Paramedic Field - Case Study Example

Assessment Item 3 - Clinical Case Reviews 1 - Medical Patients Value: 15% of final mark for FPS300 Due date: 29-April-2012 (23:59 hours) Length: 1500-2000 words for all three parts Submission Method: EASTS only in MS Word format - this template (no PDFs) Format: Complete all the fields on this form (except anything highlighted), save the template in MS Word format and submit the whole document to EASTS Referencing guidelines: The Faculty of Science recommends that all referencing should be in accordance with the APA Style Guidelines (American Psychology Association). Correct and consistent referencing is an important component of producing professional and credible academic work; marks will be deducted for inadequate referencing. Use of non-discriminatory language: Students should take care to use non-discriminatory language in their work. Requirements: Students must submit and pass ALL assessment items to pass FPS300. Failure to submit or to achieve a mark of 50% or greater may result in a fail grade in this subject. Instructions Case Study 1: Read the case study and answer the 5 questions. Use contemporary references as required (25 marks) Case Study 2: Read the case study and answer the 5 questions. Use contemporary references as required (25 marks) Case Reflection: Section 1: Identify a medical case that you managed in the field or simulation setting (10 marks) Section 2: Describe your prehospital care management of this patient and use evidence to demonstrate the best practices for prehospital care of a patient with this presentation (15 marks) Section 3: Reflect on your actions, management, scene control, team dynamics and patient interaction (25 marks) Last Name:       First Name:      Student ID#:       Case Study 1: Hugh It is 0930 on a cold winter day in a small regional town. Your ambulance is called to a 72 year old male with a decreased LOC. On arrival you find Hugh slumped in a lounge room chair, dressed in day clothes, drooling and incoherent. His wife, Carol, is present and called the ambulance as she was concerned when his level of consciousness decreased to the point where she could no longer understand what he was saying. Carol tells you that Hugh took his ‘diabetes medicine’ this morning but did not get around to eating any breakfast. Carol further tells you that she doesn’t understand how Hugh gets so sick when he is taking his prescribed amount of insulin. There is no diabetes educator in the town as the position was removed from the area health service recently. Hugh has no allergies but has a history of angina for which he takes a beta-blocker (Metoprolol 25mg daily) and a calcium channel-blocker (Norvasc 5mg daily). He also uses a glyceryl trinitrate spray as required. He is a recently diagnosed Type II diabetic and takes Novarapid three times a day, which his GP is still titrating. Carol tells you he likes a ‘drink or two’ in the evenings and he had polyps removed from his bowel in the late seventies. Hugh also has a history of high cholesterol and hypertension for which he takes Atarvastatin 40mg daily and Enalapril 20mg daily respectively. He is due to see his GP in two days. Hugh is showered and well dressed. The home is neat, tidy and warm. Hugh is a slight man, weighing approximately seventy-five kilograms. He and his wife live in the house by themselves, as they have done for many years. On examination, Hugh’s airway is patent and he is breathing at a rate of 18 breaths per minute, non-laboured. He is slightly tachycardic (118 beats per minute, strong and regular) and his blood pressure is 152/96. Hugh is opening his eyes to speech, his verbal response is incomprehensible and he keeps pushing your partner's hand off his arm (localising to pain). You give him a GCS of 10/15. A blood glucose test with the glucometer reveals a ‘lo’ reading. Cardiac monitoring shows sinus tachycardia. Hugh’s pupils are equal and reactive to light although somewhat dilated. His skin is diaphoretic. Hugh has equal air entry to both lungs and a quick check of his chest while applying the ECG dots does not show any rash, scars, or other skin abnormalities of any kind. His temperature is 36.3 degrees Celsius. Answer the following questions pertaining to Case 1. Use appropriate resources as required and cite the information using APA guidelines. Information used as resources for these questions shall not be more than 5 years old. 1. Identify a minimum of five (5) reasonable differential diagnoses for Hugh's presentation and discuss why these conditions should be considered. Where appropriate, indicate the prehospital tests, assessments, or history that you would do to rule in or rule out each of the possible differential diagnoses. (5 marks 0.00) Diabetes Mellitus, Type 1: this can be differentiated basing on of history and physical examination results and also laboratory tests. Insulin Resistance: An increased fasting blood glucose level is the initial sign of insulin resistance Obesity: This is ruled out because Hugh is a slight man, weighing approximately seventy-five kilograms Metabolic syndrome: can be differentiated by testing glucose tolerance because it occurs even in people with normal glucose tolerance Pre-diabetes: this is ruled out because Hugh was recently diagnosed Type II diabetic and pre-diabetes normally precedes overt Type II diabetes (Stephen, 2010). 2. Describe and differentiate IDDM and NIDDM diabetes. (5 marks 0.00) IDDM is the insulin-dependent diabetes mellitus. The insulin does not produce enough effective insulin. IDDM normally manifests itself within teenage or youthful adult years. The symptoms encompass polyuria, polydipsia, dizziness, blurred vision, along with fast, inexplicable weight loss. Diabetic ketoacidosis (DKA) might also develop. This form normally needs lifetime treatment with insulin injections, exercise in addition to regulation of the diet (Stephen, 2010). On the other hand, NIDDM is the non-insulin-dependent diabetes mellitus. Basically, in NIDDM, the beta cells of the pancreases reduce insulin generation in addition to reduced tissue sensitivity to insulin. This condition takes place mostly in individuals over forty years and overweight people. Symptoms of NIDDM encompass lethargy, appetite change, numbness, tingling, and pain within the extremities. Nonketotic hyperglycemic-hyperosmolar coma (NKHHC) might develop in patients with this form of diabetes. Frequent late microvascular complications consist of retinopathy, nephropathy, along with peripheral and autonomic neuropathies. Macro-vascular problems consist of atherosclerotic coronary as well as peripheral arterial disease (World Health Organization, 2008). 3. Using the principles of evidence based practice, discuss the prehospital care of a diabetic patient with severe hypoglycaemia. (5 marks 0.00) The first treatment is bolus injection of 25 mL of glucose solution and follow with a constant glucose infusion. High oxygen concentration is supposed to be administered. A blood sample for the laboratory examination should be obtained prior to glucose administration. In case the level of glucose of the patient is below 60 and is indicating signs and symptoms of hypoglycaemia, glucose is supposed to be administered ((Stephen, 2010). 4 .What can you do as a paramedic in this small regional community to improve Hugh's health and meet his long-term health needs? (5 marks 0.00) Education of the community and the Hugh regarding the symptom and fast response to them with sugar intake is paramount. Hugh is supposed to be advised to always carry sugar cubes or candy. It is also important to teach Hugh’s family members administration of glucagon subcutaneous injection. Hugh and the entire community should be taught about diet control. Diet recommendations are supposed to be made in view of Hugh’s eating habits and lifestyle. Diet management will consist of education regarding the timing, size, incidence, or composition of meals to evade hypoglycemia or postprandial hyperglycemia. Hugh will get a comprehensive diet plan that comprises a daily caloric intake recommendation, proposals for the quantity of dietary carbohydrate, fat, and protein in addition on how to divide calories between meals and snacks. A professional nutritionist will be involved in creating Hugh’s diet plan (Leibson, 2008). 5. What is hyperglycemic hyperosmolar nonketotic (HHNK) coma, how does it present, and how is it treated in prehospital care? (5 marks 0.00) HHNK coma HHNK coma is a grave complication of type II diabetes. Normally, the residual insulin might not be sufficient to allow peripheral tissues to utilize glucose or reduce gluconeiogenesis to the liver. The hyperglycemia generates a hyperosmolar condition where an osmotic dieresis, dehydration is addition to electrolyte losses follow. It is normally caused by severe elevation of the level of blood glucose, normally above 600 mg/dl (Douglas, 2007). Presentation of HHNK coma Weakness, elevated thirst and urination, nausea, fatigue, and eventually convulsions and coma Pre-hospital treatment of HHNK Pre-hospital management is supposed to be directed at maintenance of an airway, high concentration of oxygen administration as well as ventilatory support. An IV is supposed to be started utilizing Ringer’s or a saline solution for replenishing fluids as well as electrolytes. On suspecting alcohol or drug usage, Narcan should be administered prior to glucose administration. If it not possible to obtain a blood glucose level, glucose is supposed to be administered. The additional glucose load won’t impact the hyperglycemic patient adversely but it is helpful in hypoglycemic patients (Leibson, 2008). Case Study 2: Jim Your ambulance is called to a house in Penrith where Jim, a 65 yr old male, is complaining of chest pain. On arrival you find an obese male weighing approximately 130 kg in a recliner chair in a semi sitting position with his hand on the centre of his chest. The patient’s wife, Jenny, tells you that her husband was out for a 10 minute walk and returned home complaining of chest pain. Jenny tells you that Jim had a heart attack 2 years ago, he now suffers from stable angina and took one spray of Anginine approximately 15 minutes ago with no effect. The patient tells you, “I’ve had this pain before but it usually goes away with one spray of that stuff. It didn’t go away this time so I called you guys”. Jim is alert and orientated to time, place and person, answers questions appropriately when asked, and follows commands - you give him a GCS of 15. Jim is tachypnoeic at 28 respirations per minute. Upon auscultation, Jim has bilateral, clear lung sounds; however his breathing is shallow and slightly laboured. His oxygen saturation levels are 93% on room air. Jim’s skin is a pale, ashen grey colour and he is peripherally cyanotic. When you touch his skin he is clammy and diaphoretic. He has a rapid, weak radial pulse at a rate of about 120 beats per minute. Jim has a blood pressure of 130/80 mmHg. When asked if this is normal, he states that it is slightly lower than usual, but he is taking a drug called Atenolol for high blood pressure. He also states that he is on Mevacor for high cholesterol, and ASA for some reason that he doesn't know. Jim has a blood glucose level of 5.2 mmol/L and a temperature of 37.5 degrees Celsius. When you record a 12-lead ECG you see the following. When you ask Jim his medical history, he denies having any other medical conditions, denies being on any other medications, has no allergies, but was a smoker until he quit 5 years ago. He tells you that he had a ham and salad sandwich with some water approximately an hour ago. He confirms what his wife said on arrival, that is, he had a myocardial infarction two years ago and has stable angina. Answer the following questions pertaining to Case 2. Use appropriate resources as required and cite the information using APA guidelines. Information used as resources for these questions shall not be more than 5 years old. 1. Identify a minimum of five (5) reasonable differential diagnoses for Hugh's presentation and discuss why these conditions should be considered. Where appropriate, indicate the prehospital tests, assessments, or history that you would do to rule in or rule out each of the possible differential diagnoses. (5 marks 0.00) Pulmonary embolism: Chest pain is one of the key symptoms of a massive pulmonary embolism. Pericarditis: Changes of the intensity of chest pain with posture and the characteristic signs within the ECG, are important in differentiating pericarditis from myocardial infarction. Aortic dissection: Chest pain in the back can indicate aortic dissection. The diagnosis can be differentiated through transesophageal echocardiography, or MRI. A spontaneous pneumothorax: This can lead to precordial tightening and a tendency for syncope. Musculoskeletal chest pain: In case there is no injury or an occurrence that could lead to injury this should be ruled out (Brooks, 2010). 2. List your steps of history taking and assessment for a patient who complains of "chest pain". Be specific and rationalise why you would perform each step and what you are looking for. Indicate which steps you could delegate to your partner or to a paramedic student. (5 marks 0.00) The assessment will start by interviewing the patient and carrying out a history of the chest pain in order to come up with the precise diagnosis. The questions to be asked during history taking consist of: 1. What is the character and severity of the chest pain? This is important in determining the intensity of patient’s discomfort. Crushing pain indicates acute coronary syndrome while ripping pain indicate aortic dissection. If the patient says that he/she suspects angina, assume so. 2. How has it evolved? Sudden chest pain indicates aortic dissection or pulmonary embolus, building up of chest pain implies ACS while chest pain accompanied by physical or emotional stress indicates ACS. Chest pain onset accompanied by coughing indicates pneumothorax and gradual chest pain accompanied by vomiting indicates esophageal rapture. 3. Where is the chest pain greatest and does it radiate? Radiation of the pain to the jaw, shoulders or arms is indicates ACS 4. Does the chest pain change with breathing or other movements? Chest pain that increases when the patient lays flat indicates pericarditis while chest pain that increases with movement indicates musculoskeletal pain 5. Are there additional symptoms? Collapsing normally suggests presence of ACS or aortic dissection while dyspnoea also indicates causes allied to cardio-respiratory 6. Is there a history of ischaemic heart disease? Any medical history that might be allied to the cause of the chest pain should be confirmed where ACS has a high likelihood of occurring if there has been prior ischaemic heart disease, old age, diabetes, hypertension, smoking, etc. 7. What medications is the patient with chest pain taking? The prescribed anti-anginal medications that have been administered to the patient should be confirmed (Messenger, 2010). 8. During all aspects of the assessment, monitor for fatigue or discomfort and if required give the patient some time to rest (Atar, et al, 2007). 3. Identify the 12-lead ECG provided. List the 4 most common locations for an ST Elevation myocardial infarction and describe the ECG findings for each type. (5 marks 0.00) I: Left Chest II: Left Upper Quadrant III: Right Upper Quadrant AVR: Right lateral arm AVL: Left lateral arm AVF: Right lateral lower leg The initial 12-lead ECG indicates ST elevation within leads II, III, and aVF, and this correspond a myocardial infarction of the inferior wall. The tall, wide, peaked T waves accompanying the ST-segment elevation indicates an early ECG change that takes place within myocardial infarction. The ST-segment depression as well as T-waves inversion within leads I, aVL, V1, and V2 manifests reciprocal changes. Basically, reciprocal changes indicate the electrical activity opposite the infarction region. These are early ECG finding and resolve fast. The tall, peaked T waves as well as reciprocal changes on Jim’s ECG illustrate that he was within the early stages of his myocardial infarction (Hamm, 2011). 1 mm or more of ST elevation in the inferior leads (II, III, aVF) with reciprocal changes in the lateral leads (I, AVL, V5, V6) implies that reciprocal changes are not necessary for making diagnosis. 1 mm of ST elevation in the anterior leads. (V1-V4) indicates Infarct pattern in the presence of LBBB with cardio-genic clinical presentation (Hamm, 2011). 4. Using the principles of evidence based practice, discuss the most comprehensive and contemporary prehospital care of a patient with an acute myocardial infarction. Include the pharmacological interventions with doses and routes. (5 marks 0.00) Primary PCI is appropriate in case the procedure can be carried out within the ninety minutes following the first medical contact with the patient. Primary PCI is suitable for the patients presenting contraindication to fibrinolytic therapy, patients with increased bleeding risk with fibrinolytic therapy, patients with tachycardia, hypotension or pulmonary congestion because these indicate high risk of complications allied to a myocardial infarction as well as patients with cardiogenic shock. Finrinolytic therapy is suitable for patient whose initial medical contact takes place less than three hours following symptoms’ onset but who PCI is not available instantly, those seeking medical care less than one hour and also the patients having a history of anaphylaxis because of radiographic contract material. Balloon angioplasty is appropriate for patients whose clopidogrel is contraindicated. It is also appropriate when the size of the infarct-related artery is inadequate for the placement of a stent (Betriu, et al, 2008). Oral aspirin, intravenous unfractionated heparin, and oral clopidogrel should be administered to patients with a myocardial infraction with ST-segment elevation. However, oral clopidogrel should only be administered after establishing that emergency bypass surgery is not needed. Initiation of Beta-adrenergic blockers as well as angiotensin-converting–enzyme inhibitor should be done as long as the patient does not present any contraindications and is hemodynamically stable. Platelet glycoprotein IIb/IIIa inhibitors or antibodies should be administered to patients who undergo primary PCI. Treatment with a high dose of a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor is recommendable for all patients with acute myocardial infarction. Aspirin and heparin reduce aggregation of platelets as well as vessel’s inflammation. Glycoprotein IIb/IIIa agents like eptifibatide and abciximab are important in improving reperfusion due to their antiplatelet characteristics that instigate lysis of the thrombus and decrease inflammation. Administration of nitroglycerin and morphine is also important to relief the pain (Brooks, 2010). 5. What is an inferior AMI? What is significant about the presentation of a patient's signs and symptoms with an inferior AMI? How do you treat a patient with an inferior AMI? What pharmacological agent should you use with caution? Why? (5 marks 0.00) Inferior AMI is also known as heart attack occurs when a coronary artery is blocked and this prevents blood from being supplied to a region of myocardium. Inferior refers to the area that the heart gets affected (Messenger, 2010). Specific presentations include severe chest pain, normally retrosternal and might radiate into the jaw, shoulders as well as down the arms, dyspnoea because of the pain or pulmonary congestion resulting from hypertension, extreme pallor because of reduced cardiac output, nausea and vomiting, lethargy, tachyrhythmias and pyrexia, where the temperature increases to about 39°C (Betriu, et al, 2008). Treatment is through administration of oxygen, aspirin and also nitroglycerine. Percutaneous coronary intervention (PCI) or fibrinolysis, are also used in patients with an STEMI (Betriu, et al, 2008). Morphine should be used with caution in patients with inferior AMI because it can raise mortality within NSTEMI setting. In addition, studies have shown that morphine might increase mortality as well as the size of an infarct (Betriu, et al, 2008). Case Reflection: Section 1: Identify a medical case that you managed in the field or simulation setting. Present the patient's chief complaint, assessment findings, history provided, signs and symptoms, and vital signs. (10 marks 0.00) Chief Complaint Breathing difficulties History of Present illness . General malaise, a reduced of appetite for 3 days. Past Medical History Pneumonia, diabetes type 2, cardiac problems. Medications Antibiotic tablets, Oxygen, Metformin, Aspirin & tablets for adverse effects of Aspirin. Allergies No allergies Demographics Gender-male 90 year old suffering from breathing difficulties. Head & Neck No abnormality detected Chest Right lateral expiratory wheeze & shallow respirations. Abdomen No abnormality detected Extremities No abnormality detected Pulse 110 bpm Blood Pressure 85/60 Respirations Respiratory rate-22/minute Mentation Withdrawn, irritable, and restless. Blood Sugar 4.1 mmol SpO2 93% on room air Skin Flushed and warm. Temperature is 38.5 No cyanosis I really enjoyed working with not only my team but with all the members of the station. This resulted in developing my critical thinking, analysis and how to manage patients with different views, due to the variation of the paramedics’ perceptions. For example, on the 8th of Nov 2011, the manager of the station, the most experienced paramedic in the station and I got another job to a 90 year old male who had a respiratory distress and diagnosed previously with pneumonia. On the way to the patient’s address, I put in my mind to find the signs and symptoms related to the case, which have been explained in the classes. On arriving, the patient was in the supine position and really fatigue. During the primary assessment, I asked the team leader to listen to the patient’s chest. I found that the absence of breathe sound in the left lung comparing to the right lung and there was an audible wheeze. Also, I asked to take the body temperature (tympanic route) which gave me the reading of 38.5 c degree. The other vital signs were taken by another paramedic. The blood pressure was 85/60 which is low. As a result, the manager decided to give i.v fluid (hartmanns) 500 ml and asked me to setup the i.v giving set after administering 15 L/m non-rebreather mask followed by 5 mg of nebulised Salbutamol. While I was performing the ongoing assessment enroute to the hospital, I remembered the required posture for this patient which is the shock position to increase blood retune to the heart. Immediately, I asked the paramedic officer to give me my hand case for my safety helmet and vest to put it under feet part of the stretcher in order to elevate the patient’s legs. This simple technique left a good impression about me to the manager of the station when he told me this way is better than usually placing the medication kit under the feet part of the stretcher. What is more in this case, when we arrived to the hospital, the patient started to throw up a “black” thick fluid, which is medically termed as haemostasis. Technically we signed out from the case when we gave the handover but I was with the patient until the ER doctor diagnosed the problem as an old gastrointestinal bleeding. The patient is on some medications such as antibiotics, aspirin, type 2 anti-diabetic tablets and a drug used to reduce the adverse effect of aspirin. Personally, I analysed the hememesis problem due to the complications of using aspirin for a long time, which could cause GIT ulcerations leading to the internal haemorrhage according to my textbook for BMS292. This possible diagnosis was accepted by my team members when we backed to the station which reflected positively to my self-confidence in order to indicate the illness based on the knowledge that I still obtaining from theories and clinical scenarios in CSU. I feel that I acquired vital elements that could improve my skills or behaviours as a professional paramedic, such as self confidence and respect to the patient, all team members and other health care professionals in the hospital. I was really impressed with my team members’ self-confidence, fast diagnosis and good obtaining of the SAMPLE history and these vital elements resulted in professional outcome of our work leading to minimise the time stay in the scene. Section 2: 1 Describe, in detail, your prehospital care management of this patient including your rationale for clinical judgment and decision making. The primary treatment of breathing difficulties was prevention of hypoxia by supplementing oxygen. The patient was given early treatment with antibiotics in order to improve symptoms as well as disease resolution. In addition, the patient was administered with albuterol and Atrovent nebulization in order to decrease wheezing (Thompson, 2008). Oxygen was administered through mask and its monitoring was done to check oxygen saturation. Capnorgraphy was used to assess and monitor the adequacy of the patient’s ventilatory condition. The other paramedic instantly placed the patient on a NRB mask and the set of vitals were obtained while I assembled a positive airway pressure (CPAP) circuit. The patient’s heart rate was obtained, as well as respiratory rate within all lung fields and also blood pressured was taken. I connected the CPAP tubing on the portable oxygen tank, administered nitroglycerin under the patient’s tongue and placed the tight-fitting mask on his face and one of the team members obtained IV access. A short while following the application of the mask, the patient became less anxious. An inch of nitroglycerin paste was applied on his chest, and 40 mg of furosemide IV and package administered. The manager reassessed the patient’s vitals and another spray of nitroglycerin was administered. 2 Using retrospective reflection, provide the current evidence to demonstrate the best practices for prehospital care of a patient with this presentation (in other words, what would you do now if you were presented with this case, based on the best evidence in current literature?) (15 marks 0.00) The first assessment would be to asses if there is an obvious threat to the patient’s life, for example respiratory arrest, the position of the patient, in addition to if the patient is able to speak complete sentences or if he is struggling to catch their breath and speaking in short sentences. I will also examine the position of the patient because the position can give an indication to the gravity of the problem since most patients having breath shortness prefer sitting bolt upright for unlimited expansion of both the diaphragm and chest wall. When introducing myself to the patient, I would examine their mental status in accordance with the AVPU (alert, verbal, painful, unresponsive) criteria. It is possible to observe several alterations within the mental status due to difficult breathing as well as hypoxia, which range from restiveness, agitation to fatigue. If any mental status alteration is discovered or low blood oxygen concentration is discovered, high-concentration supplemental oxygen should be administered and locked closely at the sufficiency of breathing and ventilation. This is because breathing difficulties result into anxiety and agitation in most patients (Siegenthaler, 2007). I would decide if the patient needs positive-pressure ventilation and rely on my assessment. The criteria I would use in determining if the patient requires positive-pressure ventilation encompass, slow and irregular breathing, shallow breathing which is indicated by little or no chest rise, reduced breath sounds, reduced conscious level along with other signs of severe hypoxia. Since for this patient the breathe sound was absent in the left lung comparing to the right lung and there was an audible wheeze, I would set up positive-pressure ventilation for the patient (Siegenthaler, 2007). If the patient is not able to maintain the airway, I would use endotracheal intubation for securing the airway and maintain oxygen saturation at more than 90-92 percent. In addition, I would titrate IV fluid therapy to a systolic blood pressure of 90-100 mm Hg because the patient presents low blood pressure and also this practice provides the mean blood pressure that is required in maintaining perfusion of the vital organs (Siegenthaler, 2007). The key aim of the oxygenating the patient is supposed to be an Oxygen saturation of higher than 95%. Assisted ventilation is necessary if the patient has poor ventilatory effort. A capnorgraphy waveform above or below 40 ought to alert the paramedic of the patient’s difficult to exchange CO2 and maybe the earliest alert for the requirement of bagging the patient. Since breathing distress is an emergency, EMS providers have numerous tools for treating and improving discomfort. After making a differential diagnosis for causing the breathing difficulty, high-flow oxygen as well as suitable medications, are valuable in alleviating it. Whereas it is normally appropriate for the patient’s survival, endotracheal inhibition has its drawbacks and hence should be avoided (Thompson, 2008). Noninvasive ventilatory supports is coming out as an efficient treatment in pre-hospital setting for patients needing support for breathing, but are still able to maintain an airway. Noninvasive ventilatory support is administered through CPAP as well as bilevel positive airway pressure (BiPAP) devices (Wilfong, 2008). Section 3: Reflect on your actions, management, scene control, team dynamics and patient interaction - What went well? What could have gone better? What did you learn from this experience? How will you change your practice in the future? (25 marks 0.00) The purpose of this reflection is to reflect upon a case of my professional practice I have encountered as a paramedic. According to Baird (2008) reflective practice generates the practice knowledge, helps in adapting to new situations, and develops self-confidence in addition to developing and professionalizing practice. It also helps in identifying when to improve, learn from own mistakes and enhancing the future practice through the past. In my context with the patient, I need to enhance the therapeutic relationship. Within the therapeutic relationship, there is the therapeutic relationship which is established from a sense of trust as well as a mutual understanding existing between the patient and the paramedic that builds the relationship. Kathol (2008) argues that therapeutic communication enhances the capacity of the patient to function. When dealing with the patient, the first step was introducing myself and attempted to establish a good rapport. With the relationship I had with this patient, I discovered what I say has an effect on the patients. A great deal is vested in my status as a paramedic and this power comes with the responsibility of working through the effects of my influence for the patient’s good or bad. As result, I realized that it is beneficial to use my power wisely and carefully in order to accomplish the best results possible for those entrusted to my care. At all times during this case, my team supported me and their input was so valuable during the experience. In particular, when I analyzed the hememesis and my possible diagnosis was supported by my team members, the manager praised my action and I welcomed this since it gave me confidence and made me aware that I was doing things in the correct way. My mentor was talking me through the procedure step by step as I was conducting the analysis. There before, I was relying heavily on my notes. However, after building up some confidence, I still utilized the notes but I would only use the notes for referencing important and the things I found extremely difficult. One reference is where I analyzed the hememesis problem from my textbook for BMS292. I found this very valuable. This boosted my confidence because I made the correct diagnosis and also that I felt very comfortable working with other team members and I never felt as self conscious as I did when I was making diagnosis for the first time. Generally, I found this case an extremely valuable experience. I feel that my confidence has risen within this area and will continue to rise after my qualification and gaining daily experience. In addition, I feel that the experience has assisted me to become more knowledgeable of other nursing care aspects. In the few instances that did not go to plan, I realize that an unpleasant experience can be turned into a positive one because it is a learning experience. I feel more secure in that it is acceptable for me to get things wrong and to utilize reflection as a tool of turning unpleasant experiences into positive ones. References Atar, D, et al. (2007). "European guidelines on cardiovascular disease prevention in clinical practice: executive summary: Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur. Heart J. Vol. 28/19. Baird, M. (2008). Nursing reflection. Austria: HarperCollins. Betriu, A, et al. (2008). Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology". Eur. Heart J. Vol. 29/23. Brooks, S. ( 2010). Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. Vol. 18/3. Douglas, C. (2007). Differential Diagnosis in Primary Care. Melbourne: Lippincott Williams & Wilkins. Hamm, C. (2011). ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)". Eur. Heart J. Vol. 32/23. Kathol, G. (2008). Therapeutic Relationship. Maryland: Lippincott Williams & Wilkins. Leibson, C. (2008). Diabetes Mellitus. London: Sage. Lorgis, L. (2011). Prevalence, incidence, predictive factors and prognosis of silent myocardial infarction: a review of the literature". Arch Cardiovasc Dis. Vol. 104/3. Messenger, JC. (2010). Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention". J. Am. Coll. Cardiol. Vol. 56/4. Ricardo, L. (2010). Endocrine Pathology: Differential Diagnosis and Molecular Advances. New York: Springer. Siegenthaler, W. (2007). Differential Diagnosis in Internal Medicine: From Symptom to Diagnosis. Sydney: Thieme. Stephen, P. (2010). Diabetes Type 2 Disorders: A Case-Study Approach to Diagnosis and Treatment. Oxford: Oxford University Press. Thompson, J. (2008). Out-of-hospital continuous positive airway pressure ventilation versus usual care in acute respiratory failure: a randomized controlled trial. Ann Emerg Med. Vol. 52:232–241. World Health Organization (2008). The Global Burden of Disease. Geneva: World Health Organization. Wilfong, DA. (2008). Estimates of cost-effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema. Prehosp Emerg Care. Vol. 12:277–285. Read More