can expect to live another can spiral into depression, anger, and frustration, which can 18.9 years and that a child born in the year 2000 could expect develop into crisis—even suicide. to be alive at least 86.9 years. Aging Parents This increased life longevity—29 more years of life in 2000 when compared to a person born in 1900—is the result At a time when many middle-aged adults are seeing their of a number of factors. These include improved sanitation, children become adults, and are looking forward to the better health care, and improved nutrition, as well as reduced “empty nest,” they are confronted with aged parents in need death rates in children and young adults. of care. Children of aged parents, particularly daughters, are The most widely circulated theory for senescence is the often expected to care for their parents. wear and tear theory. It is assumed that after years of exposure For some middle-aged adults, the strain of caring for to the elements, toxins, free radicals, and pollution, the human aged parents, especially if they lack fi nancial means, results body simply breaks down over time. Others have postulated in frustration, anger, and, in rare cases, elder abuse. that the human body has a gene that starts the aging process, ensuring a turnover in the species. For whatever reason, aging has signifi cant effects upon the body. Professional Paramedic Physical Development A quick system-by-system review of organ systems quickly The professional Paramedic recognizes that aging is demonstrates the impact of aging (Figure 9-9). The most visible vestige of a person is skin. The skin of an elderly person not a disease but a developmental event beginning wrinkles and sags as a result of a decrease in subcutaneous before birth. connective tissues. The bones of an elderly person also tend toward demineralization, a process called osteoporosis, leading to spontaneous fractures and falls. While the cardiovascular system as well as the cardio- Late Adulthood pulmonary system are in decline, worsened by cardiovascular Late adulthood is somewhat synonymous with being elderly. disease, it is the sensory system that fares worse. Cataracts, The traditional defi nition of an elderly person is anyone glaucoma, and loss of hearing are common to all elderly. who is 65 years old or older. This arbitrary cut-off is a poor Not a single organ system in the body is spared the ravages marker for the onset of senescence, the breakdown in the of aging. Each organ system, according to the genetic make- body’s ability to monitor for organ system failure and to up of an individual (sometimes called a person’s constitution) repair those organs, which is inherent in the concept of being fails over time. elderly. People less than 65 years of age may have symptoms of senescence whereas others with a chronological age of 80 Cognitive Development years may in fact have the health of a 50-year-old. The changes in mental functioning are generally related to However, the fact remains, regardless of any cut-offs in the health of the person, not to age. It is not inevitable that age, that the human population is aging. In 1900 only about every elderly person will become senile. 1% of Earth’s human population was greater than 65 years of When discussing an elderly person’s mental state, it is age. By 1992 that number had jumped to 6%, or 342 million important to differentiate dementia from delirium. Delirium people. An estimated 2.5 billion, or 20%, of the human is a sudden change in mental function. It is an acute brain population will be older than 65 years by the year 2050. syndrome, which is usually associated with reversible Paramedics may consider the elderly to be frail or feeble, metabolic derangements (e.g., hypoxia, or the toxic effects based upon their interactions with a limited percentage of of medications). the entire population of the elderly (i.e., the approximately Senile dementia is the result of irreversible damage 1.5 million residents in nursing homes). This stereotypical to the brain that typically is manifest over a longer period view of the elderly, called ageism, is self-defeating for the of time (e.g., a series of brain attacks, such as strokes).49–51 Paramedic and fails to recognize the large population of A common cause of dementia is Alzheimer’s disease, a Lifespan Development 147 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 9-9 With age comes physical decline. gradual degenerative disease of the brain characterized by extent possible, over living conditions and the availability of confusion, forgetfulness, and ending with coma and death. companionship (Figure 9-10). While passive senile dementia can occur, due to a loss of brain cells, the majority of elderly patients are in good Death and Dying health and any acute alteration in mental function should be As one ages, one is faced with the inevitability of death. immediately investigated for a potentially reversible cause. Most aging people begin to plan for it. An acceptance of the inevitability of death should not be confused with a desire Psychosocial Development to die. The fi nal stage of human development, per Erikson, is integrity However a desire to die and suicide are closely linked versus despair. Efforts to maintain one’s dignity and using to aging. Unfortunately, a large number of elderly persons, one’s wisdom for the greater good will lead to feelings of particularly males, are clinically depressed, never seek or integrity, whereas chronic poor health and substandard living obtain the assistance they need, and commit suicide.52,53 conditions may cause an elderly person to fall into despair. Depression in the elderly, like delirium, is a potentially Most elderly persons want to be self-suffi cient and reversible mental illness which should be confronted and live as independently as possible. In the past, options were dealt with immediately. generally limited to living at home while being assisted by When a terminal disease threatens an elderly person’s adult children or living in a nursing home. New assisted- life, the person will begin the dying process. Kubler-Ross living centers, where meals are prepared for the residents; identifi ed fi ve stages of dying in her landmark work on adult-care programs; and at-home, long-term care programs death and dying. While these fi ve stages are presented in a have provided much-needed steps between independent linear order, they can occur in variations. Some people may living and the nursing home. The key to satisfaction with manifest all of the stages and some may only undergo a few these living arrangements is control of the individual, to the of the stages.54,55 148 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. refusal to seek more medical attention to seeking the opinion of multiple physicians. The next stage of dying is anger: anger at the world, anger at God, anger at family. Self-reproach is sometimes heard from a patient in anger. The next stage of dying is bargaining. These patients will attempt to bargain with God, promising to stop sinful behaviors or to do some extraordinary good. The patient eventually falls into a depression. Depression is the natural acceptance of the inevitable and the start of mourning. Patients who are depressed should be given support and observed for signs of suicidal thought. In time, and in many cases there is not enough time, a patient will reach the fi nal stage, acceptance. Acceptance of death is a reasonable conclusion when faced with the facts of the patient’s situation. Paramedics are, on occasion, called to help care for dying patients. In many instances all that is asked of the Paramedic is to honor a Do-Not-Attempt-Resuscitation (DNAR) order or to follow the wishes of a healthcare proxy who is speaking on the patient’s behalf. In some instances, EMS may be called to Figure 9-10 Companionship is important to the scene of a dying person to administer comfort measures, the elderly. called palliative care, such as morphine sulfate. Sometimes this happens at the request of a hospice nurse. Hospice is a concept of care which differs from mainstream medicine. Traditional medicine’s mission is The fi rst stage of dying is denial, a refusal on the part of largely curative, whereas hospice medicine is focused on the patient, or the patient’s family, to accept what is happening. providing for the physical, emotional, and spiritual needs of Behaviors seen in patients in denial may range from a fl at a terminal patient. Lifespan Development 149 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. From conception to the crypt, a person undergoes dramatic changes over the span of an entire lifetime. Understanding these changes, and their impact upon the person,
helps the Paramedic empathize with the patient’s situation. It also allows the Paramedic to adjust patient care to the patient’s stage of life development in order to help ensure a more therapeutic outcome. Key Points: • Understanding the patient’s developmental stage • From the moment of conception to the end of will help the Paramedic adjust his approach the ninth week, the newly developed embryo accordingly and to connect more therapeutically begins the formation of the major organs. At this with the patient. The three components of point in time the infant is at high risk for fetal development are (1) physical, (2) mental or malformation. Potential causes of malformation cognitive, and (3) emotional or the affective self. include illegal drug use, alcohol consumption, and • severe infections during pregnancy. Sigmund Freud’s psychosocial developmental theory attached great importance to sexuality and • The female gender is a result of both gametes linked the psychosocial development of a person to contributing an X chromosome. The male gender sex. Fundamental to Freud’s theory are the ideas is a result of the male gamete contributing a Y of a person’s id, ego, and superego. Freud’s theory chromosome. The child’s physical appearance is stressed the physical developments and supported due to the genetics of both parents. Chromosomes the idea that nature controlled one’s development. can be considered dominant or recessive, with the • dominant contributor controlling the phenotypic or Erikson stressed the social infl uences and supported physical appearance. the idea that nurturance had a great impact upon personal development. Confl ict is the pivotal event • Sex chromosomes can also be linked to genetic that moves people through the eight stages of diseases. If the child carries both genes then he or Erikson’s psychosocial development. she will have the disease. If the child has only one • gene linked to the disease, the disease will not be Pavlov, Skinner, and Bandura took the approach expressed, but he or she will be a carrier. that life experiences (nurturance) are the dominant infl uence in a person’s psychosocial development. • A developing embryo, now called a fetus, will • come to term in about nine months. The stages of Jean Piaget suggested that people develop in a pregnancy are divided into trimesters. building block fashion by developing schemas, one learned behavior building upon another. This • Childbirth occurs in three stages. The fi rst stage process of assimilation, along with accommodation, begins when the uterus starts to contract in a is considered the source of human development process called labor. The second stage is the over a lifespan. infant’s movement down the birth canal, and the • third and fi nal stage is the delivery of the placenta. The path of fertilization begins at the moment of sexual climax and ends with the fertilization of the • During the fi rst minute of life the umbilical blood female ovum by a single spermatozoon. The newly fl ow diminishes, raising carbon dioxide levels, fertilized ovum or zygote begins to develop in the which in turn stimulate the newly born’s fi rst fallopian tubes as it travels down to the uterus. The breath. The increase in intrathoracic pressure, placenta is formed from zygotic cells and provides from the air-fi lled lungs, causes the cardiac the fetus with nutrition though the umbilical cord. shunts—the foramen ovale and the ductus 150 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. arterious—to reverse blood fl ow and then close. become larger and taller. Those who fail to grow, The newborn’s pulse is between 100 and 160 beats exhibiting failure to thrive, may be under severe per minute, and respirations are between 40 to 60 psychosocial pressures or have nutritional defi cits. breaths per minute. Paramedics need to identify these toddlers and • encourage the parent to seek medical attention for The Paramedic should recognize that infants can the child. quickly fatigue and experience respiratory failure due to an easily obstructed airway, compensation • The growing neuromuscular system in a toddler is for increased oxygen demand, weak accessory made evident by the toddler’s ability to perform muscles, and loss of heat. more complex motor activities. The toddler is in • the preoperational stage of cognitive development The developmental milestones represent a typical and is not able to think abstractly. Young children child’s development and are used to gauge an also develop mathematical reasoning and language individual child’s development against a norm. acquisition. During the fi rst six months the infant displays primitive refl exes. During the assessment of an • Physical growth slows during the middle childhood infant the Paramedic should be attentive to the stage, although the child is more interactive with presence of infantile refl exes. Infantile refl exes may his environment. In this concrete operational include the Moro refl ex, palmar grasp refl ex, and stage, the child is able to understand such concepts Babinski refl ex. as spatial relation, nature of time, and the • sequential nature of certain activities. The multiple Cognitively, primitive refl exes continue to develop intelligences of a person may also become evident. as the infant assimilates experiences into old schemas, thus building new schemas. The infant also • Middle childhood is also a time when the child begins to acquire language skills. The Paramedic develops a sense of self and a desire to succeed may witness bonding or behavior such as mutual and achieve. At this age children begin to relate gazing, refl ective smiling, and response to touch. to others more in terms of common interests and This behavior is the beginning of psychosocial goals. With less infl uence by parents, peers take on development between a mother and child. a greater role in shaping the person’s personality. • The continued social interaction between infant • During the school-age years, children start to and parents is the start of the socialization process. attach a gender-role identity to themselves, that During this early period of socialization, autism is sense of being a male or a female. Regardless of a often discovered. child’s gender-role identity, it is important that the • Paramedic remain nonjudgmental in this matter and Parenting methods may be divided into four styles focus on the patient’s medical condition. with an emphasis—or de-emphasis—on nurturance. The styles include the permissive or indulgent • The most remarkable changes in the human parent, the authoritarian parent, the authoritative physique, or body habitus, occur during adolescent parent, and the uninvolved parent. physical development. Entering into puberty, males • and females see dramatic sexual changes in their The child raised by the uninvolved style of parenting physical bodies as they develop secondary sex may be more aggressive, to the point of violence. characteristics. When the Paramedic is faced with a situation in which the child is aggressive, the Paramedic should • Unhealthy situations can arise as adolescents seek acknowledge the behavior without becoming out opportunities for freedom. Because of a desire aggressive in either words or action, all the while to experiment, adolescents may engage in drug remaining authoritative. use and explore their sexuality in unsafe ways. • The advent of sexuality brings the risk of acquiring During the period of early childhood, from ages 2 to sexually transmitted diseases. 5, there is extraordinary growth where all children Lifespan Development 151 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • Chaotic schedules, the ease and availability of “junk of the few social supports readily available during foods,” and peer pressure contribute to poor teenage a time of acute distress. Paramedics should also nutrition and a national epidemic of teenage obesity. be sensitive to the fact that 5% of married adults The health risks associated with obesity include cannot, or do not want to, have children. type 2 diabetes mellitus, secondary hypertension, accelerated coronary artery disease, and stroke. At • Middle adulthood can be characterized as a period the other extreme of teenage weight problems is a of maximal productivity as well as a period of psychiatric illness called anorexia nervosa. readjustment and realignment. Middle adulthood is also a period of physical decline and changes in • There is an increased risk of premature death interpersonal focus and information processing. among teenagers secondary to engaging in increased risk-taking behaviors and having a false sense of • The quintessential milestone of middle age is the invulnerability. However, teenagers are also at “mid-life crisis,” and central to the concerns of higher risk of death from suicide. a middle-aged adult is the idea of legacy. Legacy implies that life had meaning, and that the dream • Cognitive development of the adolescent enters of young adulthood has come to fruition. Middle- the formal stage and revolves around using logic to aged adults are also confronted with aged parents in solve problems, as well as seeing problems as “less need of care. black and white and more gray.” The psychosocial development involves a return of egocentrism, a • Late adulthood is somewhat synonymous with being stage previously encountered in early childhood. elderly, but is marked by the onset of senescence. During this time, adolescents turn their attention to Most Americans ranging in age from 65 to 84 have morality and their own moral development. suffi cient health to allow them to independently perform their activities of daily living. However, due • Early adulthood is a period of striving and to the stereotypical view of the elderly that exists, accomplishment that is punctuated by fundamental called ageism, the Paramedic may fail to recognize decisions, like going to college or entering the the large population of active and vivacious senior workforce, and peak life events such as marriage citizens. and childbirth. • Improved sanitation, better health care, and • The majority of people, both male and female, improved nutrition, as well as reduced death rates reach their peak height in their early twenties, in children and young adults, have all contributed and their health is generally at its peak as well. to increased life longevity. The effects of physical However, obesity is becoming more common and aging include osteoporosis, cardiovascular and the risk for developing unhealthy behaviors still cardiopulmonary decline, and a decreased sensory remains. system. • Cognitive development of young adults includes • Changes in mental functioning among the elderly exploration of the world through interaction with are generally related to the person’s health, not to others and seeking out new experiences that age. Delirium is a sudden change in mental function, engender questions about themselves, the people which is an acute brain syndrome that is usually with whom they associate, and the world in general. associated with reversible metabolic derangements • such as hypoxia. Senile dementia is the result of Psychosocial development of young adults involves irreversible damage to the brain that typically is fi nding that special someone with whom to share manifested over a longer period of time, such as common goals and aspirations. These goals and Alzheimer’s disease. While passive senile dementia aspirations may include marriage and parenthood. can occur, the majority of elderly patients are in • Paramedics should understand that single mothers good health. Therefore, any acute alteration in may have limited resources and that EMS is one mental function should be immediately investigated for a potentially reversible cause. 152 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not
materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • The goal of most elderly persons is to be self- is asked of the Paramedic is to honor a Do-Not- suffi cient and live as independently as possible. Attempt-Resuscitation (DNAR) order or to follow the Independence can be maintained at assisted-living wishes of a healthcare proxy who is speaking on the centers, through adult-care programs, and at-home. patient’s behalf. • Depression in the elderly, like delirium, is a • Hospice medicine is focused on providing for potentially reversible mental illness that should be the physical, emotional, and spiritual needs of a confronted and dealt with immediately. When a terminal patient. In some instances, EMS may be terminal disease threatens an elderly person’s life, called to the scene of a dying person to administer the person will begin the dying process marked by comfort measures, called palliative care (such as what is referred to as the fi ve stages of dying. morphine sulfate), sometimes at the request of a • hospice nurse. Paramedics are, on occasion, called to help care for dying patients. In many instances, all that Review Questions: 1. Describe the main points for each theory of 9. What are some health risks that teenagers face psychosocial development put forth by Freud, and why are they more prone to engage in Erickson, Skinner, and Piaget. unhealthy behavior? 2. How is the gender of a fetus determined? 10. What confronts an adult when he or she reaches 3. Explain how two parents, both with recessive middle age? genes for a disorder, can potentially have a child 11. Why is the stereotypical view of elderly people that will have the disorder. inaccurate? 4. What are the stages of childbirth? 12. What factors have helped to increase our life 5. What are some developmental milestones for expectancy? infants and toddlers? 13. Differentiate between delirium and dementia. 6. Describe the four different types of parenting. 14. What are the fi ve stages of dying per Kubler- 7. At what stage of development is there Ross? extraordinary growth and development? 15. Discuss the importance of palliative care and 8. Starting with concrete thinking, what is the the effects of hospice. progression of cognitive development of a child through young adulthood? Case Study Questions: Please refer to the Case Study at the beginning of the • Physical development chapter and answer the questions below. • Cognitive development 1. Based on lifespan development, what • Affective development expectations should Paramedics have for the following considerations in a 13-year-old male? Lifespan Development 153 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. References: 1. Erikson E. Identity and the Life Cycle. New York: W. W. Norton 19. Brown JE, Murtaugh MA, Jacobs DR, Jr., Margellos HC. & Company; 1980. Variation in newborn size according to pregnancy weight change 2. Greenberg-Edelstein R. Nurturance Phenomenon: Roots of by trimester. Am J Clin Nutr. 2002;76(1):205–209. Group Psychotherapy. Norwalk, Conn.: Appleton & Lange; 1986. 20. Aylott M. The neonatal energy triangle. Part 2: Thermoregulatory 3. Hall C. A Primer of Freudian Psychology. New York: Plume; and respiratory adaption. Paediatr Nurs. 2006;18(7):38–42. 1999. 21. Sherman TI, Greenspan JS, St. Clair N, Touch SM, Shaffer TH. 4. Slater L. Opening Skinner’s Box: Great Psychological Optimizing the neonatal thermal environment. Neonatal Netw. Experiments of the Twentieth Century. New York: W. W. Norton 2006;25(4):251–260. & Company; 2005. 22. Stern L. The newborn infant and his thermal environment. Curr 5. Sanders B. Uterine factors and infertility. J Reprod Med. Probl Pediatr. 1970;1(1):1–29. 2006;51(3):169–176. 23. Sedin G, Agren J. Water and heat—the priority for the newborn 6. Vercammen EE, D’Hooghe TM. Endometriosis and recurrent infant. Ups J Med Sci. 2006;111(1):45–59. pregnancy loss. Semin Reprod Med. 2000;18(4):363–368. 24. Shott SR, Myer CM, III, Willis R, Cotton RT. Nasal obstruction 7. Szamatowicz M, Grochowski D. Fertility and infertility in aging in the neonate. Rhinology. 1989;27(2):91–96. women. Gynecol Endocrinol. 1998;12(6):407–413. 25. Coates H. Nasal obstruction in the neonate and infant. Clin 8. ACOG. ACOG Committee Opinion No. 383: Evaluation of Pediatr (Phila). 1992;31(1):25–29. stillbirths and neonatal deaths. Obstet Gynecol. 2007;110(4): 26. Hanson LA, Adlerberth I, Carlsson B, Zaman S, Hahn-Zoric 963–966. M, Jalil F. Antibody-mediated immunity in the neonate. Padiatr 9. Mathews TJ, MacDorman MF. Infant mortality statistics from the Padol. 1990;25(5):371–376. 2004 period linked birth/infant death data set. Natl Vital Stat Rep. 27. Zafeiriou DI. Primitive refl exes and postural reactions 2007;55(14):1–32. in the neurodevelopmental examination. Pediatr Neurol. 10. Sharps PW, Laughon K, Giangrande SK. Intimate partner 2004;31(1):1–8. violence and the childbearing year: Maternal and infant health 28. Futagi Y, Tagawa T, Otani K. Primitive refl ex profi les in infants: consequences. Trauma Violence Abuse. 2007;8(2):105–116. differences based on categories of neurological abnormality. 11. Ashdown-Lambert JR. A review of low birth weight: Brain Dev. 1992;14(5):294–298. predictors, precursors and morbidity outcomes. J R Soc Health. 29. Zafeiriou DI. Plantar grasp refl ex in high-risk infants during the 2005;125(2):76–83. fi rst year of life. Pediatr Neurol. 2000;22(1):75–76. 12. Boy A, Salihu HM. Intimate partner violence and birth outcomes: 30. Suveg C, Aschenbrand SG, Kendall PC. Separation anxiety a systematic review. Int J Fertil Womens Med. 2004;49(4): disorder, panic disorder, and school refusal. Child Adolesc 159–164. Psychiatr Clin N Am. 2005;14(4):773–795, ix. 13. Berenson AB, Wiemann CM, Wilkinson GS, Jones WA, 31. Jurbergs N, Ledley DR. Separation anxiety disorder. Pediatr Ann. Anderson GD. Perinatal morbidity associated with violence 2005;34(2):108–115. experienced by pregnant women. Am J Obstet Gynecol. 32. Manworren RC, Hynan LS. Clinical validation of FLACC: 1994;170(6):1760–1766; discussion 1766–1769. preverbal patient pain scale. Pediatr Nurs. 2003;29(2):140–146. 14. Lipsky S, Holt VL, Easterling TR, Critchlow CW. Impact of 33. Hummel P, van Dijk M. Pain assessment: current status and police-reported intimate partner violence during pregnancy on challenges. Semin Fetal Neonatal Med. 2006;11(4):237–245. birth outcomes. Obstet Gynecol. 2003;102(3):557–564. 34. Johnston CC. Pain assessment and management in infants. 15. Polgar G. The fi rst breath: A turbulent period of physiologic Pediatrician. 1989;16(1–2):16–23. adjustment. Clin Pediatr (Phila). 1963;2:562–571. 35. Bjorklund DF. In search of a metatheory for cognitive 16. Scarpelli EM. Perinatal lung mechanics and the fi rst breath. development (or, Piaget is dead and I don’t feel so good myself). Lung. 1984;162(2):61–71. Child Dev. 1997;68(1):144–148. 17. 2005 American Heart Association. AHA guidelines for 36. Blakeslee J, Lewis S, Lewis J, Wallerstein J. The Unexpected cardiopulmonary resuscitation (CPR) and emergency Legacy of Divorce: A 25 Year Landmark Study. Westport, Conn.: cardiovascular care (ECC) of pediatric and neonatal patients: Hyperion Books; 2000. Pediatric basic life support. Pediatrics. 2006;117(5):e989–1004. 37. Johnson HL, Erbelding EJ, Zenilman JM, Ghanem KG. Sexually 18. Ehrenkranz RA. Early, aggressive nutritional management for transmitted diseases and risk behaviors among pregnant women very low birth weight infants: what is the evidence? Semin attending inner city public sexually transmitted diseases clinics in Perinatol. 2007;31(2):48–55. Baltimore, MD, 1996–2002. Sex Transm Dis. 2007;34(12): 991–994. 154 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 38. Gray-Swain MR, Peipert JF. Pelvic infl ammatory disease in 47. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, adolescents. Curr Opin Obstet Gynecol. 2006;18(5):503–510. Kooperberg C, Stefanick ML, et al. Risks and benefi ts of estrogen 39. McKinzie J. Sexually transmitted diseases. Emerg Med Clin plus progestin in healthy postmenopausal women: principal North Am. 2001;19(3):723–743. results from the Women’s Health Initiative randomized controlled 40. Rambout L, Hopkins L, Hutton B, Fergusson D. Prophylactic trial. Jama. 2002;288(3):pp. 321–333. vaccination against human papillomavirus infection and disease 48. Rossouw JE, Prentice RL, Manson JE, Wu L, Barad D, Barnabei in women: a systematic review of randomized controlled trials. VM, et al. Postmenopausal hormone therapy and risk of Cmaj. 2007;177(5):469–479. cardiovascular disease by age and years since menopause. Jama. 41. Sodersten P, Bergh C, Bjornstrom M. Prevalence and recovery 2007;297(13):1465–1477. from anorexia nervosa. Am J Psychiatry. 2008;165(2):264–265. 49. Kirshner HS. Delirium: a focused review. Curr Neurol Neurosci 42. Steele MM, Doey T. Suicidal behaviour in children and Rep. 2007;7(6):479–482. adolescents. Part 1: etiology and risk factors. Can J Psychiatry. 50. Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in 2007;52(6 Suppl 1):21S–33S. elderly patients: evaluation and management. Mayo Clin Proc. 43. Steele MM, Doey T. Suicidal behaviour in children and 1995;70(10):989–998. adolescents. Part 2: treatment and prevention. Can J Psychiatry. 51. Borja B, Borja CS, Gade S. Psychiatric emergencies in the 2007;52(6 Suppl 1):35S–45S. geriatric population. Clin Geriatr Med. 2007;23(2):391–400, vii. 44. Wintersteen MB, Diamond GS, Fein JA. Screening for suicide 52. Heisel MJ. Suicide and its prevention among older adults. Can J risk in the pediatric emergency and acute care setting. Curr Opin Psychiatry. 2006;51(3):143–154. Pediatr. 2007;19(4):398–404. 53. Manthorpe J, Iliffe S. Suicide among older people. Nurs Older 45. Furstenberg FF, Jr. History and current status of divorce in the People. 2006;17(10):25–29. United States. Future Child. 1994;4(1):29–43. 54. Kubler-Ross E, Wessler S, Avioli LV. On death and dying. Jama. 46. Espie M, Daures JP, Chevallier T, Mares P, Micheletti MC, De 1972;221(2):174–179. Reilhac P. Breast cancer incidence and hormone replacement 55. Curry LC, Stone JG. The grief process: a preparation for death. therapy: results from the MISSION study, prospective phase. Clin Nurse Spec. 1991; 5(1):17–22. Gynecol Endocrinol. 2007;23(7):391–397. Lifespan Development 155 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Cellular physiology and the need for homeostasis • Fluid movement as dynamic driven by concentrations and hydrostatic pressure • The body’s general adaptation syndrome • Cell-mediated sympathetic and parasympathetic responses • The body’s thermoregulatory mechanism • The cell’s ability to adapt to variable conditions Case Study: “Hey, take a look in today’s paper. Remember that man from the auto crash two weeks ago? He died!” The Paramedics remembered the man. He was in a serious auto crash and had suffered some serious injuries. On-scene, it took a while before they could get him out of the car so he could be properly ventilated with a bag–mask assembly. He kept asking for a glass of water during the extrication and thought he could get up and walk away. They got a couple of large IVs into him. By the time he was transferred to the hospital, he had a blood pressure of 100/80 and a heart rate of 100. “Wonder what happened to him?” 156 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Basic Human Physiology 157 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if
subsequent rights restrictions require it. OVERVIEW The systems of the body work together to carry out the body’s functions. These systems can be broken down into individual organs, then to specifi c tissues, and further into specialized cells. This chapter begins with a look at cellular physiology and the process of maintaining an internal equilibrium. This balance or homeostasis is seen throughout systems of the body in response to internal and external stimuli. For the Paramedic, this includes the sympathetic and parasympathetic responses of the nervous system, the body’s thermoregulatory mechanism, and the cell’s ability to adapt to variable conditions. Physiology Resisting homeostasis are a myriad of external factors, such as cold and heat, lack of food, and infectious diseases. The study of the body’s functions, in its normal human Abnormal internal conditions, broadly called diseases, also condition, is called physiology. Different from anatomy, challenge homeostasis. The body must overcome them in order which studies human form, physiology studies the physical, to maintain homeostasis. Because these factors are always mechanical, and biochemical processes that go on inside the changing, the human body is in a constant state of fl ux, resisting body every day (i.e., how the body works). This chapter is and adapting to external and internal conditions, while trying to a brief overview of human physiology, with an emphasis maintain normalcy within a certain set of acceptable parameters on physiology that may have particular importance to the called a range. Because of this ever-changing internal milieu, Paramedic. some scientists and physicians have suggested that the more correct term for this process would be “homeodynamics,” in Cellular Milieu recognition of the ever-changing conditions. The sum of the biological processes within the body— The human body is actually a complex association of circulation, ventilation, and so on, through symbiosis— independent cells which, together, form tissues. The tissues support the cells of the body. in turn become organs, and ultimately all the cells comprise a person. Therefore, a person’s overall well-being is dependent on the health of all of the person’s constituent cells. Cellular Physiology To survive and thrive (i.e., to be healthy), cells need an environment, a milieu, that has (1) water, the most The outside of a cell is made up of a cell wall membrane, abundant substance in the body; (2) food stuffs, in the form a porous semipermeable dual layer lipid–protein matrix. of glucose, amino acids, and fatty acids; and (3) oxygen. All Inside the cell is an internal fl uid called cytoplasm, which of these essential elements must be maintained in an internal is primarily water and organelles, subunits with a specifi c environment where there is suffi cient heat and acidity for cellular function(s). biochemical reactions, or metabolism, to occur and life In the center of the cell is the fi rst organelle, the nucleus, processes to go on. which contains chromosomes and DNA. These are the blueprints for cellular protein production and reproduction. Homeostasis Outside of the nucleus, but inside the cytoplasm, are lysosomes, tiny sacs that contain enzymes which can break One of the primary functions of the human body is to maintain down proteins. Lysosomes can break down foreign proteins a relatively even state of temperature, acid load, oxygenation, in bacteria, called antigens, or the cell’s own chromosomes. blood glucose, and so on, for internal life processes. When the The largest organelle in the cell is the mitochondria. goal is achieved it is called wellness, a state of physiologic Inside the mitochondria, glucose is transformed into the equilibrium free of disease. The body’s process to attain this energy source adenosine triphosphate (ATP), which is used state of internal equilibrium is called homeostasis. to power the rest of the cell’s functions. This function, the Coined by Cannon in 1939, the term “homeostasis” production of ATP, earned the mitochondria the nickname of attempts to describe the processes that the body undertakes the cell’s “powerhouse” (Figure 10-1). to try to maintain a constant state of equilibrium.1 Key to For the all important mitochondria to work properly, the understanding the complex concept of homeostasis is an body must maintain a complex set of conditions—including understanding of the regulatory mechanisms that the body fl uid balance, acidity, oxygenation, and temperature. The utilizes to help to maintain homeostasis, namely the endocrine body depends on the nervous system, the endocrine system, system and autonomic nervous system. and the immune system to maintain that crucial balance. 158 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Ribosomes Centriole Lysosome Nucleolus Nucleus Rough endoplasmic reticulum Golgi Mitochondrion apparatus (complex) Plasma membrane Smooth endoplasmic reticulum Figure 10-1 Cross-section of a typical cell. Sodium Potassium Pump requiring the complex interactions of other organs required in aerobic metabolism. To make adaptations to the constantly changing conditions Under ideal conditions, and in the presence of suffi cient that exist within the body, the cells need energy. For the cell, glucose and oxygen, the cell uses oxygen in the next step that energy is in the form of adenosine triphosphate (ATP). of its metabolism, a process called aerobic metabolism, to The phase of glucose metabolism does not utilize oxygen create ATP from glucose (Figure 10-2). and is called anaerobic metabolism. During anaerobic During this process, the body uses eight different enzymes metabolism, the cell changes glucose into pyruvate acid, to divide glucose, a process called glycolysis (glycol- – which is in turn converted into lactic acid by an enzyme called “sugar”; -lysis – “to divide”), to create a chemical called lactate dehydrogenase (de- – “without”; hydrogen; -ase – pyruvate. Pyruvate and oxygen enter into the citric acid or indicating an enzyme). Krebs cycle, another complex series of changes facilitated by Although anaerobic metabolism is relatively ineffi cient enzymes, and there they undergo a process that creates ATP. in that it only yields two ATP, or about 2% of the energy that The end result of this chemical reaction creates carbon is available from glucose if oxygen were to be used, it is 100 dioxide (CO ), water (H O), energy (in the form of ATP), times faster than aerobic metabolism. For this reason, cells 2 2 and heat from the carbohydrate glucose. Aerobic metabolism that need quick energy in a short amount of time (i.e., skeletal produces about 36 ATP for the cell to use as energy compared muscles) use anaerobic metabolism. to the 2 ATP produced from glucose during anaerobic Interestingly, red blood cells (erythrocytes) that carry metabolism. oxygen cannot use the oxygen they carry. They depend on anaerobic metabolism and save the oxygen for the cells of the body instead. Glucose Storage Anaerobic metabolism only yields two ATP but can still When glucose is abundant, such as after a meal of release 619 kCal of heat. This amount of heat is comparable carbohydrates, any glucose which is not needed immediately to the amount of heat released by aerobic metabolism by the body is stored in the liver and muscles as a dual molecule (696 kCal). Thus, anaerobic metabolism can help keep the called glycogen (glycol- – “sugar”; -gen – “create”). When body warm (a very important factor discussed later) while not glucose levels fall, then the body liberates some glucose from Basic Human Physiology 159 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Glucose (C6H12O6) Glycolysis O2 67% Cytoplasm Pyruvic acid Citric acid cycle Electron-transport chain 2 lactic acid + 2 ATP Anaerobic respiration 6CO2 + 6H2O + 38ATP Interstitial Aerobic respiration Fluid Intravascular Fluid 26% (blood plasma) 7% Figure 10-2 First aerobic then anaerobic metabolism. Cerebrospinal Fluid (less than 1%) these glucose stores. These two bonded glucose molecules Figure 10-3 Distribution of water in the body. (glycogen) are broken down by an enzyme called glucagon into individual glucose molecules. In the absence of other readily available glucose stores, remaining fl uid is extracellular water which is in one of two the body can use other food sources to create glucose, a types. Interstitial fl uid is the fl uid between cells. It is about process called gluconeogenesis (glycol- – “sugar”; neo – 16% of the TBW, or 11 L. The second type of extracellular “new”; genesis – “creation”). For example, the body can water is fl uid found in the blood, which is called intravascular release glucose from fats, and in the process leave fatty acids fl uid. It is primarily made of plasma and constitutes about 4% behind. In extreme cases when glucose is not readily available, of the TBW or 3 or 4 L. (For clarifi cation, the blood volume the body can even break down muscles, liberating proteins in in the 70 kg male is about 6 L but only a portion of the blood the process. These proteins are then further broken down into is plasma, the rest being formed elements.) amino acids and glucose, leaving urea behind. Anatomists in the past referred to the volume of fl uid The process of aerobic metabolism is dependent upon inside the cells (intracellular) as the fi rst space, the volume of many organ systems working together in synchrony in order fl uid in the bloodstream (intravascular) as the second space, to be effective. To make ATP, the mitochondria needs ideal and the volume of blood in between the cells (the interstitial conditions of temperature and acidity. The body temperature space) as the third space. must be maintained at a fairly constant range of 99.6°F / While these volumes of fl uid in each compartment 1°F by a complex system of cooling and heat preservation are illustrative of the general distribution of fl uids within which uses bodily fl uids in the same way as an automobile the body, it should not be thought that fl uid levels between engine uses radiator fl uid. Acidity is also maintained by body compartments are static. In fact, there is a constant a complex system of dilution and diuresis (Greek “to pass movement of fl uids between compartments, an ebb and fl ow urine”). Central to maintaining both of these conditions is of living sustaining water laden with glucose, oxygen, and fl uid balance. other chemicals necessary for life. This is also known as nutritional fl ow. Fluid Balance Fluids can move from outside to inside the cells and from compartment to compartment by diffusion or osmosis. What The body is primarily made up of water—some 50% to 55% controls the amount of fl uid transferred from one compartment of total body weight (TBW) in women and 55% to 60% of to another is either the pressure behind the fl uid or the salts TBW in men.2 The water within the body can be divided into or the proteins in the fl uid of the other compartment. In both two portions or compartments. The water that is within the cases, nature is trying to reach a balance between the amounts cells is intracellular water and the water that is outside of of solutes in the two compartments. the cells is extracellular water. For example, when the interstitial fl uid volume is low, The majority of body water is intracellular. This amounts such as during dehydration, then fl uids are drawn out of the to about 35% to 40% of the TBW, or 25 liters (L) in the intravascular compartment into the interstitial space. This average 70 kilogram (kg)/154 pound male (Figure 10-3). The pressure created by the force behind the volume of water is 160 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Extracellular Intracellular Fluid Fluid called the hydrostatic pressure. An analogy can be made to Alternatively, when a fl uid has less water and more the garden hose. A garden hose can fl ow so many liters of salt (electrolytes), then the solution is called hypertonic. water per minute (lpm) and this fl ow can be measured as a A hypertonic fl uid on the other side of a semipermeable pressure (mmHg). Interestingly, as the circumference of the membrane will pull fl uids into itself (Figure 10-4). The opening narrows, such as when one places a thumb over the military has made limited use of hypertonic solutions during end of the hose, the pressure increases but the volume of fl uid resuscitation of wounded soldiers who have hemorrhaged (lpm) remains the same. However, when the hose is narrowed and are in need of intravascular volume replacement. to a critical point, about 70% to 90%, then the volume starts The capillary membrane, however, is relatively permeable to decline. Therefore, when the capillary hydrostatic pressure to electrolytes, such as sodium chloride. For this reason, is greater than the tissue hydrostatic pressure, which is near electrolytes in the blood, for example, do not create a great zero, then fl uid freely moves, or diffuses, across the capillary deal of osmotic pressure. However, capillary membranes are wall and into the tissues. semipermeable to proteins. These proteins can be found in Resisting this infusion of fl uids into the interstitial both the intercellular and extracellular space, including the space is the tissue’s hydrostatic pressure. This pressure is a intravascular space. These proteins create a force similar to combination of factors including maximal interstitial fl uid osmotic pressure called oncotic pressure. volume and compliance of the tissue (i.e., its elasticity). In short, the tissues have mechanisms that stop the free infusion Hypotonic (Hyposmotic) of fl uids once the tissues are adequately hydrated; adequate (low extracellular solute conc.) hydration being a function of the cells’ needs at the time. water flows in Constantly draining the tissues (the interstitial space) is the venous system and the lymphatic system. The venous system does the bulk of the elimination of the fl uids from the interstitial space. The lymphatic system acts as a storm sewer of sorts, ridding the tissue of excess fl uid beyond what the venous system can drain. Therefore, any backup of the venous system, or blockage of the lymphatic system, can result in dramatic fl uid buildup in the tissues called edema. As a result of this constant fi lling of the interstitial space Isotonic with nutrient-laden fl uids and the subsequent drainage of (same solute conc. in and out) those tissues, a fl ow is created. Another factor in this fl ow no net flow of water is osmotic pressure. Osmosis occurs whenever a semi- permeable membrane exists and there is a concentration of a substance, typically salt, on one side. Since the salt cannot cross a semipermeable membrane, water diffuses across the semipermeable membrane to try to balance the solution. If the solution being infused into the bloodstream has the same amount of salt (solute) and water (solvent) as the solution on the other side of the capillary membrane, then osmosis will not occur. Such a fl uid is said to be a balanced solution. Another name for a balanced solution is an isotonic solution (iso- – “equal”; tonic – “tension”). An example of Hypertonic (Hyperosmotic) (high extracellular solute conc.) a balanced solution that is used for intravenous infusions water flows out, plasmolysis is “normal saline”; termed “normal saline” because it has approximately the same amount of saline (sodium chloride 0.9%) as exists in blood and is therefore isotonic.1,3,4 Therefore, when a fl uid has more water and less salt (electrolytes) than the solution on the other side of a semipermeable membrane, then the fl uid is labeled hypotonic. In an effort to obtain a balance of concentrations, the water from the hypotonic solution will cross the membrane until the two solutions are balanced (i.e., equal parts water and salt). An example of a hypotonic solution is 5% dextrose in sterile water (D W). Since there is more water in intravenous D W 5 5 Figure 10-4 Effects of isotonic, hypotonic, than in the interstitial space, the water passes into the tissues. and hypertonic fl uids across a semipermeable This is useful when treating dehydration. membrane. Basic Human Physiology 161 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Hydrostatic (blood) Temperature Regulation Artery pressure Vein The enzymes within the cells operate best in a narrow temperature range of 98.6°F / 1°F. All endothermic (i.e., warm-blooded) animals create heat during cellular Capillary metabolism and use that heat to maintain a relatively constant core temperature. However, at least 90% of all cellular metabolism is used to maintain that heat production, leaving little for other life processes.8 While this may seem like an enormous cost, the benefi t is that it permits people to move about freely regardless of the environmental conditions. However, this ability to adapt to conditions is not unlimited. If too much heat builds up in the body’s core, a condition Colloidal Osmotic called hyperthermia, then the cell walls become more fl uid- Pressure (COP) like and cannot maintain their integrity. If there is too little Artery Oncotic pressure Vein heat, a condition called hypothermia, then the cell walls become gel-like, almost crystalline, and all cell wall activities stop. Thus, the body takes measures to both accumulate heat as well as dissipate heat. Capillary The anterior hypothalamus regulates the body’s temperature, acting as a thermostat and controlling heat loss mechanisms. With a set point of approximately 99°F, if 25 mmHg the body gets warmer than 99°F the hypothalamus engages drawing fluid into capillary certain heat loss mechanisms including rapid breathing, sweating, and vasodilatation. Vasodilatation is perhaps one of the most effective Figure 10-5 The effects of oncotic and heat-dissipating mechanisms that the body has. Controlled hydrostatic pressure upon intravascular volume. by the parasympathetic nervous system, surface capillaries under the skin react to dissipate the heat. Surface capillaries normally hold about 300 mL of blood but can be dilated to accommodate as much as 3,000 mL of blood. This causes the The most common intravascular protein is albumin, skin to act as a massive radiator to allow heat to dissipate by principally made in the liver. Albumin creates about 70% of conduction, convection, and radiation.9,10 the oncotic pressure. The remainder is provided by formed If the body should start to cool, then the hypothalamus elements such as red blood cells (erythrocytes). Together can either increase heat production by causing shivering, these blood proteins are called colloids and the pressure that an involuntary contraction of muscles, and/or by vasocon- they produce is called colloidal osmotic pressure (COP). striction. Alpha receptors of the sympathetic nervous system Whenever COP is high fl uids are pulled out of the tissues cause peripheral vasoconstriction by contracting the capillary and into the intravascular space. Whenever COP is low (e.g., sphincters (round muscles) that control the blood fl ow in the when albumin levels are low during liver failure) fl uid leaks capillary bed. Vasoconstriction can reduce blood fl ow in from the intravascular space and into the interstitial space, a the skin from 300 mL to as little as 30 mL for short periods process called third spacing (Figure 10-5). of time. Street Smart Street Smart When a patient is developing edema (e.g., from heart Understanding blood shunting in hypothermia explains failure), the condition may be described as “third why trauma patients often do not bleed signifi cantly spacing.” While the patient’s total body weight is when out of doors, but begin to bleed in earnest when increased due to retained fl uid, the patient can moved to the relative warmth of the back of the actually be intravascularly depleted.5–7 ambulance. 162 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Temperature and Stage One: ALARM the Oxyhemoglobin Curve When stressors are threatening or perceived to Increased body temperature (i.e., a fever) has been maligned be threatening, the body activates physiological by laypersons as being harmful to the body. Nothing could changes that ready it for fight or flight. be further from the truth. Fever is actually benefi cial to the healing process at many levels. The hypothalamus, located in the brain, controls the mean temperature of the body and maintains it at a steady Stage Two: RESISTANCE state of approximately 99.6°F. During an infection, poisons The fight-or-flight response occurs. Long-term from the bacteria, called endotoxins, stimulate chemical coping with stressors depletes adaptive energy, mediators (such as interleukin and interferon) to affect the resulting in exhaustion. hypothalamus. In essence, these chemical mediators reset the hypothalamus thermostat, thereby causing it to raise the body’s temperature. Stage Three: EXHAUSTION These pyrogens (fever producers) therefore create a pyrexia (Greek—fever) which makes the environment When the body has used up its adaptive energy and can no longer cope with stressors, it breaks hostile to bacteria, increases motility of macrophages, and down in disease, collapse, or death. enhances phagocytosis (cell eating) of bacteria by white blood cells.11–13 The increased temperature also moves the oxyhemoglobin Figure 10-6 The stages observed in the general dissociation curve to the right, improving oxygen off adaptation syndrome. loading to the cells. Also, metabolism is increased at the site of a localized infection vis-á-vis Hoff’s law where a 1°C temperature rise results in a 13% increase in metabolism. The fi rst stage of the general adaptation syndrome is While fever can be helpful in mild infections, in the the alarm stage. During this stage, the body responds to the case of a severe systemic infection high fever can lead to stressor via the central nervous system. The next stage is the delirium and/or convulsions. One possible cause of these stage of resistance in which the body attempts to reestablish convulsions is cerebral hypoxia. While hemoglobin readily homeostasis, utilizing the endocrine and/or the immune releases oxygen to the cells whenever the tissues are acidotic system. The fi nal stage is exhaustion or recovery. Exhaustion or hyperthermic, hemoglobin picks up less oxygen in the occurs when the body’s response is insuffi cient to meet the lungs. Tissues that are sensitive to even small drops in oxygen challenge of the stressor (Figure 10-6). saturation of hemoglobin, such as nervous tissue, will suffer Stress that overcomes the body’s innate defenses, and from the resultant systemic hypoxia. leads to exhaustion, is termed distress and heralds the onset of disease. However, not all stress is harmful. Stress is a condition Stress of daily living. Daily stress essentially keeps body defenses on guard for larger stress threats. This daily stress is called Stress and Cellular Response eustress. An example of stress being purposefully introduced Environmental conditions, both internal and external, are is the vigorous physical training in military boot camps. This constantly changing and therefore can cause an imbalance activity prepares the body for the physical challenges or within the body (i.e., a disruption in the homeostasis of stressors that await the soldier on the battlefi eld. the body). These constantly changing conditions, called From a physiologic perspective, stress creates a physical stress, cause the body to respond in an effort to regain
or chemical disturbance at the cellular level. However, to homeostasis. the layperson stress implies a psychological origin. There is In 1946 Hans Selye noted this physiologic response in a connection between the body’s response to psychological lab rats while injecting them with an ovarian extract. He stress and the resulting physiological response. Any emotional quickly noted the physiologic response was not limited to stress (e.g., fear or joy) can trigger the same response as a injections only but to cold and injury as well. Selye labeled physical stress. these noxious stimuli as stressors. As might be assumed, the body goes through the three Selye noted that when a person was stimulated with a stages of the general adaptation syndrome whether the stressor suffi cient stressor there was a predictable progression of is physical or psychological. This includes the fi nal stage, responses by the body. These responses occurred in stages, exhaustion, and the beginning of certain disease states. There and involved the central nervous system, the endocrine is ample evidence that persistent psychological stress upon system, and the immune system. Selye labeled the body’s the body can lead to hypertension, coronary artery disease, predictable pattern of response to these stressors as the strokes, asthma, stomach ulcers, obesity, and impotence, to general adaptation syndrome.14,15 name just a handful of stress-related diseases. Basic Human Physiology 163 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Stress and the Autonomic Lacrimal gland Midbrain Nervous System Paravertebral and nasal septum Medulla chain The autonomic nervous system controls the moment-to- ganglion Eye moment functions of most of the organs within the body and is composed of two divisions: the sympathetic and the Parotid parasympathetic nervous systems. Some have compared gland the sympathetic nervous system to the accelerator on a car and the parasympathetic to the brake. This analogy is not accurate. The better analogy for the parasympathetic Submandibular nervous system would be the idle adjustment on the and sublingual carburetor.16 salivary glands Many organs have dual innervations from these two divisions of the autonomic nervous system and the dominance T1 Trachea of one division over the other is a function of the body’s needs T2 Heart at the time. T3 The effects of the parasympathetic system can be grossly Lung T4 characterized as the “feed and breed” regulation of the organs. T5 The parasympathetic nervous system increases digestion in Celiac ganglion T6 Stomach the gut, slows the heart rate down, and causes erections in T7 males. The control of the parasympathetic nervous system is Pancreas maintained primarily by the vagus (Latin – wander) nerve, T8 the 10th cranial nerve, through its many branches. T9 Small intestine The sympathetic nervous system is reactive, stimulated T10 Liver Spleen by stressors, and promotes protection of the body. For this T11 reason, the responses of the body’s organs to stimulation from Adrenal gland T12 (medulla) the sympathetic nervous system has been described as “fi ght L1 or fl ight.” L2 The sympathetic nervous system (Figure 10-7), origin- Large ating from the thoracic–lumbar region (thoracolumbar Superior intestine division) of the spinal cord, causes a litany of bodily mesenteric responses. ganglion Neurotransmitters Kidney Both the sympathetic and parasympathetic systems affect Inferior organ function by their virtual connection at the motor mesenteric ganglion endplate. It is a virtual connection because neurons do Urinary bladder and genitals not physically contact the organs that they innervate, the neurons being separated by a gap called the synapse. The nervous signal is transmitted across this synapse by a Figure 10-7 Sympathetic nervous system. chemical messenger called a neurotransmitter to awaiting chemical receptors across the synapse called neuroreceptors (Figure 10-8). The sympathetic nervous system, at the motor endplates, creating an electrical transference across the cell wall uses the neurotransmitter norepinephrine, or adrenaline membrane that propagates the nervous signal or stimulates (ad- – “above”; renal – “kidneys”; -ine – for hormone). The the affected organ. transmission of a nervous signal using adrenaline as the The parasympathetic nerve uses the neurotransmitter neurotransmitter is called an adrenergic transmission. acetylcholine. Originally acetylcholine was called vagus- In a typical sympathetic nervous system transmission, schtuff by German physiologists because it was released by an electrical stimulus releases norepinephrine from storage the vagus nerve and affected the heart rate. The transmission in pockets, or vesicles, within the neuron that travel to the of a nervous signal using acetylcholine as the neurotransmitter synapse. The chemical neurotransmitter norepinephrine at the motor endplate is called a cholinergic transmission then travels across the synapse to occupy neuroreceptors on (Figure 10-9). the next neuron. These neurotransmitters cause increased Note that acetylcholine is the prime neurotransmitter for permeability of the affected neuron, specifi cally to potassium, all preganglionic fi bers of the autonomic nervous system. 164 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Presynaptic neuron Ciliary ganglion Direction of conduction Cranial nerve III Midbrain of nerve impulse Cranial Vesicles containing nerve VII Medulla neurotransmitters Mitochondrion Pterygopalatine Synaptic ganglion cleft Submandibular ganglion Cranial nerve IX T1 Otic ganglion T2 Cranial nerve X T3 Lung T4 T5 Heart T6 Postsynaptic Receptors on postsynaptic neuron membrane bound to neurotransmitter T7 Liver Figure 10-8 Neurotransmission across T8 a synapse. T9 Stomach T10 Paramedics are interested in the postganglionic neurons, T11 those that connect with the target organs, of the autonomic nervous system. Pancreas T12 Small Spleen There are different neurotransmitters in the different por- intestine L1 tions of the nervous system throughout the body: monoamine L2 class neurotransmitters like norepinephrine, dopamine, hista- mine, and serotonin; amino acid class neurotransmitters like glycine and gamma aminobutyric acid (GABA); and neuro- Large intestine peptide class neurotransmitters like endorphins. These are just some examples of the over 30 major neurotransmitters in the body. Many current drug therapies affect these neurotrans- Kidney mitters by simply supplanting or blocking them. Atropine, for example, blocks the neurotransmitter acetylcholine and thus impairs the parasympathetic nervous system conduction. S2 Urinary Neuroreceptors bladder and S3 genitals Pelvic nerves Each division of the autonomic nervous system joins with the S4 target organs at the motor endplate via neuroreceptors. Each Figure 10-9 The innervations of the division has two neuroreceptors. parasympathetic nervous system. The parasympathetic nervous system has nicotinic and muscarinic receptors, named after the fi rst chemicals that initially were used to stimulate them. in onset and short in duration, causing a sodium infl ux and Nicotinic receptors are found in the central and peripheral local depolarization. nervous system as well as the neuromuscular junction with The other parasympathetic neuroreceptors, muscarinic skeletal muscles. Certain paralytic drugs, like curare and receptors, are slower and indirectly open ion channels that succinylcholine, are nicotinic antagonists. They act by blocking cause depolarization. Muscarinic receptors, by defi nition, are the nicotinic receptors and are called neuromuscular blocking more sensitive to muscarine, a naturally occurring chemical agents. Cholinergic stimulation of nicotinic receptors is quick found in mushrooms, than to nicotine. Basic Human Physiology 165 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The effects of muscarine poisoning, from poisonous they are more active on the beta adrenergic receptors than 2 mushrooms, provides a clue to the location of muscarinic beta adrenergic receptors. 1 receptors. The symptoms of muscarine ingestion are contained A certain class of drugs that imitate epinephrine, called within the mnemonic SLUDGEM: Salivation, Lacrimation sympathomimetic, will affect adrenergic neuroreceptors. (tearing of the eyes), Urination, Defecation, Gastrointestinal However, each has a predilection for one of the specifi c pain, Emesis (vomiting), and Miosis (pinpoint pupils). While adrenergic receptors. For example, norepinephrine is these symptoms can be severe, the stimulation of muscarinic more active with alpha adrenergic receptors. Because receptors in the heart, affecting cardiac contraction, and alpha adrenergic receptors affect peripheral vascular beds, the lungs, causing bronchial constriction, can be more life norepinephrine is effective in states of massive vasodilation threatening. such as septic shock.20–22 The sympathetic neuroreceptors are also divided into two Isoprenaline hydrochloride (isoproterenol) is almost types of receptors. These receptors, called alpha receptors exclusively a beta adrenergic receptor stimulant and increases and beta receptors, are further divided into type 1 and type 2 heart rate (chronotropy) and strength of contraction (inotropy), receptors. Alpha adrenergic receptors are primarily making it useful in treating cardiogenic shock.23–25 1 involved with excitation. They are located in the peripheral vascular beds, on the arteriole side, and control the sphincters (round muscles) of the bladder, intestine, and the iris of Stress and the Endocrine System the pupil. The endocrine system can also be stimulated by stress. When the Stimulation of alpha receptors results in constriction endocrine system is activated by stress there are two effects. 1 of the precapillary sphincters of the peripheral vascular Initially, the sympathetic nervous system stimulates the bed, resulting in a displacement of blood volume to the core medulla of the adrenal glands, an endocrine organ, to secrete circulation, a phenomenon known as shunting. The result the hormone, adrenaline. Adrenaline is physiologically and is that the skin, drained of blood, appears pale. Vasomotor chemically the same as the neurotransmitter epinephrine regulation may be one of the most important functions of the (EP). Circulating adrenaline then goes to the liver and muscles sympathetic nervous system, ensuring perfusion to the body’s where it stimulates glycolysis of glucogen stores and liberates core organs. The shunting of blood, during crisis, provides for glucose into the bloodstream. increased blood fl ow to the vital organs of the heart, lung, and Simultaneously, the sympathetic nervous system brain, while decreasing the chance of excessive hemorrhage stimulates the release of corticotrophin-releasing factor (CRF) from external trauma.17–19 from the hypothalamus. In turn, CRF stimulates the pituitary Alpha adrenergic receptors are found in the gland to release several important stress hormones including 2 gastrointestinal tract where they decrease bowel motility, via antidiuretic hormone (vasopressin), from the posterior relaxation of the smooth muscles within the intestinal walls. pituitary gland, and adrenocorticotropic hormone (ACTH), Paramedics are generally more interested in the from the anterior pituitary gland. effects of the beta adrenergic receptors because they Vasopressin is a powerful vasopressor, a chemical affect the heart and lungs. Beta adrenergic receptors are that causes vasoconstriction particularly on the arterioles. also subdivided into beta adrenergic receptors and beta Vasopressin’s fi rst action is to prevent diuresis by 1 2 adrenergic receptors. vasoconstricting the distal arterioles in the kidneys and Beta adrenergic receptors are found in abundance preventing diuresis.26–28 This helps to maintain blood volume, 1 in the heart, though not exclusively, as there are beta which is especially important if one is hemorrhaging. 2 adrenergic receptors in the heart as well. Beta adrenergic At the same time adrenocorticotropic hormone (adreno- – 1 receptors cause the muscle of the heart, the myocardium, to “adrenals”; cortico – “cortex”; -tropic – “affecting”) stimulates beat harder (i.e., inotropy) and stimulate the heart to beat the cortex of the adrenal glands to secrete cortisol. Cortisol faster (i.e., chronotropy) as well. Beta adrenergic receptors is a glucocorticoid hormone that stimulates the production 1 are also found in the kidneys where they cause the secretion of glucogen from amino acids and fatty acids contained in of renin, which is converted into angiotensin, a powerful lipids, a process called glyconeogenesis (gluco- – “glucose”; vasoconstrictor. The addition of angiotensin increases neo- – “new”; genesis
– “creation”). Cortisol helps to ensure the shunting of blood to the core organs (i.e., the heart, that there are adequate levels of glucose circulating in the lungs, and brain), which was started by alpha adrenergic bloodstream once the immediately available glucose from the 1 receptors. liver is exhausted. Beta adrenergic receptors act upon the smooth Other hormones also excreted during times of stress 2 muscles found in the bronchial walls, the level of the terminal include endorphins, naturally occurring opiates within the bronchioles, and cause bronchodilation. The original body that reduce the perception of pain, and growth hormone. bronchodilator was racemic epinephrine (EP), which was a Growth hormone or somatotropin (soma- – “body”; tropin – potent bronchodilator that also caused unintended tachycardia. “affecting”) affects the metabolism of carbohydrates, proteins, Newer bronchodilators are more beta-specifi c, implying that and lipids. 166 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Stress and the Immune System Hypertrophy The last leg of the neuro–endo–immune axis of the stress Hypertrophy is an increase in either the weight or functional response is the immune system. The major organs of the capacity of a tissue or organ beyond what is normal. It should immune system—the thymus, spleen, and lymph nodes— not be confused with hyperplasia, which is an actual increase are directly innervated by the nerve fi bers of the autonomic in the number of cells. Cells that hypertrophy cannot normally nervous system. divide to increase their numbers and therefore must increase in The hypothalamus, located in the brainstem, acts size to accommodate demands upon them. The classic example through the pituitary gland and then the adrenal gland to is the bodybuilder who undergoes resistance training to create modulate the immune response. The now-activated adrenal enlarged, or hypertrophied, biceps muscles. A more pertinent glands increase levels of glucocorticosteroids, which in example would be myocardial hypertrophy (i.e., an enlarged turn suppress white blood cells, the macrophages and the heart), where the heart has to overcome hypertension. monocytes. An important function of the immune system may be Cell Replacement to alert other organs, through the release of infl ammatory Metaplasia is replacement of one adult cell type with another mediators such as interferon, of an impending systemic threat, type of adult cell. For example, tobacco smoke causes a be it from infection, cancer, or trauma. This mechanism is decrease in the number of cilia in the bronchial airways and discussed more fully in the section on systemic infl ammatory an increase in the number of mucus-producing goblet cells. response syndrome. Metaplastic cell changes are typically due to chronic irritation and may develop into precancerous cells. Hyperplasia (hyper- – “increase”; genesis – “creation”) Cellular Adaptation is an abnormal increase in the number of cells due to frequent cell division/reproduction which causes the tissue or organ Cells live in a highly volatile environment where changes to increase in size. Examples of common hyperplasia are in conditions, such as acidity or temperature, are constant callouses on the hands and benign prostatic hyperplasia, more even as the body strives to maintain homeostasis. Even the commonly known as prostate enlargement, which commonly availability of basic materials—such as glucose, oxygen, affects men over 50 years of age. proteins, carbohydrates, and fats—for metabolism and Some cellular hyperplasia is physiologic. Breast reproduction are highly variable. In order to survive in such enlargement during pregnancy is an example of a hormone- a hostile environment, cells must adapt to the conditions. driven hyperplasia. Cells must overcome those hostile conditions or be overcome Some cellular hyperplasia is compensatory. For example, themselves. Cells have developed some unique methods after the surgical removal of a portion of the liver, a procedure of adaptation. called a hepatectomy, the various human growth factors encourage the liver to regenerate itself.33,34 Some cellular hyperplasia can be pathologic. A form of Atrophy hyperplasia that is of concern to women is lobular carcinoma Atrophy is the reduction of cells. A physical loss of cells as in situ (carcinoma – “tumor”; in situ – “in place”). While a result of the normal changes of aging or simple disuse is the word “tumor” is thus included within the term “lobular considered physiologic, a natural development of cells. An carcinoma in situ,” it seldom progresses to invasive cancer. example of physiologic atrophy is the reduction in uterus However, the woman is at great risk for other types of mass following childbirth. Cell atrophy can also be the result breast cancers. of disease, or pathologic. For example, the atrophy can be A tumor, a form of hyperplasia, is an abnormal mass of due to diminished blood fl ow. cells which result from excessive cell division but serve no Muscle atrophy secondary to disease can be broken down useful purpose in the body. Tumors may be benign (kind, in two general categories: (1) atrophy due to a neuromuscular no danger) or they may be malignant (disposed to do evil). disease and (2) atrophy due to diseases that affect the muscles Malignant tumors are always cancerous; in fact, the term directly. Examples of diseases that cause problems at the “malignancy” means cancer. Cancer is not a single disease neuromuscular junction include poliomyelitis, amyotrophic but a collection of over 100 varieties of malignancies. lateral sclerosis (Lou Gehrig’s disease), and Guillain-Barré. Primary muscle wasting diseases include muscular dystrophy Dysplasia and other congenital diseases. Cells in the body are in a constant state of turnover, with new The most common sources of muscle atrophy, secondary cells replacing old cells. When there are too many new, or to disuse, are stroke (cerebrovascular accident), spinal cord immature, cells that are not functional then dysplasia has injury with resulting paralysis, and peripheral neuropathy occurred. In some instances (e.g., cervical cancer), the presence secondary to diabetes mellitus.29–32 of dysplasia is an early warning of future malignancy. Basic Human Physiology 167 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Apoptosis rapidly dividing cells (e.g., the epithelial cells of the skin or bowels). Removal of cells that have been damaged by To prevent intrinsic biochemical errors from accumulating virus or damaged by exposure to radiation or toxins is also within a cell, or to simply replace old worn out or senescent benefi cial. cells, all of the cells in the body are programmed to commit Apoptosis can also be a pathological condition when suicide. This process of planned cell death, called apoptosis it is stimulated by DNA damage caused by oxygen-free (Greek – apo- –“from”; ptosis – “falling”), is controlled by radicals. Oxygen-free radicals have been implicated in genes in the nucleus and involves a systematic disassembly of neurodegenerative diseases, such as amyotrophic lateral the cell. Approximately 10 billion cells die every day, without sclerosis, Parkinson’s disease, and Alzheimer’s disease. endangering other cells, so that new, more perfect cells can replace them.35–37 Apoptosis can also be stimulated by stress conditions, an important comorbid factor. Apoptosis serves several vital functions, such as maintaining relatively even numbers of cells among 168 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Ar eview of the conditions necessary to maintain cellular viability or wellness, and thus human life, shows that physiology is a complex process. The body’s failure to maintain that internal milieu, through a dynamic, ongoing process called homeostasis, leads to illness and disease. Key Points: • Physiology is the study of the body’s functions in • Aerobic metabolism utilizes oxygen and glucose its normal human condition. Functions include the under ideal conditions to fi rst carry out glycolysis physical, mechanical, and biochemical processes that produces pyruvate. Pyruvate and oxygen then that are carried out inside the body. Together cells enter the Krebs cycle that generates 36 ATP. The form tissues that in turn become organs and the products for both forms of metabolism are carbon organ systems that ultimately comprise a person. dioxide, water, and energy in the form of ATP. • The essential elements water, glucose, amino acids, • Glucose that is not needed for immediate use is fatty acids, and oxygen are used in biochemical stored in the liver and muscles as glycogen. When reactions. Together these biochemical reactions there is a demand for glucose, glycogen can be become the body’s metabolism that is carried out in broken down into individual glucose molecules order for life processes to occur. by the enzyme glycagon. For a cell to carry out • aerobic metabolism, the body must maintain ideal To achieve a state of wellness, the body must temperature and acidity. The body can use other maintain a physiologic equilibrium. The body’s food sources to carry out gluconeogenesis if there is process to attain this state of internal equilibrium an absence of readily available glucose. is called homeostasis. Though in a constant state of fl ux, the body uses regulatory mechanisms to • Water comprises the greatest percentage of our maintain temperature, acidity, oxygenation, and total body weight and can be found in two basic fl uid balance within a certain range. compartments: intracellular and extracellular. The • majority of body water is intracellular. Extracellular The cell is made up of an outer semipermeable water is found in either interstitial fl uid or membrane that encompasses cytoplasm and intravascular fl uid. organelles. The nucleus is a membrane organelle containing DNA that provides the blueprints for • Fluid volumes are not static. They can move from cellular reproduction and protein synthesis. outside to inside the cells and from compartment • to compartment by diffusion or osmosis. In the past Found outside the nucleus but inside the cytoplasm the volume of fl uid inside the cells (intracellular) are several organelles that serve different was considered as the fi rst space, the volume of functions. Lysosomes can break down the cell’s fl uid in the bloodstream (intravascular) as the own proteins and foreign proteins called antigens. second space, and the volume of blood in between Mitochondria transform glucose into the usable the cells (the interstitial space) as the third space. energy source adenosine triphosphate (ATP). • • Fluid distribution from one compartment to another Anaerobic metabolism occurs without the use of is controlled by hydrostatic pressure and the oxygen and yields only two ATP. Though it generates concentrations of dissolved salts or proteins. Fluid a small amount of ATP, the process is much faster fl ow is restricted by hydrostatic pressure, which than aerobic metabolism and releases a greater is the combination of factors including maximal amount of heat energy. Basic Human Physiology 169 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. interstitial fl uid volume and compliance of the very benefi cial for mild infections, high fevers tissue, or elasticity. during severe infections can lead to delirium or • convulsions. The venous system serves to eliminate fl uids from the interstitial space while the lymphatic system • Stress is the constant change in
the environmental drains excess fl uid not carried away by the venous conditions within the body. General adaptation system. A dramatic fl uid buildup in the tissues syndrome is the body’s response to environmental, called edema can develop from a backup of the chemical, and physical changes that disrupt venous system. homeostasis. • Osmosis is the diffusion of water through a • General adaptation syndrome comes in three stages: selectively permeable membrane. The amount the alarm stage, the resistance stage, and the of solute (salt) dissolved in water (solvent) exhaustion stage. Stress that exhausts the body’s determines the osmotic pressure. Osmotic pressure defenses is termed distress. Everyday stresses that is dependent on the concentration of salt on one help the body’s defenses stay on guard are called side of a membrane. This pressure determines the eustresses. Any psychological stress can in turn net movement of water across the membrane by trigger a physical stress such as cardiac, respiratory, osmosis. or gastrointestinal disease. • Saline with 0.9% sodium chloride is an isotonic • The autonomic nervous system is divided into the solution because it has approximately the same sympathetic and parasympathetic nervous system. concentration of salt that exists in blood. A The sympathetic nervous system, originating from hypotonic solution is a fl uid with more water and the thoracic and lumbar region, is described as the less salt than a solution on the other side of a body’s “fi ght or fl ight” regulator. The sympathetic semipermeable membrane. Conversely, a hypertonic nervous system is highly reactive and promotes solution on one side of a semipermeable membrane protection of the body. has less water and more salt than the other solution. • The parasympathetic nervous system, originating • from the vagus nerve, opposes the effects of the Warm-blooded animals have a constant core sympathetic nervous system. It is characterized as temperature of 98.6°F / 1°F. To some extent, the body’s “feed and breed” regulator and controls this temperature remains constant through a large bodily processes such as digestion in the gut, range of environmental conditions. This heat is slowing of the heart rate, and erection in males. created by cellular metabolism and is controlled by the anterior hypothalamus. The most effective heat • Both the sympathetic nervous system and the loss mechanism controlled by the hypothalamus parasympathetic nervous system are virtually is vasodilation. This dilates the skin surface connected to their affected organs by way of a capillaries, allowing heat to dissipate. Under synapse. Nervous signals travel across the synapse hypothermic conditions, vasoconstriction is used to by a chemical messenger called a neurotransmitter. increase heat production. Neuroreceptors await across the synapse to receive • the signals. Pyrexia, or fever, is an essential part of the healing process. Endotoxins, or bacterial poisons, affect the • Norepinephrine or adrenaline is used by the hypothalamus by raising the body’s temperature, sympathetic nervous system as a neurotransmitter producing a fever. An increase in body temperature that creates a transmission called an adrenergic creates an unfavorable environment for bacteria. transmission. Norepinephrine is released by It increases macrophage motility and signals the electrical stimuli and travels across the synapse defense of white blood cells. to occupy the neuroreceptors and the receiving • neutron. This neurotransmitter then causes an A rise in body temperature also increases increase in permeability of the neuron to potassium, one’s metabolism vis-á-vis Hoff’s law. Though stimulating the affected organ. 170 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • Acetylcholine is used by the parasympathetic after being stimulated by the sympathetic nervous nervous system as a neurotransmitter which creates system. In turn, CRF stimulates the pituitary gland a transmission called cholingeric transmission. to release an antidiuretic hormone (vasopressin). There are over 30 major neurotransmitters in the This vasopressor vasoconstricts to prevent diuresis. body, some being categorized within the monamine class, the amino acid class, and the neuropeptide • Simultaneously, ACTH stimulates the adrenal glands class. These neurotransmitters can be blocked by to secrete cortisol. Cortisol is a hormone that the use of simple drug therapies such as atropine. stimulates the glyconeogenesis process to ensure adequate circulation of glucose in the bloodstream. • The neuroreceptors of the parasympathetic nervous system are nicotinic and muscarinic receptors. • The major organs of the immune system are Nicotinic receptors are found in the central the thymus, spleen, and lymph nodes. The nervous system, peripheral nervous system, and hypothalamus regulates the immune system through neuromuscular junction within skeletal muscles. the adrenal gland by increasing the production The stimulation of this neuroreceptor has a quick of glucocorticosteroids. The glucocorticosteroids onset and is short lived. Muscarinic receptors, in suppress white blood cells, macrophages, and comparison, are much slower. monocytes. • The neuroreceptors of the sympathetic nervous • Cells constantly live in highly variable conditions system are divided into alpha1 and alpha2 and which they must adapt themselves to by developing beta1 and beta2. Shunting occurs when the alpha1 very unique methods. receptors are stimulated. The sphincters of the • Atrophy is the reduction of cells due to aging, peripheral vascular beds are constricted and disuse, or disease. Muscle atrophy is broken down the blood volume rushes to the core circulation. into neuromuscular disease and diseases that affect Shunting ensures good perfusion to the body’s the muscles directly. Secondary to disease causing core organs while decreasing chances of excessive muscle atrophy are stroke, spinal injury, and bleeding from external trauma. Alpha2 receptors peripheral neuropathy. relax the smooth muscles of the intestinal walls, causing a decrease in bowel motility. • Hypertrophy is an increase in tissue or organ weight • beyond normal limits. Myocardial hypertrophy is Beta1 receptors are found in the heart and cause an enlarged heart, making hypertension an issue to its muscles to beat harder and faster. Beta1 overcome. receptors are also found in the kidneys where they aid in the shunting of blood due to the secretion • Metaplasia is the replacement of one adult cell type of angiotensin, a vasoconstrictor. Beta2 receptors with another. Hyperplasia is an abnormal increase cause bronchiodilation by acting upon the smooth in cell number due to cell division that causes an muscles of the bronchial walls. increase in tissue size. Some cellular hyperplasia • is physiologic, or hormonally driven. Some cellular Sympathomimetic drugs are a class of drugs that hyperplasia is compensatory due to a removal of imitate epinephrine. These drugs affect adrenergic cells. Tumors can be either benign or malignant. receptors, with each drug affecting a specifi c type of receptor. • Dysplasia occurs when cells are nonfunctional due to • an overabundance of new cells. This can be an early The endocrine system can also be activated by warning of cancer. stress. During times of stress, the adrenal gland, an endocrine organ, fi rst secretes adrenaline. After • Apoptosis is the process of planned cell death. Its being stimulated, this hormone travels to the liver functions include maintaining even cell numbers and where it stimulates glycolysis. At the same time, removing damaged cells. Apoptosis can also be a corticotropin-releasing factor (CRF) is released harmful condition due to oxygen-free radicals. This may cause neurodegenerative disease. Basic Human Physiology 171 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. How does understanding the body’s regulatory 9. Name the stages of the general adaptation mechanisms help to defi ne homeostasis? syndrome. 2. Describe the parts of the cell. 10. What is the difference between distress and 3. Compare and contrast aerobic and anaerobic eustress? metabolism. 11. Would it be possible for acetylcholine to carry 4. If more glucose is taken into the body than is out an adrenergic transmission? Why or needed, where and how is it stored in the body? why not? 5. How does increasing the salt concentration 12. What are three types of neuroreceptors? of a solution on one side of a semipermeable 13. Describe the functions that alpha and beta membrane affect the net movement of water? receptors are involved in. 6. Why is edema called third spacing of fl uid? 14. What is the effect of stress on the endocrine 7. Describe the body’s mechanism of system? thermoregulation. 15. Compare atrophy to hypertrophy. 8. How is fever benefi cial to the healing process? Case Study Questions: Please refer to the Case Study at the beginning of the 2. What effect does stimulation of the sympathetic chapter and answer the questions below. nervous system have on blood vessels? 1. Explain the importance of preventing heat loss 3. Explain why a seriously injured patient may in a patient who has suffered a severe injury. request a drink of water. References: 1. Cannon WB. The Wisdom of the Body. New York: Norton; 1932. 6. Young ME, Flynn KT. Third-spacing: when the body conceals 2. Martinoli R, Mohamed EI, Maiolo C, Cianci R, Denoth F, fl uid loss. Rn. 1988;51(8):46–48. Salvadori S, et al. Total body water estimation using bioelectrical 7. Perel P, Roberts I. Colloids versus crystalloids for fl uid impedance: a meta-analysis of the data available in the literature. resuscitation in critically ill patients. Cochrane Database Syst Acta Diabetol. 2003;40 (Suppl 1):S203–S206. Rev. 2007;4:CD000567. 3. Gala GJ, Lilly MP, Thomas SE, Gann DS. Interaction of sodium 8. Rolfe DF, Brown GC. Cellular energy utilization and molecular and volume in fl uid resuscitation after hemorrhage. J Trauma. origin of standard metabolic rate in mammals. Physiol 1991;31(4):545–555; discussion 555–546. Rev. 1997;77(3):731–758. 4. Orlowski JP, Abulleil MM, Phillips JM. The hemodynamic 9. Sessler DI, Moayeri A, Stoen R, Glosten B, Hynson J, McGuire and cardiovascular effects of near-drowning in hypotonic, J. Thermoregulatory vasoconstriction decreases cutaneous heat isotonic, or hypertonic solutions. Ann Emerg Med. 1989;18(10): loss. Anesthesiology. 1990;73(4):656–660. 1044–1049. 10. Song CW, Chelstrom LM, Haumschild DJ. Changes in human 5. Gunnar WP, Merlotti GJ, Barrett J, Jonasson O. Resuscitation skin blood fl ow by hyperthermia. Int J Radiat Oncol Biol Phys. from hemorrhagic shock. Alterations of the intracranial pressure 1990;18(4):903–907. after normal saline, 3% saline and dextran-40. Ann Surg. 11. Haahr S, Mogensen S. Function of fever in infectious disease. 1986;204(6):686–692. Biomedicine. 1978;28(6):305–307. 172 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 12. Blatteis CM. Fever: is it benefi cial? Yale J Biol Med. 27. Meybohm P, Cavus E, Bein B, Steinfath M, Weber B, Hamann 1986;59(2):107–116. C, et al. Small volume resuscitation: a randomized controlled 13. Ryan GB. Infl ammation and localization of infection. Surg Clin trial with either norepinephrine or vasopressin during severe North Am. 1976;56(4):831–846. hemorrhage. J Trauma. 2007;62(3):640–646. 14. Selye H. The general adaptation syndrome and the diseases of 28. Tsuneyoshi I, Onomoto M, Yonetani A, Kanmura Y. Low- adaptation. Practitioner. 1949;163(977):393–405. dose vasopressin infusion in patients with severe vasodilatory 15. Goldstein DS, Kopin IJ. Evolution of concepts of stress. Stress. hypotension after prolonged hemorrhage during general 2007;10(2):109–120. anesthesia. J Anesth. 2005;19(2):170–173. 16. Appenzeller O, Oribe E. The Autonomic Nervous System. 29. Trudel G, Uhthoff HK. Muscle atrophy in stroke patients. Arch Amsterdam: Elsevier Publishing Company; 1997. Phys Med Rehabil. 2003;84(4):623; author reply 623. 17. Little RA, Stoner HB. Body temperature after accidental injury. 30. Giangregorio L, McCartney N. Bone loss and muscle atrophy Br J Surg. 1981;68(4):221–224. in spinal cord injury: epidemiology, fracture prediction, and
18. Fahim M. Cardiovascular sensory receptors and their regulatory rehabilitation strategies. J Spinal Cord Med. 2006;29(5):489–500. mechanisms. Indian J Physiol Pharmacol. 2003;47(2):124–146. 31. Baldi JC, Jackson RD, Moraille R, Mysiw WJ. Muscle atrophy 19. Van Corven EJ, van Rijswijk A, Jalink K, van der Bend RL, is prevented in patients with acute spinal cord injury using van Blitterswijk WJ, Moolenaar WH. Mitogenic action of functional electrical stimulation. Spinal Cord. 1998; lysophosphatidic acid and phosphatidic acid on fi broblasts. 36(7):463–469. Dependence on acyl-chain length and inhibition by suramin. 32. Andersen H, Gjerstad MD, Jakobsen J. Atrophy of foot Biochem J. 1992;281 (Pt 1):163–169. muscles: a measure of diabetic neuropathy. Diabetes Care. 20. Groeneveld AB, Girbes AR, Thijs LG. Treating septic shock with 2004;27(10):2382–2385. norepinephrine. Crit Care Med. 1999;27(9):2022–2023. 33. Kobayashi M, Ogata T, Araki K, Hayashi T. Human 21. Singer M. Catecholamine treatment for shock—equally good or liver regeneration after major hepatectomy. Ann Surg. bad? Lancet. 2007;370(9588):636–637. 1992;216(5):616. 22. Vincent JL, De Backer D. Inotrope/vasopressor support in sepsis- 34. Yamanaka N, Okamoto E, Kawamura E, Kato T, Oriyama induced organ hypoperfusion. Semin Respir Crit Care Med. T, Fujimoto J, et al. Dynamics of normal and injured human 2001;22(1):61–74. liver regeneration after hepatectomy as assessed on the basis 23. Mueller HS. Inotropic agents in the treatment of cardiogenic of computed tomography and liver function. Hepatology. shock. World J Surg. 1985;9(1):3–10. 1993;18(1):79–85. 24. Eichna LW. The treatment of cardiogenic shock. 3. The use of 35. Beutler E. The relationship of red cell enzymes to red cell life- isoproterenol in cardiogenic shock. Am Heart J. 1967;74(6):48–52. span. Blood Cells. 1988;14(1):69–91. 25. Worthley LI, Tyler P, Moran JL. A comparison of dopamine, 36. Kay M. Immunoregulation of cellular life span. Ann N Y Acad dobutamine and isoproterenol in the treatment of shock. Intensive Sci. 2005;1057:85–111. Care Med. 1985;11(1):13–19. 37. Taylor RC, Cullen SP, Martin SJ. Apoptosis: controlled 26. Farrow S, Banata G, Schallhorn S, May R, Mers A, Cadaret L, demolition at the cellular level. Nat Rev Mol Cell Biol. et al. Vasopressin inhibits diuresis induced by water immersion 2007;9:231–241. in humans. J Appl Physiol. 1992;73(3):932–936. Basic Human Physiology 173 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The interplay between modifi able and nonmodifi able risk factors and disease and its impact on mortality • Impact of physical and chemical injury on cell physiology • Infectious disease and the body’s response to pathogens • The concept and etiologies of shock using the Hinshaw–Cox classifi cation • The pathophysiology of shock and the body’s response • Biochemical changes and cellular death Case Study: The Paramedics responded to a man who had collapsed. Upon their arrival, they found him unconscious with a slow pulse and agonal breathing. Despite their best resuscitative efforts, he had no vital signs when they transferred him to the hospital, yet they continued CPR during the transport. Both Paramedics were perplexed when the ED physician requested the transplant team. What organs would be available now? Wasn’t the man dead? 174 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Principles of Pathophysiology 175 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW There is a physiological cause for every illness or disorder that the Paramedic encounters. Although it’s not the Paramedic’s job to determine the exact cause of the disease, it is the Paramedic’s job to recognize the signs and symptoms and treat the patient appropriately based on an assessment. This chapter provides the background knowledge the Paramedic needs to better understand the disease process and treatment. After examining disease risk factors, the focus is on how the body is impacted by injury and its response to pathogens. Although the Paramedic should be familiar with the signs of shock, he or she should also know the pathophysiology causing the body’s response to determine its etiology. Often the Paramedic’s treatment reverses the pathogenesis of an illness or disorder. Pathophysiology Defi ned poverty, lack of immunizations, and so on, which infl uence the incidence of disease. For example, poor sanitation, poverty, Pathos (Greek - “to suffer”) is the prefi x added to physiology, and overcrowding make cholera infection one of the leading the study of the normal human condition, to make the causes of death, or mortality, in the world.1,2 term pathophysiology. The origins of the term defi ne The many causes of cellular death due to disease can pathophysiology: to study the causes of suffering in the normal be categorized as either known causes or unknown causes. human condition. While the causes of disease are numerous, Unknown causes of cellular death are primarily due to an they share a few common mechanisms, making the study of incomplete understanding of the disease and/or because of pathophysiology somewhat easier. a lack of evidence of the disease. The “Black Death” is one This chapter is a discussion of those mechanisms and the example of an unknown cause of cellular death. Typically, body’s reactions to illness or injury. Discussions of the many the cause of an emergent disease is unknown until scientists illnesses and ailments of humans, related to specifi c organs, have a suffi cient number of cases to study so as to identify or systemic pathology, is contained in all of the chapters the source. A more recent example is the Severe Acute that follow. This chapter will serve as the foundation for Respiratory Syndrome (SARS) epidemic. Initially the cause understanding those chapters while the previous physiology of SARS was unknown; however, it has now been identifi ed chapter serves as the foundation for understanding this as a coronavirus, the same type of virus that causes the chapter. common cold.3–5 Disease: Defi ned Disease can be defi ned as an abnormal change in the function Known Causes of Disease of cells, tissues, or organs. An example of each is cancer in The known causes, or etiologies, of cellular injury can be cells, emphysema in tissues, and acute myocardial infarction broken down into two categories: the extrinsic (external) causes in organs. These changes interfere with homeostasis of the and the intrinsic (internal) causes. Extrinsic causes include body, making the body ill at ease—or literally diseased (dis- – chemical causes, physical causes, infection/infl ammation, “not”; ease – “rest”). and metabolic imbalances. The intrinsic (internal) causes are Paramedics are often more interested in the pathogenesis causes such as genetic derangements. (patho- – Greek “suffering”; genesis – “beginning”) of a Of the three general chemical causes of cellular injury, disease, the sequence of events—at the molecular and cellular hypoxia is ranked number one and receives the largest portion level—that lead to organ dysfunction. By understanding of a Paramedic’s attention. Other chemical causes of cellular these underlying conditions, treatment can be directed toward injury include the creation of free radicals and toxins. removing the cause and not just treating the symptoms. The physical cause of cellular injury is trauma. Trauma encompasses any mechanical injury, heat or cold injury, Etiologies of Disease radiation, electrical injury, or barotrauma. At the molecular level, there can be metabolic derange- All diseases have an assumed origin, an etiology. In the case ments (an extrinsic cause) and genetic derangements (intrinsic of an infection the etiology is a microbe. cause) that lead to disease. Inappropriate immunological res- The occurrence of disease has many other compounding ponse, the so-called autoimmune response, and an exaggerated factors, such as malnutrition, overcrowded living conditions, infl ammatory response can also cause disease. 176 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Street Smart Cultural / Regional differences Physicians are currently thinking that trauma Vaccination against smallpox was discontinued patients who survive from the fi eld may die while in the United States, as the disease had been in the intensive care unit from an inappropriate eradicated throughout the world. There is a concern infl ammatory response.6–8 that terrorists might use infectious diseases, like smallpox, against human populations who have lost their resistance or who were never vaccinated against the disease.9,10 Risk Factors Frequently, medical professionals will speak of the incidence Some risk factors are conditions that predispose a person of a disease, the incidence being the number of new cases per to another disease. For example, African Americans have a standardized group per time. An example would be 1 case per higher incidence of hypertension. Hypertension has been 100,000 per year of x disease. directly linked to an increased risk of coronary syndrome The incidence of disease (prevalence) is not the same secondary to the disease of atherosclerosis. as the risk of a disease. Risk, the likelihood that a situation could lead to harm—that is, that the person would contract a Age as a Risk Factor disease—is a function of an individual’s life circumstances. Outward signs of aging include wrinkles, secondary to loss of And everyone’s life circumstances are different. the underlying layer of fat, and gray hair. These signs indicate the Every person has some risk factors that tend to make presence of the changes of aging that are occurring within that person more or less vulnerable to a disease as compared the body. The multitude of hormonal, biochemical, and to another person. Some risk factors are functions of the physiologic changes that accompany aging combine to make human condition and are therefore modifi able. Others are the elderly person more at risk for all diseases in general. In nonmodifi able risk factors which are, essentially, a fact of life addition, specifi c diseases, such as dementia, are age-related. for the individual. An example of nonmodifi able risk factors is heredity. Modifi able Risk Factors Heredity is a signifi cant risk factor. If a woman has breast The term “modifi able” would seem to indicate that the person has cancer then her offspring are at risk for breast cancer. It is some control of the existence of factors. In some cases, such as thought that more diseases can be partially or completely tobacco smoking, obesity, and alcohol consumption, the person explained by genetics. With the unraveling of the DNA does have control over these risk factors. However, eliminating mystery by the Human Genome Project, some 35 diseases these risk factors is seldom as simple as it might appear. have been directly linked, or at least partially attributed to, Some risk factors are a function of one’s lifestyle or genetic origins. Cystic fi brosis, a disease of the lungs, is due occupational choices. These modifi able risk factors are called to a malfunctioning gene. Sickle-cell anemia, a disease of red environmental risk factors. Farmers, for example, inhale blood cells, also has a genetic origin. dust from moldy hay that leads to a pulmonary disease called Another nonmodifi able risk factor is a person’s gender. farmer’s lung. Wearing a simple dust
mask can help to modify For example, the overwhelming majority of patients with or eliminate the risk of acquiring farmer’s lung. breast cancer are women, though breast cancer is a reality for a small subset of men. There are a number of other gender- related diseases (e.g., prostate cancer) that are exclusive to one gender. There are other diseases that tend to be more Professional Paramedic prevalent in one gender. In some cases, gender helps protect a person from disease, as is the case with acute coronary The professional Paramedic does not blame the syndrome. A person’s race may be a risk factor, especially in cases patient for the disease. For example, tobacco of infectious disease. For example, Europeans were generally smoking is now known to be a risk factor for lung more resistant, and therefore had a lower risk of contracting diseases such as emphysema and cancer. However, smallpox due to centuries of exposure to smallpox. This risk tobacco smoking was encouraged by the U.S. is considered lower when compared to the fi rst Americans who had no exposure experience with smallpox until the government in World War II and tobacco companies arrival of Europeans. They suffered staggering losses of life advertised that tobacco was an aid to digestion. due to smallpox. Principles of Pathophysiology 177 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Prognosis unsuspecting and physically weakened patients. This can occur simply because a healthcare professional failed to wash his or The expected outcome from a disease is called the prognosis. her hands or take proper infection control precautions.12–14 A good prognosis, or the likelihood of recovery and survival, Iatrogenic disease does not end with infections. Every or a poor prognosis, which suggests death or disability, is a medical intervention carries with it some risk of harm to the culmination of modifi able risk factors (such as nutrition), patient and the potential to cause disease. Patients, as was nonmodifi able risk factors (such as age), and the availability of discussed in Chapter 6 on medicolegal responsibilities, have treatments. For example, a middle-aged male who experiences a right to know about these risks and to make an informed sudden cardiac death in an airport has a better prognosis than decision (i.e., informed consent). the same male stricken while in a rural community, owing to the rapid availability of automated external defi brillators in airports. Disease as a Process The origin and development of a disease follows an ordered Iatrogenic Disease sequence of events at the cellular, biochemical, and molecular Iatrogenic (iatro- – “physician”; genic – “cause”) disease is a level, which is called its pathogenesis. Thus, the disease has previously known cause of disease that was introduced to the predictable effects upon the patient. When a patient becomes patient as a result of medical intervention.11 diseased, one of three outcomes is inevitable: recovery, death, The classic example of an iatrogenic disease was described or survival with remission. by Dr. Ignaz Semmelweis, the father of microbiology. For cells, recovery means a return to a former functional While attending to patients at Vienna General Hospital, capacity. For a person, recovery means a return to health. To Dr. Semmelweis noted a connection between childbed fever be cured, the patient must have no remnant of the disease. (then referred to as puerperal fever) and the dirty hands of Recovery does not necessarily mean that the patient is birth attendants. He immediately ordered that hands be unchanged. Some patients recover with physical or chemical washed with “chlorine liquida,” a chlorinated lime solution changes remaining after the encounter with the disease; these (calcium hypochlorite). As a result, the death rate from changes are called residuals. Scars, called poxmarks, are a puerperal fever immediately dropped after the institution of visible residual left after recovery from the disease smallpox. this simple intervention. Unfortunately, fellow physicians Hemiplegia (hemi- – “half ”; plegia – “paralyzed”) is a failed to heed his advice until the emergence of the germ residual that can remain after a stroke. theory some 40 years later. Some people learn to co-exist with their disease having Death from a hospital-acquired infection, called a learned to compensate for their disease. Often with the help nosocomial infection (in this case, childbed fever), was the of medications, a patient may become asymptomatic. direct result of medical intervention. Hippocrates, in his Periodically patients will decompensate and become treatise “Epidemic,” advised aspiring physicians that their symptomatic. These episodes in which a chronic disease fi rst responsibility was to “do no harm,” an edict that has been returns, or fl ares up, is called an exacerbation. Asthma, a maintained to this day. chronic disease of the airways, is largely managed by the use Drug-resistant strains of diseases, grown in the hospitals of bronchodilators and anti-infl ammatory drugs. Occasionally, and the intensive care units, can be easily transmitted by the patient will experience an exacerbation of his or her unwitting healthcare professionals, including Paramedics, to asthma, usually triggered by some stimulus. This patient will present to EMS emergently with an acute exacerbation of the chronic disease asthma. In some cases, after a person has become diseased, the body’s defense, or medical treatment, may force the disease Professional Paramedic into a non-active state called remission. Remission does not mean the patient has been cured, but rather that the disease Whenever a medical intervention is being considered, has been stopped. the Paramedic must consider the risk/benefi t of the Some diseases, particularly certain infections, become dormant (Latin – “to sleep”) and remain in a state of procedure before making a decision. Even with the biological rest. These diseases remain dormant until favorable best of intentions and using the best techniques, conditions exist for them to reanimate. Tuberculosis is an iatrogenic disease—which can be caused by an excellent example of a disease that can infect a person and infi ltration of an intravenous line—will occur in every then remain dormant. It remains in spore form for years—and even decades—only to re-infect the person when the person Paramedic’s practice. The key is to identify and is aged or debilitated.15 consider the risk, monitor for its occurrence, and Ultimately disease will kill everyone. When a body’s mitigate its harm as soon as possible. defense mechanisms become overwhelmed, and the body cannot compensate, the patient will succumb to disease and 178 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. death will ensue. The process of death is described at the end Fick Principle of this chapter. Morbidity and Mortality Oxygenation Physicians, nurses, and allied health professionals monitor the Ventilation Lungs incidence of disease (called the morbidity) and death rate (or mortality) for trends. Awareness of these leading indicators Heart of disease (i.e., death and disability) provide healthcare Respiration professionals an opportunity to prepare for outbreaks of Circulation these diseases and to properly treat the population when an outbreak occurs. Epidemiology deals with the study of the causes, distribution, and control of disease in populations. Advances in epidemiology permit public health authorities to stockpile needed antibiotics, medicines, and the like in anticipation of epidemics and other public health emergencies. In the United States, the federal Centers for Disease Control and Prevention (CDC), located in Atlanta, Georgia, has taken the lead in this area and regularly disseminates epidemiological information through its publication of Morbidity and Mortality Reports (MMR). These reports appear both on-line and in print.16 Chemical Causes of Cell Injury Chemical causes of cellular injury can be divided into hypoxia (the leading cause of cell injury and death), free oxygen radicals, and toxins, which include poisons. Each of these sources of cellular injury is unique because it works Cellular primarily at a biochemical level, the foundation level of respiration cellular physiology. Figure 11-1 The Fick principle. Hypoxic Injury The classic cause of cell injury is low oxygen concentrations, The fi rst element of the Fick principle addresses the a condition called hypoxia. Hypoxia causes cells to redirect availability of oxygen in the ambient air going into the lungs. their metabolic processes to anaerobic respiration in an effort Lack of oxygen, due to an oxygen poor environment, can lead to sustain the cell. While this response can be effective for a to hypoxia and is categorized as hypoxic hypoxia. time, eventually anaerobic metabolism proves insuffi cient to The next element in the Fick principle is ventilation. sustain the cell. Even high fl ow oxygen via nonrebreather mask is useless if the airway is compromised. Hypoxia and Dr. Fick With oxygen-laden air in the lungs, the process of Key to effective cellular metabolism is the ready availability respiration can occur. Respiration depends on an intact of oxygen for the cells. The process of getting oxygen to the capillary–alveolar interface. An interruption of blood fl ow cells is outlined by the Fick principle (Figure 11-1). Fick, in (e.g., by a pulmonary embolism) or alveolar fi lling (e.g., his monograph Medical Physics, described the function of the pneumonia) will interfere with respiration and create hypoxic lungs; the hemodynamics of the body, including the work of hypoxia. the heart; and the properties of the gasses oxygen and carbon An adequate volume of circulating red blood cells is dioxide. The Fick principle can be summed up in fi ve key needed to carry the oxygen to the various organs of the body. concepts: oxygenation, ventilation, respiration, circulation, The volume of red blood cells is expressed as the percentage and cellular respiration. of red blood cells in the blood and is called the hematocrit. The Fick principle places hypoxia at the center of disease A low hematocrit, or other red blood cell abnormality, can and makes the resolution of hypoxia the fi rst priority in the lead to oxygen deprivation at the cellular level. This is called treatment of disease. Too little oxygen in the blood perfusing anemic hypoxia. the cells causes hypoxemia (hypo- – Greek “under”; ox – With the hemoglobin loaded with oxygen, the body now “oxygen”; -emia – “blood”) and leads to disease. must move the blood about the body via the circulatory system. Principles of Pathophysiology 179 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Problems of circulation can lead to oxygen deprivation at the and tissues. The key is to provide oxygenation via perfusion cellular level and is called ischemic hypoxia. Examples of to the affected cells before the lysosomes swell. circulation problems include occlusion of blood vessels, such These near-miss events are not completely harmless. as a deep vein thrombus, or heart failure. During the course of reperfusion, products of incomplete Finally, the cells must be able to accept the oxygen; that is, metabolism (hydrogen peroxide and other reactive oxygen oxygen must be able to be diffused across the cell membrane chemicals) are created.17 The analogy of a smoldering fi re is and utilized in the Krebs cycle. The inability of the cells to useful. A smoldering fi re results in products of incomplete accept or use oxygen, such as in cyanide poisoning, is called combustion such as cyanide, which are dangerous. In the same histoxic hypoxia. manner, the reactive oxygen chemicals which are products of Paramedic practice involves preventing hypoxia by incomplete metabolism, such as hydrogen peroxide, wreak supporting the
different elements of the Fick principle. For havoc in the cell. example, the administration of oxygen via nonrebreather face Reactive oxygen chemicals consist of an electrically mask supplements the available oxygen in the air. Intravenous uncharged atom with an unpaired electron. This unpaired fl uids help to support circulation. electron is unstable, by nature, and looks for another electron with which to pair up and thus stabilize. Unfortunately the ACLS View of Hypoxia reactive oyxgen chemicals tend to either pair up with amino Some Paramedics simplify the causes of cellular hypoxia acids within the DNA, causing their destruction, or pair up by referring to problems with the pipes, the pump, or the with lipids in the cell wall, a process called lipid peroxidation, fl uid—a familiar mantra in Advanced Cardiac Life Support which also results in destruction. (ACLS). As a result, these reactive oxygen chemicals fragment Problems of the pipes include vasodilatation, such as that DNA, thus impairing the cell’s ability to make proteins and which occurs with neurogenic shock and anaphylactic shock to reproduce itself. They may also cause cell wall damage, (discussed later). Problems with the pipes can also include making the cell walls more permeable to sodium. Increased leaky pipes which may occur during severe infections. intracellular sodium leads to cell swelling and autolysis (auto- – Problems with the pump include acute myocardial “self ”; lysis – “divide”). infarction leading to pump failure (cardiogenic shock). Also, an impaired heart cannot meet the body’s demands for perfusion, which is called heart failure. Street Smart Problems with fl uids imply problems with the oxygen- carrying capacity of the blood itself. This can be caused by a One therapy that has been given consideration is condition called anemia. the co–administration of drugs called antioxidants Ischemic Cascade during a resuscitation. Antioxidants, like vitamin C When cells are deprived of oxygen, and subsequently convert and vitamin E, absorb reactive oxygen chemicals to anaerobic respiration, a cascade of biochemical changes and effectively neutralize them before they can start to take place which can eventually lead to cell death. do damage.18 The fi rst step in the pathogenesis of hypoxia is called ischemia. The cells, fully dedicated to anaerobic respiration, rapidly deplete available glucose. Lactic acid, the by-product Toxins of glycolysis, is all that then remains. Some substances are so lethal that they are called poisons. As With an abundance of acid present, the cytoplasm pH little as a few micrograms of these substances can kill a person. drops rapidly and cellular proteins start to denature. At this However, any substance taken in excess—even water—can be point the cell is injured and recovery is questionable. toxic to the body. The defi nition of a toxin is any substance As the cell’s proteins continue to denature, the lysosomes capable of causing cell injury and death, and that includes within the cell swell and burst, releasing proteases, which poisons. Toxins injure cells by one of two basic mechanisms: hasten the cell’s destruction. The now dead cell is said to by direct reaction with the cell or through metabolites. have necrosis (Greek for dead). If a large number of cells are Metabolites are the by-products of drugs and chemicals involved, then the term infarction is applied. after the cell has reacted with them. The biochemical changes that occur in the cell can convert a previously harmless drug or Reperfusion Injury and Free Radicals chemical into a toxin. For example, acetaminophen is harmless Acute interventions during a medical emergency can reverse to the liver until after the liver metabolizes it. Thereafter, hypoxia and prevent permanent injury and even infarction. excessive amounts of metabolites of acetaminophen can build Emergency interventions that have an impact on the Fick up to toxic levels, causing liver necrosis.19–21 principles of oxygenation, ventilation, respiration, circulation, Toxins that affect the cells directly usually react and cellular respiration can reestablish perfusion to the cells with a molecular component of the cell. By mutating or 180 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. neutralizing that molecule the toxin impairs the cell’s Initially, in the case of heat exhaustion, the body is unable function, thereby injuring the cell. By way of example, to compensate for the heat load that it is being exposed to the poison cyanide works by inactivating an enzyme, and most of the emergency medical care is supportive of the cytochrome oxidase, which is needed in cellular metabolism body’s efforts to correct it. When the heat becomes excessive, for the cell to use oxygen in the mitochondria.22 Without this the lipid–protein cell membrane starts to liquefy. This allows enzyme the mitochondria cannot make ATP. In essence, sodium and water into the cell, as well as intracellular cyanide suffocates the cell by making the abundantly proteins such as enzymes, and DNA starts to break down. available oxygen useless. These conditions lead to cell death. Concurrent conditions that result from heat stroke include Physical Causes of Cellular Injury rhabdomyolysis (rhabdo- “rod like”– “”; myo – “muscle”; -lysis – “split”), a breakdown of muscle, and myoglobulinuria Those forces that exist outside of the body, in the physical (myo- – “muscle”; globin – “protein”; -uria – “urine”), a world, can cause injury to the body and the cells within. condition in which the protein products of muscle breakdown Such forces include mechanical forces, referring to those clog the kidneys. This leads to renal failure. injuries sustained by physical force or violence; extremes of The opposite situation, hypothermia and cold-related temperature; radiation, including electromagnetic radiation; injury, can lead to some localized injury (Figure 11-3) as a and changes in atmospheric pressures. result of freezing and coagulation of the microcirculation, as well as the potential for more systemic injury. When the Mechanical Injury body’s core temperature drops, cells suffer hypothermic Mechanical injury is due to abrupt and sudden physical injury from two mechanisms. forces acting upon the body, such as friction, blunt force, The first mechanism of injury is a disturbance in the or penetrating force. This mechanical injury is referred to ion concentrations of the cell, particularly sodium. As the as trauma (Figure 11-2). These traumatic injury-producing cell wall starts to gel, eventually becoming crystalline, forces tend to either stretch, tear, or crush tissues. Examples the sodium–potassium pump fails and sodium and water of traumatic injury, ranging from superfi cial to deep, are rush in. If the hypothermia is reversed in a timely fashion, abrasions, lacerations, punctures, and fractures. the result will be edema. Cellular death can also occur. Even as the cells start to cool, the cells continue Heat or Cold Injury with metabolism. This slowed metabolism is akin to the The body has excellent mechanisms for keeping itself smoldering fi re and smoke analogy used earlier. Partial within the range of normal temperatures needed for cellular products of metabolism—the reactive oxygen chemicals and metabolism. When these mechanisms fail, cellular metabolism particularly the oxygen-free radicals—start to accumulate. is affected and cells die. Examples of some heat-related These chemicals have their greatest potential for cellular diseases include heat cramps, exhaustion, or heat stroke. injury during the reperfusion stage or recovery phase. Figure 11-2 Trauma as a source of mechanical injury. (Courtesy of David J. Reimer Sr.) Principles of Pathophysiology 181 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 11-4 Burn injury. Therefore, the exposure to sunlight (visible light) is actually Figure 11-3 Frostbite as a result of cold injury. exposure to celestial radiation. There are many sources of photons and all can cause photo burns. Another form of electromagnetic radiation is radio frequency radiation (RFR), or radio waves. Contact with a Burn Injury noninsulated source of radio waves, such as a microwave Burn injury (Figure 11-4) involves exposure to large amounts antenna, can cause burns. However, RFR (including of energy from sources along the electromagnetic spectrum. microwaves) are generally non-ionizing. The danger of radio Burns can be caused by fi ve sources of electromagnetic energy: frequency radiation is with the production of thermal energy. thermal (infrared), radiation (gamma), light (ultraviolet), Electrical energy, the movement of electrons, is what radio, and electricity. powers the cell’s metabolic processes (i.e., electron transport). The most widely known source of thermal burns is However, when massive amounts of electron energy enter the direct contact with fi re. However, other sources of thermal tissues then injury will occur. The cells suffer from thermal energy—such as superheated steam, boiling liquids, and burns as well as electrolysis (electro- – “electron”; lysis – heated objects—can also cause thermal injury. “divide”). The buildup of thermal energy occurs as a result of Sources of nuclear radiation (e.g., uranium or plutonium) the fl ow of electricity overcoming resistance from the tissues can also cause burns. Radiation exposure can be divided and creating heat, called joule heat as a by-product of that into particulate exposure (i.e., alpha and beta particles), and reaction. electromagnetic energy in the form of X-rays and gamma More problematic can be electroporation, the effect of rays. The electromagnetic energy exposure (Figure 11-5) is electrical current passing through the tissue. The effect of considered to be more dangerous. electricity upon the lipid–protein layer of the cell membrane Intense light, which includes the light of the sun, contains is to denature the proteins that are in the cell’s pores. The photons (Greek – light) and are represented by the symbol end result is that sodium and water rush into the cell and the of gamma. High-intensity photons are called gamma rays. cell lysis. 182 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Electromagnetic Spectrum 10–13 cm 10–9 cm 10–6 cm 10–4 cm 1–2 cm 1 cm 1 km Visible Microwave Gamma ray Ultraviolet X-ray Radio Infrared Figure 11-5 Electromagnetic spectrum. Mechanism of Injury and eardrums. It occurs in the same manner that slapping an The major mechanism of injury for a burn is either direct heat air-fi lled paper bag destroys the paper bag. transfer or ionization. Heat placed in direct contact with the cells There is also indirect barotrauma secondary to dissolved denatures their proteins. That is, it breaks down the protein’s gasses. Gasses such as oxygen, carbon dioxide, and nitrogen complex folded structure. This can be seen when the clear liquid are dissolved in blood. When there is increased pressure, such protein of an egg white is cooked on a griddle. The egg white as occurs during deep sea diving, then the gasses compress. coagulates, becoming solid and turning white. As the diver ascends, the gasses “come out of solution” and Ionization, on the other hand, strips away electrons, leaving take up volume in the bloodstream, causing occlusions. At highly reactive chemicals to break down chemical bonds and the same time, the volume of air within the lungs expands alter cellular chemistry. High levels of ionization lead to (Boyle’s law) thereby overpressurizing the lungs and creating conditions such as radiation poisoning or sun poisoning. Low a risk of a ruptured lung or pneumothorax (Figure 11-6). levels of ionization, particularly the penetrating radiation of Barotrauma is not restricted to diving incidents only. The gamma rays, can alter amino acids in the DNA and cause same pathophysiological processes in decompression illness long-term complications. occur in
mountain sickness. The likelihood of long-term complications from ionizing radiation exposure, the stochastic effects, is a function of the length (duration of time) of exposure and/or the strength of the radiation. Ionizing radiation is thought to cause cancers in individuals. Frequent exposure to radiation, such as sunburns while sun tanning, can lead to an increased susceptibility to cancer. Exposure to ionizing radiation can also cause birth defects and cancer in subsequent generations, called the teratogenic effect, as a result of changes in the structure of Heart that all important protein, the DNA. Tension pneumothorax Barotrauma Barotrauma is physical damage to tissues, an injury caused Mediastinal by an imbalance between pressures in the environment and shift those within the body. The pathophysiology of barotraumas revolves around the fact that gasses, in the air or within the blood, are more compressible, or distensible, than the surrounding tissues. The classic example of direct barotrauma is injury due to the shock wave of an explosion.23–25 During an explosion there is a rapid rise in atmospheric pressure that can cause Figure 11-6 Tension pneumothorax possibly mechanical damage to any air-fi lled organs such as the lungs secondary to barotrauma. Principles of Pathophysiology 183 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Metabolic Disorders Nutritional defi ciencies can lead to metabolic derangement and disease. Scurvy, for example, is an ancient disease, having been recorded by the Egyptians in 1559 B.C., which became more problematic when early sailing voyages became prolonged. In 1520 Magellan lost more than 80% of his crew to scurvy while trying to circumnavigate the globe. British Navel Surgeon Sir James Lind linked scurvy with a defi ciency of vitamin C, ascorbic acid, in 1746. He immediately ordered citrus fruit, known to be high in vitamin C, aboard every British Navy ship; hence the origin of the British sailors’ nickname “limeys.” Nutritional excess can also lead to disease. The current epidemic of obesity in America (Figure 11-7) has led to an increase in obesity-related disease, such as diabetes mellitus, as well as an increase in obesity-linked diseases such as sleep apnea and Pickwickian syndrome. Genetic Disorders The existence of genetic diseases has been recognized for Figure 11-8 This child with Down syndrome is centuries. These disorders were described as running in a encouraged to develop psychomotor skills. (From family. What was missing was an understanding of why these Down Right Beautiful 1996 Calendar, Marijone’s Designer disorders ran in families. Abnormalities in a person’s genes Portraits) can cause a genetic disorder. Within the DNA, genes carry the blueprint for protein production which is the life work of most cells. These proteins are essential to cell health. rejoinings at new locations, called translocations; extra If the DNA sequence of one gene is altered, called a copies of chromosomes; or missing copies of chromosomes mutation, then protein production can be altered. Examples leads to genetic disorders. Down syndrome is a common of monogenic disorders include Marfan syndrome, sickle- genetic disorder linked to having three copies of the 21st cell anemia, and cystic fi brosis. chromosome.26,27 A child with Down syndrome (Figure 11-8) In some instances the entire chromosome is structurally may have a fl attened nose and widely spaced eyes. defective. Gross breaks in some chromosomes with subsequent However, most genetic disorders are complex and involve a combination of environmental and multiple genetic mutations. Many chronic diseases—such as Alzheimer’s disease, heart disease, arthritis, and obesity—are thought to have genetic underpinnings. Not all genetic differences necessarily lead to disease. In fact, some genetic changes may be evolutionary in nature. In an incredible case of genetic detective work, it has been discovered that some people cannot contract human immunodefi ciency virus (HIV), the cause of AIDS. The reason is because of a genetic mutation which prevents the white blood cells from creating the receptor, CCR5, that permits the HIV virus to gain entrance into the white blood cell. Infection The majority of deaths during recorded history have been due to infectious diseases. Infectious diseases, referred to in ≥30% 10%–14% medical circles as pathogens, stem from a number of sources. 25%–29% <10% Listed from smallest to largest, they are prions, viruses, bacteria 20%–24% No data (Figure 11-9), fungi, protozoa, and helminthes (worms). All 15%–19% of these microorganisms are parasites, dependent on the host for survival. Figure 11-7 Obesity in the United States. Infectious diseases have three pathogenic mechanisms. (Courtesy of Centers for Disease Control and Some infectious agents (e.g., herpes simplex) replicate Prevention) themselves inside the host cells. Eventually these 184 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 11-9 Common microorganisms that can cause disease. (Courtesy of Centers for Disease Control and Prevention Public Health Image Library) microorganisms destroy the cell’s structural integrity, thereby killing the cell, which is a direct cytopathic effect. The microorganisms are then released to infect other cells or other potential hosts. Other microorganisms are dangerous to the host because they produce a toxin that is harmful (poisonous) to the Figure 11-10 Patient experiencing an allergic cell. Toxins can be categorized as either being exotoxins reaction. (Courtesy of Robert A. Silverman, M. D., Clinical or endotoxins. Exotoxins are proteins that are produced by Professor, Department of Pediatrics, Georgetown University, bacteria and released into the interstitial fl uid where they are Georgetown, MD) absorbed, because they are highly soluble, into surrounding the body has a disproportionate response to a foreign protein cells. Exotoxins can be cell specifi c. For example, the toxins or polysaccharide, an antigen (anti- – “not”; gen – “self ”) and that produce tetanus and botulism affect nervous tissue whereas the results are life-threatening to the patient. This exaggerated the toxins of the streptococcus bacteria affect vascular tissue. immune response, called an anaphylactic response, can lead Some bacteria produce toxins by their death. These to severe airway compromise and/or cardiovascular collapse toxins, called endotoxins, are the result of the breakdown of secondary to relative hypovolemia. This may be exemplifi ed the bacteria’s cell wall membrane.28,29 Endotoxins are complex by a patient with an allergic reaction (Figure 11-10). substances made up of polysaccharides or phospholipids In the case of the autoimmune response, described and are attracted to other cell wall membranes. The bacteria earlier, the body sets upon itself and starts to destroy normal Clostridium tetanus produces a phospholipase (phospholipids cells along with infected cells. Autoimmune response has make up cell wall membranes and the suffi x -ase means been implicated in the diseases multiple sclerosis, diabetes enzyme) which breaks down cell walls. mellitus, scleroderma, Crohn’s disease, lupus erythematosus, Finally, some infections are dangerous because they rheumatoid arthritis, and gluten sensitivity. trigger an immune response that causes damage to the host, an autoimmune response. For example, the causative agent Effect: Systemic Defense of rheumatic fever, streptococcus, triggers an undifferentiated immune response that destroys healthy tissue (frequently the The body’s defenses to disease start with general nonspecifi c heart valves) in the process. barriers and end with targeted cellular attacks against the offending disease. If these defenses are overwhelmed, then Immune Reactions the patient is diseased. Patients with disease go into shock, a condition of deranged Immune reactions can be classifi ed as either exaggerated metabolic functions that have systemic effects described later immune responses or autoimmune responses. In the fi rst case, in this chapter. The shock syndrome, a predictable pattern of Principles of Pathophysiology 185 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. signs and symptoms, can either culminate with recovery or any remain alive, they are carried to the acidic environment of death. The Paramedic’s mission is to support the body in its the stomach to be destroyed. Note that external bodily fl uids struggle against shock. such as perspiration, tears, and ear wax are either mucus- like, trapping potentially infectious materials, or contain the Nonspecifi c Defenses enzyme lysozyme. While the analogy is not glamorous, the truth is that the body Like the skin, the internal organs can be protected from is essentially two hollow tubes, with one tube being a cul de foreign invaders by mechanical means such as regurgitation, sac. The outside of the tube is covered by skin, the largest defecation, menstruation, and urination. organ of the body. Skin is a barrier to physical attack by trauma, chemicals, and so on and from biological attack from Infl ammatory Response microorganisms such as fungus, bacteria, and virus. If the nonspecifi c defenses of the skin or the mucosa are The key to the skin’s effectiveness as a barrier lies breached and internal cells and tissues are injured, the in the fact that the outermost layer of skin is dead. Most second-string defenders, the infl ammatory system, responds. microorganisms depend on the host cells being alive. The The infl ammatory system is made up of white blood cells and layers of dead epithelial cells, contained in the epidermis, chemical intermediaries that act as messengers. prevent infection from reaching the live cells deeper in the A variety of causes can stimulate the infl ammatory tissue. Barrier devices, such as gloves (Figure 11-11), are response. Causes include infections that lead to systemic in- simply adjuncts to the fi rst defense, the skin. fections; trauma, such as burn trauma; anaphylactic reactions; But the defense does not stop there. Sebaceous glands complications of childbirth; and eclampsia, to name just a few. excrete acidic (pH 3–5) secretions—lactic acid and fatty acids—which act as a biochemical barrier and create a hostile Infl ammation: Acute Phase environment for fungi and bacteria. Finally, if any infection obtains a foothold in the skin it is Forward scouts, the mast cells contained in the bloodstream, only temporary. Skin is sloughed off, or mechanically abraded, are triggered by trauma, hypoxia, toxins, or any source of continuously, and replaced as quickly. The combination of cellular injury. They respond from the bloodstream almost these three mechanisms culminates in a very effective barrier immediately. Outwardly, the response of the infl ammatory defense against outside sources of disease. system is visible as redness (rubor), swelling (tumor), pain Internally, the body is lined with mucous membranes that (dolor), and warmth (calor) at the injury site. cover the pulmonary tree, the cul de sac mentioned earlier, and Looking beneath these outward manifestations, a complex the gastrointestinal tract that extends the length of the human process of infl ammation is revealed. Mast cells, containing torso. Mucous membranes secrete mucus, a sticky liquid that granules of chemical mediators like histamine and serotonin, entraps foreign invaders, such as bacteria. Bacteria-laden break down or degranulate, releasing their contents into the mucus in the lungs is either expectorated, and thus sputum surrounding interstitial fl uids (Figure 11-12). may be infectious, or ingested, where the bacteria meet their The chemical mediators histamine and serotonin cause fate in the stomach’s acid. vasoconstriction of the smooth muscle in the surrounding Infectious trespassers in the oropharynx are fi rst greeted arterioles, thereby limiting the spread of injury. They also by lysozyme-carrying saliva, which breaks down cell walls. If dilate the postcapillary venules, resulting in swelling and pain. Dilation of the capillary beds is important because it increases the permeability of the capillary walls and allows more white blood cells to migrate out of the blood and
into the interstitial space surrounding the cells. The collection of white blood cells and fl uids is called an exudate. Mast cells also release two chemical messengers: chemotactic factors, which attract specifi c leukocytes (white blood cells) to the injury site. These chemotactic factors— neutrophil chemotactic factor and eosinophil chemotactic factor of anaphylaxis (ECF-A)—bring out the workhorses of infl ammation—neutrophils and eosinophils—during the early stages of the infl ammatory response. Neutrophils destroy bacteria by engulfi ng them in a process called phagocytosis (Figure 11-13). Then the neutrophils break down the bacteria with their lysosomes. Eosinophils destroy parasitic infestations, such as helminthes Figure 11-11 Barrier devices, such as gloves, (worms), and release enzymes that slow the infl ammatory support the body’s own nonspecifi c defense, the response.30 Chief amongst these enzymes is histaminase, an skin. enzyme that breaks down histamine. 186 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Allergen (e.g., cigarette smoke, pollen, bee sting, etc.) IgE antibodies attach IgE antibodies to Mast cell Lower Mast cell airway degranulates T cells Airway Macrophages damage/ constriction/ mucous Eosinophils plugging Triggers acute inflammatory mediators Produce mucous plugging, airway edema and constriction, and damage airway lining. Figure 11-12 Mast cell degranulation. Infl ammation: Prolonged or Chronic vascular permeability and smooth muscle contraction later in Mast cells also create chemical mediators such as the infl ammatory response. leukotrienes (slow acting substances of anaphylaxis— If the infection is persistent (i.e., greater than 24 hours), SRS-A). Leukotrienes produce chemical effects which are then monocytes, which later become macrophages, come to similar to histamine and help to prolong the infl ammation, if the aid of the neutrophils and a similar process continues.31 necessary. Leukotrienes could be considered as long-acting At this stage the body typically mounts a fever response. histamine. The fever is induced by chemicals from the neutrophils and Perhaps most notable to the patient is the presence of the macrophages, which are released after exposure to the prostaglandins, a chemical mediator released from the mast bacterial remains (endotoxins). cell that creates the sensation of pain. However, the primary The cellular remnants of this battle, containing dead and function of prostaglandins is not to create pain but to increase dying leukocytes and bacterial remains, either migrate to the Principles of Pathophysiology 187 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Bacterium Support for Infl ammation: The Coagulation System The term “coagulation” evokes thoughts of blood clots and hemorrhage. However, during the infl ammatory response the coagulation system acts to entrap fl uids (exudates) and foreign bodies (Figure 11-15). Bacterium Both endotoxins (via the extrinsic pathway) and kinins (via engulfed the intrinsic pathway) can stimulate the coagulation cascade to begin. Circulating prothrombin, a plasma protein, is converted into thrombin, which in turn is converted into fi brinogen and then fi brin. The resulting fi brin net prevents the spread of the infection to adjunct tissues by essentially walling off the site. Perhaps as important as preventing the spread of infection, the fi brin net keeps the offending microorganisms confi ned Enzymes destroy Products absorbed to a smaller area for phagocytic action by neutrophils and bacterium by cell macrophages. Finally, the fi brin net serves as scaffolding for Figure 11-13 Neutrophils engaged in scar formation and healing. phagocytosis of an invading bacteria. (Diagram by Support for Infl ammation: Ruth Lawson, Otago Polytechnic, licensed under the Creative The Kinin System Commons Attribution-Sharealike versions 3.0, 2.5, 2.0 and 1.0) Another class of circulating plasma proteins is the kinin group, made up of chains of amino acids. Like the skin’s surface as pus or are carried away in the lymphatic coagulation cascade, kallikrein is activated and converted system as purulent exudate. If the purulent exudate is walled to bradykinin in a cascade. However, kallikrein is present off in a specifi c area, then it is called an abscess. Abscesses in sweat, tears, saliva, urine, and feces and can be converted can be diffi cult to resolve without a surgical procedure such into bradykinin. as incision and drainage (I&D).32 Support for Infl ammation: The Complement System The complement system, as the name suggests, supports and controls the infl ammatory response. Plasma proteins circulate Antigen in the blood and make up almost one half of the blood Antibody C1 complex proteins. The other half of the blood proteins are albumin. The blood proteins comprise the complement system and can be activated by either one of two mechanisms. C2a and C4b fragments The fi rst mechanism includes the classic pathway, an immune complex, in which an antibody (e.g., IgG or IgM) has Classical pathway C3 convertase attached to an antigen and stimulates the complement system. Alternative pathway The activated plasma proteins of the complement system act C3 hydrolysis as anaphylatoxins, increasing the degranulation of mast cells and attracting other white blood cells (leukocytes) to the site. C3b and C3a fragments The plasma proteins mark resistant bacterium by attaching fragments of themselves to the bacterial cell wall, a process called C3b cleaves C5 into opsonization, thus enhancing the impact of the leukocytes. C5a and C5b With the second mechanism, the alternative pathway, toxins Cell swells secreted by the bacterium or fungi stimulate the complement and bursts system and cause all of the same effects as the classic pathway. In some cases the body does not recognize the bacteria C5b, C6, C7, C8 and cannot mount an effective antigen–antibody defense. In and C9 together form those cases, the complement system creates a membrane the membrane attack complex attack complex (MAC), which attaches itself to the cell’s walls and forms a tube from the outside to the inside. The tube allows water to enter the cell, the cell to swell, and the Figure 11-14 The complement system creating cell to lysis (Figure 11-14). a membrane attack complex. 188 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Vessel cut Hemorrhage Aggregation of platelets Prothrombin Fibrinogen Red Cells Thromboplastin Red cells Thrombin Platelets enmeshed in fibrin Figure 11-15 Coagulation. Bradykinin is similar to histamine in its actions. It causes Five types of immunoglobulins have been identifi ed: vasodilation, increased permeability of the vascular bed, and IgA, IgD, IgE, IgG (gamma globulin), and IgM, and each works with prostaglandins to produce pain. Bradykinin was immunoglobulin fi ts into the surface of an antigen in a key and fi rst discovered in Brazil by three pharmacologists working lock fashion, linking them together. The result of this union is with snake venom which caused circulatory collapse. to either neutralize bacterial toxins or activate the complement Using this early work, scientists developed a new class of system. Complement proteins then cause the swelling and antihypertensive drugs called ACE inhibitors. rupture of the cells via membrane attack complexes. If the same antigen is introduced again, circulating Immune Response memory cells will recognize the antigen and plasma cells will start to release antibodies. This phenomenon is called The immune response is the body’s specifi c defense against humoral immunity. substances that are not part of the body (by defi nition, antigens). Antigens can be exogenous, from outside of the T Lymphocytes body, and enter the body by injection, ingestion, or inhalation. Antigens can also be endogenous, from within the body (e.g., Originating in the bone marrow with B lymphocytes, a virus that has replicated within a cell). Whatever the source T lymphocytes travel to the thymus where they mature and of the antigen, the body’s immune system reacts. exit the thymus immunocompetent (i.e., capable of providing Lymphocytes within the body respond to the site of immunity) and travel to the lymphatic system. Once in the injury and, depending on the type of lymphocyte, incapacitate lymphatic system, specifi c cytotoxic T lymphocytes, or killer the antigen. B lymphocytes, from bone marrow, produce T cells, attack antigens which antibodies could not bind to. antibodies that then attack the cell. T lymphocytes, from the They form an antigen–antibody complex (i.e., antigens for thymus gland, recognize the antigen and attack it directly. which the patient does not yet have immunity). Cytotoxic T cells can release lymphokine, a chemical that attracts macrophages, or they can release cell-killing toxins. B Lymphocytes Some even release interferon, a glucoprotein that inhibits cell After an infection, some remaining B lymphocytes remain growth. in contact with the antigen. This contact stimulates the Helper T cells bind to macrophages or B lymphocytes B lymphocyte to divide. The resulting clones can either have a and together produce a protein (interleukin) which stimulates memory of the antigen, called memory cells, or they become more production of both B and T lymphocytes. The plasma cells. Plasma cells generate antibodies, a type of resulting activity of T lymphocytes produces cell–mediated protein globulin called immunoglobulins. immunity. Principles of Pathophysiology 189 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Outcomes: Shock Syndrome with severe infections and during anaphylactic reactions, to name a few causes. Whenever a Paramedic approaches a patient, the quintessential The fi nal classifi cation of shock, obstructive shock, question in the Paramedic’s mind should be, “Is the patient in dealt with the physical impairment of forward blood fl ow shock?” Shock is of great signifi cance in emergency medicine. despite an effective pump, an adequate blood volume, and a While seemingly a simple question to answer, the defi nitions normal vasculature. Examples of obstructive shock include of shock are as different as the causes of shock. massive pulmonary clots, embolism, and a collapsed lung The common layperson defi nition of shock might be any (pneumothorax), which proceeds to crush the heart as well. condition that could potentially lead to death. In 1862, Samuel Recently a fi fth classifi cation has been added, endocrine Gross, a surgeon, described shock as the “rude unhinging shock. Endocrine shock recognizes the importance of of the machinery of life.” John Collins Warren made the hormones in maintaining homeostasis. The classic endocrine statement that shock is but “a momentary pause in the act of shock is hypoglycemic shock. death.” If asked to defi ne shock, a Paramedic might describe a Regardless of the etiology of shock or its classifi cation, state of hypoperfusion and inadequate tissue circulation, and all shock leads to cell injury. Cellular injury is generally owed this would be technically correct. Yet all of these defi nitions to ischemia, whether it is from a lack of oxygen (hypoxia) or are insuffi cient for the Paramedic’s purposes. glucose (hypoglycemia), the creation of infl ammation as well A better defi nition of shock is the “body’s inability to as free radical injury. provide the necessary substrates, oxygen and glucose, for example, to the cells for cellular life and the inability of the Pathophysiology of Shock body to maintain homeostasis.”33–36 This defi nition emphasizes the body’s complexity and The body’s homeostatic mechanisms engage at the fi rst sign interaction and the
singular importance of maintaining the of hemodynamic instability in an effort to maintain adequate viability of cells. The importance of identifying shock to a tissue perfusion. Chemoreceptors in the carotid arteries Paramedic’s practice cannot be overemphasized. Failure to and the medulla oblongata, as well as baroreceptors in the identify declining trends in the vital signs and subtle signs aortic arch and the carotid arteries, sense variations in blood of hypoperfusion can lead to missed rescues and increased pressure, oxygenation, and acidosis. This early hemodynamic morbidity and mortality. Shock deserves aggressive treatment instability activates the sympathetic nervous system and starts from the moment subtle signs are identifi ed. the body’s compensatory mechanisms, which compensate for shock.38–40 Classifi cations of Shock Henri Francois Le Dran, a French surgeon, fi rst originated Organs in Shock the term “choc,” meaning jolt or impact, when describing the The earliest organs to suffer in shock are the organs of the fatal syndrome that was associated with gunshot wounds. The gastrointestinal system. Hypoperfusion of the gut leads term was later expanded to include any lethal deterioration in to erosions of the stomach (erosive gastritis), irritations a patient’s condition. of the pancreas (pancreatitis), cessation of peristalsis As time progressed, additional etiologies besides trauma (paralytic ileus), and fi ne hemorrhage of the bowel (colonic for the shock syndrome were identifi ed. These included severe hemorrhage). infections and shock of a cardiac origin. In 1972 Hinshaw and The next set of organs—the liver, spleen, and kidneys— Cox advanced a universal system for inclusion of all causes enjoy the protection of the thoracic cage and are important of the shock syndrome. to short-term survival. These are often referred to as core The Hinshaw–Cox shock classifi cation included four organs. major categories. The fi rst, hypovolemic shock, included The fi rst organs to be affected by hypoperfusion are shock that arose from trauma (hemorrhagic shock) but also the paired kidneys which attempt to conserve volume and included other etiologies where there was a loss of circulating produce small amounts of urine (i.e., oliguria), sometimes blood volume.37 less than 0.5 mL/kg per hour. This conservation of volume is The next category of shock was cardiogenic shock, or mainly created by sympathetic stimulation and angiotensin shock of a cardiac origin. Cardiogenic shock could include that combine to create vasoconstriction. The net effect of diseases of the muscle (e.g., cardiomyopathy), diseases of prolonged hypoperfusion is acute renal failure (ARF) the coronary arteries, and diseases of cardiac conduction. secondary to tubular ischemia. Whatever the cause, there has to be a failure of the heart as The liver also fails, a condition called shock–liver, and is an effective pump. associated with massive ischemic changes that peak in one to Originally called vasogenic shock, the classifi cation was three days and resolve in three to ten days, provided the cause renamed distributive shock, a term that is more descriptive of the shock has been resolved.41,42 Systemically, the loss of of the problem of poor blood distribution. Distributive shock liver function leads to decreased blood proteins, especially included shock caused by the widespread vasodilatation seen albumin. 190 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Without albumin in the bloodstream to help maintain Eventually, a mismatch occurs between the increasing work colloidal osmotic pressure (COP), intravascular fl uids leak of breathing and the muscle impairment from ischemia, into the third space, creating total body edema or anasarca resulting in respiratory failure. (ana- – “throughout”; sacra – “fl esh”). Impaired gas exchange at the alveolar level causes an Blood proteins created from the liver are also critical to the infl ammatory response. The resultant leaky pipes of the coagulation cascade. Blood clotting factors are stimulated by alveolar capillaries spill into the alveolar space, fi lling it with the infl ammatory response. After initial blood clotting factors exudate that is appreciated as rales (crackles) by the Paramedic. are partially consumed by massive coagulation throughout the The combination of alveolar edema, from infl ammation and body, the remaining clotting factors are insuffi cient to protect pulmonary hemorrhage, from disturbed coagulation causes the body, a condition called disseminated intravascular adult respiratory distress syndrome (ARDS).47,48 coagulation (DIC). As time progresses, the resulting difference between the The paradox of DIC is that the patient’s body forms amount of lungs fi lled (alveolar ventilation) and the capillary clots where they are not needed, leading to localized tissue circulation (pulmonary perfusion) results in a mismatch, ischemia. The patient does not form clots where they are termed a V/Q mismatch. Blood, now unoxygenated, bypasses needed, which leads to hemorrhage. whole sections of the lung, a process called shunting, Splenic injury can be either direct parenchymal injury, producing systemic hypoxia from acute respiratory failure. such as blunt trauma, or cellular injury induced by ischemia that leads to impaired cellular or humoral immunity. Heart Subsequent dysfunction of the immune system leaves the Hypovolemia (from hemorrhage), vasodilatation (from patient prone to massive infections and life-threatening sepsis sepsis), and hypoxia all drive the heart to try to compensate (Greek – putrefaction). and maintain cardiac output, which equals stroke volume Sepsis involves the widespread activation of both the times heart rate. infl ammatory response as well as the coagulation cascade The primary mechanism is sympathetic stimulation, an and generally indicates the body’s failure to control the adrenergic surge which races the heart and increases the blood infection.28, 43–46 The subsequent massive shift of fl uids into pressure. Catecholamines, such as adrenaline/epinephrine, third space, with resulting anasarca, leads to hypotension, work to support the sympathetic nervous system. hypoperfusion, and widespread cellular ischemia. The sympathetic nervous system, in turn, starts to Systemic infections involving the whole body which lead constrict capillary sphincters, effectively closing off capillary to sepsis can cause multiple organ dysfunction syndrome beds, thereby shunting blood to the core organs. The order of (MODS), a failure of two or more organ systems. the shunting, sometimes called the pecking order of shock, MODS can also be caused by an uncontrolled infl ammatory starts with the fetus. The mother’s body will sacrifi ce the response from any disease. Diseases could include pulmonary fetus in order to save the mother; hence, the EMS axiom “to embolism, electrocution, and complications of childbirth, save the baby, you have to save the mother fi rst.” such as amniotic embolism. The alpha receptors of the sympathetic nervous During infection, MODS is the fi nal step in a process system then close down the skin, leading to pale, cool, and known as systemic infl ammatory response syndrome clammy skin. Then the gastrointestinal tract is closed down, (SIRS). The evolution of SIRS is localized infection leading producing nausea. Thereafter, the remaining core organs are to systemic infection leading to sepsis, then on to septic shock affected. and MODS. The sympathetic nervous system also stimulates the vital organs through the beta receptors. Adrenaline/epinephrine Shock: Vital Organs stimulates the beta receptors in the two lungs to breathe 2 The differentiation of decompensated and irreversible shock faster (tachypnea) and to breathe deeper (hypernea), may be academic for Paramedics because the timetable for increasing available oxygen to balance the oxygen demand recovery from ARF, DIC, MODS, and SIRS is often days of the tissues. or weeks. What may have more utility to the Paramedic is The heart’s beta receptors are stimulated by the 1 distinguishing shock that affects the vital organs: the lungs, sympathetic nervous system to increase the heart’s strength heart, and brain. of contraction (inotropy) as well as the rate of contraction (chronotropy). Lungs A factor working against the heart is the health of the The fi rst system to respond to hypoperfusion, to shock, is the coronary arteries. Coronary arteries can be narrowed by pulmonary system. Increased acid production from anaerobic chronic infl ammation or occluded by a blood clot (thrombus) respiration stimulates chemoreceptors in the carotid artery in a condition called acute coronary syndrome (ACS), and in the medulla oblongata. The resulting tachypnea (rapid leading to coronary ischemia. For this reason, and as a matter breathing) and hyperpnea (deep breathing) increases the of practice, ACS should be suspected as a comorbid factor in work of breathing for the muscles, particularly the diaphragm. high-risk patients with shock syndrome.49–51 Principles of Pathophysiology 191 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. In a corollary to ACS, increased demands upon the The leading theory of decompensated shock involves heart can induce tachydysrhythymias. Both tachycardias of the body’s production of acid, both carbonic acid (respiratory a ventricular origin and those of a supraventricular (supra- – acid) and lactic acid (metabolic acid). This acid accumulates, “above”; ventricles – Latin “belly” of the heart) do not permit called an acid load, to the point that tissues are acidotic. adequate ventricular fi lling time, affecting cardiac output The round muscles of the capillary sphincters, that have (CO SV X HR) adversely. The target heart rate should be until that moment been shutting down capillary beds and less than 150 beats per minute. shunting blood to core organs, can no longer remain closed Conversely, heart rates that are too slow can also reduce in an acidotic environment and the muscles relax. The result cardiac output, adversely affecting the patient’s hemodynamic of this relaxation is massive vasodilatation and a relative status. Vagally mediated bradycardias occur with head hypovolemia as blood leaves the central circulation for injuries, with neurogenic shock, in end-stage hemorrhage the periphery. shock, and under certain conditions with acute coronary Another theory, either working alone or in concert with syndrome. The resultant cardiac output is insuffi cient to meet the acid load theory, states that catecholamine depletion (loss demands and global ischemia occurs. The target heart rate of the neurotransmitters of the sympathetic nervous system) should be greater than 50 beats per minute (BPM). leads to relaxation of capillary sphincters and a rapid decline Finally, during sepsis or hemorrhagic shock, toxic in peripheral vascular resistance. circulating myocardial depressant factors cause myocardial The last theory suggests that there is a decrease in depression. Also, there is a decrease in the strength of sympathetic tone due to loss of perfusion to the central myocardial contraction (inotropy), which results in profound nervous system. The signifi cant fi nding in all three conditions hypotension as well. is the sudden loss of peripheral vascular resistance (closed capillary beds that shunt blood to the core) and subsequent Brain loss of blood pressure and perfusion to the core organs. The brain requires an almost steady state of perfusion to ensure adequate oxygen and glucose because neurons are Axioms of Shock Treatment extremely sensitive to any ischemia or hypoxia. The brain Paramedic care largely revolves around making a tentative needs a mean arterial blood pressure (MAP) of approximately fi eld diagnosis of shock syndrome based upon the symptom 50 to 60 mmHg to maintain adequate perfusion, and the complex and then directing treatments toward supporting the brain is highly adaptive in its efforts to maintain perfusion. patient’s body in its efforts to maintain homeostasis. Without adequate perfusion, suffi cient oxygen and/or The traditional approach to treatment follows the same glucose becomes unavailable and brain damage starts to line as assessment: airway, breathing, and circulation. The occur. therapeutic goals, following this ABC system, are universally Starting with irreversible damage in the cerebral cortex, applicable to all forms of shock and are as follows. ischemic changes will start to progressively affect all areas of First, it is important to provide and optimize the unloading the brain. Outwardly, the manifestations of these changes will of oxygen at the cellular level. The
provision of supplemental include symptoms of anxiety and urgency before descending oxygen, as needed, is essential in order to prevent hypoxia. into feelings of doom and confusion, with concomitant Perhaps more importantly, ventilation must be assured. combativeness followed by unconsciousness. Ventilation is critical in the acid–base balance mechanisms. Maintenance of cerebral perfusion is the target goal of Profound acidosis, respiratory or metabolic, not only shifts all Paramedics. Every effort is made to either support the the oxyhemoglobin curve, but also causes capillary sphincter brain directly, via oxygen and/or glucose administration, or relaxation and massive vasodilatation. to support auxiliary organs, such as the heart and lungs, in The next goal is the maintenance of an adequate order to support the brain. circulatory pressure for perfusion. The end goal is to maintain adequate cerebral perfusion pressure (CPP). Cerebral Decompensated Shock perfusion pressure is the difference between the mean arterial Decompensated shock is the end-stage of a series of pressure (MAP) and the intracranial pressure (ICP). Its range cumulative physiologic derangements typically involving one should be greater than 10 to 15 mmHg in adults. The normal organ system which goes on to affect the entire body. Affected CPP range is 70 to 100 mmHg, and when the CPP falls to are the infl ammatory system and the complement system, less than 50 mmHg acutely, or 70 mmHg for a prolonged leading to coagulation, and culminating in a pathological period of time, the brain suffers ischemia secondary to process called the shock syndrome. hypoperfusion.53–55 Key to survival from shock is the maintenance of In the out-of-hospital environment, it is diffi cult to perfusion to the vital organs, particularly the brain. The monitor some of these values. Therefore, Paramedics focus body, through the sympathetic nervous system, attempts to on monitoring the mean arterial pressure, when automated maintain perfusion, but reaches a break point where it fails.52 noninvasive oscillometric technique is available, or the pulse This failure has been attributed to several mechanisms. pressure (systolic pressure minus diastolic pressure) when 192 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. auscultatory manual sphygmomanometry is used. Then, starts to shrink and fragment and the cell undergoes the fi nal making a reasonable estimate of the ICP, the Paramedic processes of necrosis, a cascade of cellular changes that lead measures the MAP, typically in a range of 50 to 150 mmHg, to death. and estimates the CPP. After the lysosomal rupture, there is a free effl ux of The average ICP in a conscious and alert adult is calcium. The effl ux of calcium joins unused phosphate, approximately 10 to 15 mmHg. When the patient starts to from the remains of the ATP, and precipitates (i.e., falls become confused or drowsy (a Glasgow Coma Scale (GCS) out of solution) as a solid mass. At this point, the cell has of 13 to 15) then the ICP is approximately 20 mmHg. If the experienced irreversible hypoxic injury. Free oxygen patient’s GCS drops to 8 or less, then the ICP is approximately radicals, such as hydrogen peroxide, perforate the cell wall 30 mmHg. These values assume that the patient has not been membrane, making it defective. Finally, the combination of medicated with sedatives such as diazepam. mitochondrial damage, leading to the release of oxygen-free The importance of oxygenation and ventilation cannot radicals, and cytoskeletal damage, as seen on the cell wall be overemphasized enough. Hypoxia and hypercapnia membrane, cause the cell to fragment. (increased carbon dioxide) levels raise cerebral blood fl ow (CBF), which in turn raises intracranial pressure. Hypoxia Patterns of Necrosis is poorly tolerated and hypercapnia, in the form of carbonic acid (respiratory acid) with values greater than 45 mmHg When a mass of cells within a tissue or organ die there are should be avoided.56–60 characteristic changes that affect the remaining tissues. When Next, cardiac function should be maximized, in large muscle cells die, such as in myocardial infarction, the skeleton part to maintain the MAP in a range that supports adequate of the cell remains and the tissue remains fi rm.62,63 This state cerebral perfusion pressures. Typically, the fi rst objective is to is called coagulative necrosis. normalize the heart rate within the range of 50 to 150 BPM, Coagulative necrosis permits the dead cells to act with 60 to 80 BPM being optimal.61 as a scaffolding for other tissue, but the tissue no longer If the MAP remains suboptimal, then the use of functions. In the case of an acute myocardial infarction, vasopressors, such as dopamine, may be needed to support the affected portion of the muscle mass is considered to be the sympathetic nervous system. Vasopressors should be akinetic (without motion) and does not contribute to the titrated, keeping the CPP and the MAP in mind. heart’s work. The fi nal goal should be to redistribute blood fl ow to Cells that are largely lipid in content, such as the neurons ensure perfusion of vital organs. The kidneys help to maintain of the brain, simply liquify upon death and leave a pool in intravascular volume by reducing urine output and by their place. This process is called liquifactive necrosis. When utilizing the renin–angiotensin–aldosterone mechanism. This a patient experiences a series of small ischemic strokes, the mechanism helps ensure not only that there is reabsorption dead tissue undergoes liquifactive necrosis and leaves a small of sodium at the kidneys but also that adrenal epinephrine cavity, called a lacuane (Latin – lacuna). release increases. When tissues die from ischemia (e.g., the toes of a patient From a prehospital point of view, the need is to provide with diminished distal circulation secondary to complications optimal intravascular volume, particularly preload (the of diabetes mellitus), tissues undergo gangrenous necrosis. In volume of venous blood entering the heart during diastole), to this type of gangrene, called dry gangrene, the affected portion optimize stroke volume and cardiac output. This is achieved generally blackens and then simply falls off the body. through intravenous infusions of crystalloid- or colloid- If a secondary infection sets in, resulting in toxin- containing solutions. producing bacteria such as clostridium, then the condition These goals are not in treatment priority order. Rather, is called wet gangrene. Wet gangrene can lead to systemic they should be individualized to each patient. It should be infections and systemic infl ammatory response syndrome. clear that the overarching mission is to support the body while If the tissues involved are invaded by anaerobic bacteria, it tries to provide oxygen delivery to the vital organs. typically secondary to wounds, then gasses form and the gangrene is called gas gangrene. Gas gangrene must be Pathological Cell Injury aggressively treated with antibiotics, for without treatment gas gangrene is invariably fatal. Cellular injury, due to any of the previously discussed causes, can be reversible in the early stages. Reversible cellular injury is characterized with cellular swelling, from an accumulation Death of sodium and water, and changes in the cell wall membrane When the body’s compensatory mechanism fails to maintain called blebs, which have the appearance of bubble wrap homeostasis, and the cells of the body are irreversibly injured, commonly used for packing. fi rst the tissues, then the organs, and then the organism There comes a point when the lysosomes rupture, will die. Somatic death (soma—“body”) is the death of the emptying their contents of enzymes, which begin to autolysis organism. There are specifi c changes within the body that are proteins (i.e., denature the proteins). Eventually the nucleus associated with death, referred to as postmortem changes. Principles of Pathophysiology 193 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Initially, the patient experiences what is called 12 hours the entire body is rigid and afterwards (about 36 clinical death, the absence of vital signs. Clinical death hours after clinical death) the breakdown of the proteins is characterized by unresponsiveness to loud verbal and returns the body to a fl accid condition.64–66 painful stimuli, absence of breathing, and an absence of a The second mortis is livor mortis. Livor mortis, or central pulse. Barring any restrictions to the contrary, cardio- lividity, is a condition caused by relaxation of the vascular pulmonary resuscitation is usually indicated. bed and a pooling of blood in dependant portions of the Although a patient may be dead, it is possible for some body.67,68 All bleeding stops and fl uids start to drain from the tissues or organs to still be alive. These tissues and/or organs body. Often the most notable changes occur when the fl uids can be harvested for transplantation if the remaining living drain from the face, leaving gaunt cheekbones and a peaked tissue is removed quickly. nose with a beak-like appearance. In certain circumstances the patient is beyond The third mortis is algor mortis. Algor mortis is the resuscitation. These patients have undergone biological body’s natural cooling. As the body’s metabolic processes death. Biological death is associated with irreversibility, cease, so does the production of heat. On average, the body meaning that any resuscitative efforts would be futile. cools about 1ºF to 1.5ºF an hour until the body reaches room Biological death is usually associated with an absence of temperature, usually about 24 hours.69–71 brain activity, as evidenced by an electroencephalogram. The presences of the three mortis, as well as the The patient is termed brain dead. This defi nition has limited signs of clinical death, are often felt to be suffi cient to utility to Paramedics. withhold resuscitative efforts. Some EMS systems include Paramedics rely on other signs to determine biological other conditions, such as decapitation, incineration, and death. Initially, Paramedics confi rm clinical death and then hemicorporectomy (amputation at the waist) for inclusion in proceed to confi rm biological death. Paramedics use the fi ndings their criteria for obvious death. of the three “mortis” to help confi rm biological death. When the body has undergone putrefaction, it is The fi rst mortis (Latin – death) is rigor mortis, a stiffening assumed that the patient is dead. Putrefaction is a process of the muscles. Muscles stiffen following anoxia (a- – of decomposition within the body characterized by greenish “without”; ox – “oxygen”; -ia – “state”) from acid buildup in discoloration, secondary to hemolysis of blood, and slippage of the tissues that interferes with the release of the contractile the skin from the skeleton, due to breakdown of subcutaneous protein actin from myosin. Initially, the short muscles of the fat. Putrefaction starts between 24 and 48 hours after clinical body (e.g., the muscles of the jaw) are affected. In about death. 194 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. From birth to death, disease is a constant in the human condition. The study of pathophysiology, the study of the suffering of the human condition wrought by disease, provides Paramedics with an understanding on how to intercede and reduce suffering through medical therapeutics. Key Points: • Pathophysiology is the study of the causes of • Paramedics work to prevent hypoxia by supporting suffering in the normal human condition. the elements of the Fick principle. • Disease is an abnormal change in the function • Ischemia is the fi rst step in the pathogenesis of of cells, tissues, or
organs which in turn interferes hypoxia, followed by injury and then death. with homeostasis. • A toxin is defi ned as any substance capable • All diseases have an origin or etiology. of causing cell injury and death. • Each person has certain risk factors—some • Metabolites are the by-products of drugs and modifi able and some not—that make that person chemicals after they interact with a cell. more or less vulnerable to a disease. • Outside forces such as trauma, extreme • Modifi able risk factors are factors over which a temperature, radiation, and atmospheric pressures person has some control. can all cause injury to the body and its cells. • Nonmodifi able risk factors include family • During heat emergencies, the body has diffi culty (genetics), aging, and gender. compensating for excessive heat. • Prognosis is the expected outcome from a disease. • Burns can be caused by fi ve sources of • electromagnetic energy: thermal, radiation, light, Iatrogenic disease is produced as a consequence of radio, and electricity. medical intervention. • Nosocomial infection is death from a hospital- • A burn uses the method of either direct heat transfer or ionization as its mechanism of injury. acquired infection. • Pathogenesis is the origin and development of • Stochastic effects are the long-term complications a disease followed in a sequential order at the from exposure to ionizing radiation. Teratogenic cellular, biochemical, and molecular level. effects are the harmful effects of ionizing radiation on future generations. • Exacerbation of a disease may occur where the disease returns or fl ares up. In remission, the • Low temperatures, or hypothermia, lead to disease may be forced into a nonactive state. impaired cell walls. • Morbidity (the incidence of disease) and mortality • Barotrauma is physical damage to tissues due (death rate) are constantly monitored for trends. to pressure imbalances between those in the environment and those in the body. A common • Hypoxia is a low oxygen concentration in the body. condition found in the prehospital setting is a pneumothorax. • The Fick principle can be summed up in fi ve concepts: oxygenation, ventilation, respiration, • Either a defi ciency of nutrition or excess circulation, and cellular respiration. of nutrition can lead to metabolic disease. Principles of Pathophysiology 195 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • A genetic disorder is an abnormality in a person’s • The pecking order of shock is the order of shunting genes which may be passed on through future which begins with the fetus. The skin is then closed family generations. down, followed by the gastrointestinal tract. The • core organs are the last to be affected. Infectious diseases stem from prions, viruses, bacteria, fungi, protozoa, and helminthes, all of • In order to adequately perfuse the brain, a mean which are parasites. arterial blood pressure (MAP) of 50 to 60 mmHg • is needed. Cerebral perfusion pressure can be Skin is the body’s fi rst defense against physical, estimated from mean arterial pressure. chemical, and biological attacks. • • Decompensated shock is the body’s inability to Mucous membranes line the internal “tubes” of the maintain perfusion. body with mucus, engulfi ng any foreign predators. • • Attention to airway, breathing, and circulation is Various acids and saliva create another line of necessary in all forms of shock. defense. • Mechanical defenses include regurgitation, • Hypoxia and hypercapnia can result in increased intracranial pressure. defecation, menstruation, and urination. • The infl ammatory system defends the body when • Vasopressors such as dopamine are used to maximize cardiac function and to support the nonspecifi c, external defenders are weakened. sympathetic nervous system during times when the • Complement, coagulation, and kinen proteins mean arterial pressure is suboptimal. support infl ammation. • Cellular injury can be reversible. • The immune response is an internal, specifi c method of defense. • Cellular injury occurs in steps: swelling, cell wall changes, lysosome changes, cellular death. • The immune response consists of B lymphocytes (humoral immunity) and T cells (cell-mediated • Coagulative necrosis occurs when muscle cells die immunity). but remain fi rm. • Shock is the body’s inability to provide the • Liquifactive necrosis occurs when lipid cells liquify necessary substrates to the cells, which makes the when they die. body unable to maintain homeostasis. • Dry gangrene occurs when tissues die from • The Hinshaw-Cox shock classifi cation system ischemia. includes four categories: • Wet gangrene forms when secondary infections 1. Hypovolemic invade the ischemic tissues. 2. Distributive 3. Cardiogenic • Gas gangrene forms when the tissues are invaded 4. Obstructive by anaerobic bacteria. • The body begins compensating for the shock state • Somatic death is the death of an organism. by activating the sympathetic nervous system. • • Death occurs in stages. Multiple organ dysfunction is a failure of two or more organs due to total body systemic infection • Clinical death is when a person no longer has vital leading to sepsis. signs. • The Paramedic must identify shock affecting the • Biological death is the absence of any brain core organs. activity. 196 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. Defi ne pathophysiology. 8. Describe how hypoxia impacts cellular function 2. How is a tentative fi eld diagnosis helpful to the and the resultant consequences. Paramedic in the treatment of a patient? 9. Describe how trauma impacts cellular function 3. What is the difference between a disorder and and provide an example of resultant harm. a syndrome? 10. Initially, how does the body respond to an 4. List several modifi able and nonmodifi able risk infection on the skin? (Hint: Think of the three factors. cardinal signs.) 5. Choose one modifi able risk factor and discuss 11. What are the four classifi cations of shock using its impact on an associated disease. the Hinshaw–Cox descriptions? 6. What is meant by the term “iatrogenic disease”? 12. How does the sympathetic nervous system 7. What term is used to describe the crossover support the body in shock? from recovery toward death? Case Study Questions: Please refer to the Case Study at the beginning of 2. What type of death has been described with the the chapter and answer the questions below. absence of vital signs? 1. Describe the changes that occur in cells as 3. Why might some organs in a deceased individual perfusion ceases. still be viable for transplant? References: 1. Atkins D. Reports of Hospital Physicians and Other Documents 8. Plank LD, Hill GL. Sequential metabolic changes following in Relation to the Epidemic of Cholera of 1832. New York G. & induction of systemic infl ammatory response in patients C. & H. Carvill; 1832. with severe sepsis or major blunt trauma. World J Surg. 2. Guerrant RL, Carneiro-Filho BA, Dillingham RA. Cholera, 2000;24(6):630–638. diarrhea, and oral rehydration therapy: triumph and indictment. 9. Nafziger SD. Smallpox. Crit Care Clin. 2005;21(4):739–746, Clin Infect Dis. 2003;37(3):398–405. vii. 3. van der Hoek L. Human coronaviruses: what do they cause? 10. Parrino J, Graham BS. Smallpox vaccines: past, present, and Antivir Ther. 2007;12(4 Pt B):651–658. future. J Allergy Clin Immunol. 2006;118(6):1320–1326. 4. Cheng VC, Lau SK, Woo PC, Yuen KY. Severe acute respiratory 11. Fleming ST. Complications, adverse events, and iatrogenesis: syndrome coronavirus as an agent of emerging and reemerging classifi cations and quality of care measurement issues. Clin infection. Clin Microbiol Rev. 2007;20(4):660–694. Perform Qual Health Care. 1996;4(3):137–147. 5. Gu J, Korteweg C. Pathology and pathogenesis of severe acute respiratory syndrome. Am J Pathol. 2007;170(4):1136–1147. 12. Jefferson T, Foxlee R, Del Mar C, Dooley L, Ferroni E, 6. Kohl BA, Deutschman CS. The infl ammatory response to Hewak B, et al. Physical interventions to interrupt or reduce surgery and trauma. Curr Opin Crit Care. 2006;12(4):325–332. the spread of respiratory viruses: systematic review. Bmj. 7. Pallister I. Current concepts of the infl ammatory response after 2008;336(7635):77–80. major trauma: an update. Injury. 2005;36(1):227–229; author 13. Hart S. Using an aseptic technique to reduce the risk of reply 229–230. infection. Nurs Stand. 2007;21(47):43–48. Principles of Pathophysiology 197 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 14. 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Med Sci Sports of myocardial infarct (critical analysis of experimental studies). Exerc. 2007;39(9):1544–1553. Rev Esp Cardiol. 1971;24(6):575–584. 19. Tang W. Drug metabolite profi ling and elucidation of drug- 41. Seeto RK, Fenn B, Rockey DC. Ischemic hepatitis: clinical induced hepatotoxicity. Expert Opin Drug Metab Toxicol. presentation and pathogenesis. Am J Med. 2000;109(2):109–113. 2007;3(3):407–420. 42. Henrion J. Hypoxic hepatitis: the point of view of the clinician. 20. Park BK, Kitteringham NR, Maggs JL, Pirmohamed M, Acta Gastroenterol Belg. 2007;70(2):214–216. Williams DP. The role of metabolic activation in drug-induced 43. O’Brien JM, Jr., Ali NA, Aberegg SK, Abraham E. Sepsis. Am hepatotoxicity. Annu Rev Pharmacol Toxicol. 2005;45:177–202. J Med. 2007;120(12):1012–1022. 21. Prescott LF. Reactive metabolites as a cause of hepatotoxicity. Int 44. Hollenberg SM. Vasopressor support in septic shock. Chest. J Clin Pharmacol Res. 1983;3(6):437–441. 2007;132(5):1678–1687. 22. 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Rev Pathol. 2006;1:467–496. Clin North Am. 2007;91(4):701–712; xii. 29. Bahador M, Cross AS. From therapy to experimental model: a 51. Iakobishvili Z, Hasdai D. Cardiogenic shock: treatment. Med Clin hundred years of endotoxin administration to human subjects. North Am. 2007;91(4):713–727; xii. J Endotoxin Res. 2007;13(5):251–279. 52. Peitzman AB, Billiar TR, Harbrecht BG, Kelly E, Udekwu 30. Dombrowicz D, Capron M. Eosinophils, allergy and parasites. AO, Simmons RL. Hemorrhagic shock. Curr Probl Surg. Curr Opin Immunol. 2001;13(6):716–720. 1995;32(11):925–1002. 31. Surgical Wound Healing and Management. Stockholm: Informa 53. Meybohm P, Cavus E, Bein B, Steinfath M, Weber B, Hamann Healthcare; 2007. C, et al. Small volume resuscitation: a randomized controlled 32. Bryant R, Nix D. Acute and Chronic Wounds: Current trial with either norepinephrine or vasopressin during severe Management Concepts. St. Louis, MO: Mosby; 2006. hemorrhage. J Trauma. 2007;62(3):640–646. 33. Greenhalgh DG, Saffl e JR, Holmes JHT, Gamelli RL, Palmieri 54. Earle SA, de Moya MA, Zuccarelli JE, Norenberg MD, Proctor TL, Horton JW, et al. American Burn Association consensus KG. Cerebrovascular resuscitation after polytrauma and fl uid conference to defi ne sepsis and infection in burns. J Burn Care restriction. J Am Coll Surg. 2007;204(2):261–275. Res. 2007;28(6):776–790. 55. Alspaugh DM, Sartorelli K, Shackford SR, Okum EJ, 34. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Buckingham S, Osler T. Prehospital resuscitation with et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis phenylephrine in uncontrolled hemorrhagic shock and brain Defi nitions Conference. Crit Care Med. 2003;31(4):1250–1256. injury. J Trauma. 2000;48(5):851–863; discussion 863–864. 35. Robertson CM, Coopersmith CM. The systemic infl ammatory 56. Stiefel MF, Udoetuk JD, Spiotta AM, Gracias VH, Goldberg A, response syndrome. Microbes Infect. 2006;8(5):1382–1389. Maloney-Wilensky E, et al. Conventional neurocritical care and 198 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. cerebral oxygenation after traumatic brain injury. J Neurosurg. 64. Henssge C, Madea B, Gallenkemper E. Death time estimation in 2006;105(4):568–575. case work. II. Integration of different methods. Forensic Sci Int. 57. Young JS, Blow O,Turrentine F, Claridge JA, Schulman A. Is 1988;39(1):77–87. there an upper limit of intracranial pressure in patients with 65. Krompecher T. Experimental evaluation of rigor mortis. VIII. severe head injury if cerebral perfusion pressure is maintained? Estimation of time since death by repeated measurements Neurosurg Focus. 2003;15(6):E2. of the intensity of rigor mortis on rats. Forensic Sci Int. 58. Jeremitsky E, Omert L, Dunham CM, Protetch J, Rodriguez 1994;68(3):149–159. A. Harbingers of poor outcome the day after severe brain 66. Krompecher T. Experimental evaluation of rigor mortis. V. Effect injury: hypothermia, hypoxia, and hypoperfusion. J Trauma. of various temperatures on the evolution of rigor mortis. Forensic 2003;54(2):312–319. Sci Int. 1981;17(1):19–26. 59. Plurad D, Brown C, Chan L, Demetriades D, Rhee P. 67. Sannohe S. Change in the postmortem formation of hypostasis Emergency department hypotension is not an independent risk in skin preparations 100 micrometers thick. Am J Forensic Med factor for post-traumatic acute renal dysfunction. J Trauma. Pathol. 2002;23(4):349–354. 2006;61(5):1120–1127; discussion 1127–1128. 68. Bockholdt B, Maxeiner H, Hegenbarth W. Factors and 60. Manley G, Knudson MM, Morabito D, Damron S, Erickson circumstances infl uencing the development of hemorrhages in V, Pitts L. Hypotension, hypoxia, and head injury: frequency, livor mortis. Forensic Sci Int. 2005;149(2–3):133–137. duration, and consequences. Arch Surg. 2001;136(10): 69. Bisegna P, Henssge C, Althaus L, Giusti G. Estimation of the 1118–1123. time since death: sudden increase of ambient temperature. 61. Cotton BA, Snodgrass KB, Fleming SB, Carpenter RO, Kemp Forensic Sci Int. 2007;176(2):196–199. CD, Arbogast PG, et al. Beta-blocker exposure is associated with 70. Green MA, Wright JC. The theoretical aspects of the time improved survival after severe traumatic brain injury. J Trauma. dependent Z equation as a means of postmortem interval 2007;62(1):26–33; discussion 33–35. estimation using body temperature data only. Forensic Sci Int. 62. Baroldi G. Different morphological types of myocardial 1985;28(1):53–62. cell death in man. Recent Adv Stud Cardiac Struct Metab. 71. Henssge C. Death time estimation in case work. I. The rectal 1975;6:383–397. temperature time of death nomogram. Forensic Sci Int. 63. Baroldi G. Anatomy and quantifi cation of myocardial cell death. 1988;38(3–4):209–236. Methods Achiev Exp Pathol. 1988;13:87–113. Principles of Pathophysiology 199 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Understanding the origins of medical terminology • How prefi xes and suffi xes complement a root word’s meaning • The importance of standard abbreviations • Using topographic anatomy to accurately describe the body’s position and direction Case Study: As a new member to the agency’s quality improvement committee, the young Paramedic was assigned to review patient run records. He complained that many providers abbreviated terms haphazardly or misspelled medical or anatomical terms. Relying on his previous educational degree, he devised a game to teach medical terms, acceptable abbreviations, and terms to describe a body’s position or location. 200 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Medical Terminology 201 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW To communicate accurately and clearly to other healthcare providers, the Paramedic needs to use proper medical terminology. By examining common grammatical rules and the breakdown of words, terms can be used more effi ciently and accurately. A clear and accurate report includes a body’s location via topographic anatomy and the standard anatomical position. Medical Terminology suffi x, and a combining form. These parts can be thought of as the building blocks of medical terminology. While reading the medical literature, the fl edgling Paramedic A root word relates to the main idea and often describes may come across many unfamiliar terms and wonder about their the organ involved or the key symptom. For example, “cardi” meaning. These medical terms may appear diffi cult to learn and is Latin, meaning the heart. Learning root words means even more diffi cult to pronounce. One might even think one is memorizing these words.2 Fortunately, using prefi xes and/or learning a second language. That would actually be correct. suffi xes, many terms are built from a relative handful of root The language of medicine is called medicalese.1 By under- words (Table 12-1). Prefi xes and/or suffi xes build on a root standing a few rules of medical terminology, the Paramedic can word, giving it a new meaning. quickly learn a term’s meaning. The Paramedic’s vocabulary will When a prefi x complements a root, it is placed at expand and the Paramedic will become fl uent in medicalese. the beginning of the root (Tables 12-2 to 12-5). Take, for This chapter is an overview of terms and abbreviations commonly used by Paramedics. Table 12-1 Common Word Roots Used in EMS Medicalese Root Meaning Aden/o- Gland Medicalese has its roots in Greek and Latin words. In the Arthr/o- Joint ancient past these two dialects were common to all men of science, regardless of their national origins, and it was Card/o- Heart through this common medium that scientists were able to Cephal/o- Head share ideas. As medicine began to embrace science it also Cerebr/o- Cerebrum adopted the Latin and Greek vocabulary for the same pur- Cyst/o- Bladder pose, as a medium for communication. Encephal/o- Brain As time went on, medicine started to develop an exten- Enter/o- Intestines sive vocabulary (a lexicon) of medical expressions and ter- minology. The use of the medical lexicon continues to the Erythr/o- Red present day as a means for communication between medical Gastro/o- Stomach professionals of differing practice. Gloss/o- Mouth Hem/o- Blood Hepat/o- Liver Professional Paramedic Ile/o- Small intestine Lingu/o- Tongue The professional Paramedic, when mentoring Nephr/o- Kidneys healthcare students, should use the correct medical Neur/o- Nerves Onc/o- Cancer term and then follow that up with the common term. Oste/o Bone This helps teach medicalese as well as reinforces Ot/o- Ear medical terminology for the Paramedic. Path/o- Disease Ped/o- Children Ren/o- Kidneys Anatomy of Medical Terminology Splem/o- Spleen By following several basic rules, the Paramedic can under- Thromb/o- Clot stand and learn medical terminology. First, most medical Trach/o- Trachea terms consist of four parts: the root word, a prefi x and/or a 202 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 12-2 Partial List of Medical Prefi xes Table 12-4 Prefi xes of Position Prefi x Meaning Origin Prefi x Position a/- “without” Greek Ad/- “toward” ab/- “from”/“away from” Latin Ante/- “in front” ad/- “toward” Latin Anti/- “against” ambi/- “both” Greek Apo/- “separate” dextro/- “right side” Latin Circum/- “around” levo/- “left” Latin Contra/- “against” dia/- “throughout” Greek Dia/- “through” entero/- “within” Greek Dis/- “apart” hetero/- “different” Greek Dorso/- “back” homo/- “same” Greek Epi/- “upon” hyper/- “beyond”/“high” Greek Later/ “side” hydro/- “water” Greek Eco/- “out” hypo/- “beneath”/“low” Greek Endo/- “in” iatr/- “healer” Greek Exo/- “out” leuko/- “white’ Greek In/- “in” macro/- “large”/“long” Greek Opistho/ “backwards” mega/- “great” Greek Peri/- “around” micro/- “small” Greek Posto/- “after” neo/- “new” Greek Pre/- “in front” oligo/- “scant” Greek Pro/- “in front” orth/- “straight” Greek Re/- “again” osteo/- “bone” Greek Retro/- “backwards” oto/- “ear” Greek Trans/- “through” patho/- “suffering” Greek Ventro/- “in front” phlebo/- “vein” Greek pneumo/- “air” Greek poly/- “many” Greek pro/- “before” Latin tachy/- “rapid” Greek Table 12-5 Prefi xes of Numbers toc/- “childbirth” Greek Prefi x Amounts trans/- “across” Latin Aniso/- “unequal” Diplo/- “double” Hyper/- “above” Hypo/- “below” In/- “none” Table 12-3 Prefi xes of Color Iso/- “equal” Prefi x Color Macro/- “large” <Alb/- “White” Mega/- “large” Chlor/- “Green” Micro/- “small” Cirr/- “Yellow” Multi/- “many” Cyan/- “Blue” Oligo/- “few” Erthr/- “Red” Pan/- “all” Glauco/- “Grey” Poly/- “many” Leuk/- “White” Prim/- “fi rst” Melan/- “Black” Prot/- “fi rst” Medical Terminology 203 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. example, the word “pericardium.” The root, on the right, is When two or more roots are placed together, they must “cardi,” meaning heart. The prefi x, “peri,” means around. be separated by a vowel. Physicians often use these combin- Therefore, the term “pericardium” would mean “around the ing forms to explain a complex process. For example, the heart.” term “cardiomyopathy” has as its roots “cardia-,” meaning When a suffi x complements a root, it is placed after the
heart, “my,” meaning muscle, and “patho,” meaning disease. root and changes the meaning of the term (Tables 12-6 to The letter “O” separates the roots “cardia,” “my,” and “path.” 12-9). Using the term “myocarditis,” for example, and read- “Cardiomyopathy,” reading from right to left, means disease ing from right to left, the term “-itis” means infection, the of the muscle of the heart. term “cardi-” means heart, and the prefi x “myo-” means mus- cle. The term “myocarditis” means an infection of the cardiac Combining Forms muscle. Sometimes two root terms are used and a combining vowel must be used to make the two root terms distinguishable but connected (Table 12-10). Typically the letter “o” is used. For Table 12-6 Partial List of Common Suffi xes example, “cardi-: “o” “-logy” is the study of the heart. for Diagnosis However, if the root word ends with a vowel, then it is Suffi x Meaning Used Meaning unnecessary to use a combining vowel. For example, combin- -algia Pain Neuralgia Nerve pain ing “cyst-” with “-itis” would be “cystitis,” not “cystoitis.” -cele Swelling Hydrocele Water cyst Plural Forms -emia Blood Anemia Without blood To establish a plural meaning from a singular word, the -ectasis Expansion Bronchiectasis Enlarged bronchi Paramedic only needs to apply a few rules (Table 12-11). For -dynia Pain Angiodynia Pain with IV example, if the singular word ends with “ax” then remove the -edema Swelling Laryngoedema Swollen throat “ax” and replace it with “aces” to make the meaning of the -gen Begin Carcinogen Cancer causing word plural. -iasis Formation Cholelithiasis Gall stone -itis Infl ammation Pharyngitis Sore throat Table 12-8 Diagnostic Suffi xes -megaly Enlargement Cardiomegaly Enlarged heart for Medical Instruments -oma Tumor Carcinoma Cancer Suffi x Meaning Used -pathy Disease Myopathy Disease of muscle -gram Record Electrocardiogram -phasia Speech Aphasia Speechless -graph Recording tool Electrocardiograph -plegia Paralysis Hemiplegia Help paralysis -meter Measurement tool Capnometer -phobia Fear Agoraphobia Fear of places -scope Instrument Laryngoscope -rrhagia Flow Dysmenorrhagia Excessive menstrual fl ow -rrhage Burst Hemorrhage Bleeding Table 12-9 Medical Suffi xes -rrhea Discharge Otorrhea Discharge from ear Suffi x Meaning Used -scopy Examine Bronchoscopy Examine the bronchi -iac Affl icted Hemophiliac -spasm Contraction Bronchospasm Contraction of -ia Unhealthy Anesthesia bronchi -ism Condition Alcoholism -ist Expert Cardiologist Table 12-7 Surgical Suffi xes Suffi x Meaning Used Table 12-10 Examples of Combining Terms -clasis Breakdown Osteoclasis Root Suffi x Use -ectomy Removal Appendectomy Cardiology -ist Cardiologist -centesis Tap or drain Pericardial centesis Enter -lysis Enterolysis -lysis Loosen/divide Fibrinolysis Bronchi -scopy Bronchoscopy -plasty Formation Rhinoplasty Lith -tripsy Lithotripsy -stomy Opening Tracheostomy Ortho -pnea Orthopnea -tripsy Crush Lithotripsy Trachea -tomy Tracheotomy -tomy Cut Tracheotomy Trachea -stomy Tracheostomy 204 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 12-11 Making Plural Forms of Terms Spelling Singular Form Plural Form Many medical terms have a similar sounding constituent but -a add -e are spelled differently. Spelling them correctly can be diffi cult, -ax drop –ax, add -aces especially if the Paramedic hears the word spoken and then must -en drop –en, add -ina spell it. For example, the “si” sound can be spelled with “psy,” as -is drop –is, add -es in “psychiatry,” “sy” as in “symptom,” or “cy” as in “cystitis.” To avoid errors and confusion the term should be spelled -ix drop –ix, add -ices correctly. When in doubt, the Paramedic should consult a -sis drop –sis, add -ses medical dictionary for the correct spelling. -um drop –um, add -a -us drop –us, add -i -x drop –x, add -es Professional Paramedic -y drop –y, add -ies While speaking medicalese is an expectation among Reading Medical Terminology medical professionals, it may be inappropriate to use medical terminology with a patient.3, 4 Use When both a suffi x and a prefi x are used in a word, then the suffi x is read fi rst, then the prefi x, and then the root (read last, appropriate common language to interview or explain fi rst, and middle). For example, the term “hypoglycemia” has interventions to the patient. “gly” as its root and “gly” refers to glucose. To read this term correctly, fi rst read the suffi x, “-emia,” referring to blood, then “hypo-,” meaning low, and then “gly.” Together the term Abbreviations means blood with low sugar. The basis for abbreviations is brevity, meaning short and con- All medical terms are interpreted with the suffi x read cise. Paramedics strive to be short and concise in their medi- fi rst, prefi x next, and root last (last, fi rst, and middle). This cal writing. Correct use of abbreviations can help with that concept is diffi cult for those Paramedics who have been edu- process, provided that the meaning of the communication is cated to read from left to right. It takes practice to become not lost in the process. For example, the abbreviation “Ca” profi cient at deciphering medical terminology. With a little can mean both “calcium” and “cancer.” practice, the Paramedic rapidly becomes profi cient at learn- Emergency physicians, allied healthcare professionals, ing the meaning of these terms and can incorporate them into EMS managers, educators, and attorneys are just a few of the the documentation. people who may read a PCR. Without a common translation, abbreviations can become meaningless to the reader, and the Pronunciation PCR loses its potency as a vehicle for communication. Proper pronunciation of medical terms is key to understanding. As a result of common medical errors, some abbrevia- While verbalizing these terms may seem diffi cult, dissection tions are no longer accepted.5 For example, the abbreviation of the term to its constituent parts (prefi x, root, and suffi x) and for morphine sulfate is MSO . Unfortunately, during tran- 4 careful articulation will likely produce satisfactory results. scription, the MSO may be confused with MgSO , which 4 4 Often other medical professionals will help to correct is magnesium sulfate. For this reason clinicians, including errors in infl ection or in pronunciation. By repeating the cor- Paramedics, should spell out MSO as morphine in order to 4 decrease confusion and prevent errors.6-9 rected pronunciation, the Paramedic helps to commit the term to memory. To help resolve the problem, many EMS agencies have a list of accepted abbreviations (Table 12-12). This list is usu- ally gleaned from a similar list of abbreviations used by the Cultural / Regional differences healthcare professionals at the local hospital(s). Paramedics should obtain and utilize their agency’s abbreviation list. As with all languages, there are some regional dialects that make the same word sound different depending Street Smart on the region. Whenever there is a question, the term should be spelled out. This is particularly important in Whenever there is a possibility that an abbreviation radio communications where two words with a similar might be unclear to another healthcare provider, then pronunciation can have very different meanings (for the word should be spelled out. The maxim is “when example, “hypo” and “hyper”). in doubt, spell it out.” Medical Terminology 205 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 12-12 List of Common Abbreviations /a Before DOE Dyspnea on exertion AAA Abdominal aortic aneurysm DPT Diphtheria, pertussis, tetanus AAL Anterior axillary line DTs Delirium tremens AB Abortion Dr. Doctor ABCs Airway, breathing, circulation Dx Diagnosis Abd Abdominal ECG/EKG Electrocardiogram AC Antecubital fossa EEG Electroencephalogram ACLS Advanced cardiac life support EENT Ears, eyes, nose, throat ADL Activities of daily living EID Esophageal intubation detector AED Automatic external defi brillator EJV External jugular vein A fi b Atrial fi brillation EMD Emergency medical dispatch AIDS Acquired immune defi ciency syndrome EMS Emergency medical service ALS Advanced life support EMT Emergency medical technician AMA Against medical advice EPI Epinephrine AMI Acute myocardial infarction Eq Equivalents AMS Altered mental status ET Endotracheal tube A/O Alert and oriented ETA Estimated time of arrival A/P Anterior–posterior EtOH Ethyl alcohol ASA Aspirin °F Fahrenheit ASHD Arteriosclerotic heart disease FU Follow up ARDS Adult respiratory distress syndrome FUO Fever of unknown origin ATV Automatic transport ventilator Fx Fracture AV Atrioventricular GCS Glasgow coma scale BAC Blood alcohol content GI Gastrointestinal BBB Bundle branch block GSW Gun shot wound BG Blood glucose gtt Drops Bid Twice per day GU Genitourinary BLS Basic life support GYN Gynecologic BM Bowel movement H Hour BP Blood pressure HBO Hyperbaric oxygen Bpm Beats per minute HBV Hepatitis B virus BSA Body surface area HIV Human immunodefi ciency virus BVM Bag valve mask h/o History of Bx Biopsy HPI History of the present illness /c With HTN Hypertension C Celcius/Centigrade Hx History Ca Cancer I&D Incision and drainage CABG Coronary artery bypass graft ICP Intracranial pressure CAD Coronary artery disease ICU Intensive care unit C/C Chief complaint or concern IDDM Insulin dependent diabetes mellitus cc Cubic centimeters IM Intramuscular CCU Critical care unit IO Intraosseous CHF Congestive heart failure IPPB Intermittent positive pressure breathing CNS Central nervous system IUD Intrauterine device c/o Complained of IV Intravenous CO Carbon monoxide IVP IV push (medication) CO2 Carbon dioxide JVD Jugular venous distention COBS Chronic organic brain syndrome KED Kendrick extrication device COPD Chronic obstructive pulmonary disease kg Kilogram CP Chest pain KVO Keep vein open CPR Cardiopulmonary resuscitation L Liter CSF Cerebrospinal fl uid Lac Laceration CSM Circulatory/sensory/motor function LLQ Left lower quadrant CT Computerized tomography LMP Last menstrual period CVA Cerebral vascular accident LPN Licensed practical nurse D5W 5% Dextrose LOC Loss of consciousness or level of consciousness d/c Discontinue LR Lactated ringers solution DKA Diabetic ketoacidosis LUQ Left upper quadrant DM Diabetes mellitus mcg Microgram DOA Dead on arrival MCI Multiple casualty incident DOB Date of birth MCL Modifi ed chest lead 206 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 12-12 (continued) MD Physician RMA Refused medical assistance mEq Milliequivalents RN Registered nurse mg Milligram ROM Range of motion MI Myocardial infarction RUQ Right upper quadrant mL Milliliter r/o Rule out mm Millimeter ROM Range of motion mmHg Millimeter Mercury RR Respiratory rate MRI Magnetic resonance imaging Rx Prescription or treatment MVA Motor vehicle accident /s Without MVC Motor vehicle collision SSS Sick sinus syndrome MVP Mitral valve prolapsed S1 First heart sound N/A Not applicable S2 Second heart sound NAD No apparent distress S3 Third heart sound NC Nasogastric S4 Fourth heart sound NKA No known allergies SA Sinoatrial NPA Nasal pharyngeal airway SIDS Sudden infant death syndrome NPO Nothing by mouth SE Sublingual NRB Nonrebreather face mask SOB Shortness of breath NS Normal saline SQ/SC Subcutaneous NSR Normal sinus rhythm SSCP Substernal chest pain NTG Nitroglycerine STD Sexually transmitted disease N/V Nausea and vomiting STAT Immediately O2 Oxygen SVT Supraventricular tachycardia OB/GYN Obstetrics/gynecology TB Tuberculosis OD Overdose TIA Transient ischemic attack OPA Oral pharyngeal airway Tid Three times a day OR Operating room TKO To keep open OTC Over-the-counter TOT Turned over to oz. Ounce Tx Treatment or traction P Pulse URI Upper respiratory infection /p After UTI Urinary tract infection PA Physician assistant VD Venereal disease PAC Premature atrial contraction VS Vital signs PAT Paroxysmal atrial tachycardia VF/VFib Ventricular fi brillation PCN Penicillin VT/VTach Ventricular tachycardia PE Physical exam w/ With PEA Pulseless electical activity WNL Within normal limits PEARL Pupils equal and
reactive to light w/o Without PIAA Personal injury auto accident WPW Wolff-Parkinson White Syndrome PID Pelvic infl ammatory disease y/o Year old PJC Premature junctional contraction xport Transport PMH Past medical history PND Paroxysmal nocturnal dyspnea Approved Symbols PO By mouth ♂ Male Pm As needed ♀ Female PSVT Paroxysmal supraventricular tachycardia Equal Pt Patient Positive PVC Premature ventricular contraction Negative Q Every > Increase Qd Every day < Decrease Qh Every hour Change Qid Four times a day R Right Qod Every other day L Left RLQ Right lower quadrant Times or multiply Medical Terminology 207 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Topographic Anatomy divides the body into upper and lower. With these reference points in place, the Paramedic can more accurately describe a Medical terminology includes a number of positional and specifi c location on the body using topographic anatomy. directional terms (Tables 12-13 to 12-16). These terms direct a In every case, the assumption is that the patient is stand- Paramedic to an area of the body or the organs involved. To serve ing in the standard anatomical position; that is to say, the as a reference, the body is divided into three planes. The frontal patient is standing upright, eyes forward, hands to the side plane divides the body in half front from back. The sagittal plane with the palms of the hand forward and feet together. divides the body from left to right, whereas the transverse plane Table 12-13 Directional Terms Table 12-15 Terms Describing Patient Positions Term Plane Relation Description Term Description Caudal Transverse Inferior Toward the feet Prone Lying on belly Cephalic Transverse Superior Toward the head Supine Lying on back Dorsal Frontal Inferior Toward the back Left lateral Lying on left side Ventral Frontal Anterior Toward the front Fowlers Sitting up right Trendelenburg Supine with legs elevated Sims Side lying knee to chest Table 12-14 Relational Terms Table 12-16 Terms Describing Movement Term Description Term Description Apex Top of the pyramid Abduction Away from midline Base Bottom of the pyramid Adduction Toward the midline Distal Away from the structure Circumduction Circular motion Lateral To the side of the structure Dorsifl exion Backwards Medial Toward the structure Eversion Turn outward Deep Away from the surface Extension Straightening Superfi cial Toward the surface Flexion Bending Inversion Turn inward Pronation Turn downward Supination Turn upward 208 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Abbreviations and medical terminology, when used inappropriately, only serve to confuse the message. With practice and attention to detail, the Paramedic can learn medicalese and become conversant with fellow healthcare professionals. Key Points: • Medicalese has its roots in Greek and Latin words. • Terms should be spelled correctly. Use a medical • dictionary for the correct spelling. Medical terms may consist of four parts: the root word, a prefi x and/or a suffi x, and a combining form. • Paramedics should use appropriate and accepted • abbreviations. A prefi x complements a root; it is placed at the beginning of the root. • The body can be divided up into three planes: • frontal, sagittal, and transverse planes. A suffi x complements a root; it is placed behind the root. • The standard anatomical position is when a patient • is standing upright, eyes forward, hands to the Sometimes when two root terms are used a side with the palms of the hand forward, and feet combining vowel must be used to make the two root together. terms distinguishable but connected. • • Using the three planes and standard anatomical All medical terms are interpreted with the suffi x position, the Paramedic can use topographic being read fi rst, then the prefi x, and then the root anatomy to describe a specifi c location. (last, fi rst, and middle). Review Questions: 1. What are the origins of medical terminology? 4. List several examples of commonly accepted 2. Explain how a prefi x complements a root medical abbreviations. word’s meaning. 5. What is standard anatomical position? 3. Explain how a suffi x complements a root word’s meaning. Case Study Questions: Please refer to the Case Study at the beginning of the contained misspelled words, as chapter and answer the questions below. well as inappropriately used words or 1. Why would the correct use and spelling of abbreviations? medical terms be of concern to the quality 3. Using topographical anatomy, describe a bruise improvement committee? located on the left arm between the elbow and 2. How would you perceive the care given by a wrist on the same side of the arm as the palm of Paramedic if the only documentation available the hand. Medical Terminology 209 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. References: 1. Waife SO. Medicalese. Miss Valley Med J. 1958;80(1):10–11. 6. JCAHO says: watch your p’s and q’s. Nursing. 2004; 34(3): 55. 2. Dzuganova B. Word analysis—a useful tool in learning 7. Brunetti, L., J. P. Santell, et al. The impact of abbreviations on the language of medicine in English. Bratisl Lek Listy. patient safety. Jt Comm J Qual Patient Saf. 2007; 33(9): 576-83. 1998;99(10):551–553. 8. Scalise, D. Clinical communication and patient safety. Hosp 3. Williams N, Ogden J. The impact of matching the patient’s Health Netw. 2006; 80(8): 49-54, 2. JCAHO says communication vocabulary: a randomized control trial. Fam Pract. problems were the leading root cause of sentinel events in 2005. 2004;21(6):630–635. The reasons are manifold: a harried environment, a hierarchical 4. Zeng Q, Kogan S, Ash N, Greenes RA. Patient and clinician staffi ng system and illegible handwriting, to name a few. This vocabulary: how different are they? Medinfo. 2001;10(Pt 1): gatefold examines the scope of the problem, including data and 399–403. risk factors, and offers some strategies for improvement. 5. Nagel KR. Prohibited abbreviations. Am J Health Syst Pharm. 9. National Patient Safety Goal on abbreviations clarifi ed, 2005;62(15):1559. implementation revised. Jt Comm Perspect. 2003; 23(12): 14-5. 210 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. C ommunication with and assessment of the patient is essential to every encounter. Through this process, the Paramedic gains the information needed to form a differential diagnosis and develop an appropriate treatment plan for the patient. These seven chapters provide the Paramedic with the base skills to obtain an effective history and perform a thorough physical examination. • Chapter 13: Scene Size Up and Primary Assessment • Chapter 14: Therapeutic Communications • Chapter 15: History Taking • Chapter 16: Physical Examination and Secondary Assessment • Chapter 17: Clinical Decision Making and Teamwork • Chapter 18: Communications • Chapter 19: Documentation 211 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Thorough scene size-up • An algorithmic approach to carry out the primary assessment • Determining level of consciousness, airway, breathing, and circulation status plus treatment of life-threatening conditions • The value of vital signs Case Study: Two Paramedic crews were called to the scene of a motor vehicle versus bicycle collision. When the fi rst crew arrived, they notifi ed dispatch that there was a teenager, down on the ground, apparently unresponsive; the driver of the pickup truck was complaining of shortness of breath; and an elderly gentleman was leaning against a tree complaining of chest pain. A witness stated that the bicycle darted out from between two parked cars. She did not see an airbag deploy in the truck and didn’t believe that the truck was moving very fast as it had been stopped for a traffi c signal just before the incident. As soon as the bike was struck, she said the elderly gentleman yelled that he was his grandson and immediately slumped down against a tree. 212 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Scene Size-Up and Primary Assessment 213 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW An experienced care provider at any level may take only minutes to complete a primary assessment. However, in those moments he or she may acquire pertinent information that will dictate further care. This chapter outlines the methods used to carry out this valuable assessment. Paramedic safety and patient safety are paramount when arriving on-scene and treating the patient. Knowing how to size-up a scene reduces the risk for injury or exposure and offers an organized way to assess environmental conditions, type and number of patients, and need for additional resources. Each component is vital in determining any life-threatening conditions that require immediate interventions. Patient Assessment patients, and need for specialized resources to assist in scene management. Some of this information may be obtained, and Patient assessment is required as part of every patient con- some at least anticipated, before the Paramedic arrives at the tact. During a medical emergency, time is of the essence— scene. What was the dispatch information? Did the dispatch environmental conditions may be less than ideal, sometimes give any hints of possible scene hazards, such as fi re or haz- even dangerous, and the sights and sounds stressful. In these ardous materials? What is the area like that the Paramedic situations the Paramedic must quickly and thoroughly form is responding to? Is it possible that there may be multiple an impression of the patient’s medical condition and assess patients or the need for specialized rescue services? All of the need for any additional resources, all while continuously these issues should be considered while on the way to the assessing the safety of the scene. This requires both the sci- scene. ence of medicine and the art of crisis and resource manage- ment. Regardless of skill level,
an algorithmic approach to Scene Safety these situations will assist the Paramedic to provide assess- ment in the safest, most effi cient, most effective, and most The fi rst step in any patient assessment is to assure that the consistent manner. scene is safe to enter. Scene safety assures the Paramedic’s Initially, the Paramedic must assess the scene to evaluate well-being. An injured Paramedic is not helpful to anyone. its safety and determine the need for other resources. Next, Likewise, unsafe scenes must never be entered. The Para- she must determine the general problem, and then perform a medic must continually ask if the conditions remain safe primary assessment of the patient (Figure 13-1). enough for continued work on the scene. It must be remem- The goal of the primary assessment is to fi nd and man- bered that even dangerous scenes may initially appear safe age any life-threatening injuries or conditions the patient and that conditions may deteriorate quickly. might have by assessing for, and correcting, if possible, any When assessing scene safety, the fi rst priority should threats to airway, breathing, and circulation. Once life threats always be that of personal protection.4–7 Many of the scenes have been assessed for and managed within the skills of the where EMS is called have the potential for danger. Vehicular Paramedic, he/she identifi es patients in need of immediate crashes, industrial accidents, and rescue scenes all expose the transport.1–3 Paramedic to potential injury from moving vehicles, sharp High priority patients are generally transported surfaces, pinching or crushing hazards, and electric shock or immediately, with further assessment being performed en exposure to fi re. route. The assessment of low priority patients is typically Certain situations involve hazardous materials, toxic conducted in a more focused manner while remaining on the gasses, or an environment without adequate oxygen. These scene. If time and personnel allows for it, a full set of vital can lead to injury or death. Crime scenes and calls for assis- signs can be obtained at any point during the primary assess- tance to emotionally disturbed persons always carry the risk ment. This process should, however, never interfere with the for violence. performance of the primary assessment. Often Paramedics are injured at scenes by far less obvi- ous hazards. Falls from slips on unstable surfaces, ice, pud- Scene Size-Up dles, and unseen trip hazards are quite common. Domestic animals, often agitated by the unusual and chaotic activities Every scene that the Paramedic responds to requires an assess- at emergency scenes, have also been known to injure emer- ment of safety, environmental conditions, type and number of gency personnel. 214 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Scene size-up Initial assessment Focused history Focused history and and physical exam physical exam TRAUMA MEDICAL Mechanism Mental of injury status Significant Not Responsive Unresponsive significant Rapid trauma Focused trauma HPI Rapid assessment assessment SAMPLE physical exam Vital Vital Focused Vital signs signs physical exam signs Vital HPI SAMPLE SAMPLE signs SAMPLE Transport Transport Transport Transport Detailed physical exam Ongoing assessment Figure 13-1 Algorithm of scene size-up and primary assessment. Body Substance Isolation infection.15,16 For an in-depth review of infection control tech- niques and exposure management, please refer to Chapter 3. Along with the visible safety hazards at an emergency scene, one should always remember the unseen potential for expo- sure to blood- and airborne pathogens. The Paramedic should apply body substance isolation (BSI) precautions to all patient Street Smart encounters regardless of the suspected diagnosis. BSI cre- ates a barrier between the Paramedic and possibly infectious For hands that are not visibly soiled, waterless hand materials through the use of gloves, masks, gowns, and eye protection (Figure 13-2).8–11 Gloves should always be worn cleaner is a good option. The Paramedic should wash when the Paramedic is interacting with body fl uids, non- with soap and water as soon as time and location intact skin, and moist body surfaces.12–14 permit. The use of a mask and eye protection or a face shield to protect the eyes, nose, and mouth is imperative whenever performing procedures or patient care activities that might generate splashes or sprays of blood or body secretions. A gown should also be worn to protect skin and prevent soil- Mechanism of Injury ing of clothing whenever the possibility of splashes of blood or Nature of Illness or body secretions exists. After assuring the safety of the scene, the next step is to Proper hand washing is one of the most important assess the patient’s mechanism of injury (MOI) or the things that the Paramedic can do to prevent the spread of patient’s nature of illness. For patients who have experienced Scene Size-Up and Primary Assessment 215 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 13-2 Personal protective equipment for body substance isolation includes gloves, gown, goggles, and a mask. traumatic events, the Paramedic must determine the MOI by The Primary Assessment obtaining information from the patient, family, or bystand- ers, as well as from an inspection of the scene. The MOI is After assuring the scene is safe to enter and making a scene the instrument or event which resulted in harm to the patient. size-up, the Paramedic can begin the primary assessment. Often, the MOI is obvious, such as a motor vehicle collision The primary assessment—the fi rst evaluation performed on (MVC) or a fall. Sometimes, however, it is not so clear. every patient—is the beginning of “hands on” patient assess- When in doubt, it is safest to assume that the condition ment and is performed to address life-threatening problems. is related to trauma and take appropriate precautions to avoid The primary assessment involves forming a general worsening possible injuries which might not be immediately impression of the patient, assessing the patient’s mental obvious (Figure 13-3). status, airway, breathing, and circulation and determining When assessing the MOI, remember to note the environ- which patients require immediate transport. Any immedi- mental surroundings so as to make a report of these fi ndings ate life threats found in the primary assessment must be to hospital staff who are unable to determine these conditions addressed as they are discovered and then reassessed on a for themselves. The nature of illness is essentially the history regular basis. of present illness. Number of Patients General Impression Every scene must be investigated to determine the actual num- The fi rst step of the primary assessment is to integrate the ber of patients.17 Although this probably seems intuitive, it is not observations obtained in the scene survey into a general unusual to have “tunnel vision” and focus efforts immediately impression of the patient’s condition. The Paramedic should on caring for the fi rst patient found rather than determining if concentrate on the patient and ask himself if this patient there are more patients. It is essential to make a determination appears very ill or severely injured. Experienced providers of how many patients will need care on the scene. often can identify critically ill patients within a few seconds If there are more patients than the responding units can of entering the room (Figure 13-4). This initial impression effectively care for, then a mass casualty plan should be ini- has been called “the look test” or “gut impression” by some tiated. Any additional resources required should be called experienced clinicians attesting to the speed at which these for. In these situations, it is important for the fi rst respond- providers can determine through observation if a patient is ing unit to establish command and begin triage. A Paramedic critically ill or not. Some demographic information can also is less likely to organize an adequate response of additional be obtained by observation, and the Paramedic should note resources if directly involved in patient care activities. the patient’s approximate age, sex, and race. 216 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 13-3 Questionable mechanism of injury: The Paramedic must assume a traumatic cause until proven otherwise. Mental Status Completely normal mental status is considered to be a good indication of adequate perfusion, and therefore an important parameter to evaluate in the primary assessment.18 Upon approaching a patient, it is often fairly easy to determine a patient’s general state of consciousness. Most of the time patients will be awake and aware of the Paramedic’s approach. Of course, some patients will not be awake upon the Paramedic’s arrival, and it is important to try to determine how impaired their mentation may be. Even when a patient appears alert, it is also important to try and quantify how oriented he is to his surroundings. The abbreviation AVPU is often used to report the patient’s general level of consciousness. A stands for alert, V stands for responsive to voice, P stands for responsive to pain, and U stands for unresponsive.19 Alert If the patient’s eyes are open and he appears aware of the Paramedic, then he is referred to as alert. Any patient deter- mined to be alert should have the level of consciousness fur- ther qualifi ed by eliciting how well the patient is oriented. To determine orientation, the Paramedic commonly asks three questions relating to person, place, and time. After introductions to the patient, ask him what his name is, where he is, and what the date is. If he can correctly answer all three questions, then he is determined to be alert and oriented to person, place, and time or “alert and oriented times three.” The statement “alert and oriented times three” is often abbreviated as A&O. If the patient cannot correctly answer all three questions, then he is determined to be disoriented. It is useful for the purpose of reassessment to report which Figure 13-4 Forming a general impression. questions the patient cannot answer upon primary evaluation. Scene Size-Up and Primary Assessment 217 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. For example, the patient who is oriented to person, but unsure used for medical patients or a jaw thrust for trauma patients may of place or time, would be reported as “alert and oriented to relieve the obstruction and open the airway (Figure 13-6). Once person only.” open, the airway must be reassessed to make sure it is clear. Listen for noises such as gurgling, which may indicate fl uid in Voice the airway, or snoring or high pitch whistling, which may indi- If the patient does not seem to be awake upon approach, cate continued obstruction of the airway. If there is fl uid in the the Paramedic should attempt to awaken the patient before airway, suction should be used to evacuate it. making physical contact with him. Before closing in on the If the airway remains obstructed after positioning and patient’s personal space, the Paramedic should say in a loud suctioning,
then an attempt at repositioning the airway is clear voice, “Sir, can you hear me?” If the patient opens his warranted. If repositioning does not resolve the obstruction, eyes to the Paramedic’s voice, but shuts them again, he is then the Paramedic should consider the possibility that there determined to be responsive to voice. may be a foreign body in the airway. This obstruction must be relieved before continuing with the assessment. Pain If repositioning the airway only temporarily relieves If the patient does not awaken or respond to the Paramedic’s the obstruction, or there continues to be a partial obstruc- voice, the Paramedic should attempt to awaken him with tion, consider the use of an airway adjunct. As a general physical stimuli. The Paramedic should fi rst fi rmly tap him rule, it makes sense to start with less invasive devices such on the shoulder while asking in a loud clear voice, “Can you as oropharyngeal or nasopharyngeal airways. However, if a hear me?” If this does not arouse the patient, a more noxious less invasive device does not maintain the patency of the air- physical stimuli must be used. way, the Paramedic must consider a more defi nitive method Several techniques can be used to elicit a painful stimulus. to control the airway. One common technique is the sternal rub. The sternal rub is The Paramedic may need to consider immediate endotra- performed by applying the knuckles of one hand on the patient’s cheal intubation, a blindly placed supraglottic airway device, sternum and moving it in a fi rm, circular motion (Figure 13-5a). or a surgical airway. Remember that the patient’s survival depends on achieving and maintaining a patent airway.21 Other methods include squeezing the trapezius muscle on either side of the base of the neck (Figure 13-5b), applying pressure above the eyes (supraorbital pressure—Figure 13-5c), or pres- Breathing sure with one fi nger to the soft area just behind the angle of the Once the airway has been determined to be patent, assess- mandible (Figure 13-5d). The Paramedic assesses for purpose- ment should continue to evaluate the adequacy of the patient’s ful movement by the patient to stop the painful stimulus.20 breathing. The Paramedic should also check for any possible threats to adequate breathing. To remember what to assess, Unresponsive think “Look, listen, and feel.” If the patient does not respond in any way to verbal or painful Look stimuli, then he is considered unresponsive. The unresponsive patient is considered to be very ill until proven otherwise. The chest should be exposed enough to inspect for wounds and for the work of breathing. Any open wounds on the chest Airway wall should be immediately covered to prevent the potential After determining the patient’s level of consciousness, the Paramedic must next assess the status of the patient’s airway. If the patient is conscious and alert, then the airway is most Cultural / Regional differences likely being maintained without diffi culty. The Paramedic should confi rm this assumption by observing the patient’s The chest must be exposed to allow a visual exam effort to breathe and listening to the patient’s speech. If the patient has normal speech and noiseless, effortless for wounds and effort of breathing. Additionally, the breathing, then the airway is patent and unlikely to need any stethoscope should be placed directly on the skin. immediate interventions. If the patient is not awake or has Efforts should be made, whenever possible, to protect noisy or diffi cult breathing, then the airway must be further the patient’s modesty. A sheet or towel can be loosely evaluated for possible obstruction. The number one cause of airway obstruction is simply the patient’s tongue. placed over the patient’s chest or a bystander can The protective refl ex and muscle control of the upper air- be employed to hold a sheet up as a visual barrier. way decreases as the level of consciousness decreases. This loss Depending upon local custom, it may be prudent to of control leads to relaxation of the soft tissues of the pharynx and occlusion of the upper airway. The ability to swallow is have a Paramedic of the same gender, if available, affected and this condition leads to a buildup of airway secre- examine the patient. tions. Simple positioning maneuvers such as a head-tilt chin-lift 218 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (a) (b) Figure 13-5 Methods used to assess response to painful stimulus: (a) Sternal rub (b) Trapezius squeeze. for sucking chest wounds. Bruising should be noted as it may painful, can cause decreased ventilation, and should be stabi- be a sign of signifi cant underlying injury. lized as soon as possible. The Paramedic should also observe If two or more ribs are broken in two or more places, the the chest to determine the respiratory rate.22,23 segment may move out when the chest wall moves in with Ventilatory rates which are either too fast or too slow exhalation and in when the chest wall moves out with inspira- will not allow for adequate gas exchange in the lungs. If tion. The paradoxical movement of this fl ail segment is quite the patient’s ventilatory rate is less than 10 or greater than Scene Size-Up and Primary Assessment 219 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (c) (d) Figure 13-5 Methods used to assess response to painful stimulus: (c) Supraorbital pressure (d) Mandibular pressure. 30 breaths per minute, then the Paramedic should consider the possible need for ventilatory support. Listen A quick way to ascertain that the patient’s respiratory After inspecting the chest, the Paramedic should listen to the rate is between 10 and 30 is to observe the chest and start chest with a stethoscope to determine the effectiveness of counting the seconds between the fi rst breath and the second. air movement. At this point in the assessment it is important If the time between the fi rst and second breath is 6 seconds to determine that air is entering each lung and that the air or greater, then the respiratory rate is 10 breaths per min- entry is equal on both sides. The best place to listen during ute or less. If the time between the fi rst and second breath is the primary assessment is just below the axilla on each side 2 seconds or less, then the respiratory rate is 30 breaths per (Figure 13-7). One inhalation/exhalation cycle is generally minute or more. enough to assess the depth and equality of breath sounds. 220 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Paramedic should make note of any unusual or abnormal breath sounds heard, but a full assessment of breath sounds can be made later after life threats are ruled out. If air exchange is inadequate, all measures should be taken to correct the defi cit. The patient may require positive pressure ventilation, thoracic decompression, or medication adminis- tration to correct problems. Feel After listening to the chest to assure adequate and equal air entry, the Paramedic should palpate the chest to assess for potential life threats. Place a hand on each side of the chest and feel full inspiration and expiration. If the patient is conscious, ask her to take a deep breath and ask about pain. While palpating the chest, evaluate for tenderness, crepitus, or subcutaneous air. Any of these conditions may indicate a signifi cant underlying chest injury. Also feel for equal expan- sion of the chest wall. Circulation After securing the patient’s airway and breathing, the next step in the primary assessment is to evaluate the effectiveness of circulation. As with the airway and breathing steps, any life threats discovered must be corrected whenever possible during the primary assessment. Pulse The Paramedic should evaluate the presence of a radial pulse. If a radial pulse is present, it is reasonable to assume that the Figure 13-6 Assessing the airway can be patient’s blood pressure is adequate to supply perfusion to simplifi ed to the mantra “Look, listen, and feel.” that peripheral site.24,25 If there is no radial pulse, immediately Figure 13-7 Auscultation of lung sounds at the axilla during the primary assessment. Scene Size-Up and Primary Assessment 221 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. assess the carotid pulse. If the carotid pulse is present, but assessment. However, a complete and accurate set of vital the radial pulse is not, the patient’s blood pressure should be signs can be a useful triage tool to estimate the severity of the assumed to be quite low. patient’s condition. Some life-threatening conditions can be identifi ed by the Bleeding vital sign abnormalities they cause. Taking vital signs at this After assessing for the presence and quality of pulses, the time establishes a set of baseline vital signs to which all sub- next step is to check for external bleeding. Any active bleed- sequent vital signs are compared. ing should be further evaluated and any life-threatening hem- All other sets of vital signs taken are considered to be orrhage must be corrected immediately whenever possible. serial vital signs and are useful to illustrate trends in vital With gloved hands, the Paramedic should sweep under sign changes. For example, a low normal blood pressure dis- all non-visible parts of the patient’s body and expose the covered when the fi rst set of vital signs is taken is not as sig- patient enough to assure that any external bleeding site can nifi cant as a blood pressure which gets slightly lower with be adequately assessed (Figures 13-8). each measurement. After assessing for the presence of external bleeding, the A set of vital signs should include, at a minimum, an patient’s skin should be evaluated for signs of internal bleed- assessment of pulse, respirations, and blood pressure.26 ing. Pale, cool, and clammy skin may be signs of signifi cant hypoperfusion. Sick or Not Sick: Vital Signs Priority Decision Making As time, available personnel, and patient condition allows, Once the primary assessment has been completed, the Para- a full set of vital signs should be taken during the primary medic must make a determination of the patient’s priority. assessment. In no way should obtaining vitals take prece- This determination is made by integrating all of the fi nd- dence over—or interfere with—the completion of the primary ings gathered in the primary assessment to make a decision Figure 13-8 A Paramedic performing a sweep for blood during the primary assessment. 222 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves
the right to remove additional content at any time if subsequent rights restrictions require it. whether or not the patient has any life-threatening complaints Those patients who are not determined to have poten- which would require immediate, rapid transport to the hospi- tial life threats may be considered low priority and should tal (Table 13-1). These patients are considered high priority have full assessment and any necessary treatments performed patients and require that only life-saving interventions and on the scene prior to being packaged for transport. Although appropriate packaging take place before they are expedi- scene time should never unnecessarily be delayed to com- tiously moved to the hospital. plete these tasks, it is appropriate to spend time on-scene All other assessments and interventions performed on with these patients managing their condition as local medical high priority patients should take place en route to the hospi- authority allows. tal. This type of patient generally receives a minimal amount of interventions while on scene. Focused History Table 13-1 Clues to Life-Threatening Conditions and Physical Exam • Poor general impression Once the primary assessment has been performed and a pri- • Unresponsiveness ority determined, the appropriate focused history and physi- • Decreased level of consciousness cal exam may be performed. For medical patients who are responsive, the Paramedic should conduct a focused history • Diffi culty breathing and physical exam. For unresponsive patients, the Paramedic • Shock (Hypoperfusion) should use a rapid physical exam. • Complicated childbirth For trauma patients with signifi cant mechanism of injury, • Chest pain the Paramedic should carry out a rapid trauma assessment • Uncontrolled bleeding with a detailed physical exam being performed en route to the • Severe pain anywhere hospital. For trauma patients without signifi cant mechanism • Multiple injuries of injury, the Paramedic should conduct a focused trauma assessment. Scene Size-Up and Primary Assessment 223 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. As described in this chapter, the Paramedic’s assessment starts the moment she pulls onto the scene. Observation skills are key to rapidly identifying hazards, determining if additional resources are needed, and determining when to move quickly into a rapid transport mode with a critically ill patient. Key Points: • Patient assessment is necessary for each patient • A patient alert to voice will respond to verbal stimuli. contact and offers an algorithmic approach to quickly and thoroughly form an impression of the • A patient who is not responsive to voice but patient’s condition; determine the need for any responds to a painful stimulus is said to be alert to additional resources, and continuously assess the pain. safety of the scene. • A patient that does not respond in any way to • The primary assessment is the fi rst “hands on” verbal or painful stimuli is considered unresponsive. assessment of the patient and is performed to • A patient with normal speech and noiseless, address life-threatening problems. effortless breathing has a patent airway. • Responding to an emergency requires an • The patients’ airway may be obstructed by the tongue, assessment of safety, environmental conditions, foreign body object, or buildup of airway secretions. type and number of patients, and need for specialized resources. • In opening the airway, consider simple positioning • fi rst. Use suction as needed. Scene safety is the fi rst priority before initial patient contact. • Evaluate the need for airway adjuncts such as oro- or • nasopharyngeal devices or more invasive devices such The Paramedic should use body substance isolation as an endotracheal tube or alternative airway device. (BSI) precautions in all patient encounters regardless of the suspected diagnosis. • After an airway is established, assess depth, rate, • and effort of breathing. Proper hand washing is one of the most important things that the Paramedic can do to prevent the • After auscultation of the chest, the Paramedic spread of infection. should inspect the chest for wounds such as • bruising or fl ail segments as well as tenderness, The Paramedic must determine the mechanism of crepitus, or subcutaneous air. injury (MOI) for patients who have experienced traumatic events. • If the patients’ respiratory rate is less than 10 or greater than 30 breaths per minute, ventilatory • The Paramedic must determine the number support may be needed to treat inadequate gas of patients in order to determine if adequate exchange in the lungs. resources are available. • The presence of a radial pulse represents a blood • Regardless of whether the patient appears alert, pressure that is adequate to supply perfusion to the Paramedic should quantify orientation to that peripheral site. surroundings. • Circulation also includes evaluating for any active • Alert refers to responding appropriately to bleeding or life-threatening hemorrhage that must questioning relative to person, place, and time. be corrected immediately whenever possible. 224 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. In addition, skin color, temperature, and condition must make a determination of the patient’s should be noted. priority. • Vital signs are assessed to establish a baseline to • After an primary assessment is performed and a which all subsequent vitals are compared. priority is determined, the Paramedic may perform • appropriate further exams. After integrating all of the fi ndings from the primary assessment, the Paramedic Review Questions: 1. What is the primary goal of the primary 6. Name four different painful stimuli that assessment? can be used to determine a patient’s level of 2. When the Paramedic arrives on-scene, what consciousness. should be assessed? 7. After performing a head-tilt chin-lift on the 3. Who is the Paramedic responsible for while nontraumatic patient, ventilations on the on-scene? unconscious patient do not go in. What 4. Name the pieces of personal protective should be done? equipment the Paramedic can use for body 8. What does a weak and thready radial pulse say substance isolation. about a patient’s perfusion? 5. Describe what the Paramedic is looking for 9. What is included in a complete set of vital signs? when conducting the “look test.” 10. What information is used to assign a priority to the patient’s transport? Case study Questions: Please refer to the Case Study at the beginning of 2. Describe the primary assessment of the three the chapter and answer the questions below. different patients. 1. Describe the scene size-up needed for this 3. Name the further exams that will be conducted incident. for each of the three patients. References: 1. Koenig KL. Quo vadis: “scoop and run,” “stay and treat,” or 5. Corbett SW, Grange JT, Thomas TL. Exposure of prehospital “treat and street”? Acad Emerg Med. 1995;2(6):477–479. care providers to violence. Prehosp Emerg Care. 1998;2(2): 2. Seamon MJ, Fisher CA, Gaughan J, Lloyd M, Bradley KM, 127–131. Santora TA, et al. Prehospital procedures before emergency 6. Grange JT, Corbett SW. Violence against emergency department thoracotomy: “scoop and run” saves lives. J Trauma. medical services personnel. Prehosp Emerg Care. 2007;63(1):113–120. 2002;6(2):186–190. 3. Cone DC, Wydro GC. Can basic life support personnel safely 7. Neely KA. Scene control in prehospital care. Top Emerg Med. determine that advanced life support is not needed? Prehosp 1987;9(1):79–86. Emerg Care. 2001;5(4):360–365. 8. Carrillo L, Fleming LE, Lee DJ. Bloodborne pathogens risk and 4. Eckstein M, Cowen AR. Scene safety in the face of automatic precautions among urban fi re-rescue workers. J Occup Environ weapons fi re: a new dilemma for EMS? Prehosp Emerg Care. Med. 1996;38(9):920–924. 1998;2(2):117–122. Scene Size-Up and Primary Assessment 225 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 9. Marcus R, Srivastava PU, Bell DM, McKibben PS, Culver 18. Limmer D, Monosky K. Assessment of the altered mental status DH, Mendelson MH, et al. Occupational blood contact among patient. Emerg Med Serv. 2002;31(3):54–58, 81. prehospital providers. Ann Emerg Med. 1995;25(6):776–779. 19. Gill M, Martens K, Lynch EL, Salih A, Green SM. Interrater 10. Eustis TC, Wright SW, Wrenn KD, Fowlie EJ, Slovis CM. reliability of 3 simplifi ed neurologic scales applied to adults Compliance with recommendations for universal precautions presenting to the emergency department with altered levels of among prehospital providers. Ann Emerg Med. 1995;25(4): consciousness. Ann Emerg Med. 2007;49(4):403–407, 512–515. 407, e401. 11. Hellinger WJ, Gonsoulin SM. Risking everything. EMTs, 20. Mistovich JJ, Krost W, Limmer DD. Beyond the basics: patient universal precautions, and AIDS. Jems. 1998;23(7):56–59. assessment. Emerg Med Serv. 2006;35(7):72–77; quiz 78–79. 12. Lund S, Jackson J, Leggett J, Hales L, Dworkin R, Gilbert D. 21. Krost WS, Mistovich JJ, Limmer D. Beyond the basics: airway Reality of glove use and handwashing in a community hospital. assessment. Emerg Med Serv. 2006;35(1):85–89; quiz 90–91. Am J Infect Control. 1994;22(6):352–357. 22. Pettiford BL, Luketich JD, Landreneau RJ. The management of 13. Kaczmarek RG, Moore RM, Jr., McCrohan J, Arrowsmith-Lowe fl ail chest. Thorac Surg Clin. 2007;17(1):25–33. JT, Caquelin C, Reynolds C, et al. Glove use by health care 23. Davignon K, Kwo J, Bigatello LM. Pathophysiology workers: results of a tristate investigation. Am J Infect Control. and management of the fl ail chest. Minerva Anestesiol. 1991;19(5):228–232. 2004;70(4):193–199. 14. Wolfe FD. Wearing gloves: is it protection or punishment? Rdh. 24. McManus J, Yershov AL, Ludwig D, Holcomb JB, Salinas 1998;18(9):22–24, 26, 30 passim. J, Dubick MA, et al. Radial pulse character relationships to 15. Larson EL, Quiros D, Lin SX. Dissemination of the CDC’s Hand systolic blood pressure and trauma outcomes. Prehosp Emerg Hygiene Guideline and impact on infection rates. Am J Infect Care. 2005;9(4):423–428. Control. 2007;35(10):666–675. 25. Benson M, Koenig KL, Schultz CH. Disaster triage: START, 16. Bubacz MR. Community-acquired methicillin-resistant then SAVE—a new method of dynamic triage for victims Staphylococcus aureus: an ever-emerging epidemic. Aaohn J. of a catastrophic earthquake. Prehosp Disaster Med. 2007;55(5):193–194. 1996;11(2):117–124. 17. Zoraster RM, Chidester C, Koenig W. Field triage and patient 26. Mistovich JJ, Krost WS, Limmer DD. Beyond the basics: maldistribution in a mass-casualty incident. Prehosp Disaster interpreting vital signs. Emerg Med Serv. 2006;35(12):194–199; Med. 2007;22(3):224–229. quiz 200–201. 226 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The process of effective communication • Cultural competence when serving others • Defi nitions of space • Common strategies for establishing patient rapport • Interview techniques for the Paramedic Case Study: Paramedics were called to the home of Susan Garratt for her 22-month-old daughter, who had fallen from the swings and injured her
leg. When they arrived, the toddler was crying and wouldn’t let her mother touch her right leg. The new Paramedic spoke to Mrs. Garratt but she didn’t turn toward him. He yelled her name, which caused the toddler to cry even harder. His partner quickly wrote a short note which asked, “Are you deaf? If so, do you sign or read lips?” Mrs. Garratt appeared relieved and her answer to the questions was, “Yes I am deaf and I do both.” The Paramedic then introduced himself by name and function using both sign language and voice, which was normal toned and well articulated. The interview proceeded smoothly and the child was transported for evaluation of an injured ankle. Later, the new Paramedic inquired as to where his partner had learned sign language. His reply was, “The community college.” 228 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Therapeutic Communications 229 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Communication goes beyond articulate speech and good handwriting. The Paramedic’s actions, as well as those of the patient, can speak louder than words. This chapter examines how the Paramedic can be compassionate and understanding while still effectively performing his duties. The Paramedic must also be able to recognize nonverbal behaviors and establish patient rapport. To make the most of patient communication, several interview techniques are discussed. Therapeutic Communications the communication and improves the chance that the message conveyed and the message received are the same. Carefully chosen words and a gentle hand on a patient’s shoulder—actions which bring comfort to a patient—help Encoding defi ne Paramedics as compassionate caregivers. Caregivers are aware of the limitations of medicine to cure disease and Before conveying the message, the Paramedic needs to reduce suffering as well as the power of interpersonal com- assemble the message carefully. Ill chosen words can send munication as a therapeutic tool. As healthcare providers, an incorrect message to the patient and can also elicit an Paramedics bring both high touch as well as high technology unwanted response. to the patient’s bedside. Take the word “pain,” for example. All patients have some pain history. When the word “pain” is used it can sub- Human Communications consciously bring back memories of prior painful events. As a result, the patient’s sympathetic nervous system responds to People communicate with one another directly through the stimulus (i.e., fear engendered by the word “pain,”) and speech (verbal) or indirectly, through a medium such as the causes the patient’s heart rate and blood pressure to rise. The written word, in order to convey a message. For the commu- word “discomfort,” on the other hand, does not necessarily nication to be successful, the message must fi rst be encoded, conjure the same memories. Therefore, the word may be less transmitted by the sender, then received and decoded by the infl ammatory than pain and allows the patient to avoid the receiver (Figure 14-1). This process, which occurs similarly physiological response that the word “pain” elicits. in radio communications, can experience transmitter failure, Dr. Gnatt, of Johns Hopkins Medical School, has studied interference, and poor reception. Identifying those problems the human physiological response to words and has advanced and resolving them before they occur improves the quality of the theory of schizokinesis.1,2 A student of Ivan Pavlov, Dr. Gnatt’s theory suggests that past painful experiences, unconsciously recalled by trigger words, can elicit an auto- Sender Encodes nomic nervous system response. In some cases, this response message could be harmful to the patient. Street Smart Examples of words that trigger a negative response Message Speaking include the statement “he’s walking with a time bomb Feedback Listening in his chest,” or “those are tombstone ST changes on Gesturing Writing the ECG.” Whether intended for the patient’s ears or not, the effect is the same. The patient is left to feel fearful. Transmission Receiver The process of conveying a message, its transmission, can Decodes message be either a true and accurate representation of the sender’s Figure 14-1 The process of communications. thoughts (i.e., the message expressed is the message meant 230 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to be conveyed) or may be conveyed in such a way that the patient to have an altered mental status can interfere with the meaning is misconstrued by the receiver. Factors that affect patient’s ability to decode the message. whether a message’s transmission is true include the choice of words as well as the sender’s body language. Body language Feedback is the transmission of a message by nonverbal visual cues. Feedback is the mechanism by which the Paramedic can Experts suggest that 70% of any spoken message is conveyed ensure that the message sent was the message received and by body language. Body language is important and discussed decoded; that is, the message heard was the message sent. in more detail shortly. Feedback is obtained by asking the patient some simple questions. Reception To use feedback effectively, the Paramedic must practice Factors that infl uence the receiver’s reception of the message, active listening. It has been estimated that the average person what the patient understands the message to be, include both can hear 500 words per minute yet can only speak about 125 physical and cultural infl uences. An example of a physical to 150 words per minute. Therefore, in an average conversa- infl uence that would have an impact on the message’s recep- tion the listener is only listening, receiving, and decoding the tion is the presence of pain. The patient in pain tends to be spoken word about one-third of the time. The remainder of the self-absorbed and shuts out the outside world. Therefore, pain time the listener is left to think. The active listener uses that can be a powerful distracter that interferes with the patient’s time to note nonverbal cues such as body language, as well as reception of the message. To get the patient’s attention it may cognitive gestures, such as facial expressions and fi dgeting, be necessary to speak loudly or to fi rst provide some form of to add depth of comprehension to the feedback. analgesia to remove the pain. To practice active listening skills, the Paramedic should Cultural infl uences, in the form of customs, and language stop talking. Interruptions are disruptive to the communica- barriers can also affect the reception of the message. For tion process. The Paramedic should also take a non-defensive example, a person of Japanese descent may nod in agree- posture, with arms open, and a genuine look of interest on the ment. However, the nod may be a consequence of respecting Paramedic’s face. The Paramedic should proceed to ask clari- authority rather than of understanding. In such a case, the nod fying questions which add detail to the patient’s responses. may not mean that the patient understands the message sent The use of encouraging words, such as “I understand,” and by the Paramedic. hand gestures will encourage the patient to be forthright with answers. Decoding An intangible in the process of communication is the receiv- er’s ability to understand, or decode, the message. That ability to decode a message is based upon intelligence, the person’s Street Smart basic knowledge of language, life experience (which varies from person to person), and maturity, among many other Patients expect Paramedics to take notes.6 It would be variables. unreasonable for a Paramedic to remember everything The statement “I know what you heard, but that’s not that was said. However, when the Paramedic appears what I said,” illustrates how two people can take two different meanings from the same statement. Many humorous stories to be “treating the clipboard” (taking more interest in have been told of children who hear an allegorical message completing a form than what the patient has to say), and take it literally. the patient tends to ignore the Paramedic. An obstacle to decoding the message is the use of medi- calese. Paramedics who choose to use medical terminology when speaking to patients are at risk of being misunder- stood or not understood at all. During a Paramedic–patient c onversation, the Paramedic should attempt “double–speak,” Hermeneutics offering lay terms to explain medical terminology to the The overarching goal of communications is to obtain clini- patient. Then it will be easier for the patient to understand cally relevant information about the patient so that a diagno- what is being said. sis can be made and treatment offered. Key to decoding the message is the patient’s mental Key to a successful interview is for the Paramedic to put capacity. Medical conditions, such as stroke, can impair the himself in the patient’s situation, with all of the accompany- patient’s ability to decode the message, a condition called ing physical and cultural infl uences, in order to understand receptive aphasia. the patient better. This approach is called hermeneutics. Other conditions that can impair the patient’s ability to By taking a “fi rst person” perspective, the Paramedic understand include hypoxia, hypoglycemia, hypoperfusion, gains understanding, as well as empathy, for the patient’s and poisoning.3-5 In fact, any condition which causes the plight. Therapeutic Communications 231 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Improving Communications Paramedics who view their own cultural practices and customs as superior, a form of ethnocentrism, may have dif- Improving communications starts with an awareness of fi culty communicating with people from other cultures. p ersonal factors which have an impact on communications. A person’s education also can have a great deal of infl u- Everyone is shaped and changed by personal life experience; ence over one’s ability to communicate. It is estimated that these infl uences and experiences, in turn, color our p erception 50% of the U.S. population communicate at or below the of ourselves and other people. By being self-aware, hav- eighth-grade literacy level.8 ing a conscious understanding of one’s life infl uences and To be culturally aware, the Paramedic must fi rst be aware prejudices, the Paramedic can factor those infl uences into the of all of his or her own biases and attempt to eliminate their process, suppress negative infl uences, and augment positive impact upon the Paramedic–patient interaction. Bias can infl uences. not only prevent effective communication but it can cause A key feature of self-awareness is the person’s physical the patient to mistrust the Paramedic and thus harm the being, which is a manifestation of one’s genetics. A person’s Paramedic–patient relationship. genetic make-up—those physical characteristics that make up a person, including appearance, disposition, and so on— Interview Techniques can have a tremendous impact on one’s outward appearance. For example, a man who has a large stature and stands over The goal of every patient communication is to be complete, six feet tall may appear to be very intimidating to a short clear,
concise, courteous, and cohesive. A number of tech- elderly woman. The self-aware Paramedic compensates for niques can help improve the probability of success. this by kneeling on one knee, bringing himself to the patient’s When approaching a patient, the Paramedic should make eye level. an estimate of the degree of distress that the patient is pres- Culture, that culmination of life experiences in a local- ently experiencing in order to modify his or her approach ity or region that affects the way a person thinks and behaves, to the patient. For example, the patient “in extremis” is not also has an impact on how the Paramedic acts toward, and likely to want long-winded conversations about past medical is perceived by, the patient. The self-aware Paramedic is not history. On occasion, it is better to reassure the patient that only aware of how culture affects behavior but also is aware relief is coming and that conversation, for the moment, is not of how the patient’s culture infl uences the patient’s interaction needed. with the Paramedic. However, in most cases the patient is not in extreme Culture relates in part to countries and areas within coun- distress and the Paramedic needs to engage the patient in a tries. There are tremendous variations among people from a meaningful conversation to ascertain a symptom pattern for particular region. For example, among the fi rst Americans, diagnostic determination. the native American population, there are over 700 different cultures. People of Asian descent originally came from over a dozen countries. One cannot identify a person as being of a particular culture based simply on one characteristic. Cultural / Regional differences It is estimated that over 14% of the United States popu- lation, or 31.8 million Americans, do not speak English as their primary language.7 In New York and California, it is The Paramedic must take care in judging a degree of estimated that 30% of the population speak Spanish. This distress. Many persons express their culture’s stoicism cultural diversity makes communications a formidable chal- in the face of discomfort while others are more vocal lenge to the Paramedic. or effusive. Cultural / Regional differences Proxemics While language is an important component of culture, The physical distance between a Paramedic and a patient dur- ing the history gathering can have either a positive impact or simply speaking the same language does not mean a chilling effect on the dialogue. The idea that interpersonal persons are of the same culture. People from South distance affects communication was advanced in a theory by and Central America may speak Spanish as the primary Edward T. Hall in 1959. Dr. Hall studied the effect of inter- language but their cultures are very different from personal space upon communications and advanced the the- ory of proxemics.9 that of Spain. In many cases their cultures are quite The theory of proxemics is based on the concept of four different from each other. spaces that surround a person. The fi rst space, the intimate 232 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. space, about the size of a beach blanket or one-half to one and Kinesics one-half feet, is that space where patients feel most vulner- Dr. Ray Birdwhistell suggested that body language may consti- able. Entry into that space is only permitted to those people tute 70% of a person’s interpersonal communication.10,11 This whom the patient trusts. All Paramedics must work toward statement makes it clear that effective communication is more being permitted into that intimate space in order to perform than just the spoken word (Figure 14-3). A Paramedic should invasive treatments and routine patient care. be aware of the messages, intended and unintended, which the The second space is the personal space, that area where body language is sending to the patient. A knowledge of kine- a patient would engage in a one-on-one conversation. The sics, the study of nonverbal behavior for communications, can personal space, about one and one-half feet to four feet, is help the Paramedic improve communication skills the distance within which most Paramedics initially interview The simplest example of kinesics might be nodding one’s patients for a history. head yes or shaking one’s head no. However, kinesics includes The third space is the social space, an area of relative all the movements of the body including facial expression, pos- safety where strangers can enter, with certain expectations of ture, stance, and gestures. Understanding the concepts of kine- conduct. A dining room in a restaurant is an example of the sics, a Paramedic knows that standing above a seated patient use of social space, where everyone is expected to eat politely and speaking down to the patient is conveying a message of and maintain a conversational tone. superiority or strength. This position may be counterproduc- The fourth space, greater than 12 feet, is called the pub- tive to the task at hand (e.g., gathering a patient history). lic space. It is that area one would occupy with a stranger Similarly, when a Paramedic, unwittingly or purposefully, without fear but with an ability to fl ee if danger should arise blades a patient (stands in front of but at a tangent to the patient) (Figure 14-2). to limit exposure and in preparation for a fi ght or fl ight, the When walking in a public space (e.g., in a shopping Paramedic is telegraphing the patient a message of distrust. mall), people become immediately aware of an unknown per- Gestures and mannerisms can also have unintended son who is closing the public space and entering the social meanings. For example, most patients will perceive fi nger- space. The expectation is that the person will step aside and pointing as an aggressive act and that fi nger-tapping is a sign allow the other person to pass unhindered. of impatience. The O.K. sign made with the thumb and fore- Dr. Hall’s theory of proxemics is based upon American fi nger means alright in New England. However, the O.K. sign cultural practices and traditions. A Paramedic must also be in Japan means money and in France means zero. Perhaps aware of other cultures which may have larger spaces. An more alarming, the O.K. sign is an insult in Brazil and Turkey. area that a Paramedic might consider a social space may be Lacking knowledge of the patient’s background and heritage, perceived by the patient as within the personal space. it is best not to use hand gestures and other mannerisms dur- Similarly, when a person (e.g., a mental health patient) ing patient care. feels threatened, the distances tend to grow larger. Intimate space, normally defi ned as one to one and one-half feet, might be four feet for a patient with schizophrenia. Invading Compassionate Touch that intimate space may result in violence. Nurses have known about the power of the human touch to bring comfort and solace to patients for years. Whether in the form of handholding, stroking a forearm, or rubbing a back, the compassionate touch is very human and therapeu- Intimate Personal Social tic. Studies performed in critical care units have shown that (1.5 ft) (4 ft) (9 ft) intracranial pressure, heart rate, and blood pressure can lower toward normal with compassionate touch. Dr. Dolores Krieger, RN, has researched and spoken about the power of touch to heal, or therapeutic touch.12,13 Dr. Krieger states that therapeutic touch is fi rst established in the human experience when a mother strokes the soft cheek of a distressed infant. It is developed throughout life dur- ing interactions with others. Therapeutic touch is intentional touching that mimics these earlier experiences and telegraphs reassurance, understanding, and caring to the patient. Paramedics should consider using therapeutic touch, such as hand-holding, to help calm patients and as a means to transmit a message of compassion to the patient. The key to success with therapeutic touch is to recognize the opportu- nity and to intervene at that time. However, some caution is advised. Misapplied, therapeutic touch can be perceived as an Figure 14-2 Proxemics illustrated. unwanted intrusion into the patient’s privacy. Therapeutic Communications 233 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 14-3 Body language often speaks louder than words. Hearing Impaired subconsciously fi lter out ambient background noise, the hearing aids of the hearing impaired amplify all noise. The Conveying a message to the patient who is either hearing resulting mass of noise is diffi cult for the patient to decipher impaired or hard of hearing (HOH) requires the Paramedic into an intelligent message. to take deliberate action. While communicating with the Having identifi ed that there may be a potential impediment hearing impaired can be diffi cult, demanding patience and to communication (i.e., that the patient is hearing impaired), persistence from the Paramedic, the end result (improved the Paramedic should be especially conscious of the mes- communication) ultimately results in better patient care. sages being sent to the patient by body language. Patients The fi rst step in communicating with this patient popu- with a hearing impairment often utilize facial expressions, lation is recognizing that the patient is hearing impaired. In hand gestures, and the person’s general posture to assist in some cases the patient may be forthright and tell the Para- ascertaining the meaning of a message. medic that he is hearing impaired. In other cases subtle clues, Next, the Paramedic should attempt to gain the patient’s such as inattention to the Paramedic during a conversation or attention before speaking. Sitting directly in front of the inappropriate answers to questions, may lead the Paramedic patient is often all that is needed to get the patient’s attention. to suspect that the patient is hearing impaired. The Paramedic should be cautious about tapping the patient If the patient is hearing impaired, the Paramedic should inquire if the patient can read lips, uses sign language, or would prefer to write down his or her responses. If the patient is a lip reader then the Paramedic should Street Smart position himself in front of the patient, so that his lips can be clearly seen, and enunciate words carefully. Some EMS services have special language boards available to improve Some patients with a hearing impairment have communication with the hearing impaired patient. working dogs. These working dogs listen for and Whenever possible, the Paramedic should consider protect their masters; they are the ears of their moving the patient to a quiet area or attempt to elimi- nate background noises, such as squawking radios or idle masters. It is inappropriate to touch or pet a working conversation. While hearing people automatically and dog without the master’s permission. 234 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. on the shoulder or waving his hands in front of the patient’s communications, some EMS services have special language face. These actions could be misconstrued as aggressive. If boards available for use by the Paramedic. These language needed, a simple touch of the hand or forearm will get the boards provide visual cues that permit the Paramedic and the patient’s attention. patient to communicate quickly. When speaking to the patient, the Paramedic should speak slower than normal, carefully enunciating words, and
avoid putting her hands in front of her face. The Paramedic should avoid the use of “yeah” or “nah” as these two words are diffi cult to distinguish. Instead, the Paramedic should Street Smart clearly say “no” or “yes,” taking time to enunciate (hiss) the letter s. When possible, the Paramedic should move the The Paramedic should avoid the temptation to shout. patient with a hearing aid indoors or to the back Shouting not only makes the Paramedic appear impatient but of the ambulance. The blowing wind generates a also strains the vocals cords, thereby distorting sounds and making comprehension more diffi cult. whistling sound in the ear of the patient, making it The Paramedic may want to inquire if the patient can read almost impossible for the patient to hear what is said. lips. If the patient is a lip reader then the Paramedic should position herself in front of the patient, so that the lips can be clearly seen. It is important that the Paramedic’s face be well- lighted so that the patient can clearly see the Paramedic’s Introductions lips. A common error made which can reduce the visual cues It is not only a common courtesy to introduce oneself to a available is standing in front of a window or a light source. patient, but it is a professional responsibility for the Para- The result is that the Paramedic is silhouetted and the Para- medic to advise the patient who he is and what qualifi cations medic’s face cannot be seen clearly. he possesses to care for the patient. Some states even mandate After the message has been conveyed to the patient, the that all healthcare providers identify themselves to the patient Paramedic should ask the patient to repeat the message back. by name and title. Frequently this can be accomplished by use This “echo” technique helps to ensure that the intended mes- of identifi cation tags or name badges. sage was transmitted and the patient understands. But for the professional Paramedic, it is more than com- In some cases a hearing interpreter may accompany pliance with the law. The tradition of introducing oneself the patient. If the patient has an interpreter, the Paramedic helps to set the groundwork for future dialogue between the should introduce herself to the interpreter and briefl y dis- patient and the Paramedic. Some Paramedics prefer to shake cuss the intent of the conversation. Even though the inter- the patient’s hand, a generally accepted activity that is seen as preter is present, the Paramedic should still speak directly nonthreatening. Besides conveying a message of goodwill, to the patient. The interpreter will then use American sign the Paramedic has the fi rst opportunity to assess the patient’s language or signed English to convey the message to the physiologic state. Cold and sweaty palms may indicate shock patient after the Paramedic is done speaking. The Para- while a weak grasp may indicate exhaustion. When the cour- medic should speak in short sentences and then allow time tesy is returned and the patient gives the Paramedic his name, for translation. After receiving the message, the patient will the Paramedic can further assess the patient’s speech and use sign language to speak to the interpreter and then turn to mental status. face the Paramedic as the interpreter translates the message to the Paramedic. If the patient has diffi culty understanding the message, the Paramedic should repeat the question or restate the mes- Street Smart sage in other words. A large number of hearing aids are available for the hear- The Paramedic should inquire as to the patient’s ing impaired patient including those that are worn behind the ear (BTE) and in the ear (ITE). If the patient has a hearing preferred manner of address. If the patient states that aid, then the Paramedic should talk to the side of the patient his name is Joe Smith, the Paramedic can immediately in which the hearing is best; the patient often indicates this ask if he prefers Joe or Mr. Smith. by turning that side of the head toward the Paramedic. It is appropriate to ask the patient if he or she has a good side and then to direct conversation to that side. In some cases, the easiest method of communication is to The saying goes that a “picture is worth a thousand write down the message. While time-consuming, this method words.” The image of the patient seated in a chair, obtained can help reduce errors. The Paramedic should write plainly during the introduction, helps the Paramedic immediately and avoid the use of cursive handwriting. To facilitate visual gauge the severity of the illness or injury (Figure 14-4). Therapeutic Communications 235 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 14-4 A Paramedic’s fi rst opportunity for assessment. Selecting the Correct Questions Using Proper Tone The Paramedic should carefully select questions that The tone of voice is thought to transmit some 23% of the spo- maximize patient information and provide for a free fl ow of ken message (the remaining 77% is left to the actual words dialogue. The Paramedic may elect to use either open-ended spoken). When talking to a patient, the Paramedic should be questions or closed-ended questions to obtain the patient’s aware that the infl ection of the voice can transmit a meaning history during the interview. Each type of question has altogether different than the one intended. its merits. Open-ended questions allow the patient to express himself without restriction and the answers can be used as a Encouraging Behaviors springboard to other questions. Open-ended questions usu- By practicing certain behaviors, a Paramedic can help facili- ally begin with words like “how,” “what,” or “could” and tate the dialogue. For example, acknowledging the patient’s ask for an explanation. Patients with limited patience may response, either verbally or nonverbally, can encourage the fi nd these questions frustrating, but generally speaking open- patient to volunteer more information. ended questions provide the greatest yield of information. In certain instances, when the patient is making what Closed-ended questions require the person to answer appears to be a painful disclosure, it may be appropriate for a question with a limited number of options. Closed-ended the Paramedic to remain silent. Silence, in this instance, is questions are used when specifi c information is needed comforting to the patient and shows that the Paramedic quickly. A closed-ended question generally starts with words respects the patient’s privacy. like “do,” “is,” or “are” and result in automatic answers— Sharing one’s observations with the patient can also help single word responses such as “yes” or “no”—that add small focus the patient’s thoughts as well as direct the dialogue. amounts of information. For example, the statement “You seem upset” may bring During an emergency Paramedics often prefer to use the patient’s behavior to the patient’s attention and allow the closed-ended questions in order to obtain succinct answers. patient to correct the impression or explain the behavior. However, the use of closed-ended questions can lead to a lim- Conveying empathy, the message that “I am with you” ited history from the patient. can be as simple as acknowledging the patient’s feelings or Some Paramedics prefer to use an indirect statement to asking for clarifi cation. Both approaches show the patient obtain needed patient information. An indirect statement is a that the Paramedic is interested and cares. question that asks for an explanation that is not constrained Clarifi cation is an excellent tool when the Paramedic is by the question. An example of an indirect statement would sensing a mixed or confusing message. Clarifi cation asks the be, “Please tell me about your pain.” patient to restate the message in other words. By asking the 236 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. question (e.g., “What do you mean when you say . . . ?”) the patient from the behavior, and accept the patient but reject Paramedic is bringing the previous statement to the patient’s the behavior. The Paramedic should understand that the attention and asking for further explanation. patient is expressing genuine feelings (care) in an inappro- At the end of a patient interview, the technique of sum- priate manner. The Paramedic needs to express his feelings marization can be helpful to ensure the Paramedic’s under- (e.g., “I am uncomfortable with what you just said.”) and standing of the information in the interview. Summarization then proceed to establish boundaries. In most cases, the involves taking the patient’s own words, then paraphrasing the patient needs the help that EMS can provide and will dem- patient’s words to ensure that the message sent was received onstrate correct behavior. correctly. Summarization allows the Paramedic to focus on specifi cs of a patient history. Summarization also reassures Provider Errors in Interviewing the patient that the Paramedic was attentive during the patient interview. Sometimes the Paramedic is his or her own worst enemy when it comes to facilitating a dialogue. The following are a few behaviors that are counterproductive to the task of Behaviors Detrimental to Dialogue gathering a patient history and maintaining a therapeutic A Paramedic should keep in mind that certain behaviors can communication. be detrimental to the Paramedic–patient dialogue. For exam- Some Paramedics take pride in their ability to use medi- ple, inappropriate slang words, curse words, and laughter cal terms and professional jargon. However, when speak- can have a devastating effect upon the conversation between ing to a patient such medicalese is confusing and erodes the patient and Paramedic. While patients do sometimes get patient’s confi dence that the Paramedic can relate to the situ- themselves into genuinely humorous situations, the laughter ation or problem. is best left for after the call. During the call, all providers Another common pitfall is frequent interruptions. When should be professional and polite. a patient is frequently interrupted by the Paramedic, the patient gets the sense that the Paramedic does not really care Patient Conduct about the patient. Patients may exhibit self-protective behaviors, called block- Paramedics should also avoid giving false assurances. ing behaviors, which inhibit free dialogue with the Para- While reassuring clichés, such as “everything will be alright,” medic. Many of these blocking behaviors are manifestations can come glibly off the tongue, these words are altogether of psychological defense mechanisms. For example, when a meaningless to the patient and undermine the trust that the patient slams a door he may be displacing his anger from a patient has in the Paramedic. threatening object (e.g., the Paramedic) to a nonthreatening Similarly, Paramedics should avoid giving advice. Such object (e.g., the door). statements usually begin with “If I were you,” or “You should Similarly, the patient may deny the feelings. Denial, a do this.” Such advice is generally not based upon a suffi cient strong defense mechanism, is commonly used and is an knowledge base and assumes authority. Even physicians gen- unconscious refusal to acknowledge feelings or situations. erally couch their words of advice with statements like, “It is An example of denial is the patient who appears to be hav- my recommendation that,” or “You might want to consider ing an acute coronary event but keeps telling the Paramedic this,” leaving the decision to the patient. that it is just indigestion. The patient fears the truth and all of As a rule, Paramedics should also avoid “why” questions. the consequences that would accompany an acute coronary Questions prefaced with the word “why” imply judgment. event, including a loss of independence. When a patient senses judgment, a sense of futility prevails
Fear is a powerful feeling. Patients overwhelmed with and the patient tends to become uncooperative. Moralizing fear may experience debilitating panic attacks or exhibit also falls along the same lines as giving advice and asking outright hostility toward the Paramedic. When confronted “why” questions. with a hostile patient, the Paramedic is under no obliga- tion to remain in danger. However, if the Paramedic can recognize the source of the fear or anger and help the patient recognize that fear or anger, the Paramedic could potentially Street Smart defuse the situation and continue providing patient care. To deescalate an angry or frightened patient, the Para- medic should permit the patient some control of the situa- The Paramedic should listen carefully to the words of tion and then, using a problem-solving approach, analyze and the patient’s spouse. Generally speaking, the spouse neutralize the cause of the fear.14 of a patient is genuinely concerned and can often add On rare occasions, a Paramedic may be confronted with inappropriate sexual behavior, often in the form of sexual important information about the situation which the innuendo. It is important that the Paramedic separate the patient may not know or may be withholding. Therapeutic Communications 237 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Statements by Friends and Family In some cultures, the practice of folk medicine is the Friends and family can offer a rich source of information prevalent medical care. Special practitioners may use concoc- about a patient, but such information should always be looked tions of herbs and special rituals to cure illness. The Mexican at with a skeptical eye. The Paramedic cannot be sure of the folk healer, for example, is called a “Curandero.” In one study motives of friends and families and such hearsay information of 405 Hispanics in Denver, Colorado, 29% indicated that can be inaccurate. they had visited a Curandero in the past.19 All Paramedics should strive for cultural competence, an Special Communication Situations ability to function effectively within the populations that they serve. Cultural competence requires an awareness and knowl- There are many situations which require the Paramedic to use edge of common medical practices in the communities. specifi c techniques or actions to handle communications with the patient. Death and Dying Drugs and Alcohol No situation puts the Paramedic’s therapeutic communication Paramedics commonly encounter drug- or alcohol- intoxicated skills to the test more than a patient’s death. A caring Paramedic patients. These patients, despite distasteful mannerisms or can support the patient’s family during this stressful moment behaviors, are deserving of care and may not be aware of the in a person’s life through therapeutic communications. danger to their health.15–17 The Paramedic should fi rst listen. Listening, nonjudg- When confronted with an intoxicated patient, the Para- mentally, to the patient’s spouse or loved one allows the medic should not moralize about the patient’s conduct, but p rocess of grieving to begin. If the patient’s family is in denial, rather recognize that the patient may have unresolved prob- the Paramedic should gently reestablish reality by refocusing lems. This recognition paves the way for the Paramedic to the person to the reality of the situation (i.e., that the patient separate patient from behaviors and provides the start of a has died). therapeutic relationship with the patient. Any displays of anger or criticism from the family should not be taken personally. The professional Paramedic can sep- Alternative Medicine arate the behavior from the person and understands that the Paramedics may also encounter patients who lack faith in behaviors are part of the mourning over the patient’s death. western medicine. These patients may have already used alternative medicine or complementary medicine before calling EMS. Unsure of the Paramedic’s reaction, the patient may withhold such vital information from the Paramedic. Paramedics should recognize that alternative medicine is becoming increasingly popular and is more commonplace Professional Paramedic in some cultures. A study in the New England Journal of Medicine indicated that some 34% of Americans have tried Some allied health programs including paramedicine alternative medicine.18 The domain of alternative medicine includes mega-vitamins, therapeutic massages, chiropractic offer courses in thanatology, the social and medicine, and acupuncture, to name just a few. psychological study of death and dying. 238 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. While Paramedics are in many respects taught to “romance the technology,” EMS is—above all else—a caring profession. Therapeutic communication helps to establish Paramedics as professionals in the minds of their patients, other healthcare team members, and the general public. Key Points: • The overarching goal of communications is to obtain • Knowledge of kinesics, the study of nonverbal clinically relevant information about the patient behavior for communications, can help the so that a diagnosis can be made and treatment Paramedic improve communication skills. offered. Communication should be complete, clear, concise, courteous, and cohesive. • Applied correctly, therapeutic touch, such as hand- holding, can help calm patients and transmit a • Successful communication depends on correctly message of compassion to the patient. sending and receiving the message. The reception of the message can be affected by physical, cultural, • Conveying a message to the patient who is either and educational differences between the message’s hearing impaired or hard of hearing (HOH) requires sender and receiver. the Paramedic to take deliberate action. • A common obstacle to successful communication • The Paramedic should carefully select questions is the use of diffi cult to understand medical that maximize patient information and provide for a terminology. It is good practice to offer lay terms free fl ow of dialogue. to explain medical terminology to ensure that the • Open-ended questions allow a patient to give more patient understands. thorough answers, while closed-ended questions • Any medical condition causing the patient to have result in fast responses and limited information. an altered mental status can interfere with the • Clarifi cation and summarizing are both excellent patient’s ability to understand the message. ways to ensure that the message sent was received • The Paramedic should check for patient correctly. understanding by looking for feedback in the form • Patients may exhibit self-protective behaviors, of body language, facial expressions, and questions called blocking behaviors, which inhibit free and answers. dialogue with the Paramedic. • Active listening skills include taking a nondefensive • The Paramedic should not give false assurances or posture, keeping arms open, having a genuine look advice. of interest, asking clarifying questions, and not interrupting the patient responses. • In interviewing, avoid “why” questions, as they • imply judgment. Paramedics should put themselves in the patient’s situation in order to understand the patient better • Paramedics should strive for cultural competence, (hermeneutics). an ability to function effectively within the • populations that they serve. The theory of proxemics illustrates the importance of keeping the appropriate physical distance • Therapeutic communication is crucial when dealing between Paramedic and patient. Different with a patient’s death. people require differing amounts of space to feel comfortable. Therapeutic Communications 239 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. What theory explains how words can trigger 6. In an interview with an elderly woman who has unpleasant memories and subsequent physical mild dementia and is slow to respond, what reaction? techniques can the Paramedic use to promote 2. Describe how the process of radio effective communication? communications is similar to communication 7. Explain how cultural competence allows between two people. Paramedics to function effectively within the 3. Defi ne the study of kinesics and explain why populations that they serve. it makes up a majority of person-to-person 8. How should the Paramedic conduct him- or communication. herself when dealing with the spouse of a 4. Describe the four types of space that the theory patient who just died? of proxemics outlines. 5. What are some blocking behaviors the patients or family members might display? Case Study Questions: Please refer to the Case Study at the beginning of the 3. How should the speaker position himself for the chapter and answer the questions below. lip reader? 1. Explain why speaking louder may increase the 4. In addition to Mrs. Garratt’s hearing impairment, anxiety of persons present on a scene. what other factors are likely to interfere with 2. How does “yelling” affect lip reading? communication? References: 1. Gantt WH. Principles of nervous breakdown-schizokinesis and 7. National Institute For Literacy. Available at: http://www.nifl .gov/ autokinesis. Ann N Y Acad Sci. 1953;56(2):143–163. nifl /facts/facts.html Accessed May 16, 2009. 2. Gantt WH. Pain, conditioning and schizokinesis. Cond Refl ex. 8. Kaestle C, Damon-Moore H. Literacy in the United States. New 1973;8(2):63–66. Haven: Yale University Press; 1991. 3. Barratt K, von Briesen JD. The continued vitality of a patient’s 9. Meade DM. Mixed messages: interpreting body language. informed consent, or, when the patient says “no.” Wmj. Emerg Med Serv. 1999;28(9):59–62, 73. 1999;98(2):60–61. 10. Birdwhistell RL. Introduction to Kinesics: An Annotation System 4. Sturman ED. The capacity to consent to treatment and research: for Analysis of Body Motion and Gesture. Louisville: University a review of standardized assessment tools. Clin Psychol Rev. of Louisville; 1952. 2005;25(7):954–974. 11. Birdwhistell RL. Kinesics and Context: Essays on Body-Motion 5. Tunzi M. Can the patient decide? Evaluating patient capacity in Communications. London: Lane Press; 1970. practice. Am Fam Physician. 2001;64(2):299–306. 12. Krieger D. Alternative medicine: Therapeutic touch. Nurs Times. 6. Johnson A. Note to self: tips on internal & external 1976;72(15):572–574. communication. Jems. 2007;32(6):26–27. 240 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 13. Krieger D. Therapeutic touch: two decades of research, teaching 17. Remy JD. Prehospital care of the intoxicated individual. Emerg and clinical practice. Imprint. 1990;37(3):83, 86–88. Med Serv. 2004;33(12):88–89, 91. 14. Hills LS. Working with anxious or fearful patients: a training 18. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional tool for the medical practice staff. J Med Pract Manage. medicine in the United States. Prevalence, costs, and pattern of 2007;23(1):50–53. use. N Engl J of Med. 1993;328(4):246–252. 15. Dick T. Stinky people. Respecting your limitations & other 19. Padilla R, Gomez V, Biggerstaff SL, Mehler PS. Use of people’s predicaments. Emerg Med Serv. 2005;34(11):26. curanderismo in a public health care system. Archives of Internal 16. Nordberg M. Mixed emotions. EMTs and Paramedics are often Medicine. 2001;161(10):1336–13340. ambivalent about treating the homeless. Emerg Med Serv. 1992;21(5):39–45, 48–39, 75. Therapeutic Communications 241 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is
expected that the reader will understand these following concepts: • The need for an accurate medical history to provide competent patient care • Using a comprehensive medical history to discover as much information about a patient’s complaints, interpersonal relationships, and medical history as possible • Using a focused health history to generate the historical fi ndings necessary to manage an emergent medical condition • The benefi ts of asking open-ended questions so patients are allowed to answer in their own words and generate a less-biased history Case Study: The Paramedics approached Mrs. Jones, an elderly woman who called EMS frequently. One Paramedic said quietly, “Let’s just get her into the bus and get going. She always has the same complaint and her history doesn’t change.” His partner said, “No, we’ll use a history gathering mnemonic to work this through. There’s something different here but I’m not sure what it is.” Mrs. Jones always complained of shortness of breath. However, this time the onset was slower and it was accompanied by extreme fatigue. Her physical exam was essentially the same as always but the pair worked her up for a possible myocardial infarction, which was later confi rmed at the hospital. 242 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. History Taking 243 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Obtaining an accurate medical history is an essential provision of quality patient care. This chapter discusses the art and science behind history taking. A patient’s medical history is best obtained by asking the right questions and developing a rapport that allows for a free exchange of information. Asking questions in an open-ended manner allows patients to answer in their own words and generates a history that is less biased by the Paramedic’s own interpretation. Once the dialogue has been opened, the Paramedic should guide the patient through the interview using the techniques of facilitation, refl ection, clarifi cation, interpretation, and direct questioning to gather the history without diverting the patients from their own account. Using the information generated from a focused health history, the Paramedic is able to expose historical fi ndings necessary to manage a patient’s emergent medical condition. History Taking Setting the Stage History taking is the most important skill for a Paramedic Any medical records available should be briefl y reviewed; for to master. History taking is defi ned as the medical ques- example, a Vial of Life® (Figure 15-1). Important data such as tioning of a patient to determine the disorder, syndrome, previous illnesses and treatments can often be easily obtained or condition affecting the patient that resulted in the call from such records. If the patient is in the care of another pro- for assistance. With most patients, the medical condition vider upon arrival, then a brief report should also be obtained related to their chief concern can be correctly identifi ed from that person. The Paramedic should also consider the envi- by history taking alone.1 Often physical exam fi ndings and ronment in which the interview takes place, as a proper atmo- other tests assist in confi rming the paramedical diagnosis. sphere can greatly enhance effective communication. If a Paramedic listens to the patient, she will tell the Para- The Paramedic should try to make the patient as comfort- medic what is wrong, and if the Paramedic really listens, the able as possible and be respectful of personal space. Gener- patient will tell the Paramedic how to fi x it!2 If history tak- ally, there should not be any obstacles, but a distance of a few ing is improperly performed, however, the Paramedic can be feet should lie between the Paramedic and the patient. During led to a completely different conclusion about the patient’s the interview, the Paramedic should be alert to the patient’s illness. Therefore, the history must be conscientiously gath- comfort level.6,7 The Paramedic should watch for any signs of ered on a patient-by-patient, case-by-case basis. The history and chief concern must also be confi rmed with the patient and not be taken for granted from dispatch information or other EMS providers. The Art and Science of History Taking The science in history taking is asking the right questions of the patient and interpreting the answers to those questions. The art in history taking is developing a relationship with the patient that allows the Paramedic to ask the right questions and also allows the Paramedic to trust that the patient will provide open and honest answers to those questions. Emergency medicine is a fi eld of medical practice which often requires a great deal of data to be gathered in a very limited amount of time.3–5 To achieve this goal, the Paramedic must combine art and science to a great degree. Patient care experience is the best teacher in the art of history taking. Figure 15-1 The Vial of Life® can provide However, some basic tenets apply. important patient information. 244 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. uneasiness and, if necessary, ask the patient directly about his The Paramedic should pay close attention to the way the feelings. Standing over a supine or sitting patient implies a patient responds. People who introduce themselves with titles position of power and can be detrimental to good communica- or their full name usually expect the Paramedic to address tion. Remember that just as the Paramedic watches the patient them that way. Avoid using demeaning terms like “Honey” for nonverbal clues, so is the patient watching the Paramedic. “Sweetheart” or “Bud.” Paramedics must always be aware of the messages transmit- ted by both words and actions. Paramedics must be sensitive Starting the Interview to those messages and control them as well as possible. After introductions are made, the Paramedic should ask the patient open-ended questions in an effort to help determine the problem.6 An open-ended question is one which cannot be answered simply with yes or no. This type of question allows Street Smart the patient to answer in his or her own words and generates a history which is less biased by the Paramedic’s own interpre- A good provider appears like the duck: smooth, calm, tation. A good example of an open-ended question would be: “What’s seems to be the trouble today?” or “Why did you call and well ordered on the surface, but underneath for EMS today?” Once a dialogue has been opened, the Para- paddling like crazy. An unfl appable demeanor in the medic should follow the patient’s lead and guide him through face of crisis is a great tonic not only to the patient, the interview without diverting the patient from his own but to the Paramedic’s fellow crewmembers. account. Some follow-up questions might be: “Can you tell me any more about that?”, and “Anything else you can think of?” Some techniques which might assist the Paramedic in this pro- cess include facilitation, refl ection, clarifi cation, interpreta- The Paramedic only has one chance to make a good tion, and direct questioning about feelings (Table 15-1). fi rst impression. A clean, neat, and professional appearance implies to a patient that the Paramedic will be a profi cient Table 15-1 Interviewing Techniques medical provider. A slovenly appearance, in contrast, leaves Facilitation the patient wondering if the Paramedic will take better care of Actions such as the Paramedic nodding his head in acknowledgement him than the patient can give himself. Due to the volume of and saying “Go on,” as well as trying to make eye contact, may information contained in the patient’s history, it may be nec- encourage the patient to continue talking about a subject. essary for the Paramedic to take notes during the interview. Refl ection Most patients are just fi ne with note taking, but it should never divert the Paramedic’s attention from the patient. If Repeating the patient’s words may encourage additional responses. An example would be: Paramedic: “You said it was a crushing pain?” note taking is necessary, the Paramedic should try to make Patient: “It felt like a vise around my chest.” Refl ection is helpful “shorthand” notes which she can then later transcribe onto because it typically doesn’t interrupt the patient’s train of thought. the fi nal report. Clarifi cation When the Paramedic meets the patient for the fi rst time, he should formally introduce himself and explain his job Make sure to clarify statements which are unclear or vague. function. For example, a Paramedic might say, “Good morn- Empathetic Response ing sir, I’m Marvin, a Paramedic with the ambulance.” If the Try to show the patient acceptance and understanding of how patient does not identify himself, then the Paramedic should he or she feels. ask for her name. The Paramedic might ask, “What would Confrontation you like us to call you?” When the patient’s story has been inconsistent, directly presenting the patient with the inconsistencies about the words or actions can sometimes be helpful. An example might be when a patient tells the Paramedic that the topic they are discussing is not disturbing to him, but then begins to cry. The Paramedic could then directly question the Cultural / Regional differences patient about this inconsistency. Interpretation In some regions, the fi rst name is used with Miss A step beyond confrontation in which the Paramedic, as the history or Mr., regardless of marital status. This denotes taker, actually makes an interpretation of the patient’s words or actions and presents it to the patient. For example, as in the previous case in respect. Using madam or sir when unsure of the interpretation the Paramedic might state why the Paramedic thinks the name is generally considered respectful. However, story is inconsistent. the Paramedic is advised to obtain the exact way the This results in direct questioning about feelings. patient wishes to be addressed. Madam may have Unless asked, patients may not offer how their chief concern makes them feel. negative connotations in some locales. History Taking 245 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Structure and Content of the Patient History Street Smart The patient history consists of several individual elements, each of which serves a specifi c purpose. Together these parts A patient’s vulgar language might at times be provide the structure of the history. A comprehensive medical appropriate to document as a refl ection of the mental history (Table 15-2) is taken to discover as much information status or state of behavior. Whenever a Paramedic about a patient’s concerns, interpersonal relationships, and medical history as possible. chooses to directly quote a patient’s words, she should make sure to use quotation marks around the The Focused History words and the phrase “patient states” before or after The comprehensive history, due to the extensive amount the quote. of data it collects, is often not used in emergent situations.
When time is of the essence, a focused history concentrating on the chief concern (CC), history of present illness (HPI), signifi cant past medical history (PMH), and pertinent cur- Table 15-3 SAMPLED History rent health status information is obtained. S Signs and symptoms (chief concern plus OPQRST AS/PN) The mnemonic SAMPLED can be used to help remem- A Allergies ber the different historical components that are important to M Medications obtain (Table 15-3). P Past medical history L List whatever is important based on chief concern: meal, MD visit, Chief Concern menses, and so on E Events leading up to chief concern The chief concern is the main reason for which the patient is D Does the patient have any advance directives (e.g., healthcare seeking medical care. It is best discovered by asking an open- proxy, POLST)? ended question. Whenever feasible, it should be expressed Table 15-2 Elements of a Comprehensive History Date and time • Psychiatric illnesses Identifying data • Accidents and injuries • Age • Operations • Sex • Hospitalizations • Race Current health status focuses on present state of health • Birthplace • Current medications • Occupation • Allergies Source of referral • Tobacco use • Who called the ambulance? • Alcohol, drugs, and related substances Source of history • Diet • Patient • Screening test • Family • Immunizations • Friends • Sleep patterns • Police • Exercise and leisure activities • Others • Environmental hazards • Reliability • Use of safety measures • Variable reliability Family history • Memory, trust, and motivation Psychosocial history • Assessed at the end of the interview • Home situation and signifi cant other Chief concern • Daily life History of present illness • Important experiences Past history • Religious beliefs • General state of health • Patient’s outlook • Childhood illnesses Review of body systems • Adult illnesses 246 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. and documented in the patient’s own words. Occasionally a Table 15-4 OPQRST AS/PN Mnemonic to Help patient’s own words will be too vulgar or ambiguous to use Obtain a History about Painful Concerns directly. In these cases, it is often best to paraphrase the com- Onset When did the pain start? ments in more precise medical language. Provoke What caused the pain? What makes it worse? History of Present Illness Quality Describe the pain. Region Where is the pain? Where did it start? Once the Paramedic has determined the main symptom that is causing the patient’s distress, it is important to gather as many Radiation Does the pain radiate or migrate? attributes of that symptom as possible. The responses given by Relief Is there anything that improves or relieves the pain? the patient allow the Paramedic to think about associated body Recurrence Is there anything that makes the pain return? systems and develop an idea of the nature of the illness. Sev- Severity How severe is the pain? eral mnemonics can be used to help the Paramedic recall the Timing When did it start? essential elements of the history based on the chief concern. Associated What other symptoms does the patient have along with The mnemonic OPQRST AS/PN (Table 15-4) can be used Symptoms the chief concern? for any concern of pain. The severity of pain can be measured Pertinent Associated symptoms important to the chief concern using a simple “mild, moderate, severe” scale or using a 0 to Negatives that are not present; for example, chest pain without 10 or Faces scale (Figure 15-2). Other mnemonics can also be shortness of breath. useful for specifi c chief concerns (Table 15-5). To gather further information, the Paramedic often needs to directly ask the patient questions about the symptoms. Past Medical History When asking a direct question of the patient, the Paramedic and Current Health Status should be careful not to ask a leading question. Certain information about the patient’s past medical history A leading question is one which may direct the patient and current heath status should be obtained with every patient toward an answer that might not necessarily have been given contact. However, there are many aspects of one’s medical his- if asked in another manner. For example, instead of asking tory, most of which are not necessary to obtain during a medi- “Was the pain crushing?” the Paramedic should ask, “Tell me cal emergency. The key is to focus on signifi cant historical what the pain in your chest was like.” The Paramedic should information or those aspects necessary to determine the nature also be careful to ask only one question at a time to avoid and potential severity of the patient’s illness or injury. All confusing the patient. The Paramedic should remember to patients should be questioned about chronic illnesses, medica- use language that is appropriate to the patient’s education and tions taken, allergies, and tobacco, alcohol, or other drug use. knowledge level. When in doubt, it is always best to use plain Some medical conditions are specifi c to related body sys- language instead of medical jargon. An example might be, tems (Table 15-6). Most patients should be specifi cally asked “Do you ever feel like your heart is racing?” as opposed to about heart problems, hypertension, breathing problems, and “Do you have palpitations?” diabetes. Universal Pain Assessment Tool This pain assessment tool is intended to help patient care providers assess pain according to individual patient needs. Explain and use 0–10 Scale for patient self-assessment. Use the faces or behavioral observations to interpret expressed pain when patient cannot communicate his/her pain intensity. 0 1 2 3 4 5 6 7 8 9 10 Verbal descriptor No Mild Moderate Moderate Severe Worst pain scale pain pain pain pain pain possible Wong-Baker facial grimace scale Alert No humor Furrowed brow Wrinkled nose Slow blink Eyes closed Smiling Serious Pursed lips Raised upper lips Open mouth Moaning Flat Breath holding Rapid breathing Crying Activity tolerance No Can be Interferes Interferes Interferes Bedrest scale pain ignored with tasks with concentration with basic needs required Figure 15-2 Example of several different pain assessment scales in one reference. (Photo courtesy of UCLA Department of Anesthesiology, David Geffen School of Medicine at UCLA) History Taking 247 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 15-5 Other Useful Mnemonics Table 15-6 Past Medical Conditions Related for Obtaining the History of Present Illness to Specifi c Body Systems System Elements System Past Medical History Any concern of pain OPQRST AS/PN as described Neurological Stroke, seizure, head injury previously Cardiovascular Acute myocardial infarction, angina, coronary Altered mental status AEIOU-TIPS artery bypass graft (CABG), angioplasty/cardiac A – alcohol catheterization E – epilepsy/seizure Respiratory Asthma, emphysema, smoking, hospitalization, I – insulin (hyper- and intubation hypoglycemia) O – overdose Gastrointestinal Surgery, abdominal aortic aneurysm, appendicitis, U – uremia/metabolic small bowel obstruction T – trauma Genitourinary STD, pregnancy, abortions, kidney stones I – infection Musculoskeletal Fractures, surgery, multiple sclerosis, sports injuries P – psychiatric S – stroke Psychiatric Depression, suicide attempts, admission, medications, drug and alcohol use Shortness of breath HAPI-SOCS H – history of pulmonary disease Endocrine Diabetes, thyroid disorder, surgery A – activity at onset Hematologic Leukemia, infection, travel, transfusion P – pain on inspiration Allergic Known allergies, allergy testing, anaphylaxis I – infection symptoms (chills, history night sweats, fever) S – smoker (# packs per day x number of years # pack years O – orthopnea C – cough? productive? Allergies S – sputum (and color)? The Paramedic should determine if the patient has any aller- Psychiatric/Depression IN SAD CAGES gies to medications. If an allergy is reported by the patient, IN – interest (apathy, withdrawn, the Paramedic should inquire what type of reaction the patient disinterested) had to the medication. In some cases, a reported allergy is S – sleep disorder (insomnia, night actually a common side effect or a familial “allergy” in which walking) A – appetite the patient’s relative is allergic, so the patient avoids a certain D – depression/mood swings medicine. If related to the chief concern, such as a bee sting, C – concentration the Paramedic should inquire about environmental allergies. A – activity G – guilt Medications E – energy The Paramedic should ask the patient about any medication S – suicidal ideation use and inquire about prescription, over the counter, and homeopathic or nutritional substances. The Paramedic should also determine if the patient is compliant with medication use and how long the patient has been taking each medicine. It is important to ask about recent changes in medications, such Street Smart as dosage. Occasionally when Paramedics ask a patient if he has Tobacco, Alcohol, and Drug Use any medical problems, some patients will tell the The use of tobacco, alcohol, or other recreational drugs is Paramedic that there are not any, even though there a signifi cant risk factor for many diseases.8–22 Knowledge of their use may raise the Paramedic’s index of suspicion for is a history of a chronic disease. People sometimes certain illnesses such as heart or vascular disease, COPD, and feel that, since they are under care for an illness, it cirrhosis. is no longer “a problem.” The best approach is to ask Clinical Reasoning if the patient has any medical problems and then ask Based on the patient’s chief concern, history of present ill- if the patient has ever been under a health provider’s ness, and answers to direct questioning, the Paramedic can care for any reason. develop a general sense of the body systems that may be involved in the patient’s problem. Forming this impression 248 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. will allow the Paramedic to decide which other questions she Regardless of the situation, the Paramedic should not should ask and which physical exams she should perform to let impatience show. If necessary, he should explain to the confi rm the Paramedic’s conclusion. Clinical decision mak- patient that time is short and that the current discussion will ing is discussed further in Chapter 17. be continued later. Special Challenges Patients with Multiple Symptoms Some patients seem to have every possible symptom. to History Taking Although it’s possible that this patient might have multiple The Paramedic can face diffi culty in obtaining an accurate organic illnesses, it’s more likely that other confounding fac- medical history in some situations. Application of several tors are present. The Paramedic should refocus the patient on simple techniques can assist the Paramedic in obtaining a his- one concern by asking the patient about the most important tory in these situations. concern, for example, “You told me many concerns. Which is the most important concern, or the reason you called us to Sensitive Topics help you today?” It is often imperative to question the patient about topics that Anxious Patients may be embarrassing or socially sensitive in order to learn more about factors which may have contributed to the illness. It is natural for a patient to be anxious during a medical These topics might include such issues as drug and alcohol emergency. For some patients, anxiety has signifi cant impli- use, physical abuse, and sexual history. Much of the diffi - cations in their
reaction to their illness or even may have culty in asking sensitive questions lies with our own biases, contributed to their illness. The Paramedic should be con- embarrassment, or perceptions with these topics. Some scious of nonverbal clues to the patient’s anxiety and, when patients will readily answer these questions when asked in a he senses anxiety, encourage the patient to talk about his or professional manner. Questioning a patient about these top- her feelings. ics becomes easier with experience. It is often helpful for each individual Paramedic to observe more seasoned provid- Reassurance ers obtaining this information and then develop an effective Providing reassurance to patients can be both benefi cial and method which works. harmful depending on the way it is provided. In an emer- gency situation, many patients worry not only about their Silence condition, but also how it affects others they care for or love. For many of us, silence is uncomfortable. Nonetheless, it By providing reassurance, the Paramedic can help calm the must be remembered that silence has many uses and possible patient down, allowing him to make appropriate medical meanings. Patients may use silence to collect their thoughts decisions or be more cooperative with the assessment and or remember details about their concerns. Silence may be the treatment. Conversely, reassurance can provide false hope if result of insensitivity by the Paramedic in asking questions, provided improperly. Statements like, “Everything will be or the patient may be taking some time to decide whether or OK” and “You have nothing to worry about” are detrimen- not to trust the Paramedic. tal when patient receive the news that they have developed Whenever confronted with unexpected silence, the Para- a severe condition. It is more appropriate to acknowledge medic should be alert for nonverbal clues of distress and try that there are factors that are of concern, but state that it is to determine if anything in his interview technique might be better to focus on getting well fi rst and take it a step at a responsible for them. time. Reassurance that the patient is in good hands or going to see a good physician can also help the Paramedic provide Overly Talkative Patients positive reassurance to the patient without creating a false It is easy to become impatient with an overly talkative patient expectation. when time is of the essence. A few techniques may be helpful in this diffi cult situation. Anger and Hostility Although not ideal, the Paramedic may have to lower It is not unusual for patients to exhibit anger toward health- expectations and accept a less comprehensive history. It care personnel for a variety of reasons, including feeling may be helpful for the Paramedic to allow the patient free unwell, suffering anxiety, or developing a feeling they have reign for the fi rst few minutes and then directly question the lost control over their lives. Paramedics should not take this patient about the most important details. If necessary, he behavior as anger against them personally. They can attempt should interrupt the patient as gently as possible and sum- to defuse the patient’s anger by identifying that, although they marize the history as succinctly as possible. Phrases such as understand he is angry, you are there to help him. Paramed- “I’d like to hear more about the chest pain you had before ics should always remember that their safety and that of their you called us” may help to refocus the patient on the chief crew are paramount, and thus they should retreat from any concern. situation which becomes dangerous.23,24 History Taking 249 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Intoxicated Patient patient’s concerns and instead attempt to focus in on a single chief concern. Acutely intoxicated patients who are belligerent, angry, or uncooperative can be some of the most diffi cult patients to Limited Intelligence interview. Paramedics should use a calm, direct voice and simple directions to encourage the patient to allow himself to Most patients with even moderately limited intelligence can be assessed and treated. The Paramedic should try to avoid usually give adequate histories. When patients suffer from talking to the patient in a confi ned area, as the patient may severe mental impairment, however, most of the history will feel trapped and react with hostility. Intoxicated patients can have to be derived from other sources, such as family, friends, be unpredictable; as a result, sudden violence is always a pos- or medical charts. The Paramedic should use simple language sibility.25 Paramedics should always have an escape route when interviewing the patient and listen closely as the patient planned and retreat from any situation which cannot be easily describes tests or other elements of his medical history. de- escalated.26 Patients who appear clinically intoxicated do However, the Paramedic should be careful about mak- not have the capacity to refuse care. Signs of clinical intoxica- ing assumptions about the patient’s level of functioning. The tion include slurred speech, disorganized thinking, inappropri- best technique, just as with any other patient, is to establish a ate responses to your questions, combativeness, and staggering relationship fi rst with the patient and then, if necessary, seek gait. A Paramedic may need to enlist the aid of local law other sources for history. enforcement to assist in bringing the patient to the emergency department for evaluation if the patient refuses to go. Language Barriers When confronted with a patient–provider language barrier, Crying the Paramedic should make every effort to obtain a transla- Crying is an important clue to emotions.27–29 The Paramedic tor. The best translator is a neutral, objective observer who should be supportive and wait for the patient to recover. Quiet is fl uent in both languages. Using a family member often acceptance or a supportive comment may assist the patient in leads to distorted meanings and may present a confi dentiality problem.31,32 composing herself and continuing the interview. Handing the The Paramedic should look at the patient when patient tissues is a gesture that is always appreciated. talking, and not the translator. Also, he should ensure that the translator asks the patient the question and is not just answer- Depression ing the question for the patient. Depression is a common medical problem and can have mul- tiple manifestations. The Paramedic should always maintain a high index of suspicion for depression in patients complain- Cultural / Regional differences ing of multiple, vague symptoms. If the patient is depressed, one should be concerned for the possibility of self-harm and question the patient directly about suicidal thoughts.30 Any In many regions and cultures, it is disrespectful patient with the potential for self-harm must be transported to for children to question their elders, especially in an emergency department for further evaluation. personal matters. Usually, however, the children Seductive Patients are fl uent in the two languages. If it is necessary Occasionally a provider may feel attracted to a patient. If to use children as translators, one should ask as the Paramedic becomes aware of such feelings, one should few questions as possible and alert the staff at the realize that these thoughts are normal responses. However, hospital so that a more thorough and accurate history one must prevent these feelings from affecting her profes- can be obtained. sional interaction with the patient. Some patients may make sexual advances toward the Paramedic. Paramedics need to make clear to these patients that the relationship with them is purely professional. It is unethical, and in some states illegal, Hearing Impaired Patients for a Paramedic to have a personal and/or sexual relationship Patients with hearing impairments may present as many issues with a patient who is under his or her care. as those with language barriers. The Paramedic should look at the patient directly while talking and speak slowly. Often Confusing Behaviors or Histories the patient is able to read lips well enough to answer the Para- Occasionally, despite best efforts, the patient’s history does medic’s questions. He should avoid shouting or raising his not appear to make sense and the Paramedic may feel baffl ed voice unless the patient indicates it helps her hear the ques- or confused. While many of these situations involve an emo- tions. If the patient has a “good ear,” the Paramedic should tional component, the Paramedic should avoid dismissing the make a point of speaking toward that ear. Communication 250 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. through written notes, although time-consuming, may be the Paramedic should avoid making any sudden movements that only solution to obtaining an adequate history. may increase the patient’s anxiety in what is likely already a stressful situation. Vision Impaired Patients When talking to a patient with limited vision, the Paramedic Family and Friends should make sure to identify herself, alert the patient to her Sometimes the Paramedic may need to elicit the history location, and explain what is being done. She should remem- from family, friends, or other bystanders.33 Whenever pos- ber to always respond vocally to the patient and avoid rais- sible, the Paramedic should get the patient’s permission to ing her voice while speaking. The Paramedic may need to discuss the condition with the other person. If the Para- explain procedures and actions in more detail than is needed medic cannot get permission, then he should remember that for patients with normal vision. If walking with a patient with all medical information derived from the patient interview vision impairment, the patient should grasp the Paramedic’s or exam must be held confi dential and not shared with the arm rather than the Paramedic grasping his or hers. The third party.34–37 History Taking 251 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The novice Paramedic must master the skill of history taking in order to be effective at providing care to the vast array of patients encountered during one’s career. With practice and by observing other experienced healthcare providers obtain a history from a patient, the novice Paramedic will soon develop and refi ne her skill. Key Points: • History taking is the medical questioning of a • The chief concern is the main reason EMS patient for purposes of ascertaining the disorder, was activated and should be expressed and syndrome, or condition affecting the patient that documented in the patient’s own words using resulted in the activation of EMS. quotation marks. • The Paramedic must be aware of the messages • Several methods can be used to assess a patient’s transmitted by words and actions and have a pain, from a simple “mild, moderate, severe” scale professional appearance and calm demeanor. to a 0 to 10 or faces scale. • The Paramedic should formally and respectfully • The mnemonic device OPQRST AS/PN can be used introduce himself and explain his job function. for any concern of pain. The mnemonic AEIOU-TIPS • is used for altered mental status. The Paramedic should inquire as to the patient’s preferred manner of address. • The mnemonic HAPI-SOCS is used for shortness of • breath. An open-ended question allows the patient to answer in his or her own words rather than give a • The mnemonic IN SAD CAGES is used for psychiatric
simple answer of yes or no. issues/depression. • Interviewing techniques which assist the • The mnemonic SAMPLE is used for gathering Paramedic in developing questions and promote past history. Ask additional questions for dialogue include facilitation, refl ection, clarifi cation. clarifi cation, interpretation, and direct questioning. • The Paramedic should be conscious of nonverbal • A comprehensive medical history is taken to clues to anxiety or anger. discover as much information as possible about a patient’s concerns, interpersonal relationships, and • When communicating with an acutely intoxicated medical history. However, it is often not used in patient, the Paramedic should use a calm direct emergent situations due to the extensive amount of voice, and give simple directions to encourage data it collects and time required. patient access to evaluation and treatment. • A focused history can be conducted by the • Strong emotions exhibited by the patient during an Paramedic to concentrate on the chief concern, interview may require the Paramedic to assist the history of present illness, signifi cant past medical patient through quiet acceptance or a supportive history, and pertinent current health status. comment. The mnemonic SAMPLE is used to remember the • The Paramedic should always keep the patient different historical components of a focused relationship professional. history. 252 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • The Paramedic should use simple language, listen • The Paramedic should explain who he is, where he closely, and not make assumptions about a patient’s is, and what he will be doing in a clear, normal tone level of function when interviewing patients with of voice for the vision impaired patient. mental impairments. • All medical information derived from the patient • When confronted with a patient––provider language interview or exam must be held confi dential and not barrier, the Paramedic should make every effort to shared with a third party. obtain a translator. Review Questions: 1. How can the Paramedic set the stage for an responsive, and hypoxemic on room air. You effective patient interview? attempt to obtain a history from the patient 2. List the interviewing techniques that can assist without success due to his mental status. What the Paramedic in developing questions and other sources of information can be helpful promote dialogue with a patient. to you and the emergency department? What 3. A male patient makes sexually suggestive questions are important to ask? statements to a female Paramedic. How should 7. If confronted with an overly talkative patient, the Paramedic handle this patient? what can the Paramedic do to effectively gather 4. List the components of the focused history a medical history? and the information acquired by asking those 8. Using a translator, a Paramedic is speaking with questions. a patient with a language barrier. What should 5. Why is it critical for the Paramedic to ask about he be conscious of when asking and receiving tobacco, alcohol, and other recreational drugs? responses to questions? How might the Paramedic do so? 6. You are called to a nursing home to transport an elderly male patient who is febrile, barely Case Study Questions: Please refer to the Case Study at the beginning of the • Altered mental status chapter and answer the questions below. • Psychiatric disorders or depression 1. What mnemonic is best for 2. What is the value of a mnemonic in history • Shortness of breath gathering? • Pain History Taking 253 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. References: 1. Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination results from an FMRI study. Neuropsychopharmacology. and History Taking (9th ed.) with E-Book (Guide to Physical 2008;33(2):247–258. Exam & History Taking (Bates)). Philadelphia: Lippincott 20. Swahn MH, Bossarte RM. Gender, early alcohol use, and Williams & Wilkins; 2007. suicide ideation and attempts: fi ndings from the 2005 youth risk 2. Trautlein JJ, Lambert RL, Miller J. Malpractice in the emergency behavior survey. J Adolesc Health. 2007;41(2):175–181. department—review of 200 cases. Ann Emerg Med. 1984; 21. Cunningham R, Walton MA, et al. Past-year violence typologies 13(9 Pt 1):709–711. among patients with cocaine-related chest pain. Am J Drug 3. Considine J, Botti M, Thomas S. Do knowledge and experience Alcohol Abuse. 2007;33(4):571–582. have specifi c roles in triage decision-making? Acad Emerg Med. 22. Levis JT, Garmel GM. Cocaine-associated chest pain. Emerg 2007;14(8):722–726. Med Clin North Am. 2005;23(4):1083–1103. 4. Croskerry P, Sinclair D. Emergency medicine: a practice prone 23. Hodge AN, Marshall AP. Violence and aggression in the to error? Cjem. 2001;3(4):271–276. emergency department: a critical care perspective. Aust Crit 5. Juckett G. Cross-cultural medicine. Am Fam Physician. Care. 2007;20(2):61–67. 2005;72(11):2267–2274. 24. Ray MM. The dark side of the job: violence in the emergency 6. Novack DH, Dube C, Goldstein MG. Teaching medical department. J Emerg Nurs. 2007;33(3):257–261. interviewing. A basic course on interviewing and the physician– 25. Allely P, Graham W, McDonnell M, Spedding R. Alcohol levels patient relationship. Arch Intern Med. 1992;152(9):1814–1820. in the emergency department: a worrying trend. Emerg Med J. 7. McGuire BN, Ahmed AH, Regan T. Methods of obtaining 2006;23(9):707–708. a medical history in the emergency department. Academic 26. Ferns T, Cork A, Rew M. Personal safety in the accident and Emergency Medicine. 2001;8(5):469–470. emergency department. Br J Nurs. 2005;14(13):725–730. 8. O’Keefe JH, Bybee KA, Lavie CJ. Alcohol and cardiovascular 27. Casement PJ. Learning from the Patient. New York: The Guilford health: the razor-sharp double-edged sword. J Am Coll Cardiol. Press; 1992. 2007;50(11):1009–1014. 28. Tateno A, Jorge RE, Robinson RG. Pathological laughing and 9. http://www.cdc.gov/alcohol/ crying following traumatic brain injury. J Neuropsychiatry Clin 10. Boffetta P, Garfi nkel L. Alcohol drinking and mortality among Neurosci. 2004;16(4):426–434. men enrolled in an American Cancer Society prospective study. 29. Murube J, Murube L, Murube A. Origin and types of emotional Epidemiology. 1990;1(5):342–348. tearing. Eur J Ophthalmol. 1999;9(2):77–84. 11. Beulens JW, Hendriks HF. Alcohol and ischaemic heart disease. 30. Dominguez OJ, Jr. What’s so unusual? Emerg Med Serv. Lancet. 2006;367(9514):902; author reply 902. 2001;30(3):102. 12. Chao A, Thun MJ, Jacobs EJ, Henley SJ, Rodriguez C, Calle EE. 31. Dunckley M, Hughes R, Addington-Hall J, Higginson IJ. Cigarette smoking and colorectal cancer mortality in the cancer Language translation of outcome measurement tools: views of prevention study II. J Natl Cancer Inst. 2000;92(23):1888–1896. health professionals. Int J Palliat Nurs. 2003;9(2):49–55. 13. Villeneuve PJ, Mao Y. Lifetime probability of developing 32. Rollins G. Translation, por favor. Hosp Health Netw. lung cancer, by smoking status, Canada. Can J Public Health. 2002;76(12):41, 46–50. 1994;85(6):385–388. 33. Herman M, Le A. The crying infant. Emerg Med Clin North Am. 14. Calle EE, Miracle-McMahill HL, Thun MJ, Heath CW, 2007;25(4):1137–1159, vii. Jr. Cigarette smoking and risk of fatal breast cancer. Am J 34. Campbell SG, Sinclair DE. Strategies for managing a busy Epidemiol. 1994;139(10):1001–1007. emergency department. Cjem. 2004;6(4):271–276. 15. Pinto BM, Rabin C, Farrell N. Lifestyle and coronary heart 35. Moskop JC, Marco CA, Larkin GL, Geiderman JM, Derse disease prevention. Prim Care. 2005;32(4):947–961. AR. From Hippocrates to HIPAA: privacy and confi dentiality 16. Hughes JR. Clinical signifi cance of tobacco withdrawal. in emergency medicine—part II: challenges in the emergency Nicotine Tob Res. 2006;8(2):153–156. department. Ann Emerg Med. 2005;45(1):60–67. 17. http://www.cancer.gov/cancertopics/factsheet/Tobacco/ 36. Moskop JC, Marco CA, Larkin GL, Geiderman JM, Derse cessation AR. From Hippocrates to HIPAA: Privacy and confi dentiality 18. Daniel JC, Huynh TT, Zhou W, Kougias P, El Sayed HF, Huh J, et in emergency medicine—part I: conceptual, moral, and legal al. Acute aortic dissection associated with use of cocaine. J Vasc foundations. Ann Emerg Med. 2005;45(1):53–59. Surg. 2007;46(3):427–433. 37. Olsen JC, Sabin BR. Emergency department patient perceptions 19. Jager G, de Win MM, van der Tweel I, Schilt T, Kahn RS, van of privacy and confi dentiality. J Emerg Med. 2003;25(3): den Brink W, et al. Assessment of cognitive brain function 329–333. in ecstasy users and contributions of other drugs of abuse: 254 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The four components of each physical exam • When a focused history and physical exam should be conducted on the scene or a rapid physical exam is appropriate • Detailed physical examination and its appropriate use • Matching the proper physical assessment with the patient’s presentation or chief complaint • The ongoing assessment as a repeat of the initial assessment and used to detect trends Case Study: Two new students were in the back of the room, bored. They asked each other, “Why do we bother doing a physical exam? The nurses don’t pay attention to us and the docs just repeat everything.” The instructor for the class, a senior Paramedic, said,” Come over here. I’ll bet that after a few minutes, you can fi gure out whether this ‘patient’ has pneumonia or congestive failure. You can also select the correct treatment as the wrong one can worsen your patient’s condition.” After practicing for a while, the students were convinced! 256 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Physical Examination and Secondary Assessment 257 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW After performing the initial assessment and determining patient priority, the next step in patient assessment is to conduct the appropriate history and physical exam. This chapter reviews the basic components of a focused assessment. It also provides techniques for gathering a patient’s vital signs. In this chapter physical assessments are identifi ed by mechanism of injury or the patient’s chief concern. The detailed physical examination is performed on a patient to determine additional information. However, it may not be appropriate for all patient encounters. The ongoing assessment is also a critical component that allows the Paramedic to alter the treatment plan if needed based on established trends. The ongoing assessment is a repeat of the initial assessment, which is performed continuously throughout the patient encounter. Physical Examination vital signs to complete the physical examination. The Para- medic then combines these physical examination fi ndings, During a
physical examination (also called exam), the Para- the vital signs, and the history (discussed in Chapter 15) and medic performs an assessment of the patient from head to formulates a treatment plan for the patient. These skills are toe in an effort to detect signs associated with a disease or critical. Although these skills were probably addressed in the condition. This may include signs that confi rm that a disease Paramedic’s basic EMS classes, they will be expanded for the or condition is present, thus helping the Paramedic decide Paramedic as a higher skill level is required. which condition is most likely causing the patient’s chief con- cern during this encounter. One example is auscultation of Inspection the breath sounds to decide whether the patient’s shortness Inspection is a physical examination technique that involves of breath is due to heart failure or asthma. The physical exam looking at the patient (Figure 16-1). This can take many forms may also detect signs of a disease or condition that is pres- depending upon the specifi c body system under inspection. ent and not related to the patient’s chief concern, but which The Paramedic should observe the patient and her immedi- may need to be addressed by the Paramedic. For example, ate environment. Observing the patient’s posture and apparent when evaluating a patient who complains of chest pain, the level of distress can give clues to the severity of the illness. Paramedic may determine, by the patient’s history, that the Making observations about the environment in which the condition is cardiac in nature. This could lead the Paramedic Paramedic fi nds the patient can help in determining the mech- to decide that the patient has developed heart failure during anism of injury, the patient’s ability to carry out the activities this cardiac event after auscultating the breath sounds. of daily living, or hazards in the patient’s living environment By developing excellent physical examination skills, the that may lead to future injury or illness. Observing the envi- Paramedic can determine a treatment plan when the history ronment may allow the Paramedic to discover information that does not clearly provide a guide. These skills are also impor- leads to additional history taking. Make note of such things as tant in situations where the history is not obtainable, as in the mechanism of injury, medication bottles, any evidence of any case of an unconscious patient. Excellent physical examination illicit drug or alcohol use, and general living conditions.2,3 skills develop through practice, understanding the pathophysi- Examples of body system-specifi c fi ndings from inspec- ology of disease, and understanding how diseases commonly tion include discovering lacerations, ecchymosis (bruising), present themselves.1 Whether performing clinical rotations or or abrasions in an injured extremity; observing jugular being a practicing Paramedic, it is helpful to ask the ED prac- venous pressure during a cardiovascular exam; or observ- titioners to point out interesting examination fi ndings. This ing the abdomen for distention. These fi ndings are discussed helps Paramedics recognize them on future patients. later in the chapter during the system specifi c examinations. As inspection is diffi cult to fully accomplish with a Physical Examination Techniques clothed patient, it typically requires the patient to be exposed. J udgment is required to balance the need for a complete exam- There are four components to every physical exam: ination and the need to keep the patient warm ( considering (1) inspection, (2) auscultation, (3) palpation, and (4) per- the environment in which the examination is occurring) and cussion. These four components are the essential “hands on” the patient’s modesty intact. Certain components of inspec- techniques used to assess the patient. In addition to these four tion may need to wait until the patient is moved to the relative techniques, the Paramedic routinely measures the patient’s privacy of the ambulance. 258 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. made up of a hollow fl exible tube connected to ear pieces that are placed in the Paramedic’s ears. The other end of the stetho- scope comes in several different sizes (depending on whether the patient is a neonate, adolescent, or adult) and typically consists of two heads: one that is fl at (called the diaphragm) and one that is cup-shaped (called the bell) (Figure 16-2). The diaphragm is covered with a thin plastic membrane and acts like the tympanic membrane (eardrum) to amplify and transmit sounds up the stethoscope to the Paramedic’s ears. The diaphragm is placed fi rmly against the bare skin (Fig- ure 16-3a) and is used to pick up higher pitched sounds (e.g., breath sounds). In contrast, the bell is placed lightly on the bare skin (Figure 16-3b) and is used to pick up lower pitched sounds (e.g., the whoosh of a carotid bruit). If the bell is held too tightly against the skin, the skin will stretch tight and act like the diaphragm. In this case, it will lose the ability to detect the lower pitched sounds.4,5 When auscultating the patient, note both normal or abnormal sounds, the location of the sounds, and the intensity of the sounds. Specifi c auscultation techniques and fi ndings will be detailed later in this chapter when discussing specifi c body system exams. Palpation Palpation is the most frequently used physical exam tech- Figure 16-1 Inspection of a trauma patient’s nique. It involves the provider placing his hands or fi ngers abdomen for ecchymosis. on the patient’s body in an effort to detect any abnormali- ties. Palpation can take many forms depending upon the abnormality the Paramedic is assessing. Different forms Auscultation of palpation can be used to assess for stability and assess Auscultation is assessing the patient through listening. The for tenderness. Deep palpation can be used to assess deeper assessment tool used during auscultation, the stethoscope, is structures (e.g., deep palpation of the abdomen to detect Tubing Bell Diaphragm Earpieces Figure 16-2 Anatomy of a stethoscope. Physical Examination and Secondary Assessment 259 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (a) (b) Figure 16-3 (a) Auscultation using the diaphragm. (b) Auscultation using the bell. tenderness or masses) (Figure 16-4a), while light palpa- Vital Signs Measurement tion can be used to assess for superfi cial fi ndings (e.g., Vital signs are objectively measured characteristics of basic light palpation of the anterior chest wall to detect subcu- body functions. Vitals signs provide the Paramedic with an taneous emphysema) (Figure 16-4b). Firm palpation along indication as to how well the patient’s body is functioning a bony structure can assess for tenderness or crepitus or compensating for an injury or illness. Historically, the (Figure 16-4c). The stability of a joint may be assessed by vital signs included pulse, respirations, blood pressure, and fi rmly grasping the bones distal and proximal to the joint temperature. In the late 1990s, with the emphasis on appro- and applying stress to the joint’s connective tissues (Figure priate assessment of pain and discomfort by all medical 16-4d). Specifi c fi ndings and palpation techniques are dis- professions, the Joint Commission on Hospital Accredita- cussed later in this chapter. tion suggested adding the assessment of the patient’s pain as the fi fth vital sign, even though pain is technically clas- Percussion sifi ed as a symptom.6,7 Finally, some consider measurement Percussion is the act of lightly but sharply tapping the of the patient’s peripheral oxygen saturation (SpO2), also body surface to determine the characteristics of the under- known as pulse oximetry, as the sixth vital sign. Assessment lying tissue. It is performed by sharply striking the hyper- of the patient’s vital signs is reviewed in the following text extended distal joint of one middle fi nger with the tip of and the concept of assessing for orthostatic hypotension is the partially fl exed middle fi nger of the other hand (Figure discussed. 16-5). Percussion assesses whether the underlying tissues are air-fi lled, fl uid fi lled, or solid by the quality of the per- Pulse cussion note. Air-fi lled structures will produce a hollow, The pulse can be assessed at one of several locations tympanic percussion note similar to that of a drum. Fluid- where a major artery lies close to the surface of the skin fi lled structures will produce a dull percussion note. This (Figure 16-7). The most easily accessed area for conscious can be simulated by taking a full plastic bottle of water, patients is the radial pulse at the wrist over the radial artery. laying it on its side, and percussing the bottle. Solid struc- For unconscious patients, the carotid pulse in the ante- tures will provide a loud, well-defi ned percussion note. rior neck is often used during the initial assessment. Other This can be simulated by performing percussion on a table pulses the Paramedic may utilize are the femoral pulse at or desk. the patient’s groin and the dorsalis pedis (DP) pulse over Due to the high level of background noise in the fi eld, it the dorsum of the foot. Assess the pulse for rate, rhythm, is often diffi cult to hear the percussion note generated dur- and quality. The pads of the fi ngers are used to assess for the ing percussion. In that event, the Paramedic may be able to pulse by placing light pressure over the location of the pulse. modify the percussion technique and use her stethoscope to The pads of the fi ngers are used as they have more nerve amplify the percussion note (Figure 16-6). Percussion can add endings than the tips and can better detect the presence and valuable information to the patient examination. Specifi c per- quality of the pulse.8 Firm pressure can alter the perception cussion fi ndings and techniques will be discussed later in the of the pulse quality and rhythm, or in some cases occlude the chapter. pulse completely. 260 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (b) (a) (c) (d) Figure 16-4 Examples of palpation. (a) Deep palpation of the abdomen. (b) Light palpation of the anterior chest wall. (c) Palpation along a bony structure. (d) Assessing joint stability. Street Smart While it is relatively easy to detect a pulse in a normal patient, it can be very diffi cult to detect a carotid pulse when the patient is in cardiac arrest.9,10 This fact is emphasized by research that indicates laypeople could not reliably fi nd a pulse in patients in cardiac arrest. Subsequently, the American Heart Association removed pulse checks from its citizen CPR Figure 16-5 The technique of percussion. Note program and replaced it with “signs of life.” the fi nger position used by the Paramedic. Physical Examination and Secondary Assessment 261 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (a) (b) Figure 16-6 Modifi cation of the percussion to allow improved detection of the percussion
note. Table 16-1 Normal Pediatric Heart Rates by Age Temporal Patient Age Beats/Minute Carotid Newborn 120–160 Infant (0–5 months) 90–140 Infant (6–12 months) 80–140 Apical Toddler (1–3 years) 80–130 Brachial Preschooler (3–5 years) 80–120 School-ager (6–10 years) 70–110 Adolescent (11–14 years) 60–105 Radial Femoral Young or middle-aged adult (15–64 years) 60–100 A normal pulse rate for an adult is considered anywhere from 60 to 100 beats per minute. The normal pulse rates are different for children (Table 16-1). Bradycardia is defi ned Popliteal as a heart rate that is under 60 beats per minute for an adult or below the lower limit of normal for a child. Tachycardia is defi ned as a heart rate that is over 100 beats per minute for an adult or above the upper limit of normal for a child. While the most accurate way to determine the patient’s pulse Posterior tibial Dorsalis pedis rate is to count the number of beats that occur in one minute, two other methods also provide a reasonable determination of pulse rate. One method is to count the number of heartbeats in Figure 16-7 Common pulse points. a 15-second time period and multiply that by four. A second 262 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. is to count the number of beats in a 30-second time period quality. An injury to an upper extremity may cause the radial and multiply that by two. If the patient’s pulse is regular, pulse to be absent in that extremity. Peripheral vascular dis- the shorter time can be used to determine an accurate pulse ease in a lower extremity, which decreases blood fl ow to that rate. The more irregular the patient’s pulse, the longer time is extremity, can cause a decrease in pulse quality compared to required to determine an accurate estimate of the pulse rate. the upper extremities. In some cases, the pulse is so irregular or the rate changes so Finally, it is important to note that the pulse rate palpated rapidly that a range of pulse rates is reported (e.g., the patient’s by the Paramedic, which determines the patient’s mechanical pulse rate varies between 120 and 140 beats per minute). pulse rate, may be different than the heart’s electrical rate as Generally, the Paramedic can assess the pulse rate by pal- shown on an electrocardiogram (ECG) rhythm monitor. pating the pulse at one of the locations previously described. However, when the patient is signifi cantly tachycardic, in the 180 to 220 beats per minute range, it can be diffi cult to count Street Smart the pulse rate using palpation. In this situation, the Paramedic may need to use a stethoscope to listen to the heart and count an apical pulse, or the pulse rate at the chest. In infants and During shock, the patient will lose distal pulses toddlers, where the normal heart rate is well over 100 beats fi rst (i.e., radial before femoral and femoral before per minute, the Paramedic may also need to assess the apical carotid). A quick survey of pulses can be helpful in pulse rate (Figure 16-8). Assess the rhythm of the pulse to determine its regularity. establishing the presence of shock. However, no Is the rhythm regular or does the timing between individual statement can be made about the patient’s blood beats vary signifi cantly? Are there premature beats that occa- pressure based upon the presence or absence of distal sionally and briefl y interrupt the underlying regular rhythm, pulses. or is the rhythm chaotically irregular, one that does not follow any pattern? This chaotically irregular pulse is sometimes termed an irregularly irregular pulse to indicate the complete absence of a pattern to the pulse rhythm. Respirations Pulse quality is a description of the amplitude or strength Respirations are assessed by observing the respiratory rate, of the pulse at that particular location. Pulse quality is often depth, pattern, and work of breathing. The respiratory rate is described as normal, absent, strong, bounding, weak, or assessed by watching chest rise or auscultating breaths with a thready. The term “thready” is usually given to pulses which stethoscope and counting the number of breaths (Figure 16-9). are both weak and very rapid, as seen with heart rates that The normal adult respiratory rate at rest is between 12 and 24 are signifi cantly tachycardic. Pulse quality may be different breaths per minute. The respiratory rate can be determined by depending on the location of the pulse and the patient’s condi- counting the number of respirations in either a full minute or tion. In a healthy individual free of disease or complaint, the the number of respirations in 30 seconds and multiplying that pulse quality should be the same regardless of the location count by two. In general, the respiratory rate is best counted of the pulse. However, some conditions will affect the pulse when the patient is not aware that the Paramedic is counting the rate. In contrast to the pulse rate, a patient can control his respiratory rate much easier than his pulse rate (Table 16-2). Figure 16-8 Paramedic assessing an apical pulse in a child. The stethoscope is held over the lower sternum to the left and the pulse rate is counted Figure 16-9 Paramedic assessing a patient’s as described in the text. respirations. Physical Examination and Secondary Assessment 263 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 16-2 Normal Respiratory Rate by Age Patient Age (yr) Breaths/Minute Infant (birth-1) Initially 40–60; rate drops to 30–40 after a few minutes; slows to 20–30 by 1 year Toddler (1–3) 20–30 Preschooler (3–5) 20–30 School-ager (6–10) 15–30 Adolescent (11–14) 12–20 Young or middle-aged adult (15–64) 12–20 Older adult (65) Depends on patient’s health Along with the rate, the Paramedic should note the depth 1. Eupnea (normal) of respiration. The depth can be described as shallow, nor- mal, or deep. A shallow respiration is less than the normal chest excursion and typically produces an inadequate respi- 2. Tachypnea 3. Bradypnea ration. Another term used to describe shallow respirations is hypoventilation. Hypoventilation can be caused by drug overdose, head injury, or other conditions that can cause 5. Cheyne-Stokes coma. A deep respiration is deeper than normal and is termed 4. Apnea hyperventilation. Examples of conditions that can cause hyperventilation include respiratory distress, a metabolic condition, or drug overdose. 6. Biot’s 7. Apneustic The respiratory pattern is considered the rhythm of the respirations. The respiratory pattern is the combination of the timing of the respirations and the depth of respirations 8. Agonal 9. Shallow (F igure 16-10). Different causes exist for many of these abnormal patterns (Table 16-3). 10. Hyperpnea 11. Air trapping Street Smart 12. Kussmaul’s 13. Sighing The Paramedic should be prepared to assist ventilations whenever a patient is either hypoventilating or hyperventilating, as both of these Figure 16-10 Abnormal respiratory patterns. respiratory situations can represent ineffective ventilation.11,12 Table 16-3 Selected Abnormal Respiratory Patterns, Their Description, and Cause Pattern Description and Cause Cheyne-Stokes Gradually increasing rate and tidal volume, which increases to a maximum, then gradually decreases; occurs in brain stem injuries Biot’s Irregular pattern and volume, with intermittent periods of apnea; found in patients with increased intracranial pressure Agonal Slow, shallow, irregular respiration; results from brain anoxia Kussmaul’s Deep gasping respirations, representing hyperventilation, “blowing off” of excess carbon dioxide and compensation for an abnormal accumulation of metabolic acids in the blood; though possible in any patient with metabolic acidosis, best known with diabetic ketoacidosis Central neurogenic hyperventilation Deep, rapid, regular respiration; found in patients with increased intracranial pressure 264 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Accessory muscle use (a) Sternal retractions (d) (b) (c) (e) Figure 16-11 Signs of increased work of breathing. (a) Accessory muscle use. (b) Sternal retractions. (c) Rib retractions. (d) Tripod position. (e) Pursed lip breathing. The patient’s work of breathing is also assessed to to breathe and accessory muscles are recruited to help measure the level of respiratory distress. There are several expand the rib cage, allowing the patient to inhale. When signs that indicate an increased work of breathing. During these muscles are used, they tend to become more defi ned normal respiration, the chest expands effortlessly. When (Figure 16-11a). When the work of breathing increases, a patient is in respiratory distress, more effort is required more effort is needed to generate the negative pressure in Physical Examination and Secondary Assessment 265 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. the thorax required for inspiration. When this happens, the provide the Paramedic with an indication about the blood skin at the top of the sternum and the skin between the volume status or compensation for illness in a given patient. ribs are pulled inwards because of this negative pressure Both the arterial and venous blood vessels have elasticity and in the chest. These fi ndings are termed sternal retrac- change vessel diameter in response to changes in fl uid vol- tions (Figure 16-11b) and rib retractions (Figure 16-11c), ume, pressure, and pathological conditions, with the arterial respectively. Patients in respiratory distress also will posi- system much more elastic than the venous system. Younger tion themselves in a way to help improve breathing. The patients can compensate for changes in pressure and volume tripod position (Figure 16-11d) is a sign that the patient status because of the increased elasticity of their blood ves- is in severe respiratory distress. This position allows the sels. The pulse pressure in an adult at rest is normally approx- overworked accessory muscles to work better, although imately 40 mmHg. Conditions that affect cardiac output, the most patients begin to tire when they are in such severe volume of blood pumped out of the left ventricle in one min- respiratory distress. Pursed lip breathing (Figure 16-11e) ute, can cause a decreased pulse pressure. In general, the dia- is another sign of increased work of breathing. When the stolic pressure holds relatively steady or drops slightly, while exhalation pressure is high, the alveoli tend to collapse dur- the systolic pressure drops more than the diastolic p ressure. ing exhalation. The patient puckers his or her lips while Conditions that cause a drop in blood fl uid volume (e.g., exhaling, providing some resistance to exhalation that pro- hemorrhage or shock from other causes) can cause a widen- vides pressure to keep the alveoli open.13–16 ing of the pulse pressure, especially in younger or otherwise fi t patients.18 Those patients may be able to initially sustain a Blood Pressure near normal or slightly decreased systolic pressure. However, Blood pressure is a measure of the pressure within the blood when the heart relaxes, the diastolic pressure is signifi cantly vessels that make up the circulatory system. The pressure will less than normal for that patient. Pulse pressure may provide vary depending
upon the type of vessel and the phase of heart the Paramedic with an early clue to shock in patients who contraction. When the Paramedic measures blood pressure, otherwise appear to be stable. he is measuring the pressure within the arterial system. Blood To properly measure blood pressure, the patient’s arm pressure is measured at its maximum and minimum. The should be positioned at the level of her heart. Support the maximum blood pressure is measured during systole when patient’s arm at mid-chest level and center a properly sized the heart contracts, and is called the systolic blood pressure. cuff over the brachial artery of the arm (Figure 16-13). The The minimum blood pressure is measured during diastole blood pressure can be measured by either palpation or by aus- when the heart relaxes and fi lls, and is called the diastolic cultation. When measuring the blood pressure by palpation, blood pressure. These two levels of blood pressure are gen- the radial pulse is palpated by the Paramedic while infl ating erated by the heart’s intermittent contractions. Blood pressure the blood pressure cuff. The Paramedic infl ates the blood pres- can also be reported as a single pressure, the mean arterial sure cuff approximately 10 to 20 mmHg above the loss of the pressure (MAP), which is the average pressure in the arte- pulse, and then slowly defl ates the cuff until the pulse returns. rial system over time (Figure 16-12). A typical mean arte- The point where the pulse returns is the systolic pressure. rial pressure that will maintain adequate cerebral perfusion is When reporting a blood pressure measured by palpation, the about 60 to 80 mmHg.17 An adequate blood pressure is neces- Paramedic verbally reports the pressure “by palpation” (for sary for adequate perfusion of the body’s organs; however, a example, “124 by palpation”) and records the systolic pres- chronically elevated blood pressure can lead to increased risk sure as a fraction with a P as the denominator (e.g., 124/P). of catastrophic cardiovascular events. The palpation method is useful in situations where there is a The pulse pressure is defi ned as the difference between lot of ambient noise that would make it diffi cult to auscultate the systolic and diastolic pressures. The pulse pressure can the blood pressure. The auscultation method is a more accurate method of measuring blood pressure. The Paramedic places the blood pressure cuff on the patient’s arm as previously described and MAP = SBP + (2 × DBP) places the diaphragm of the stethoscope over the brachial artery (Figure 16-14).19 The Paramedic infl ates the cuff until 3 the sound of the heartbeat disappears and infl ates the cuff MAP = mean arterial pressure an additional 10 to 20 mmHg. Next, the Paramedic slowly SBP = systolic blood pressure defl ates the cuff at a rate of approximately 2 to 3 mmHg per second and notes the pressure at which she hears the sounds of DBP = diastolic blood pressure at least two consecutive beats. This is the systolic blood pres- sure. The Korotkoff sounds heard during the infl ation and Figure 16-12 Computing mean arterial pressure defl ation of the cuff are caused by the change in the nature of (MAP). Many automated noninvasive blood blood fl ow though the artery.20,21 To obtain the diastolic blood pressure monitors automatically calculate and pressure, the Paramedic continues defl ating the cuff slowly, display MAP. until she notes a muffl ing and then a disappearance of the 266 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 16-13 Proper placement of a blood pressure cuff helps ensure accurate measurement. Figure 16-14 Measuring the blood pressure by auscultation. Korotkoff sounds. This is the diastolic blood pressure. The limit of normal indicates hypertension. A systolic blood pres- Paramedic records both systolic and diastolic blood pressure sure below the lower limit of normal indicates hypotension. readings to the nearest 2 mmHg. In an adult, a blood pressure greater than 139 mmHg systolic Blood pressure readings vary signifi cantly with patient or 89 mmHg diastolic are always considered abnormally ele- age, underlying physical and medical conditions, and current vated and a systolic pressure below 90 mmHg is considered medications. A systolic blood pressure that is above the upper abnormally low (Table 16-4). Physical Examination and Secondary Assessment 267 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 16-4 Normal Blood Pressures Blood Pressure (mmHg) Patient Age (Years) Systolic Diastolic Infant and toddler (0–3) 80 (2 times age in years) Two-thirds systolic Preschooler (3–5) 78–116 average 55 School-ager (6–10) 80–122 average 57 Adolescent (11–14) 88–140 average 59 Young and middle-aged adult (15–64) 90–150 60–90 Older adult (65) Depends on patient’s health Depends on patient’s health Temperature the color of the mucous membranes in the mouth, the palms The body’s normal core temperature ranges from 36.1°C to of the hands and soles of the feet, or the conjunctiva (Fig- 37.7°C (97°F to 99.8°F). A temperature above 38°C (100.4°F) ure 16-16) in darker skinned patients to determine skin color. is considered a fever. An elevated body temperature is called Skin condition is generally categorized as normal, dry, moist, hyperthermia. In contrast, hypothermia is defi ned as a or diaphoretic. A patient with diaphoretic skin is sweat- body temperature less than 35°C (95°F). Relatively accurate ing profusely. This state is associated with many different estimates of core temperature can be obtained from oral, rec- conditions. tal, or tympanic thermometers (Figure 16-15), with the rectal temperature as the most accurate estimate of the core body Pain temperature. As previously discussed, assessment of pain was consid- ered the fi fth vital sign by the Joint Commission on Hospital Skin Condition and Color Accreditation in the late 1990s in an effort to strongly encour- Skin condition and color is an important indicator of the age all healthcare providers to adequately assess every patient patient’s ability to provide suffi cient oxygen-rich blood to the for pain and reassess the patient after interventions.22,23 Vari- tissues. While there is a wide range of normal skin tones, ous pain scales have been developed in an attempt to quantify normally many fair skinned individuals will have a pink the amount of pain. However, pain assessment is still a sub- color or tone to the skin. The Paramedic may need to assess jective report that varies between patients. A more detailed Figure 16-15 Measuring temperature with a tympanic thermometer. (Courtesy of Melissa King/iStockphoto) 268 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. discussion of the pain scales useful for the prehospital envi- ronment can be found in Chapter 15. Pulse Oximetry Hemoglobin is the molecule in red blood cells that accepts oxygen in the lungs and carries it to the body’s tissues to allow cellular respiration. Pulse oximetry is a noninvasive measurement of the percentage of hemoglobin in arterial blood that is bound to oxygen molecules.24 An accurate read- ing provides the Paramedic a good measure of the patient’s oxygenation, or his ability to move oxygen from the air in the lungs into the blood. It does not provide an indication of how well the patient is using that oxygenation. It also does not provide an indication of the patient’s ventilation, or note how well the patient is moving air in and out of the lungs during inhalation and exhalation. A normal pulse oximetry value in a healthy individual without lung disease is between 96% and 100% saturation. For individuals with chronic lung diseases, the patient’s personal normal pulse oximetry may actually be as low as 85% without supplemental oxygen.25 Pulse oximetry is determined by measuring the change that occurs when a beam of red light and infrared light is directed across a capillary bed. When hemoglobin binds to oxygen, it will cause an imperceptible change in the red and infrared light as it passes through the pulsating capillary bed. This change is translated into a percentage of oxygen satura- tion that is displayed for the Paramedic. Some pulse oxime- Figure 16-16 Assessing the conjunctiva for ters provide a waveform display in addition to the numerical pallor that may indicate anemia or blood loss. value (Figure 16-17). This waveform fl uctuates with changes (Courtesy of CDC/Dr. Lyle Conrad) in the patient’s blood fl ow during normal contraction of the patient’s heart. Because it is simple to measure the rate of these fl uctuations, most oximeters will provide the patient’s pulse rate in addition to the oxygen saturation. Figure 16-17 Normal pulse oximetry waveform. Notice the fl uctuations that correspond with the patient’s pulse rate (red arrow). Physical Examination and Secondary Assessment 269 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 16-18 Poor oximetry waveform (red arrow). Several factors may affect the accuracy of the pulse Capnography o ximetry reading. In order for the reading to be accurate, the The process of respiration includes the following steps patient must have suffi cient blood fl ow in the capillary bed of ( Figure 16-19): the body part where the probe is attached. If the waveform is poor (Figure 16-18), then the oximeter will either not read or ■ Inhalation of oxygen-containing air into the lungs will provide an inaccurate reading. Blood fl ow to the capillary ■ Movement of oxygen from the air across the alveolar bed is decreased if the limb is cool, if the patient is hypo- membrane into the blood volemic (decreased circulating blood volume), or the patient is ■ Movement of oxygen through the blood to the tissues hypotensive. Traditional pulse oximeters only detect whether ■ Absorption of oxygen into the cells or not the hemoglobin is bound to another molecule. Other ■ Production of carbon dioxide by the cells as they use the compounds (e.g., carbon monoxide) can also bind to hemoglo- oxygen and glucose for fuel bin in the red blood cells. If carbon dioxide is present, the pulse ■ Delivery of carbon dioxide back to the lungs oximeter will still read a normal saturation level, even though ■ Movement of the carbon dioxide back across the alveolar the patient’s tissues do not receive suffi cient oxygen and are membrane into the lungs hypoxic.26 Newer co-oximeters utilize additional wavelengths ■ Exhalation of the carbon dioxide into the atmosphere. of light and can detect the presence of carbon monoxide and other compounds that can bind to hemoglobin. From a respiratory system standpoint, the amount of It is important to note that even patients who present exhaled carbon dioxide is related to the patient’s ability to with a pulse oximetry reading within a normal range can move air in and out of the lungs. If the patient cannot venti- benefi t from supplemental oxygen. In many conditions, the late adequately, the concentration of exhaled carbon dioxide surface capillary beds utilized to measure oxygen saturation will
increase because the patient exhales a smaller amount with may have fully saturated blood; however, due to blood loss each breath, allowing the carbon dioxide level to build up in the or hypotension, deeper vessels—including those supplying lungs. If the patient hyperventilates, the exhaled carbon dioxide the heart, brain, kidneys, and the intestines—may not have level will decrease because a larger amount of carbon dioxide is an adequate supply of oxygen. Blood itself not only carries exhaled with each breath, decreasing the overall concentration oxygen by hemoglobin in red blood cells, but can also carry of carbon dioxide in the lungs. In situations where the patient is dissolved oxygen molecules within the plasma, or liquid por- able to circulate the blood adequately, capnography provides an tion of the blood. Patients who are in respiratory distress or indication of how well the patient is able to ventilate. suffering from a signifi cant illness or injury should receive From a circulatory standpoint, the amount of exhaled car- supplemental oxygen to ensure the organs continue to receive bon dioxide is directly related to the body’s ability to perfuse a suffi cient amount of oxygen. the tissues, or carry oxygen, glucose, and other nutrients to 270 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Alveoli O2 CO2 O2 O O2 2 O2 O2 O Cells 2 Blood vessel CO2 CO2 CO2 O2 Alveoli O2 CO2 CO2 CO2 Figure 16-19 The process of respiration. the cells in order to carry on the metabolic processes required 50 Exhalation/Inhalation to sustain life.27 If the patient is perfusing well, the carbon dioxide produced by the metabolic processes inside the cells 40 * will be transported back to the lungs for exhalation. Condi- 30 tions that decrease the patient’s ability to circulate the blood (e.g., shock and cardiac arrest) will decrease the level of car- 20 bon dioxide in the lungs. Waveform capnography provides a graphical representa- 10 tion of the exhaled carbon dioxide level over time.28,29 The 0 level of carbon dioxide will vary with inhalation and exhala- Time tion (see the curve shown in Figure 16-20). The normal level of exhaled carbon dioxide is approximately 40 mmHg. End- *Peak EtCO2 level tidal carbon dioxide levels (EtCO ) below 10 mmHg in the 2 Figure 16-20 Typical capnography waveform. setting of cardiac arrest is associated with a 0% chance of sur- vival. Elevated levels are seen in patients who are not ventilat- ing adequately. A decrease in EtCO level during mechanical tube by the change in waveform before the patient’s oxygen 2 ventilation may indicate the patient has become hypotensive. saturation is affected (Figure 16-21).30–32 The use of wave- It could also mean the ventilation rate is too high and should form capnography is discussed further in Chapter 25. be slowed to a lower rate. The waveform’s shape and pattern can provide clues to the disease process in patients complain- Orthostatic Vital Signs ing of shortness of breath. Finally, using EtCO with patients Orthostatic vital signs are vital signs that change with posi- 2 who are intubated is an excellent patient safety tool, as the tion. When an individual changes position from lying down Paramedic can immediately detect a dislodged endotracheal to standing, the blood pressure normally has a tendency to Physical Examination and Secondary Assessment 271 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. CO2 (mm Hg) 50 in pulse rate with position change could reasonably detect 40 blood loss of between 500 mL and 1 L.36 Care must be taken 30 20 when measuring orthostatic vital signs on a patient, espe- 10 cially when assuming the standing position. If the patient 0 develops severe symptoms on changing position, measure- Time ment should not be completed, as it puts the patient at risk for fall and injury. Figure 16-21 Sudden loss of the waveform in an intubated patient likely indicates endotracheal tube dislodgement. Concern-Based Physical Exam Conceptually, every call for assistance begins with a patient’s chief concern or complaint. This is true whether the call drop due to gravity. The body will compensate initially for was received emergently through the 9-1-1 system or non- this drop in blood pressure by constricting the arterial sys- emergently through a secondary system. From a dispatch per- tem.33 If that does not provide suffi cient compensation, then spective, the algorithms used to determine response resources the heart rate will increase in an effort to maintain an ade- are keyed from the patient’s or caller’s chief concern. From quate blood pressure. If the patient has a decreased blood a Paramedic perspective, the chief concern is used to help volume, whether through hemorrhage or through dehydra- focus the history and physical examination to fi nd the most tion, the body will not be able to completely compensate for likely cause of the patient’s chief concern and detect life- or this change by decreasing the size of the blood vessels alone. limb-threatening conditions that are associated with that con- Therefore, measuring orthostatic vital signs can assess the dition. Detailed physical examinations are time-consuming patient for subtle volume loss that may not be evident during and often provide more information than what is useful to the a supine or a seated set of vital signs. To measure orthostatic Paramedic. During most patient contacts, the Paramedic will vital signs, the Paramedic measures the blood pressure and perform a focused physical exam based upon the patient’s heart rate in the supine, sitting, and standing positions with chief concern. at least one minute rest between position changes to allow the body to compensate for the change. Although this may be Focused Exam Matrix diffi cult to achieve in the prehospital environment, it is inad- visable with patients who have sustained suffi cient trauma to In the prehospital environment, detailed head to toe exams require spinal motion restriction. are not practical for many patients. Instead, a focused physi- Positive orthostatic vital signs are defi ned as a heart cal exam is performed on the systems associated with the rate increase of 20 beats per minute or greater, a systolic patient’s chief concern. The Paramedic performs a detailed blood pressure drop of greater than 20 mmHg, a diastolic examination of one or two related body systems and a brief blood pressure increase of 10 mmHg, and/or dizziness or examination of other relevant body systems. In this way, the lightheadedness with position change.34,35 While ortho- Paramedic can effi ciently use her time during the patient static vital signs have been traditionally used as a means of contact and assess for fi ndings that can help confi rm the determining blood loss or hypovolemia in patients who had paramedical diagnosis suspected by the history or suggest otherwise normal vital signs, other factors—including med- alternate conditions that require assessment. ication, age, ingested substances (e.g., alcohol), and other The physical examination is also guided by the complex- medical conditions—can also produce orthostatic changes. ity of the patient’s chief concern. A patient who is complaining In several studies specifi cally looking at blood loss, changes of ankle pain after twisting his right ankle on the sidewalk and did not strike any other part of his body may be appropriate for a single system-focused exam on that ankle. A patient with Street Smart a strong cardiac and respiratory history complaining of gen- eral weakness may require a more extensive physical exami- nation. The discussion throughout the rest of the chapter will Two Paramedics should take orthostatic vital signs. provide a guide to the elements of the physical examination One Paramedic remains dedicated to watching the that should be covered based upon the patient’s chief concern. patient. Any change in level of consciousness, ability It is not meant to be all inclusive, and should be modifi ed by the Paramedic based upon clinical judgment, the specifi c to remain in the necessary position, or complaint of patient’s presentation, and examination fi ndings that suggest new or worsening symptoms is enough for the fi rst other conditions that may contribute to the chief concern. Paramedic to cancel the remainder of the orthostatic Both the focused and detailed physical examinations take place after correcting life-threatening conditions that vital signs. The second Paramedic is dedicated to were discovered during the primary assessment. Some of the measuring the pulse and blood pressure. items assessed during the focused or detailed examinations are items that were assessed during the primary assessment. 272 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. CO2 (mm Hg) Table 16-5 Physical Examination by Chief Concern (CC) Chief Concern Primary System Secondary System Tertiary System Chest pain Cardiovascular Respiratory Neurological Gastrointestinal Shortness of breath Respiratory Cardiac Neurological Abdominal pain Gastrointestinal Cardiac Loss of consciousness Neurological Cardiac Musculoskeletal Altered mental status Neuorological Psychiatric Musculoskeletal Musculoskeletal Skin Psychiatric Psychiatric Neurological They should be reassessed during the focused exam as neces- Once the primary assessment is completed, the focused sary to provide the Paramedic with the information needed to assessment follows. As part of the focused physical exam, effi ciently and adequately treat the patient. some general features should be assessed for every patient. These features include vital signs, appearance, and the scene. Examination Matrix All three of these features are part of the Paramedic’s initial An examination matrix (Table 16-5) provides a guide to the impression; an assessment of these features should be per- systems the Paramedic should assess based upon the patient’s formed during every single patient encounter. chief concern. The table is divided into columns that indicate The constitutional examination consists of the assess- the primary system to focus upon during the exam, as well as ment of the patient’s vital signs. At a minimum, this includes a secondary and a tertiary system to include in the examina- the blood pressure, pulse, and respirations. The Paramedic tion. The primary system is most closely associated with the should obtain a baseline set of vital signs on every patient conditions that produce the chief concern listed in the fi rst after completing the primary assessment. A room air pulse column. The secondary system is also associated with condi- oximetry reading should also be obtained on patients with tions that can produce that chief concern, but not as closely. chief concerns that involve the respiratory system. If a ther- The tertiary system generally can be affected by disease con- mometer is available, the patient’s body temperature can be ditions from the other systems that cause the chief concern. assessed. The patient’s approximate weight is also important For example, the chief concern of shortness of breath has the in determining medication dosages for certain medications. respiratory system as its primary system. However, cardiovas- At least two sets of vital signs should be taken during every cular conditions (e.g., angina) can cause shortness of breath. patient encounter as an assessment of stability and to identify The cardiovascular system is listed as the secondary system. changes during treatment. The neurological system may have fi ndings associated with The patient’s appearance can also provide an indica- shortness of breath, so it is listed as the tertiary system in the tion of her ability to compensate for the disease process. matrix under the shortness
of breath chief concern. Document the position in which the patient was found (e.g., As previously discussed, this matrix should be used to “seated on the couch” or “supine on the ground 50 feet from guide the Paramedic’s focused physical examination based the vehicle”). The level of distress experienced by the patient upon the patient’s chief complaint. The systems and features on initial contact should also be noted as part of the consti- examined in a specifi c patient may be different based upon tutional examination. This may include distress from painful the history obtained from the patient as well as the Paramed- conditions or respiratory distress. Skin condition and color ic’s fi ndings. can also provide clues toward level of distress and compensa- General Exam tion for the disease process causing the chief concern. The patient’s position may provide clues to the level of distress. In Chapter 13, an algorithmic approach was discussed for per- For example, a patient in severe respiratory distress may be forming the primary assessment in every patient. During the leaning forward in a tripod position to help ease her breath- overall scene assessment, the Paramedic assesses the scene ing. A patient experiencing the pain from a kidney stone may to determine and call for appropriate resources to handle the not be able to sit still and will pace or roll on the stretcher in situation. On each individual patient, the goal of the primary an attempt to fi nd a comfortable position. assessment is to rapidly detect and treat any life-threatening Observations made about the scene also provide impor- conditions (e.g., inadequate respirations, shock, or massive tant clues to the Paramedic and the ED staff. During the pri- bleeding). Triage algorithms based on the primary assess- mary assessment, the Paramedic views the scene for hazards ment exist to help the Paramedic treat and transport patients to his health and safety. As part of the focused exam, the in order of severity. scene should be viewed for evidence of the patient’s ability Physical Examination and Secondary Assessment 273 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to care for herself. A patient with a disheveled appearance external jugular veins will distend, or stretch and become with torn and dirty clothing in an unkempt apartment may not larger. This can be measured by positioning the patient in a be able to care for herself. Empty pill bottles present at the semi-Fowler’s position at approximately a 45-degree angle, scene of a patient who has altered mental status may suggest asking her to turn her head away from you, and inspecting the an intentional overdose. For trauma patients, the scene can external jugular vein for distention (Figure 16-22a).38 It can provide important clues as to the mechanism of injury that be helpful for the Paramedic to shine a penlight perpendicu- can help focus the Paramedic’s examination to areas most lar across the vein to improve visualization. In a patient with likely injured. Position in the vehicle, restraint use, or prox- a normal jugular venous pressure, the external jugular vein imity to hazards all provide the Paramedic with important will be distended about three centimeters above the sternal information. notch. Distention greater than three centimeters above the sternal notch is considered an elevated JVP (Figure 16-22b). Chest Pain Inspect the patient’s extremities for peripheral edema, a condition that also can indicate heart failure. The most com- Approximately 15 million Americans suffered from cardio- mon areas where peripheral edema occurs are in the ankles vascular diseases in 2004, with half of those people suffering and feet. However, edema can occur up into the thighs and a myocardial infarction.37 Heart disease remains the top cause scrotum in males and external labia in females, as well as in of death in the United States. Chest pain is one of the more the upper extremities. Pitting edema is a term that refers to common chief concerns which patients provide to dispatchers the amount of indention produced when the edematous limb is during the 9-1-1 call and tell Paramedics during the patient pressed over the tibia by the examiner’s fi nger ( Figure 16-23). interview. As part of the focused examination, the Paramedic The level of pitting edema is often described as trace, mild, should assess the cardiovascular system as the primary sys- moderate, or severe based upon the size and duration of the tem, and the respiratory, gastrointestinal, and neurological indention. systems as the secondary and tertiary systems. The physical Auscultation of the heart involves listening to the heart examination elements for a patient with a chief concern of with the diaphragm of the stethoscope in four locations (Fig- “chest pain” are inspection, auscultation, and palpation. ure 16-24). Lightly hold the diaphragm of the stethoscope against the chest for approximately 20 seconds in each area. Cardiovascular System The normal sounds heard at these locations correspond to Inspection of features related to the cardiovascular system the heart valves closing during the contraction and relaxation starts with an assessment of jugular venous pressure (JVP). phases of the heart. The two normal heart sounds are called The jugular veins run on either side of the neck at an angle the S1 and S2 sounds (Figure 16-25a). The S1 sound corre- from the corner of the mandible to the mid-clavicle on the sponds to the closing of the mitral and tricuspid valve at the same side. The jugular veins feed into the large veins that beginning of systole, or ventricular contraction. The S2 sound feed into the superior vena cava and into the right atrium. corresponds to the closing of the aortic and pulmonic valves When the heart is not pumping effectively or when the patient at the end of systole, marking the beginning of diastole, or has a signifi cant amount of extra fl uid in the circulation, the ventricular relaxation and fi lling. Two extra heart sounds, S3 (a) (b) Figure 16-22 (a) Patient positioning for evaluation of jugular venous pressure. (b) Elevated jugular venous pressure. 274 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. NORMAL HEART SOUNDS 1+ 2+ 3+ 4+ 2 mm 4 mm 6 mm 8 mm S1 S2 S1 S2 S1 S2 A Figure 16-23 Assessment of the severity of peripheral edema. EXTRA SOUNDS S4 S1 S2 S3 B MURMURS S1 S2 S1 S2 S1 S2 Systolic Diastolic Aortic A P murmur murmur stenosis (heard best over aortic area) C T M Figure 16-25 Heart sounds. (a) Normal. (b) Extra sounds. (c) Murmurs. murmur associated with aortic stenosis. Aortic stenosis is Figure 16-24 Locations for auscultation of heart a condition in which the leafl ets of the aortic valve become sounds. A aortic area. P pulmonic area. scarred over time and the pathway through the valve narrows. T tricuspid area. M mitral area. The murmur associated with aortic stenosis is best heard over the aortic area and is a high-pitched, sometimes loud sound and S4, are diastolic sounds that occur with changes in ven- that begins just after the S1 sound and runs until just before tricular fi lling (Figure 16-25b). When either sound is present the S2 sound. This is clinically important because, in patients it is often called a gallop, as the combination of the normal with severe stenosis, a higher pressure is required to propel and extra sounds produces a galloping rhythm, similar to blood out of the left ventricle and into circulation. The patient hearing a horse gallop. The S3 sound is sometimes normal in tends to have signifi cant hypertension; however, this hyper- children and young adults as the heart fi lls quickly. In patients tension is necessary for the patient to circulate blood. Medi- with a chief concern of chest pain or shortness of breath, it cations that can lower the blood pressure should be used with can indicate fl uid overload associated with heart failure. The caution in patients with a loud murmur from aortic steno- S4 sound occurs close to the S1 sound and can indicate the sis (one that can almost be heard before the stethoscope is ventricles are stiff and are not fi lling properly. placed on the chest) as that higher blood pressure is essential Murmurs are abnormal heart sounds produced by tur- to maintain circulation. bulent blood fl ow across the four valves. Different types of Another abnormal heart sound that is sometimes heard murmurs are associated with different conditions and can is called a rub. A rub is a low-pitched, soft scratching sound occur during both systole and diastole. Many murmurs are that occurs at any time during the cardiac cycle and indicates described as a low pitched “whoosh” sound. This sound is pericarditis, or an infl ammation of the pericardial sac that sometimes separate from, and sometimes integrated with, the surrounds the heart. The sound of the rub is produced when normal heart sounds (Figure 16-25c). A discussion of all the the infl amed pericardium rubs against the heart muscle dur- different murmurs is beyond the scope of this text; however, ing heart contraction or relaxation. This sound can be diffi - one that may be clinically important to the Paramedic is the cult to hear in the loud prehospital environment. Physical Examination and Secondary Assessment 275 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Several features of the cardiovascular system are assessed by palpation. While auscultating the chest for heart sounds, the Paramedic can spread her fi ngers out over the diaphragm and simultaneously palpate the chest for a thrill, or vibration of the chest associated with heart contraction. Forceful con- tractions can produce a signifi cant pounding inside the chest wall, causing a heave. Peripheral pulses are also assessed by palpation for strength and equality in the left and right extremities. Capillary refi ll is a measure of the patient’s ability to perfuse the extremities with oxygenated blood. Capillary refi ll is assessed by squeezing the tip of a digit hard enough to blanch it, releasing it, and then counting the number of seconds for it to return to a normal color. A normal capillary refi ll is two seconds or less. A delayed capillary refi ll indi- Figure 16-26 A cyanotic patient. (Courtesy of cates poor perfusion.39 Wellcome Trust/Custom Medical Stock Photo) Blood pressure is normally equal in both arms. If pulses are unequal in both arms, assess the arms for a difference in systolic pressures. A signifi cant difference in blood pressure over the larger airways are called bronchial sounds. These in both arms can indicate a problem with the aorta. sounds are louder and sound like air rushing through a hollow tube. Normal respiration involves an inspiratory phase that is Respiratory System longer than the expiratory phase. In addition, there is good Assessment of the respiratory systems begins with inspect- movement of air in and out of the lungs. Certain conditions ing the patient for respiratory effort. Assessment fi ndings that cause a prolongation of the expiratory phase. For example, indicate the patient has increased respiratory effort include several abnormal lung sounds can indicate specifi c conditions use of accessory muscles, sternal or intercostal retractions, that help guide the
Paramedic toward determining a cause for increased respiratory rate, or tripod positioning. Accessory the patient’s chief concern (Table 16-6). muscles of respiration include the muscles in the front of the neck. When the patient is in severe respiratory distress, these muscles contract to help lift the upper portion of the rib cage Street Smart during inspiration (Figure 16-11a). Sternal and intercostal retractions occur when the patient struggles to move air into the lungs (Figures 16-11b and 16-11c). Patients in severe To differentiate a pericardial rub from a pleural rub, respiratory distress will frequently assume a tripod position have the patient hold his breath. Pleural rubs are where they sit leaning slightly forward resting their hands on heard when the patient is breathing while pericardial their knees (Figure 16-11d) in an effort to improve their abil- ity to inhale. rubs occur with each heartbeat. The patient’s skin and mucous membranes should also be inspected for color. In a well-oxygenated patient, the mucous membranes will be pink. Cyanosis is a bluish hue that devel- Percussion of the chest can also offer additional informa- ops when the patient develops hypoxemia, or a decreased tion about lung fi ndings (Figure 16-5). One fi gure is placed oxygen level in the blood (Figure 16-26). In patients with a against the chest wall in-between two ribs while the other taps darker complexion, the Paramedic may have to inspect the the fi rst fi nger. This should be performed at several levels on oral mucous membranes or the nail beds to assess for cyano- both the left and right side of the chest, comparing sides for sis. In severe hypoxemia, the patient’s entire skin becomes equality. A normal chest percussion note is a somewhat hol- cyanotic. The Paramedic needs to intervene rapidly with low sound. A hyperresonant percussion note sounds similar supplemental oxygen, airway management, and ventilatory to striking a drum and indicates an increased amount of air support to correct the hypoxemia. in the chest. This is often seen with a pneumothorax on the The Paramedic should then auscultate the lungs for lung side of the hyperresonant percussion note. A hyporesonant sounds. Lung sounds should be assessed posteriorly and on percussion note is dull in character, and often indicates fl uid both sides of the chest, assessing both the left and right lung in the lung from either a pleural effusion or hemothorax. at the same level, so that sounds can be compared between Due to noise at the scene of the call, it may be diffi cult to the left and right lung. Normal sounds differ depending on assess a percussion note until the patient is in the back of the the location in the chest. Lung sounds auscultated over the ambulance. peripheral, smaller airways are called vesicular sounds, and Palpation of the chest is used to assess for stability of sound like leaves rustling in the wind. Lung sounds auscultated the rib cage, tenderness, equal expansion of the chest, and 276 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 16-6 Abnormal Lung Sounds Sound Description Conditions Associated Wheezing High-pitched sounds, often heard in inspiration, but can be Asthma present on expiration Chronic obstructive pulmonary disease (COPD) Heart failure Rales Crackles similar to Rice Krispies™ crackling in milk Fluid in smaller airways Heart failure Rhonchi Coarse crackling in larger airways Mucus in larger airways Acute bronchitis Pneumonia Consolidation Bronchial sounds heard over periphery, unequal compared to Pneumonia same fi eld on opposite lung Stridor High-pitched inspiratory upper airway sound Upper airway obstruction from upper airway edema or foreign body Absent • Specifi c fi eld • Pleural effusion, pneumonia, lower airway obstruction • Entire lung • Pneumothorax, hemothorax, massive pleural effusion Friction rub Intermittent coarse rubbing sound similar to sandpaper rubbing Indication of infl ammation of pleura with inspiration or expiration the presence of subcutaneous emphysema. Point tenderness Neurological along the rib or sternum may indicate a fracture in the set- The patient’s mental status is the best indicator of the brain’s ting of an injury to the chest. Place the hands on either side perfusion with oxygenated blood. All of the body systems are of the lower rib cage. During inspiration and expiration, the designed to support adequate blood fl ow and oxygen deliv- chest should expand equally with inspiration. Subcutane- ery to the brain. A normal mental status indicates that the ous emphysema is the presence of air between the layers of brain is receiving a suffi cient amount of oxygenated blood. the skin and indicates a leak in the respiratory system. Most An altered mental status, which may vary from confusion to often this is due to a pneumothorax with air escaping into the unconsciousness, can indicate that the brain is not receiving skin. At other times, it can occur after a tracheal or larger air- enough oxygenated blood. way rupture. Subcutaneous emphysema is often described as feeling like bubble wrap underneath the skin. Subcutaneous Put It All Together emphysema can become extensive, traveling up the neck into the face or down the abdomen into the genitals.40 The assessment of a patient presenting with the chief concern of chest pain includes many possibilities (Figure 16-27). Gastrointestinal The abdominal exam in a patient with a chief concern of chest Shortness of Breath pain is limited to assessing for pain and signs of fl uid over- Shortness of breath is another common chief concern of load related to right heart failure. The abdomen is palpated patients calling EMS. Shortness of breath occurs primarily to assess for tenderness, especially over the epigastrium, from respiratory causes (e.g., asthma or pneumonia), but can which may indicate a gastrointestinal origin for the patient’s also occur from cardiac causes (e.g., heart failure or angina). chief concern. Hepatojugular refl ux is assessed by plac- The physical exam for a patient with a chief concern of ing the patient in a semi-reclined position at approximately “shortness of breath” is similar to that of patients who have a a 45-degree angle. The jugular vein is fi rst assessed for level chief concern of chest pain. However, the emphasis is on the of distention (Figure 16-22). The Paramedic then applies fi rm respiratory system. pressure to the patient’s right upper quadrant over the liver. The hepatojugular refl ux is positive if the jugular vein disten- Respiratory tion increases. This is seen in conditions that cause the patient The Paramedic starts by inspecting the patient for respira- to become fl uid overloaded, including heart failure and kid- tory effort and cyanosis. As previously discussed, fi ndings of ney failure.41,42 severe respiratory distress are signifi cant and require rapid Physical Examination and Secondary Assessment 277 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Mental status Cyanosis Accessory muscles Jugular venous pressure (JVP) Lung auscultation Trachael position Heart Percussion note Blood ausculation pressure Chest palpation Radial pulses Capillary refill Hepatojugular reflux Abdominal palpation Peripheral edema Pedal pulse Capillary refill Figure 16-27 Assessment of a patient with the chief concern of chest pain. intervention. Also note if the patient appears to be tiring. described. Rales can indicate a cardiac cause for the short- As the respiratory distress progresses, the patient will begin ness of breath while many of the other sounds indicate a to grow weary of breathing. Immediate intervention at this respiratory cause. As previously described, a hyperresonant point with airway management is key to preventing respira- percussion note can indicate a pneumothorax while a dull tory arrest. One additional feature to assess is the tracheal percussion note can indicate fl uid or pneumonia if present position. Tracheal position is assessed just above the sternal in one lung fi eld. When palpating the chest, ask the patient notch (Figure 16-28). Normally, the trachea is found in the to speak. Vibrations palpated on the chest wall that occur center of the neck, centered in the sternal notch. Deviation of with speech are called tactile fremitus, and can also indi- the trachea toward one side can indicate conditions that cause cate an infective process in that portion of the lung. These a shift of the heart and lungs to one side, and is usually a late abnormal vibrations are produced as the vocal sounds are sign of the condition. transmitted into the lung and are altered in the area of the The Paramedic assesses the patient using auscultation infection, causing a vibration that can be palpated over that to identify normal and abnormal lung sounds as previously portion of the lung. 278 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Abdominal Pain Sorting out the cause of abdominal pain is challenging as the abdominal cavity contains many organs with a multi- tude of causes for pain. There are many conditions that cause abdominal pain; some are life-threatening while others are not. Following is the physical assessment for a patient who has a chief concern of “abdominal pain.” Gastrointestinal The focused examination of a patient with the chief concern of abdominal pain begins with an examination of the gastro- intestinal system. The abdomen is inspected for distention, or protruding of the abdomen past its normal size (Figure 16-30). Figure 16-28 Assessing for tracheal position. Localized protrusions at the umbilicus or in the midline of the abdomen may be a hernia, or openings in the muscle and tissue layers that allows the intestines to protrude through the opening. The abdomen is also inspected for prominent sur- face veins, especially around the umbilicus, that may indicate Cardiovascular a history of liver failure. The skin is also inspected for jaun- The Paramedic should inspect the patient for an elevated dice, a yellowish hue of the skin, which can indicate liver jugular venous pressure and the presence of peripheral failure or obstruction of the bile duct (Figure 16-31). Ecchy- edema. These may indicate a cardiac cause for shortness mosis, or bruising, may also be present in several locations on of breath. The Paramedic then auscultates the heart sounds the abdomen, including the umbilicus, the fl anks, or across for the presence of additional heart sounds and murmurs. the lower abdomen, and can indicate internal bleeding from These may also indicate a cardiac cause for the shortness of either a medical condition or traumatic injury. breath. Finally, the Paramedic assesses the peripheral pulses The bowels produce sounds from the rhythmic movement and capillary refi ll to determine the patient’s perfusion. Poor of material through the gastrointestinal tract. These sounds can perfusion with a lack of oxygen to the body’s organs can be auscultated by the Paramedic and may provide some clue produce the sensation of shortness of breath without respi- as to the cause of the patient’s abdominal pain. Bowel sounds ratory disease. are generally softer pitched gurgling sounds as compared to lung sounds and may be diffi cult to hear in the prehospital Neurovascular environment.44 In order to declare bowel sounds completely absent, the Paramedic would be required to listen for sounds The Paramedic assesses the patient’s mental status to determine for approximately three minutes, which is not realistic in the level of alertness. As respiratory distress worsens and the the prehospital environment. High-pitched, loud sounds that patient becomes
tired, the patient’s mental status will begin to sound like water dripping may indicate a bowel obstruction. decline.43 This can result from lack of energy, but also may be The Paramedic can also assess the abdomen using per- due to the buildup of the blood’s carbon dioxide (CO ) level. 2 cussion. The percussion note over the liver and spleen, which Patients in respiratory distress use more energy to breathe, are solid organs, should be dull. The percussion note over thus producing more CO . As the level of distress increases, 2 other parts of the abdomen should be a normal sound similar the ventilation becomes poorer and the patient is not able to to that of the lung. If the abdomen is distended, a percus- exhale the CO that is produced. The CO levels increase in the 2 2 sion note can help differentiate between a fl uid-fi lled abdo- blood. When the CO levels become high enough, the patient’s 2 men and an air-fi lled abdomen. If the distended abdomen is respiratory drive and mental status is further depressed, again distended with ascites, or fl uid, the percussion note will be impairing the patient’s ability to remove the CO from the 2 dull. If the distended abdomen is fi lled with air, as in the case blood. This cycle continues until the patient becomes uncon- of a bowel obstruction, then a tympanic percussion note will scious and develops respiratory arrest. Patients with a chief be heard. Tenderness with percussion over a portion of the concern of shortness of breath who have an altered mental abdomen may indicate irritation of the peritoneum, the inner status require aggressive airway management and ventilatory lining of the abdomen. Irritation of the peritoneum can occur support in order to halt this dangerous cycle. with infection, infl ammation, or blood in the peritoneal cav- ity. Finally, costovertebral angle tenderness, also known as Put It All Together CVA tenderness, can indicate kidney irritation from a kid- The assessment of a patient presenting with the chief con- ney stone or infection. The costovertebral angle is located cern of shortness of breath includes many possibilities over the lower ribs just medial to the posterior axillary line (Figure 16-29). (Figure 16-32). Physical Examination and Secondary Assessment 279 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Mental status Cyanosis Jugular venous pressure (JVP) Lung auscultation Tracheal position Tactile fremitus Heart Percussion auscultation Radial pulse Pedal pulse Peripheral edema Figure 16-29 Assessment of a patient with the chief concern of shortness of breath. Figure 16-30 Abdominal distention. (Courtesy of Figure 16-31 Jaundice of the skin and scleral Michael English, M.D./Custom Medical Stock Photo) icterus. 280 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. during palpation and may indicate irritation of the perito- neum. Rovsing’s sign is pain in the right lower quadrant that occurs when the left lower quadrant is palpated, and is often associated with appendicitis. Murphy’s sign is right upper quadrant tenderness that worsens when the patient takes a deep breath while the quadrant is palpated and may indicate gallbladder infl ammation. In addition to looking for tenderness, the abdomen is pal- pated to detect masses. An abdominal mass is a general term used to describe an abnormally fi rm area of the abdomen. Masses can be tender or nontender, fi rm or soft, or pulsatile. Figure 16-32 Percussion of the costovertebral Pulsatile masses in the setting of hypotension raise concern for angle. vascular rupture of the abdominal aorta. Protrusions through the patient’s midline are likely related to a ventral hernia. Two different methods are used to divide the abdomen. Cardiovascular One method utilizes quadrants and the other method uses A limited cardiovascular examination is performed in patients “nines.” Quadrants are made by running both an imaginary with a chief concern of abdominal pain. For patients who have vertical line and an imaginary horizontal line through the epigastric pain, the Paramedic should be diligent and perform umbilicus (Figure 16-33a) such that there are four quad- a more extensive cardiovascular examination.45 rants. Nines are made by dividing the abdomen into three Inspect the patient’s skin for color and perfusion. Aus- horizontal sections and three vertical sections, similar to a cultate the heart for heart tones and murmurs. Palpate the tic-tac-toe board (Figure 16-33b) such that there are nine extremities for equality of the pulses, especially in the lower sections. Either method is acceptable. When the abdomen is extremities that may indicate a vascular problem with the divided up into quadrants, fi ndings correspond to the quad- abdominal aorta. When the abdomen is palpated, also assess rant where the fi nding was discovered. The Paramedic should the patient for hepatojugular refl ux. decide which method to use and stick with it. Each section should be palpated at least one time by applying gentle, but Put It All Together fi rm pressure with one hand while the other hand lies on top The assessment of a patient presenting with the chief and helps guide the fi rst. Rebound tenderness is tenderness concern of abdominal pain includes many possibilities that becomes worse when the pressure is suddenly released (Figure 16-34). Figure 16-33 Abdominal territories. (a) Quadrants. (b) Nines. Physical Examination and Secondary Assessment 281 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Costovertebral Jugular venous Skin color angle (CVA) pressure (JVP) percussion Ecchymosis Hepatojugular reflux Heart ausculation Abdominal Abdominal distension percussion Abdominal auscultation Radial pulses Abdominal palpation Femoral pulses Pedal pulse Figure 16-34 Assessment of a patient with the chief concern of abdominal pain. Syncope (place), and time. She also assesses the patient’s memory Syncope is a transient loss of consciousness that resolves spon- for the events leading up to the call for assistance. Amnesia taneously. Near syncope is the feeling that one is going to pass to the events can indicate a trauma patient sustained a head out, although one does not actually lose consciousness. Though injury. The Paramedic then assesses the patient’s attention by these are two separate conditions, both are treated the same observing whether the patient follows the conversation or is in regard to assessment and treatment. While there are many easily distracted. Next, the Paramedic assesses the patient for causes of syncope—ranging from benign to life-threatening— appropriate language. Do the sentences make sense? Is the the Paramedic should focus her examination on the more life- speech garbled or clear? Are the responses to questions in the threatening ones. Following is the physical examination of a proper context? patient with a chief concern of syncope or near syncope. The remainder of the neurological exam is divided up into the cranial nerve exam, the peripheral nerve exam, assessment Neurological of deep tendon refl exes, and assessment of coordination. The The neurological exam begins with assessing the patient’s cranial nerves are a set of 12 paired nerves that begin within mental status. The Paramedic assesses the patient for respon- the brainstem and are responsible for movement and sensation siveness, alertness, and orientation to self (person), location in the head and neck. The fi rst cranial nerve provides the sense 282 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. assessed by asking the patient to stick out his tongue and say “ah.” The tongue should protrude in the midline, and the soft palate near the pharynx should elevate symmetrically. The last part of the cranial nerve examination is to ask the patient to shrug his shoulders while observing for symmetry, which tests the eleventh cranial nerve. Peripheral sensation of the skin is organized into dermatomes that correspond to the spinal nerve roots ( Figure 16-36). The trunk can be rapidly assessed by running one fi nger down each side of the thorax, looking for equality of sensation. Lack of sensation below the same level on both sides of the trunk may indicate a spinal cord injury. A similar method can be used to assess sensation in the extremities. A difference in sensation between the extremities may indicate nerve root compression, a stroke, or damage to the peripheral nerve itself. Figure 16-35 Examination of the eyes for The deep tendon refl exes (DTRs) are tested by tapping a extraocular movements. large tendon and looking for involuntary muscle contraction in the muscle associated with that tendon. The biceps ten- don DTR is tested by supporting the patient’s fl exed forearm of smell, which is diffi cult to assess in the prehospital environ- and tapping over the biceps tendon in the antecubital fossa ment. The second cranial nerve is examined by assessing the (Figure 16-37a). The arm should quickly fl ex in response to patient’s visual acuity. This can be as simple as asking him to tapping the tendon. The patellar tendon DTR is tested by fl ex- read something printed and held at a normal reading distance ing the patient’s knee and allowing it to hang unsupported or assessing the visual acuity through a Snellen eye chart. with the patient is seated. The patellar tendon is tapped just Light perception is the ability to see light only. If the patient below the patella (Figure 16-37b). The knee should quickly has enough vision only to count the number of fi ngers held up extend in response to the tap. The plantar refl ex is assessed by in front of the eye, the visual acuity is measured as counting running a blunt object along the sole of the foot and observing fi ngers. The third, fourth, and sixth cranial nerves are assessed by examining the patient’s extraocular movements (EOM). Ask the patient to look at a fi nger, pencil, or the unlit penlight and follow that object with just his eyes. Make an H in the air C-2 and watch the patient’s eyes (Figure 16-35). If there is nor- C-2 mal EOM (sometimes documented as EOM intact or EOMI), the eyes will follow the object smoothly and with full range C-2 of motion. Abnormalities may include unequal movement or C-3 C-3 C-4 C-4 oscillating movements at the end of the excursion. These oscil- T-2 C-5 T-2 C-5 T-3 T-3 C-6 lating movements are termed nystagmus. A few beats of nys- T-4 T-4 T-2 T-5 T-2 T-5 tagmus are normal. Sustained or prolonged nystagmus may be T-6 C-6 T-6 T-7 a sign of intoxication or central nervous system problems. The T-7 T-8 T-8 T-9 C-8 C-7 third cranial nerve also controls the pupillary response, which C-7 T-9 T-10 T-11 T-10 T-12 is assessed by shining a penlight into the patient’s pupils one T-11 L-1 T-1 T-12 L-2 T-1 at a time, looking for constriction of both pupils. L-2 S-3 C-8 L-1 S-5 Sensation and motor function to the face are carried by S-4 S-3 the fi fth and seventh cranial nerves, respectively. Sensory L-2 Umbilicus S-2 function is assessed by touching the
forehead, cheeks, and L-3 lower jaw on the left and right side of the face and looking for L-3 equality of sensation. Motor function is assessed by looking for symmetry of certain actions. The Paramedic should ask L-5 L-4 the patient to smile and then look for a symmetrical smile. L-4 The patient should be asked to open his eyes as wide as he L-5 can while the Paramedic looks for symmetry in the wrinkles in the forehead. The patient should also be asked to close his S-1 eyes as hard as he can, as the Paramedic looks for symmetry. S-1 The eighth cranial nerve is examined by assessing the patient’s hearing. The ninth and twelfth cranial nerves are Figure 16-36 Dermatomes. Physical Examination and Secondary Assessment 283 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (a) (b) (c) Figure 16-37 Testing deep tendon refl exes. (a) Biceps. (b) Patella. (c) Plantar. toe movement (Figure 16-37c). In a normal response, the toes Cardiovascular fl ex and move downward. An abnormal response is when the Auscultate the heart sounds for tone, murmurs, and extra great toe pulls upward and the other toes fan out, indicating heart sounds that may provide a clue as to the reason for syn- spinal cord injury or a problem with the brain. cope. Loud or harsh murmurs that are new may indicate valve The fi nal portion of the neurological examination tests scarring or papillary muscle rupture that may contribute to the patient’s coordination. Pronator drift is tested by asking the patient’s chief concern.46,47 The papillary muscles stabi- the seated patient to hold her arms out with the palms fac- lize, open, and close the valve leafl ets with each myocardial ing the ceiling and then close her eyes (Figure 16-38a). The contraction. The carotid arteries are auscultated to assess test is positive if one arm drifts away from the starting posi- for carotid bruits. A bruit is a whooshing sound heard in a tion. The arm that drifts also tends to begin to rotate toward blood vessel that has plaque buildup on the vessel walls. This a palm-down position. Coordination is also tested by asking buildup causes turbulent blood fl ow. The Paramedic places the patient to touch her nose with one pointer fi nger and then the bell of the stethoscope over the carotid artery on one side to touch the Paramedic’s fi nger and move back and forth sev- of the neck and asks the patient to take in and hold a deep eral times (Figure 16-38b). This is repeated with the opposite breath. The Paramedic then listens for the bruit. If a bruit is hand. The lower extremities can be tested by asking the semi- present, it may indicate atherosclerosis in the carotid artery reclined patient to touch the heel of one leg to the opposite that puts the patient at risk for a stroke. leg just below the knee and slide it down the tibia (Figure Pulses are palpated for strength and equality. Weak or 16-38c). Abnormalities in coordination often indicate a prob- absent peripheral pulses may indicate hypotension as a lem in the cerebellum, the portion of the brain responsible cause of syncope. Unequal pulses may indicate a vascular for balance. 284 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (a) (b) (c) Figure 16-38 Coordination testing: (a) Pronator drift. (b) Finger to nose. (c) Heel to shin. problem as a cause of the patient’s syncope. Perfusion is also and dorsifl ex the feet (Figures 16-40a and 16-40b) against assessed using capillary refi ll and strength of the pulses in the resistance. If the patient is lying or reclined, the Paramedic extremities. tests proximal muscle strength by asking her to lift her leg Finally, orthostatic vital signs may be helpful in assess- against resistance. If the patient is seated, the Paramedic tests ing for hypovolemia that is not present with the resting vital proximal muscle strength by asking the patient to lift or raise signs. Care should be taken when positioning the patient in a her fl exed knee against resistance (Figure 16-40c). Unequal standing position so the patient does not fall and injure her- muscle strength may indicate stroke, injury to the extremity self a second time. muscles, or a spinal cord problem. The bony surfaces of the upper and lower extremities are Musculoskeletal palpated for tenderness with special attention to the joints The goal of the musculoskeletal examination is to assess for and areas that the patient complained were painful during weakness and detect injury sustained during the syncopal the interview. Assess the stability of straight extremities by episode. The Paramedic examines any painful areas closely placing opposing forces over the bony surfaces and the joints for injury using palpation and inspection. Muscle strength of (Figure 16-41). Angulated extremities where the long bone the upper extremities is tested by asking the patient to grip is obviously fractured and displaced at an abnormal angle the Paramedic’s fi nger (Figure 16-39a). The proximal portion should not be stressed (Figure 16-42). In patients who have of the upper extremities is tested by asking the patient to fl ex sustained an injury, palpate the patient’s spine along the bony her elbows against resistance (Figure 16-39b). Lower extrem- prominences in the midline while maintaining spinal motion ity muscle strength is also tested distally and proximally. restriction to assess for tenderness that may suggest a spinal Distally, the Paramedic asks the patient to both plantarfl ex fracture. Physical Examination and Secondary Assessment 285 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (b) (a) Figure 16-39 Upper extremity motor examination. (a) Grip strength. (b) Elbow strength. (a) (c) (b) Figure 16-40 Lower extremity motor examination. (a) Plantarfl exion against resistance. (b) Dorsifl exion against resistance. (c) Proximal lower extremity muscle strength examination. 286 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 16-41 Applying oppositional forces over an extremity to test stability. Figure 16-42 Example of an angulated extremity fracture. (Courtesy of Deborah Funk, MD, Albany Medical Center, Albany, NY) If the patient is ambulatory at the scene, the Paramedic should observe the patient’s gait, or the way the patient walks, common causes of altered mental status and is immediately for abnormalities. Normally, a steady gait appears balanced treatable by the Paramedic. The Paramedic’s goal in assessing with the feet approximately shoulder width apart and fl ows the patient with altered mental status is to identify reversible smoothly as the patient ambulates. A multitude of gait dis- causes while providing supportive care to the patient. turbances are possible. It is best to describe and document what you see. The patient may stagger or appear off balance. Neurological The patient’s feet may be spread far apart. The gait may not be smooth or may include additional movements. If the The objective of the neurological exam in a patient with a patient is ambulatory, then the Paramedic should comment chief concern of altered mental status is to identify signs of a focal neurological issue.48–50 on the patient’s gait. If he decides to ambulate a patient who For example, unequal motor is not already ambulating, he should do so with care that the strength or unequal sensation may indicate a localized dis- patient does not fall, causing further injury, or worsening ruption in brain function, which may be caused by a stroke the medical condition related to the chief concern. The Para- or a cerebral hemorrhage. A focal neurological issue differs medic should follow the service policies as some services from a condition that causes a global disruption such as low do not ambulate patients who are not already ambulating at or high blood sugar or fever. The exam is carried out as pre- the scene. viously described. Some components of the exam may be diffi cult to perform if the patient is not able to follow the Paramedic’s commands. Put It All Together The assessment of a patient presenting with the chief concern Cardiovascular of syncope includes many possibilities (Figure 16-43). The objective of the cardiovascular examination in a patient with a chief concern of altered mental status is to identify Altered Mental Status issues with perfusion that can lead to altered mental status. A rapid method of assessing perfusion is to palpate the periph- “Altered mental status” is a phrase used to describe any change eral pulses for strength and check the capillary refi ll in a hand from a normal mental status. This may range from “feeling or foot. The Paramedic should auscultate the heart for new fuzzy” or mild “confusion” up to complete loss of conscious- murmurs. An irregular heartbeat may indicate atrial fi brilla- ness. The number of causes of altered mental status varies tion, a rhythm that is associated with stroke, another potential widely, with some causes being the result of aging, infection, cause of altered mental status. intoxication, toxic substances, or hypoxia. The chief concern of altered mental status is often provided by family members, bystanders, or other individuals as the patient may not even be Respiratory able to express this as a chief concern. Often at the extremes The objective of the respiratory system examination is to of age—the elderly and the very young—fever is a cause detect respiratory conditions that can cause altered men- of altered mental status. Hypoglycemia is one of the most tal status, most commonly hypoxia and pneumonia. As Physical Examination and Secondary Assessment 287 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Mental status examination Mentation Romberg/pronator drift Cranial nerve examination Heart auscultation Carotid arteries Peripheral Extremity nerve palpation Biceps DTR sensory (all four) examination Radial pulses Upper extremity motor Patella DTR Gait and balance Lower extremity motor Pedal pulses Plantar DTR Figure 16-43 Assessment of a patient with the chief concern of syncope. discussed before, a buildup in the level of carbon dioxide in the blood will cause sleepiness and altered conscious- Skin ness. The Paramedic should assess the patient’s respira- The skin is assessed for color, condition, and temperature, all tory rate and effort, observing for signs of increased work features that may indicate infection, fever, or dehydration as of breathing, poor ventilation, and respiratory failure. She a cause of altered mental status. In bedbound patients, includ- should also assess the lung sounds for abnormal sounds that ing patients with paraplegia or past strokes with an inabil- may indicate a cause of respiratory distress. Measurement ity to ambulate,
decubitus ulcers (also known as pressure of the patient’s pulse oximetry will provide an indication of ulcers) can form and become another source of infection. hypoxemia. Percussion of the chest may help detect signs of Skin that is cyanotic indicates severe hypoxemia requiring pneumothorax or pneumonia. immediate ventilatory support by the Paramedic. Ecchymosis, 288 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. lacerations, or abrasions indicate trauma and suggest a trau- table, and a penny). Then, continuing the examination a few matic cause for the altered mental status. minutes later, the Paramedic asks the patient to repeat back those three objects. The patient’s language and knowledge is examined as previously described. Abnormalities in the Psychiatric patient’s mood and affect may also indicate a psychiatric ori- Psychiatric conditions or worsening dementia can also cause gin for his altered mental status. A fl at affect occurs when an altered mental status. The fi rst episode of a psychiatric dis- the patient’s face is absent of an expression. Mood can be order may present with altered mental status. Patients with described as depressed, elated, or normal. a history of a psychiatric disorder may present with altered mental status if they decompensate, either through a worsen- Put It All Together ing of their chronic disease or through noncompliance with The assessment of a patient presenting with the chief con- taking their medications. Components of the psychiatric exam cern of altered mental status includes many possibilities include assessment of speech, thought processes, suicidal or (Figure 16-44). homicidal ideation, judgment, insight into medical condition, and mental status. Much of this examination is required to Extremity Pain ensure a patient who wishes to refuse medical attention has suffi cient capacity (i.e., mental ability) to understand the Extremity pain as a chief concern can have a traumatic origin potential medical condition and the consequences of refusing or a medical origin. The most common cause of extremity treatment or transport. pain is an injury. In order to assist in determining the cause, The Paramedic should listen to the patient’s speech. the pain should be localized to a particular joint, muscle, or Abnormal speech may be either fast or very slow compared bony landmark. to a normal rate. Pressured speech occurs when the patient Musculoskeletal is speaking so fast it appears she has an urgency or pressure to speak quickly. The volume of speech may be decreased The painful extremity should be inspected for signs of an in a patient who is depressed, while it may be signifi cantly obvious injury, including a laceration, abrasion, ecchymosis, increased in a patient exhibiting pressured speech. The speech or edema that can indicate an underlying bone injury. Inspec- may not be understandable in a patient with an altered mental tion may indicate signs of an obvious fracture or disloca- status. For example, a patient may mumble or only grunt in tion, including angulation of that extremity. The Paramedic response to questions or stimulus. should assess both the left and right extremities for edema. For the verbal patient, the Paramedic should assess the Bilateral, or both left and right, extremity edema tends to patient’s thought process. A normal thought process will indicate a systemic cause while unilateral, or one, extremity be clear, understandable, and logical. Abnormalities in the edema indicates a cause within that extremity. The extent of patient’s thought process include psychotic or paranoid the edema should be noted, as edema localized to a joint or thoughts and auditory or visual hallucinations. Patients with to a small area may indicate an underlying localized injury. hallucinations should be asked what they are seeing or what Extensive unilateral edema may indicate an acute problem the voices are telling the patient to do. All patients who with the blood supply to that extremity. The extremity should exhibit signs of depression should be asked about intent to also be palpated for stability as well as to help localize the harm themselves or others, as well as if they have a plan to pain. Edema is assessed for pitting, as discussed in the sec- carry out this suicidal or homicidal ideation.51 tion on focused cardiovascular examination for patients with Another component of the psychiatric examination a chief concern of chest pain (Figure 16-23). assesses the patient’s insight into the medical condition and Skin judgment, or ability to make reasonable decisions. Insight is an understanding of the patient’s current or chronic medical Skin color and temperature may also indicate the origin of condition, as well as the consequences of inappropriate treat- the patient’s extremity pain. Erythema, or redness in the skin, ment. An example of poor insight into one’s medical condition along with warmth may be an indication of cellulitis, or a is a patient who has insulin-dependent diabetes, packs up her skin infection. Erythema and warmth over a joint may indi- insulin when moving, then cannot fi nd her medications and cate an infection in the joint or an arthritis caused by infl am- waits several days until she is sick with an elevated glucose mation within the joint. Finally, abrasions, lacerations, and to call for an ambulance. A patient with good insight into her ecchymosis can indicate trauma to the extremity. condition would have kept medications separate in a known location so they could be accessed and taken as directed. Cardiovascular The mental status exam is often thought of only as an The Paramedic should palpate the peripheral pulse to ensure assessment of the patient’s orientation to person, place, it is present and the extremity is well perfused, especially and time; however, it involves several other components. in the situation of trauma to the extremity. He should check The patient’s memory is tested when the Paramedic asks the the pulse before and after splinting to detect overtightening patient to remember three distinct objects (e.g., an apple, a of the splint or loss of pulse from vessel damage during the Physical Examination and Secondary Assessment 289 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Mental status examination Cranial Psychiatric examination nerve Pupils examination Respiratory effort Skin color, Lung auscultation temperature, Cyanosis conditions Percussion note Ecchymosis Heart auscultation Extremity palpation (all four) Decubitus ulcers Dextrostick Upper extremity strength Gait and balance Lower extremity strength Figure 16-44 Assessment of a patient with the chief concern of altered mental status. splinting process. In patients with nontraumatic extremity High Blood Pressure pain and edema, the Paramedic should perform a cardiovas- cular examination to assess for signs of heart failure as the According to the American Heart Association, approximately cause of the patient’s chief concern. 72 million people in the United States are diagnosed with high blood pressure, with an even greater number of people Neurological unaware their blood pressure is high.52 Blood pressure can be The Paramedic should assess the painful extremity for sensa- elevated due to pain or the condition the patient is experienc- tion and motor function distal to the injury both before and ing. It is estimated that in the year 2004, hypertension caused after splinting. Sensation and motor function should also be approximately 54,000 deaths in the United States. High blood assessed in the situation of nontraumatic extremity pain. pressure is a signifi cant risk factor for kidney failure and heart disease, and a primary cause of stroke. Many patients do not Put It All Together exhibit symptoms for a long time prior to diagnosis. The assessment of a patient presenting with the chief concern The Paramedic’s goal in assessing patients with the of extremity pain includes many possibilities (Figure 16-45). chief concern of high blood pressure is to look for signs that 290 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Palpation of painful extremity Sensation Skin color, temperature Ecchymosis Edema (unilateral or bilateral) Distal pulses Motor function in affected extremity Figure 16-45 Assessment of a patient with the chief concern of extremity pain. the high blood pressure is causing organ damage, including palpate to determine the amount of fl uid present. Auscultate damage to the brain, heart, lungs, and kidneys. The major- the heart for murmurs or extra heart sounds that may indicate ity of patients encountered by the Paramedic do not require fl uid overload. He should palpate the peripheral pulses for acute lowering of their blood pressure in the prehospital equality and limb perfusion, and assess the blood pressure in environment. For patients who have a chief concern other both arms to detect a signifi cant difference that may indicate than high blood pressure, refer to the section of this chap- a problem with the aorta. ter that covers a focused examination related to that chief concern. Respiratory The Paramedic should inspect the patient for signs of Cardiovascular increased respiratory effort and work of breathing that indi- The cardiovascular examination focuses on detecting signs cate diffi culty breathing, as this may be related to heart fail- of heart failure. The Paramedic should inspect the patient ure or cardiac disease. The Paramedic should auscultate the for an elevated jugular venous pressure as well as peripheral lungs for rales or wheezes that may indicate fl uid in the lungs edema. If peripheral edema is present, the Paramedic should from heart failure. Physical Examination and Secondary Assessment 291 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Mental status Romberg/pronator drift Cranial nerve examination Jugular venous pressure (JVP) Lung auscultation Respiratory effort Heart auscultation Radial pulses Upper extremity motor strength Lower extremity motor strength Peripheral edema Pedal pulses Figure 16-46 Assessment of a patient with the chief concern of high blood pressure. Neurological HEENT The objective of the neurological examination is to assess for Patients may complain of a variety of chief concerns related defi cits that may be caused by a stroke or other brain event to the head, eyes, ears, nose, and throat, with the most com- that may be related to the high blood pressure. The Paramedic mon concern being pain. This may be associated with fever, should assess the patient’s cranial nerves and peripheral nerves vision changes, sore throat, foreign body sensation, or other for function. She should assess muscle strength and coordina- symptoms. In the setting of trauma, there is also a concern of tion for issues that are unilateral, as these may indicate a brain an underlying head injury. lesion. Altered mental status can result from severe hyperten- sion that disrupts the perfusion of blood to the brain. Head Assess the head for evidence of trauma, including abra- Put It All Together sions, lacerations, ecchymosis, and obvious deformities. For The assessment of a patient presenting with the chief con- patients with a chief concern of headaches or facial pain, the cern of high blood pressure includes many possibilities Paramedic should percuss the sinuses (Figure 16-47) to elicit (Figure 16-46). tenderness that may indicate a sinus infection. 292 Foundations
of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. mucous membrane for a source of the bleeding in the anterior portion of the nare. In the setting of nasal trauma, a septal hematoma (Figure 16-52) is a fi nding that requires attention) at the emergency department to ensure permanent damage to the nasal cartilage does not occur. Discharge from the nose may indicate a viral or bacterial infection of the sinuses.53–55 Throat The examination of the throat is important with any patient who has a concern related to the upper airway, including those patients with neck trauma or a suspected allergic reaction. The throat is examined for erythema and exudates, whitish discharge on the mucous surface, of the posterior pharynx (Figure 16-53). Swelling in the pharynx may also indicate Figure 16-47 Percussion of the sinuses. an impending airway issue. The uvula typically hangs in the midline of the pharynx. Deviation of the uvula from the mid- line may indicate an abscess or hematoma that can poten- tially threaten the airway. The external aspects of the anterior neck and mandible are also assessed for edema that may indi- cate a potential airway issue. The oral mucous membranes are also examined for signs of dehydration. Normally, the mucous membranes should be pink and glisten with the usual amount of moisture in the mouth. Patients who are dehydrated will lose that glisten in the mucous membranes as less saliva is produced. In extreme dehydration, the lips will become chapped. Neurological The Paramedic should perform a cranial nerve examination to ensure proper function of the cranial nerves. Abnormali- ties in cranial nerve function can indicate an underlying brain Figure 16-48 Conjunctival erythema. (Courtesy of concern or compression of an individual cranial nerve. Custom Medical Stock Photo) Put It All Together The assessment of a patient presenting with the chief concern Eyes related to the head, eyes, ears, nose, or throat includes many The eyes are inspected for erythema on the conjunctiva that possibilities (Figure 16-54). indicates irritation of the eye (Figure 16-48). Pupillary reac- tion is tested for responsiveness and equality using a penlight. Fever If a foreign body sensation is present, or signs of irritation Fever is a common chief concern for both young and old, with exist, the eye is stained using fl uroescein to inspect for a for- the extremes of age more likely to develop sepsis, the infl am- eign body or corneal abrasion (Figure 16-49). matory response to a systemic infection, or septic shock, where the patient develops hypotension from the systemic Ears infection. Fever is also a common cause of altered mental The Paramedic should inspect the external ear for erythema, status, especially in the elderly. Altered consciousness or per- signs of trauma, discharge, or edema. She should palpate the sonality in the very young can also indicate a severe illness external ear for tenderness. Using an otoscope (Figure 16-50), that requires further evaluation at the emergency department. the Paramedic should inspect the ear canal and middle ear for While fever is most often caused by an infection, fever can erythema, discharge, fl uid behind the tympanic membrane, or also be caused by other conditions including toxic ingestion, signs of otitis media, a middle ear infection (Figure 16-51). environmental related illness, and disorders of a patient’s thermoregulatory system. Nose The nares, or nostrils, are inspected for erythema and edema Respiratory of the mucous membranes or turbinates If an epistaxis, or The respiratory exam focuses on searching for a cause of the nosebleed, is present, the Paramedic should inspect the fever, especially when combined with hypoxemia determined Physical Examination and Secondary Assessment 293 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (c) (a) Uptake indicating abrasion (d) Foreign body (b) (e) Figure 16-49 Examination of the eye for foreign body or corneal abrasion. (a) Instill two drops of tetracaine into the eye to be examined. (b) After 30 to 60 seconds, apply the fl uorescein strip, asking the patient to blink several times. (c) Examine the eye under a Wood’s lamp or using the cobalt blue fi lter on an ophthalmoscope. Direct the patient to move through the full range of motion of the eye. (d) Uptake of the dye indicates a corneal abrasion. (e) Foreign body present on the cornea. (Photo (d) is Courtesy of SPL/Custom Medical Stock Photo, (e) Courtesy of Michael Friedburg, O.D.) 294 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 16-50 Paramedic assessing the ear with Image not available due to copyright restrictions an otoscope. from the vital signs. The Paramedic should inspect the patient for signs of increased respiratory effort. He should auscultate the lungs for signs of focal consolidation that may indicate Figure 16-51 Appearance of the tympanic pneumonia. Auscultation may also reveal wheezing from membrane in a patient with a middle ear infection associated bronchospasm, or constriction of the smaller air (otitis media). (Courtesy of B. Welleschik; licensed under passages that sometimes accompanies a respiratory infection. the Creative Commons Attribution ShareAlike 2.5) A dull percussion note over one area of the chest may also indicate a pneumonia in that portion of the lung. Gastrointestinal A gastrointestinal source of the fever is often suggested in a patient who is vomiting or has diarrhea. The Paramedic should inspect the patient’s abdomen for distention and dis- coloration. She should auscultate the abdomen to assess the patient’s bowel sounds, and palpate the abdomen, assess- ing for tenderness starting with the quadrant or section furthest away from the area of pain. The Paramedic should also palpate for the signs of peritoneal irritation as previ- ously described. Tenderness to percussion over the abdomen Septal hematoma may also indicate peritoneal irritation. A dull percussion note indicates ascites that can be the source of infection. A Figure 16-52 Septal hematoma. tympanic percussion note can indicate bowel obstruction or Physical Examination and Secondary Assessment 295 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Head trauma Pupil Cranial nerve Extraoccular movement (EOM) examination Conjunctiva Otoscopic examination Sinus percussion Examination Oropharynx examination for foreign body redness, uvula, mucous membrane) Nasal examination Throat/neck hematoma Figure 16-54 Assessment of a patient with the chief concern of related to the head, eyes, ears, nose, or throat. rupture that may be the source of infection. Tenderness with Gynecological percussion of the costovertebral angle can indicate pyelone- A brief gynecological examination is indicated when immi- phritis, or an infection of the kidney as a possible source of nent delivery is considered. While maintaining privacy with a the fever. sheet or other covering, the Paramedic should briefl y inspect Skin the vaginal opening for the presence of bleeding or discharge. Crowning occurs as the infant’s head begins the passage into The skin is inspected for signs of infection. Cellulitis can the birth canal (Figure 16-56), indicating delivery will occur present with erythema over an area of the skin. Patients with within several minutes. a history of diabetes are more likely to develop cellulitis over The abdomen is palpated to assess for tenderness and the lower extremities.56,57 Streaking, also known as lymphan- signs of peritoneal irritation in the pregnant female patient gitis, is infl ammation of the lymphatic channels in the skin complaining of abdominal pain. The uterus can often be pal- and occurs when there is spread of an infection located distal pated as a fi rm mass in the midline of the lower abdomen. It is to the streaking. As discussed earlier, decubitus ulcers can fi rst detected at approximately 12 to 15 weeks of gestation and develop and become infected in patients who are bed or chair grows until almost reaching the costal margin of the lower ridden. Finally, assessing the skin turgor, or elasticity, can portion of the rib cage by full term. Contractions can also indicate dehydration.58 be detected by the Paramedic during palpation as the uterus tightens and constricts. Contractions are measured for dura- HEENT tion and timing. The duration contraction is the length of time Examine the oropharynx for signs of infection and dehydra- the uterus is contracted. The timing is measured as the number tion in patients who have a chief concern of fever. of minutes between the beginning of one contraction and the beginning of the next, to include both one cycle of uterine con- Put It All Together traction and relaxation. This information is often reported as The assessment of a patient presenting with the chief concern “contractions of one minute in duration, three minutes apart.” of fever includes many possibilities (Figure 16-55). Respiratory Pregnancy The Paramedic should inspect the patient for signs of increased respiratory effort. He should also auscultate the While most pregnancies are uneventful, at times the Para- lungs for abnormal sounds (e.g., wheezes and rales). Signifi - medic will care for patients who have, or potentially have, a cant rales in combination with lower extremity edema may chief concern related to their pregnancy. Some of the com- indicate issues with hypertension or heart failure that have mon concerns include vaginal bleeding, abdominal cramp- developed during pregnancy. ing or pain, trauma in pregnancy, or impending childbirth. Many chronic medical conditions (e.g., asthma or diabetes) Cardiovascular can worsen during pregnancy and may require more frequent The Paramedic should inspect the patient for increased jugu- medical care.59 Seizures can occur secondary to issues with lar venous pressure and signifi cant peripheral edema that may hypertension in pregnancy. indicate problems with hypertension or heart failure related to 296 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Mental status Temperature (tympanic Oropharynx examination or oral) (mucous membranes) Lung auscultation Skin color, condition, Percussion turgor Abdominal inspection (palpation, percussion) Costovertebral angle Decubitus (CVA) tenderness ulcer Streaking Cellulitis Figure 16-55 Assessment of a patient with the chief concern of fever. pregnancy. Gallops and certain murmurs are normal in preg- response signifi cantly more brisk than normal, can indicate nancy as the blood volume increases and the growing fetus impending neurological issues. For pregnant patients treated compresses pelvic and abdominal blood vessels. However, with magnesium, one indication of too much magnesium is these conditions may be of concern in patients with a chief deep tendon refl exes that are hyporefl exive, or signifi cantly concern of chest pain or shortness of breath. The Paramedic less brisk than normal. should palpate the peripheral pulses or assess capillary refi ll to assess perfusion, then palpate the edematous extremities to Put It All Together assess the level of
edema. The assessment of a patient presenting with the chief con- cern related to pregnancy includes many possibilities Neurological (Figure 16-57). Neurological issues during pregnancy are often related to the patient’s underlying seizure disorder or can be related to Trauma hypertension in pregnancy. In a pregnant patient with hyper- Trauma-related concerns are a signifi cant portion of the tension, the Paramedic should assess the deep tendon refl exes. requests for assistance encountered by Paramedics. The exam- Deep tendon refl exes that are hyperrefl exive, or produce a ination of patients who have sustained a suspected traumatic Physical Examination and Secondary Assessment 297 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Head Starting with the patient’s head, the Paramedic should inspect the scalp and face for lacerations, abrasions, ecchymosis, or obvious deformities that indicate the presence of a head injury. She should also inspect the mouth to assess for for- eign material and unstable or missing teeth that may occlude the airway if untreated. The Paramedic should palpate the skull and face to assess for stability of the bony structure. She should also assess pupil reaction and gross cranial nerve function to look for abnormalities that may indicate cerebral hemorrhage. Neck Figure 16-56 Crowning. While maintaining spinal motion restriction, the Paramedic should inspect the anterior neck for signs of trauma or edema injury follows a systematic head to toe approach after the pri- that may affect airway management or compromise the air- mary survey is completed to ensure detection of injuries based way. She should also palpate the trachea and larynx, assess- on the mechanism of injury. Even with a minor mechanism, the ing for stability, tenderness, and position of the trachea. The Paramedic needs to be thorough to ensure the presence of life- Paramedic should palpate the neck for subcutaneous emphy- threatening injuries is detected as early as possible. Prehospi- sema caused by a leak in the respiratory system, and palpate tal trauma triage guidelines have been developed to provide the cervical spine in the midline posteriorly, assessing for guidance to Paramedics in determining which patients should tenderness and deformity from a cervical spine injury. be transported directly to a trauma center and which patients can be cared for at a community hospital (Figure 16-58). Once Chest the primary survey is completed and any life-threatening The Paramedic should inspect the chest for respiratory effort, airway, breathing, or circulatory concerns are addressed, the abnormal chest wall movement, and signs of trauma, includ- Paramedic begins a more detailed head to toe examination. ing wounds and ecchymosis. He should also auscultate the Figure 16-57 Assessment of a patient with the chief concern related to pregnancy. 298 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. chest for the presence and equality of lung sounds in addi- tion to abnormal sounds. The Paramedic should palpate the chest for the presence of subcutaneous emphysema, for ten- derness, and instability. A fl ail segment develops when two or more adjacent ribs are fractured in two or more places (Figure 16-59). This produces an unstable area of the chest that impedes normal respiration. During inhalation, the fl ail segment is drawn inward by the negative pressure in the chest rather than expanding outward with the rest of the chest wall. During exhalation, the opposite occurs due to the increased pressure in the thorax during exhalation. This movement opposite of the normal chest wall movement is called para- doxical respiration. A hyperresonant percussion note can indicate a pneumothorax, where air is trapped between the pleural layers surrounding the lung, while a hyporesonant percussion note may indicate a hemothorax, or blood fi lling the space between the pleural layers. Abdomen The abdomen is inspected for wounds and other signs of direct trauma. Ecchymosis along either fl ank can indicate internal bleeding. A seat belt sign, or ecchymosis along the lower abdomen corresponding to the position of the lap belt, indicates enough force to produce internal damage.60–62 The Paramedic should note any distention present and palpate the abdomen for tenderness and fi rmness. Tenderness over the upper quadrants may indicate injury to the solid organs. A fi rm and distended abdomen is worrisome for internal bleed- ing that is not controllable in the prehospital environment. Pelvis The bony pelvis is assessed for stability and tenderness using palpation. After taking fi rm hold of the iliac wings (Fig- ure 16-60), the Paramedic gently applies pressure to com- press the pelvis. Tenderness may indicate a pelvic fracture, whereas instability is indicative of life-threatening internal pelvic bleeding and requires stabilization by the Paramedic. Extremities Finally, each extremity is inspected for obvious deformity, angulation, or wounds. The Paramedic should palpate each extremity for tenderness and stability (Figure 16-41). She should also palpate each extremity for the presence of a distal pulse or capillary refi ll to assess perfusion. The Paramedic should perform a rapid motor and sensory assessment on each extremity to ensure full function, then assess and docu- ment circulation, sensation, and motor function both before and after splinting injured extremities. Figure 16-58 National EMS trauma triage protocol. (Courtesy of Centers for Disease Control and Prevention, CDC) Physical Examination and Secondary Assessment 299 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Inspiration Expiration Flail section moves paradoxically (inward) Flail section moves paradoxically (outward) Figure 16-59 A fl ail segment paradoxically moves opposite the rest of the chest during inspiration and expiration. Spine The Paramedic should inspect the back for signs of lacera- tions, abrasions, and ecchymosis. He should palpate the spine for tenderness, stability, and alignment. This is often performed with the patient log-rolled to one side, main- taining spinal motion restriction (Figure 16-61) during the assessment. Any deformity or step off should be treated as a potential fracture with full immobilization and transport to an appropriate facility. Put It All Together The assessment of a patient presenting with the chief concern of major trauma includes many possibilities (Figure 16-62). Figure 16-60 Assessing the pelvis for stability. 300 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 16-61 Assessment of the back and spine in a patient who was involved in a traumatic event. Primary survey: Focus on airway, breathing, circulation Secondary survey: Systematic head to toe approach after the primary survey is completed Scalp trauma Cranial Head nerve Pupils trauma/skull examination Face palpation Jugular venous stability pressure (JVP) Spine palpation Chest Tracheal position inspection: subcutaneous Lung emphysema, auscultation respiratory Tenderness effort, Heart and stability stability, auscultation spine percussion palpation Abdominal inspection, palpation Flank ecchymosis Pelvic stability Extremity examination (all extremities): palpation, distal circulation, motor, sensory Figure 16-62 Assessment of a patient with the chief concern of major trauma. Physical Examination and Secondary Assessment 301 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. While these common chief concerns will cover the majority of patients that the Paramedic will encounter, there will be some patients that do not have one of these chief concerns. By using these principles to perform a physical assessment, a Paramedic can perform an examination on patients in an effi cient manner which allows a full patient assessment. Key Points: • The four components to every physical exam are • The respiratory pattern or rhythm of the inspection, auscultation, palpation, and percussion. respirations is the combination of the timing of the respirations and the depth of respirations. • Inspection is a technique that involves looking at patients and their surroundings. • Blood pressure is the pressure within the arterial vessels of the circulatory system. • Auscultation of the patient is performed using a stethoscope. • The mean arterial pressure (MAP) is the average pressure in the arterial system over time while • Palpation is touch used to assess the stability of the pulse pressure is the difference between the bony structures and tenderness of muscle and systolic and diastolic pressures. tissue. • • The patient’s core temperature can be measured Percussion is lightly but sharply tapping the body from oral, rectal, or tympanic thermometers. surface to determine the characteristics (air-fi lled, fl uid-fi lled, or solid) of the underlying tissue. • Skin condition and color is an important indicator of perfusion. • Vital signs are objectively measured characteristics of basic body functions and include pulse, • Pulse oximetry is a noninvasive measurement of the respirations, blood pressure, and temperature. percentage of hemoglobin in arterial blood that is Assessment of a patient’s pain level and peripheral bound to oxygen molecules. oxygen saturation (SpO2) may also be included in the Paramedic’s assessment of vital signs. • Factors that may affect the accuracy of the pulse oximetry reading include poor blood fl ow due to • The pulse is assessed for rate, rhythm, and quality. hypovolemia or hypotension, and other compounds (e.g., carbon monoxide) that can also bind to • For patients with signifi cant tachycardia, 180 to hemoglobin and interfere with pulse oximeter 220 beats per minute, or infant and toddlers, the readings. Paramedic may use a stethoscope to listen to the heart and count an apical pulse. • The amount of exhaled carbon dioxide is related to the patient’s ability to move air in and out of the • Respirations are assessed by observing the lungs and is directly related to the patient’s level of respiratory rate, depth, pattern, and work of perfusion. breathing. • Orthostatic vital signs are signs that change when • Depth of respirations can be described as an individual changes position from lying down shallow (hypoventilation), normal, or deep to a standing position due to the heart’s inability (hyperventilation). 302 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to compensate and maintain an adequate blood • The abdominal exam in a patient with a chief pressure and pulse. concern of chest pain is limited to palpation for pain and signs of fl uid overload. Positive hepatojugular • Positive orthostatic vital signs are defi ned as a heart refl ux is a sign of fl uid overload related to right- rate increase of 20 beats per minute or greater, sided heart failure. A normal mental status indicates a systolic
blood pressure drop of greater than 20 that the brain is receiving a suffi cient amount of mmHg, a diastolic blood pressure increase of 10 oxygenated blood. An altered mental status, which mmHg, and/or dizziness or lightheadedness with may vary from confusion to unconsciousness, can position change. indicate that the brain is not receiving enough • A patient’s chief concern or chief complaint is used oxygenated blood. to focus the history and physical examination on Shortness of Breath specifi c body systems. • The physical exam for a patient with a chief Chest Pain concern of shortness of breath is similar to the • The inspection of a patient with the chief concern exam performed for chest pain and begins with of chest pain begins with the assessment of jugular the assessment of respiratory effort and cyanosis. venous pressure (JVP) and signs of peripheral edema. Deviation of the trachea is also assessed and is usually a late sign of conditions that can cause a • Auscultation of heart sounds proceeds shift of the heart and lungs to one side. systematically and should note the normal heart sounds (S1 and S2), potential extra sounds (S3 and • The Paramedic assesses the patient using S4), and abnormal heart sounds such as murmurs auscultation to identify normal and several and rubs. abnormal lung sounds that can indicate a respiratory cause of shortness of breath. Other lung sounds, • Palpate the chest for a thrill or cardiac heave. elevated venous blood pressures, and peripheral Assess a patient’s peripheral pulse for strength and edema may also indicate a cardiac cause of equality in the left and right extremities. shortness of breath. Peripheral pulses and capillary refi ll can be used to assess a patient’s level of • Indications of a patient’s respiratory effort include perfusion. use of accessory muscles, evidence of sternal or intercostal retractions, increased respiratory rate, • Patients in respiratory distress use more energy or tripod positioning. The patient’s skin, mucous to breathe; thus, they produce more CO2. As the membranes, and nail beds can be assessed for level of distress increases, the ventilation becomes cyanosis developed from hypoxemia. poorer and the patient is not able to exhale the CO2 that is produced. The CO2 levels increase in the • When auscultating lung sounds, the Paramedic blood. When the CO2 levels become high enough, should auscultate posteriorly and the left and the patient’s respiratory drive and mental status right sides of the chest, comparing the same levels are further depressed, again impairing the patient’s from apex to base. The Paramedic may be able ability to remove the CO2 from the blood. Patients to determine conditions associated with certain with a chief concern of shortness of breath who abnormal lung sounds (e.g., wheezing, which is have an altered mental status require aggressive associated with asthma or COPD). airway management and ventilatory support in order • Percussion of the chest may reveal normal hollow to halt this dangerous cycle. sounds, a hyperresonant note often seen with a Abdominal Pain pneumothorax, or hyporesonant notes that may indicate fl uid in the lung from either a pleural • The abdomen is inspected for distention and effusion or hemothorax. The Paramedic should prominent surface veins and the skin is inspected palpate the chest to assess the stability of the for jaundice or ecchymosis. Bowel sounds can be rib cage, tenderness, equal expansion, and the auscultated by the Paramedic and may provide some presence of subcutaneous emphysema. clue as to the cause of the patient’s abdominal Physical Examination and Secondary Assessment 303 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. pain. Percussion can also be used by the Paramedic fourth, and sixth cranial nerves are assessed by to assess the abdomen for ascites or fl uid, as well as examining the patient’s extraocular movements tenderness indicative of irritation of the kidney or (EOM). Sustained or prolonged nystagmus may be peritoneum. a sign of intoxication or a central nervous system problem. The third cranial nerve also controls the • The abdomen can be divided into either four papillary response, which is assessed by shining a quadrants or by a method of nines. Each section penlight into the patient’s pupils one at a time, found in either method is palpated by applying looking for constriction of both pupils. gentle, but fi rm pressure with one hand while the other hand lies on top and helps guide the fi rst. • Sensation and motor function impulses to the face Patients may demonstrate rebound tenderness are carried by the fi fth and seventh cranial nerves, or exhibit different signs associated with specifi c respectively, and are assessed by looking for any conditions. The abdomen is also palpated for any asymmetry in sensation or movement of the face. masses that can be tender or nontender, fi rm or The eighth cranial nerve is examined by assessing soft, or pulsatile. the patient’s hearing. Asking the patient to stick out his tongue and say “ah” assesses the ninth and • For patients who have epigastric pain, the Paramedic twelfth cranial nerves. The last part of the cranial should be diligent and perform a more extensive nerve examination is to ask the patient to shrug his cardiovascular examination. Skin color and perfusion shoulders while observing for symmetry, which tests should be inspected, accompanied by auscultation the eleventh cranial nerve. of heart tones and murmurs. The Paramedic should palpate for hepatojugular refl ux and assess the • Peripheral sensation of the skin is organized into extremities for equality of the pulses, especially in dermatomes that correspond to the spinal nerve the lower extremities. An inequality may indicate a roots. Differences in sensation between extremities vascular problem with the abdominal aorta. may indicate nerve root compression, a stroke, or Syncope damage to the peripheral nerve itself. Deep tendon refl exes (DTRs) are tested by tapping a large tendon • Syncope is a transient loss of consciousness that and looking for involuntary muscle contraction in resolves spontaneously. Near syncope is the feeling the muscle associated with that tendon. The bicep that one is going to pass out, although one does not tendon DTR and patellar tendon DTR, along with the actually lose consciousness. Assessment of syncope plantar refl ex, are refl exes that can be evaluated or near syncope begins with the determination of during an assessment. the patient’s level of responsiveness, alertness, and orientation to person, place, and time. It • The Paramedic can assess a patient’s coordination also assesses the patient’s memory for the events by testing the patient for pronator drift. Further leading up to the call for assistance and whether assessment of coordination can be carried out by the patient is able to pay attention or is easily asking the patient to touch her nose with one fi nger distracted in conversation. The patient should and then touch the Paramedic’s fi nger, or asking the exhibit appropriate language with clear speech and patient to touch the heel of one leg to the opposite respond to questions in an appropriate context. leg just below the knee and slide it down the tibia. • The remainder of the neurological exam is divided • The cardiovascular assessment for syncope or near up into the cranial nerve exam, the peripheral syncope involves auscultation of heart sounds for nerve exam, assessment of deep tendon refl exes, tone, murmurs, and extra heart sounds. Pulses should and assessment of coordination. The cranial nerves be palpated for strength and equality. Orthostatic are a set of 12 paired nerves that begin within the vital signs may help assess for hypovolemia that is brainstem and are responsible for movement and not present with the resting vital signs. sensation in the head and neck. • The musculoskeletal examination is used to assess • The second cranial nerve is evaluated through for weakness and detect injury sustained during the assessment of the patient’s visual acuity. The third, syncopal episode. The Paramedic should palpate 304 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. and inspect any areas that are painful while testing including a fracture or dislocation, laceration, the muscle strength of both the upper and lower abrasion, ecchymosis, or edema that can indicate extremities. Bony surfaces and joints should also an underlying bony injury. Erythema, or redness in be assessed for stability. The Paramedic should also the skin, along with warmth may be an indication of observe and document any abnormalities in the cellulitis, or a skin infection. patient’s gait. • The Paramedic should palpate the peripheral pulse Altered Mental Status of the extremity for adequate perfusion in a trauma situation. Assessment of sensation and motor function • Altered mental status can be described as any should be performed in situations of nontraumatic as change from a normal mental status. Some well as traumatic extremity pain. Sensation and motor causes of altered mental status can be aging, function distal to the injury should also be performed infection, intoxication, toxic substances, hypoxia, with a pulse check before and after splinting. hypoglycemia, or trauma. The Paramedic’s goal in assessing the patient with altered mental status High Blood Pressure is to identify reversible causes while providing supportive care to the patient. • The majority of patients encountered by the Paramedic do not require acute lowering of the • The objective of the neurological exam in a patient blood pressure in the prehospital environment. with a chief concern of altered mental status is to However, it is the Paramedic’s goal in assessing the identify signs of either a focal neurological issue, patient to look for signs that the high blood pressure such as a stroke or a cerebral hemorrhage, or a is causing organ damage, including damage to the global disruption, such as low blood sugar or fever. brain, heart, lungs, and kidneys. For the respiratory system examination, one of the most common causes of altered mental status is • The cardiovascular examination focuses on hypoxia. The Paramedic should again focus on the detecting signs of heart failure. The Paramedic patient’s ability to oxygenate and ventilate. should palpate for peripheral edema and pulses, auscultate for heart murmurs or extra heart sounds, • The assessment of skin color, condition, and and assess the patient’s blood pressure. temperature may indicate infection, fever, or dehydration as causes of altered mental status. • The Paramedic should auscultate lung sounds and Ecchymosis, lacerations, or abrasions indicate inspect the patient for signs of diffi culty breathing trauma and suggest a traumatic cause for the that may be related to heart failure or cardiac altered mental status. disease. Assessment of the cranial nerves and muscle strength and coordination may identify • Psychiatric conditions or worsening dementia can defi cits that may be caused by a stroke or other also cause an altered mental status. Components of brain event that may be related to high blood the psychiatric exam include assessment of speech, pressure. Severe hypertension that disrupts the thought processes, suicidal or homicidal ideation, perfusion of blood to the brain can result in the judgment, insight into medical condition, and mental patient presenting with altered mental status. status. Much of this examination is required to ensure a patient who wishes to refuse medical attention HEENT has suffi cient capacity (i.e., mental ability) to understand the potential medical condition and the • A variety of chief concerns are related to the head, consequences of refusing treatment or transport. eyes, ears, nose, and throat, with the most common concern being pain. The Paramedic should inspect Extremity Pain the head for evidence of trauma
and the eyes for responsiveness to light, erythema on the conjunctiva, • Extremity pain as a chief concern can have a and signs of irritation or a foreign body present. traumatic origin or a medical origin. To determine the cause, the Paramedic should inspect the • Ears should be inspected for erythema, signs of painful extremity for signs of an obvious injury, trauma, and discharge or edema. The nares, or Physical Examination and Secondary Assessment 305 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. nostrils, are also inspected for erythema and edema. the presence of bleeding or discharge and evidence If an epistaxis is present, the Paramedic should of crowning. The abdomen is palpated to assess inspect the mucous membrane to fi nd a source of for tenderness and signs of peritoneal irritation. the bleeding in the anterior portion of the nare. Contractions may also be detected and should be measured for duration and timing. • The throat is examined by the Paramedic for erythema, exudates, swelling, and deviation of • Signifi cant rales in combination with lower the uvula from the midline of the pharynx. Oral extremity edema may indicate issues with mucous membranes are also examined for signs of hypertension or heart failure that have developed dehydration. during pregnancy. Signifi cant peripheral edema, increased jugular venous pressure, and chest pain or Fever shortness of breath may also indicate problems with • Fever is a common chief concern for both young hypertension or heart failure. and old, with the extremes of age more likely to • Neurological issues during pregnancy are often related develop sepsis, or septic shock. Fever is also a to the patient’s underlying seizure disorder or can be common cause of altered mental status, especially related to hypertension in pregnancy. For pregnant in the elderly, but fever may also be caused by patients treated with magnesium, one indication of toxic ingestion, environmental related illness, and too much magnesium is deep tendon refl exes that are disorders of the patient’s thermoregulatory system. hyporefl exive, or signifi cantly less brisk than normal. • The respiratory exam focuses on searching for Trauma a cause of fever. The Paramedic should inspect the patient for signs of diffi culty breathing, and • The examination of patients who have sustained auscultate lungs for signs of focal consolidation and a suspected traumatic injury follows a systematic constriction of the smaller airway passages. head to toe approach after the primary survey is completed to ensure detection of injuries based on • The Paramedic should have a high index of suspicion the mechanism of injury. Starting with the patient’s of a gastrointestinal source of fever with patients head, the Paramedic inspects the scalp and face who present with vomiting or diarrhea. Palpation for lacerations, abrasions, ecchymosis, or obvious of the abdomen should be performed to assess deformities that indicate the presence of a head pain, infl ammation, ascites, and the possibility of injury. Inspection of the skull, face, and mouth is pyelonephritis. performed along with evaluating pupil reaction and gross cranial nerve function. • Besides assessing the patient’s skin color and temperature, the skin should be inspected for • With proper spinal motion restriction in place, the signs of infection as well as skin turgor that can Paramedic should inspect the anterior neck for indicate dehydration. The oropharynx should also be signs of trauma or edema that may affect airway examined for signs of infection and dehydration. management or compromise. The cervical spine should be assessed for midline position and palpated Pregnancy for tenderness and deformity. • Some of the common concerns for a patient who is pregnant include vaginal bleeding, abdominal • Assessment of the chest for patients with a chief cramping or pain, trauma in pregnancy, or concern of trauma involves inspection of the impending childbirth. The patient may also have a chest for respiratory effort, abnormal chest wall history of medical conditions such as diabetes or movement, and signs of trauma. A fl ail segment hypertension, although she may also have developed develops when two or more adjacent ribs are these conditions as a result of her pregnancy. fractured in two or more places. This results in paradoxical respirations whereby the fl ail segment • A brief gynecological examination is indicated when moves opposite of the normal chest wall movement. imminent delivery is considered. It involves the Further inspection and auscultation may indicate a Paramedic briefl y inspecting the vaginal opening for pneumothorax or hemothorax. 306 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • The abdomen is inspected by the Paramedic for and after splinting injured extremities. Each wounds and other signs of direct trauma such as extremity should be assessed for the presence ecchymosis and distention. Tenderness or fi rmness of a distal pulse, sensation, and motor function. upon palpation of the abdomen may indicate Inspection and palpation of the spine is often injury to solid organs or internal bleeding. Pressure performed with the patient log-rolled to one side applied to the iliac wings of the pelvis is performed with proper spinal motion restriction carried out. to assess the stability of the pelvis. Any deformity or step off should be treated as a potential fracture with full immobilization and • Assessment and documentation of circulation, transport to an appropriate facility. sensation, and motor function is performed before Review Questions: 1. You are called to the scene of a 55-year- he may have gotten a piece of metal in his eye old female with the chief concern of chest and his eye is in pain. How do you assess the eye pain. Describe the elements of the physical for a foreign body? examination that you will perform during your 4. You are called by the husband of a 32-year-old patient assessment. female patient who is obviously pregnant. The 2. During your patient examination, you fi nd patient has a chief concern of shortness of that she has tenderness to palpation of her breath with a history of asthma. During your abdomen. Describe what you should do. assessment, you fi nd she is also having severe, 3. You are called to a construction site to care for a crampy lower abdominal pain. What should 25-year-old male patient with eye pain. He states you do? Case Study Questions: Please refer to the Case Study at the beginning of the 3. Describe a situation in which the incorrect chapter and answer the questions below. treatment could actually worsen your patient’s 1. What are the four components of each physical condition. exam? 2. When examining a patient, what elements of a patient’s condition can you see? Hear? Feel? Detect by the return of sound? Physical Examination and Secondary Assessment 307 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. References: 1. 19. Singer AJ, Kahn SR, Thode HC, Jr., Hollander JE. Comparison Rock, M. Underexposed. The neglected art of the physical exam. of forearm and upper arm blood pressures. Prehosp Emerg Care. Jems. 2006;31(5):40, 42–43. 2. 1999;3(2):123–126. Dickinson ET, O’Connor RE, Krett RD. The impact of prehospital instant photography of motor vehicle crashes 20. Naqvi NH. A universal celebration: 100 years of Korotkoff on receiving physician perception. Prehosp Emerg Care. sounds, 1905–2005. Vesalius. 2005;11(2):59–60. 1997;1(2):76–79. 21. Shlyakhto E, Conrady A. Korotkoff sounds: what do we know 3. Scott LA, Brice JH, Baker CC, Shen P. An analysis of Paramedic about its discovery? J Hypertens. 2005;23(1):3–4. verbal reports to physicians in the emergency department trauma 22. Phillips DM. JCAHO pain management standards are unveiled. room. Prehosp Emerg Care. 2003;7(2):247–251. Joint Commission on Accreditation of Healthcare Organizations. 4. Kantola I, Vesalainen R, Kangassalo K, Kariluoto A. Bell or Jama. 2000;284(4):428–429. diaphragm in the measurement of blood pressure? J Hypertens. 23. Noe C, et al. New JCAHO standards for pain management. Tex 2005;23(3):499–503. Nurs. 2001;75(4):7. 5. Welsby PD, Parry G, Smith D. The stethoscope: some preliminary 24. Kelleher JF. Pulse oximetry. J Clin Monit. 1989;5(1):37–62. investigations. Postgrad Med J. 2003;79(938):695–698. 25. Weg JG, Haas CF. Long-term oxygen therapy for 6. Lanser P, Gesell S. Pain management: the fi fth vital sign. Healthc COPD. Improving longevity and quality of life in hypoxemic Benchmarks. 2001;8(6):62, 68–70. patients. Postgrad Med. 1998;103(4):143–144, 147–148, 7. Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, 153–155. Ganzini L. Measuring pain as the 5th vital sign does not improve 26. Thrush D, Hodges MR. Accuracy of pulse oximetry during quality of pain management. J Gen Intern Med. 2006;21(6): hypoxemia. South Med J. 1994;87(4):518–521. 607–612. 27. Soubani AO. Noninvasive monitoring of oxygen and carbon 8. Ochoa FJ, Ramalle-Gomara E, Carpintero JM, Garcia A, dioxide. Am J Emerg Med. 2001;19(2):141–146. Saralegui I. Competence of health professionals to check the 28. Benumof JL. Interpretation of capnography. Aana J. carotid pulse. Resuscitation. 1998;37(3):173–175. 1998;66(2):169–176. 9. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova 29. Grmec S, Klemen P. Does the end-tidal carbon dioxide (EtCO ) 2 I. Checking the carotid pulse check: diagnostic accuracy of fi rst concentration have prognostic value during out-of-hospital responders in patients with and without a pulse. Resuscitation. cardiac arrest? Eur J Emerg Med. 2001;8(4):263–269. 1996;33(2):107–116. 30. Hatlestad D. Capnography as a predictor of the return of 10. Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills spontaneous circulation. Emerg Med Serv. 2004;33(8):75–80; of lay people in checking the carotid pulse. Resuscitation. quiz 115. 1997;35(1):23–26. 31. Werner SL, Smith CE, Goldstein JR, Jones RA, Cydulka RK. 11. American Academy of Orthopedic Surgeons. Emergency Care Pilot study to evaluate the accuracy of ultrasonography in and Transportation of the Sick and Injured (Book with Mini CD- confi rming endotracheal tube placement. Ann Emerg Med. ROM for Windows & Macintosh, Palm/Handspring, Windows 2007;49(1):75–80. CE/Pocket PC eBook Reader, Smart Phone). Boston: Jones & 32. Ahrens T, Wijeweera H, Ray S. Capnography. A key Bartlett Publishers; 2002. underutilized technology. Crit Care Nurs Clin North Am. 12. Hermansen CL, Lorah KN. Respiratory distress in the newborn. 1999;11(1):49–62. Am Fam Physician. 2007;76(7):987–994. 33. Medow MS, Stewart JM, Sanyal S, Mumtaz A, Sica D., Frishman 13. Bianchi R, Gigliotti F, Romagnoli I, Lanini B, Castellani C, WH. Pathophysiology, diagnosis, and treatment of orthostatic Grazzini M, et al. Chest wall kinematics and breathlessness hypotension and vasovagal syncope. Cardiol Rev. during pursed-lip breathing in patients with COPD. Chest. 2008;16(1):4–20. 2004;125(2):459–465. 34. Burri C, Henkemeyer H, Passler HH, Allgower M. Evaluation of 14. Ritz T, Roth WT. Behavioral interventions in asthma. Breathing acute blood loss by means of simple hemodynamic parameters. training. Behav Modif. 2003;27(5):710–730. Prog Surg. 1973;11:108–131. 15. Holloway E, Ram FS. Breathing exercises for asthma. Cochrane 35. Gauer OH, Henry JP, Sieker HO. Changes in central venous Database Syst Rev. 2004;1:CD001277. pressure after moderate hemorrhage and transfusion in man. Circ 16. Truesdell S. Helping patients with COPD manage episodes of Res. 1956;4(1):79–84. acute shortness of breath. Medsurg Nurs. 2000;9(4):178–182. 36. Shenkin HA, Cheney RH, Govans SR, et al. On the diagnosis of 17. Lang EW, Chesnut RM. Intracranial pressure. Monitoring and hemorrhage in man: a study of volunteers bled large amounts. management. Neurosurg Clin N Am. 1994;5(4):573–605. Am J Med Sci. 1994;25(5):421. 18. White WB. Systolic versus diastolic blood pressure versus pulse 37. Roger VL. Epidemiology of myocardial infarction. Med
Clin pressure. Curr Cardiol Rep. 2002;4(6):463–467. North Am. 2007;91(4):ix, 537–552. 308 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 38. Sinisalo J, Rapola J, Rossinen J, Kupari M. Simplifying 50. Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati the estimation of jugular venous pressure. Am J Cardiol. Prehospital Stroke Scale: Reproducibility and validity. Ann 2007;100(12):1779–1781. Emerg Med. 1999;33(4):373–378. 39. Lima A, Bakker J. Noninvasive monitoring of peripheral 51. Bray JE, Martin J, Cooper G, Barger B, Bernard S, Bladin, perfusion. Intensive Care Med. 2005;31(10):1316–1326. C. Paramedic identifi cation of stroke: community validation 40. Sanchez LD, Ban KM, Bramwell K, Sakles JC, Davis D, Wolfe of the Melbourne ambulance stroke screen. Cerebrovasc Dis. R, et al. A 29-year-old man with subcutaneous emphysema of the 2005;20(1):28–33. neck following blunt trauma. Intern Emerg Med. 52. Ekker T. When hope is lost . . . dealing with the suicidal patient. 2007;2(1):50–52. Jems. 1991;16(11):64–67. 41. Pullen RL, Jr. Assessing for hepatojugular refl ux. Nursing. 53. Whelton PK, Beevers DG, Sonkodi S. Strategies for improve- 2006;36(2):28. ment of awareness, treatment and control of hypertension: 42. Mueller C, Frana B, Rodriguez D, Laule-Kilian K, Perruchoud results of a panel discussion. J Hum Hypertens. 2004;18(8): AP. Emergency diagnosis of congestive heart failure: impact of 563–565. signs and symptoms. Can J Cardiol. 2005;21(11):921–924. 54. Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in 43. Sydow M. Ventilating the patient with severe asthma: adults: part I. Evaluation. Am Fam Physician. 2004;70(9): nonconventional therapy. Minerva Anestesiol. 2003;69(5): 1685–1692. 333–337. 55. Wald ER. Purulent nasal discharge. Pediatr Infect Dis J. 44. Eskelinen M, Ikonen J, Lipponen P. Contributions of history- 1991;10(4):329–333. taking, physical examination, and computer assistance to 56. Louie JP, Bell LM. Appropriate use of antibiotics for common diagnosis of acute small-bowel obstruction. A prospective infections in an era of increasing resistance. Emerg Med Clin study of 1333 patients with acute abdominal pain. Scand J North Am. 2002;20(1):69–91. Gastroenterol. 1994;29(8):715–721. 57. Frykberg RG. Diabetic foot ulcers: pathogenesis and 45. Culic V, Miric D, Eterovic D. Correlation between management. Am Fam Physician. 2002;66(9):1655–1662. symptomatology and site of acute myocardial infarction. Int J 58. Popov T. Review: capillary refi ll time, abnormal skin Cardiol. 2001;77(2-3):163–168. turgor, and abnormal respiratory pattern are useful signs 46. Goldberg R, Goff D, Cooper L, Luepker R, Zapka J, Bittner for detecting dehydration in children. Evid Based Nurs. V, et al. Age and sex differences in presentation of symptoms 2005;8(2):57. among patients with acute coronary disease: the REACT Trial. 59. Torgersen KL, Curran CA. A systematic approach to the Rapid early action for coronary treatment. Coron Artery Dis. physiologic adaptations of pregnancy. Crit Care Nurs Q. 2000;11(5):399–407. 2006;29(1):2–19. 47. Davis N, Sistino JJ. Review of ventricular rupture: key 60. Chandler CF, Lane JS, Waxman KS. Seatbelt sign following concepts and diagnostic tools for success. Perfusion. blunt trauma is associated with increased incidence of abdominal 2002;17(1):63–67. injury. Am Surg. 1997;63(10):885–888. 48. Guhathakurta S, Chen Q, Nalladaru Z, Squire BH, Sharma AK. 61. Samoilenko MV, Magomedov MK, Shabalkin BV. Delayed traumatic mitral regurgitation after blunt chest trauma. Arteriosclerosis of the right gastro-omental artery. Kardiologiia. J Trauma. 1999;47(5):982–984. 1992;32(1):16–18. 49. Kothari R, Barsan W, Brott T, Broderick J, Ashbrock S. 62. Randhawa MP, Jr., Menzoian JO. Seat belt aorta. Ann Vasc Surg. Frequency and accuracy of prehospital diagnosis of acute stroke. 1990;4(4):370–377. Stroke. 1995;26(6):937–941. Physical Examination and Secondary Assessment 309 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Paramedic approach to clinical decision making • Developing a Paramedic fi eld diagnosis • The importance of enveloping a mechanism of injury or nature of illness • Differentiating between emergent and urgent • Methods of improved clinical decision making Case Study: The Paramedics saw both patients approach the ambulances parked at the fi rst aid station at the county fair. Each patient had the same complaint—chest pain which was worse when they took a deep breath. In obtaining a brief history, they found that Joseph Gonterman, a tall lanky 19-year-old, had just developed the pain after some coughing. He had a history of simple pneumothoraxes and currently had normal vital signs and oxygen saturation. Guiseppe Ferrari, a 68-year-old with a history of chronic lung disease, had been ill for several days before the fair. Since his granddaughter was showing her prized calf, he had decided to come to the fair anyway. Now it was diffi cult for him to breathe and he felt a little faint. 310 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Clinical Decision Making and Teamwork 311 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW The out-of-hospital environment is heavily infl uenced by factors that create an environment like no other where medicine is practiced. The spectrum of patient care in the out-of-hospital environment ranges from obvious critical life threats and potential life threats to non life-threatening presentations. Effective practice in this environment requires the gathering, evaluating, and synthesizing of a great deal of information. The Paramedic must apply independent decision-making skills to make judgments and work effectively under immense pressure. Protocols, standing orders, and patient care algorithms can greatly assist the Paramedic in decision making. This approach has limitations, however: (1) It only addresses “classic” patient presentations, (2) it does not speak to those patients with multiple disease etiologies or those requiring multiple treatment modalities, and (3) it promotes linear thinking or “cookbook medicine.” The components of critical thinking include concept formation, data formation, application of principle, evaluation, and refl ection on action. Clinical Decision Making A Paramedic’s diagnosis is based upon a collection of the patient’s signs and symptoms, called the symptom complex, Using a process of systematic analysis and critical think- obtained by the Paramedic during the history and physical ing, the Paramedic makes clinical decisions that will be exam. incorporated into a patient’s treatment plan. This process of The Paramedic then compares the patient’s symptom assessment and treatment planning is called clinical decision complex against her knowledge base of diseases, disor- making. ders, and syndromes to fi nd a similar grouping of signs and symptoms and matches the symptom patterns to derive a Medical Intelligence diagnosis. Using his intelligence (i.e., past experience and medical Ordinarily, a Paramedic is hard pressed to make a diagno- knowledge), the Paramedic takes a systematic approach to sis of a disease in the fi eld. Generally, a medical diagnosis of a investigating a problem and coming to a decision. This sys- disease is made after exhaustive medical tests lead a physician tematic approach to clinical decision making is called medi- to one irreducible conclusion which excludes all other possible cal intelligence. In essence, it is how Paramedics think. It conclusions. The physician arrives at this medical diagnosis as has been suggested that medical intelligence—the process of a result of a deductive process that eliminates, or rules out, all learning from experience and past practice and then coming other possible known explanations for the patient’s condition. to a decision—is what separates healthcare providers from Paramedics do not have the resources or the time to use the lay public. deductive logic in the fi eld. Paramedics instead rely on their Medical intelligence starts with information gather- faster, but less precise, inductive logic to make a diagnosis. ing. For the Paramedic, this means taking a patient history This diagnosis tends to be broad in its scope, and treatments and performing the physical exam. With the facts in hand, derived from the diagnosis tend to be palliative in nature the Paramedic compares the data against his own previous (i.e., providing supportive care and relief from suffering, experiences, anecdotal information, and formal medical rather than being curative). education.1–3 This is called the knowledge base. The Para- Therefore, whenever a Paramedic makes a tentative deci- medic then starts to form ideas about what is causing the sion, called a Paramedic fi eld diagnosis, it is a broad all- patient’s condition. encompassing conclusion. A Paramedic fi eld diagnosis is a This process of forming ideas, called concept forma- complaint-based conclusion about the nature of the illness tion, is based on inductive logic. Inductive logic begins with or injury. observations, such as the history and physical exam. The A Paramedic’s fi eld diagnosis generally identifi es a dis- facts are then incorporated with the knowledge base. Then order or a syndrome. A disorder is a physiological deviation the Paramedic reduces it all to a single theory, a hypothesis. from a normal homeostasis (e.g., hypoxia). A syndrome is a In the case of patient care, the hypothesis is the cause of the collection of symptoms that characterize a condition or state patient’s illness or the Paramedic’s diagnosis. (e.g., acute coronary syndrome). 312 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. When arriving on a potential trauma call, the Paramedic Street Smart uses his knowledge of kinematics, the study of motion, and the mechanism of injury to derive a predictable injury pattern.8–14 For example, a front-end motor vehicle collision Some Paramedics, when faced with a scarcity of would propel a patient forward against the windshield and information, will make a hasty fi eld diagnosis that is cause head and neck injuries. broad and overgeneralized. This imprecise diagnosis, The patient’s chief complaint, or concern, and the lack of a sometimes called a garbage can diagnosis, lends mechanism of injury helps establish the medical nature of a call. The Paramedic then goes about ascertaining the nature of the little direction to patient care. illness. The nature of the illness is the sum of the patient’s chief complaint, or concern, and the history of the present illness. When conditions prohibit a more intensive history and Urgent or Emergent physical, the Paramedic should elect to treat the patient with Early in the assessment process, the Paramedic makes a gen- supportive care based upon the chief concern.4–6 This is eral decision whether the patient is emergent (i.e., arising referred to as symptom-based care.7 The Paramedic should unexpectedly and in need of immediate medical attention) or then strive to obtain more clinical information when condi- urgent (i.e., not emergent and in need of further assessment tions improve. For example, a Paramedic confronted with a and evaluation before treatment is initiated). patient with air hunger should elect to treat the hypoxia fi rst This general assessment of the patient’s condition is and then proceed to provide
rapid transport and perform fur- termed the initial impression. An initial fi eld impression ther assessment en route. is based on a myriad of factors such as patient presentation, environmental factors, gross observation, and resources on- The Method of Paramedic Practice scene. These factors assemble in the Paramedic’s mind to cre- ate a sense of emergency or urgency. Starting with the patient’s chief complaint, or concern, the Paramedic forms a cognitive map of the potential etiolo- gies of the chief concern. For example, if the patient’s chief concern is chest pain, that elicits thoughts of numerous conditions which could account for the chest pain, including Street Smart acute coronary syndrome, costracondritis, and pulmonary embolism, to name a few. A fi eld impression can be reduced to simply thinking The thought of each of these conditions, and their accom- panying symptom complex, is contained in the Paramedic’s whether the patient is sick or not sick. This initial mind as a script. A script can be thought of as an idea which fi eld impression (i.e., if the patient failed the “look has an associated symptom complex and an associated fi eld test”) is used to decide the tempo of the team’s diagnosis and treatment plan. activities. For example, when thinking of acute coronary syndrome, the Paramedic thinks of not only those signs and symptoms in the symptom complex which are coupled with the diagnosis of acute coronary syndrome (such as substernal chest pain, If the patient is emergent, then initial life-saving maneu- ST segment elevation, and so on), but the associated treat- vers during the primary assessment must be performed on- ments as well. scene. The patient is then rapidly moved to the ambulance for transportation to defi nitive care. Initial Impression If the patient is urgent then, after a primary assessment is Upon arrival at the patient’s side, the Paramedic must fi rst completed, a more detailed history and physical is performed. make a decision whether the call is medical or trauma in Some experienced Paramedics come to this decision nature. To make that decision, the Paramedic considers if very quickly. These master Paramedics use what is termed there is a mechanism of injury, suggesting trauma, or a Gestalt, a way of seeing a pattern in the patient observation nature of illness, suggesting the call is medical. as a whole. It is not obtained by a summation of symptoms In the case of trauma, the mechanism of injury can pro- but rather from patterns having been observed in similar situ- vide some valuable clues to underlying injuries. The mecha- ations in past practice and experience. nism of injury includes those forces (e.g., shearing or tearing) Following the general impression, the Paramedic pro- that create physical harm to the patient. ceeds with obtaining the history and performing a physical Certain mechanisms of injury have characteristic injuries examination in order to ascertain the symptom complex. that are associated with that mechanism. These characteristic Using a standardized approach, such as the mnemonic injuries are referred to as the predictable injury pattern. OPQRST, reveals the symptom complex. Clinical Decision Making and Teamwork 313 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Some findings, such as nausea or headache, are non- specific (i.e., not indicative of any one disease), and are Street Smart often common to all sick patients. These general find- ings of illness are often referred to as constitutional signs. While constitutional signs help to establish that Paramedics who routinely perform tests, such as blood the patient is not well and in need of supportive care, glucose analysis, without consideration of the meaning they do not assist the Paramedic toward reaching a clini- of the results may be practicing defensive medicine. cal decision. The practice of performing random tests in order to limit liability, or criticism from the medical director, rather than performing just those tests that benefi t the patient should not be encouraged. Professional Paramedic Savvy patients may inquire about the necessity of fi eld Differential Diagnosis tests. Questions will arise regarding the accuracy of After gathering the facts in the case (the symptom complex), the test and whether the test delays transportation. comparing that to similar symptom patterns, and recognizing The professional Paramedic knows how often the test the similarity, the Paramedic advances a fi eld diagnosis. On occasion, the Paramedic may be confl icted whether to gives a correct positive result (its sensitivity) but also state one fi eld diagnosis or another. In those cases, the Para- how often it fails to give a correct positive result (its medic should consider applying Ockham’s razor. Ockham’s specifi city). Paramedics must be able to describe the razor, simply stated, says that if all things are equal, the simplest solution tends to be the best one. In other words, common things time the procedure takes and how it will enhance occur commonly. While exotic diseases do exist, the probability overall care. is low that these diseases are involved. Tests Street Smart Owing to the urgent nature of a medical emergency, the Para- medic must choose those tests that have the greatest yield The saying goes “When one hears hoof beats think horses of information. A random test, such as obtaining a 12 lead not zebras.” While the physician is tasked with “ruling ECG, without conscious consideration of what the results might reveal is wasteful. Before implementing any test, the out” these diagnoses, the Paramedic should focus on the Paramedic should ask, “Will this test affect my decision mak- more common and predictable causes of illness. ing?” If the answer is no, or unknown, then the test may be a waste of time. Whenever a test is performed, the Paramedic should be When the Paramedic is faced with a situation in which aware of its specifi city and the sensitivity, the test’s predictive several plausible explanations for a disorder exist and the Para- value. medic cannot narrow the causes down to one disease or another, For example, when the 12 lead ECG machine analysis then the Paramedic should treat the patient aggressively. The states “acute myocardial infarction suspected” the Paramedic Paramedic should assume that the disorder which can harm the can have confi dence that the patient is having an acute myo- patient the most exists. For example, while epigastric discom- cardial infarction. In other words, the Paramedic can assume fort could be gastric esophageal refl ux disease, it might also be the machine is correct, based on research that has shown good connected to an inferior wall acute ischemic event.17,18 Keeping sensitivity (97% accurate in one study).15,16 the patient’s best interests in mind, the Paramedic should treat However, the Paramedic must also be skeptical of the the patient as if he were having an acute coronary event and results as well. The 12 lead ECG machine may lack specifi c- consider the possible cardiac origin for this discomfort. ity (i.e., the machine may not read “acute myocardial infarc- If the Paramedic errs in the fi eld and treats the patient tion suspected” when in fact one does exist). with GERD as a cardiac patient, then the patient will most Understanding the limitation of every machine or test, likely be no worse for the care. However, if the Paramedic the Paramedic should never rely on one test result to make a treats the cardiac patient for heartburn only, missing the clinical decision. Instead, the Paramedic should consider the potential for an acute coronary event, then the patient could entire patient presentation, coupled with the test results, to have a catastrophic event and the opportunity for timely inter- arrive at a fi eld diagnosis. vention may be lost. 314 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. decisions. Implicit with the use of guidelines is accountabil- Street Smart ity. Whenever guidelines are in use, the Paramedic must be willing to discuss and defend the clinical decisions. Every Paramedic should look forward to the opportunity The Paramedic’s treatment philosophy could be to defend a clinical decision. These conversations with fellow summed up with the saying “Hope for the best but Paramedics or the medical director permit the Paramedic the treat for the worst.” opportunity to improve clinical decision making. Emergency medicine is a dynamic fi eld that requires fl exibility in thought and a willingness to see a different point of view. The Paramedic must become a good clinical decision Paramedics who are unwilling to consider alternatives to maker. The Paramedic’s ability to take all of the clinical infor- patient care, other than the routine care, because it has always mation and separate out irrelevant information from critical been done this way, are experiencing paradigm blindness.19 data is important for clinical decision making. Prepared with Good clinical decision making depends on a willingness to a well-conceived fi eld diagnosis, the Paramedic can then pro- accept new ideas and to practice creative thinking in the fi eld ceed with a treatment plan. (i.e., thinking outside of the box). The greatest danger to any Paramedic’s clinical deci- Barriers to Effective Clinical sion making is fear. Whenever a Paramedic feels unsure, or even threatened, by a clinical situation, the response will Decision Making be an adrenaline surge. Adrenaline can help to sharpen the Paramedic’s senses, improving the patient assessment, but it Skill in good clinical decision making is a function of formal can also narrow the Paramedic’s focus. This narrow focus of education and practical experience. It is essential that gradu- attention (e.g., to a task) causes the Paramedic to miss see- ate Paramedics have a formal education which provides both ing the larger picture and therefore miss important clinical depth and breadth in achieving a comprehensive understand- information. ing of paramedicine. Paramedics should strive to see situations as challeng- However, the knowledge base of the Paramedic who ing, not threatening, and maintain a sense of control from graduated, even with highest honors, is soon outdated. Every within. This internal locus of control (i.e., the idea that one Paramedic must understand and accept the need for continu- has the ability to control the situation) gives the Paramedic ing education for competency assurance and professional a sense of control over the situation. This sense of control development. This attitude can be best summed up by the can translate to a feeling of confi dence and improved clinical Japanese idea of Kaizen, meaning continuous performance decision making. Others, seeing the confi dence evident in the improvement. Paramedic, tend to follow the Paramedic’s lead. Improved clinical decision making can also be obtained from practical experience with a master Paramedic. Mentors, experienced master Paramedics, accept graduate Paramedics Improved Clinical as their protégés to teach good clinical decision making. These mentors often depend on intuition when making decisions in Decision Making ambiguous or complex situations. This clinical intuition, borne The Paramedic’s best ally for clinical decision making is the of experience, can be described as understanding without ratio- patient. While the patient always has a right to make informed nale, as opposed to irrational guessing. Sharing intuition with decisions about patient care, shared decision making goes novice Paramedics permits the novice Paramedic to develop beyond consent and engages the patient in a conversation about expert judgment. clinical decision making whenever possible. The patient is seen With limited education, and even more limited experi- as not being dependent (a paternalistic view), but rather inter- ence, the novice Paramedic may resort to applying protocol- dependent with the Paramedic. In a shared decision-making driven care in every circumstance. Protocols are a set of model, the patient is consulted
about clinical decisions. Pro- mandatory behaviors meant to be applied in specifi c clini- viding the patient with current information about his or her cal conditions. Protocols, almost by defi nition, assume that state of health and offering medically reasonable alternatives the one patient’s situation is the same or similar to another empowers both the patient and the Paramedic. patient’s condition in the same situation. Obtaining patient concordance, the process of shared In many cases this approach is acceptable, and has advan- decision making, includes a communication of risk, the tages in a time-sensitive emergency. However, some patients advantages of compliance, and a shared responsibility to do not fi t the prescribed clinical condition. That is, the patient report changes. Shared clinical decision making fosters does not fi t into the mold. openness and trust between the patient and the Paramedic. In In those cases, the Paramedic should view the protocols addition, shared clinical decision making decreases patient as a set of guidelines. Guidelines provide direction while per- dissatisfaction, even allowing the patient to decide to with- mitting use of knowledge and experience to shape clinical hold treatment until arrival at the hospital. Clinical Decision Making and Teamwork 315 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Illnesses are progressive. Watchful waiting while provid- Cultural / Regional differences ing supportive care can sometimes make a cloudy clinical picture clearer or may demonstrate the ineffectiveness of a particular treatment. This may lead the Paramedic to consider It should be noted that while younger and better other treatment pathways. educated patients prefer to share clinical decision This process of assessment, treatment, and then reas- making, cultural and ethnic differences may decrease sessment is consistent with the quality improvement cycle patient cooperation. This lack of cooperation should (plan–do–check–act). Attention to evaluation of treatments and then consideration of further interventions leads to higher not be viewed as resistance to care but rather as a quality of care. trust in the Paramedic’s decision. Disposition Treatment Paramedic care is the beginning of the continuum of care Paramedics typically start patient care with empiric therapy, which is continued in the emergency department, critical care treatment based on initial observations obtained during the units, rehabilitation fl oors, and homecare services. In many primary assessment. For example, a person with obvious cases, the Paramedic’s decision in the fi eld puts the patient diffi culty breathing may receive oxygen immediately. Such onto a treatment pathway. For example, the Paramedic’s fi eld treatments are considered basic life support. Though they diagnosis might activate a “cardiac team” at a center for inter- may be complex, such as intravenous therapy, they are not ventional cardiology, alert a critical care unit of an impend- intended to treat a specifi c disorder. Rather, they are intended ing arrival, and set about a cascade of events, all designed to to support the body (palliative care). return the patient to the best state of health possible.20–25 Key to this process is good clinical decision making. Evaluate Clinical decision making is a process of systematic anal- Some novice Paramedics are compelled to act either by train- ysis, using medical intelligence and critical thinking, aided ing or cultural infl uences within an organization. This action by input from the team, which in the end is the basis for a plan imperative (i.e., don’t just stand there, do something) is some- of care. It always has the patient’s best interests in mind. times ill advised and can lead to catastrophic events. 316 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Paramedic of the future is a thinking practitioner who essentially operates almost independently in the prehospital environment. By using the methods discussed in this chapter, the Paramedic can move away from blindly following protocols and toward a thinking, professional practitioner. Key Points: • “Medical intelligence” is a term used to describe • Before implementing any test, the Paramedic should the Paramedic’s systematic approach to clinical determine whether the test will affect the decision- decision making. making or treatment plan. • The symptom complex is compared to the • Before the test is performed, the Paramedic should Paramedic’s own knowledge base to determine if be aware of its specifi city and sensitivity. any familiar symptom patterns exist. • The idea of preparing or treating for the worst and • Gathering information and reducing it to a hoping for the best is one way the Paramedic can single theory is called inductive logic. The keep the patient’s best interests in mind while Paramedic uses this line of thinking to investigate developing an appropriate fi eld diagnosis and a problem and develop an appropriate treatment treatment plan. plan. • Skill in good clinical decision making is a function of • When presented with a chief complaint or formal education and practical experience. concern, the Paramedic should begin to develop a list of possible etiologies of the • Protocols should be viewed as a set of guidelines chief concern. This cognitive list is then that provide direction while permitting the associated with a fi eld diagnosis and treatment Paramedic to use knowledge and experience to plan. shape clinical decisions. • To determine whether an emergency call is medical • Good clinical decision making depends on a or trauma in nature, the Paramedic must consider willingness to accept new ideas and to practice either the mechanism of injury or the nature of creative thinking in the fi eld (i.e., thinking outside illness. of the box). • The initial impression of a patient is based on • An internal locus of control, or one’s sense of factors such as patient presentation, environmental control over a situation, can translate to a factors, and resources available. feeling of confi dence and improved clinical decision making. Shared decision making goes • The initial impression is used in conjunction with beyond consent and engages the patient in a the primary assessment to determine if the patient conversation about clinical decision making is emergent or urgent. whenever possible. • Some fi ndings, such as nausea or headache, are • Treatment may begin with empiric therapy, based referred to as constitutional signs because they on the initial assessment. Further interventions are nonspecifi c and are often common to all sick should be based on a reassessment of treatments patients. given. Clinical Decision Making and Teamwork 317 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. Explain the process of medical intelligence. 6. Explain the difference between protocols and 2. Defend the concept of Paramedic fi eld diagnosis. guidelines. 3. Explain mechanism of injury and its 7. List methods of improved clinical decision relationship to a predictable injury pattern. making. 4. Explain the difference between emergent and 8. Explain how identifying inaccurate fi eld urgent. diagnoses can lead to improved patient care. 5. List the barriers to effective clinical decision making. Case Study Questions: Please refer to the Case Study at the beginning of the 2. Are each of these patients suffering from a chapter and answer the questions below. trauma event or a medical one? Explain your 1. Name the symptom complex for Joseph answers. Gonterman. Name the symptom complex for 3. Do Mr. Gonterman and Mr. Ferrari have the Guiseppe Ferrari. same priority? Why or why not? References: 1. Glick TH. Evidence-guided education: patients’ outcome and stratifi cation strategies. Md Med J, Suppl. 1997;7(1)(Suppl): data should infl uence our teaching priorities. Acad Med. 79–84. 2005;80(2):147–151. 8. Eid HO, Abu-Zidan FM. Biomechanics of road traffi c 2. Kilminster SM, Jolly BC. Effective supervision in clinical practice collision injuries: a clinician’s perspective. Singapore Med J. settings: a literature review. Med Educ. 2000;34(10):827–840. 2007;48(7):693–700; quiz 700. 3. Dornan T, Littlewood S, Margolis SA, Scherpbier A, Spencer 9. Mackay M. Mechanisms of injury and biomechanics: vehicle J, Ypinazar V. How can experience in clinical and community design and crash performance. World J Surg. 1992;16(3):420–427. settings contribute to early medical education? A BEME 10. Green RN, German A, Nowak ES, Dalmotas D, Stewart DE. systematic review. Med Teach. 2006;28(1):3–18. Fatal injuries to restrained passenger car occupants in Canada: 4. Fleischer AB, Jr., Gardner EF, Feldman SR. Are patients’ chief crash modes and kinematics of injury. Accid Anal Prev. complaints generally specifi c to one organ system? Am J Manag 1994;26(2):207–214. Care. 2001;7(3):299–305. 11. Kumar S, Ferrari R, Narayan Y. Kinematic and 5. Rottman SJ, Schriger DL, Charlop G, Salas JH, Lee S. On-line electromyographic response to whiplash loading in low-velocity medical control versus protocol-based prehospital care. Ann whiplash impacts—a review. Clin Biomech (Bristol, Avon). Emerg Med. 1997;30(1):62–68. 2005;20(4):343–356. 6. Kothari R, Barsan W, Brott T, Broderick J, Ashbrock S. 12. Kumar S, Ferrari R, Narayan Y. The effect of trunk fl exion Frequency and accuracy of prehospital diagnosis of acute stroke. in healthy volunteers in rear whiplash-type impacts. Spine. Stroke. 1995;26(6):937–941. 2005;30(15):1742–1749. 7. MacDonald GS, Steiner SR. Emergency medical service 13. Mikhail JN. Side impact motor vehicular crashes: patterns of providers’ role in the early heart attack care program: prevention injury. Int J Trauma Nurs. 1995;1(3):64–69. 318 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 14. Loo GT, Siegel JH, Dischinger PC, Rixen D, Burgess AR, Addis 21. Feldman JA, Brinsfi eld K, Bernard S, White D, Maciejko T. MD, et al. Airbag protection versus compartment intrusion effect Real-time Paramedic compared with blinded physician determines the pattern of injuries in multiple trauma motor identifi cation of ST-segment elevation myocardial infarction: vehicle crashes. J Trauma. 1996;41(6):935–951. results of an observational study. Am J Emerg Med. 15. Sekiguchi K, Kanda T, Osada M, Tsunoda Y, Kodajima N, 2005;23(4):443–448. Fukumura Y, et al. Comparative accuracy of automated computer 22. Strauss DG, Sprague PQ, Underhill K, Maynard C, Adams GL, analysis versus physicans in training in the interpretation of Kessenich A, et al. Paramedic transtelephonic communication to electrocardiograms. J Med. 1999;30(1-2):75–81. cardiologist of clinical and electrocardiographic assessment for 16. Willems JL, Abreu-Lima C, Arnaud P, van Bemmel JH, Brohet rapid reperfusion of ST-elevation myocardial infarction. C, Degani R, et al. The diagnostic performance of computer J Electrocardiol. 2007;40(3):265–270. programs for the interpretation of electrocardiograms. N Engl J 23. Adams GL, Campbell PT, Adams JM, Strauss DG, Wall Med. 1991;325(25):1767–1773. K, Patterson J, et al. Effectiveness of prehospital wireless 17. Sheps DS, Creed F, Clouse RE. Chest pain in patients with cardiac transmission of electrocardiograms to a cardiologist via and noncardiac disease. Psychosom Med. 2004;66(6):861–867. hand-held device for patients with acute myocardial infarction 18. Miller CD, Lindsell CJ, Khandelwal S, Chandra A, Pollack (from the Timely Intervention in Myocardial Emergency, CV, Tiffany BR, et al. Is the initial diagnostic impression of NorthEast Experience [TIME-NE]). Am J Cardiol. “noncardiac chest pain” adequate to exclude cardiac disease? Ann 2006;98(9):1160–1164. Emerg Med. 2004;44(6):565–574. 24. Wojner-Alexandrov AW, Alexandrov AV, Rodriguez D, 19. Camp R. Benchmarking: The Search for
Industry Best Practices Persse D, Grotta JC. Houston Paramedic and emergency That Lead to Superior Performance. Portland: Productivity Press; stroke treatment and outcomes study (HoPSTO). Stroke. 2006. 2005;36(7):1512–1518. 20. Le May MR, Dionne R, Maloney J, Trickett J, Watpool I, Ruest 25. Qazi K, Kempf JA, Christopher NC, Gerson LW. Paramedic M, et al. Diagnostic performance and potential clinical impact of judgment of the need for trauma team activation for pediatric advanced care Paramedic interpretation of ST-segment elevation patients. Acad Emerg Med. 1998;5(10):1002–1007. myocardial infarction in the fi eld. Cjem. 2006;8(6): 401–407. Clinical Decision Making and Teamwork 319 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Duality of EMS communications • A history of radio communications from ground to satellite • Breakdown of radio architectures, bandwidths, and technology • Phases of EMS communications, from the initial call for help to turning the care over to hospital staff • The standardized radio report for communicating with physicians Case Study: The Paramedic was the fi rst on-scene of a two-car motor vehicle collision with possible patient entrapment. A fi rst due report was relayed to the dispatcher and different members of the public safety team began to arrive. A fellow Paramedic took up EMS command and the Paramedic was directed to care for a critically ill trauma patient. After a primary assessment and treatment of life-threatening injuries, the patient was extricated and moved to an ambulance. While en route to the hospital, the Paramedic contacted medical control for advanced procedures and to initiate a trauma alert. 320 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Communications 321 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Communication can involve the exchange of ideas or interactions between two parties, as well as the technology that is behind sending and receiving information. Both of these aspects of communication are examined in this chapter. First, the chapter looks at the duality of EMS communications. A fundamental part of the Paramedic’s day-to-day operations involve interacting with fellow members of a public safety team as well as healthcare providers at hospital care facilities. Because the Paramedic relies on technology to perform these functions, the Paramedic should have an understanding of radio communications and the technology used in the prehospital setting. Communications and Teamwork Teamwork is an outward demonstration of the power of com- munication. Health care is a team activity; its goal is the patient’s health. Paramedics, in the prehospital phase, actu- ally play for two teams. The fi rst team is the public safety team, a triad made up of law enforcement offi cers (LEO), fi refi ghters (FF), and Paramedics. This team’s goal is to pro- vide for the public’s safety through control and command of public emergencies. As with any team, communication is essential. Communications are essential to maintain the threefold concerns of the rescuer’s safety, the public’s safety, and the patient’s safety as the Paramedics go about accom- plishing their mission. While Paramedics are part of the public safety team, Figure 18-1 A Paramedic giving a verbal report a Paramedic is also part of a healthcare team. Healthcare to a nurse. teams, ranging from primary care providers to rehabilita- tion services, are dedicated to helping the patient through a has both medical and legal importance.1–7 This chapter deals medical emergency. A Paramedic’s communication with the with the fi rst communication, verbal communication, while healthcare team serves the patient’s interests by providing the the next chapter deals with the second, written communica- patient’s past medical history, information about the history tion or documentation. of the patient’s present illness, and the patient’s response to Verbal communications is further divided into mobile prehospital treatment. The Paramedic’s communication with communications and face-to-face exchanges. Before discuss- the healthcare team also represents a hand-off of the patient, ing the fi rst, mobile communications, it is important to have or the transfer of care, from the prehospital team to the emer- a foundation in radio theory. gency department team. Communication occurs between team members within the team as well as with other teams. Instances of communica- History of Radio tion, called interfaces, occur in both oral and written forms, Since the fi rst radio transmission, from St. John’s, New- and take place at many times during the duration of the patient foundland, to Cornwall, England, the potential for com- contact. The fi rst interface may be between lay fi rst responders munication through radio has been ever growing. The early or emergency medical responders and the Paramedic. The next theorists, such as James Clark Maxwell, a Scottish physicist, interface may be between prehospital and emergency depart- hypothesized that an electrical or magnetic disturbance could ment personnel (Figure 18-1). In fact, there are often many spread across the “ether” (ether was invisible substance interfaces with other members of both the public safety team thought to fi ll space) like waves on the ocean from a distant and the healthcare team during the course of a patient’s care. storm. This theory was substantially correct. Electrical cur- For the sake of expediency, most of these c ommunications rent passing through a wire creates a fi eld of electromagnetic are either face-to-face or via a mobile communications energy around it as it passes. Alternating current, electricity device such as a radio or cellular telephone. In every case, that fl ows to and fro through a wire, repeatedly creates and these contacts are then recorded in a written document which increases these fi elds. 322 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. These developments gave strength to the theory of a Street Smart ground wave and to the idea that a signal could be transmit- ted across the ground. The fi rst “wireless” communication system used a ground wave for signal transmission. Efforts to In the United States, as a standard, alternating create a ground-based wireless system were met with frustra- current (AC) electricity passes through a wire tion, primarily because the use of alternating current was still 120 times in each second, or 60 cycles per second in its infancy, until Marconi intervened. (60 CPS), creating a temporary fi eld effect in the Guglielmo Marconi, of Bologna, Italy, utilized the works of Heinrich Hertz. In 1887, Hertz caused a spark to process. This electrical fi eld can be sensed by an ECG, leap across a gap and create an electromagnetic wave.9 At as 60 cycle interference, unless the cable and ECG that time, this phenomenon was known by various terms machine are shielded. including “ether waves” and “Hertzian waves.” Using this idea of an electric spark, Marconi invented a spark transmit- ter, a primitive black box with an antenna that could trans- mit the “spark,” or signal, over a distance to a receiver that would produce an audible snap. That snap, in turn, could At smaller frequencies, these fi elds tend to collapse, or be used similarly to the telegraph’s Morse code. This black dissipate, over time. However, scientists learned that when box, developed in December 1894, was eventually brought electricity approaches 10,000 CPS the electromagnetic fi eld to England. After obtaining a patent, the Wireless Telegraph tends to radiate outwards and the electromagnetic fi eld is and Signal Company was formed. Marconi, 23 years old at sustained. These radiating waves of electromagnetic energy, the time, would later receive the Nobel Prize for physics in or radio waves, can be detected at great distances In other 1908 for his invention. words, radio waves are a part of the spectrum of electromag- After the fi rst transatlantic wireless transmission in 1915, netic energy (Figure 18-2). wireless communications, a branch of telecommunications, The discovery of radio was a great breakthrough, espe- grew rapidly. The U.S. Navy, interested in the potential of cially for remote settings, such as at sea. Previously, sailors, wireless communications for ship-to-ship communication soldiers, and merchants depended on semaphore, a system of as well as ship-to-shore interactions, investigated Marconi fl ag signals that can be seen over great distances. Later, they and his device. Before long, many U.S. warships had a radio. depended on the hardwired telegraph before the advent of the Often the radio was placed in hastily constructed wooden wireless radio. sheds, later called the “radio shack,” on deck. Telegraph has a close relationship with the development Earlier radios, restricted by the technology of the of radio. Telegraph, a system of communication transmitted time, operated in either low-frequency (LF) or medium- over wires, was the predominant communication method dur- frequency (MF) ranges. They were subject to a great deal ing the 1800s. The fi rst telegraph message, sent by Samuel of atmospheric interference and were therefore reduced to F.B. Morse in 1844, carried the message, “What hath God using Morse code. Later developments in radio technol- wrought?”8 From that point, telegraph messages using Morse ogy, by such notables as Reginald Fessenden of Canada and code were the predominant means of rapid communication. Harold D. Arnold, permitted both voice transmission and Original telegraphs often used multiple wires, one for each transatlantic transmission. letter in some cases. There was a continuous effort to reduce the number of wires. Eventually, the telegraph required only two wires—one to signal and the other a return. Some scien- tists, thinking that electricity could travel through the ground Street Smart for thousands of kilometers, buried the return wire into the ground, and found that the telegraph still worked. The fi rst weather report, transmitted by the U.S. Department of Agriculture in 1912, may have Infra-red Ultra-violet represented one of the earliest uses of radio for public Visible safety.10 Public safety offi cials have continued to take light an interest in radio as a means of communication. Radio waves Gamma ray and x-rays 106 1012 10141015 1018 1022 Radio Technology Frequency (Hz) Radio technology has eclipsed even the wildest dreams of Figure 18-2 Radio waves in the electromagnetic those early radio pioneers. The fi rst mechanical radio wave spectrum. generators were restricted to a maximum of 100 KHz, Communications 323 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. To reduce static interference heard between radio trans- missions, called white noise, electrical engineers developed squelch control. Squelch control reduces the amount of sig- nal received between transmissions, narrowing the reception of radio waves, and eliminating background interference. There are two types of squelch control. Carrier
squelch AM — Amplitude Modulation eliminates background static during pauses in a transmis- sion, essentially muting the radio between transmissions and thereby improving the message’s overall quality. Coded (or tone) squelch permits the radio to receive only the intended signal. Sometimes also called private line (PL), coded squelch eliminates reception of near-broadcast messages by only accepting signals with the correct code. The quality and the privacy of radio transmissions are thus improved. FM — Frequency Modulation Figure 18-3 AM radio transmission versus FM radio transmission. Street Smart In the past, public health nurses would take a severely restricting their usefulness. Later, electronic genera- portable AM transistor radio and dial it between tors, or oscillators, markedly expanded the properties of the radio wave. To achieve voice transmission, an audio signal radio stations and then place it over a pacemaker. produced from a microphone was “impressed upon” a radio The electric spark of the pacemaker could be heard signal, called a radio frequency (RF) carrier. This heralded distinctly on the radio. the era of radio telecommunications. To understand how an audio signal might be impressed upon a radio frequency, consider the analogy of fl otsam and waves. While the waves continue to crash on the beach, the Radio Frequency fl otsam, or audio signal, slowly washes to shore. Through Radio waves are transmitted literally at the speed of light. The modulation techniques which modify the wave by either difference in radio waves is not in the speed but rather in the changing the wave’s height (amplitude modulation [AM]) frequency of the waves in the radio transmission. These radio or by changing the wave’s speed (frequency modulation waves, measured in cycles per second, are called Hertz, after [FM]), the message can be carried through antennas to be the scientist who discovered them. A Hertz is an international transmitted (Figure 18-3). unit of measurement. One thousand Hertz, or cycles per second, Often the key to adequate radio transmission was the equals a kiloHertz, labeled kHz. Similarly, one million Hertz is size of the receiving or transmitting antenna. The length of called a megaHertz (mHz), and one billion is called a giga- an antenna is a function of the length of the wave. The lower Hertz (gHz). New electronic technology, using lasers, is able to the frequency, the longer the radio wave and, therefore, the generate a trillion Hertz, or a teraHertz (tHz) radio wave. longer the antenna. In some cases the radio wave was over The various radio waves are all part of the overall radio 20 feet, often making mobile radios impractical. To shorten spectrum (Figure 18-4). The human ear is able to detect radio antennas from being 9- or 10-foot-long “whips,” a radio sound in the form of waves in the 15 Hz to 20,000 Hz range. antenna would be cut down to one-half the wavelength, a The human voice is able to produce sound in the 200 Hz to half-wave antenna, or even one-quarter of the wave length. 2,500 Hz range.11 However, the radio spectrum goes from An antenna which was correctly matched to a radio greatly 3 Hz to over a trillion Hertz. The lowest radio frequency, improved radio transmission. termed extremely low (ELF), is between 3 and 30 Hz and However, despite an adequate antenna, the quality of is able to be transmitted over 5,000 miles or more. Perhaps many radio transmissions suffered from interference. Inter- more importantly, extremely low radio frequencies can pen- ference can be thought of as extraneous electromagnetic etrate water for a distance of several hundred feet. The ELF is energy heard on the radio as crackles and dead spots, some- therefore useful for submarine communications. times called static. Sources of static include other unshielded The next band of radio frequency, by international electrical devices emitting 60 cycle interference, lightning in designation, is the super-low (SLF) frequencies between the atmosphere, bursts of radio waves from sunspot activity, 30 to 300 Hz. The earliest radios were only capable of creating and even the spark plugs in an automobile. about 100 Hz, thus limiting them to the SLF frequency band. 324 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 0.003 MHz 300 mHz, can be cleanly transmitted over 25 to 50 miles. Very low frequency (VLF) VHF is useful to EMS because it takes less power to transmit 0.03 MHz using the higher frequencies. This is an advantage for emer- Low frequency (LF) 0.3 MHz gency services telecommunications devices that depend on Medium frequency (MF) batteries. VHF is also the bandwidth used by commercial 3 MHz television broadcasts. High frequency (HF) 30 MHz Very high frequency (VHF) 300 MHz Ultra high frequency (UHF) Cultural / Regional differences 3,000 MHz Super high frequency (SHF) 30,000 MHz In rural and frontier environments, a transmission Extra high frequency (EHF) distance of 100 miles is too short. To overcome 300,000 MHz the problem of distance, some radio systems have Figure 18-4 The radio frequency spectrum. resorted to the use of radio repeaters. Repeaters— radios that pick up, amplify, and then retransmit a The next three radio bands—ultra-low frequency (ULF), radio transmission—can extend the range of a VHF very-low frequency (VLF), and low frequency (LF)—also almost indefi nitely. The transmission’s distance is a have limited utility because of extreme radio interference. function of the number of repeaters available. The medium frequency (MF), 300 to 3,000 kHz, was the fi rst to see extensive use because the problem of interference was being overcome. Early commercial radio stations, using AM technology that would transmit on RF carriers in the 550 to Ultra-high frequency (UHF) radios, in the 300 to 3,000 mHz 1,600 kHz range, started to broadcast entertainment programs range, can transmit in a LOS for 15 to 100 miles, dependent to the public using these new technologies. on terrain. If the UHF radio antenna is on-board an airplane, After the advent of crystal-oscillator radios, high- the distance can be boosted to over 300 nautical miles, and f requency (HF) radio transmissions, in the 3 to 300 mHz if the radio transmitter is in a satellite the signal can travel range, that were capable of “crystal-clear” transmission literally thousands of miles. Super-high frequencies (SHF), blossomed. These tighter radio waves were capable of being otherwise known as microwave transmissions, within the transmitted over the land, as a ground wave, from point A to 3 to 30 gHz bandwidth and extremely-high frequencies (EHF), point B. These waves provided remarkable quality as long as within the 30 to 300 gHz bandwidth, are used for satellite there were no obstacles in the line of sight (LOS) to block transmissions. While a SHF or EHF radio may be limited to the transmission. a LOS of about 40 miles, a SHF or EHF radio can literally To overcome the problem of obstacles to LOS, the HF bounce a signal off a satellite and back to Earth, bypassing radio antenna could be directed toward the sky. The HF radio obstructions such as mountains. This feature makes these sat- signal would rise until it struck the ionosphere, a layer of ellite phones, also called Earth stations, extremely useful in atmosphere where the sun’s ultraviolet rays ionize the gasses, frontier communities with little or no development, as well as and the signal would be refl ected back to Earth.12 This phe- in wilderness situations. nomenon, known as skip, could permit HF transmissions to At present, there are two satellite phone systems in place. travel over 300 miles on a sky wave. One uses satellites in a geosynchronous orbit. With as few Amateur civilian short-wave radio operators, using this as four satellites, these satellite phone systems can provide phenomenon to their advantage, can now communicate with worldwide coverage. Unfortunately, obstacles such as high other short-wave radio operators all the way around the world terrain can block the view of satellites on the horizon. To under the right atmospheric conditions by skipping signals resolve this problem, newer low Earth orbit (LEO) satellite from one receiver to another.13 These “ham operators,” as technology was developed. A LEO satellite is not geosyn- short-wave radio operators have come to be known, have chronous and orbits the Earth at a high rate of speed, with assisted during disasters and can be instrumental in other an average orbital time of 80 minutes. A LEO satellite phone public safety emergencies. system, such as Globalstar or Iridium, has a larger number of The principal radio frequency band used by emergency satellites in orbit, which are constantly crossing the sky and services is very-high frequency (VHF). VHF, from 30 to creating a grid with interlocking cells of coverage. Communications 325 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Street Smart Besides the obvious advantage of satellite phones in rural and frontier EMS, satellite phones are also useful during disasters. During a disaster, traditional telephone wires may be down and cellular towers “locked up” from overwhelming use. During these times, dedicated satellite phones could be used. Wave Propagation Figure 18-5 Mobile radio. As mentioned earlier, there are two types of wave propaga- tion: ground and sky. The distance that a ground wave travels A base station is a fi xed facility which generally serves is a function of its length. A longer wave will roughly follow as a focal point in an EMS system. Base stations generally a surface path. However, it is diminished by each obstacle it have more powerful transmitters because they do not rely meets (called fading) until either it is too weak to be received upon batteries. Hard-wired in the electric power supply, a or it reaches its target (the receiver’s antenna). A ground wave base station is vulnerable to power outages. For this reason, is also affected by the surface over which it travels. Soils that many EMS agencies have a backup power supply, such as a are poor conductors will shorten the length of the transmis- generator, to ensure reliable operation. sion whereas a HF radio transmission may travel 700 miles Mobile radios (Figure 18-5) are affi xed to vehicles and over the open water of the ocean. use the vehicle’s battery for power. Often the radio itself Shorter waves (e.g., UVF), when using a ground wave, is secured inside a trunk, or behind a seat, protected from are easily blocked by any obstacle in the LOS such as foliage impact in case of collision. A small remote radio control and buildings. Using a UVF radio in rough terrain, such as panel, called a radio head, is placed in the driver’s and/or a city, requires that the operator either build a tall antenna to patient compartment. overcome the obstacles, or depend on a phenomenon called The simplest radio system is simplex. A simplex radio bounce. Bounce occurs whenever a short wave strikes a only allows communication in one direction at a time. The refl ective surface and is redirected in another direction. With oldest example of a portable simplex radio may be the Motor- enough refl ective surfaces, the refl ected path will roughly ola walkie-talkie used in World War II. These handy portable result in the intended direction of travel. radios permitted communication between platoons and regi- Radios that use the sky wave, tropospheric (TROPO) mental command in the same manner that modern radios per- radios bounce the radio signal off the ionosphere in the direc- mit communication “car-to-car” between emergency vehicles tion of the receiver antenna. As radio signals are wave-like, a (Figure 18-6). sky wave will scatter, permitting worldwide reception.14 The The diffi culty with simplex radio
is that it requires one United States military has used troposcatter radio systems party to complete the message before the other party can since the 1950s for long distance radio. respond. In some instances, it is desirable to have a dialogue. Radio Systems Thus, duplex radios were invented. A duplex radio operates in the same manner as a hard-wired telephone, referred to as Radio systems consist of components that permit a radio a landline. Using two frequencies—one to transmit and one message to be transmitted and received. The arrangement of to receive—an operator could talk and listen at the same time, radio components is referred to as the system architecture. permitting more rapid communications. Communication was Currently, two radio architectures exist in EMS: traditional enhanced since clarifi cation questions could be asked at the land mobile radio (LMR) architecture and cellular system time they were germane to the discussion. architecture. Multiplex radios permit the transmission of both audio signals as well as data. The transmission of an electrocardio- Land Mobile Radio Architecture gram (ECG), called telemetry, during patient report is an A traditional land mobile radio (LMR) architecture has many example of the use of a multiplex radio.15,16 components, in varying numbers, depending on the size, Transmission via a handheld radio is affected by the location, and complexity of the EMS system. Factors include size of the battery. A larger battery, while providing more the existence of base station(s), mobile radio(s), portable power, may be too bulky to be portable, thus limiting its use radio(s), and repeater(s). in the fi eld. 326 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Up to 1,000 watts Single 40' to 100' Antenna antenna Fixed frequency high power Shared several transceiver radio channels Microphone and Dispatcher speaker Up to Dispatch center 25 watts antenna Fixed frequency radio transceiver *Note: radios may have a manual switch to change frequencies Figure 18-7 Standard land mobile radio architecture. Figure 18-6 Portable radio. To improve the transmission distance of a portable radio, departments within a city at once, via a simulcast, or to all some EMS systems depend upon repeaters to boost the signal public services leaders, or to an individual department such (Figure 18-7). as EMS. Trunking also prevents one message from blocking another message. The computer, in the example used earlier, Computer-Assisted Radios would detect that an EMS message from a portable radio, a The overwhelming public demand for general radio frequen- high-priority communication, was more important than the cies within the available radio band set aside by the federal water department’s transmission. The computer could elect to government has forced some EMS agencies to have to share either switch the water department radio to another radio fre- radio frequencies with school buses, livery services, and pub- quency or to store the message in the computer’s short-term lic works departments. The resultant channel crowding may memory, so it could be rebroadcast when airtime became cause a high priority EMS radio transmission from a porta- available. This in effect gives emergency radio transmissions ble radio to be suppressed (walked on) by a more powerful a higher priority. mobile transmitter from another department. In examining the problem, engineers realized that the majority of time there Cellular System Architecture are no radio transmissions on any one channel and that this The advent of cellular telephones may have revolutionized so-called dead airtime could be used to greater effi ciency if emergency communications during day-to-day operations it was controlled. Using computers, engineers devised a tech- (Figure 18-8). Cellular telephones are actually low-powered nique whereby multiple users could communicate over fewer wireless transmitters (radios) that work within close prox- frequencies, with the computer selecting the frequency to be imity to a radio tower. Each tower provides service to an used based on availability. area referred to as a cell. Each mobile radio (cellular tele- This technique of computer-assisted radio commu- phone) has a forward link to the tower as well as a reverse nications, called trunking, has several other advantages. link and operates as a duplex radio within that cell. As the For example, a computer-assisted mobile or portable radio cellular phone reaches the boundaries of the cell, the next allows an administrator (e.g., a city manager) to talk to all tower (linked by computer) automatically transfers the call Communications 327 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Components of a Cellular System Radio telephony systems Forward link Mobile base station Reverse link Mobile Mobile base station control equipment PSTN Mobile Network operator interface equipment Figure 18-9 Facsimile (FAX) machines can receive high-quality electrocardiograms (ECG) Figure 18-8 Cellular radio system architecture. from the fi eld. to another radio channel, without interruption of service. As with distant medical centers where Paramedics may be able each tower switches, or hands-off, the transmission to the to benefi t from the available expertise. next tower, there is no interruption in transmission. The fi rst cellular systems, created in the late 1970s, were Alternative Communication Devices analog systems operating at 800 mHz and quickly became Both the facsimile machine (Figure 18-9) and the computer mainstream in the public. Unfortunately, transmissions have seen use as an alternative means of communication. The between cellular telephones could be picked up by multi- facsimile machine, using digital technology, can transmit a band receivers called scanners that monitor several radio fre- high-quality copy from one location to another (e.g., an elec- quencies, including those used by cellular telephones. This trocardiogram (ECG) can be sent to an emergency depart- practice of scanning for conversations breached patient con- ment or a cardiologist’s offi ce). fi dentiality and made cellular telephone use problematic for The advent of the computer has added a number of pos- Paramedics. sibilities. By using laptop or handheld computers inside a The subsequent generations of cellular service, such vehicle, called a mobile data terminal, a Paramedic can cre- as the personal cellular service (PCS), used digital service ate a document and then download it for transmission over instead of analog. Digital cellular systems have encrypted a telephone line, via modem, over the Internet, or by using voice and data features that increase security and help main- wireless technologies including Bluetooth®. Paramedics can tain the confi dentiality of patient information.17,18 also use palm-sized personal digital assistants (PDA) or Cellular Telephone personal palm computers (Figure 18-10) and move about the patient compartment at will, all the while transmitting and There are three varieties of cellular phones or mobile sub- receiving critical patient information. scriber units (MSU) for use within a cellular radio system. The most common MSU is the portable cellular telephone which boasts about 0.6 watts of power. These small, personal Public Safety Communications cellular telephones are convenient but often lack the range The fi rst use of a telephone to call for emergency medical necessary to reach towers outside of a service area. assistance may have occurred when Alexander Graham Bell The transportable cellular telephone boasts more power, spilled acid on himself and called out over the telephone, 1.6 watts. However, its larger battery makes it less convenient “Mr. Watson, come here, I want your help.” From those early to carry. The mobile telephone, with its 4.0 watts of power, beginnings, telecommunications, and especially radio, have is powerful and dependable. The mobile telephone is usually grown enormously. mounted to the interior of the vehicle and has an external The easy availability of either radio transmitters or radio antenna to improve reception. components created a surge of amateur radio enthusiasts, New satellite mobile telephones, formerly the sole many of whom competed with commercial radio providers domain of the military, are seeing increased use, especially in for the limited radio bands. To stem this growing problem, remote and rural areas where cellular service is often unde- Congress passed a resolution, the Communications Act of pendable or nonexistent. Satellite telephones offer the prom- 1934, which states that the President of the United States ise of dependable and secure (encrypted digital) connectivity has control over all government radios and that the Federal 328 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 18-10 Paramedic using a PDA on-scene. (Courtesy of Computerworld Honors Program) Communications Commission (FCC) has control over the civilian use of radios.19,20 The FCC, the agency with rule-making and enforcement responsibility, quickly began allocating frequencies to spe- cifi c interest groups and then required them to license with the FCC for permission to use those frequencies. The earliest frequencies assigned to public safety included those in the VHF and UHF bandwidth.21 Early EMS Radio Communications Despite the availability of a number of designated radio fre- Figure 18-11 Dedicated emergency hotline. quencies for public use, a 1970 study showed that less than 5% of ambulances had a mobile radio. In the seminal white the importance of communications to the “chain of survival,” paper, “Accidental Death and Disability,” one recommenda- EMS communications continue to be problematic. tion spoke of the need for dedicated frequencies for EMS: frequencies to be used between the ambulance and the hospi- Phases of EMS Communications tal as well as between the dispatch center and the ambulance. There are three phases of communication in every EMS Another recommendation advocated for a centralized radio incident: (1) the occurrence and the detection of the occur- and telephone communications center. During that era, it was rence, (2) the notifi cation and response of responders, and not uncommon for a citizen to either call the operator for help (3) the treatment and transportation of the patient. Delays due or call a seven-digit emergency hotline. These hotlines, dedi- to communications problems during any one of these three cated telephone numbers, usually rang into someone’s house. phases can result in increased harm, and even death, for the That person would then use a call-down tree to summon an patient. emergency crew. Some hospitals still maintain an emergency hotline (Figure 18-11) as a backup to radio communications. Detection While other emergency notifi cation systems also evolved, In 1967, the President’s Commission on Law Enforcement they all had one thing in common: ineffi ciency. and Administration of Justice recommended that there be a The fi nal recommendation of the white paper called for single universal emergency number in the United States. Brit- the creation of a single nationwide telephone number for all ain had used a national three-digit emergency number, 9-9-9, emergency services. The practice at the time was that every since 1937 and had a great deal of success with a universal jurisdiction had its own seven-digit emergency telephone number. In November of 1967, the FCC and the American number. Unfortunately, the telephone company’s service area Telegraph and Telephone Company (AT&T) announced that did not always line-up with the boundaries of a particular AT&T would use 9-1-1 as its universal emergency number in EMS service. This resulted in frequent errors. all of the areas served by AT&T. The number 9-1-1 was cho- Despite the recognition of communications as an inte- sen, in part, because no exchange or area code in the AT&T gral component of EMS and a growing public awareness of system used the number 9-1-1. Communications 329 Copyright 2010 Cengage Learning. All
Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. infant. After reviewing the incident, Chief Allen Brunacini of the Phoenix Fire Department ordered that callers receive instruction on how to self-rescue before responders arrived. Most current EMS dispatch procedures include some form of prearrival instruction. This instruction, called medical self- help, added another dimension to the role of communications specialists—being the “fi rst” fi rst responder. Notifi cation and Response The next phase of emergency communications is the notifi ca- tion phase. During the notifi cation and response phase, the greatest danger is posed for a Paramedic. Using the lights and siren in response to an emergency, the Paramedic is at risk of bodily harm secondary to motor vehicle collision. This Figure 18-12 Communciations center or public danger is accepted in light of the potential good which can be safety access point. created by prompt treatment of the patient as well as the fact that the danger can be mitigated by the cautious operation of the emergency response vehicle. Nevertheless, in many Shortly thereafter, on February 16, 1968, Representative cases, Paramedics and the public are put in harm’s way dur- Rankin Fite, Speaker of the House of Representatives, placed ing a call for assistance in which a delayed response would the fi rst 9-1-1 call in Haleyville, Alabama. Since that fateful not harm the patient. Concerned about the widespread prac- fi rst call, 9-1-1 service has been extended to over 96% of the tice of sending all EMS units out with lights and sirens on to United States. Canada has also adopted the 9-1-1 emergency the scene regardless of the nature of the emergency, in 1977 number, making it an international emergency number. Dr. Jeff Clawson went about systematically placing EMS When a 9-1-1 call is placed, a specially trained “call- calls in a priority classifi cation. taker” takes down information regarding the nature of the Dr. Clawson’s objective was to send the right response to emergency to pass along to fellow workers or responders. the right person at the right time. Original trials of the new The entire 9-1-1 operation is generally located in a central- Medical Priority Dispatching™ were successful in Salt ized communications center called a public safety access Lake City, Utah, and the system proliferated across the United point (PSAP) which runs 24 hours a day, seven days a week States and Canada.22,23 According to emergency medical dis- (Figure 18-12). patch (EMD) protocols, the communication specialist was Subsequent generations of 9-1-1 service have been to interrogate the caller, give prearrival instructions, and use enhanced (E9-1-1) to include a call-back feature as well as preset criteria to make a response determination before dis- location identifi er. These features allow emergency commu- patching the appropriate EMS responder units. nications specialists (COMSPEC) to dispatch emergency The use of EMD has become so widespread in the United responders to people who are unable to speak or who have States that the American Society of Testing and Materi- lapsed into unconsciousness. als (ASTM) issued a practice standard in 1990. In addition, At its inception, 9-1-1 service was very effective in get- the National Association of Emergency Medical Services ting help to those in need of assistance. However, the wide- P hysicians (NAEMSP) advanced a position paper that essen- spread use of mobile cellular telephones has reduced some of tially states that EMD is the standard of care for dispatching the advantages of the E9-1-1 system. Communications spe- EMS calls. cialists receiving a 9-1-1 call from a cellular telephone do not have a call-back number nor do they have a location identifi er First-Due Report to assist them with rushing aid to the patient’s side. Recogniz- Almost all Paramedics notify the PSAP of their depar- ing this problem, the telecommunications industry has agreed ture from their assigned post or station and their arrival to rectify the problem in two phases. During phase I, cellular on-scene. In some cases, particularly where there are mul- telephones will not only provide a call-back number to the tiple casualties, a fi rst-due report is important for scene PSAP but also provide the location of the transmitting tower. command and control. A fi rst-due report is a brief synop- During phase II, the cellular telephone will be able to emit sis of the scene size-up obtained by the fi rst arriving EMS a location fi nder, a homing beacon of sorts, which multiple responder. Typically it includes the exact location of the towers can use to triangulate the position and give the cellular call, the nature of the incident, known or suspected hazards, telephone’s exact location in terms of latitude and longitude. and the anticipated number of patients. If special resources (e.g., heavy rescue) are needed, they would be requested at Prearrival Instructions that time. In 1975, Phoenix fi refi ghter Paramedic Bill Tune success- In the 1920s, police offi cers used 10-codes. These fully coached a woman while she performed CPR on her police departments often had one radio frequency and used 330 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 10-codes as abbreviated messages designed to minimize complete past medical history may appear helpful, this airtime. In 1940, the Associated Police Communications Offi - amount of information may serve to only confuse the phy- cers, now the Association of Public Safety Communications sician who is trying to understand the underlying problem. Offi cials (APCO), published its fi rst 10-code list. Since that A Paramedic uses judgment to select the information that is publication, and despite efforts at standardization, dozens of pertinent to share with the physician in order to optimize time versions of the 10-code have been created. These 10-codes and increase effi ciency. are useful when only used intradepartmentally; however, the The Paramedic would then proceed to the physical exami- use of 10-codes can be confusing in cross-jurisdictional com- nation. Paramedics will have already completed an initial munications, and especially to responding mutual aid com- survey. If the patient is high priority, then all life-saving inter- panies that do not use the same codes. Therefore, many EMS ventions should be conveyed to the physician in a standard ABC systems and disaster planners prefer the use of plain English order. Provided that all life-threatening conditions have been transmissions and discourage the use of 10–codes. treated and temporarily stabilized, the Paramedic would then proceed to report the patient’s vital signs: temperature, pulse, Radio Conduct respirations, and blood pressure. Following the initial assess- While plain English transmissions can be clear, the ability to ment and vital signs, the Paramedic should report the fi ndings use plain English has caused some emergency personnel to of a focused/vectored physical examination (PE). The Para- take free license and use vulgarity over the air. The FCC has medic understands that he is the emergency physician’s eyes the authority to fi ne, suspend, or terminate any radio license and ears in the fi eld. The Paramedic should anticipate what for failure to comply with the standards for radio opera- observations the physician will likely request. Clinical prac- tion, including the misuse of radio or use of profanity while tice, working side-by-side with the emergency physician, can on-the-air. As a result, and as part of the culture of EMS, a help educate the Paramedic as to the expectations that a physi- characteristic form of spoken communication has arisen. Fre- cian will have for a physical examination report. quently, Paramedics will use a standard nomenclature, such In the case of a medical patient, the history of present as the terms “affi rmative,” “negative,” and “stand-by,” as well illness plays a pivotal role in the decision-making process. as the use of concise radio reporting style, to ensure that a In the case of a trauma patient, the mechanism of injury clear message gets through. It is also common for Paramed- coupled with the physical examination fi ndings is of para- ics to suspend pleasantries, such as saying “please” or “thank mount importance. Paramedics learn through experience to you” during a transmission. There is an implicit understand- emphasize the appropriate fi ndings according to the patient’s ing among Paramedics that the Paramedic is both courteous presentation. Once the patient presentation is complete, it is and professional when foregoing the use of pleasantries in appropriate for the Paramedic to make a fi eld diagnosis of favor of conserving airtime. the patient’s condition. Providing a fi eld diagnosis over the radio helps the emergency physician understand the Para- Treatment and Transportation medic’s direction and intent. At this time, the EMS physician Communications can ask for more assessment fi ndings, both history and physi- The Paramedic shares a special relationship with an emer- cal, as well as redirect the Paramedic’s attention to alternative gency physician that requires a more complete disclosure of conclusions. the patient’s condition than would be expected from an EMT. What follows is usually a discussion of the treatments This duty is owed, in part, because of the invasive procedures provided up to that point in time, including their effect, and that a Paramedic is allowed to perform. Typically, when a Para- a dialogue about how to proceed. Whenever a Paramedic medic is contacting medical control for guidance and instruc- accepts a medical order, he or she should practice the echo tion, the report begins with the Paramedic’s identifi er. Many technique. With echo technique, when the physician gives an systems assign numbers to Paramedics which indicate that order the Paramedic should repeat the order back to the phy- the person on the radio is a recognized Paramedic with clini- sician exactly as received. The physician should then confi rm cal privileges. The following format is an example of a stan- the accuracy of the read-back. dardized radio report. Each EMS system varies with regard to To prevent confusion, some EMS systems only allow the information required and the order of presentation. a Paramedic to accept one order at a time. Stacking orders, Starting with patient demographics (age, sex, and weight each received one at a time, is acceptable provided that ade- in kilograms) and the patient’s chief concern (in the patient’s quate time is permitted between interventions to assure that own words, if possible), the Paramedic would provide a his- the therapeutic goal has been met, or not met as the case may tory of the present illness (HPI). Mnemonics such as AEIOU be, before proceeding. TIPS or PQRST can be helpful in organizing the mass of Many systems also require an alert report be sent to patient health information into a meaningful whole. the triage station or a charge nurse. In some EMS systems, the What follows is the patient’s past medical history Paramedic is tasked with alerting the receiving facility. The (PMH). The mnemonic AMPLE can be useful for orga- information in the alert report is brief and concise: age, sex, nizing the patient’s information. While advising the physi- chief complaint, mental status, vital signs, treatments in prog- cian about every allergy, every medication, and the patient’s ress, and an estimated time of arrival (ETA). Communications 331 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Radio Diffi culties The question of interagency interoperability is impor- tant in the post September
11, 2001 era. It is imperative that Paramedics frequently encounter problems while trying to all public safety agencies be able to communicate with one operate their radio systems. The Public Safety Wireless Net- another in order to more effi ciently carry out their mission work study indicated that some 15% of public safety provid- with the maximum degree of safety. The Fire and EMS Com- ers had problems with static, batteries, or both, while another munications Interoperability study indicated that less than 23% complained of signal fading. Despite the fact that 24 35% of the agencies surveyed—some 1,045 agencies nation- more mHz of bandwidth has been dedicated for public safety wide—indicated confi dence in the interoperability of their use, some 32% of public safety providers complained about radios during a large scale task force operation typically seen channel crowding. at a multiple casualty incident. 332 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Whether communicating with other members of the healthcare team or the public safety team, the quality of communications is important to overall teamwork. Working as a team, and optimizing communications at both levels, will help facilitate patient care and the patient’s recovery from a medical emergency. Key Points: • Paramedics are a part of both the public safety • The principal radio frequency band used by team and the healthcare team. Communication emergency services is very-high frequency within the public safety team, made up of law (VHF). VHF, from 30 to 300 mHz, can be cleanly enforcement offi cers, fi refi ghters, and Paramedics, transmitted over 25 to 50 miles. serves to provide safety to the rescuer, the public, and the patient. • To overcome the problem of distance, repeaters— which pick-up, amplify, and then retransmit a • The Paramedic’s communication with the radio transmission—can extend the range of a VHF healthcare team serves the patient’s interests almost indefi nitely. by providing the patient’s past medical history, information about the history of the patient’s • Two radio architectures exist in EMS today: present illness, and the patient’s response to traditional land mobile radio (LMR) architecture prehospital treatment. and cellular system architecture. • Communication occurs between team members as • The simplest radio system, simplex (or a walkie- well as with other teams. talkie), only allows communication in one direction • at a time. Interfaces can occur in both oral and written forms. • • A duplex radio is similar to a landline and uses two AM and FM radio signals are generated through frequencies. One frequency is used to transmit and modulation techniques which modify a wave by one is used to receive, allowing an operator to talk either changing the wave’s height (amplitude and listen at the same time. modulation [AM]) or by changing the wave’s speed (frequency modulation [FM]). The message can then • Multiplex radios permit the transmission of both be carried through antennas to be transmitted. audio signal as well as data such as telemetry. • The antenna’s length is a function of the wave’s • To reduce channel crowding, computers allow length; therefore, an antenna correctly matched multiple users to communicate over fewer to a radio greatly improves radio transmission. The frequencies by selecting the frequency to be used difference in radio waves is not in the speed but based on availability, a process called trunking. rather in the frequency of the waves in the radio transmission, measured in cycles per second or Hertz. • Cellular telephones are actually low-powered wireless transmitters (radios) that work within • To overcome obstacles in the line of sight that can close proximity of a radio tower. block transmissions, high-frequency radio waves are directed toward the atmosphere and the signal • Technology today allows Paramedics to use is refl ected back to Earth, covering great distances laptop or handheld computers along with with great quality. personal digital assistants (PDA) before, during, Communications 333 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. and after calls to gather, transmit, and receive • The fi rst phase of communication in an EMS incident critical patient information using cable or wireless is a call received at a centralized communications technologies. center or public safety access point. • The Communications Act of 1934 granted the • The next phase of emergency communications is the Federal Communications Commission (FCC) control notifi cation and response phase. over all civilian use of radios. • The third phase of emergency communications is • The 9-1-1 system that we use today, which covers the treatment and transport of the patient. over 96% of the United States, was adapted from the British 9-9-9 national emergency number and • Paramedics need a formalized radio report initially put in place by AT&T. method. Review Questions: 1. What is meant by the duality of EMS 6. Compare the two radio architectures that exist communications? in EMS. 2. Where did radio communications get its start? 7. Who has control over the civilian use of 3. What is the principal radio frequency band used radios? by emergency services? 8. Describe early EMS radio communications 4. What is the difference between amplitude and the development of public safety access modulation and frequency modulation? points. 5. Describe ways the transmission and reception of 9. List and describe the elements of a radio report. a radio signal can be improved. Case Study Questions: Please refer to the Case Study at the beginning of the 3. H ow does communication improve a Paramedic’s chapter and answer the questions below. clinical decision making? 1. W hat should be included in the radio report to 4. I f you were asked to manage and provide EMS the medical control physician? for a large event in your area, how would you 2. H ow important was the fi rst-due report given by the assess the importance of communication between fi rst member of the public safety team on-scene? the public safety team and healthcare team? References: 1. Kelly CG. The ways and whys of documentation. Good 4. Lazar RA, Schappert RJ, 3rd. Presumed insuffi cient. The impor- documentation is more than what’s on a PCS form. Emerg Med tance of the prehospital care report. Jems. 1991;16(1):101–104. Serv. 2007;36(7):30. 5. Harkins S. Documentation: why is it so important? Emerg Med 2. Perkins TJ. Tell me a story. The importance of good Serv. 2002;31(10):89–90, 93–94. documentation. Emerg Med Serv. 2007;36(9):30, 32–33. 3. Krentz MJ, Wainscott MP. Medical accountability. Emerg Med 6. Maltz HM. EMS documentation. A legal necessity to avoid Clin North Am. 1990;8(1):17–32. liability claims. Emerg Med Serv. 2002;31(10):96, 98, 146. 334 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 7. Erich J. Documenting your life away: common EMS report hand-held device for patients with acute myocardial errors. Emerg Med Serv. 2003;32(11):47–49, 52. infarction (from the Timely Intervention in Myocardial 8. Mabee C. The American Leonardo: A Life of Samuel F. B. Morse. Emergency, NorthEast Experience [TIME-NE]). Am J Fleischmanns: Purple Mountain Press; 2000. Cardiol. 2006;98(9):1160–1164. 9. Hertz H. Electric Waves: Being Researches on the Propagation 17. Nazeran H, Setty S, et al. A PDA-based fl exible of Electric Action with Finite Velocity Through Space. New York: telecommunication system for telemedicine applications. Cornell University Library; 1893. Conf Proc IEEE Eng Med Biol Soc. 2004;3:2200–2203. 10. http://www.nal.usda.gov/speccoll/collectionsguide/mssindex1. 18. Kline JA, Johnson CL, et al. Prospective study of clinician- shtml entered research data in the emergency department using an 11. Fausti SA, Erickson DA, et al. The effects of impulsive noise Internet-based system after the HIPAA Privacy Rule. BMC upon human hearing sensitivity (8 to 20 kHz). Scand Audiol. Med Inform Decis Mak. 2004;4,(17):1–16. 1981;10(1):21–29. 19. Granados MR, Sr. New FCC rules affect EMS radio 12. Sizun H. Radio Wave Propagation for Telecommunication frequencies. Emerg Med Serv. 1996;25(2):24–25. Applications (Signals and Communication Technology). New 20. Johnson MS, Van Cott CC. The FCC may be listening. An York: Springer; 2004. update on EMS communications. Jems. 1992;17(5):19–24, 13. http://www.arrl.org 26–27. 14. Tse D, Viswanath P. Fundamentals of WirelessCcommunication. 21. Johnson MS, Van Cott CC. New radio service targets EMS New York: Cambridge University Press; 2005. communications. Emerg Med Serv. 1993;22(7):70–74. 15. Sillesen M, Sejersten M, et al. Referral of patients with 22. Kuisma M, Holmstrom P, et al. Prehospital mortality in an EMS ST-segment elevation acute myocardial infarction directly to system using medical priority dispatching: a community based the catheterization suite based on prehospital teletransmission cohort study. Resuscitation. 2004;61(3):297–302. of 12-lead electrocardiogram. J Electrocardiol. 2008; 23. Bailey ED, O’Connor RE, et al. The use of emergency medical 41(1):49–53. dispatch protocols to reduce the number of inappropriate scene 16. Adams GL, Campbell PT, et al. Effectiveness of prehospital responses made by advanced life support personnel. Prehosp wireless transmission of electrocardiograms to a cardiologist via Emerg Care. 2000;4(2):186–189. Communications 335 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The patient care report as an important medical, business, and legal document • The patient care report as part of the quality assurance and performance—improvement program • Different formats available for documentation that focus on a precise refl ection of the events that occurred • Special incidents, such as disasters, that require special reports Case Study: After all the excitement of the cardiac arrest was over, the new Paramedic realized she was faced with the tedium of documentation. Her senior Paramedic partner reminded her that documentation is important. He said, “The patient care report is a medical document that helps the physician determine the cause of the cardiac arrest. The patient care report is also used as a quality improvement tool, allowing our supervisor to ascertain whether we met certain performance goals, to identify weaknesses in our performance and to help establish training goals to correct those weaknesses. And,” as he continued, “the patient care report is a legal record.” Nodding acknowledgment she opened up the laptop and started to fi ll the fi elds. 336 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Documentation 337 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if
subsequent rights restrictions require it. OVERVIEW Documentation—whether it consists of patient care reports, special incident reports, affi davits, or triage tags—is an important responsibility for Paramedics. One study suggested that Paramedics spend as much as 28% of their patient contact time writing the patient care report (PCR), underscoring its importance.1 Some Paramedics, in order to focus on patient care, facilitate their report-writing by taking notes on 3 5 cards or notepads and then transcribe their notes to a more formal PCR later. It is also common to see a Paramedic writing critical patient information on a piece of tape affi xed to a pant leg or on the corner of a sheet. Purpose of EMS Documentation Patient care documentation is a record of the pertinent fi nd- ings and observations of the patient’s health obtained through examination. It is also a log of the tests and treatments performed. There are six-fold reasons for Paramedics to write an accurate patient care report. First and foremost, the PCR is a part of the patient’s present medical care. Based upon the outcomes of treatments, noted on the PCR, the emergency department can make further treatment decisions. The PCR is a communication tool between the Paramedic, who has left the patient, and the emergency physician at the hospital still treating the patient. The PCR is therefore essential to the con- tinuity of patient care. It emphasizes the Paramedic’s role as Figure 19-1 Physicians use prehospital patient a part of the healthcare team as well. care records to obtain information that might Second, the PCR is also a part of the medical record, otherwise be unavailable. which will be used in the future by other physicians and allied healthcare professionals for patient care. As a part of the medical record, the PCR often provides vital informa- Fourth, the PCR is a business record used for billing tion to physicians about the origin of a condition or disease and operations. Careful and accurate documentation helps (Figure 19-1). to ensure that insurance claims reviewers, during utilization For example, a PCR written about a low-priority patient review, will accept the patient care charges submitted. contact during a hazardous materials spill may be the evi- Fifth, EMS researchers may also use the PCR as a research dence that links a minor exposure to a toxin to liver cancer document. Following changes in EMS care documented on 20 years later. the PCR, researchers can publish either descriptive research Third, the PCR is a tool for quality assurance and per- fi ndings or, using an experimental design, investigate new formance improvement programs. Through PCR audits—a treatments in the fi eld. careful review of the documentation for specifi c data— EMS educators often use selected PCRs for case pre- healthcare managers, EMS administrators, and EMS physi- sentation in a case of the utility of a practice. EMS physi- cians can assure that the patient care provided out-of-hospital cians, in the course of a medical audit, often select illustrative meets the established standard of care. PCR audits help to cases documented on a PCR for individual instruction or an ensure that acceptable patient care is provided to all patients agency’s continuing education. The PCR can also be utilized equally. in a case-based method of teaching. These PCRs are often Analysis of the results of these PCR audits also helps to illustrative of a unique solution to an unusual problem or as a identify trends, such as increased patient contacts in a certain reinforcement to established methods. segment of a city or a consistent problem with patient care in Finally, the PCR is a legal record. The Paramedic can a specifi c patient population. Identifi cation of system issues be subpoenaed to court with the PCR to testify during a trial in this manner provides EMS managers with an opportunity (Figure 19-2). The PCR can be used as evidence in a trial. to remodel the system or educate the Paramedics. The trial may or may not even involve EMS as an issue. That 338 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The last statement is somewhat problematic as it assumes a foreknowledge of a determination yet to be made. Appreci- ating that the patient lacks this knowledge, and that the patient calls for EMS because of a belief that it is an emergency, the federal government has accepted the prudent layperson stan- dard. The prudent layperson standard means that another person, not a physician, who was in the same or similar cir- cumstances would think it is appropriate to call EMS; this is paraphrased from larger state and federal defi nitions.4,5 However, simply stating that there is a medical emer- gency, using the previous standard, is insuffi cient information for the purposes of the medical record, utilization review, and the courts. To fulfi ll the needs of these other parties, the Para- medic needs to provide complete documentation of care from Figure 19-2 The prehospital patient care report the arrival on-scene to the transfer of care at the hospital. is a legal document as well as a medical record. Following a proscribed format the Paramedic should legibly write down his or her observations on the patient care record in black ink. If an action or observation is not PCR, exhibited to others in the legal system and the public, documented, then that information is lost. While the loss of refl ects upon its author and all other Paramedics.2 vital information can potentially harm the patient, it also A PCR is an important tool for a Paramedic during a calls into question the thoroughness of the Paramedic’s trial. With the number of lawsuits against Paramedics rising, exam and the justifi cations for treatment. The saying “If it Paramedics will depend on the PCR as a source of informa- wasn’t written down, then it didn’t happen,” suggests that a tion to aid recall for activities on an EMS scene which may treatment performed by the Paramedic is considered never have occurred fi ve or six years previously.3 to have happened, despite a Paramedic’s protestations, if it wasn’t recorded. As a result, there may be an appearance Elements of a PCR of dereliction of duty or possible negligence on the Para- medic’s part. A PCR has many fi elds, which are places to enter data. Most of the fi elds are for patient care information, although some fi elds on a PCR are for administrative and/or business information. Street Smart In the past, documentation of patient care was impre- cise and simply noted. For example, documentation may The use of black ink for documentation permits a have stated that a person was transported and indicate very little else. clear copy when the PCR is faxed, photocopied, Physicians have entrusted a great deal of responsibility microfi ched, or scanned into a document reader. to Paramedics. However, physicians need to know how the For this reason, many agencies only permit black ink patient was treated in the fi eld. This reveals the need for thor- to be used. ough documentation. In addition, administrators (both public and private) who have interested “stakeholders,” as well as the legal system, have mandated more thorough documenta- Legibility is another important issue in documentation. tion of patient care. The purpose of the PCR is to transfer the information to, or Documentation Standards communicate with, the physician and other patient care pro- viders. If the writing is indecipherable, then the function of At a minimum, a Paramedic should document the reason for the document is lost. It is a good practice to have another Para- the urgent transportation of a patient to an emergency depart- medic, one who was on-scene, read the PCR. Such proofread- ment. The federal Center for Medicare and Medicaid Ser- ing serves several purposes. It helps to establish consensus vices (CMMS), in its defi nition of an emergency, states that regarding the observations and actions of the team, as well as an EMS call is medically necessary when the patient experi- ensures the readability of the PCR. ences a sudden onset of acute symptoms for which emergency The use of slang and jargon in a PCR is inappropriate and medical intervention at a hospital would seem necessary. unprofessional. Such terms do not add to the patient record Medical necessity further requires that the absence of imme- and unnecessarily serve to distract the reader from the mes- diate medical attention could reasonably result in jeopardy sage. Similarly, bias and prejudice have no place on a PCR. to health, serious impairment of bodily function, or a serious As a rule, Paramedics practice conservation with words dysfunction of a body organ or part. and avoid excessive wordiness. While reading such technical Documentation 339 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. writing may seem dry, its intention is to be precise and to The central question with facsimiles is confi dential- convey a maximum amount of information in a short period ity (i.e., did the PCR get to the intended recipient?). When of time. “faxing” a PCR, the Paramedic should contact the receiver and advise that a facsimile will be transmitted shortly. When Errors and Omissions the facsimile is received, the recipient should respond with a When an error is made on the PCR, the Paramedic should verifi cation of receipt. “strike-out” the mistake with a single line, leaving the content If the PCR is inappropriately sent to the wrong address, below the strike-out legible. Next to the strike-out, the Para- the cover sheet should clearly indicate that the facsimile is medic should place the date and initial the strike-out to indicate confi dential and ask the recipient to destroy the copy. If the authorship. Heavy cross-outs give an appearance of deception, Paramedic knows that the transmission was made in error, as does the use of erasure polishes such as White-out®, leaving then the Paramedic should call the other party and request the Paramedic open to questions about integrity. that the unintended recipient destroy the PCR. It is common practice to place a single diagonal line Current regulations under the 1996 Health Insurance across any open areas of the document, called “line-out,” in Portability and Accountability Act (HIPAA) may make the use order to prevent the addition of new content to a PCR by oth- of a facsimile machine inadvisable in the future (Figure 19-3). ers after the Paramedic has completed the PCR. Also, such practices should be carefully scrutinized for compli- Upon completion of the document, some Paramedics ance with regulations regarding confi dentiality.6 sign-out with time, date, and initial after the last entry. The line-out and the sign-out indicate that the PCR was written Forms of Documentation and completed by the person listed “in-charge” at the time and date listed. Electronic Documentation Upon re-reading the PCR and determining an entire pas- Electronic documentation, although still in its infancy, is rap- sage or entry is substantially in error, the passage should not idly becoming state of the art. The use of mobile data ter- be removed but instead “crossed out” with a single slash that minals (MDT) on-board the ambulance or personal digital is then dated and initialed. A revision should then be writ- assistants (PDA) have replaced the pad and paper. ten on another page or on a continuation form with cross- Electronic documents have several advantages over tradi- reference made to the fi rst entry (e.g., see PCR 123). tional documentation. Computers have built-in spell checker It is also permissible to add to the record after the call. and grammar checker
programs, increasing the readability of In that instance, another page should be added. Additions the PCR. Electronic documents can also have forced fi elds, should only be added when the entry will substantially clarify mandatory fi elds which must be completed before submis- the record or document important patient information useful sion. The use of forced fi elds helps to ensure that a minimum to the physician. data set is completed. Data sets are discussed shortly. As a rule, there should be only one author for each PCR. Concerns about limited data entry has plagued electronic Multiple authors generate concerns about the authenticity of documentation programs in the past, but the addition of drop- the document and the accuracy of the events depicted. Dis- down menus and handwriting recognition programs have cussion and collaboration with fellow EMS providers during helped eliminate some of those concerns. the creation of the PCR should eliminate the need for mul- To ensure patient confi dentiality, all electronic docu- tiple authors (Table 19-1). mentation programs should be password protected and the Confi dentiality Some Paramedics use a facsimile machine to transmit docu- mentation (e.g., to send the PCR from a base station to the Completed P hospital). The use of a facsimile machine (FAX) may be CRs acceptable provided a few safeguards are in place. Table 19-1 Documentation Standards • Black ink is preferred. • Legibility is important. • Slang and jargon is not used. • Errors noted with single strike-through and initialed. • Empty space is lined out. • Sign-out includes initials, date, and time. • One author for each record. Figure 19-3 HIPAA regulations impact recordkeeping. 340 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. password changed as frequently as every 30 days. To further EMS PCR Formats safeguard patient confi dentiality, Paramedics should rou- tinely shut down documentation programs when not in use Early EMS providers adopted the SOAP notes system for to prevent uninvited intruders from entering the program and their documentation system. In some states, the progress note altering the record. was virtually a blank sheet of paper, called an open form. The Paramedic was expected to document assessments and On-Scene Medical Records other information in SOAP format on the paper. While this approach permitted a great deal of freedom for document- The combination of mobile data terminals, secure satellite ing the patient’s condition in a narrative manner, almost like uplinks, and computer databases makes the possibility of telling a story, it made data gathering diffi cult for both the obtaining patient medical records, while on-scene, not only physician (who had to read the entire report to fi nd one vital possible but probable. The American Society of Testing and piece of information) and researchers (who looked at dozens Materials (ASTM) has already produced standard F1652-95, of reports for one set of information). Standard Guide for Providing Essential Data Needed in In response to the need for standardized data collection, Advance for Prehospital Emergency Medical Service. The minimum data sets have been established. A minimum data standard includes requirements for secure access and autho- set requires that the Paramedic complete certain fi elds with rized use in order to protect patient confi dentiality, as required the requested information. The minimum data set permits the under federal HIPAA regulations. Paramedic and physician to track trends and note patient prog- ress. A simple example of a data set would be response times. Problem-Oriented All EMS agencies strive to meet preset maximum response Medical Recordkeeping times (e.g., to be on-scene, or off the fl oor, in 10 minutes). In the past, physicians had private records for each patient that Some agencies are obligated by contract to be on-scene in a were stored in their offi ces. These were shared only with the minimum time. In both cases, the EMS agency wants to know patient and offi ce staff whom the physician generally knew its response times. personally. Tracking the progression of a patient’s disease in Every data set must also have a defi nition. In the previous some cases was largely a function of the physician’s memory. example, does scene arrival mean when the ambulance is at With the advent of hospitals, medical specialties, and the dispatched location or at the patient’s side? The differ- allied healthcare providers, all of whom need the same infor- ence in these two interpretations of response times can mean mation, some order had to be brought to the massive collec- minutes to a patient—minutes that make a difference in the tion of records generated for each patient by each provider. To patient’s survival, such as with cardiac arrest. help solve the dilemma, Dr. Lawrence Weed of the Univer- The American Society of Testing and Materials (ASTM) sity of Vermont’s Medical School advocated the concept of has proposed a minimum data set for EMS, standard E1744. problem-oriented medical recordkeeping (POMR) infor- E1744-04 contains similar data sets as the Data Elements mation systems in 1969 to track and manage patient records. for Emergency Departments (DEEDS), a program distrib- In a POMR system, the master problem list of the uted by the Centers for Disease Control and Prevention in record would list the medical conditions for which that 1979. Inclusion of DEEDS data sets into EMS data sets helps patient had been, or currently was, receiving treatment.7–10 ensure a seamless documentation of care from the prehospital Indexed as such, new entries in the medical record, called environment to the emergency department. progress notes, would be placed into the patient’s fi le under Using standardized data sets has tremendous research the problem listed. All healthcare professionals, from physi- potential. With integrated standardized data sets, the effi - cians to nurses to dieticians, would place their entries into the ciency of prehospital interventions can be measured against patient’s record using the SOAP notes format. hospital patient outcomes and recommendations made for The SOAP format may be one of the earliest standardized future practice. documentation formats. With POMR, any allied healthcare To integrate patient information with minimum data sets, provider could open up the patient’s record, called a chart, many EMS systems use a closed form method of documenta- and read what other providers were planning to do, as well as tion. Closed form documents use bubble forms, circles next to review the patient’s progress. With this knowledge in hand, options, which the Paramedic fi lls in to provide information. the provider would make a patient assessment and then enter These bubble forms can then easily be scanned by electronic his or her SOAP note following the last entry. readers to quickly obtain vast quantities of information. The SOAP note would contain subjective (S) information Closed form documents assume most patients will have obtained from the patient or the patient’s family, objective (O) the same or similar complaints, symptoms, and so on, and are information obtained during physical examination, an assess- very restrictive. As a result, many Paramedics complain about ment (A) of the patient’s problem, and a plan (P) for action. their inability to document unique conditions or situations. SOAP notes proved to be invaluable for integrating informa- Many EMS systems use a combined form, one that has tion among a variety of healthcare professionals and ensuring characteristics of a closed form and an open form. These the continuity of patient care. c ombined forms allow rapid information gathering (the Documentation 341 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. minimal data set), as well as the freedom to use some narrative, the patient’s symptoms. The patient’s history consists of an if needed. explanation of the symptoms (i.e., history of present illness) and the patient’s past medical history. CHEATED History of Present Illness Good patient care records paint an accurate picture of the The history of present illness (HPI) is a chronological patient’s condition. For a time, SOAP notes were adequate. description of the development of the patient’s present ill- But as time progressed, Paramedics became increasingly dis- ness, starting with the patient’s chief complaint. If the patient satisfi ed with SOAP notes and started to modify the format to is nonconversational (e.g., because the patient is uncon- include elements unique to EMS. scious), then family and/or bystander comments should be documented. Elements of an HPI typically include location, Early EMS Documentation Formats quality, severity, duration, timing, context, modifying factors, One of the fi rst EMS documentation formats was the CHART and any associated signs or symptoms of the illness. (chief complaint, history, assessment, Rx [prescription], The Paramedic’s intent when gathering a history is to treatment) method. Rather quickly, Paramedics realized develop a symptom pattern. These symptom patterns (i.e., that CHART lacked some needed fi elds, such as an evalua- the list of symptoms) are then compared to the Paramedic’s tion of the interventions. CHART was modifi ed to become knowledge of other diseases, disorders, and syndromes. CHARTIE, adding I for intervention and E for evaluation to When the current symptom pattern matches a symptom pat- the previous information. tern for one of these diseases, disorders, or syndromes, then a Another documentation format that was in common usage diagnosis can be made. is NAP (narrative, assessment, plan of treatment). NAP is a The mnemonic OPQRST (onset, provocation, quality of short documentation format that is particularly well-adapted pain, radiation, severity, timing) is commonly used by Para- for fi rst responder use. Narrative, the N in NAP, is a written medics to help develop a symptom pattern (Table 19-2).11 For description of the patient’s complaints, current history, and any example, the S in the OPQRST stands for severity. Using the physical fi ndings such as vital signs, which is written like a anesthesiologists’ pain scale, the patient is asked to rate the story. Assessment, the A in NAP, is typically complaint driven pain from 0, being no pain, to 10, being the worst pain (e.g., shortness of breath). The plan of treatment, the P in NAP, the patient ever experienced. This line of questioning helps to includes disposition, or to whom the patient was turned over. establish the severity of the patient’s pain as well as establish a baseline to gauge the effectiveness of pain relief. CHEATED Format While a patient history can be endless, the Paramedic To help meet the Paramedic’s needs for a more complete chart- focuses on those questions that will illuminate the cause of ing format, Valerie Conrad, EMS QI Coordinator in Traverse the patient’s problem. It is helpful to have a more structured City, Michigan, developed an EMS-specifi c, user-friendly series of questions for a given problem. documentation method using the mnemonic CHEATED. The Many EMS agencies have adopted the federal Evalua- elements of CHEATED (chief concern/complaint, h istory, tion and Management Documentation Guidelines created examination, assessment, treatment, evaluation, disposition) by the Health Care Finance Administration (HCFA), now contain all of the additional fi elds needed by Paramedics and called the Center for Medicare and Medicaid Services (CMS), is inclusive of the SOAP notes previously used. This docu- and the American Medical Association (AMA). Standardized mentation method is a representation of one effective means histories permit the Paramedic to identify diseases, disorders, of documenting an EMS event. and syndromes, vis-á-vis, through symptom pattern recogni- tion, and document the medical necessity of the therapeutic Chief Concern services provided to the patient. With the standardized history in hand, the Paramedic is The C in CHEATED, chief complaint (CC) or chief concern, now able to establish a diagnosis of the disease, disorder, or is usually the reason that the patient called for EMS. If
pos- syndrome using the International Classifi cation of Diseases sible, the chief complaint should be stated in the patient’s own (ICD-10) coding system.12–14 words and placed within quotation marks. If the patient is unable to speak, then the reason the patient Table 19-2 OPQRST Mnemonic is unable to speak (e.g., “unconscious”) should be noted. The caller’s words should then be noted. These are the words usu- O Onset, the beginning of the symptoms ally transmitted to the Paramedic by the dispatcher. P Provocation, what started or intensifi ed the symptoms Q Quality of the pain History R Radiation (Does the pain migrate to another body part?) The H in CHEATED, history, contains the subjective infor- S Severity, the intensity of the pain mation provided by he patient, the patient’s family, and/or T Timing (Do the symptoms wax and wane?) bystanders. The subjective information provided is called 342 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The ICD-10 is the latest edition of the international diag- Starting in a head-to-toe progression, the traditional per- nostic classifi cation system that fi rst started in 1893 as the tinent negatives are loss of consciousness, chest pain, short- International List of Causes of Death. Since that time, the ness of breath, and abdominal pain. Other EMS systems may ICD coding system has evolved and become the standard for add other pertinent negatives as needed. These four pertinent the description and classifi cation of diseases. negatives are ominous if, instead, they are positive. These With the diagnosis made, physicians and administrators conditions typically require advanced life support measures. can group patient populations with the same or similar diag- nosis into diagnosis-related groups (DRG). The original Past Medical History purpose of a DRG was to group patients who used similar Once the HPI is complete, the Paramedic would proceed resources together for reimbursement from Medicare. These to document the past medical history (PMH). To aid with DRG assignments are based on the ICD diagnosis. Currently documentation of the PMH, the Paramedic often uses the the DRG, version 25, also takes into account procedures per- mnemonic AMPLE (allergies, medications, past medical formed as well as the presence of signifi cant comorbidities. history, last meal, events). In the case of EMS, a patient transport might be reimbursed The fi rst element (A) of AMPLE is the patient’s allergies, for respiratory failure, as a DRG, if the patient was intubated. to both prescription and over-the-counter medications. If the The patient may also be reimbursed for obesity, if the patient patient has no allergies to drugs, then the acronym NKDA had that comorbidity. (no known drug allergies) is often used. If the patient has an For a high-priority patient, the Paramedic would obtain allergy to a medication, and time permits, it may be helpful to answers to a minimum of three elements among those listed. get a history of the reaction to determine if it is a true allergy Elements of a history are listed according to body systems in or an unpleasant side effect of the medication. the guidelines. The next element (the M in AMPLE) stands for medica- For a low-priority patient, the Paramedic would obtain a tions. The Paramedic should list all medications— including more detailed history that contains a minimum of six of the prescription, over-the-counter, botanicals, and illicit drugs—by elements listed as well as some past medical history, and/or name, dose, and frequency, if possible. It is appropriate for family and social history. the Paramedic to use standard prescription shorthand to list These minimum standards are used for all patients. The the frequency (e.g., QD for once-a-day). These Latin terms Paramedic’s problem-focused history may elect, based on are listed in the medical terminology chapter. patient condition and clinical judgment, to expand on the history The next item (the P in AMPLE) stands for past medical in order to more completely understand the patient’s condition. history and should include the primary diseases recognized in each major body system (Table 19-3). Again, progressing in a head-to-toe fashion, a minimal past medical history would include questions about strokes and seizures (neurological), Street Smart heart attack and hypertension (cardiovascular), asthma and chronic obstructive pulmonary diseases (COPD) (respira- Special notation should also be made if the patient tory), diabetes (endocrine), and cancers (Ca). If the patient threatens suicide. If possible, the patient’s exact has a preexisting diagnosis for a disease, then that should also be listed. words and the context in which they were said should be noted. It may be the only utterance the patient Review of Systems makes about suicide. A more complete past medical history uses a systems review approach to history gathering. Using a head-to-toe approach, the following systems review represents a more complete Many Paramedics also document any constitutional symptoms noted. Constitutional symptoms are those gen- eral systemic reactions to illness that include fevers, unex- Table 19-3 Example of a Minimal Past plained weight loss, night sweats, chills, headaches, nausea, Medical History and vomiting. Constitutional symptoms can indicate that the • Stroke patient may be infected and the Paramedic should reconsider • Seizure the choice of personal protective equipment (PPE). The HPI typically ends with the patient’s pertinent nega- • Heart attack tives. Pertinent negatives are those symptoms which, if pres- • Hypertension ent, could indicate a more serious underlying problem. There • COPD could potentially be a large number of pertinent negatives, • Asthma but Paramedics tend to limit the pertinent negatives spe- • Diabetes cifi cally to those symptoms that imply pathology in a major • Cancer organ system. Documentation 343 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. history gathering. The systems review can be used as a part include documentation of prior sprains, strains, and fractures, of a comprehensive examination, or portions can be used to especially those that required surgical correction. Often Para- obtain a more complete focused examination. medics also take and document a pain history at this point, Starting at the head, the patient should be asked if he has especially in regard to the prior use of morphine for similar ever had a stroke, seizure, or traumatic brain injury (TBI). If injuries, in anticipation of orders for analgesia. the patient answers affi rmatively to any of these stated con- The Paramedic should document any endocrine disorders ditions, then the Paramedic would use that opportunity to including diabetes, thyroid disorders, and thyroid surgeries. launch into a more extensive line of questioning. For exam- Similarly, any hematological disorders—such as leukemia, ple, if the patient admits to a history of seizures, then the infections, blood transfusions, and overseas travel—should Paramedic could inquire about the frequency of seizures, the be documented. date/time of the last seizure, what medications the patient is If the patient has a behavioral disorder, then the Para- taking for the seizure condition, as well as compliance with medic should document previous psychiatric admissions, any those medications. psychotropic medications, and use of alcohol or illicit drugs. Proceeding to the cardiovascular system, the patient While the review of systems can be exhaustive, the intent should be asked if he ever had angina (chest pain) or a diag- is to discover preexisting medical conditions and then explore nosis of acute myocardial infarction (AMI). If the patient the medical treatments received for those conditions which answers yes, then the Paramedic might inquire which portion might impact on current prehospital care. The previously of the heart was affected. Next, the Paramedic would inquire listed questions in the review of systems merely cites some about angioplasty, including the results and/or a coronary representative questions that could be used. More questions artery bypass graft (CABG). Some patients are so well edu- may be appropriate (Table 19-4). cated about their condition that they can tell the Paramedic The L in AMPLE has various interpretations. It typi- which vessel was involved, the percentage of blockage, and cally stands for last meal. This is an important question if even their last ejection fraction. the patient may be destined for the operating room. Surgeons A review of the respiratory system starts with documen- prefer patients who have not eaten prior to surgery (N.P.O.), tation of any lung disease and often includes smoking history, thereby lowering the risk of aspiration. Some Paramedics also listed in packs/years, and a diagnosis of emphysema. use the L to indicate last bowel movement (if the chief con- The Paramedic should document any abdominal surger- cern is abdominal pain) or last menses (if the patient could ies, including appendectomy, history of small bowel obstruc- have a gynecological problem). Some Paramedics may use tion, and the presence of an abdominal aortic aneurysm, L to mean last time a medication was taken when the patient repaired or not repaired (Figure 19-4). has a known history of epilepsy or diabetes. Proceeding to the genitourinary system, the Paramedic The fi nal element in AMPLE (E) refers to events and should document any history of sexually transmitted diseases. generally is aimed at previous events of the same or similar If the patient is a female, then a reproductive history— including nature and/or other previous encounters with EMS. the number of pregnancies and delivery of newborns—should be documented. A history of kidney stones may also explain Examination fl ank/groin pain and should be documented. The physical examination of the patient, the E in CHEATED, If the patient has an extremity injury, then past medical often starts with the position and condition in which the history of injuries to the extremities, as well as the musculo- patient was found. For example, if the Paramedic fi nds the skeletal system, should be documented. The history should patient with shortness of breath in a tripod position, the Para- medic would note that as part of his general impression and document the same. This type of “from the doorway” assessment is referred to as a constitutional examination. The constitutional examination Table 19-4 Standard Review of Systems • Neurological • Cardiovascular • Pulmonary • Gastrointestinal • Endocrine • Genitourinary • Integumentary • Musculoskelal Figure 19-4 A Paramedic taking a history. 344 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. assesses the patient’s general appearance. Examples of the two extremes of appearance is the patient in extremis, or having great diffi culty, and the patient in no apparent distress (NAD) (i.e., not appearing to be having diffi culty). This “sick–not sick” impression can help the Paramedic establish the tempo of the call. The constitutional examination may also contain objec- tive observations about the patient’s physical development such as “emaciated” or “obese.” These descriptions speak to the patient’s body habitus. For example, the morbidly obese patient typically has a list of medical conditions, such as heart failure and diabetes, associated with being obese. These descriptions of the patient are not slanderous or insulting, but are objective statements which are intended to make an infer- ence about the patient’s health. Similarly, any overt deformities as well as personal grooming habits relate to the patient’s health or the patient’s ability to maintain health. The fi rst sign of Alzheimer’s dis- ease, for example, may be the patient’s inability to perform the activities of daily living, including
personal grooming. The Paramedic would then proceed to document the fi nd- ings of the initial assessment, including the treatment of any Figure 19-5 Paramedic performing a physical life-threatening injury. examination. Next, the patient’s vital signs are recorded. For blood pres- sure, it should be noted whether it was taken while the patient was supine, seated, or standing. For pulse, regularity (as well as For example, all ECG criteria should be listed (QRS width, rate, respirations, and temperature) should be recorded. etc.) prior to noting an identifi cation of the ECG rhythm. If the patient was high priority, then the Paramedic would Many Paramedics will use a broad label, such as a narrow- document the problem-focused examination fi ndings. The complex tachycardia, and then note a presumptive interpreta- problem-focused examination, sometimes referred to as a vec- tion, such as paroxysmal atrial tachycardia. tored examination, is limited to the affected body area or organ system refl ected in the chief complaint. The various body sys- Assessment tems examined in a problem-focused examination include, While it is important for the Paramedic to accurately and com- from head-to-toe, the neurological system, the cardiovascular pletely describe the patient’s condition, in order to arrive at a system, the respiratory system, the gastrointestinal system, the paramedical diagnosis, it is almost as important for the Para- musculoskeletal system, and the psychiatric exam. medic to consider what is not seen. Documentation showing For example, a problem-focused physical examination consideration of other possible etiologies demonstrates that the for a patient with a complaint of substernal chest pain would Paramedic has an open mind to other potential diagnoses and include the cardiovascular system. Taking a look, listen, and has considered them and then rejected them. This “head’s up” feel approach to physical examination, the Paramedic would attitude helps prevent the Paramedic from focusing too nar- document the presence or absence of jugular venous disten- rowly based on an assumption, without considering other pos- tion and pedal edema. The auscultatory fi ndings, including sibilities. For example, the chest pain experienced by a patient bilateral blood pressures and heart sounds, would be docu- could be due to pulmonary embolism secondary to a deep vein mented. Finally, fi ndings assessed by palpation, such as pedal thrombus. If the Paramedic were to focus exclusively on a car- pulses and the location of the point of maximal intensity diac examination, he might miss the source of the pathology. (PMI), might be documented. Following the discussions of various pathologies in sub- It should be noted that any documentation of the abnormal sequent chapters, the “rule out” or differential diagnosis for without further elaboration is insuffi cient. The assumption is specifi c complaints will be discussed. that the patient has normal fi ndings unless otherwise noted. If the patient is a low-priority patient, then a more detailed Paramedical Diagnosis physical examination would be performed (Figure 19-5). With the history and physical examination documented, the Some Paramedics, especially in trauma cases, prefer a head- Paramedic would proceed to document the assessment. The to-toe approach to the detailed physical examination, whereas assessment is, partly, a protocol-driven medical decision. Typ- others prefer a body systems approach to the examination. ically, for high-priority patients Paramedics use advanced life If an ECG is attached to the documentation, it is important support (ALS) protocols, whereas for low-priority patients that the Paramedic standardize the notation of interpretation. basic life support (BLS) protocols are used. Documentation 345 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The documentation of the protocol-driven fi eld diagnosis Special Documentation asserts and reinforces the Paramedic’s medical control. If direct contact with medical control is made for purposes of consulta- Several situations are not amenable to standard documentation tion and specifi c orders, then that should be noted as well. procedures. These situations require special documentation or special notations, which will be discussed individually in the Treatment following section. The next section of the PCR is the treatment section. All interventions performed, both BLS and ALS, should be Refusal of Medical noted in the treatment section. If BLS fi rst responders had Assistance Documentation already initiated patient care, then these treatments should The CHEATED format works well for documentation of also be noted in the treatment section, with the notation “per- refusal of medical assistance (RMA). Starting with the chief formed by EMT Jones.” complaint, or chief concern, the Paramedic would document Evaluation the history and the physical examination to the extent permit- ted by the patient. Following every treatment there should be an evaluation of In the assessment section, the Paramedic would address the the effectiveness of that treatment, or, at a minimum, a state- issue of competence, including noting the patient’s age. If the ment about the patient’s ongoing condition. This is the evalu- patient is of age, or is an emancipated minor, then the Paramedic ation phase of patient care. would proceed and document the patient’s mental status. Some have argued that Paramedic care is an unnecessary The key to capacity to consent, or to refuse, is the patient’s expense and that the majority of the Paramedic’s treatments mental status, discussed further in Chapter 6. Any physical or are ineffective, at best. Accurate documentation of the effect medical conditions that would prohibit the patient from con- of prehospital care helps to demonstrate the value of early senting (e.g., intoxication or presumption of stroke) should medical treatments performed by Paramedics. be documented. Actions taken by the Paramedic to enlist the assistance of family, medical control, or law enforcement offi - Disposition cers to convince the patient to seek medical attention should The last section of the CHEATED PCR is disposition. Some be documented as well. Paramedics refer to this as the patient report, a summary of In the treatment portion of the PCR, all treatments per- the patient’s condition and the status of treatments in progress mitted by the patient, including those offered but refused, when patient care was given over to another Paramedic or should be documented. healthcare provider. It is imperative that the Paramedic docu- Instead of completing an evaluation, because treatment ment to whom the patient was turned-over-to (TOT) in order is being refused, the E in CHEATED means explanation of to avoid accusations of patient abandonment. outcomes. The Paramedic should document that the patient The disposition should also contain information about was advised of foreseeable complications that are reasonably the patient’s condition (i.e., changes and improvement), as likely to arise, which could seriously jeopardize the patient’s well as the status of treatments. For example, a Paramedic health and bodily functions or result in a serious dysfunction might document that oxygen was continued, that the IV of an organ or body part if medical attention is refused. remained patent, and state the rate of infusion. The Para- The explanation of outcomes documented should include medic might also want to document the volume of fl uid a list of the symptoms for which the patient should reconsider infused as well as whether blood samples were turned over and recall EMS. Also, the encouragement to seek medical to the emergency department personnel. Finally, the Para- attention from a private physician should be noted. medic may document if the patient was left in the care of Under the fi nal disposition portion, the Paramedic should family, friends, or hospital personnel. document with whom the patient was left and the patient’s ability to summon aid or recontact 9-1-1. The patient should then be asked to sign the completed PCR. A copy of the PCR should be left with the patient, if Street Smart possible. Some EMS systems use special documentation forms for refusals of medical care. If the patient is unwilling After the patient is transferred from the ambulance to sign the PCR, the Paramedic should note the refusal and gurney to the hospital stretcher, the side rails on obtain the names, and signatures, of witnesses. the stretcher should be raised unless the patient is Hazardous Materials attended to by a hospital staff member. “Side rails up Operations Documentation times two” is often the fi nal line of documentation on Key to hazardous materials operations documentation is an the PCR. understanding that such documentation may be called into play in lawsuits and disability hearings years after the patient 346 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. was seen by the Paramedic. Complicating matters, the aver- proceed to ask about inherited risk factors, personal habits age hazardous materials technician being assessed by EMS (such as smoking or alcohol use), as well as document a sys- may not have any signifi cant complaints and yet is given an tems review of the patient’s health. When the prenatal ques- on-scene physical examination as a part of the process of tionnaire is completed, the Paramedic would document the decontamination. patient’s pregnancy history, including past diffi culties with Using the CHEATED format in this venue, the Paramedic delivery. should document, under chief complaint, the exact potential chemical exposure, or exposures, if known. Under the his- Special Incident Report tory section, the Paramedic should explain the circumstances which caused the exposure. Many Paramedics are asked to complete documentation A standard well-person physical examination, includ- that is not directly related to patient care. These documents, ing vital signs, should be documented. Many EMS systems that can be broadly termed special incident reports (SIR), also perform a baseline cardio-thoracic examination for later are used for administrative purposes or as a part of a court comparison. proceeding. The patient’s assessment and treatment are usually based One special incident report is an exposure report. upon prewritten protocols. The Paramedic should docu- The exposure report, separate from the patient care report ment if the patient’s physiological condition meets or fails to that should be generated for each individual who was seen meet those parameters and if treatment is indicated. In some after exposure, details the circumstances that resulted in instances, the treatment is limited to what is typically offered the Paramedic being exposed. The intention of an expo- in a fi re rehabilitation sector. sure report is to identify the problem and then correct the Finally, the patient’s disposition, such as discharged to problem so that another exposure cannot occur. Therefore, rehabilitation, discharged to home, or transported for further names of exposed individuals may not be needed on the evaluation, should be documented. report. Under most circumstances, the designated offi - cer (DO) for the agency receives the exposure report and Documentation of Multiple Casualties would make recommendations for corrections to prevent problems in the future. Understandably, Paramedics cannot take the time to perform In most states, Paramedics are considered mandatory standard documentation during a mass casualty incident. In reporters of child abuse and are required to complete a stan- those circumstances, the triage tag is the only documentation dardized reporting form. This type of report would be con- that will be performed. sidered a special incident report. Similar forms may also be At the end of the incident, the Paramedics should com- available for reporting domestic violence or elder abuse. plete an event report that details, like the hazardous materials incident report noted previously, the situation and conditions that occurred which led to the mass casualty incident. The Legal Proceedings event report should be as detailed as possible. The triage tags When a Paramedic has been a witness to a crime, or is a are then attached to the event report as a part of the perma- named party to a claim of negligence, the Paramedic may be nent record. called
upon to provide special documentation.17–20 In some cases, human error may have contributed to the Some attorneys, or legally authorized persons, may only incident and charges of negligence may be brought against request that the Paramedic make a legal sworn statement, those individuals who are believed to be responsible.15–16 In called an affi davit, about the events surrounding an incident. that situation, the Paramedic may subsequently be called to These statements are voluntary and typically witnessed by a testify about the conditions on-scene as well as the patient notary public. care provided. During the discovery phase of a trial, discussed in Chap- Documentation of Pregnancy ter 6, the Paramedic may be requested to give a deposition. A deposition is the testimony of a witness (in this case, a and Childbirth Paramedic) in a setting outside of a court, where attorneys Standard EMS documentation is designed to document the from both parties can interrogate the witness. The sworn tes- condition of an ill or injured person. The pregnant woman timony given by the witness is recorded by a stenographer. is neither ill nor injured. The wellness examination of the A transcript, a word-for-word account, is then produced for pregnant woman focuses on documenting the state of the use in the lawsuit and may be submitted into evidence in a pregnancy as well as identifying potential complications of court of law. Often Paramedics rely on the PCR or a SIR to childbirth. refresh recollection or for background information regarding Starting with a prenatal questionnaire, the Paramedic the case. should document the answers to the questions about this preg- In some cases, the attorney may elect to have the Para- nancy, such as date of last menstrual period (LMP) and/or the medic answer questions in a written deposition, in a manner expected date of delivery (EDD). The Paramedic should then similar to an affi davit. This is discussed further in Chapter 6. Documentation 347 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Documentation is an important aspect of EMS. The quality of patient care, and the Paramedic’s professionalism, is often refl ected in the patient care report. The benefi cial nature of a patient care report is a function of its ability to communicate the message that the sender (the Paramedic) intended for the receiver (the emergency physician). By learning the correct medical terminology and abbreviations, and reporting thoroughly but concisely while utilizing a charting format consistently, the Paramedic can expect success with her documentation. Key Points: • The fi rst purpose of documentation is to use it as a • Specifi c protocols should be in place to resolve medical record. errors and omissions. • The patient care report is also used for quality • In an electronic age, safeguards must be in place to assurance and performance improvement. ensure patient privacy from unwarranted invasion. • The PCR is also a business record used to bill • While many documentation formats exist, federal and state governments as well as private Paramedics should choose the one that meets their insurance. agency’s needs and provides the most complete • documentation of the events that transpired. The PCR is a legal document used in litigation. • • Special events, such as hazardous materials Documentation standards help to ensure that the incidents or multiple casualty incidents, require a standard of care was met. special incident report. Review Questions: 1. What are the six reasons cited for documenting 6. Defi ne “pertinent negatives.” patient care? 7. What are the minimum elements required for a 2. What is meant by the phrase “prudent layperson refusal of medical assistance? standard”? 8. What are the minimum elements required for 3. What are the accepted practices for documenting patient care for responders at the documenting errors and omissions? scene of hazardous materials operation? 4. How does the federal Health Insurance 9. What is the documentation tool used at a Portability and Accountability Act (HIPAA) multiple casualty incident and what are the affect documentation? fi elds required? 5. List three documentation formats and provide 10. What are the different legal instruments used at details for one of them. a legal proceeding? 348 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Case Study Questions: Please refer to the Case Study at the beginning of the 2. How is the patient care report used for chapter and answer the questions below: performance improvement? 1. Why is accurate documentation of a cardiac 3. Medically, what use does a physician have for a arrest important? Paramedic’s patient care report? References: 1. Shah R, Geisler CD, et al. A study of hospital based ambulance news_and_articles/columns/Edgerly/Assessing_Your_ systems in Wisconsin. J Clin Eng. 1979;4(3):275–281. Assessment.html Accessed May 16, 2009. 2. Belding J. Patient refusal. What to do when medical treatment & 12. Cimino JJ. Review paper: coding systems in health care. transport are rejected. Jems. 2006;31(5):116–118. Methods Inf Med. 1996;35(4-5):273–284. 3. Goldberg RJ, Zautcke JL, et al. A review of prehospital care 13. Alexander S, Conner T, et al. Overview of inpatient coding. Am litigation in a large metropolitan EMS system. Ann Emerg Med. J Health Syst Pharm. 2003;60(21 Suppl 6):S11–S14. 1990;19(5):557–561. 14. Watzlaf VJ, Garvin JH, et al. The effectiveness of ICD-10-CM 4. Stapczynski JS. Is the prudent layperson standard really a in capturing public health diseases. Perspect Health Inf Manag. “standard”? Ann Emerg Med. 2004;43(2):163–165. 2007;4(6):6. 5. Johnson LA. Coverage disputes and the prudent layperson 15. Zoraster RM, Chidester C, et al. Field triage and patient standard. Ann Emerg Med. 2004;44(4):426; author reply maldistribution in a mass-casualty incident. Prehosp Disaster 426–427. Med. 2007;22(3):224–229. 6. Davis, N, et al. Practice brief. Facsimile transmission of health 16. Risavi BL, Salen PN, et al. A two-hour intervention using information (updated). J Ahima. 2001;72(6):64E–64F. START improves prehospital triage of mass casualty incidents. 7. Rakel RE. The problem-oriented medical record (POMR). Am Prehosp Emerg Care. 2001;5(2):197–199. Fam Physician. 1974;10(3):100–111. 17. Nagorka FW, Becker C. Immunity statutes: how state laws 8. Silfen E. Documentation and coding of ED patient encounters: protect EMS providers. Emerg Med Serv. 2005;34(6):93–94, an evaluation of the accuracy of an electronic medical record. 96–97. Am J Emerg Med. 2006;24(6):664–678. 18. Wiggins CO. Ambulance malpractice and immunity. Can a 9. Bossen C. Evaluation of a computerized problem-oriented plaintiff ever prevail? J Leg Med. 2003;24(3):359–377. medical record in a hospital department: does it support daily 19. Maguire BJ, Porco FV. An eight-year review of legal cases clinical practice? Int J Med Inform. 2007;76(8):592–600. related to an urban 9-1-1 Paramedic service. Prehosp Disaster 10. Sandlow LJ, Bashook PG, et al. Gradual acceptance of POMR. Med. 1997;12(2):154–157. Internist. 1980;21(3):6–7, 17. 20. Colwell CB, Pons P, et al. Claims against a Paramedic ambulance 11. Edgerly D. Assessing your assessment. Journal of Emergency service: A ten-year experience. J Emerg Med. 1999;17(6): Medical Services on-line. Available at: http://www.jems.com/ 999–1002. Documentation 349 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The fi nal section of this volume includes the essential material in airway management, monitoring devices, intravenous access, pharmacology and ECG monitoring and acquisition that forms the basis for Paramedic assessment and treatment. This section provides the foundation for the clinical chapters in Volume II. • Chapter 20: Airway Anatomy and Physiology • Chapter 21: The Algorithmic Approach to Airway Management • Chapter 22: Non-Intubating Airway Management • Chapter 23: Intubating Airway Management • Chapter 24: Medication-Facilitated Intubation • Chapter 25: Ventilation • Chapter 26: Principles of Medication Administration • Chapter 27: Intravenous Access • Chapter 28: Blood Products and Transfusion • Chapter 29: Introduction to Pharmacology • Chapter 30: Pharmacological Interventions for Cardiopulmonary Emergencies • Chapter 31: Pharmacological Therapeutics for Medical Emergencies • Chapter 32: Principles of Electrocardiography • Chapter 33: The Monitoring ECG • Chapter 34: Diagnostic ECG—The 12 Lead 351 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The route an oxygen molecule takes from the oral or nasal cavities to the alveolar capillaries • Anatomy of airway structures as viewed with a laryngoscope • Lung volumes/capacities and mechanisms for negative pressure ventilation • Composition of air and the physiology of the internal and external exchange of respiratory gasses • Key anatomical differences between the pediatric and adult airway and respiratory physiology Case Study: A Paramedic student is presented with a 120 kg patient who had a sudden onset of diffi culty breathing while sleeping. The patient had a history of congestive heart failure and high blood pressure. The patient states he has had increased swelling in his legs over the past two days and sleeps with several pillows because of diffi culty breathing while lying fl at. The physical exam reveals increased work of breathing with diminished lung sounds in bases and diffuse rales. The student’s treatment plan includes oxygen therapy, a breathing treatment, nitroglycerin, and furosemide. As the patient does not improve, the Paramedic student places the patient on continuous positive airway pressure (CPAP). 352 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Airway Anatomy and Physiology 353 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Assessing the patient’s airway is a fundamental part of any initial patient assessment. Therefore, interventions may be needed to open and secure the airway or assist with ventilations. The act of breathing transports air entering the oral or nasal cavities to the alveolar sacs where gas exchange can occur. This chapter will examine the anatomy of the adult and pediatric airway and the physiology of each component. The Paramedic should have knowledge of how an oxygen molecule is transported from the oral or nasal cavities to the alveolar capillaries. When performing
advanced airway procedures, every Paramedic must possess an intimate knowledge of a patient’s airway anatomy and respiratory physiology. Although minor individual anatomic variations exist, every patient will have a similar anatomic structure and respiratory physiology. If the Paramedic has a clear understanding of normal airway anatomy and ventilation, he can maximize his interventions and greatly improve his chances of successful airway management. Airway Anatomy addition of 1 L of fl uid produced by glandular secretion and transudation, or liquid diffusing across the mucous membrane The airway is divided into the upper and lower airway into the nasal cavity. This fl uid not only serves to humidify (Figure 20-1). The upper airway begins at the nares and mouth the air entering the lungs but also has signifi cant antibacterial and extends to the glottis. The lower airway extends from the properties. In addition, large particulate matter is fi ltered via glottis to the alveoli. The respiratory system is composed of the nasal hairs and trapped in mucus. The area is also served many other structures including a number of ligamentous, by extensive lymphatic drainage.1 Anatomically, the passage muscular, and bony structures in the neck and chest. The from the nare to the nasopharynx is a straight line parallel to following section will look at each of these components and the roof of the mouth. Knowing this anatomy is important their role in both ventilation and airway management. prior to the placement of such devices as nasotracheal tubes, nasopharyngeal airways, and nasogastric tubes. The Upper Airway The nasopharynx lies posterior to the turbinates and The openings of the mouth and nose defi ne the beginning superior to the soft palate. It terminates into the oropharynx of the airway. From a functional perspective, the nose is inferior-posteriorly. The pharynx is the area of the airway the primary structure for air entrance. The nose provides an composed of the spaces behind the nose (the nasopharynx) immunologic barrier (mucus), warms and humidifi es air, and and the oral cavity (the oropharynx). serves as a threat/food detection system (sense of smell). This When the facial bones and the bones of the skull develop compact unit allows an individual to simultaneously eat and in the fetus, small air pockets called “sinuses” form. These breathe. In times of high ventilatory demand (e.g., exercise, sinuses are attached to the main airway passages and thus fear, pulmonary disease) or instances when the nares are normally have an internal pressure equal to atmospheric blocked, a person can also utilize the mouth for ventilation. pressure. The sinuses are lined with mucous membranes and Air enters the nares and immediately passes along may have a role in trapping bacteria. In addition, the weight the turbinates (Figure 20-2). The nasal fossae are divided savings of replacing bone with air make the skull signifi cantly by the septum—a midline cartilaginous structure. In the lighter. The walls of the sinuses are thin and easily fractured. average adult the fossae extend approximately 12 cm to the Given their locations, fractures of certain sinuses may allow nasopharynx and, due to folds in the mucosa, each fossa a direct connection from the inside of the skull to the exterior provides approximately 60 cm2 of surface area for fi ltration, world, particularly in the case of a basilar skull fracture. warming, and humidifi cation.1 This heavily vascularized Despite occasionally serving as a passage for air, the mucosa is composed primarily of ciliated columnar cells mouth is much less suited for the processes of ventilation and goblet cells. Relatively minor trauma (e.g., insertion than is the nose. The mouth does not have the nose’s ability of a nasopharyngeal airway) can result in signifi cant to provide and maintain humidifi cation and is not as well hemorrhage. equipped to serve as a particulate/pathogen fi lter. Nonetheless, For an average-sized adult with normal ventilatory the Paramedic must be cognizant of the mouth’s structures function, approximately 10,000 liters (L) of air pass through as the oropharyngeal route is the most common route for the nasal fossae each day. This air is humidifi ed through the assisted airway management. The oral cavity is bound by 354 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Sinuses Nasal cavity Upper respiratory system Mouth Pharynx Epiglottis Larynx Right lung Trachea Bronchus Lower Pulmonary vein respiratory Pulmonary artery system Cut edge of parietal pleura Bronchiole Cut edge of diaphragm Bronchial artery Alveoli Bronchiole Pulmonary arteriole Pulmonary venule Figure 20-1 Overall respiratory system anatomy. Nares Nasopharynx Hard palate Soft palate Oral cavity Uvula Tongue Oropharynx Larynx Epiglottis Thyroid cartilage Cricoid Esophagus cartilage Trachea Figure 20-2 Upper airway anatomy. Airway Anatomy and Physiology 355 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. the lips anteriorly, the buccal surfaces (cheeks) laterally, vasculature of the mucous membrane make this a high-risk area the tongue inferiorly, the hard palate superiorly, and the soft for bleeding during airway management. In addition, during palate posteriorly (Figure 20-3). The tongue occupies much times of pharyngeal or oral infections, these tissues can swell of the oral cavity and, as a muscular structure, can move freely and actually occlude the airway. Therefore, they may preclude throughout the cavity. standard orotracheal airway management practices. The lower jaw, or mandible, articulates with the temporal The pharynx and hypopharynx are the areas of common bones at the temporomandibular joints. The mandible is able passage for food and respiratory gasses (Figure 20-1). The area to move inferiorly and superiorly (i.e., mouth opening and clo- contains numerous structures including multiple constrictor sing), laterally (i.e., moving side to side), and anteriorly (i.e., and elevator muscles to aid in swallowing. The epiglottis “jaw jutting”). The temporomandibular joint is relatively loose also resides in this space. The hyoid bone, another structure and the ball of the joint can move partially out of its socket to of importance in this region, is the only bone in the body allow greater opening and anterior movement. Diseases that that does not directly articulate with another bone. Instead, affect the temporomandibular joint decrease mouth opening it serves as a common point of attachment for a number of and can make airway management more diffi cult. muscles and ligaments that function in swallowing and airway The average adult has 32 teeth—16 upper and 16 lower. maintenance. The hyoepiglottic ligament is one such structure Through disease, wear, and trauma, the teeth may become that will be discussed in more detail in the following text. Other loose or may be replaced by appliances. The teeth and these attachment points include the mandible, the styloid process of appliances (e.g., dentures, partials, etc.) give the lips and the skull, the posterior skull, the sternum, the scapula, and the cheeks structure and help the Paramedic maintain an adequate thyroid cartilage, making the hyoid a critical anchor point for face seal during ventilation. During intubation, however, teeth many physiologic functions (Figure 20-4). can impede the view of the lower airway structures. Thus, The epiglottis is one of the most important anatomic and dental appliances should be removed before intubation. physiologic structures of the upper airway. This “U” shaped The tonsillar pillars that form the walls of the oropharynx structure composed of fi broelastic cartilage is attached to the are composed of lymphatic tissue (the palatine tonsils) and anterior pharynx between the base of the tongue and the larynx. the muscles used for swallowing. Along with a ring of other Although considered by some to be vestigial,2 the epiglottis lymphoid tissue, these structures serve as an immunological seems to serve a function in protecting the lower airway from barrier to pathogen entry in the pharynx. The palatine tonsils foreign body aspiration. It is covered by a mucous membrane deserve special mention for the Paramedic. As with the rest of that is contiguous with the tongue. The space formed between the upper airway, these structures are covered by a thin mucous the anterior-superior surface of the epiglottis and the posterior membrane. The prominence of the palatine tonsils and the base of the tongue is the valecula. The epiglottis is attached to the midline of the thyroid cartilage by the thyroepiglottic ligament. Given its size, contents, and multiple functions, the pha- Upper lip rynx is a very common area for airway obstruction to occur. Traditional teaching has suggested that the tongue falls posteriorly in the obtunded patient and obstructs the airway. However, imaging work by Shorten et al.3 has demonstrated that, in fact, the soft palate and epiglottis make contact with Hard palate the posterior wall of the oropharynx and pharynx before the tongue does and that these structures cause airway obstruction. Soft palate Thus, the action for opening an airway actually depends on Uvula the anterior traction on the epiglottis. This is accomplished Tonsil through the hyoepiglottic ligament by the anterior displacement Pharynx of the hyoid bone. The hyoid is lifted by anterior mandibular displacement (the hyoid has multiple muscular attachments Tongue to the mandible) that occurs with a head-tilt chin-lift or jaw thrust. The Lower Airway The visible structures of the lower airway (Figure 20-5a) can be seen by the Paramedic during orotracheal intubation. The larynx, also known as the “voice box,” is the upper group Lower lip of structures of the lower airway and opens with a number of cartilaginous structures. From anterior to posterior, these structures include the base of the epiglottis, the thyroid Figure 20-3 The oral cavity. cartilage, and the aryepiglottic folds (Figure 20-5b and 356 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Stylohyoid Mandible muscle Mylohyoid muscle (severed) Digastric muscle Digastric muscle (posterior belly) (anterior belly) Thyrohyoid muscle Geniohyoid muscle Hyoid bone Omohyoid muscle Stylo p h a r yngeus muscle Thyroid cartilage Cricoid cartilage Sternothyroid muscle Sternohyoid muscle (partially severed) Figure 20-4 The hyoid bone and its muscular attachments. Figure 20-5c). The aryepiglottic folds contain three separate apple” in men as well as a lower pitched voice.1 The posterior cartilaginous structures: the cuneiform, corniculate, and margins of the thyroid cartilage terminate in the superior arytenoid cartilages (from anterior to posterior). These and inferior thyroid horns or cornu.4 The superior horns are structures are attached to each other and other structures by attached to the hyoid via the thyrohyoid ligament and the ligaments as well as the intrinsic and extrinsic muscles of the inferior horns articulate with the cricoid cartilage via a true larynx. The whole complex is covered by mucosal folds. synovial ball and socket joint similar to the hip joint. The open space below the laryngeal opening and superior to the vocal cords is called the vestibule. Small outpouchings in Street Smart the mucosal folds that overlie the vestibular membrane of the quadrangular membrane form the false cords. The false cords, which do not serve in phonation (the production of speech and The arytenoids are the posterior-most structures sound), are important because they can seal over the glottis to of the laryngeal opening. Any endotracheal tube help protect the airway from aspiration of foreign materials. visualized passing anterior to the arytenoids is, The vocal cords are visible at the bottom of the vestibule. As with other structures of the larynx, the vocal cords are by defi nition, passing
into the larynx and trachea, composed of mucosal folds overlying ligaments, cartilages, even if the cords are not visualized. Any tube and muscles. The cricothyroid ligament starts anteriorly as visualized passing posterior to the arytenoids is the cricothyroid membrane that attaches the cricoid ring to in the esophagus. the thyroid cartilage. The thickened central portion of the cricothyroid membrane, called the “conus elasticus,” extends to the interior border of the thyroid cartilage and then turns The thyroid cartilage is the large, anterior shield-like posteriorly, splitting in half and attaching on the arytenoid cartilage structure that forms the majority of the anterior cartilages. The medial edges of this portion of the cricothyroid portion of the larynx. It is attached superiorly to the hyoid via ligament thicken and are called the vocal ligaments. With the thyrohyoid membrane and inferiorly to the cricoid ring by their associated mucosal folds, the vocal ligaments form the the cricothyroid membrane. From its anterior, superior midline true vocal cords. These structures are typically found at the notch, the thyroid cartilage extends laterally and posteriorly level of the 5th cervical vertebrae in an adult. to form a “half-pipe” shape. In females, the thyroid cartilage The vocal cords serve two main functions in the airway. is fl atter than in males, resulting in a more prominent “Adam’s The fi rst is phonation. The extrinsic and intrinsic muscles of Airway Anatomy and Physiology 357 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Thyroid cartilidge vocal cords are abducted (moved away from each other) to maximize laminar (linear, nonturbulent) airfl ow. In the cadaver (and in paralyzed patients who have lost laryngeal Cricoid Glottis cartilage muscular function), the resting position of the vocal cords is abducted and “loose” or “wavy” appearing. Vocal ligament The second function of the vocal cords (the glottis) is airway protection. The muscles that produce phonation can also adduct the glottis and the false cords to provide an impenetrable barrier to foreign material. The stimulation Superior horn of the thyroid of nerve endings in the supraglottic region (the vestibule) cartilage triggers a short-lived involuntary refl ex resulting in glottic (a) closure. A number of stimuli including touch, temperature, and chemicals can trigger this refl ex. If the glottis remains Epiglottis closed, it is called laryngeal spasm and can make airway management challenging. Hyoid bone Thyrohyoid membrane Street Smart Thyroid cartilage Cricothyroid ligament Most laryngospasms will resolve with positive pressure ventilation, timed with the patient’s natural Cricoid cartilage inspiration. If that does not succeed, then chemical Trachea paralysis or a rapid surgical airway may be required in (b) order to oxygenate the patient. Epiglottis Body of The remaining cartilaginous structure of the larynx is the cricoid ring (Figure 20-5b). The cricoid ring, the only Thyrohyoid hyoid bone membrane Thyroid complete ring in the trachea, is located at the lowest portion membrane of the larynx and the beginning of the trachea. The widest Cuneiform cartilage Fatty pad part of the ring is found posteriorly and rises toward the Corniculate cartilage arytenoids. The cricoid ring supports the larynx above it Vestibular fold Arytenoid cartilage (false vocal chord) and is attached by a number of ligaments; the tracheal rings Arytenoid muscle are attached inferiorly by many muscles and ligaments. The (controls swallowing) Thyroid cartilage complete nature of the ring makes it susceptible to fractures. Cricoid Vocal fold Conversely, properly applied cricoid pressure allows the cartilage (true vocal chord) ring to compress the esophagus, essentially sealing off the Tracheal cartilages Cricothyroid esophagus and minimizing the risk of regurgitation. ligament Cricotracheal ligament (c) Street Smart Figure 20-5 a-c Laryngeal anatomy. (a) As Many well-intentioned individuals, in attempting to viewed during laryngoscopy. (b) From an anterior view. (c) From a lateral view. apply “cricoid” pressure, actually go for the largest structure visible/palpable and apply “thyroid” the larynx move the various cartilages to change the shape (cartilage) pressure. Not only does this not necessarily and tension of the cords. The intrinsic muscles are most occlude the esophagus, but pressure on the thyroid responsible for the modifi cation of the cords. The changes in cartilage at its middle to inferior margin causes the shape and tension allow the full vocal range. The innervation of the intrinsic muscles is primarily from the recurrent vocal cords to rise anteriorly, making them more laryngeal nerve. On phonation, the vocal cords are adducted diffi cult to visualize during laryngoscopy. (brought together) to produce sound. On inspiration, the 358 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Other important structures of the larynx include the There are a number of clinically signifi cant structures intrinsic and extrinsic laryngeal muscles and their nerve external to the laryngeal airway (Figure 20-6). These supply. These muscles were previously described in terms structures are of importance to the Paramedic both because of their function. Although knowledge of the individual of their potential for injury during airway management and muscles, their individual innervation, and their individual because, if injured, whether by the Paramedic or during a function is not critical to the Paramedic, understanding the traumatic event, they can cause compromise of the airway. overall function in terms of laryngeal movement, phonation, The thyroid gland is a highly vascular “H” shaped and airway protection is important. Of particular importance structure that lies along the sides of the larynx and upper is the “gag refl ex.” This refl ex arc depends on sensory nerves trachea. The crossbar of the “H” crosses the trachea just at the level of the oropharynx, the pharynx, and the larynx below the cricoid ring. A laceration of the thyroid will lead to trigger the response. The refl exive response is coughing to signifi cant bleeding. In addition, disease of the thyroid can and coordinated activity by the muscles of the hypopharynx, result in swelling and deformation of the airway anatomy. oropharynx, and pharynx to propel the offending stimulus Two sets of major vascular structures—the common into the mouth and out of the body. carotid arteries and the internal jugular veins—run parallel Hyoid bone Thyrohyoid membrane Superior laryngeal artery Superior thyroid artery Thyroid cartilage Posterior branch, superior thyroid artery Median cricothyroid ligament Anterior branch, superior thyroid artery Cricoid cartilage Common carotid artery Cricothyroid branch, superior thyroid artery Internal jugular vein Vagus nerve and its superior cardiac branch Ventral branches of C4 to C8 nerves Subclavian artery Ventral branch of T1 nerve Cupula of pleura; Subclavian vein ansa subclavia and lymphatic trunk Phrenic nerve Esophagus; thyroid Phrenic nerve; venous plexus; left pericardiacophrenic artery recurrent laryngeal nerve Figure 20-6 Superfi cial anterior neck anatomy. Airway Anatomy and Physiology 359 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Terminal of an epithelial layer, mucous glands, lymphatic tissue, nerves, bronchiole vascular structures, and structural cartilage. The most common cell in the large lower airways is the ciliated epithelial cell. The cilia (small hair-like projections) form the moving portion of the “mucociliary” escalator. The mucus secreted by goblet and serous cells traps small particles and pathogens. The cilia move the mucus up the airway into the hypopharynx where the secretions are swallowed and digested. The lymphatics also Trachea serve to move trapped pathogens to the lymph nodes so the Bronchi immune system may deal with them. Mucous glands are seen Bronchiole through the lower airway to the level of the smallest bronchi; they are not seen in the alveoli. At the level of the carina, the lower airway splits into the two mainstem bronchi—called the right mainstem bronchus and left mainstem bronchus. The two bronchi are angulated equally until age 3, when the right mainstem bronchus becomes more acutely angled. This acute angle predisposes endotracheal tubes, suction catheters, and foreign bodies to enter the right mainstem bronchus. The right mainstem Carina bronchus is larger in diameter than the left and divides into three lobar bronchi. The left mainstem bronchus separates into two lobar bronchi. These lobar bronchi further subdivide into medium bronchi. The walls of the bronchi are similar in structure and function to the walls of the trachea. They are composed of the same layers with equivalent functions. The posterior (non-cartilage containing) portion of the bronchial wall has its attachment points within the ring of cartilage rather than attaching the ends of the cartilage rings; during inspiration, the posterior wall of a bronchus will collapse further into the lumen than the posterior wall of the trachea does. At the level of the medium bronchi, the rings of cartilage become plates of cartilage that allow for a more symmetric contraction of Alveoli the airway lumen. At a diameter of less than 0.8 cm, the bronchi are called bronchioles. At less than 0.6 cm, the cartilage plates disappear as well, leaving structures held open only by elastic fi bers and the muscles of the bronchial walls. Although the muscles Figure 20-7 Lower airway anatomy. continue to thin out as the airway diameter decreases, they do so at a slower rate than the rate at which the airway diameter decreases. Therefore, the muscles of the terminal bronchioles to the pharynx. The carotid arteries are the major suppliers of are proportionately larger compared with the diameter of the blood to the brain while the internal jugulars return most of airway. They are more capable of closing off the airway when the cerebral blood to the heart. Bleeding from these structures bronchial spasm occurs than are the muscles of the larger can result in signifi cant deformity of the airway. Additionally, bronchioles or bronchi. injury to the carotids compromises blood fl ow to the brain A terminal bronchiole ends in the acinus, or a sac-like part and can result in cerebral hypoxia or anoxia. of the lung supplied by a single terminal bronchiole. Alveoli The trachea is a conduit for respiratory gasses. In an adult, may branch off of the bronchiole at this level. However, it is 10 to 20 cm long and 1 to 1.5 cm in diameter. Its superior the ends of the terminal bronchioles are the alveolar ducts attachment is the cricoid ring (level of the 6th cervical vertebrae) that open into the alveolar air sacs. The alveolar sacs open and it terminates at the carina (level of the 5th thoracic into large collections of alveoli (single units being called vertebrae) (Figure 20-7). The cartilage rings of the trachea are alveolus). This large collection of smaller sacs provide a incomplete, with the posterior element void of cartilage and larger surface area for gas exchange than if the lung were composed of muscle and elastic fi bers.5 The muscles of the made up of a single large sac (Figure 20-8). Although the trachea include an inner circular layer and an outer longitudinal trachea is the largest lower airway structure and the alveoli layer. The walls of the trachea (and the bronchi) are composed the smallest, each successive airway structural level (main 360 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the
right to remove additional content at any time if subsequent rights restrictions require it. Exhaled CO Inhaled O 2 of the thorax consist of the thoracic vertebrae, the rib cage, 2 the sternum, the clavicles, and the scapulae (Figure 20-9). Entering The clavicles and scapulae are not directly responsible for capillary Leaving ventilation but serve as accessory anchoring points for either with CO2 capillary accessory muscles or for muscles that support the rib cage. with O2 The thoracic vertebrae are articulation points for the 12 ribs and form the posterior bony border of the thoracic cavity. The thoracic vertebrae typically do not move during respiration. The exception to this occurs during highly active breathing when an individual leans forward during expiration and then extends the spine and stands straight during inspiration. The ribs, however, do move and articulate with the transverse processes of the thoracic vertebrae. The sternum is a dagger- shaped bone that attaches to the clavicles and the ribs. It is the anterior-most bony structure of the thorax and provides structural support to the ribs during respiration. The rib cage is the primary bony structure of respiration. Composed of 12 matched pairs of curved bones, the rib cage acts to protect the thoracic structures and serves as the fulcrum for the intercostal muscles of respiration. The ribs are numbered 1 through 12 and articulate posteriorly with their similarly numbered thoracic vertebrae. Anteriorly, the ribs are attached to the sternum by the costal cartilages. Ribs 1 to 7 are considered “true” ribs in that each has its own Figure 20-8 An acinus is composed of many costal cartilage that attaches it to the sternum. Ribs 8 to 12 alveoli and is surrounded by a capillary bed. This are considered “false” ribs. Ribs 8, 9, and 10 are attached to is where the exchange of oxygen and carbon the sternum through a common costal cartilage; the cartilages dioxide occurs. from each of the rib tips merge into a single cartilage that is attached to the sternum. Ribs 11 and 12 are called “fl oating ribs” because, although they are attached to other ribs via the bronchi, lobar bronchi, etc.) increases the number of struc- intercostal musculature and serve in respiration, they only tures and, with it, the cross-sectional area of the airway. articulate posteriorly on the thoracic vertebrae and are not Therefore, with 500 million alveoli in the average adult lung, directly attached to the sternum via a costal cartilage.6 the cross-sectional area of the alveoli is 350 thousand times The muscles of respiration can be divided into the principal greater than the cross-sectional area of the trachea. This high and accessory muscles of inspiration and the active muscles cross-sectional area allows for massive gas exchange, which of expiration. During quiet breathing, without pathologic occurs by diffusion. The surfaces of the alveoli are covered with surfactant, a fl uid that decreases the alveoli’s surface tension and prevents them from collapsing during expiration. The surfactant holds the alveoli open and prevents atelectasis (collapse of the alveoli and loss of gas exchange surface). Premature infants and drowning victims who aspirate water may have inadequate Sternocleidomastoid surfactant to prevent atelectasis, leading to signifi cant hypoxia muscle and ventilatory failure. The remainder of the lungs not occupied by the airway Apex of lung Upper lobe structures and blood vessels (the lung parenchyma) is right lung Upper lobe composed primarily of structural support and immune left lung structures. The supporting structures are important during the Middle lobe mechanical act of respiration. right lung Lower lobe Bony Thorax Anatomy Sternum left lung Base of Lower lobe lung The bony anatomy of the thorax not only provides protection right lung to the thoracic organs and major blood vessels, but also Diaphragm produces the air pressure difference responsible for air movement in and out of the respiratory system. The bones Figure 20-9 The bony thorax. Airway Anatomy and Physiology 361 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. derangement, the principal muscles of inspiration drive bag. Since the bottle is on the outside of the bag, there are inspiration while passive recoil of the chest wall and lungs two layers of the bag underneath the bottom of the bottle. If drives expiration. During active breathing (e.g., with heavy the bag is then lifted up around the bottle, there will be two activity or disease), the accessory muscles of inspiration are layers of garbage bag all around the bottle. Finally, the bag is recruited, as are the active muscles of expiration. Knowledge collected at the neck of the bottle and attached with a rubber of the normal muscles of quiet breathing is critical to band. The end result is a bottle inside of a two-layered bag. understanding respiratory physiology (Figure 20-10). The layer of the bag against the plastic bottle represents the One muscle and a major muscle group contribute visceral pleura and the outside layer of plastic represents the to inspiration. The fi rst and largest muscle involved in parietal pleura. The sealed area at the neck of bottle represents inspiration is the diaphragm. This large, thin, dome-shaped the way the pleura seals against the bronchi as they leave the muscle divides the abdomen from the thorax. At rest, the lungs. In the body, the visceral and parietal pleura lie against diaphragm rises to the level of the 5th rib (approximately each other with a small amount of fl uid between them. This the level of the nipple). During inspiration, the diaphragm allows them to slide against each other but not to pull apart contracts and fl attens. Since the margins of the diaphragm from each other. are fi xed to the thoracoabdominal wall, contraction pulls the Under normal physiological conditions, the two pleural contents of the thorax inferiorly and pushes the abdominal layers are held together by the pleural fl uid and expand and contents inferiorly. Contraction of the diaphragm also assists contract as a unit. The space between the pleura is a “potential” the intercostal muscles to elevate the lower ribs. space because, under normal conditions, it does not exist. The second major muscle group involved in inspiration is However, excessive fl uid can build up between these spaces the intercostal group. The intercostal muscles are muscles that attach the ribs to each other. There are external and internal intercostals; the internal intercostals are further divided into interchondral (between ligaments) and intercostal (between bones) divisions. At rest, the ribs—attached anteriorly to the sternum and posteriorly to the thoracic vertebrae—tend to sag inferiorly and medially (Figure 20-11a). When the external intercostal muscles and the interchondral part of the internal intercostal muscles contract, they elevate the ribs in a motion similar to that of a bucket handle (Figure 20-11b). Functionally, when this happens in the rib cage, the volume of the rib cage increases. The chest wall interacts with the lung parenchyma via the pleura (Figure 20-12). The easiest way to visualize the pleura is to think about standing a bottle up on a fl at garbage Inhalation Figure 20-11 a-b Rib movement. (a) Full Scalene muscles exhalation position. (b) Full inhalation. elevate 1st and 2nd ribs Inferior part Visceral of sternum pleura moves anteriorly External intercostal Parietal muscles elevate ribs pleura Diaphragm moves inferiorly during contraction Figure 20-12 Pleural layers against the organs Figure 20-10 Muscles of respiration. (visceral pleura) and chest wall (parietal pleura). 362 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. during various disease states (e.g., heart failure) and air can of the conducting airways. Gas exchange does not occur in potentially enter the space (e.g., during chest trauma). When the conducting airways, hence the term “dead space.” The the pleural layers separate, they no longer function as a unit. anatomic dead space is typically 150 mL in the average adult This disrupts the pleural layers’ ability to generate an adequate male. There is also a physiologic dead space, which is the negative pressure during inspiration, thus reducing lung volume of the lungs not eliminating carbon dioxide; in certain volumes and creating a sensation of diffi culty breathing. disease states (e.g., pneumonia, congestive heart failure (CHF), pulmonary embolus, chronic obstructive pulmonary Respiratory Physiology disease (COPD), atelectasis, etc.) this volume may be greater than the anatomic dead space.8 Understanding the anatomy of the airway and respiratory Capacities are another way of describing the lungs’ system only tells half of the story. Knowledge of the respiratory volumes. Total lung capacity is the sum of the residual physiology, or the function, of the respiratory system allows volume, the expiratory reserve volume, the tidal volume, and the the Paramedic to understand the effects disease has on the inspiratory reserve volume. It is a measure of all of the airspace patient, the effects treatments have on the patient, and ways volume in the lungs with the potential to exchange carbon to troubleshoot the process when the patient does not respond dioxide. The total lung capacity can be broken down into smaller as expected. capacities. The vital capacity is a measure of the maximum volume that can move through the lungs in a single respiratory Lung Volumes and Capacities cycle and equals the inspiratory and expiratory reserve volumes Physiologically, the lung can be divided into several plus the tidal volume. The inspiratory capacity equals the tidal components. The measurements of lung volumes and capaci- volume plus the inspiratory reserve volume and is a measure ties (Figure 20-13) are important to facilitate descriptions of the maximum air that can be inspired. The air that remains of the physiologic occurrences during respiration. The total in the lungs at the end of expiration of the tidal volume is the lung volume is divided into a number of volume subsets. functional residual capacity and equals the expiratory reserve The fi rst, and most important, volume is the tidal volume. volume plus the residual volume.9 This is the volume of a normal breath and is approximately Minute ventilation measures the total volume of gas that 5 to 7 cc/kg of ideal body weight.7 During exercise or certain passes through the lungs in a minute. It equals the respiratory pathological situations, a greater volume—the inspiratory rate (RR) times the volume per breath (Tidal Volume, or reserve volume—is used. This is the maximum volume that TV). Normally, the volume per breath is the tidal volume. can be inspired above the tidal volume. The maximum volume Therefore, the standard formula for minute volume is RR that can be expired beyond the tidal volume is the expiratory TV9 (Figure 20-14). However, when other lung volume subsets reserve volume. Any air left in the lungs after the expiratory are used (e.g., inspiratory and expiratory reserve volumes) reserve volume is exhaled is the residual volume and cannot or the patient is breathing breaths that are smaller than tidal be exhaled; it refl ects the smallest possible airspace volume volume breaths, the volume per breath will change and thus based on the anatomy of the lungs. change the minute ventilation. Calculating minute ventilation Alveolar volume is the volume of air in the alveoli. In becomes important when determining the rate and volume at the average adult male, this volume is 350 cc and refl ects which a patient should be ventilated. the volume of air available for gas exchange. The fi nal Minute alveolar ventilation takes into account anatomic volume is the anatomic dead space, which is the volume dead space (Figure 20-14). It is calculated by subtracting (VC) (TLC) (IC) Inspiratory Reserve Volume (IRV) IRV Tidal Volume (VT) VT (FRC) Expiratory Reserve
Volume ERV (ERV) Residual Volume RV (RV) Figure 20-13 Lung volumes. Airway Anatomy and Physiology 363 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Vital Capacity Total Lung Capacity Functional Inspiratory Residual Capacity Capacity RR × TV = Minute Ventilation the thorax. The parietal pleura is attached to the expanding structures and so increases in volume as well. Since the parietal and visceral pleura are functionally attached under BV − DS × RR = Minute Alveolar Ventilation normal conditions, the expanding parietal pleura pulls the Figure 20-14 Minute ventilation and minute visceral pleura along with it. Being attached to the exterior of alveolar ventilation. the lung parenchyma, the expanding visceral pleura expands the parenchyma and, through the network of connective tissue structures, pulls open the alveoli. The alveoli are connected to the external atmosphere via the lower and upper airways. Just as increasing the volume inside a syringe by pulling back the plunger creates a suction which pulls in air or medication, air is also pulled into the alveoli when their volume increases. Air fl ows from a higher pressure to a lower pressure and fi lls the vacuum in the expanding alveoli with air. In this way, inspiration of fresh respiratory gasses occurs. The volume of gas inspired from contraction of the diaphragm (primarily) and the intercostal muscles during resting ventilation is the tidal volume. As the lungs expand during inspiration, special sensory nerves called stretch receptors begin to fi re and, via the vagus nerve, inhibit further inspiration. This action is called the Hering-Breuer refl ex. Expiration during quiet breathing is the result of the passive recoil of the lung parenchyma and of Figure 20-15 Paramedic measuring peak fl ow in the chest wall. As these structures collapse, air simply fl ows a patient. out of the airspaces until the interthoracic pressure equals the atmospheric pressure. This is similar to what happens to an infl ated balloon when the neck is released; the elastic recoil of the balloon forces the air out into the environment. the dead space from the volume per breath and multiplying This elastic recoil is the expiratory component of the tidal the result times the respiratory rate ([Breath Volume – Dead volume and leaves the functional residual capacity in Space] RR). This calculation becomes important as various the lungs. devices such as endotracheal tubes, face masks, end-tidal High volume, active respiration (e.g., during illness, carbon dioxide detectors, or ventilator circuits are added. exercise, or other periods of high respiratory drive) uses These devices all increase the dead space. the accessory muscles of respiration. The accessory mus- While the capacities of the lungs and dead spaces are cles include the sternocleidomastoid muscle and scalenes important, equally important is the fl ow of gasses through (Figure 20-16). The sternocleidomastoid muscle elevates the structures. One of the most important fl ows is the peak the sternum and the scalenes elevate and hold in place the expiratory fl ow, or maximum velocity of gas movement upper ribs.11 Furthermore, the action of the intercostal during exhalation (Figure 20-15 and Skill 20-1). Many diseases restrict the fl ow of gasses during exhalation. Peak fl ow measurement can be used in the prehospital environment in to assess an asthmatic patient’s response to treatment.10 Scalene Sternocleidomastoid For a step-by-step demonstration of Peak Flow Trapezius Measurement, please refer to Skill 20-1 on page 371. Pectorialis The Bony and Muscular Thoracic Internal major inter- Structures and the Pleura costals Normal respiration occurs through a process of negative pressure, or vacuum, ventilation. Air moves into the lungs by the creation of a vacuum at the level of the alveoli. The structures Abdom- responsible for this vacuum are the bony and muscular structures inal of the chest wall, the diaphragm, and the pleura. muscles At the end of expiration, the air pressure in the alveoli is essentially atmospheric pressure. When the principal muscles Figure 20-16 Accessory muscles of inspiration of inspiration contract, they increase the external volume of and expiration. 364 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. muscles becomes more pronounced, resulting in “intercostal retractions” in which the musculature pulls in and the ribs become more pronounced and visible. Although the use of accessory muscles is effective in increasing minute ventilation by increasing the volume of the thorax, involving the accessory muscles in respiration is very tiring. Patients with minimal reserve energy may rapidly decompensate. Just as there are situations in which inspiratory reserve volume must be recruited, so too are there times in which active expiration must occur. During exercise or when expiratory airfl ow is obstructed (e.g., asthma, COPD exacerbation), the muscles of expiration may be recruited to increase the expiratory airfl ow above what can be accomplished through passive expiration. The muscles Intrathoracic pressure of expiration can be divided into two groups: the thoracic Preload muscles of expiration and the abdominal muscles of expiration (Figure 20-16). The thoracic expiratory muscles Cardiac output are the intercostal parts of the internal intercostals. When the intercostal parts of the internal intercostals contract, Figure 20-17 Effects of normal and positive they pull the ribs down and together, causing the rib cage to pressure ventilation on the circulatory system. collapse. This decreases thoracic volume and forces air out of the lungs.11 The abdominal muscles are also important for active expiration. The rectus abdominis, external obliques, internal Neurological Control of Breathing obliques, and transversus abdominus muscles perform Although the process of breathing is essentially involuntary, two major expiratory functions. First, they depress and there is a voluntary component as well. Differentiating anchor the lower ribs, which assist the thoracic expiratory between the two components assists the Paramedic in muscles to collapse the rib cage. Second, they compress the recognizing abnormal ventilation and considering possible abdominal contents and lower the intraabdominal volume. causes. This contraction causes the abdominal contents to push up on Sensory information comes from stretch receptors in the the diaphragm, further lowering the intrathoracic volume.11 lungs, the partial pressure of carbon dioxide in the bloodstream, Although the muscles of expiration are used much less the partial pressure of oxygen in the bloodstream, muscle frequently than the muscles of inspiration, they are effective spindle fi bers, and proprioceptors (position sensors) and in improving expiratory airfl ow. stretch sensors in the tendons and joints. Of these, increasing It is important to recognize that there are cardiac carbon dioxide is the greatest stimulus for ventilation in most implications of negative pressure ventilation. When the patients. All of the signals are processed in the brainstem and intrathoracic pressure decreases, the pressure in the vena modifi ed by the cortex. Primitive, involuntary control occurs cava and right atrium decreases, increasing venous return. in the medullary respiratory center of the medulla oblongata Therefore, during normal inspiration, venous return—and (the brainstem) with major nerve input from the vagus nerve. therefore preload—increases. When a patient receives There is an inspiratory center and an expiratory center of positive pressure ventilation, either during intubation or the medulla oblongata. The inspiratory center is responsible bag-valve-mask ventilation, intrathoracic pressure remains for inspiration and regular, rhythmic ventilation. There are positive during the entire respiratory cycle (Figure 20-17). As a number of nerve inputs; output from this group is via the a result, venous return—and therefore preload—decreases, phrenic nerve (from the 3rd, 4th, and 5th cervical nerve roots) resulting in a loss of cardiac output and blood pressure. to the diaphragm.9 Air trapping and hyperventilation also cause an increase in The expiratory center (the ventral respiratory group) is intrathoracic pressure, producing a potential drop in blood not normally active. It is responsible only for active expiration pressure in patients with borderline or poor cardiac function. and therefore stimulates abdominal wall musculature and the Additionally, the positive pressure in the lungs can increase intercostal parts of the internal intercostals. pulmonary vascular resistance and right ventricular afterload, Several chemicals act as stimuli for respiration. Carotid further exacerbating right heart failure. It is important to sinus and aortic arch chemoreceptors monitor carbon dioxide consider the hemodynamic effects of positive pressure levels in the blood. Additionally, chemoreceptors monitor ventilation when ventilating a patient. In general, patients the cerebrospinal fl uid for carbon dioxide, oxygen, and pH should be ventilated at a slower rate and with a slightly levels. Although carbon dioxide is the major determinant smaller volume than physiologic respiration to avoid the of respiratory drive, hypoxia is also a powerful stimulus to hemodynamic effects of overventilation. breathe. For some individuals with diseases that chronically Airway Anatomy and Physiology 365 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. increase the carbon dioxide levels (e.g., COPD), hypoxia may apnea without a sensation of needing to breathe. In addition, be the predominant stimulus. The chemoreceptors exert their strong emotions, fever, and pain will increase respiratory effects through the medulla. rate. The body’s response to metabolic acidosis is to increase There are two other important involuntary respiratory the respiratory rate and lower the carbon dioxide level (such centers, both located in the pons. The fi rst is the apneustic center as Kussmaul’s respirations in diabetic ketoacidosis). that serves as a backup stimulus for inspiration. The second is Pregnancy increases minute ventilation. Some medi- the pneumotaxic center, which inhibits inspiration. This center cations and drugs of abuse increase respiratory rate while serves to control respiratory rate and inspiratory volume.9 others (e.g., opioids) will decrease respiratory rate. Sleep Finally, as previously mentioned, there are other also decreases the respiratory rate. For the vast majority important contributions to respiration, particularly from the of breathing, involuntary control by the medullary centers cerebral cortex. There is some degree of voluntary control predominates (Figure 20-18). over ventilation. In times of stress, it is possible to suppress respiration to the point of syncope from hypoxia. However, Oxygen and Carbon Dioxide without the control of the cortex, the medullary centers resume control of breathing during unconsciousness. Additionally, Metabolism the cortex controls hyperventilation, an activity that can raise Respiration is the process of exchanging gasses, specifi cally the blood content of oxygen and lower the blood content oxygen and carbon dioxide, between an organism and its of carbon dioxide, allowing extended periods of conscious environment. The two major subtypes of respiration are Voluntary control Pain Emotions Temperature + = Stimulus increases rate + – and depth of breathing – = Stimulus decreases rate and depth of breathing Central Pons – chemoreceptor Respiratory center (↑CO2) + + + + Receptors in muscles – and joints + + + Irritant reflex Peripheral chemoreceptors (↓O2 ↑CO2 ↑H+ ↓pH) Hering-Breurer reflex External intercostal muscle Deflation reflex J-receptors Figure 20-18 Neurologic control of respiration. 366 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. external respiration, which is the exchange of gasses between 160 torr (Figure 20-19). Decreases in atmospheric pressure, the lungs and the red
blood cells, and internal respiration, such as could occur during an air medical transport, will which is the exchange of gasses between the red blood cells decrease the partial pressures of a gas. Therefore, if the total and cells that make up the various body tissues. The airway, pressure were decreased to one half atmospheric pressure lungs, respiratory structures, and circulatory system exist to (380 torr), the partial pressure of oxygen would be one half assure adequate delivery of oxygen to the tissues and removal of what it was at sea level (21% 380 torr = 80 torr) even of carbon dioxide to the atmosphere. if the percentage of oxygen remained the same (21%). This The mechanisms described previously act to deliver decreases oxygen delivery to the bloodstream. If the patient oxygen to the alveoli and expel carbon dioxide out to the were placed on supplemental oxygen that increased the FiO 2 atmosphere. The amount of oxygen available at the alveoli, to 0.6 (60%) at sea level, the partial pressure of oxygen would called the partial pressure of oxygen, depends on the total increase to 456 torr, thus increasing the amount of oxygen atmospheric pressure and fraction of inspired oxygen, delivered to the bloodstream. Partial pressures, therefore, are abbreviated FiO . Room air, regardless of the atmospheric more important than percentages of the gas in determining 2 pressure, is made up of approximately 78% nitrogen, 21% how much oxygen will transfer from the alveoli to the oxygen, and 1% assorted other gasses. The concentrations of bloodstream and, ultimately, to the tissues. alveolar gasses, after dilution and humidifi cation, are 75% The pulmonary artery exits the right ventricle and nitrogen, 13% oxygen, 5% carbon dioxide, 6% water, and divides into smaller and smaller subdivisions. Eventually, less than 1% other gasses. The inspired FiO of room air is large capillary networks form over the surface of the alveoli. 2 21/100. Since FiO is typically expressed as a decimal, room Small amounts of interstitial fl uid and the very thin, highly 2 air FiO is 0.21. Placing a patient on a high fl ow oxygen permeable walls of the alveoli allow for rapid diffusion of 2 delivery device (e.g., a nonrebreather mask can increase the respiratory gasses from areas of high concentration to areas of percentage of inspired oxygen to between 80% and 100%. If a low concentration (Figure 20-20). In the case of carbon dioxide person breathes 100% oxygen, then the FiO is 100/100, or 1. (a waste product of metabolism), the highest concentration 2 A FiO of 1 is the highest FiO that can be delivered, because is in the pulmonary artery and the blood arriving at the 2 2 it means that all of the inspired air is composed of oxygen. capillaries. The inspired air (and therefore the air in the alveoli) The closer the FiO is to 1, the more oxygen is available at the has a much lower concentration of carbon dioxide. Therefore, 2 alveoli to diffuse into the blood. carbon dioxide diffuses from the bloodstream to the alveolar The concept of partial pressure is another factor in space. Conversely, oxygen is at its lowest concentration in determining the amount of oxygen available to the tissues. the blood arriving from the pulmonary artery (having been Normal atmospheric pressure at sea level is 760 torr (centi- used by the body during metabolism) and is at a much lower meters of water) and each gas in air makes up a percentage of that total amount, or total pressure. This is termed partial pressure (Figure 20-19) and is calculated by multiplying the air pressure by the fraction of that gas in the air. For example, to calculate the partial pressure of oxygen in room air at one atmosphere, multiply 0.21 (the FiO ) by 760 torr (atmospheric 2 Terminal brachiole pressure at sea level) to get a partial pressure of oxygen of CO O O 2 2 2 CO2 O2 O2 CO2 Room Air at Sea Level O2 CO2 O2 Alveoli atmospheric pressure : 760 torr O CO2 CO2 2 O O FiO2 21% : 0.21 2 2 Partial Pressure Oxygen 160 torr O2 O2 O2 O2 Room Air at Altitude CO2 atmospheric pressure : 380 torr O2 FiO2 21% : 0.21 CO2 CO2 Partial Pressure Oxygen 80 torr CO2 CO2 Capillary bed Supplemental Oxygen at Sea Level CO2 atmospheric pressure : 760 torr FiO2 60% : 0.60 Figure 20-20 Diffusion of oxygen and carbon Partial Pressure Oxygen 456 torr dioxide across the alveolar membrane occurs because of the concentration gradient across Figure 20-19 Partial pressure of gasses. the membrane. Airway Anatomy and Physiology 367 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. concentration than in the air in the alveoli. Therefore, oxygen Pediatric Anatomy will diffuse from the alveoli into the bloodstream. In this way, The most important differences between pediatric and the major respiratory gasses are exchanged. adult airway anatomy are those of size and proportions. If oxygen simply dissolved into the blood, only small One of the most challenging differences between adult amounts of oxygen could be carried at a time. Therefore, a and pediatric airway management is that pediatric patients more effi cient method of carrying oxygen is necessary. This are simply smaller. Smaller spaces, smaller patients, and a method uses hemoglobin, a large molecule in red blood cells requirement for more precision in action all combine to make that is intended to carry oxygen from the alveoli to the tissues the management of these patients potentially more diffi cult. (and, to a lesser degree, to carry carbon dioxide back to the The relative proportions of various structures are also alveoli). Approximately 97% of the oxygen carried in the important. These different proportions result in differences blood is bound to hemoglobin; the rest is dissolved directly in management and technique between adult and pediatric into the plasma. Usually all of the systemic arterial hemoglobin patients. However, these differences do not necessarily make is carrying oxygen and is therefore saturated with oxygen. pediatric airway management more diffi cult; it is simply Devices such as a pulse oximeter can measure the percentage different. For the experienced Paramedic, the pediatric airway of hemoglobin that is carrying oxygen. In healthy individuals, may be easier to manage than the adult airway; the key is oxygen saturation is typically 98% or greater. Arterial pressure the degree of familiarity with the structures, proportions, and of oxygen, PaO , is a measurement of the amount (pressure) 2 equipment. Therefore, an understanding of the anatomical and of oxygen in the blood. In a healthy adult breathing room air, proportional differences, as well as experience in pediatric the PaO will be between 80 and 100 cm water. 2 airway management, is critical in making the provider Carbon dioxide (CO ), produced by the tissues 2 comfortable with pediatric airway management. Table 20-1 during metabolism, is returned to the alveoli for disposal. summarizes the anatomical differences in pediatric patients. Approximately 33% of CO is attached to hemoglobin. The 2 The most obvious difference between pediatric and adult rest is either dissolved in the blood or combines with water to patients is size. However, it is probably the relative proportions form bicarbonate ions. These release the carbon dioxide when that are most important. A pediatric patient’s head, when they reach the alveoli. The arterial pressure of carbon dioxide compared to his body, is disproportionately larger than an (PaCO ) is the measure of carbon dioxide in the blood and is 2 adult’s head. This is due to the more protuberant pediatric normally 35 to 45 mmHg. occiput.12 Therefore, when a pediatric patient is in a supine Numerous disease states can affect the amounts of position, the protuberant occiput will tend to fl ex the neck oxygen and carbon dioxide in the blood. Lowered atmospheric and compress airway structures, resulting in turbulence and concentrations associated with partial pressures of oxygen increased resistance to airfl ow. As mentioned, the child’s airway and lowered hemoglobin concentrations both decrease the is smaller, so even a small degree of obstruction can signifi cantly total amount of oxygen in the blood. Decreased surface area affect the pediatric patient’s oxygenation and ventilation. for exchange such as occurs in trauma (e.g., hemothorax, Advancing into the oropharynx, a child’s tongue is pneumothorax, pulmonary contusion) and medical diseases disproportionately larger compared to the oral cavity than (e.g., COPD, pneumonia, effusions, atelectasis, CHF with an adult’s tongue. In addition, the tonsils and adenoids are pulmonary edema, etc.) will decrease the amount of oxygen disproportionately large and the mucosa over them and the reaching the tissues. Also, decreased mechanical effort—such entire pharynx is more friable, or fragile. When traumatized, as occurs with head injuries, strokes, overdoses, and pain— these structures tend to bleed. Therefore, precision in blade will decrease the available oxygen. Carbon dioxide levels are primarily controlled by ventilation. Therefore, PaCO will rise with hypoventilation and 2 fall with hyperventilation. Although some metabolic processes Table 20-1 Differences Between Pediatric can increase production of carbon dioxide, the lungs typically Airway Anatomy and Adult Airway Anatomy do an excellent job of compensating for these changes. • More pronounced occiput, fl exing head and neck when supine on a fl at surface Pediatrics • Proportionately smaller airway diameter • Proportionally larger tongue, tonsils, and adenoids Although there are signifi cant differences between adult and pediatric patients—which are refl ected in some changes in • More friable mucosa practice and equipment—the fundamental anatomy and • Floppier and posterior sloping epiglottis physiology are the same. The same structures exist in both • Larynx position more anterior and toward head the adult and the pediatric airway and the ultimate purpose— • Vocal cords pinker and angled toward feet exchange of respiratory gasses—remains the same. Therefore, • Airway smallest at level of cricoid cartilage with the previous discussion of adult anatomy and physiology • Trachea angled anterior and shorter in mind, this section will focus on the major differences • More susceptible to gastric distention between adult and pediatric patients. 368 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. placement, care in movement of the devices and equipment in pediatric patient should be ventilated with smaller pressures in the mouth, gentle pressure, and control of the tongue are all an effort to minimize gastric infl ation. Decompression of the critically important in the management of the pediatric airway. distended stomach will signifi cantly improve the respiratory Moving deeper into the hypopharynx, there is a much mechanics and should routinely be performed on any child more acute angle from the pharynx to the epiglottis. The who has received positive pressure ventilation. epiglottis is also “U” shaped and less rigid as the cartilage has not fully matured.13 This immaturity also causes the epiglottis Physiology to slope more posteriorly, potentially obscuring the view of Four major physiologic differences between adults and chil- the glottis. dren are of signifi cance to ventilation and airway management. At the level of the larynx, the fi rst recognizable difference The fi rst of these relates to the nature of respiratory distress, is the position. At birth, the tracheal opening lies at the level respiratory failure, and cardiovascular collapse in pediatric of the fi rst cervical vertebrae (C-1). By ages 5 to 7, relative patients. Multiple disease processes affect the basal metabolic differences in structural growth rates have moved the glottic rate and respiratory status of children. The common pathway opening to the C-3 to C-4 level, and by adulthood,
the glottis to morbidity and mortality for many of these diseases is rests at the C-5 level.14 On laryngoscopic view, therefore, respiratory failure. Initially, pediatric patients are able to the glottis will be signifi cantly closer to the oropharynx and compensate for increasing respiratory demands. However, will be in a relatively more anterior position than would be their dependence on the diaphragm for almost all inspiratory expected in an adult. effort, their ability to recruit intercostal and accessory mus- Examining the laryngeal opening, a number of differ- cles, and the immaturity of the accessory musculature puts ences are noted. The arytenoids are disproportionately large pediatric patients at risk to tire rapidly. Therefore, these and are thus more prominent. The vocal cords are pinker and patients decompensate quickly. By the time a pediatric more diffi cult to differentiate from the surrounding tissue. In patient goes into respiratory failure, most of his metabolic addition, the cords are angled toward the feet anteriorly and and oxygen reserves are depleted.15 Secondary cardiovascular toward the top of the head posteriorly, sloping upward from the collapse, which is often irreversible, is likely to occur. This front of the child toward the back. This is different from adult ability to initially compensate and then rapidly and irreversibly vocal cords that tend to be on the same plane from front to decompensate is a hallmark of pediatric respiratory failure. back and creates the perception that the space is signifi cantly Table 20-2 summarizes the differences between pediatric smaller. These anatomic differences can be striking the fi rst respiratory physiology and adult respiratory physiology. time a Paramedic visualizes the pediatric larynx. At the level of the thyroid cartilage, another important difference is noted. The cricothyroid membrane is propor- tionately smaller in children and is almost nonexistent in Street Smart infants. Up to age 10, it is diffi cult to identify the cricothyroid membrane by palpation. The cricoid ring is also different in By the time a pediatric patient is in respiratory failure the pediatric patient. In the adult airway, the vocal cords are the and cardiovascular collapse, it may be very diffi cult narrowest point in the upper airway. For the pediatric patient, the cricoid ring has the smallest cross-sectional area. This to reverse the process. Early recognition of subtle makes the larynx and trachea funnel-shaped. An endotracheal signs (e.g., agitation, grunting, tripod positioning, tube that is introduced into the airway, therefore, may pass retractions, etc.) of respiratory distress and rapid the vocal cords without a problem but may have diffi culty intervention are necessary to prevent respiratory passing the cricoid ring. Aspirated foreign bodies may also lodge at this point. failure and the ensuing cardiovascular collapse. There are also signifi cant differences in the trachea itself. Compared to the adult trachea, the pediatric trachea is angled much more anteriorly as it travels inferiorly. In addition, the Table 20-2 Differences Between Pediatric trachea is proportionately shorter and there is signifi cantly Respiratory Physiology and Adult Respiratory Physiology less distance between the vocal cords and the carina. Minimal head movement in the pediatric patient can result in signifi cant • Respiratory failure is primary cause of death in pediatric patients displacement of the tip of an endotracheal tube. compared to cardiovascular failure in adults. One other important anatomic difference related to • Pediatric patients decompensate rapidly. management of the pediatric airway actually relates to the • Pediatric patients have proportionately higher oxygen consumption pediatric gastrointestinal tract. Pediatric patients are much than adults. more susceptible to gastric distention during positive pressure • Pediatric patients have a smaller residual capacity than adults. ventilation. Pediatric patients are less able to tolerate gastric • Increased vagal tone in pediatric patients causes bradycardia. distention due to their smaller lung volumes and their • Hypoxia in pediatric patients causes bradycardia. dependence on the diaphragm for respiration. Therefore, the Airway Anatomy and Physiology 369 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. A second important metabolic difference between in a similar clinical context and more likely to suffer early children and adults relates to oxygen consumption. For their hypoxic injuries. size, pediatric patients consume more oxygen. Their basal Finally, pediatric patients have the potential for high vagal metabolic rate is, by body surface area, signifi cantly higher tone. Minimal airway stimulation can result in excessively high than an adult’s and basal oxygen consumption per square vagal response including bradycardia and asystolic cardiac meter can be twice as high as that of an adult.16 Therefore, arrest. This includes stimulation from a laryngoscope blade. they become hypoxic rapidly during respiratory failure. Pediatric patients tend to have copious secretions, increasing The third difference is that, for their size, pediatric the risk for aspiration and diffi culty maintaining an airway. patients have a disproportionately smaller functional residual Therefore, administration of appropriate vagolytic medications capacity. Thus, in times of respiratory distress, children are (e.g., atropine) before airway management is critical. less able to draw upon this capacity to provide supplemental It is important to note, however, that pediatric patients ventilation. Furthermore, in times of apnea, the pediatric will also become bradycardic when hypoxic. Therefore, patient will become hypoxic up to twice as quickly as an rapid differentiation between hypoxia and excessive vagal adult.17 Therefore, pediatric patients are more likely to tone is critical when a pediatric patient in respiratory distress progress to respiratory failure faster than an adult would becomes bradycardic. 370 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Skill 20-1 Peak Flow Measurement 1 Position patient seated upright. 2 Reset indicator. 3 Instruct patient to inhale as deeply as 4 Instruct patient to tightly wrap mouth possible. around mouthpiece. 5 Instruct patient to exhale as fast as 6 Read indicator. possible. Airway Anatomy and Physiology 371 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The fi rst step Paramedics require to achieve effi cient, safe, and effective airway and ventilation management in their patients is to be familiar with normal airway anatomy and respiratory physiology. By being knowledgeable about these topics, the effective Paramedic can recognize abnormal fi ndings and troubleshoot failures in the management of an airway or ventilation. Key Points: • The airway is divided into upper and lower regions. • The head-tilt chin-lift or jaw thrust maneuvers The upper airway begins at the nares and mouth open an airway by fi rst lifting up the hyoid bone via and extends to the glottis. The lower airway anterior mandibular displacement. extends from the glottis to the alveoli. • The larynx is made up of a number of cartilaginous • The mouth and nose both defi ne the beginning of structures including the thyroid cartilage and the airway. The nose serves as an immunological the aryepiglottic folds that contain the arytenoid barrier, a source of warming and humidifying air, cartilages. and a threat/food detection system. • The “Adam’s apple,” formed by thyroid cartilage, • The pharynx is the area of the airway composed of is the large, anterior shield-like cartilage that the spaces behind the nose (nasopharynx) and the forms the majority of the anterior portion of the oral cavity (the oropharynx). larynx. • The oral cavity is bound by the lips anteriorly, the • The open space superior to the vocal cords is the buccal surfaces laterally, the tongue inferiorly, vestibule. Folds in the vestibular membrane form the hard palate superiorly, and the soft palate the false cords that can seal over the glottis to posteriorly. help protect the airway from aspiration of foreign • Food and respiratory gasses move through the oral materials. cavity and tonsillar pillars that form the walls of • The vocal cords are composed of mucosal folds the oral pharynx. These structures serve as an overlying ligaments, cartilages, and muscles. As immunological barrier to pathogen entry in the a part of the cricothyroid ligament, the vocal pharynx. ligaments form the true vocal cords that are visible • When performing airway management procedures at the bottom of the vestibule. the Paramedic should be aware of the high risk of bleeding due to vascularized mucous membranes • Vocal cords are responsible for the production as well as the risk of swelling or occlusion caused of speech and sound as well as protection of the by oral infections. airway. • The epiglottis protects the lower airway from • A number of stimuli can trigger an involuntary foreign body aspiration. refl ex that causes the muscles to adduct the glottis and the false cords to provide an impenetrable • Airway obstruction in the obtunded patient is not barrier to foreign material. caused from the tongue falling posteriorly, but rather initially by the soft palate and the epiglottis • The cricoid ring, the only complete ring in the making contact with the posterior wall of the trachea, is located at the lowest portion of the oropharynx and pharynx. larynx and the beginning of the trachea. 372 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • The intrinsic and extrinsic laryngeal muscles • Exhalation is normally passive; however, active and their nerve supply found in the larynx are muscles of expiration are utilized during periods of responsible for the “gag refl ex.” inadequate exhalation. • The thyroid gland is a highly vascular, “H” shaped • Quiet breathing or normal inspiration is a function structure that lies along the side of the larynx and of principal muscles and passive exhalation. During upper trachea. active breathing, such as heavy activity, accessory • The common carotid artery and the internal jugular muscles may be used for inspiration and active veins are two sets of major vascular structures that muscles used for expiration. run parallel to the pharynx. • The diaphragm is a large, thin, muscle that divides • The trachea is the portion of the airway from the the abdomen for the thorax. cricoid ring to the carina. • The intercostal muscles attach the ribs to each • At the level of the carina, the lower airway splits other and are the major muscle group involved in into the two mainstem bronchi, the right and left. inspiration. The right mainstem bronchus divides into three lobar bronchi and the left mainstem bronchus • The chest wall is lined with the parietal pleura separates into two lobar bronchi. The right that lies against the outer lining of the lungs, the bronchus is more acutely angled and predisposes visceral pleura. A small amount of fl uid between the endotracheal tubes, suction catheters, and foreign two layers allows them to slide against each other bodies to enter more often than the left bronchus. but not pull apart. • As the bronchi decrease in diameter they become • During inspiration, principal muscles increase the bronchioles. The muscles in the bronchi and external volume of the thorax. The parietal pleura bronchioles are capable of
closing off the airway is attached to the expanding structures and, under when bronchial spasms occur. normal conditions, pulls the visceral pleura along • with it. The expanding visceral pleura expands the The end of the terminal bronchioles have the lung tissue, pulling open the alveoli. alveolar ducts that open into the alveolar air sacs where gas exchange occurs. • As the volume inside the alveoli increases, a lower • The fl uid surfactant that holds the alveoli open pressure is created inside the alveoli. by decreasing the surface tension of the alveoli • Lung expansion is controlled by stretch receptors prevents atelectasis (collapse of the alveoli). that inhibit further inspiration. Expiration is the • Determinations of lung volumes and capacities are passive recoil of the lungs and chest wall that forces important to facilitate descriptions of the physiologic air out until interthoracic pressure equals that occurrences during respiration. The most important atmospheric pressure. measurement to the Paramedic is the volume of air • Accessory muscles are used during high volume moved at normal breath or tidal volume. active respiration. Accessory muscles include the • Tidal volume multiplied by the respiratory rate is sternocleidomastoid muscles, the scalenes, and the equal to the minute ventilation which is important intercostal muscles. in determining at what rate of volume a patient • Thoracic expiratory muscles and abdominal muscles should be ventilated. may be used to decrease the thoracic volume and • The peak fl ow, or maximum velocity of gas force air out of the lungs in times of exercise or movement, can be used to assess a patient’s when expired airfl ow is obstructed. breathing, particularly in the assessment of asthmatic patients. • During normal inspiration the decrease in • intrathoracic pressure causes an increase in venous Normal respiration occurs through a process of blood return or preload. When a patient receives negative pressure ventilation. positive pressure ventilations preload may decrease • The muscles for inspiration can be divided into the due to intrathoracic pressure remaining relatively principal and accessory muscles. the same. Airway Anatomy and Physiology 373 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • Increasing carbon dioxide is the greatest stimulus for • Some oxygen and a large percentage of carbon ventilation in most patients, but sensory information dioxide are dissolved directly in the blood. comes from stretch receptors in the lungs. • Diseases that decrease the surface area for gas • Involuntary control of respirations occurs in the exchange can decrease the amount of oxygen in respiratory center of the medulla oblongata. the blood, which decreases the amount of available Sensory information is received from the vagus oxygen reaching the tissues. nerve and stimuli are sent out via the phrenic • Carbon dioxide levels are primarily controlled by nerve. The inspiratory center of the medulla is ventilation in response to changes in PaCO2. The responsible for inspiration and regular, rhythmic lungs can compensate for changes in CO2 through ventilation. The expiratory center is responsible increasing or decreasing ventilatory rates. only for active expiration when needed. • Differences between pediatric and adult airway • Chemoreceptors monitor carbon dioxide levels anatomy are those of size and proportions: in the blood and spinal fl uid. For patients with ■ A pediatric patient’s head, when compared to his diseases that chronically increase carbon dioxide body, is disproportionately larger than an adult’s. levels, hypoxia (oxygen defi ciency) may also be the ■ In the oropharynx, a child’s tongue is predominant stimuli to breath. disproportionately larger than an adult’s when • compared to the oral cavity. Located in the pons, the apneustic center serves as ■ The structures of the oral cavity are also more a backup stimulus for involuntary respiration and the fragile in pediatric patients than in adults. pneumotaxic center inhibits inspiration. Although it ■ In the hypopharynx of the pediatric patient, the is possible to suppress respirations, once the patient epiglottis may obscure the view of the glottis is unconscious medullary centers resume control. due to the shape and acute angle of the pharynx. • The two major subtypes of respiration are external ■ The tracheal opening is relatively more anterior respiration, which is the exchange of gasses and signifi cantly closer to the oropharynx. between the lungs and the red blood cells, and ■ Large arytenoids and pinker vocal cords that are internal respiration, which is the exchange of gasses set on an angle are further differences. between the red blood cells and cells that make up ■ The narrowest point in the pediatric airway is the various body tissues. not the vocal cords as found in adults, but the • cricoid ring. Room air is made up of approximately 78% nitrogen, ■ The pediatric airway is proportionally shorter 21% oxygen, and 1% assorted other gasses. The FiO2 and more anterior than the adult’s. of room air is expressed as a decimal, 0.21. ■ Pediatric patients have smaller lung volumes • Partial pressure of gasses is a factor in determining than adults. how much oxygen will transfer from the alveoli to ■ Pediatric patients depend on the diaphragm for the bloodstream and, ultimately, to the tissues. respiration. • Diffusion of respiratory gasses from a high • Pediatric patients are able to compensate for concentration to a low concentration occurs across increased respiratory demands but are at risk to tire the highly permeable wall of the alveoli. rapidly and decompensate quickly. • Diffusing from high to low concentrations, carbon • For their size, pediatric patients consume more dioxide diffuses out of the blood as oxygen diffuses oxygen than adults and may rapidly become hypoxic from the alveoli to the bloodstream. during respiratory failure. • Hemoglobin is a large molecule found in red blood • Consider hypoxia as the cause of bradycardia in a cells that carries approximately 97% of oxygen from pediatric patient. the alveoli to tissues. In addition, 33% of carbon • Airway stimulation may also result in bradycardia dioxide is attached to hemoglobin as the blood due to the potential for high vagal tone found in returns from the tissues to the alveoli for disposal. pediatric patients. 374 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. Describe the route an oxygen molecule takes 10. List the airway structures of the lower airway. from the oral or nasal cavities to the alveolar 11. Diagram the alveolar unit including the capillaries. pulmonary capillaries. 2. List three functions of the nares. 12. List the cell types found in the walls of the lower 3. Describe the anatomic “contents” of the airway structures. oropharynx. 13. Describe the bony and muscular structures of 4. Diagram the anatomy of the epiglottis, glottis, the chest wall. vocal cords, and esophagus as viewed with a 14. Name the structure most responsible for the laryngoscope. nervous system’s control of ventilation. 5. Describe the relationship of the hyoid bone to 15. Describe the two-layer nature of the pleura. the tongue and epiglottis. 16. List two stimuli for breathing and identify which 6. Name the most common cause of airway provides respiratory drive in most individuals. obstruction. 17. Describe how positive pressure ventilation 7. Differentiate between the “upper” and “lower” changes the normal intrathoracic pressure. airway. 18. List key anatomic differences in the pediatric 8. Diagram the relationship between the thyroid upper airway versus the adult upper airway. cartilage, the cricoid cartilage, the vocal cords, 19. List key anatomic differences in the pediatric and their associated structures. lower airway versus the adult lower airway. 9. List the differences between the cricoid ring 20. List differences in pediatric and adult and lower tracheal rings. respiratory physiology. Case Study Questions: Please refer to the Case Study at the beginning of the 3. How can changing the percentage of oxygen, or chapter and answer the questions below: FiO 2, and the partial pressure of oxygen increase 1. What structures are kept open by continuous the overall exchange of respiratory gasses? positive airway pressure (CPAP?) 4. Describe “work of breathing.” 2. Which of these structures exchange gasses? Airway Anatomy and Physiology 375 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. References: 1. Boerner TF, Ramanathan S. Functional anatomy of the airway. In: 10. Richmond NJ, Silverman R, Kusick M, Matallana L, Winokur J. Out Benumof JL, ed. Airway Management: Principles and Practice. of hospital administration of albuterol for asthma by basic life support St. Louis: Mosby; 1996. providers. Academic Emergency Medicine. 2005;12(5):396–403. 2. Williams P, Warwick R, Dyson M, et al. Gray’s anatomy (37th 11. Netter FH. Atlas of Human Anatomy. Summit: Ciga-Geigy; ed.). New York: Churchill Livingston; 1989:1248–1286. 1989:183. 3. Shorten GD, Opie NJ, Graziotti P, et al. Assessment of upper 12. Luten RC. The pediatric patient. In: Walls RM, ed. Manual of airway anatomy in awake, sedated, and anesthetized patients Emergency Airway Management. Philadelphia: Williams and using magnetic resonance imaging. Anesths Intensive Care. Wilkins; 2000:144. 1994;22:165. 13. Berens R, Day S. Airway management. In: Jaimovich D, 4. Netter FH. Atlas of Human Anatomy. Summit: Ciga-Geigy; Vidyasagar D, ed. Handbook of Pediatric and Neonatal Transport 1989:23–75. Medicine (2nd ed.). Philadelphia: Hanley and Belfus; 2002:174. 5. Netter FH. Atlas of Human Anatomy. Summit: Ciga-Geigy; 14. Luten RC. The pediatric patient. In: Walls RM, ed. Manual of 1989:167–199. Emergency Airway Management. Philadelphia: Williams and 6. Netter FH. Atlas of Human Anatomy. Summit: Ciga-Geigy; Wilkins; 2000:143. 1989:170–171. 15. Strange GR. (Ed.). APLS: The Pediatric Emergency Medicine 7. Guyton AC, Hall JE. Textbook of Medical Physiology (9th ed.). Course. (3rd ed.). Dallas: ACEP; 2000:3–15. Philadelphia: W.B. Saunders; 1996:481–485. 16. Markenson DS. Pediatric Prehospital Care. Upper Saddle River: 8. Costanzo LS. Physiology. Philadelphia: Williams and Wilkins; Prentice Hall; 2002:98. 1995:107. 17. Luten RC. The pediatric patient. In: Walls RM, ed. Manual of 9. Costanzo LS. Physiology. Philadelphia: Williams and Wilkins; Emergency Airway Management. Philadelphia: Williams and 1995:108–124. Wilkins; 2000:143. 376 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Public Health and the Paramedic 377 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Algorithms that provide a specifi c planned set of actions and decisions where the if-then decisions are made in advance • Ways the Paramedic utilizes an algorithmic approach to airway management • The fi ve criteria that determine how aggressive an approach to airway and respiratory management is needed • Disease processes encountered in the prehospital environment that can
cause a patient, the patient’s airway, or the patient’s respiratory status to deteriorate • An algorithmic approach to patients who initially cannot be ventilated • Airway management after a failed intubation attempt Case Study: The Paramedics were called to the intersection of Old State and Fish House Roads for a two-car MVC with signifi cant injuries. The driver of a pickup truck was out of the vehicle and on the ground 378 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. with the fi rst responding EMTs working to ventilate him. The man had serious facial trauma and the EMTs were unable to adequately ventilate him, as evidenced by poor chest rise. They asked the Paramedic what he planned to do. The Algorithmic Approach to Airway Management 379 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW As part of the ABCs of primary assessment, airway management is a critical component in treating life-threatening conditions. As opposed to protocols that detail treatments for a specifi c working diagnosis, an algorithm provides the Paramedic with a specifi c planned set of actions and decisions where the if this––then that decisions are made in advance. The Paramedic can utilize an algorithmic approach to airway management based on criteria that determine a patient’s need for airway and respiratory interventions. The Paramedic uses the airway management algorithm and knowledge of the many different disease processes that patients can present in the prehospital setting to identify and manage a patient’s airway and respiratory status. When the Paramedic is presented with a patient who initially cannot be ventilated or whose airway is unable to be secured, the airway management algorithm offers a preplanned approach to ensure that the best patient care possible is provided. Airway Management be accomplished for a given patient for a specifi c presumptive diagnosis. For example, a chest pain protocol may dictate that Airway management is one of the most critical tasks a all patients with chest pain of possible cardiac origin must Paramedic performs. The consequences of an unmanaged or receive vital signs assessment, oxygen, aspirin, nitroglycerin, poorly managed airway are devastating and potentially fatal. morphine, an IV, and cardiac monitoring. For a Paramedic, however, the feeling of accomplishment that Although there may be some specifi c order details within comes with properly managing the impossible airway can the protocol (e.g., “The fi rst nitroglycerin may be given before be its own reward. By defi nition, any emergency airway is an IV is established if the systolic blood pressure is greater considered diffi cult. Regardless of the patient’s anatomy, the than 120”), the actual order in which they are carried out is circumstances and urgency of managing the airway make it usually not critical to patient outcomes. It is expected that the more diffi cult than in a non-emergency, in-hospital situation.1–4 Paramedic will perform all of the care specifi ed in the protocol. Preplanning becomes critical to prevent inaction, wrong action, In certain emergency situations (e.g., cardiac arrest with and panic. ventricular fi brillation), specifi c tasks must be carried out the In patient care, the most common form of preplanning is same way, in the same order, in a very limited time period. the algorithm. This chapter examines the utility of algorithms Furthermore, the care must be modifi ed based on the patient’s and introduces the reader to three algorithms that can be response to the interventions. In these cases, algorithms are utilized for the management of any prehospital emergency applied. In essence, these are care guides based on “if-then” airway. Chapters 22 and 23 will examine each technique branch points. That is, a specifi c intervention is applied (e.g., listed in the algorithms in depth. It is important to note that defi brillation). If an event occurs (e.g., conversion to sinus even if a Paramedic does not adopt a formal algorithm, the rhythm) then another action is performed (e.g., administer basic principle of preplanning remains the same. It is also an anti-arrhythmic medication). However, if a different event important to emphasize that algorithms do not replace the occurs (e.g., the patient remains in ventricular fi brillation), Paramedic’s critical thinking skills. By knowing what to do then a different action is performed (e.g., start CPR, intubate, next if what is being done now doesn’t work, the Paramedic insert an IV, and give epinephrine) (Figure 21-1). can successfully negotiate any airway. The algorithm typically does not give wide latitude in decision making. By using a specifi c planned set of actions Algorithms and decisions, the Paramedic, at the time of the emergency need only to perform the algorithm and monitor patient In every patient encounter, the Paramedic applies a group responses to ensure the best patient care is provided. of patient care activities based on a presumptive conclusion One of the greatest advantages of algorithms is that the called a working diagnosis. These activities have been if-then decisions are made in advance. Instead of having previously planned and documented, usually in the form of the Paramedic consider the advantages and disadvantages a protocol. of a particular intervention while managing a critically ill Protocols are the fundamental guides to prehospital care. patient, other individuals—in calmer and less pressured A protocol details a specifi c group of activities that are all to circumstances—have already considered the literature 380 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Defibrillation may be unable to make a good decision to try an alternative approach. Considering the use of an algorithm in every airway management event is completely appropriate. The algorithm, however, is just one of many tools used in airway and respiratory management. Appropriate equipment, education, Yes Conversion No to sinus practice, and a thorough knowledge base are also critically rhythm? important tools. Therefore, the algorithm should be used in the context of excellent airway management skills and Administer Start CPR knowledge. It is the Paramedic’s responsibility to maximize antiarrhythmic the quality of care. therapy Development of Algorithms Figure 21-1 Example of an algorithm. Currently, algorithms are the tools of choice for dictating care in critically unstable prehospital patients. Classes in which a Paramedic will be most familiar that rely on algorithms and anecdotal experience and have formed a consensus include Advanced Cardiac Life Support and Pediatric decision on treatment. Algorithms are developed in a low- Advanced Life Support. In the airway management arena, stress environment where options can be discussed and fully the American Society of Anesthesiologists’ “Diffi cult Airway evaluated as opposed to those decisions made at the patient’s Algorithm,” the Advanced Trauma Life Support Trauma side, under high-stress and high-pressure circumstances. Airway Algorithm, and the National Emergency Airway In addition, algorithms provide an impetus for continuing Management Course Algorithm all represent various authors’ action. In an emergency situation, the risk exists that a and committees’ approaches to addressing specifi c airway Paramedic can become so focused on a single task that, even management issues. Of these, the ASA’s “Diffi cult Airway in the face of failure of that task, the Paramedic repeatedly Algorithm” has the most support in the literature.5,6 continues to perform that task. Use of an algorithm can The ASA’s “Diffi cult Airway Algorithm” resulted from prevent this from occurring. the fi ndings of a closed claims analysis of closed legal For example, some scene management algorithms for actions against anesthesiologists. The analysis found that critically ill trauma patients do not allow any attempts to three mechanisms (inadequate ventilation—38%, esophageal initiate IV access on-scene before the patient is loaded and intubation—18%, and diffi cult airways—17%) accounted for transported. These algorithms come from evidence that almost three-quarters of all adverse outcomes. The Diffi cult providers can become so fi xated on inserting an IV that multiple Airway Algorithm was subsequently developed to address at attempts result in signifi cant delays on-scene. By mandating least one of these three mechanisms. that sequential tasks occur and that care “moves” and is not In developing a systematic way to reduce the bad “stalled” on a single task, algorithms promote good care. outcomes associated with diffi cult airways, the ASA Task There are some important considerations in the use Force on Management of the Diffi cult Airway looked to the of an algorithm. Although the decisions about “what to do literature for a valid methodology for guiding patient care next” have already been made, they have not been made activities in the setting of potentially critical illness. Two by the individual facing a particular airway at a particular fi ndings guided them in developing an algorithm. The fi rst time. Therefore, even the best algorithm can only serve as was the fi nding that certain specifi c management techniques a guide; it is never a rigid absolute set of rules that must be had been clearly demonstrated to improve patient outcomes. mechanically followed. Deciding not to follow an algorithm, The second fi nding was that, although there was no airway or however, is not a decision to be made lightly. anesthesia literature to demonstrate that linking the individual The Paramedic should understand and routinely apply strategies to algorithms was benefi cial, the cardiopulmonary an airway management algorithm to the point that it is done resuscitation literature clearly demonstrated that algorithms automatically. This degree of familiarity implies that, when were benefi cial in the management of life-threatening cardiac a radically different situation is encountered, the Paramedic events. Based on these two fi ndings and expert consensus, an can intelligently consider and reject the algorithm if it is algorithmic approach to airway management was adopted. inappropriate. For example, a patient with a traumatic transection of the trachea is neither an appropriate candidate for repeated oral Assessment of an Algorithm’s Impact intubation attempts nor, when they fail, for the placement of a The impact of airway management algorithms on patient blind insertion airway device. In fact, this patient is a candidate outcomes, however, has not been clearly demonstrated. for a technique not addressed in any airway algorithm: direct Assessing the impact of the ASA’s Diffi cult Airway Algorithm intubation of the trachea at the level of the transection. is confounded by a number of variables. However, without understanding standard algorithmic Although this algorithm is almost universally used in management and why it is inappropriate, the Paramedic the anesthesia setting, a repeat analysis of closed claims The Algorithmic Approach to Airway Management 381 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. in 2000 that looked exclusively at diffi cult intubations was dividing between intubating airway care (the ability to use an only able to fi nd 98 cases from prior to implementation of endotracheal tube or blind insertion airway device) and non- the algorithm. The second diffi culty in determining the intubating airway management is a reasonable approach and algorithm’s impact is the number of confounding factors. For
the one taken in the following algorithms. example, the laryngeal mask airway was not commonly used before the algorithm was published; it is now very common Decision to Intubate and/or Provide in anesthesia practice and has been added to the algorithm. Respiratory Support Algorithm Changes in the number of non-physician anesthetists and The Paramedic’s most important task is to recognize a patient’s their practice patterns all confound any analysis. need for airway or respiratory support. Generally, this patient Finally, only historical control data is available to assessment is taught as part of the ABCs: Does the patient compare with new data; this increases the risk of unmeasured have a patent airway, is the patient breathing, and what is the confounding factors impacting the outcome. In short, even patient’s circulatory status? Parameters such as “respiratory with large numbers of patients and a strong monitoring system, rate < 10 or > 28” are used to guide interventions. However, using the largest database monitoring the impact of an airway using parameters fails to address the “why” aspect of airway algorithm may be inadequate to conclusively demonstrate that management. By understanding why a patient may need an algorithmic approach to emergency airway management is airway and respiratory support, the Paramedic is better able more effective than other approaches. to determine when and how to provide that support. This limitation is true, however, only in the context of Every patient requires some degree of airway management the ASA algorithm. Emergency airway algorithms have and respiratory support. The question that must be answered the advantage of starting with a single diagnosis: a patient is how much can the patient do on his own and how much in need of airway and ventilation management. Therefore, support does he need from the Paramedic. For example, a research into the effi cacy of airway management algorithms healthy 23-year-old woman with an ankle fracture can probably in the prehospital environment may be possible if two similar completely support her own airway and respiratory status. The EMS systems can be compared—one trained in and using same patient, however, after high dose morphine may require an algorithm and one not. Until such research is completed, active airway and respiratory support by the Paramedic. The however, the debate between pro-algorithm and pro-point of key is recognizing the difference between these two scenarios. care clinical decision making will continue. There are fi ve reasons why patients may require active airway or respiratory management (Table 21-1). By assessing Prehospital Airway each of these reasons in a systematic (algorithmic) fashion, Management Algorithms the Paramedic will be able to determine how aggressive an Many algorithms are available for the prehospital provider approach to airway and respiratory management is needed. to use. Some, such as the ASA Diffi cult Airway Algorithm, The Decision to Intubate and/or Provide Respiratory Support do not fi t well in the prehospital environment since they are Algorithm (Figure 21-2) provides the algorithm for patient written for use in a relatively controlled environment of the assessment of airway and respiratory status. operating room and may not be reasonable for the prehospital Although different from a typical algorithm in that each environment.7–9 step is not necessarily an intervention but rather a question to be answered, this algorithm nonetheless systematically Others may contain techniques in which the provider may guides the Paramedic through the steps of assessing a patient’s not be trained. Still others may address only one aspect of airway and respiratory status and is therefore considered to airway management (e.g., intubation) while neglecting other be an algorithm. aspects (i.e., non-intubated management, alternative devices). The algorithm is entered in the upper left-hand corner Ultimately, it is the responsibility of the Paramedic, ALS at the point indicated “Start Here.” Looking at the left-most agency, or medical director to select algorithms for use that column, the fi ve reasons for managing an airway are listed. are suffi ciently comprehensive and refl ect current practice. To As can be seen, they are listed in an order that allows for this end, the following three algorithms are written to provide logical and rapid assessment. In each case, the Paramedic one method for an integrated approach to airway management developed by the author. There has been a traditional separation of “basic life support” and “advanced life support” airway Table 21-1 Indications for Defi nitive skills. Although state rules and regulations dictate the scope Airway Control of EMS practice at all levels, the lines distinguishing these skills have become progressively blurred. • Non-patent airway For example, some EMT-Basics may be allowed to • Inability to maintain a patent airway intubate while some EMT-Paramedics may not be allowed • Failure to oxygenate to place blind insertion airway devices such as the King • Failure to ventilate LTS-D or laryngeal mask airways. Therefore, separating care • Anticipated deterioration in the patient’s status or the airway status into “BLS” and “ALS” algorithms is inappropriate. Instead, 382 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Patient Assesment Initial intervention Ultimate Disposition Start Does the patient have No Do simple maneuvers No • Support ventilation here an open airway? open the airway? • Go to appropriate airway Yes Yes management algorithm Is the patient No Is there a clear and easily No • Support ventilation protecting his airway? reversible disorder (narcotic • Consider Narcan/D50 overdose, hypoglycemia)? • Go to appropriate airway Yes management algorithm Yes Administer Narcan/ No • Support ventilation D50. Successful? • Go to appropriate airway Yes management algorithm No Supplemental oxygen. Is the patient adequately Does oxygenation oxygenating? improve? Yes Yes No No No • Support ventilation Is the patient Consider Narcan/D50 • Go to appropriate airway adequately ventilating? if not already given. management algorithm Yes Consider CPAP Can patient/airway Yes Successful? Consider immediate support status be expected Yes versus observation to deteriorate? and transport No • Provide supplemental oxygen as needed • Transport patient • Constantly monitor patient for airway or respiratory failure Figure 21-2 Decision to intubate and/or provide respiratory support algorithm. asks a “Yes/No” question. If the factor (e.g., an occluded Some patients may have patent airways on primary assess- airway) will not have an impact on the patient’s condition, ment or their airways can be opened with a simple intervention then the Paramedic moves on to the next question. such as a jaw thrust. If the Paramedic determines that the patient If by the end of the question list there are no factors has a patent airway but is unable to maintain that airway, then that would require active airway or respiratory intervention, the provider’s response is determined by the apparent cause of the Paramedic simply monitors and continues to reassess the the disability. These are patients who are typically thought of as patient. By reaching the line of the algorithm that states “unresponsive” but not in cardiac or respiratory arrest. “Provide supplemental oxygen as needed, transport patient, Therefore, hypoglycemia and narcotic overdose need constantly monitor patient for airway or respiratory failure,” to be considered as easily reversible causes of the mental the Paramedic can be assured that immediate airway or status change. If one of these two causes is suspected, then respiratory interventions are not needed. the Paramedic should, if permitted by training and protocol, Only when specifi c conditions exist that would com- attempt to reverse these disease processes. promise a patient’s airway or respiratory status must the If 50% dextrose or naloxone successfully reverses the Paramedic perform interventions. The following evaluates altered mental status, then the patient’s airway maintenance the decision making required and actions to be taken given a issues will often also resolve. Even if hypoglycemia or specifi c condition. narcotic overdose are not clearly the causes of a patient’s If, on primary assessment, a patient does not have mental status change, the provider should consider giving a patent airway, the fi rst intervention is the use of simple these medications prior to more invasive airway management maneuvers. These consist of head-tilt, chin-lift and jaw- if it seems clinically appropriate. thrust maneuvers to lift the epiglottis and soft palate from the If the patient still is not able to maintain the airway, the posterior hypopharynx and pharynx. If these are successful at Paramedic should proceed to the airway algorithm appropriate opening the airway, then the Paramedic should continue the to his level of training. assessment. Otherwise, the Paramedic should move on to the If a patient has a patent airway and is maintaining that appropriate algorithm discussed in the following text. patent airway, it is possible that the patient may still not be The Algorithmic Approach to Airway Management 383 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. effectively oxygenating (transferring oxygen to the tissues) or experience, knowledge of the disease process, ability of the ventilating (removing carbon dioxide from the bloodstream). provider, availability of equipment including medications, A number of disease processes can affect oxygenation and and often discussion with a medical control physician. This ventilation. Typically, a single disease process will affect both. is an important decision to be made and must be done with However, there are disease processes that may cause hypoxia in careful consideration. the face of normal ventilation. Conversely, a patient may have If the patient has a patent airway, is maintaining that adequate tissue oxygenation while retaining carbon dioxide. An airway, is oxygenating and ventilating normally, and is not example of the fi rst is a patient with pneumonia. The patient expected to deteriorate, then the Paramedic has completely may be able to continue to exhale carbon dioxide at a normal assessed the patient’s airway and respiratory status. At this rate but not be able to adequately deliver oxygen to tissues. point, the Paramedic can continue with the remainder of the Rarely will hypoventilation occur without hypoxia. One patient assessment. She should return to reassess the airway example in which it does occur would be a patient with a every few minutes, or sooner if the patient’s status changes. morphine overdose. She may maintain a normal oxygen level If a patient fails any of the fi ve criteria for being able to if given high-fl ow oxygen but still be retaining carbon dioxide manage his own airway, then it is the Paramedic’s responsibility due to decreased respiratory rate or tidal volume. to perform more aggressive interventions. This is the premise By separating oxygenation from ventilation, the Paramedic of the Decision to Intubate and/or Provide Respiratory Support can rapidly screen a patient for oxygenation status and, if it Algorithm. The right-hand column directs the Paramedic to is normal, begin the more focused evaluation of ventilation provide ventilatory support and go to the appropriate airway status. management algorithm. In this case, appropriate refers not to If a patient is found to be hypoxic, the addition of what management would be most appropriate for the patient supplemental oxygen may be adequate to reverse the but rather to the algorithm that is appropriate to the Paramedic’s hypoxia. If supplemental oxygenation reverses the hypoxia, practice level. then the patient should be assessed for ventilation failure. One other important point to remember is the Paramedic If supplemental oxygen is inadequate, however, then the must perform excellent non-intubating airway skills prior patient likely has oxygenation and ventilation failure and to performing excellent intubating airway skills. In an efforts should be made to reverse the ventilation failure. emergency situation, the most experienced Paramedic must For the comatose patient with decreased respiratory rate either perform airway management or directly supervise the or drive, Narcan or 50% dextrose may
reverse the disease airway management. The Paramedic who divides airway process. For the patient in congestive heart failure or COPD management tasks into ALS and BLS and believes that he is exacerbation, use of continuous positive airway pressure only responsible for ALS skills is mistaken and is providing (CPAP) or bilevel positive airway pressure (BiPAP) may poor patient care. Therefore, it is imperative that the Paramedic overcome the oxygenation or ventilation failure.10,11 However, be comfortable with all aspects of airway management, if the patient remains hypoxic or is hypoventilating in spite including both the “non-intubating” and “intubating” airway of these interventions, more aggressive interventions are management algorithms. needed. The Paramedic should move on to the appropriate airway management algorithm. If a patient has a patent airway, is maintaining that Non-Intubating airway, and is oxygenating and ventilating normally, then Airway Management Algorithm it is unlikely that an immediate, emergent intervention is The “Non-Intubating Airway Management Algorithm” necessary. However, the Paramedic must be knowledgeable (Figure 21-3) is entered at the top with the assumption that an concerning the natural progression of diseases. There are a assessment is complete and the patient is in need of further number of disease processes encountered in the prehospital airway or respiratory support and management. The next environment that can cause a patient, the patient’s airway, or three interventions should all be automatic. The fi rst and most the patient’s respiratory status to deteriorate. A few examples important intervention is to minimize or prevent hypoxia. include airway burns, congestive heart failure, asthma Hypoxic brain death occurs within 6 to 10 minutes of apnea exacerbation, and sepsis. or signifi cant hypoxia. In each of these cases, the Paramedic must make an Therefore, immediate application of high-fl ow oxygen is important decision as to whether to intervene immediately mandatory to provide as much of a time margin as is possible. or to monitor the patient. Several conditions (e.g., airway and Ideally, since the patient is at least in ventilatory failure and inhalation burns with dyspnea, stridor, or hoarseness) are at worst is apneic, the oxygen will be applied through a bag- almost absolutely guaranteed to progress to airway occlusion valve-mask (BVM) device or, if the patient is apneic, with an and mandate early intubation. automatic transport ventilator (ATV). This may be delegated Patients in congestive heart failure, on the other hand, to another provider so the Paramedic can continue down the may improve dramatically after treatment even with hypoxia algorithm. or hypoventilation during the primary assessment. The The second automatic task is to assemble airway decision to perform early airway management is based on management equipment. The equipment will depend on what 384 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Patient assessment: Patient needs airway/respiratory support Preoxygenate, prepare equipment. Call for back-up if anticipated difficult airway Yes Open the airway/attempt ventilation: • Listen to patient’s Successful? lungs, watch chest No movement. • Insert airway. Reassess provider, patient, and • Transport patient. equipment. Insert airway. Suction/obstruction management PRN. Yes Attempt ventilation: Successful? • Listen to patient’s No lungs, watch chest movement. Reconsider obstruction. Suction. • Insert airway. Perform obstructed airway skills • Transport patient. Yes Attempt ventilation: Successful? • Listen to patient’s No lungs, watch chest movement. Transport patient emergently. • Insert airway. Consider requesting • Transport patient. physician intercept. Figure 21-3 Non-intubating airway management algorithm. skills the Paramedic is able to perform, but should ideally be Table 21-2 Conditions Requiring available in a single bag or box and be organized, complete, Emergency Transportation and up-to-date. Once these tasks have been accomplished, the next step • Abnormal vital signs that cannot be corrected/do not respond to treatment is to begin supporting the patient. Opening the airway and providing ventilation is the fi rst step in supporting the patient. • Unmanageable airway If the patient is spontaneously but ineffectively breathing, then • Ischemic compromise of an extremity supported ventilations with a BVM is the most appropriate • Complicated delivery intervention. • Uncontrollable bleeding If the patient is apneic, then either a BVM or an autom- • Cardiac arrest reversal with abnormal vital signs atic transport ventilator attached to a mask can be used. If the • Cardiac arrest without defi brillation/medications available Paramedic is successful at opening the airway and providing ventilation, then a rapid assessment of the intervention’s adequacy is performed (auscultation, observation). Either for emergent transport may be too high. In that case, the an oropharyngeal or a nasopharyngeal airway is inserted Paramedic should consider non-emergency transport. If the depending on the absence or presence of a gag refl ex, patient’s airway cannot be managed, however, then the patient respectively. Finally, the patient is transported. should be transported emergently. This approach is taken by Note that in both the intubating and non-intubating the “intubating” and “non-intubating” algorithms. In reality, algorithms, there are distinctions made between transport the decision will be made based on local protocols, local and transport emergently. These differences are based on standard of care, and medical direction. a specifi c list of conditions (Table 21-2), which require There will be times when a patient’s airway cannot be emergent transport (the assumption being that for all other established or the patient cannot be ventilated on the fi rst conditions, the risks of emergent transport may outweigh any attempt. If this is the case, the Paramedic must quickly benefi ts). troubleshoot. Immediate actions should include repositioning If a patient’s vital signs are otherwise stable and the airway the patient’s head and, if needed, suctioning the airway and and ventilation adequately managed, the risk-to-benefi t ratio performing obstructed airway skills. The Algorithmic Approach to Airway Management 385 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Once these interventions are performed, the Paramedic should make a second attempt to open the airway and ventilate Cultural / Regional differences the patient. If the second attempt is successful, then, as before, the Paramedic should assess the adequacy of ventilation, insert an oropharyngeal (OP) or nasopharyngeal (NP) airway, and In some regions, prehospital physician intercepts are transport the patient. possible and, if available, should be requested at If, after the second attempt, the Paramedic is unable to this time as well. If these intercepts will increase the establish a patent airway or ventilate the patient, an obstruction time to defi nitive care (e.g., physician, emergency should be assumed. The appropriate obstructed airway management skills (Heimlich maneuver, unconscious patient department, or operating room), then they should not abdominal thrusts, chest thrusts, or back blows) should be occur and the patient should be emergently and safely performed and another attempt should be made to ventilate transported. The Paramedic should not wait on-scene the patient. If this attempt is successful, then the Paramedic should assess the adequacy of ventilation, place an OP or for an EMS Physician to arrive. NP airway, and transport the patient. If, however, the third attempt at ventilation fails, then a change in tactics must be made. An analysis of the actions performed gives insight into Intubating Airway Management why, after three ventilation attempts, the Paramedic should Algorithm change tactics. As with the Non-Intubating Airway Management Algorithm, When the fi rst attempt is made to ventilate the patient, a patient enters the Intubating Airway Management Algorithm it is assumed that the patient has normal anatomy and that by virtue of having met one of the fi ve criteria for airway and “normal” (not including foreign body obstruction) causes of respiratory management and by having a Paramedic capable respiratory and airway failure have occurred. In most of these of intubating and performing other advanced airway skills. patients, a head-tilt, chin-lift or jaw thrust, in combination The top of the algorithm (Figure 21-4) is the entrance point with BVM or ATV ventilation, will be adequate to open the and assumes that the patient needs to be intubated. As will be airway and provide ventilation. recalled, other non-intubated ventilatory support modalities If these interventions fail, the next intervention is to should have been tried by this point. The algorithm directs rapidly troubleshoot and correct easily identifi able problems, the Paramedic toward a goal: a secure airway with adequate including inadequate performance of skills, on the fi rst ventilation. ventilation attempt. Therefore, when the second attempt is The Paramedic places the patient on high-fl ow oxygen or made at ventilation, the Paramedic will still assume the patient ventilates the patient with a BVM. At this point, if possible, the has normal anatomy and “normal” causes of the airway and most experienced Paramedic should be performing or directly respiratory failure. In most of the remaining patients, these supervising the patient’s care. While the Paramedic is doing this, few corrections will open the airway and allow adequate the least experienced Paramedic on the scene, who is capable of assisted ventilation. preparing the intubation and airway management equipment, If the second attempt at ventilation fails, however, the should be doing so. Having the most experienced providers Paramedic must consider abnormal conditions. Therefore, directly managing the patient’s care will optimize that care. between the second and third ventilation attempts, the While there is some debate as to the defi nition of Paramedic performs all of his skills to correct or compensate an intubation attempt, the National Association of EMS for anatomical issues, airway obstruction, and physiological Physicians (NAEMSP) developed a standardized reporting defects. The Paramedic corrects all the variables for which tool (Table 21-3). As each unsuccessful intubation attempt he is able to compensate. The third attempt at ventilation, will cause edema, bleeding, and patient deterioration, it therefore, is an optimized attempt.12 If this attempt fails, there is important that the fi rst intubation attempt be the best is little else the Paramedic can do. Therefore, after the third intubation attempt.13 Conditions must be optimized through attempt, a different tactic must be taken. proper, working equipment and, if used, drug selection. The The failure of the third ventilation attempt signifi es that patient must be correctly positioned, the Paramedic must be the Paramedic has no additional changes in care to offer. correctly positioned relative to the patient, and lighting should Therefore, the patient must be transported immediately to be controlled as much as possible. The proper route must be another provider capable of offering additional, advanced selected. In short, everything that can be controlled should be care. These are critically unstable patients and should so as to make the fi rst attempt most likely to succeed. be transported emergently. During that transport, the Once the equipment is prepared and conditions are Paramedic should continue to perform obstructed airway optimized, the route must be selected. For a breathing patient, skills and attempt to ventilate. If it will shorten the time to particularly one with a primary respiratory disease such as access advanced care, ALS providers should intercept the CHF or a COPD exacerbation, nasal intubation is an excellent transport. choice.14–18 These patients are likely to become hypoxic 386 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Patient assessment: Patient needs to be intubated Preoxygenate, ventilate PRN, prepare equipment If patient is breathing, consider nasal intubation Yes Attempt orotracheal intubation: • Confirm position Successful? with 3 methods. No
• Secure tube. • Monitor patient. Ventilate. Reassess provider, patient, and equipment. • Confirm position with 3 methods. Yes • Secure tube. Attempt intubation (x 2): Successful? • Monitor patient. No Ventilate, prepare Blind Insertion Airway Device • Confirm position Yes with 3 methods. Attempt BIAD placement: Successful? • Secure tube. No • Monitor patient. Attempt to ventilate with BVM/ATV: Yes Monitor patient, Successful? transport No emergently Consider obstructed airway. If unable to clear Yes Monitor patient, obstruction, attempt surgical airway: Successful? transport No emergently Transport patient emergently. Consider requesting physician intercept. Figure 21-4 Intubating airway management algorithm. Table 21-3 NAEMSP Defi nition First, auscultate over the epigastrium while the patient is of Intubation Attempt ventilated. If the endotracheal tube is correctly placed in the trachea, there should be an absence of gastric sounds. Next, 1. Insertion of laryngoscope blade into mouth (for orotracheal auscultate over both the left and right lung fi elds for presence methods) of equal breath sounds. If the right lung sounds are louder than 2. Insertion of tube through nares of nose (for nasotracheal methods) the left, the endotracheal tube is likely in the right mainstem 3. Insertion of rescue airway device into mouth (for Combitube, LMA, bronchus. Check depth of endotracheal tube placement and and other oral rescue airway devices) withdraw the tube by 1 or 2 cm, reinfl ate the balloon, and 4. Insertion of rescue airway devices through the neck (for reassess lung sounds. If the lung sounds remain unequal, then cricothyroidotomy, needle jet ventilation, retrograde ETI, and other assess the patient for a pneumothorax, as discussed in later “surgical” methods of airway management) chapters. H.E. Wang, R.M. Domeier, D.F. Kupas, M.J. Greenwood, R.E. O’Connor, The two commonly accepted additional methods of “Recommended guidelines for uniform reporting of data from out-of-hospital airway management: position statement of the National Association of EMS confi rming tube placement are esophageal detector devices Physicians,” Prehospital Emergency Care 8, no.1 (2004): 58–72. and colorimic end-tidal carbon dioxide measurement.19–21 Each of these methods has benefi ts and drawbacks. Using two or three tend to cancel out the problems inherent in each rapidly if medications are used to sedate or paralyze them as method. they have no reserve capacity. If the patient is not breathing, Once the endotracheal tube is confi rmed to be in a tracheal however, or has evidence of a basilar skull fracture, then an position, it must be secured using either a commercial device or attempt at oral intubation is the next step. tape. Additionally, the use of a cervical immobilization collar After the endotracheal tube is passed, tube position is and cervical immobilization device (head blocks) will minimize confi rmed by auscultation and another confi rmation device. tube movement and the potential for displacement. The use of The Algorithmic Approach to Airway Management 387 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. waveform capnography in the intubated patient can provide an having a tube beyond the vocal cords with direct access to additional layer of safety as endotracheal tube dislodgement can the trachea, it is more secure than with simple face-mask be identifi ed and corrected almost immediately. The Paramedic ventilation. There will be occasions when these devices will must continue to monitor the patient for changes in respiratory not provide adequate ventilation. For example, in a patient status and transport the patient. with an inhalation burn and vocal cord edema, none of these If the fi rst intubation attempt fails, however, then the devices can guarantee that air will pass through the cords to Paramedic must reconsider his actions and determine adequately ventilate the patient. However, as noted before, the best course to increase the chances of success on the failure to provide some improvement in ventilation is rare. second attempt. Sometimes it is possible to identify a single Once the BIAD is in place, it needs to be confi rmed. item that caused the intubation attempt to fail, such as In this case, auscultation and end-tidal carbon dioxide laryngoscope light failure, insuffi cient suction, or the need measurement can be utilized. Esophageal detection devices for sedation and/or paralysis. Other times, the Paramedic will not necessarily work with any of the BIADs. Therefore, simply recognizes that a different approach must be tried monitoring the patient’s condition over time becomes the without being completely sure why the fi rst approach failed. third method of confi rming device placement. Once the Therefore, if the fi rst intubation attempt failed, the patient placement has been confi rmed, the BIAD must be secured must be ventilated as needed and the Paramedic must attempt in the manner recommended by the manufacturer and the to optimize the subsequent intubation attempt. The changes patient should be monitored and transported. If the patient made to optimize the second attempt should be based on the has no other concurrent issues and the BIAD is allowing for fi ndings of the fi rst attempt. adequate oxygenation and ventilation, then a non-emergency Once the Paramedic is ready to reattempt intubation, no mode transport may be appropriate. more than two more attempts should be made to intubate the If the BIAD will not pass (for anatomical reasons, injuries, patient. If, after a total of three attempts, the patient is not etc.) or does not seem to be providing adequate ventilation, intubated and no clearly correctable problem is identifi ed, then then the Paramedic must fall back on the fundamentals of a different approach to the specifi c patient is required. By the airway management. The objective of airway management is time the third attempt has been made, the Paramedic should to allow adequate oxygenation and ventilation. have maximized conditions. In all likelihood, further attempts Therefore, if all previous methods of securing the will result only in more bleeding and edema and a more airway have failed, then face-mask ventilation with a BVM diffi cult airway to manage. The greater the number of attempts or ATV and an oropharyngeal or nasopharyngeal airway is at endotracheal intubation, the lower the chance of success.22 appropriate. There will be patients whose airways cannot If the second or third intubation attempt is successful, then otherwise be managed due to injury or anatomy who will the tube should be confi rmed with three methods, it should be do well with face-mask ventilation. If the patient can be secured, and the patient should be monitored and transported. adequately ventilated by these interventions, then the patient If these two additional attempts are not successful, however, should be monitored and transported. These patients with then the airway manager must move on with his management clearly diffi cult airways will usually qualify for emergent plan. The patient should be ventilated as needed. transport. If the patient improves and remains stable with The next class of devices that are likely to succeed in at face-mask ventilation alone, however, non-emergent transport least partially securing the airway are devices designed for can be considered. blind insertion into the upper portion of the airway above the If all other airway management modalities have failed and glottis. Several terms have been used to describe these devices, the patient still cannot be ventilated, then the Paramedic must including supraglottic airway devices, non-visualized airway assume that there is a pathological obstruction of the airway. devices, and blind insertion airway devices (BIADs). For the This obstruction may be visualized during an intubation remainder of this discussion, we will use the term BIADs attempt or assumed from either the patient’s disease process when referring to these airways. The BIADs commonly or simply from the failure to ventilate. If basic and advanced used include the King LTS-D airway, laryngeal mask airway obstructed airway skills do not clear the airway, then the (LMA), and the esophageal tracheal Combitube. Each of Paramedic is left to attempt to establish a surgical airway. If these devices has its strengths and weaknesses. In general, the the pathology is at the level of the thyroid cartilage or above, a esophageal obturator airway (EOA) and esophageal gastric surgical airway will allow ventilation and oxygenation. If the tube airway (EGTA) should rarely be considered as they obstruction is at or below the level of the trachea, however, a have a history of high complication rates and both require surgical cricothyrotomy will most likely fail. maintenance of a mask seal during use. Although they are If the surgical airway succeeds, the patient should be still the BIADs of choice for some agencies, standard of care monitored and transported emergently. If, however, the is moving away from the EOA and EGTA and toward one of surgical airway fails, then the patient must be transported the other devices. emergently while the Paramedic attempts to oxygenate and It is rare that a blind insertion airway device will not ventilate the patient. If available, the Paramedic may consider provide at least some ability to effectively ventilate a patient. a physician intercept or an intercept with a more experienced Although the airway may not be secure in the sense of Paramedic while en route to the hospital. 388 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Airway management can be one of the most life-saving tasks a Paramedic can perform for a patient. As has been demonstrated in the cardiopulmonary resuscitation arena, algorithms can greatly enhance consistent and correct task performance during life-threatening emergencies. The value of an algorithmic approach to airway management has been recognized by professional organizations. Although the use of algorithms can greatly facilitate airway management, it is important to recognize that the algorithm is written for the majority of situations and that algorithms are not “one size fi ts all.” Therefore, the Paramedic must recognize that an algorithm is simply one more tool to improve the quality of patient care. While it does not replace clinical judgment in a specifi c situation, it allows a systematic approach that will enhance patient care. Key Points: • The algorithm is a form of preplanning in an • Despite having a patent airway, it is possible that emergency situation. the patient may still not be effectively oxygenating or ventilating. • Emergency airway algorithms all begin with a patient in need of airway and ventilation management. • If the patient with a patent airway is maintaining that airway, is oxygenating and ventilating • The Paramedic must determine what degree of normally, and is not expected to deteriorate, airway management and respiratory support is then the Paramedic has completely assessed the needed for every patient. patient’s airway and respiratory status. She should • Active airway or respiratory management is continue monitoring for effect. required for each of the following: • The “Non-Intubating Airway Management ■ Non-patent airway Algorithm” addresses the need for airway or ■ Inability to maintain patient’s own airway respiratory support and management, which is the ■ Failure to oxygenate fi rst and most important automatic intervention to ■ Failure to ventilate minimize or prevent hypoxia. ■ Anticipated deterioration of the patient’s status or the airway status • The second automatic task is to assemble airway management equipment appropriate to the • If, on primary assessment, a patient does not have a Paramedic’s skill level. patent airway, the fi rst intervention is the use of a head-tilt, chin-lift or jaw-thrust maneuver to open • The Paramedic should support the patient with the airway. If the patient has a patent airway but ineffective breathing or apnea by opening the is unable to maintain that airway, the Paramedic airway and providing ventilation. should determine the cause of the disability. • The following
conditions require emergent • Hypoglycemia or narcotic overdose should be transport: considered when presented with patients who are ■ Abnormal vital signs that cannot be corrected/ typically thought of as “unresponsive” but not in do not respond to treatment cardiac or respiratory arrest. ■ Unmanageable airway The Algorithmic Approach to Airway Management 389 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. ■ Ischemic compromise of an extremity ■ Complicated delivery • After the endotracheal tube is passed, tube position is confi rmed by auscultating fi rst over the ■ Uncontrollable bleeding epigastrium, then over the left and right lung fi elds ■ Cardiac arrest reversal with abnormal vital signs for presence of equal breath sounds. ■ Cardiac arrest without defi brillation/medications available • The Paramedic confi rms placement with at least If the patient’s airway cannot be managed, the one additional method. Waveform capnography is patient should be transported emergently. required in many EMS systems. • The Paramedic should consider suctioning and • The Paramedic should note the depth of the repositioning the head as initial interventions for a endotracheal tube placement and secure the patient who cannot be ventilated. endotracheal tube with tape or a commercial • device. If a second attempt is successful, the Paramedic should consider an OPA or NPA along with patient • The Paramedic should use a cervical immobilization transport. device to minimize tube movement and potential • for displacement. If a second attempt is unsuccessful, an obstruction should be assumed. The Paramedic should perform • The Paramedic should continue monitoring the the appropriate obstructed airway management patient for effect. skills (Heimlich maneuver, unconscious patient abdominal thrusts, chest thrusts, or back blows) and • If the fi rst intubation attempt fails, the patient must make another attempt to ventilate the patient. be ventilated. No more than two more attempts should be made to intubate the patient. • Continued failure to ventilate is an abnormal circumstance requiring all measures available to • Blind insertion airway devices (BIADs) are likely to obtain a patent airway, including transporting succeed in at least partially securing the airway the patient to a provider capable of offering an and are designed for blind insertion into the upper advanced level of airway care. portion of the airway above the glottis. • Conditions prior to the fi rst intubation attempt must • Once the BIAD is in place, the Paramedic should be optimized by fi rst selecting the proper provider, confi rm it by auscultation, end-tidal carbon dioxide equipment, medications, and route. The Paramedic measurement, or simply monitoring the patient’s and patient must also be in proper positions with condition over time. suffi cient lighting. • An obstruction may be visualized during an • Nasal intubation is an excellent choice for the intubation attempt or assumed from either the spontaneously breathing patient with a respiratory patient’s disease process or the failure to ventilate. disease history. • A surgical airway is often considered the last • Oral intubation is a good choice for an apneic patient course of action that may allow ventilation and or one with a suspected basilar skull fracture. oxygenation. 390 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. Contrast the “if-then” approach of protocols Algorithm before using the Intubating Airway with the methodology that algorithms offer. Management Algorithm? 2. What criteria are used to make a patient’s 6. What are the automatic tasks the Paramedic transport decision? should perform under the Non-Intubating 3. What are two easily reversible conditions where Airway Management Algorithm? the patient is thought of as “unresponsive” but 7. What are the fi ve reasons for which a patient not in cardiac or respiratory arrest? may require active airway or respiratory 4. Provide a disease process for each situation: a management? patient who is hypoxic with normal ventilation 8. After the endotracheal tube is passed, how is and a patient who has adequate tissue tube position confi rmed? oxygenation but is retaining carbon dioxide due 9. What should the Paramedic do if the fi rst to ventilatory failure. intubation attempt fails? 5. Why should the Paramedic have mastered 10. Describe the function of a blind insertion airway the Non-Intubating Airway Management device. Case Study Questions: Please refer to the Case Study at the beginning of the adequately ventilate the patient? Explain your chapter and answer the questions below: answer. 1. What early interventions can be performed to 3. How would you assess the success of the increase the likelihood of successful ventilation placement? for this patient? 4. What other devices/interventions are available 2. What airway device would you choose for the provision of adequate airway/ventilation? if the providers remained unable to References: 1. Combes X, Jabre P, Jbeili C, Leroux B, Bastuji-Garin S, 4. Gerich TG, Schmidt U, Hubrich V, Lobenhoffer HP, Tscherne Margenet A, et al. Prehospital standardization of medical airway H. Prehospital airway management in the acutely injured management: incidence and risk factors of diffi cult airway. Acad patient: the role of surgical cricothyrotomy revisited. J Trauma. Emerg Med. 2006;13(8):828–834. 1998;45(2):312–314. 2. Dorges V, Wenzel V, Knacke P, Gerlach K. Comparison of 5. Bishop MJ. Practice guidelines for airway care during different airway management strategies to ventilate apneic, resuscitation. Respir Care. 1995;40(4):393–401; discussion 401. nonpreoxygenated patients. Crit Care Med. 2003;31(3):800–804. 6. Candido KD, Saatee S, Appavu SK, Khorasani A. Revisiting 3. Hoyle JD, Jr., Jones JS, Deibel M, Lock DT, Reischman D. the ASA guidelines for management of a diffi cult airway. Comparative study of airway management techniques with Anesthesiology. 2000;93(1):295–298. restricted access to patient airway. Prehosp Emerg Care. 7. Timmermann A, Russo SG. Which airway should I use? Curr 2007;11(3):330–336. Opin Anaesthesiol. 2007;20(6):595–599. The Algorithmic Approach to Airway Management 391 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 8. Ezri T, Szmuk P, Warters RD, Katz J, Hagberg CA. Diffi cult 17. Arora MK, Karamchandani K, Trikha A. Use of a gum elastic airway management practice patterns among anesthesiologists bougie to facilitate blind nasotracheal intubation in children: a practicing in the United States: have we made any progress? J series of three cases. Anaesthesia. 2006;61(3):291–294. Clin Anesth. 2003;15(6):418–422. 18. Butcher D. Pharmacological techniques for managing acute pain 9. Ron M, Walls R, Michael F, Robert C, Robert E. Manual of in emergency departments. Emerg Nurse. 2004;12(1):26–35; Emergency Airway Management. Hagerstwon: Lippincott quiz 36. Williams & Wilkins; 2004. 19. Hayden SR, Sciammarella J, Viccellio P, Thode H, Delagi 10. Hunjadi D. From provider to patient. Emerg Med Serv. R. Colorimetric end-tidal CO detector for verifi cation of 2 2005;34(8):157–160. endotracheal tube placement in out-of-hospital cardiac arrest. 11. Goss JF, Zygowiec J. Positive pressure: CPAP in the treatment of Acad Emerg Med. 1995;2(6):499–502. pulmonary edema & COPD. Jems. 2006;31(11):48, 50, 52–58 20. Cummins RO, Hazinski MF. Guidelines based on the principle passim; quiz 64. “First, do no harm.” New guidelines on tracheal tube confi rmation 12. Wang HE, Yealy DM. How many attempts are required to and prevention of dislodgment. Resuscitation. 2000;46(1–3): accomplish out-of-hospital endotracheal intubation? Acad Emerg 443–447. Med. 2006;13(4):372–377. 21. Zaleski L, Abello D, Gold MI. The esophageal detector device. 13. Butler KH, Clyne B. Management of the diffi cult airway: Does it work? Anesthesiology. 1993;79(2):244–247. alternative airway techniques and adjuncts. Emerg Med Clin 22. Wang HE, Domeier RM, Kupas DF, Greenwood MJ, O’Connor North Am. 2003;21(2):259–289. RE. Recommended guidelines for uniform reporting of data from 14. Iserson KV. Blind nasotracheal intubation. Ann Emerg Med. out-of-hospital airway management: Position statement of the 1981;10(9):468–471. National Association of EMS Physicians. Prehosp Emerg Care. 15. Danzl DF, Thomas DM. Nasotracheal intubations in the 2004;8(1):58–72. emergency department. Crit Care Med. 1980;8(11):677–682. 16. O’Brien DJ, Danzl DF, Hooker EA, Daniel LM, Dolan MC. Prehospital blind nasotracheal intubation by Paramedics. Ann Emerg Med. 1989;18(6):612–617. 392 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Public Health and the Paramedic 393 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The benefi ts of preoxygenation for any patient in need of active airway management or ventilatory support • The use of cricoid pressure during manual ventilation • Simple airway maneuvers that can make all the difference • Understanding ventilatory pressure and reducing gastric infl ation • Indications and application of continuous positive airway pressure (CPAP) • Assessing the adult and pediatric patient for appropriate oxygenation and ventilation Case Study: The Paramedics were called to the home of Mrs. Tedesco, an elderly woman with a lengthy history of congestive heart failure. When they arrived, Mrs. Tedesco’s breathing appeared worse than usual. One Paramedic placed her on a nonrebreather mask but she continued to labor. 394 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Non-Intubating Airway Management 395 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Knowledge and skill in basic airway management is mandatory. Often some of the most basic techniques are the most critical and fundamental airway management skills a Paramedic can perform. This chapter addresses a number of skills and simple devices the Paramedic can utilize to effectively ventilate patients through simple face- mask techniques. In addition, continuous positive airway pressure (CPAP) and other advances in airway technology allow critically ill patients to be managed without the need for intubation. Basic Airway Management Using the Non-Intubating Airway Management Algorithm (Figure 22-1) as a guide, this chapter will review Basic airway management is one of the most critical the fundamentals of basic airway skills. In addition, tech- and fundamental skills an emergency medicine pro- niques to avoid intubation, such as CPAP and assisted venti- vider can possess.1–3 Whether that provider is an EMT, lation, will be discussed. a Paramedic,
a nurse, or a physician, knowledge and skill in basic airway management is critical. As stated suc- cinctly in the 1994 EMT national standard curriculum, “a patient without an airway is a dead patient.” Although Street Smart the knowledge and skill to perform intubations and other advanced airway maneuvers, as described in the next chapter, are a critical part of the Paramedic’s practice, Correct positioning of the patient and the airway is the non-invasive, basic skills are truly the most critical the most basic airway maneuver. to master. Patient assessment: Patient needs airway/respiratory support Preoxygenate, prepare equipment. Call for back-up if anticipated difficult airway Yes Open the airway/attempt ventilation: • Listen to patient’s Successful? lungs, watch chest No movement. • Insert airway. Reassess provider, patient, and • Transport patient. equipment. Insert airway. Suction/obstruction management PRN. Yes Attempt ventilation: Successful? • Listen to patient’s No lungs, watch chest movement. Reconsider obstruction. Suction. • Insert airway. Perform obstructed airway skills • Transport patient. Yes Attempt ventilation: Successful? • Listen to patient’s No lungs, watch chest movement. Transport patient emergently. • Insert airway. Consider requesting • Transport patient. physician intercept. Figure 22-1 Non-intubating airway management algorithm. 396 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Basic Airway Management systems, the fl ow meter is generally separate from the regula- tor. Oxygen fl ow rates range from 0.5 to 25 LPM. In addi- Algorithm tion, many regulators can deliver a 50 PSI source of oxygen By the time the Paramedic enters the basic algorithm, the for various devices (e.g., ventilators, continuous and bilevel decision has already been made to provide airway and ven- positive airway pressure, and trans-tracheal jet ventilation tilatory support to the patient. Once that decision has been equipment). made, the Paramedic must proceed in an orderly manner Oxygen is delivered to the patient from the regula- through the steps of care. tor through a number of devices. The most commonly used devices are the nasal cannula, the simple face mask, and the Preoxygenation nonrebreather mask. In addition, demand valve devices also provide a method for providing high concentration oxygen Any patient in need of active airway management or ventila- but are less commonly used. tory support is in need of supplemental oxygen. Providing a The nasal cannula is a pronged device designed for nasal patient with supplemental oxygen serves a number of pur- oxygen delivery (Figure 22-2). With oxygen fl ows from 0.5 poses. Supplemental oxygen replaces nitrogen in the dead to 6 LPM, these devices can deliver up to a 40% FiO . They space of the lungs with oxygen, referred to as nitrogen wash- 2 are generally well tolerated and do not require a patient to out. Not only does this increase the diffusion gradient, causing breathe through his nose to be effective. Only complete bilat- more oxygen to dissolve into the plasma, but it also provides eral nasopharyngeal obstruction would prevent oxygen deliv- a “reservoir” of oxygen in the lungs in the event the patient ery. Indications include the need for supplemental oxygen. becomes apneic.4,5 Oxygen can often decrease the patient’s Contraindications include severe hypoxia, apnea, and intoler- respiratory distress, in turn decreasing catecholamine release ance of the device. and myocardial oxygen demand. The high-fl ow nasal cannula (HFNC) is an advance in Oxygen Delivery Devices nasal cannula technology. By humidifying and warming the oxygen, and using membrane technology, the device is able Oxygen equipment includes oxygen storage devices, regula- to comfortably deliver up to 40 LPM to the patient through tors, and delivery devices (i.e., masks, nasal cannula). It is a nasal cannula. Although this technology has not yet been important that the Paramedic be skilled in the use of these applied in the prehospital environment, it does offer some devices. promise. Oxygen is stored as either a compressed gas, in steel or The simple face mask is a low- to mid-concentration aluminum tanks, or as a liquid. Common compressed gas oxygen delivery device. The mask seals over the mouth and cylinders in the prehospital environment include D cylinders, nose, delivering oxygen through an input port and drawing which hold 400 L of oxygen when completely fi lled; E cyl- air through an open side port. At 10 LPM, a 40% to 60% FiO 2 inders, which hold 660 L of oxygen; and M cylinders, which is attained.8 Unfortunately, increasing the oxygen fl ow above hold 3,450 L.6,7 Since the cylinders contain oxygen at high 10 LPM does not signifi cantly increase FiO since the same 2 pressure (1,800 PSI), it is important that they be handled with amount of room air will still be drawn through the side port on care to prevent damage to the valve. inspiration. Additionally, leaks around the mask will decrease Oxygen can also be chilled or compressed at high the FiO . These masks are not used as commonly as the next 2 pressures and stored in a liquid form. Although liquid class, the nonrebreather mask. oxygen (LOX), concentrated oxygen in liquid form, sys- tems permit large volumes of oxygen to be stored in a relatively small space, there are several disadvantages to these systems. The tanks must be stored upright and spe- cial equipment is required for storage and cylinder transfer. Additionally, anecdotal reports suggest that, due to sys- tem leakage, unless the oxygen is used in a high volume agency, oxygen losses may exceed usage. Therefore, com- pressed oxygen cylinders are the most common method of storing oxygen in the prehospital environment. Oxygen cannot safely be administered at the high pres- sure at which it is stored (500 to 1,800 PSI). Instead, a regula- tor is used to decrease the pressure to a tolerable level. In addition, since oxygen is usually delivered in a con- tinuous fl ow rather than on-demand, regulators are coupled with fl ow meters to deliver a fi xed fl ow, measured in liters per minute (LPM). For portable regulators, the regulator and fl ow meter are integrated, while for fi xed (on-board) oxygen Figure 22-2 Nasal cannula. Non-Intubating Airway Management 397 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. A demand valve regulator is a device available that will provide 100% FiO at appropriate liter fl ows. When attached to 2 a 50 PSI oxygen source, this device delivers high LPM fl ows of 100% oxygen when the patient inhales. When the patient is exhaling, the valve closes and oxygen fl ow stops. This device is different from a manually triggered ventilation device in that it is the patient’s inspiratory effort that triggers the device. Therefore, the risk of over pressurization injury is minimized. However, the device cannot be used in apneic patients. Venturi masks, special masks with a restricted intake that permits an exact percentage of oxygen, can also be used to deliver oxygen, although their use in the prehospital environment is gen- erally limited to specialty care services. These devices use a face mask connected to a specially designed adapter. These adapters have small holes in the sides and are designed so that when a specifi c oxygen liter fl ow is delivered to the adapter, a specifi c amount of room air is drawn into the adapter as well, called the venturi effect. This mixing provides a very specifi c oxygen con- centration. Generally speaking, unless a patient is already using a venturi mask and is not hypoxic or is on a fi xed FiO during a 2 specialty transport, there are no indications for the prehospital use of the venturi mask. Generally speaking, patients can be thought of as being at minimal risk for hypoxia, at moderate risk for hypoxia, or hypoxic. Patients at minimal risk for hypoxia may ben- efi t from a nasal cannula, depending on the patient’s clini- cal condition. Patients at moderate risk for hypoxia or who are hypoxic should receive high-concentration oxygen (i.e., a Figure 22-3 Nonrebreather face mask. nonrebreather mask). Any patient who requires active airway management should be preoxygenated with a nonrebreather Nonrebreather face masks (Figure 22-3) are designed to mask. Once the patient is being oxygenated, the remainder of overcome the issue of room air dilution by adding a reservoir the basic airway management equipment should be prepared to the oxygen supply system. While oxygen fl ows, it simul- to address ventilations. taneously supplies oxygen into the mask and into a reservoir bag. When the patient exhales, a one-way valve seals and Equipment for Basic Airway the oxygen is directed into the reservoir. When the patient Management inhales, the one-way valve opens and the patient breathes the oxygen from the reservoir. There are multiple methods for opening the airway and ven- Although a normal adult male may have a minute ventila- tilating a patient who is in respiratory distress or respiratory tion of 6 to 8 LPM, this ventilation occurs during inhalation arrest. A number of techniques can be used to manually open and airfl ow is not continuous. The fl ow during inhalation may the airway. Devices, such as oropharyngeal and nasopharyn- approach 50 LPM!9 Oxygen delivery from a regulator, on the geal airways, can be used to help maintain an open airway. other hand, is continuous and limited to the liter fl ow settings The most commonly used device for providing ventilatory on the regulator. The reservoir bag on the nonrebreather mask assistance is the bag-valve-mask assembly. When used prop- supplies the additional liter fl ow required during inhalation by erly, these devices can effectively be used to ventilate most storing oxygen during exhalation. This is why it is important patients. Other devices such as the pocket mask, the manu- that the liter fl ow is set high enough that the reservoir bag does ally triggered oxygen-powered ventilator, and the automatic not collapse during inhalation. Most nonrebreather face masks transport ventilator are also available to provide ventilation. have two exhalation ports, at least one of which is left open. Furthermore, suction is an important and frequently over- If the reservoir bag is collapsing during inhalation, room air is looked adjunct to airway management. drawn through the side port to prevent rebreathing of carbon dioxide. Oropharyngeal and Nasopharyngeal Nonrebreather face masks (NRFM), oxygen masks Airways with an oxygen reservoir, can deliver up to 80% FiO ; they Some of the most fundamental and easiest to use devices 2 do not deliver 100% FiO because there will always be some for airway management are the oropharyngeal and nasopha- 2 room air mixing through the open side port. ryngeal airways. As discussed in Chapter 20, the most 398 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 22-5 Nasopharyngeal airway. Figure 22-4 Oropharyngeal airway. common anatomic structures obstructing the airway are the Although the nasopharyngeal airway is less likely to stimu- soft palate and the epiglottis. Since the epiglottis is attached late a gag refl ex, patients may vomit or sneeze after nasopharyn- to the hyoid bone by the hyoepiglottic ligament, anterior geal airway placement. Therefore, suction must be immediately displacement of the hyoid opens the airway. The hyoid is available when a nasopharyngeal airway is placed. indirectly attached to the tongue, and anterior displacement There are a number
of advantages to the placement of of the tongue facilitates anterior displacement of the hyoid. the nasopharyngeal airway. These include the ability to place Additionally, the tongue can increase airway turbulence by them in patients with trismus or in those who are otherwise narrowing the upper airway. The oropharyngeal airway is unable to open their mouths. Nasopharyngeal airways can designed to address this issue.10,11 The nasopharyngeal air- also be used in patients who have an intact gag refl ex. way helps to displace the soft palate anteriorly, improving The only true contraindication to the placement of the airfl ow through the upper airway. Neither the oral airway nasopharyngeal airway is the patient’s inability to tolerate the nor the nasopharyngeal airway provide protection against airway. Care must be taken if it is being used in someone with a aspiration.12 head injury. Make sure that there is no evidence of a basilar skull Oral airways come in a number of sizes, from neonatal fracture, as there is some risk, although very slight, of placing to large adult (Figure 22-4). Preparation of an oropharyn- the airway into the cranium.15–20 In addition, patients with bleed- geal airway involves measuring the appropriate size for the ing disorders or who are on blood thinners are at risk of signifi - patient. Two common methods are used. The fi rst is to mea- cant epistaxis from nasopharyngeal airway placement. sure the airway from the midline of the lips to the angle of the Like the oropharyngeal airway, the nasopharyngeal air- jaw. The second is to measure the airway from the corner of way must be measured before placement to assure good sizing. the mouth to the inferior tip of the ipsilateral earlobe. Either The most common method for measuring the nasopharyngeal method is appropriate. airway is to place the airway against the face, measuring from An airway that is too small will not displace the tongue the nare to the ipsilateral inferior tip of the earlobe. Unlike the and jaw anteriorly and is at risk of being lost in the airway. An oral airway, the nasal airway should be lubricated before use. oral airway that is too large will tend to rise out of the mouth In addition, pretreatment of the nare with an inhaled vaso- and during ventilation, may actually displace the tongue pos- constrictor (e.g., neosynephrine) and topical anesthetic (e.g., teriorly. Therefore, it is important to only use an oral airway spray or viscous lidocaine) before placement may improve if the appropriate size is available. patient tolerance and decrease bleeding. It is important to note that the oral airway may stimulate a gag refl ex and should not be used in patients with an intact Bag-Mask Assembly gag refl ex.13,14 If an oral airway is to be used, suction must The bag-mask assembly is the most commonly used device be immediately available in the event that the patient vomits for providing assisted ventilation. In the operating room, during placement. anesthesiologists use high-fl ow respiratory gasses that con- While the oropharyngeal airway is made of hard plas- tinuously fl ow through a bag to a mask and that are checked tic, the nasopharyngeal airway is made of soft silicone with a by a valve which the anesthesiologist controls; hence the beveled tip (Figure 22-5). The nasopharyngeal airway is use- name bag-valve-mask. ful in patients with an altered mental status but with an intact In the prehospital environment, self-infl ating bags with gag refl ex. a reservoir, or bag-mask assembly, are the most commonly Non-Intubating Airway Management 399 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. cuff style mask is the most commonly used. These various mask types can also be attached to the ventilation devices discussed later. Barrier Devices and Pocket Masks Although mouth-to-mouth ventilation is still taught in CPR, there should be no need for an on-duty Paramedic to per- form this skill. If standard ventilation devices are not avail- able to the prehospital provider during a response, he should consider carrying a disposable face shield barrier device Figure 22-6 Bag-mask assembly. (Figure 22-7). Although not recommended by the American Heart Association except to the lay public, they are probably better than no barrier device at all. A second device that is used devices (Figure 22-6). The distal adapter of these bag- available is the pocket mask. mask assemblies is designed to attach to a mask or to the The pocket mask is a face-mask device that is powered 15 mm adapter of an endotracheal tube or an alternative air- by the lungs (Figure 22-8). Although devices without an oxy- way device. They are available in adult and pediatric sizes. gen inlet port are available, they should not be used in the There are common features to all of the devices. emergency medical environment. Rather, a device with an Every bag-mask assembly has a method of attachment to oxygen inlet port should be used to provide enrichment to the an oxygen source. This tubing runs into a self-infl ating bag. 17% oxygen in an exhaled breath. The masks are equipped Adult bags may be as large as 1,600 cc. Attached to the bag with a disposable one-way valve. is a reservoir that serves the same function as the reservoir on There are a number of limitations to the use of the pocket the nonrebreather mask. The reservoir allows oxygen fl ows mask in the prehospital environment. Although they have been far above the fl ow from the regulator without entering room demonstrated to be superior to one-person bag-mask assembly air. The oxygen passes through a one-way valve and out the distal port. On exhalation, expired gasses escape distal to the one-way valve, preventing remixing in the bag. Although bag-mask assemblies are commonly used, they are not nearly as easy to use as they appear. As early as 1983, it was clearly demonstrated that use of the pocket mask proved to be far superior to the one-person bag-mask assembly tech- nique. Although rescuers are able to deliver appropriate tidal volumes of 6 to 7 mL/kg, the excessively large volumes of adult bag-mask assembly ventilators are associated with over ventila- tion. In addition, technique can vary greatly, and overly rapid high-pressure ventilation typically results in gastric infl ation. Excellent bag-valve-mask technique is therefore an important skill for the Paramedic to master.21–23 Preparation of the bag-mask assembly is simple. The device is removed from its packaging and attached to an oxygen source fl owing at least 15 LPM. If a bag reservoir Figure 22-7 Barrier device. is attached, it should infl ate. If the reservoir is made of col- lapsible tubing, it should be extended to its fullest length. The Paramedic attaches the mask to the ventilation adaptor. Some pediatric BVMs include a pressure relief pop-off valve between the bag and the mask. This pop-off valve should be closed to ensure adequate ventilation to the pediatric patient. Although most bag-mask assemblies are packaged with a single mask, there are a number of different mask sizes and styles. Mask sizes vary from premature infant to large adult. Mask styles include masks with air-fi lled cuffs; masks with- out cuffs; soft, circular style masks; and gel-fi lled masks. The appropriate-sized mask is the mask that seats from the bridge of the nose to the chin. Specifi c applications for different mask types will be dis- cussed in the following text. In general, however, the air-fi lled Figure 22-8 Pocket mask. 400 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. ventilation in regard to delivering appropriate tidal volumes, while using oxygen only during the “inhalation” phase of their inherent design makes them undesirable to use. They ventilation. They reliably deliver 100% oxygen. In addition, require a high degree of activity and respiratory fi tness on the they can be used in patients who are awake to provide inter- part of a rescuer to provide extended ventilation. Placing one’s mittent ventilatory support. face so close to the patient’s face increases the risk of blood, There are some limitations to these devices. These vomit, and body fl uid exposure.24–28 Also, the position for use is devices may still cause gastric infl ation and barotrauma. awkward. Nonetheless, these devices can be a good alternative Without a trigger extender, two rescuers are required to effec- to one-rescuer bag-mask assembly ventilation until assistance tively use the devices. There are no studies that compare these arrives. devices to other ventilation devices. Nonetheless, they are The pocket mask is prepared by pushing the dome of still in use and may provide the Paramedic with a ventilatory the mask out of the cuff if the mask is stored in a collapsed alternative. position. The oxygen port is attached to an oxygen source at Preparation of a manually triggered fl ow-restricted, 15 LPM. An alternative is to place a nasal cannula on the oxygen-powered ventilator is relatively straightforward. The rescuer at a high (10 LPM) fl ow. A one-way valve should be device must be attached to a 50 PSI oxygen source. A mask is attached to the inhalation/exhalation port. attached to the outlet port. Care must be taken to assure that the one-way valve unit is disassembled and cleaned after each use or that an in-line fi lter is used. Manually Triggered Flow-Restricted, Oxygen-Powered Ventilation Devices Automatic Transport Ventilators Manually triggered oxygen-powered ventilation devices have Automatic transport ventilators (ATV), mechanical devices a long history in EMS. However, older models were neither that deliver a specifi ed volume of respiratory gas, have been fl ow nor pressure restricted and were prone to producing gas- used in the prehospital environment in Europe since the late tric infl ation and barotrauma.29,30 The more recent versions of 1970s. Although not used nearly as extensively in the United these devices are fl ow restricted and the valve pressures are States, these devices are gaining increasing acceptance.31,32 limited to less than 30 cm water, the commonly accepted car- There are now several models of automatic transport ventilators diac sphincter opening pressure (Figure 22-9). that are designed specifi cally for use in the prehospital environ- This pressure restriction limits gastric infl ation, but does ment (Figure 22-10). Although most studies on these devices not eliminate it. Most of these devices can be both manually have focused on their use in the intubated patient, there has been triggered or triggered in the same fashion as a demand valve some research into using automatic transport ventilators with a device. mask for face-mask ventilation. Flow-restricted oxygen-powered ventilation devices have The automatic transport ventilator has demonstrated a the advantage of delivering high oxygen fl ow rates (40 LPM) number of advantages compared to other methods of non- intubated ventilation. The ATV allows one rescuer to deliver consistent tidal volumes at a set rate. The automatic feature allows one rescuer to use both hands to seal the face mask. ATVs have demonstrated better lung infl ation and less gas- tric infl ation than bag-mask assemblies or oxygen-powered, manual-triggered devices. In addition, they consume signifi - cantly less oxygen than other devices. There are disadvantages to the ventilators. They require an oxygen source to function and some even require an electrical source. They may be inappropriate for small Figure 22-9 Flow-restricted, oxygen-powered ventilation device. Figure 22-10 Automatic transport ventilator. Non-Intubating Airway Management 401 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any
suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (< 30 kg) patients. A bag-mask assembly must always be avail- able for backup. Although ventilators will vary widely by manufacturer, there are common features. All will have an oxygen input source that must usually be attached to a 50 PSI oxygen source. All will have a means of setting rate and volume. There is usually a method for providing various rates at different vol- umes and vice versa. Most will have a disposable circuit that attaches to the oxygen output, usually with an in-line fi lter and distal one-way valve. The distal end of the ventilation circuit will have a standard 15/22 mm coupling. Beyond these features, however, the devices will vary Figure 22-11 Portable suction unit. widely. Most have a peak inspiratory pressure limit and an audible warning when that pressure is exceeded. Although most transport ventilators are volume cycled (deliver a spe- convert an unmanageable airway into an easily managed cifi c volume regardless of pressure) or time cycled (deliver airway through the removal of vomit, blood, and some a set fl ow rate for a specifi c time period), there are pressure foreign bodies. Prehospital suction units include porta- cycled (deliver to a specifi c pressure for a specifi c time) ATVs ble devices (Figure 22-11) and fi xed, wall-mounted units available. More sophisticated models will allow positive end (Figure 22-12). Having these pieces of equipment imme- expiratory pressure (PEEP) during ventilation as well as diately available d uring airway management is absolutely continuous positive airway pressure (CPAP). Finally, some critical. devices may have a demand valve mechanism that allows There are a number of different types of portable suc- patients to inspire on their own. These concepts in ventilation tion units. The least expensive are the hand-powered devices. will be discussed in more detail in Chapter 25. Using the Paramedic’s grip strength, these devices provide a lightweight, portable, and inexpensive alternative to portable Suction suction. Unfortunately, they tend to have a low volume and are One of the most critically important pieces of airway man- limited by the rescuer’s hand strength and fatigue. Oxygen- agement equipment is the suction unit. This device may powered suction units are another lightweight alternative. Figure 22-12 Wall-mounted suction unit. 402 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. They also have limited suction power and use large amounts All suction devices should be routinely checked for func- of oxygen. tion. Generally, suction tubing and sometimes even a rigid To provide more suction power, battery-powered suction catheter are left attached to the suction device. If these are not units are often used. These devices, although more expensive, attached, they should be stored on the device. Once the device provide very strong suction and can suction large volumes. has been turned on, the suction tubing should be kinked to Their greatest limitation is that, in actual use, the batteries test that adequate suction is generated. often loose their charge and integrity, resulting in loss of suction power after very short periods of suctioning. Some manufacturers have made devices that use interchangeable defi brillator batteries. The strongest suction devices are the wall-mounted, vacuum-powered units. These units provide adjustable vacuum Street Smart strength and completely disposable components. Although they provide the best suction, they are non-portable and can Placing the patient in left lateral decubitus position only be used in the ambulance. Nonetheless, they provide (side lying or recovery position) allows for drainage of excellent suction. secretions by gravity. Consider placing the patient in Regardless of type, the suction unit should be able to generate an airfl ow at the tip of 40 LPM and a vacuum of this position when the patient’s condition allows and 300 mmHg when the tubing is kinked closed. In addition, suctioning may be delayed for any reason. the collecting chambers and all parts of the device at high risk for contamination should either be disposable or easily disinfected. In addition to the suction unit, the Paramedic will need suction tubing and suction catheters. The suction tubing should Opening the Airway be thick walled and non-collapsible. The tubing should be Once the Paramedic has prepared his equipment, the next large diameter, capable of handling large and highly viscous step is to open the airway and provide positive pressure ven- substances. In addition to the tubing, a selection of suction tilation. Using basic maneuvers is often the most important catheters will be needed including rigid and soft catheters. intervention a Paramedic can perform, particularly for the The rigid pharyngeal suction catheters are known as pediatric patient in respiratory distress or arrest but not yet Yankauer or tonsil tip catheters. They are designed to suc- in cardiac arrest. tion to the posterior pharynx and can handle large volumes As was discussed in Chapter 20, the most common ana- of fl uid rapidly.33 Many of these catheters have a small tomical cause of airway obstruction is the epiglottis along side port that allows the Paramedic to apply suction only with the soft palate.9 Since uvular manipulation is less impor- when desired. These devices are available in multiple sizes tant if the patient has a patent oral cavity and oropharynx, although they are most commonly grouped into the adult or a irway manipulation techniques are oriented toward establish- pediatric size. ing a patent hypopharynx. Although traditional teaching has Multiple sizes of soft, sterile suction catheters should focused on the tongue as the most common source of airway also be available to the Paramedic. These catheters come obstruction, head-tilt, chin-lift, modifi ed jaw thrust, and jaw- in a number of sizes and are fl exible, allowing them to be thrust techniques apply equally well to epiglottis management. passed through the mouth, the nose, an endotracheal tube, This is due to the ligaments and muscles that interconnect the or a tracheostomy tube. These tubes, like the rigid pharyn- epiglottis, the hyoid, the mandible, and the tongue. geal suction tips, can become easily occluded with particu- For most non-trauma patients in respiratory arrest, the late matter. Therefore, it is important that water be available technique of choice for opening the airway is the head-tilt, chin to fl ush the catheters. These catheters are often sized using lift. The maneuver extends the neck over the atlanto-occipital the French catheter scale, which provides a measure of the joint (the joint between the skull and the fi rst vertebrae). In outside diameter of the catheter. The smaller the number addition, the chin lift displaces the mandible anteriorly. This on the French scale, the smaller the outer diameter of the in turn pulls the hyoid anteriorly and via the hyoepiglottic catheter. ligament, the epiglottis. There are side-port suction devices designed specifi cally The technique is performed by placing the palm of one to suction through endotracheal tubes. These devices fea- hand on the forehead and either actively hooking the mandible ture a “T” or “Y” piece that allows the endotracheal tube to with the fi ngers and lifting or griping the tip of the mentum be attached to the ventilator circuit (or bag-mask assembly) (chin) between two fi ngers and pulling forward. A common without interrupting the gas fl ow. There is either an integrated error is to simply place the fi ngers on the mandible and push soft suction catheter or a self-sealing port through which a upward. This action closes the mouth without moving the soft catheter can be placed. These devices greatly facilitate hyoid anteriorly. The jaw must be actively displaced in an endotracheal tube suctioning. anterior and caudad direction. In addition, minimal pressure Non-Intubating Airway Management 403 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. should be applied to the soft tissue under the mandible as this placed in the mouth and the fi ngers under the chin. The jaw may push the hyoid posteriorly. is then pulled forward. Although this technique effectively For the patient with suspected cervical spine injury, the opens the airway, it severely compromises the ability to head-tilt, chin lift can compromise the cerviocal spine; partic- ventilate the patient with a face-mask technique. In addition, ularly in high cervical injuries involving the fi rst and second it requires the Paramedic to keep his thumb in the patient’s cervical vertebrae.34–37 Therefore, an alternative technique— mouth. This technique puts the Paramedic at risk for losing the modifi ed jaw thrust—must be used. This technique dis- a digit, something that should be avoided if at all possible. places the jaw anteriorly, pulling the hyoid and epiglottis To avoid having the patient bite the Paramedic, a large oral anteriorly as well. There is minimal cervical spine movement airway can be lodged sideways in between the molars to act if the jaw thrust is performed correctly. as a bite block. Even with the placement of an oral airway The modifi ed jaw thrust is usually performed from the top as a bite block, the tongue-jaw thrust is probably of limited of the patient’s head, although it can also be performed from an practical use in the prehospital environment because it limits inferior position if needed. From above the patient’s head, the ventilation. right and left hand are placed palm-in on the right and left side of the patient’s head. The thumbs are placed on the prominence Cricoid Pressure of the cheekbones and the fi ngers are placed along the ramus While opening the airway, the Paramedic should also con- and angle of the mandible. The fi ngers are then lifted anteriorly sider the benefi ts of cricoid pressure (Figure 22-13). This and caudally (toward the feet) while the thumbs push posteriorly. technique, referred to as Sellick’s maneuver, involves the These opposing actions open the mouth and lift the hyoid and identifying the cricoid ring and assigning an individual to epiglottis. If the technique is performed from below the head, gently apply approximately 10 pounds of pressure in a poste- the only difference in hand position is that the airway manager’s rior direction throughout airway management; from the onset right hand will be on the left side of the patient’s face and vice of ventilation until completion of intubation. Since the cri- versa. The jaw will essentially be pulled toward the rescuer, again coid is a complete ring, the pressure is transferred directly to opening the airway. the esophagus and helps to keep the esophagus closed.38–42 The modifi ed jaw thrust can be performed on any patient Cricoid pressure has long been considered to prevent pas- regardless of suspicion of C-spine injury. The hand position- sive regurgitation and limit active emesis when properly applied. ing allows the Paramedic to both open the airway and form a Additionally, cricoid pressure may decrease gastric infl ation dur- mask seal at the same time. A sustained modifi ed jaw thrust, ing positive pressure ventilation. It is a non-invasive technique however, can be very tiring and may require multiple rescuers and, as long as it is maintained continuously, can limit (although to switch in and out of the role. not eliminate) the risk of aspiration. A third technique, the tongue-jaw lift, can also be used Cricoid pressure is not without its limitations. Cricoid in limited circumstances. In this technique, the thumb is pressure can actually worsen the view of the vocal cords Figure 22-13 Cricoid pressure. 404 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated,
in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. during laryngoscopy.43 Even when properly applied, it does ventilation” for the patient in respiratory distress, not arrest, not completely eliminate the risk of aspiration. In addition, will be discussed later. The technique for providing ventila- in vigorous emesis, it can lead to esophageal rupture; there- tion will depend on the device used. fore cricoid pressure should be released if the patient actively vomits. Excessive posterior pressure can also compromise an unstable cervical spine injury, as the cricoid cartilage is The Mask/Face Interface juxtapositioned across from the fourth cervical vertebrae. The most important task of bag-valve-mask ventilation is to Excessive posterior pressure may also cause laryngeal trauma form an effective mask seal while maintaining an open air- if excessive force is applied. In pediatric patients, excessive way. Recalling that the mouth is kept open by caudad (foot- force can actually occlude the trachea because the cartilage ward) displacement of the mandible while the hypopharynx rings that maintain an open trachea have not fully formed in is kept open by the anterior displacement of the hyoid, any the younger pediatric patient.44 Finally, cricoids pressure must technique to form a mask seal must also displace the man- be vigilantly maintained throughout airway management dible correctly. Although much is made of the pressure on the until large volume, high-capacity suction is available and, mask in forming the seal, the most important component of preferably, the patient is endotracheally intubated. Premature a good mask seal is to actually bring the face anteriorly and release of cricoid pressure can result in copious and explosive into the mask. emesis. The best mask seal which maintains an open airway is Another signifi cant limitation to cricoid pressure is that, made with light downward pressure on the mask and more unfortunately, pressure is often not on the cricoid at all but forceful upward displacement of the mandible. The lower face is applied to the thyroid cartilage. As will be discussed next, is, in essence, “gathered” into the mask to form the seal. This landmark recognition and appropriate identifi cation of the cri- method of forming a mask seal maintains an open mouth, coid ring can be diffi cult.45 Often, pressure will be applied to an anterior displacement of the hyoid and epiglottis, and a the most prominent structure, usually the thyroid cartilage. tight junction between the mask and the facial tissue. This There are a number of untoward consequences of thyroid is in contrast to strong posterior pressure on the mask that cartilage pressure. First, the thyroid cartilage is an incomplete may close the mouth and will push the hyoid and epiglottis structure, so posterior pressure will not achieve esophageal posteriorly. occlusion. Second, pressure on the thyroid cartilage may The fundamental method of gripping the mandible and cause the opening of the larynx to tip anteriorly, making the mask is the “C” and “E” technique. The major difference endotracheal intubation more diffi cult. Third, excessive pres- between one-rescuer bag-mask assembly ventilation and other sure may cause laryngeal injury. Therefore, proper location of techniques (two-rescuer and three-rescuer bag-mask assem- the cricoid ring is critical for effective and safe performance bly, ATV, etc.) is that with one-rescuer bag-mask assembly of this skill. ventilation, only one hand is used to make the seal while with To overcome the challenges of locating the cricoid ring, the other techniques, one of the rescuers has both hands free the Paramedic should be familiar with the anatomy of the for the procedure.47–50 region, as described in Chapter 20. Although there are a num- The mask is gripped with the thumb at the nasal side of the ber of methods for locating the cricoid ring, the easiest begins mask and the index fi nger on the chin side of the mask. These with locating the prominence of the thyroid cartilage. This two fi ngers are curved to make a “C” shape. The middle, ring, is usually the most prominent anterior midline structure of and little fi nger are extended along the mandible with the little the neck. Once this landmark is identifi ed, the index fi nger fi nger pushing forward on the angle of the mandible. These should be placed on it and then moved inferiorly along the three fi ngers are spread to make an “E” shape. Using the “C” midline. and “E” technique, the Paramedic should be able to maintain a The next landmark is the cricothyroid membrane, the liga- suffi cient mask seal while bringing the lower face up into the mentous band between the thyroid cartilage and the cricoid ring. mask. If a two-handed technique is used, both hands make mir- The inferior border of the thyroid cartilage should be easily iden- ror image “C’s” and “E’s.” tifi ed and a soft depression can be felt. The inferior border of this Certain facial characteristics will also make forming a depression is a solid structure, the cricoid ring. Once the cricoid mask seal more diffi cult. These include a small jaw (microg- ring is identifi ed, the thumb and index fi nger should be placed nathia), a large tongue (macroglossia), facial hair and trauma, on it and pressure applied posteriorly.46 This pressure should be no teeth (edentulous), and patients with minimal subcutane- maintained until the patient is intubated or, at a minimum, high- ous fat.9 Micrognathia and macroglossia require vigilance capacity suction is available. to anterior jaw displacement and maintaining the most open mouth possible. A better seal may be obtained on patients with facial hair if water-based lubricant is applied to the mask and Face-Mask Ventilation the facial hair before ventilation. Patients with facial trauma Once the airway is opened, the patient may begin to breathe present a signifi cant challenge. spontaneously. If this is not the case, the Paramedic must The best technique is to focus on gathering the face into begin ventilation of the apneic patient. The skill of “assisted the mask and suctioning frequently. Specifi c injuries such Non-Intubating Airway Management 405 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. as penetrating objects or puncture wounds to the face may This is important because the pressure is related to the fl ow require stabilization and sealing of the wound with petroleum rate of the gas. A higher pressure is needed to deliver a gauze to prevent air leakage. If a patient has dentures, these large volume in a short time period. On the other hand, less should be left in place to facilitate the mask seal.51 Premature pressure is needed if that volume is delivered over a removal of the dentures will result in a poor mask seal. Patients long time period. Since high airway pressure is the main with thin subcutaneous tissue or excessive subcutaneous fat cause for gastric infl ation and barotrauma, it is important will benefi t from the use of a softer mask or one into which to maintain as low an airway pressure as possible during air can be added and removed. ventilation. The gas fl ow/pressure/volume relationships are practi- Ventilation Volume cal because oxygenated tidal volume delivery is probably the and Airway Pressure most important goal of bag-valve-mask ventilation. Since Once the Paramedic has opened and is maintaining the airway the same tidal volume (and same amount of oxygen) can be and has achieved a good mask seal, the next action is to ven- delivered at lower pressures if the inspiratory phase is longer, tilate the patient. When a patient is receiving ventilation from the Paramedic should focus on providing slower, longer dura- a face mask, ventilatory gasses have the opportunity to enter tion, and lower pressure ventilations. In fact, ventilation that either the trachea or esophagus. Although the trachea usually delivers less oxygen to the stomach and more to the lungs is offers the path of least resistance, the lungs have a limited better ventilation. volume beyond which they will not expand. Therefore, any The practical consequences are that while the ventila- excess volume will end up in the stomach. tory rate (12 to 16 breaths per minute for an adult, 20 breaths The main determinant of esophageal resistance is per minute for a pediatric patient) remains the same, the the lower esophageal, or cardiac sphincter, opening pres- v entilations themselves are given over a longer time period. sure. Not an actual valve, the lower esophageal sphincter The inspiratory phase of ventilation should occur over two (LES) is a functional portion of the esophagus where the seconds and the expiratory phase should take about the same walls of the esophagus contract inwardly, forming a physi- amount of time. If a bag-mask assembly device is being used, cal barrier to the refl ux of stomach contents up the esopha- the Paramedic should use a mental trigger like “squeeze, gus. Although probably somewhat lower in the prehospital squeeze, release, release” while performing ventilations. patient, the accepted value for normal LES opening pressure Bag-valve-mask ventilators are available with built-in in healthy individuals is 30 cm water. Upper airway pres- and aftermarket add-on manometers that allow the Paramedic sures in excess of 30 cm water will cause the LES to open. to know exactly how much airway pressure is being gener- Most likely, LES opening occurs over a range of pressures, ated. In addition, most mechanical ventilation devices (man- with lower pressures causing small leaks and high pressures ually triggered fl ow-restricted, oxygen-powered ventilators causing larger leaks. and automatic transport ventilators) have built-in pressure In addition, there are a number of factors which relax relief valves. Whenever possible, a manometer should be the LES. Alcohol, mint, chocolate, and caffeine will all relax used to minimize the risks of overpressurization. If a manom- the LES. In addition, LES opening pressure drops in cardiac eter is not available, however, delivering the ventilations as arrest to almost zero within a few minutes. If any of these previously described should provide the minimum pressures factors are present, the LES will open at lower pressures, possible. increasing the risk of gastric distention and vomiting. These are two consequences which can be minimized with thought- Bag-Mask Ventilation ful face-mask ventilation. The most commonly used device, as discussed previously, is The tidal volume in a healthy individual is somewhere the bag-mask assembly. The greatest limitation to this device between 5 to 7 cc/kg of ideal body weight.52–54 At a respi- is that it is diffi cult for a single rescuer to provide effective ratory rate of 12, this results in a minute ventilation of tidal volumes. The diffi culty arises from the need to simul- 4 to 5 LPM. For an acutely ill patient (e.g., asthma), the taneously form a mask seal, maintain an open airway, and minute ventilation demands may reach almost 20 LPM. squeeze the bag. In general, however, the ventilation demands of most pre- Effectively performing all three techniques single- hospital patients do not exceed 7 cc/kg/breath. Therefore, handedly is almost impossible. Therefore, although the Paramedic should attempt to deliver a tidal volume of one-rescuer bag-mask ventilation is commonly performed, 6 to 8 cc/kg ideal body weight/breath. two-rescuer ventilation is much preferred. In addition, there The volume delivered can be thought of as depend- are three rescuer techniques that are also used, as will be ing on two variables: gas fl ow rate and duration of fl ow. discussed in the following text. That is, the same volume (i.e., 800 cc) can be delivered if One key to proper performance of bag-valve-mask venti- the gas fl ow rate is 800 cc/second and the patient is venti- lation is maintaining a proper mask seal (Figure 22-14). The lated for one second as is
delivered if the gas fl ow rate is Paramedic’s thumb and pointer fi nger form the letter “C” over 400 cc/second and the patient is ventilated over two seconds. the edge of the mask, applying pressure to hold the mask to the 406 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 22-14 Proper hand positioning to maintain bag-valve-mask seal. face. The other three fi ngers form the letter “E” fi rmly holding the delivered volume, then these techniques should not be the mandible, allowing the provider to simultaneously provide used. In addition, since many larger muscle groups are being either a jaw thrust or chin lift depending on the need to limit used, these techniques can be very tiring. These techniques cervical spine movement. are mentioned only because they have been described and Estimating the volume delivered can also be diffi cult. used. However, they have not been validated. The Paramedic The Paramedic should take advantage of any opportunities must decide what technique is safest and most effective for to practice this skill when volume measuring is available. the patient. Several simple rules can assist the Paramedic in estimating Although the least recommended of the bag-mask assem- the ventilation volume. bly techniques, single-rescuer bag-mask assembly ventilation First, the volume should be suffi cient to cause chest is probably the most common prehospital method of ventila- rise but not so much that the chest stops rising. The breath tion. There are several key points to remember in perform- should enter with little resistance and abdominal disten- ing single-rescuer bag-mask assembly ventilation. The fi rst tion should not be seen. There should, in fact, be almost no is that maintaining an open airway while establishing a good abdominal movement. In addition, the Paramedic should mask seal with one hand is diffi cult and, in some patients, know the volume of the bag on the bag-mask assembly. The impossible. The Paramedic should recognize when a patient average adult bag is 1,600 mL. Therefore, for a 70 kg male, cannot be ventilated without a second rescuer and immedi- approximately one third of the volume of that bag should ately call for assistance. The second key to performing good be delivered. one-rescuer bag-mask assembly ventilation is to be able to For Paramedics with small hands, there are techniques provide appropriate one-handed tidal volumes. which may be employed as an alternative to squeezing the The two-rescuer technique of bag-mask assembly venti- bag with two hands. Although no research has ever been lation (Figure 22-15) is a much more effective method of pro- performed to demonstrate the safety and effi cacy of these viding ventilatory support. The major difference between this techniques, there are anecdotal stories of effective ven- and one-rescuer ventilation is that each rescuer can now focus tilations being performed with their use. In the fi rst tech- on a specifi c component of the procedure. The Paramedic nique, the bag is compressed between the rescuer’s hand responsible for opening the airway and forming the mask seal or forearm and a solid object, such as the rescuer’s leg. In can use both hands to do this while the Paramedic responsible the second technique, the rescuer uses both hands to open for ventilation is better able to control the ventilatory volume the airway and form the mask seal while the bag mask is and rate. The same techniques and volumes as mentioned squeezed between the thighs. The major limitation of these for one-rescuer ventilation apply to two-rescuer ventilation. techniques is the possibility of poor control of the delivered This is the recommended technique for performing bag-mask volume. If the Paramedic is unable to effectively estimate assembly ventilation. Non-Intubating Airway Management 407 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 22-15 Two-rescuer bag-mask assembly ventilation. There may be times when mask seal is diffi cult but airway to be maintained open more easily. The key to pre- additional rescuers are available. There are two forms of venting hyperventilation is for the Paramedic to take a slow three-rescuer bag-mask assembly ventilation that can be deep breath during the patient’s expiratory phase and then to performed. deliver the ventilation slowly over two seconds.55,56 In the fi rst of the two techniques, the third rescuer assists in making a mask seal. Once the fi rst two rescuers are in posi- Manually Triggered Flow-Restricted, tion, the third rescuer applies posterior pressure to the mask. Oxygen-Powered Ventilation Devices Although there may be some merit to this technique if the mask seal is particularly diffi cult to obtain, it has a number These devices offer a manual alternative for one-rescuer of limitations. ventilation. The mask seal is made as described previously. As was discussed previously, the most effective mask If the ventilation device has a well-designed trigger, the seal is made by gathering the patient’s face anteriorly into mask seal can be made with two hands and the device still the mask, not by pushing the mask posteriorly. The poste- triggered without having to release the seal. If the trigger rior pressure increases the risk of occluding the airway. In is poorly placed, however, it may be necessary to perform addition, having three people this close to the head makes the a one-handed seal while the other hand triggers the device. airway very “crowded” and moving the patient or performing Otherwise, a two-rescuer approach may be needed. This sec- other techniques may become impossible. ond technique, unfortunately, negates most of the benefi ts The second technique for three-rescuer bag-mask assem- that manually triggered fl ow-restricted, oxygen-powered ven- bly involves having the third rescuer apply posterior cricoid tilation devices offer over single-rescuer bag-mask assembly pressure, as discussed previously. This technique offers the techniques. advantage of having an extra hand available (the rescuer’s Since the devices are manually triggered, it is impor- hand not applying cricoid pressure) if needed to assist the two tant that the Paramedic provide no more than two seconds of primary Paramedics without overcrowding the area around ventilation at a time. Although the devices should have inte- the patient’s face. In addition, the benefi ts of cricoid pressure grated overpressurization relief valves, a prolonged inspira- are also obtained. tory phase without an expiratory phase may result in gastric infl ation and the potential for barotrauma. Pocket Mask Ventilation Using the pocket mask requires only two skills: forming a Automatic Transport Ventilators mask seal and not hyperventilating. The pocket mask is The automatic transport ventilator is a relatively simple tool sealed to the face in the same manner as other masks. The for face-mask ventilation. As was discussed previously, the Paramedic can use a two-handed technique to make the ventilator is set at an appropriate rate and volume for the mask seal, improving the quality of the seal and allowing the patient. The ventilator circuit is then attached to the mask 408 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 22-16 Assisting ventilations with an automatic transport ventilator. and the mask seal obtained with a two-hand technique Patient Assessment (Figure 22-16). The ventilator will automatically cycle at for the Ventilated Patient the preset rate, freeing the Paramedic to focus solely on It is important for the Paramedic to assess all patients maintaining the mask seal and keeping the airway pat- whom she believes are being adequately ventilated. The ent. Shortly after ventilation is initiated, it is important to most important assessments are observation, auscultation, assess that the proper rate and volume have been selected. and physiologic monitoring. The most important task to This is done through observation of the chest rise and complete immediately is to observe the patient. Chest rise fall. In addition, all ventilators should have an overpres- and fall should be noted. The abdomen should be observed surization relief valve and alarm. If the alarm sounds, it is for signs of gastric infl ation. In addition, unless the patient important to immediately reduce the volume and check is in cardiac arrest, the signs of respiratory failure (pal- the rate to assure that “breath stacking” is not occurring. lor, cyanosis, and diaphoresis) should begin to improve. Breath stacking occurs when insuffi cient time is allowed for Immediate and ongoing observations of the patient and exhalation. of the effectiveness of ventilation will provide early warning of ventilatory failure. Continuing Ventilatory Care Once a general observation is complete, the Paramedic If the Paramedic is able to successfully ventilate the patient, should auscultate lung sounds. Auscultation can give some there are some immediate postventilation activities that must idea of the adequacy of ventilation (e.g., are lung sounds be performed. These include assessing the patient, inserting heard over the lung bases?). In addition, diagnostic clues an oropharyngeal (if tolerated) or nasopharyngeal airway, and may be discovered including asymmetric lung sounds, preparing the patient for transport. Each of these activities adventitious lung sounds (wheezes, crackles, and rhonchi), is important to assure that adequate ongoing care is being or absent lung sounds. Auscultation over the epigastrium provided. may also give the Paramedic a sense of how much gastric infl ation is occurring. In addition, a complete reassessment of airway, breathing, and circulation, including lung fi eld and epigastric auscultation, should be performed anytime Street Smart a patient’s status changes. After observation and auscultation, the patient should have physiologic signs measured and monitored. These The “look, listen, and feel” step of CPR is important include pulse, blood pressure, EKG, and pulse oximetry. for any patient who is being assisted in ventilation. The pulse oximetry probe should be applied early. A good pulse oximetry signal at a fi nger or earlobe indicates a blood Non-Intubating Airway Management 409 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. pressure suffi cient to produce at least peripheral perfusion pressure and pulse rate should then be measured manually. (Figure 22-17). An EKG (rhythm strip) should also be obtained to assess for arrhythmias. These parameters should be continuously monitored to assure that they remain stable or improve. Any Professional Paramedic deterioration (tachycardia, bradycardia, hyper- or hypoten- sion, or hypoxia) should trigger an immediate search for a cause. The professional Paramedic knows that normal After assessment, the patient should be prepared for pulmonary respiration relies on negative thoracic transport. Generally speaking, these patients are most easily pressure. This negative pressure is assistive in allowing transported on a long spine board. Care must be taken, par- ticularly for pediatric patients, to assure that the positioning blood return to the heart. By taking over ventilation, on the board does not cause the airway to obstruct. Unlike the physiology is changed from negative pressure to the intubated patient (discussed in Chapter 23), placement positive pressure. The patient may experience signs of a cervical collar for the non-trauma patient is not recom- of diminished cardiac output. This situation may mended as