- Lachlan Donnet-Jones
To provide effective patient care at a high standard it is necessary to use a clinical and systematic approach. The primary and secondary surveys are the centre of patient assessment. Primary assessment is a systematic approach to identifying critical and life threatening conditions and treating in order of severity. This includes complying with state clinical practice guidelines (CPGs) for workplace health and safety (WHS), infection control, airway management, manual handling and vital signs (AT Clinical Practice Guidelines, Protocol A0101, p. 1). Subsequent to management of life-threatening conditions the secondary survey is conducted. Secondary survey involves a thorough physical examination enacting a ‘head to toe’ approach including inspecting, palpation and auscultation using various tools at paramedic’s disposal (AT Clinical Practice Guidelines, Protocol A0101, p. 2). The clinical approach is applied to all patients as a basic level of care (AT Clinical Practice Guidelines, Protocol A0101, p. 3).
Workplace Health & Safety (WHS)
The Work Health and Safety (WHS) Act, implemented by Safe Work Australia (2012), is a framework that aims to protect the health, safety and welfare of workers in their workplace. This includes both physical and psychological health. In Australia, the highest rate of serious injury claims is from muscular stress while lifting objects, a major component of the paramedic profession (Safe Work Australia, 2012). Paramedics are often in situations that can be demanding and potentially damaging of physical and mental health, this is why it is necessary to follow the WHS guidelines to avoid and minimise any negative outcome (Mistovich, 2010). Twedell and Pfrimmers’ (2009) article provides insight into the effectiveness of teamwork and communication specific to patient care. It states that ‘effective teamwork and communication can help prevent mistakes and decrease patient risk’ (p. 294 – 295). Other WHS considerations include; lifting and weight restrictions, biological hazards, the use of personal protective equipment (PPE), bystanders and family members and environmental factors such as weather conditions (Mistovich, 2010).
Infection control is defined as ‘the process by which a disease is transmitted via micro-organisms from one person to another’ (Black, 2010). The Ambulance Service of New South Wales (ASNSW) infection control policy (2011) uses a two tier system. The first tier is called ‘standard precautions’. This is applied to all patients no matter the diagnosis, it is a blanket level of precautions used with every patient. The second tier is ‘additional precautions’, which is applied to specific patients who are suspected of having infectious disease communicable via droplet, airborne or skin contact. Multi resistant organisms (MROs) are bacteria and organisms that have developed a resistance to antimicrobial drugs. MROs, such as Multiple Drug Resistant Staphylococcus Aureus (MRSA) or Vancomycin Resistant Enterococci (VRE), can cause serious illness in infected persons and can potentially lead to death (ASNSW Skills Manual, p. 114). Infectious diseases can be avoided and infections such as MROs are preventable with proper infection control procedures and precautions (NSW Infection Control Policy, 2007).
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It is the responsibility of paramedics and health professionals alike to take the necessary precautions to prevent infectious disease from spreading in the best interest of the health and safety of patients, clinicians and the general public (National Health and Medical Research Council, 2010). In compliance with the AT clinical practice guidelines (2012), paramedics responding in the scenario are required to wear PPE in accordance with the standard precautions, which includes gloves and safety glasses with mask, vest and helmet when required (Skill A0101). With the presence of emesis and without appropriate infection control, potential illness maybe communicable by airborne transmission, such as gastroenteritis (Mandell et al, 2000).
Manual handling is defined in the New South Wales (NSW) Health Policy Directive (2011) as ‘any activity requiring the force exerted by a person to lift, lower, push, pull, carry or otherwise move, hold or restrain any object, animal or person’. Manual handling injuries are considered a large and unnecessary burden on workplace health, as most incidents are preventable (NSW Health Policy Directive, 2011). The purpose of manual handling policies and regulations is to prevent or minimise the occurrence of manual handling incidents (NSW Health and Community Services Industry Reference Group, 2005). This is accomplished with the combined effort of employees and employers in identifying, assessing and controlling workplace risks and hazards, such as those of manual handling (NSW Health Policy Directive, 2011). The safe manual handling techniques and skills required in the scenario include planning, two person log roll and team lifting with safe lifting techniques (Ambulance Victoria Clinical Work Instructions, 2001, Skill 5.1.1).
The patient in the scenario presents as unconscious with emesis present, thus requiring to be placed in the lateral position using a two person log roll (Ambulance Tasmania Clinical Work Instructions, 2004, Skill 2.2.1). Subsequent to the initial treatment the patient is required to be lifted onto a stretcher to be placed into the ambulance for transport to the emergency department (ED). Ambulance Tasmania does not specify a safe lifting load other than the recommended load bearing provided by the equipment manufacturer e.g. Ferno (Ambulance Tasmania Clinical Work Instructions, 2007, p. 5.1.22). However, according to the National Code of Practice for Manual Handling (2005) anything heavier than 55 kilograms (kg) is considered too heavy for an individual to lift and would require mechanical assistance or a team lift. The patient in the scenario weighs approximately 120 kg, therefore requiring a four person lift (National Occupational Health and Safety Commission, 2005).
Upon arrival the patient is found in a supine position, appears to be hypoventilating (AT Clinical Practice Guidelines, Protocol A0103) and is unresponsive to all stimuli with a Glasgow Coma Scale (GCS) of three (AT Clinical Practice Guidelines, Protocol A0104). AT Clinical Practice Guidelines (CPG) state that the patients respiratory rate of seven is considered dyspnoeic, and therefore inadequate. This requires the patient to be moved into a lateral position via log roll as this is the best position to manage the airway in an unconscious patient (AT Clinical Work Instructions, Skill 2.2.1; Jevon, 2008).
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The patient presents with emesis on his face and shirt suggesting that his airway may be compromised. Jevon (2008) explains that the most effective way to further examine an airway obstruction is the ‘Look, Listen and Feel’ approach, where the paramedic examines visible chest movements, audible breath sounds, abnormal noises, and palpable air flow from the nose and mouth. During the ‘Look, Listen and Feel’ airway examination it will become clear whether the obstruction is potential or actual, and partial or complete (Jevon, 2008). Additionally, the cyanosed lips and cool skin temperature of the patient would be noted. AT Clinical Work Instructions (CWI) states that paramedics are required to clear a patient’s airway with the removal of foreign bodies. It instructs the health professional to perform a triple airway manoeuvre, which consists of a head tilt, chin lift and jaw thrust, accompanied by the insertion of an artificial airway (AT Clinical Work Instructions, Skill 2.2.1).
The scenario requires an artificial airway to maintain the patients’ airway, specifically an oropharyngeal airway adjunct would be used to suppress the tongue and any other upper airway obstructions (AT Clinical Work Instructions, Skill 2.2.3). The oropharyngeal adjunct (OPA) is a good initial adjunct to use, as it is simple to insert and does not cause bacteraemia (bacteria in blood) (Patel, 2012). The inherent disadvantages of using an OPA include using the wrong size, which can contribute to airway obstruction, rather than airway patency (Khan, Sharma and Kaul, 2011). OPA’s have the potential to provoke emesis that may further obstruct the patent airway. It may also cause damage to soft tissue in the patients’ mouth and lips during insertion (Ostermayer and Gausche-Hill, 2014).
The OPA may potentially be inadequate in maintaining a patent airway, requiring paramedics to consider the use of an alternative airway adjunct to establish sufficient airway patency. Other airway adjuncts paramedics may consider include; a nasopharyngeal airway (NPA) applied via the nasal canals, laryngeal mask airway (LMA) that is orally inserted to cover the laryngeal inlet, or a endotracheal tube (ETT), inserted into the trachea, which is an intensive care paramedic (ICP) skill only and considered the gold standard of airway management (AT Clinical Practice Guidelines, Protocols A0301, A0302). The patient has gurgling respirations and may require manual airway clearance to remove obstructing substances, such as emesis. Using a yankaeur sucker, paramedics are able to suction the unwanted substances from in and around the OPA, therefore clearing the patients’ airway and eliminating the gurgling respirations (AV Clinical Work Instructions, Skill 2.2.6; ASNSW Clinical Protocol Guidelines, p. 101.7).
Once a patent airway has been achieved it is necessary to provide manual ventilation as the patient respiratory rate is currently seven per minute, an insufficient level of oxygenation to sustain the cells in the body (AT Clinical Practice Guidelines, Protocol A0103). AT clinical practice guidelines indicate the use of a bag-valve-mask (BVM) to provide additional oxygen to the hypoventilating patient (AT Clinical Practice Guidelines, Protocol A0103). The BVM resuscitation following intubation is one of the most important steps for effective airway management (Gabbott and Baskett, 1997). Despite its effectiveness, using a BVM has disadvantages including; gastric distension, regurgitation, aspiration, barotrauma and hypotension (Gabbott and Baskett, 1997; ASNSW Skills Manual, p. 102.1.1). Gabbott and Baskett (1997) emphasise the dangers of gastric distension resuscitation as they found 28% of failed resuscitations presented with pulmonary aspiration as a result of gastric distension.
Other patient care considerations
Additional precautions include accounting for accidental hypothermia. The patient has been outside on the ground for an unknown amount of time during May, which has an average temperature of 10 degrees celcius but can drop to below zero degrees celcius (Weatherzone.com.au, 2014). Ulrich and Rathlev (2004) state that hypothermia is when a person’s body temperature drops below 35 degrees celcius. Contributing factors to hypothermia include drugs and alcohol, environmental factors (e.g. wind or rain), length of exposure and time of day (Ulrich and Rathlev, 2004). Hypothermia management includes; sheltering patient from the environment, removal of damp and wet clothing, drying with towels and wrapping patient in space blanket. If hypothermia is severe, warming fluid at a temperature of 37 – 42 degrees celcius should be given to patient (AT Clinical Practice Guidelines, Protocol A0901).
To ensure comprehensive patient care is delivered at a high standard of clinical skill and safety paramedics must adhere to certain principles and guidelines. The WHS, infection control and manual handling guidelines and protocols are the initial point of notice for patient and paramedic safety. The systematic patient management framework ensures paramedics thoroughly assess patients’ conditions in order of severity, identifying life threatening conditions first and responding with appropriate treatment.
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