Providers of Medical Care and Assistance - Essay Example

? The Management of the Injured Pregnant Patient The Management of the Injured Pregnant Patient As providers of medical care and assistance to the sick as well as injured patients, technicians and paramedics have the lives of their patients on the line. Prolonging their lives as well as keeping them safe from other bodily harm while waiting for emergency transport and attention of emergency physicians is their major concern. However, when the patient is pregnant, two lives are at risk: the mother and the foetus she is carrying (Caroline, 2008). Due to risks that could affect the growing foetus inside a pregnant patient, there is a limit in the medications being administered during an injury (Pollak, 2011). Another thing to consider is the change in the anatomy of the pregnant patient, in a way that normal procedures may not actually work and give the results expected. Thus is the need of the additional knowledge of such physiological changes that occur in the body of the gravid patient (Mulholland, Lillemoe, & Doherty, 2011). Although most of the available options in alleviating stress and pain would entail similar methods used on normal people, care must be used when applying them to a pregnant woman since aside from the enlargement of the abdomen and the rearrangement of organs, there is also the presence of the foetus as well (American College of Physicians, 2008). Once the third trimester is reached, most of the organs in the abdomen are displaced upwards by the grown foetus, and the blood flow from the aorta can be diverted or cut off due to being compressed (Velmahos, Degiannis, & Doll, 2012). Therefore, to be able to provide proper care of an injured pregnant patient, proper information regarding the anatomic and physical characteristics as well as the health status of both the mother and the foetus must be carefully monitored in order to prolong their lives in an emergency situation. Several types of medical situations can be experienced by the pregnant patient. Among these are: blunt or penetrating trauma; coma associated with trauma; poor respiratory rate associated with trauma; penetrating wounds; flail chest; burns associated or in combination with trauma; bone fractures; limb paralysis or other spinal cord injury; and amputation near the wrist or ankle (Pollak, 2011). These can be attributed to the fact that pregnant women, especially those in the advanced stages are currently under stress, particularly due to too much alterations in their body shape and their internal organ arrangements (Pape, Sanders, & Borrelli, 2011). Also, the changes in their internal physiology due to the growth of the foetus could add to their worries. Increase in heart rate, renal perfusion as well as respiratory rate to accomodate foetal growth can be noted, as well as the decrease in the movement of smooth muscles such as the intestines that contribute to the delay when emptying the bowels (Velmahos et al., 2012). Is is therefore important to note such alterations in the body when performing a physical examination not just during emergency situations but also in follow-ups or any other kind of physical exam. Among recorded cases worldwide, trauma is the highest and the leading cause of maternal mortality, which accounts to 46% of maternal deaths (Pape et al., 2011). The incidence of trauma also increases as the third trimester is being reached, and just over half of the trauma cases are recorded in the advanced stages of the pregnancy (Barraco, et al., 2010). In such cases that the gravid mother is able to survive, though she may have less than 5% mortality the foetus has a higher chance of dying by around 40-71% (Velmahos et al., 2012). There is also an additional risk to falls, mainly because of the change in the physiology of a pregnant mother. Still another cause would be domestic violence, which is often not recorded and overlooked, but is a very significant cause of trauma among gravid patients (Pape et al., 2011). In a study by Kenney and Mirvis (2010), they explained how non-invasive procedures in managing injured pregnant women can have much more benefits than operative care. Through the use of non-invasive and non-operative methods of diagnosing a pregnant patient, there is recorded decrease in fluid loss as well as a better long-term outcome for patients since the only concern for the doctors would be to further prevent necessitating some additional surgery just to properly diagnose. However, there are certain controversies with regards to the use of several imaging modalities if there is the presence of a foetus in the abdominal region. Computerised Tomography (CT) scans are very reliable when it comes to the need of detecting and excluding injuries in a patient (Kenney & Mirvis, 2010). However, the exposure of the foetus to a large dose of radiation poses a threat due to its teratogenic effects. The understanding of the aspects of imaging and radiation as well as the potential for foetal injury must also be taken into consideration, and be carefully monitored (Patel, Reede, Katz, Subramaniam, & Amorosa, 2007). But according to Kenney and Mirvis, if the benefits would outweigh the risk, and if there is a higher chance of saving both the mother and the foetus’ lives, then CT scan can be used to promptly diagnose and treat the patient (2010). Non-obstetric pain may be a result of either the presence of diseases in the internal organs (cholecystitis or kidney stones) or due to blunt force trauma in pregnant women. Blunt trauma among pregnant patients comprises 7% of complications among recorded cases, which could threaten the expectant mother and child (Lowdermilk, Gavant, Qaisi, West, & Goldman, 1999). In blunt abdominal trauma, CT scan can also be used to check if there are obstructions within the gastrointestinal tract of the gravid woman (Wallace, Davis, Semelka, & Fielding, 2011). Primary imaging modalities used for such purpose are the use of Magnetic Resonance Imaging (MRI) as well as ultrasound are good choices for image diagnostics for pregnant women due to decreased risks in foetal exposure to radiation . However, when contrast dyes are used, there is still a risk to radiation exposure for the foetus, thus is the avoidance of such when dealing with pregnant patients. It is only used for extreme cases when there is no other way of diagnosing vital information with regards to a pregnant woman’s well-being. Since foetal loss and maternal disability are strong catastrophes that may have long-term effects in the pregnant woman as well as her family, it is essential that injuries must be addresses at the most non-invasive way. The unnecessary use of radiation in pregnant patients was evaluated to decrease the risks involved during emergency procedures. Possible effects of high-dose ionising radiation must be limited when used in pregnant patients (Barraco, et al., 2010). Also, any radiation exposure of less than 5 rad is considered safe in all stages of pregnancy. Miller et al. (2010) considered factors when estimating the likelihood and severity of radiation effects on patients. In order to implement as such, patient medical history including diseases and genetics as well as current condition or status, in the case of pregnancy are also considered. Monitoring the dosage of fluoroscopically guided imaging modalities was also done in order to assess the radiation levels a patient is being exposed to. Lastly, follow-ups such as patient monitoring after radiation exposure was implemented in order to check whether deterministic effects are present in the patient after such procedures are implemented. Due to the changes in the pregnant woman’s physiology, the uterus is much more exposed and is much more vulnerable to penetrating trauma, which could result to foetal injury (Pollak, 2011). Penetrating trauma is one of the leading causes of the abrupt rupture of the placenta, which could cause problems such as the separation of the placenta from the uterine wall, causing premature or forced labor (Aghababian, 2011). Whereas blunt trauma is usually accidental and unintentional, penetrating trauma is most likely intentional, with the need for the resuscitation and stabilisation of the gravid mother. Due to the displacement of the organs upwards the abdomen, the mother is protected from any bodily harm or abdominal penetrations by the growing foetus. Also, the amniotic fluid and the uterus help prevent additional injury by absorbing energy from blows. However, the shearing forces of deceleration can cause placental abruption, or the detachment of the stiff placenta from the soft uterus. Bleeding, pain as well as contractions and tenderness would be common signs for a gravid patient that sustained such injuries, and immediate medical action must be taken. There is also the possible mixing of the maternal and foetal erythrocytes which could pose problems should the mother have a different Rh-factor from the foetus. Lastly, rupture of the bladder in a pregnant woman may be present and is characterised by the presence of profuse bleeding. Airway management for a pregnant patient that needs emergency care is an urgent matter due to the need of the foetus to have ample oxygen supply. However, if the mother’s chest is deformed, there would be difficulty in supplying the strong demand for oxygen. Aggressive emergency care must be given not just to sustain the life of the pregnant woman but also to assure the best possible outcome for the foetus as well (Pollak, 2011). Resuscitation efforts’ ultimate goal is the proper delivery of oxygen, and if there is a need for the use of a basic life support (BLS) in order to give additional oxygen to the patient, then it must be done promptly (Kovacs & Law, 2011). In the case of a pregnant patient, she must be removed from a supine position since the presence of the foetus causes aorto-caval compression, which in turn would contribute to hypotension of the patient (Fulde, 2009). Also, a jaw-thrust is essential to open the airway and would help increase the entry of oxygen upon the administering of BLS. In the event that tracheal intubation is needed to further increase the oxygen input in a patient, it must also be done especially in cases where the lungs have problems or are blocked in some ways. It is imperative that overall assessment of the patient must be done quickly and efficiently in order to give the most appropriate resuscitation method for the patient (Kovacs & Law, 2011). Pregnant women may also get injuries due to fires, and may sustain burns. A pregnant woman would get additional stress due to burns, apart from their present stressful condition (Guo, Greenspoon, & Kahn, 2001). Although pregnant patients that suffer from burns may well survive, it is still important that the foetus be monitored since there can be possible effects, especially during the first and second trimesters where the foetus can easily get harmed (Agarwal, 2005). In order to prevent losses and mortalities, proper and prompt assessments of the gravid patient must be done. Fluids must be replaced within a pregnant woman to prevent further stress in both her body and the foetus. Second is the administering of oxygen as well as ventilator support, especially when the patient had the unlikely chance of inhaling smoke or had underwent smoke inhalation injury aside from sustaining burns. Next is the delivery of the foetus, if the pregnant woman is already in her third trimester. This would prevent oxygen deprivation of the foetus, which could cause mental retardation if not addressed properly. Lastly is the aggressive treatment of sepsis and thrombosis of the mother should there be a suspected infection from the burn sites. This would prevent onset of infections that may get passed onto the young child during the process of breastfeeding or due to contact with skin (Guo et al., 2001). Pregnant women are also susceptible to fractures and displacement of joints. This can be attributed to hormonal changes in the body of the pregnant woman (Pollak, 2011). Such hormonal changes loosen up the joints, and along with the weight of the foetus and the displacement of the internal organs, these can also contribute to the change in the patient’s way of balancing upright. All factors can contribute to a gravid woman losing balance and falling with risks of fractures. Aside from this, blood loss may also occur, which is hard to detect at times since the body would most likely undergo a state of shock and would therefore mask the loss of blood in the body (Velmahos et al., 2012). In order to prevent doing harm to the foetus, as much as possible all operations to be done with the fractured bone must be delayed till after delivery of the child. However, in the event that delay of procedures is not possible, consideration with regards to the use of anaesthesia, intraoperative radiology and orthopaedics must be taken into account (Pape et al. 2011). Other considerations such as the gestational age, viability, level of maternal and foetal compromise, the necessities of fixing the fracture as well as the cumulative effects of radiation to the child must also be well-taken care of . Close monitoring of both the mother and the growing foetus must be done as much as possible, and the involvement of obstetricians is much needed in order to prevent devastating foetal trauma in the future. Spinal cord injuries may also be diagnosed among pregnant patients. Obstetricians must be fully aware of the presence of such a condition since there can be additional problems such as urinary tract infections (UTI), decubital ulcers (DU), impaired pulmonary function as well as autonomic dysreflexia (AD). For the transport of such patients, lifting and moving techniques must be adjusted accordingly (Pollak, 2011). According to the American College of Obstetricians and Gynecologists (ACOG), in 2005, too much stimuli to areas such as the bladder, the bowels or the uterus could cause numerous reactions of the body such as hypertension, headache, nasal congestion, uteroplacental vasoconstriction and respiratory distress, which are usually exhibited by patients with AD. Particularly, AD can be very debilitating and could cause problems in the foetus, such as hypoxemia. During labour, if the pregnant patient has spinal injuries, care must be considered when administering anaesthetics. While the patient may not feel any pain, the anaesthetic could help in calming down the nervous system and preventing the onset of AD. However, if there is such evidence the patient has AD during the second stage of labor, delivery by forceps of vacuum assisted delivery may be done, with adequate anaesthesia (ACOG, 2005). In patients undergoing caesarean section, spinal or epidural is needed for deliveries. Before and after birth, additional exercises such as muscle-strengthening are needed in order for the patient to increase mobility as well as a form of rehabilitation. While it is true that there are major considerations when treating a pregnant woman under emergency situations, the foetal condition is equally as important when assessing the state of the patients. Since there are major physical modifications in the gravid woman’s body, aside from adjusting to her needs, foetal monitoring must also be done to assure that in keeping the mother stable, foetal mortality would also be prevented. However, in using diagnostics such as different imaging modalities, care must be used in choosing the appropriate method of assessing the woman’s injury. While some methods such as ultrasound and MRI without contrasting agents are safe to use, in the event that the life of both the mother and the child are at state, other methods utilising radiation such as CT scan or MRI with the use of radioactive fluorescent dyes may be used, as long as the benefits are more than the risks. However, extreme caution must still be present when using ionising radiation such as X-rays, especially when the woman is in her early gestation period, as this could greatly harm the developing foetus. It is highly recommended that additional learning with regards to patients with special needs be provided for emergency medical technicians. Not only must they have knowledge when comparing the anatomical structures of different age groups, but also have adequate information with regards to their needs as well as to the reactions of their bodies. Indeed, this would need additional training as well, but if that means that they would have a higher chance of prolonging the life of an injured patient until they arrive in the emergency ward, then the additional efforts would not be in vain. It would be better than causing problems or even the death of the patient due to lack of knowledge when it comes to the treatment of patients with special needs. Bibliography Agarwal, P. (2005). Thermal injury in pregnancy: predicting maternal and fetal outcome. Indian Journal of Plastic Surgery, 38 (2), 95-99. Aghababian, R. V. (2011). Essentials of Emergency Medicine. Sudbury, MA: Jones and Bartlett Publishing. American College of Obstetricians and Gynecologists. (2005). Obstetric Management of Patients with Spinal Cord Injuries. Danvers, MA: The American College of Obstetricians and Gynecologists . American College of Physicians. (2008). Medical Care of the Pregnant Patient. Sheridan Press. Barraco, R. D., Chiu, W. C., Clancy, T. V., Como, J. 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