ALS Skills within Paramedic Scope of Practice - Research Proposal Example

12 Critical Questions # 1 Critical Thinking Argue a case for having ALS skills within Paramedic scope of practice. Advanced Life Support services refer to an advanced level of emergency care and non encompassing aspects such as basic life support care (BLS), cardiac monitoring, electrocardiography, cardiac defibrillation, intravenous therapy, trauma care, use of adjunctive medical devices, and administration of medications, drugs, and solutions. Advanced Life Support (ALS) details a set of life saving protocols and skills applied to further support the circulation and clear airway and adequate ventilation (breathing). The core algorithm of ALS, mainly applied when cardiac arrest has been established, is based on the examination of the heart’s electrical activity. The employment of defibrillation and medication hinges on the form of cardiac arrhythmia. Paramedics, medics, and emergency medical technicians typically avail this level of care. Paramedics may be certified in either ALS or BLS. In most cases, ALS are provided by advanced paramedics, who possess the highest clinical level in pre-hospital care as stipulated by the regulations. The present paramedic’s scope of practice extends to incorporate procedures that early paramedics would have dreamt of performing, such as ALS skills. The advancements within the medical science have extended the advanced life support skills once found only in an emergency room to the back of ambulances. This has largely been necessitated by the ever present need for an enhanced level of care that many critical patients require (National Association of EMS Physicians, 2002). ALS skills are an essential component in aiding paramedics to provide and complement advanced levels of care for medical emergencies and trauma. While there may not be a national standard for the types of skills paramedics undertake, paramedics usually receive the award of Advanced Life Support, which is a national recognized skill level. Training paramedics in Advanced Life Support (ALS) is progressive and a critical step forward in elevating the skills of ambulance paramedics. ALS will aid paramedics to provide lifesaving medical interventions, while ensuring that the patient’s condition remains stabilized during transport to hospital (National Association of EMS Physicians, 2002). The training of paramedics in ALS gives them the ability to perform advanced airway management, administration of a variety of drugs such as pain relief medication, and perform invasive interventions inclusive of intravenous fluid replacement. Further postgraduate education and training can facilitate the attainment of enhanced skills levels, inclusive of Intensive Care Paramedic mandated to administer complex medications and undertake highly invasive medical procedures. The provision of an expanded scope of practice for paramedics is a decisive step directed at the provision of holistic care to critical patients. Having ALS skills within the paramedic scope of practice is an essential progression and is likely to enhance the profile of ambulance services in providing emergency pre-hospital healthcare, besides supporting persons with chronic medical condition, and promoting preventative health schemes. The implementation of ALS skills within the paramedic scope of practice will significantly enhance patient care and fuel progress within the profession paramedicine. The incorporation of ALS skills within paramedics’ scope of practice can lead to enhanced health outcomes and an enhanced level of patient satisfaction. Paramedics should spare no effort in order to remain proficient at delivering ALS care. # 2 Research three theorist experts in Reflective Practice (or Action Learning); using some of the concepts, why do you think Reflective Practice is important in Paramedicine? Reflective practice infers the form of learning that avails the learner with a process, framework, or support tools essential for learning enhancement based on discourse and critical reflection. Much of the literature on the reflective practice derives from the early works regarding reflective practice as presented by experts such as John Dewey (1933) and Jurgen Habermas (1971). Their philosophical approaches to the function of reflection and reflective thinking and the generation of knowledge have influenced later reflective learning experts such as Donald Schon (1983, 1988) and David Kolb (Kolb & Fry, Kolb 1984). Action learning infers the process by which a small number of people, otherwise referred to as “action learning set,” meet regularly so as to explore an opportunity or problem and learn from their reflections (Sibson, 2009). Action learning details a pedagogical theory advanced by Prof. Reg Revans (1982). The theorist outlines sources of learning, which include learning from experts and learning from thinking about one's (shared) experiences. Action learning can be implemented successfully in paramedicine as a powerful action-oriented, problem solving tool. Similarly, the approach can be applied as a key individual, team, and organization development. For individuals, reflective practice facilitates the development of meta-cognition, epistemic cognition, reflective judgement and critical thinking, emotional intelligence, and writing skills and the capability to avail representations of learning via journaling (Sibson, 2009). Overall, reflective practice is essential to paramedicine. The application of reflective practices as part of leadership and other development programs facilitates the learning from the paramedicine as participants remain actively engaged in applying new learning in the real world contexts, and shaping their skills as learners in the process (Sibson 2009). In addition, the building of skills via reflective practice aids in preparation for roles as coaches and mentors within the practice of paramedicine. # 3 What are your thoughts? Are you concerned/not concerned? Briefly explain your rationale for either argument? An initial assessment provides a general impression of the patient. Prompt and appropriate treatment of persons involved in motor vehicle crashes are a significant step towards minimizing disability and mortality. The healthcare personnel evaluating the patient must determine whether individuals, who may not have met physiologic, anatomic, or mechanisms steps, bear an underlying condition or comorbid factors that place the patients at an enhanced risk of injury. Some patients may have potentially serious injuries, especially if the patient meets such criteria as older adults. As a result, I would consider the patient as potentially time critical. The patient has an enhanced risk for injury since death or injury mainly increases after 55 years. A RR of 28bpm is relatively high and remains a significant predictor of severe injury and the need to avail high level of trauma care to the patient. In fact, multiple peer-reviewed articles published since 2006 reinforce this threshold (25-28). Furthermore, low impact mechanisms (such as a low speed motor vehicle collision) might result in severe injury. The physiologic parameters applied in younger patients may not necessarily be applicable to older patients. Blunt trauma patients with the age ≥65 or ≤2 should be perceived as high risk groups. Thus, by extension, the patient detailed in the case can be considered to be a risk patient. A review of the literature on similar cases reveals that patients with seemingly benign trauma and normal vital signs such as a clear airway may later manifest airway compromise or other complications, although in a delayed fashion. Hence, I would not overlook the probability of the patient suffering from blunt trauma from the MVA. Occult injury is highly likely to be greater among older adults, especially in cases of low energy transfers, which might yield serious injuries in the population of older patients. My first thought will be to consider the mechanisms of injury likely to have resulted from the accident. Low speed motor vehicle collision can be considered to lead to low risk mechanism injuries. During a front-end and/or rear-end motor vehicle impact, three separate forms of collision occur. The first collision is the vehicle to vehicle. The second form of collision encompass occupant to vehicle interior, while the third collision entail collision of body parts. The mechanism of injuries emanating from the collision hinges on the energy transfer during the three collisions. As a result, I will make the patient a priority patient, regardless how slight the injuries appear to be or how “normal” the vital signs are. My concerns will largely be motivated by the patient’s age (60 years) and the mechanisms of injury. Just like children, old people have limited compensatory mechanisms and may worsen speedily with seemingly minor injuries. As healthcare personnel, it would be unwise to hide behind the veil of “the patient bear normal vital signs” as the patient health may deteriorate quickly. Besides, the patient’s primary survey results borders on the extremes. Older adults may manifest decreased pain perception that can, in reality, mask the severity of an injury. For instance, the patient may have sustained head and chest injuries from the MVA, despite having no neck pain. An increasing BP, a slow pulse, and irregular breathing may point out to a rise in intracranial pressure. Vital signs indicate that there is a need to be concerned since the patient can be considered to be physiologically unstable. The field identification of serious injury among older adults should be more proactive rather than reactive since patients who may have “normal” vital signs may in reality have sustained serious injuries requiring urgent care. Some patients, on initial presentation to EMS providers, bear “normal” physiology (normal vital signs), although they might have an anatomic injury that might necessitate enhanced level of patient care within the delineated trauma system. # 4 In your opinion, which is the best airway for the pediatric patient; LMA (laryngeal mask airway) or ETT (endotracheal tube)? Rationalize your answer with some good evidence. Respiratory failure is a dominant cause of cardiopulmonary arrest among children. Acute airway obstruction can readily progress into a respiratory failure. As a result, it is time critical to spotlight early respiratory compromise and evade progression to respiratory failure and cardiopulmonary arrest. Infants and children present anatomic, physiologic, and psychological challenges that are unique and that differ from adults. Hence, it is fundamental to appreciate and understand the differences posed by the airways, in order to deliver successful airway management (Amieva-Wang, 2011). Laryngeal Mask Airways LMA is a substitute airway device employed for anesthesia and airway support. Laryngeal Mask Airways (LMA) has had a significant impact on the management of the difficulty airway. LMA is usually shaped like a large endotracheal tube at the end that hooks up to an elliptical mask on the distal end. The LMA comes in diverse designs for both pediatric and adult sizes and avails effective ventilation compared to bag valve-mask ventilation alone. Although, LMA minimizes gastric distention, compared to bag-valve mask ventilation, it does not eliminate the risk of aspiration (Amieva-Wang, 2011). Endotracheal Tube The ET tube dominant application remains in the pre-hospital setting, as well in the operating room. The ET tube is an elastic, translucent tube open at both ends, and accessible in diverse lengths from twelve to thirty-two centimeters. The tube is mainly inserted into the tracheal via the vocal chords by using a laryngoscope and a stylet to maneuver through the airway passage. The distal end of ET tube features a beveled tip designed to facilitate smooth movement. Although the two devices serve a shared purpose, the two differ on the mode of application, the functions they serve, and their styles. The laryngeal mask airway simplicity in use renders it an attractive option to endotracheal tubes, especially in children. A study, investigating the application of laryngeal mask airway compared endotracheal tubes, indicated attainment of effective ventilation with LMA when performed by pre-hospital providers. In the simulated pediatric arrests, the application of laryngeal mask airway, compared with endotracheal tubes, resulted to more rapid establishment of effective ventilation, and lower incidences of complications when undertaken by pre-hospital providers(Amieva-Wang, 2011). LMA can be employed as a conduit for passing a trachea tube with the utilization of a flexible bronchoscope. Nevertheless, LMA design fails to restrain aspiration of gastric contents, and thus should not be employed for elective, non emergent management of the airway in children, who have a full stomach or decreased gastric emptying. # 5 What is the most common cardiac arrest arrhythmia in pediatric patients? Why do you think this is the case? Breathing conditions such as anaphylaxis, apnea, pneumonia, drowning, aspiration, and suffocation may cause pediatric arrest. Paediatric cardiac arrests often result as a complication of, progression of, respiratory failure and/or circulatory shock. Other most common causes of cardiac arrest in children and infants include trauma, poisoning, underlying cardiac abnormalities, and various respiratory disorders. In cases of children and infants, trauma mainly results from accidents, injuries or impact. Trauma also features a compromised state whereby the pediatric patient is significantly susceptible to secondary complications, inclusive of cardiac arrest, shock or even death (Frazier, Hunt, and Holmes, 2011). Poisoning, which in most cases is accidental, and occur by ingestion instead of inhalation or skin contact, can result in a loss of consciousness, seizures, difficult breathing, cardiac arrest, or even death. Respiratory conditions can easily deteriorate into respiratory failure and cardiopulmonary failure, and bear the capability to lead to cardiac arrest (with or without instances of respiratory distress). Some of the respiratory disorders that invoke cardiac arrest include airway obstruction, drowning, smoke inhalation, infection, and sudden infant death syndrome. Whereas children and adults suffer the same cardiac arrest arrhythmia (irregular heartbeats) the causes of such conditions tend to differ. In adults, cardiac arrhythmias mainly emanate from cardiac events, such as myocardial infarction/heart attack. However, in children and infants, the causes behind cardiac arrhythmias are highly likely to be non cardiac (Frazier, Hunt, and Holmes, 2011). Unlike adults, much of cardiac arrest in children and infants does not bear a primary cardiac cause, and in most cases, it is the terminal result of progressive respiratory failure (cardiorespiratory arrest) or shock (asphyxial arrest). This is a critical observation since ACLS interventions geared at restoring cardiac function may cause the physician to delay properly directed therapy. For instance, a progressive decline in cardiac rate leading to bradycardia arrest can be an ominous sign of hypoxia in infants and children. Asphyxia usually begins with a variable period of systematic hypoxemia and hypercapnia, which evolves to bradycardia and hypotension, and culminates with cardiac arrest (Frazier, Hunt, and Holmes, 2011). Although the cause of paediatric cardiac arrests may vary, the goal should be the same; reestablishing effective cardiac output. Since the onset of cardiac arrest in pedriatric is predominantly respiratory related rather than cardiogenic, the ensuing pathophysiologic events and mode of presentation of cardiac arrest state are diverse, and subsequent initial efforts at resuscitation must be geared at respiratory support manoeuvres. # 6 One of your colleagues states, “Don’t worry about pediatric trauma, kids just bounce.” What are your thoughts? Use the science of kinematics to rationalize your answer. The comment “don’t worry about pediatric trauma, kids just bounce” is unfounded and erroneous. Trauma is a leading cause of death and disability for children in which blunt trauma is more predominant compared to penetrating trauma. Blunt injury represents about 80-90% with penetrating injury being less prevalent. However, children have different mechanisms of injury not comparable to adults as they engage in diverse activities. Kinematics of Pediatric Trauma Kinematic plays an essential role in evaluating child trauma. One of the factors to be considered detail that the smaller the body mass, the greater the amount of force per unit of the body are as stated by Newton’s first Law. A child’s size produces a smaller target to which the forces of blunt and penetrating trauma apply. Owing to the minimal cushioning body fat, enhanced elasticity of connective tissue, and proximity of the viscera to the body surface makes it difficult to dissipate the forces as compared to adults. Furthermore, the skeleton of children is incompletely calcified and features multiple active growths centres and is more resilient compared to an adult’s. Hence, a child’s skeleton is less able to absorb the kinetic forces occasioned by a traumatic event, which admits significant force transmission to underlying organs. Hence, there may be significant internal injuries devoid of obvious evidence of external trauma. Common Injury Patterns MVA is a predominant cause of injury in children. The injuries sustained can be perceived to be dependent upon whether the child was restrained in the vehicle or not. In instances in which the child was not restrained, the child may sustain head or neck injuries, and scalp or facial injuries. When the child is restrained, examples of injuries that might be sustained include internal abdominal injuries and lower spine fractures, especially in instances in which the restraints remain inappropriately sized (Seidel and Henderson, 1997). In cases of pedestrian, struck children often turn towards impact and tend to be thrown in front of the vehicle. Injuries sustained by children from falls depend on the height of the fall. Low level falls are mainly less severe in nature compared to fall from higher levels. Bicycle injuries, which are common in the pediatric population, depend on whether the child is wearing or not wearing a helmet (Seidel and Henderson, 1997). Handlebars may inflict abdominal injuries in cases where the child is thrown over the bike and strikes the handlebars with his or her abdomen. #7 With reference to the above scenario; describe one possible injury pattern this patient may have. Relate the injury to one of the laws of kinematics; e.g. Newton’s law of motion, cavitation, etc. Blasts have the capability to inflict multisystem, life threatening injuries to the victims. Blasts present a complex triage, diagnostic, and management complications to the healthcare providers. Blasts bear the capability to produce classic injury patterns from both blunt and penetrating mechanisms to organ systems, although they can as well result in unique injury patterns to certain organs including the lungs and the central nervous system (Brooks, Clasper, Midwinter, Hodgetts, and Mahoney, 2011). The severity and pattern of injuries hinges on aspects such as the composition of explosive materials, the quantity of explosive material, situational factors (Open space vs. Closed space), the distance between the blast and injured patient, the delivery method, and the existence of obstructions. Such information aids in predicting injury severity and type (Silver, McAllister, and Yudofsky, 2011). Types of blast injuries Blasts inflict diverse injuries, which include primary injuries emanating from the direct effect of pressure; secondary injuries due to impact of projectiles from explosion; tertiary injuries emanating from structural collapse or from individuals being thrown from the blast wind, and quaternary due to burns, inhalation injury, or exacerbations of chronic disease (Elsayed and Atkins, 2008). According to the primary survey results, the patient may have sustained blast-related polytrauma. The patient may be suffering from primary blast injuries due to his proximity to the blast (within six metres from the centre of the blast). Furthermore, the patient’s mechanism of injury may encompass a risk of spinal injury, or even traumatic brain injury. Injuries such as cervical spine trauma are life threatening and may have far-reaching impacts to the patient’s quality of life, especially at age frequency peaks of 15-35 years. An unstable pelvis bears the capability to lead to massive bleeding and shock. Patients experiencing severe abdominal pain may have abdominal injuries and may develop signs of shock abruptly. The patient’s age in the case is 25 years, which indicates an enhance risk to such injuries (AAOS, 2010). Explosion Physics According to the basic mechanism of energy exchange, the explosive material must give up its energy into the body that it hits. The impact on the tissue particles accelerates the tissue particles away from the point of impact. The tissues, in turn, become moving objects and crash into other tissue particles, ultimately producing a “falling domino” effect. This form of energy exchange occurs within both blunt and penetrating trauma. The instantaneous energy release transfers a lot of energy (particularly heat) to the patient, which inflicts more damage or injury to the patient. The energy associated with the blast can take multiple forms; kinetic and heat energy in the blast wave. Kinetic energy may arise from fragments formed by the breakup of the explosive casing and surrounding debris, and electromagnetic energy. Emergency medical service providers should be wary of the fact that primary blast injuries are prone to delayed presentation. The impact, especially over pressurization, enhances the susceptibility of the middle ear, lungs, and gastrointestinal tract (Hogan and Burstein, 2007). The form of injuries that may result from this include blast lung, abdominal haemorrhage and perforation as demonstrated by abdominal pain, tympanic membrane rupture, neurotrauma, and traumatic brain injury without obvious physical signs of head injury. # 8 Why do you think assessing for Normal breathing play such an important part in assessing our patients? ABC, which stands for airway, breathing, and circulation, details essential steps utilized by medical professionals. The protocol acts as a memory aid for personnel performing cardiopulmonary resuscitation and acts as a reminder of the priorities for evaluation and intervention for patients, in acute medical and trauma cases. Therefore, monitoring for normal breathing is an essential step in successful patient care. Assessing normal breathing is paramount in any treatment, and the loss (or loss of control of) can be detrimental to the patient’s health. Assessing whether a patient is breathing can aid to save life and facilitate proper intervention. A BPM of >25 or 29 or Read More