Study Guide to Paramedicine

  Welcome to yet another review of an article I've found on JEMS.com. Today's article is about determining whether or not a patient may be truly in pain or if they may be just seeking a fentanyl fix. Now at most ambulance services around Ontario they have actually switched out fentanyl for narcan also known as naloxone. I'm not sure about other services around the world but for this review I will refer to fentanyl for article purpose.

  This article was written by Dennis Edgarly. He begins the article with a scenario of a patient seeking fentanyl for extreme back pain. The patient stated he injured his back a couple years ago and has had two surgeries to repair disks. There is no obvious deformities, had full range of motion in lower legs, pedal pulses are present and strong, and he is able to sense touch. Vitals are as follows; pulse-106, BP-168/92, RR-22. The patient is demanding to be given fentanyl as the paramedics discuss how to move him.

  When treating patients with pain it is very important to rule out everything and figure out what the cause of pain is (if it's not already obvious) If it is not obvious as to why a patient may be experiencing pain it is best to simply treat the symptoms. For example; if they are having difficulty breathing due to the pain, apply oxygen. Edgarly states, "Keeping patients comfortable and relieving pain should be a goal in prehospital treatment" This is why we practice applying ice, giving blankets, splinting with padding, and delivering pain medication.

   But how do we know that the patient isn't faking it just to get their opioid fix? Well when people are in pain there are many physiological effects pain has on the body. Those include; increased heart rate and blood pressure. Long periods of pain requires the body to use up a lot of energy and hormones this causes effects such as alterations in blood pressure, alterations in blood glucose levels and slowed healing.

  Now as great as it is to remember these small physiological effects that will prove your patient is in pain. Relieving pain has not only become a component of patient care but also a human right. There are many way's however to relieve pain without giving pain medication, I mentioned a few above (blankets, ice, padding for splints, sitting comfortable on the stretcher, etc...) My favourite quote from this article that really changed my perspective on delivering pain medication was this "Pain management should be offered based on what the patient feels they need, not what the provider thinks they need". (Edgarly. D 2016) Everyone experiences pain differently and a paramedic should not withhold pain relief because they don't think their patient is in enough pain.

References

Limb Lead Placement

Here is a little saying to remember which lead is supposed to go where.

"White to right"

"Smoke (black) over fire (red)

  I recently read an article from JEMS Magazine. If you all don't read this magazine I suggest it, it is packed full of knowledge, case studies, research and more! This article started off with a scenario of a teenage girl who had been described by her mother as "acting weird". The young patient begins to speak of people who she believes told her the paramedics were coming, and begins to repeatedly say the date. Her vitals are all normal, there is no evidence of alcohol or drug use, and no history of trauma. After dropping off the patient at the hospital and returning with another the paramedics follow up with the doctor who begins to tell them the patient was exhibiting signs of schizophrenia. 

   Schizophrenia has a variety of symptoms. Ithas an onset during an individuals late teens to early 20's. They may experience hallucinations which can be either visual, auditory or somatic. They may experience delusions of fake belief which could be implausible or plausible. They may feel as though they are being communicated to through TV, radio or even written articles. Commonly they may present with rambling or disorganized speech or making up words. They may also appear to have a flat affect or without emotions.

  There is treatment for this individuals including medications but unfortunately more than half of them aren't receiving treatment.

  It is very important as paramedics to remember that these individuals believe in their hallucinations and beliefs because to them they are very real. These patients aren't typically combative but may be difficult to manage. Restraints may be necessary if they are at risk of jumping or running. It is also important to assess all other possible causes or these symptoms such as tumors, low BGL, or strokes. At the end of the day be supportive and caring and keep them safe.

References

Edgerly, Dennis. "Safely treating patients with schizophrenia". JEMS Magazine. Sept 2016: 18.

Check out the article for yourself!

8 Signs of Increased work of breathing

Get ready for a bunch of articles and drug of the day's as I catch up from the past week. Sorry for the lack of posting need to get back on track.

Below are some key signs you may visually and audibly be able to find on your patients with increased work of breathing. These can be quickly assessed as soon as you see the patient or after a head to toe examination.

1. Bony retractions- The sternum and the ribs will pull back into the chest during inhalations.

2. Soft tissue retractions- The soft tissue around bones of the chest will draw in on inhalation.

3. Nasal flaring- *mostly seen in younger children, the nostrils will open wide during inhalation.

4. Tracheal tugging- The trachea will appear to be pulling downward during inspirations.

5. Paradoxical respirations- The epigastrium is pulled in as the abdomen is pushed out, appears as a seesaw as the two opposite each other.

6. Pulsus paradoxus- Weak or absent peripheral pulses on inhalation

7. Pursed- lip breathing- Pursing of the lips like a kiss and exhaling slowing over a long period of time. *mostly seen in patients with obstructive disease (COPD)

The layers of the brain

The brain is encased with multiple layers to provide protection. The first layer being the one visible to the human eye is the skin of the scalp. The skin also contain hair follicles which believe it or not provide protection to the brain. Although you may not be able to feel with your hair it does send messages to the scalp if touched, therefore if you are about to hit your head the scalp will sense it by the hair follicles being touched and prevent you from hitting your head on the object.

The second layer is the periosteum (peri-around, os-bone) this layer wraps around the outside of the bone. This is found around most bone in the body and provides protection and blood supply which provides nutrients for bone tissue.

The meninges is the term used to explain the three major layers that cover the brain and spinal cord. This is why we refer to the disease meningitis this way because it is an inflammation (itis) of the meninges. These three layers includes dura mater, arachnoid mater, and pia mater. As mentioned above these layers provide protection to the brain but also provide a supportive framework for vasculature.

Lets break these layers down a bit;

Dura mater; This is the very top layer out of the three, seen in the photo is also referred to as the periosteal meningeal (peri-around os-bone) this layer is the layer the wraps underneath the bone of the skull.

Arachnoid mater; This layer is seen in the photo as being the purple layer. This layer is very delicate and provide direct protection to blood vessels. The arachnoid layer contain spider like projections (hence the name) called the arachnoid villi. These play a role in the cerebral spinal fluid (CSF) being granulated in the venous blood of the brain. CSF circulates between the subarachnoid space and the pia mater.

Pia mater; This layer covers the surface of the brain. Again this layer with provide protection, blood supply and circulates CSF.

Topic: Why do patients become altered?

Here is an explanation of each point. The acronym to remember when ruling out why your patient may be altered it “AEIOU TIPS”.

Alcohol; Alcohol directly effects the brains chemistry by effecting the neurotransmitters (chemical messengers that transmit signals throughout the body which control emotion, behaviour and thought process) Alcohol effects both excitatory and inhibitory neurotransmitters. Excitatory neurotransmitters are those that increase brain activity and energy levels which means if they are supressed by alcohol it results in a sllloooowwww down. Inhibitory neurotransmitters do the opposite and calm everything down alcohol works on these by amplifying there effects.

Epilepsy (seizures); It is still being research why patients who experience seizures are altered during the post ictal state but there are many theories. The first is the neurotransmitters are being used faster than they can be synthesized. There is no evidence that neurotransmitters become depleted during the seizure activity. Second researcher’s believe that the opioid receptors in the brain become depleted during the seizure which results in the depression state, some researchers have even tested if naloxone can reverse these effects and found that the depressed post ictal phase didn’t last as long. Lastly a decrease in blood flow to the brain may be the reason that not only does the tissue use up a large amount of glucose during the seizure and therefore there is limited blood glucose levels reaching the brain but there is a limited blood flow which decreases brain function.

Insulin; Both hyperglycemia (too much glucose in the blood that is not being taken up by the tissues) and hypoglycemia (lack of glucose in the blood to provide nutrients to tissues) can cause an altered mental state. Having plenty of glucose in the blood but no way to get it to the tissues causes it to become useless, insulin is the only way to open the gates to allow glucose to pass over. The brain is very reliant on glucose because it gives it energy which it needs lots of. The brain feels drowsy and slow when it doesn’t have enough, kind of like myself when I don’t get my coffee! Now it is the same way if the body has plenty of insulin available waiting for the glucose but not enough glucose is there to replenish the tissues and brain.

Overdose; Now there are many types of substances patients can take to cause them to overdose. Some may do it intentionally other by mistake. One important one is opioid overdose. In the brain there are many opioid receptors and when a patient takes an opioid drug such as heroin, fentanyl and many more, these receptors grab on to the opioid and do as they are supposed to. When a patient takes too much, these opioids cause there system to slow down so much to dangerous levels. This results in an altered state of mind.

Uremia; The kidneys do wonderful things and one very important job it has it to eliminate waste products from the body through urine. If the kidneys are not doing this job the body can become backed up with waste products and toxins that should not be present. This is mostly the case when individuals have issues urinating, have an infection, or disease not allowing them to urinate normally. These patients can become very altered when the brain is introduce to toxins it isn't used to. 

Trauma; The body can undergo a wide variety of trauma, from head injury to large blood loss all not good and all could be the reason for an altered level of consciousness.

Infection; Infections can vary from a small cut to a full body infection also known as sepsis. This topic correlates similarly to uremia as the body is being introduced to toxins its not used to and should be there. Its very important when performing assessments to go in depth about a possible infection.

Psychiatric or poisons; It is very important when assessing a psychiatric patient to confirm with an individual who is familiar with the patient to confirm if there behaviour is normal to there every day. These patients already have a mental disorder that inhibits the brain to function properly and they may seem altered to begin with but that may actually be there norm. Poisons follows similarly with overdose and alcohol as it affects the brain function substantially. The brain is not a place for toxins or chemicals to be hanging around.

Stroke; Strokes are either ischemic or hemorrhagic. Ischemic- lack of blood flow to a certain area. Hemorrhagic-  brain bleeding. If the brain is depleted of blood it is not receiving the amount of glucose and nutrients it needs to function properly. As well if the brain is losing the blood it is receiving it again cant function properly and the pressure that the blood entering the cranial space is restricting the brain.

I hope you enjoy this review if I have any errors I apologize. Busy day today and wanted to get this out of the way this morning!

http://www.forbes.com/sites/daviddisalvo/2012/10/16/what-alcohol-really-does-to-your-brain/#1fe13a96413b