Week 5

Week 5
Reflection:

Using the Gibb's Reflective Model, i will be reflecting on the practical session we had on the 29th of February, 2016.

Description: In this lab session I had an acute COPD attack scenario. My patient was a 58 y/o female C/O difficulty of breathing and a cough. This started 2-3 hrs before she called for help. The patient was comfortable in her position. She said that the DOB and cough were relieved when she sat down, and got worse when she moved around. She described them as moderate in severity. The patient had a history of cholesterol, HT and smoked 4-5 packs of cigarettes per day. She had medications for the HT, cholesterol, and a Ventolin inhaler. The pt’s VS were BP: 135/85, HR: 85, RR:20, SpO2: 93%. However, I took the patient’s HR later on in the case and I forgot to auscultate. Nonetheless, I treated the patient with 2 doses of Ventolin and one dose of Ipratopium Bromide.
Feelings: I felt confident in my approach, assessment, and management. However, I got shocked that I completely forgot to auscultate the patient! Also, I felt a little disappointed about that and about checking the HR late in the case.
Evaluation: In my opinion, I did a really good job at treating the patient. However, my assessment was not that good. In the VSS, I should have checked the HR first, since it can tell me a lot about the patient’s status. Moreover, this case was clearly a respiratory emergency and auscultation is very important to complete a respiratory status assessment. Therefore, it was bad that I forgot to auscultate the patient.
Analysis: I believe my management of this patient was really good because this patient was having a moderate COPD attack, and I managed the pt in accordance with the JRCALC (2013) guidelines. I felt disappointed about not checking the HR early because my teacher is constantly reminding us to check the HR early on in the case. This is because just the HR can tell us if there are any perfusion problems. Lastly, in a respiratory status assessment, chest auscultation is crucial. It helps me recognize what the possible respiratory problem was. Therefore, forgetting this makes my RSA incomplete and lacking.
Conclusion: If I get a similar case again I would follow the systematic approach and make sure to assess the pulse early on in the VSS. Also, I would auscultate the patient’s chest once I suspect a respiratory problem. Finally, I would do everything else, such as the rest of the assessment and the treatment, in the same manner as I did in this case.
Action Plan: My plan after this reflection is to continue practicing my systematic approach until I perfect it. Also, I plan to revise this approach and go into depth of all its components , so as not to forget anything. I want to also stay aware of checking the patient’s HR early on, to get a better picture of my patient. Moreover, I plan to auscultate my patient as soon as I think the case is respiratory related. Finally, I plan to continue following the JRCALC(2013) guidelines in my treatment of patients.

Reference

Joint Royal Colleges Ambulance Liaison Committee. (2013). UK ambulance services: Clinical practice guidelines 2013. Bridgwater, England: Class Professional Publishing.

Learned Concepts

In this week's lecture we learned about different lung infections and lung inflammation.Firstly, we started with pneumonia. Pneumonia is an inflammatory process of functional lung tissue that is commonly caused by infectious agents.
DD of pneumonia: Bronchitis, chest infection, pneumothorax, pulmonary edema.
Pneumonia can be classified according to the area involved (Lobar/ broncho), or according to cause(bacterial, viral, fungal, chemical, inhalational).
The mode of transmission depends on the cause where bacteria and viruses living in the nose, sinuses, mouth spread to the lungs. Or through droplet infection or through the inhalation of food, vomit, liquid from the mouth into the lungs.
Predisposing factors include:

• Cigarette smoking
• Immuno-suppression (increased chances of infection)
•  Difficulty swallowing (stroke, dementia, parkinsonism)
• Impaired consciousness
• Chronic lung disease (COPD, bronchiectasis)
• Other serious illnesses (heart or liver disease)
• Recent cold, laryngitis, influenza
• Frequent airway suctioning

Normally, 80% of cells lining central airways are ciliated, pseudo-stratified, columnar epithelial cells. Each ciliated cell contains around 200 cilia that beat in coordinated waves. This keeps the lower respiratory tract a sterile environment.

Pneumonia presents as cough, dyspnea, sputum production, fever, and abnormal breath sounds (wheezes/ crackles).

In elderly, it may also present as falls, confusion, failure to thrive, and worsening of underlying chronic illness.

Therefore, typical presentation of pneumonia includes:

• Sudden onset of fever
• Productive cough
• SOB
• Pleuritic chest pain

Atypical presentation comes as:

• Gradual onset of cough
• Cough is dry
• Prominence of headache, myalgia, fatigue, sore throat, nausea, vomitting

Diagnosis achieved through CXR, FBC, and blood/sputum cultures.

Complications of pneumonia include pleural effusion, lung abscesses, sepsis, respiratory failure, Acute Respiratory Distress Syndrome (ARDS).

Prehospitally the management of pneumonia involves positioning the patient upright (to move fluid downwards and ease breathing effort of pt., give appropriate oxygen therapy, bronchodilators, analgesia.

We then moved to learn about the Human Immuno-deficiency Virus, HIV. This is caused by retrovirus that invades T cells (defense mechanism of body) in the body of the host.

This disease is preventable and manageable BUT not curable.

HIV is the virus that causes AIDS. This disease limits the body's ability to fight infection. Pt is predisposed to multiple opportunistic infections which can increase chances of pneumonia.

There are four stages of HIV:

1. Primary: Short, flu-like illness, 1-6 weeks after infection, can be transmitted
2. Asymptomatic: Lasts for around 10 years, free from symptoms, may be swollen glands, HIV antibodies are detectable in blood
3. Symptomatic: Usually mild symptoms, immune opportunistic infections
4. AIDS: Immune system continues to weaken, illnesses become more severe, leads to AIDS diagnosis

Opportunistic infections include bacterial (pneumonia, TB), parasitic (pneumocystis), viral (herpes, influenza, kaposi sarcoma), fungal (candida, cryptococcus).

HIV patients usually take three or more different types of drugs (combination therapy). 

Cystic fibrosis is caused by mutations in the CF transmembrane conductance regulator gene which encodes a protein expressed in apical membrane of exocrine epithelial cells (recessively inherited, lifelong).

Characterized by:

• Chronic bacterial infection of airways
• Fat maldigestion (pancreatic insufficiency)
• Infertility in males
• Elevated concentrations of chloride in sweat

Some non-classic cystic fibrosis may not have overt signs of maldigestion because some pancreatic exocrine function is preserved.
Medical management of patients with CF includes preventing and controlling lung infections, removing mucous from lungs, preventing or treating blockages in intestines, providing sufficient nutrition, and preventing dehydration.
At this point we finished the first lecture and moved on to the second one, where we learned more types of lung infections and inflammation.
Tuberculosis is caused mostly by M. tuberculosis. The only myobacteria that does not cause TB is the M. avium complex.
Tuberculosis is transmitted via the air or inhalation of droplet nuclei. M. tuberculosis may be expelled when infected person coughs, speaks, and sneezes.
Transmission depends on infectiosness of infected persons, virulence of tubercle bacilli, environment of exposure, length of exposure.
Prevention is by using PPE, contact tracing for potential exposure, and providing effective and early management.
Tuberculosis can be classified as latent or active. Latent is when the tubercle bacilli are in the body but the immune system keeps it under control. Latent is not infectious.
On the other hand, active TB develops when the immune system cannot keep the tubercle bacilli under control. Active TB is infectious.
Persons with HIV may develop TB due to their weakened immune system or may be infected by M. tuberculosis which develops into TB.
TB most commonly infects the lungs, brain, larynx, pleura of lung, lymph nodes, kidneys, and spine.
TB can be classified as Pulmonary TB, extrapulmonary TB, miliary TB.
Medical management of TB involves isolation in a negative pressure room, drug therapy of four drug combination therapy, and monitoring.
The immune system protects the body from possible harmful substances by recognizing, responding to, and attacking antigens.
There are some cells that have proteins that are antigens. The immune system learns to see all of these antigens as normal and does not usually react against them.
Immunity is innate, acquired, and passive.

Image 1: Mind map about types of immunity

In allergic reactions, the immune system reacts to an outside substance that it normally ignores. 

In autoimmune disorder, the immune system reacts to body tissues that it normally ignores. 

Normally, these conditions occur when T and B lymphocytes do not work as well as they should or the body does not produce enough antibodies.

Immunosuppression is when the body's immune system is weakened due to medications. Transplant patients are given medications to cause immunosuppression to stop rejection.

Inflammation occurs when tissues are injured by bacteria, trauma, toxins, heat or any other cause. Damaged cells release chemicals including histamine, bradykinin, and prostaglandins. These chemicals cause blood vessels to leak fluid into tissues, causing swelling. This helps isolate foreign substances from further contact with body tissues.

The chemicals also attract WBC called phagocytes to engulf germs and dead/damaged cells.

Anti-inflammatory drugs reduce inflammation. These drugs are used as analgesia, where they reduce pain by reducing inflammation. Can be steroids, NSAIDS, and immune selective.

ARDS is an extremely serious disorder that can result from a number of direct and indirect causes.

Direct causes: Severe pneumonia, lung contusion from trauma, aspiration.

Indirect causes: Severe infections, acute pancreatitis, severe trauma or burns, massive blood transfusion.

These causes can trigger a series of events that lead to leakage of fluid from blood vessels into alveoli,. Pulmonary edema occurs and the basic function of absorbing oxygen can become almost impossible.

Treatment of ARDS involves supporting the lungs until they repair themselves. Ventilators will usually be required to improve oxygen delivery. If oxygen uptake does not improve, techniques such as prone ventilation is adopted. This moves the fluid to chest wall and since alveolar capillaries are under the alveoli, this allows for contact of oxygen with the capillaries. 

We then went on to the the tutorial for this week.

Image 2: Week 5 tutorial with my notes.

Additional Readings
I checked my textbook for further clarification on how to manage a pneumonia patient. This is what i found:

Image 3: Management of pneumonia patients. Adopted from (Bortle, 2013).

References

Bortle, C.D. (2013). Respiratory emergencies. In A.N. Pollak (Ed.), Nancy caroline's emergency in the streets (pp.850-901). Burlington, MA: Jones & Bartlett Learning.

Stand Out Moment
A stand out moment for me this week was understanding and learning the management of patients with pneumonia prehospitally. In the lecture it was not very clear to me as to what i can do for a pneumonia patient. However, i fixed that by searching further and reading in my textbook. In the textbook it was specific and clear as to exactly what i can do for a pneumonia patient.

Biggest Impression
Learning about pneumonia, its causes and how to manage it. This is because on previous placements i saw pneumonia patients but never understood what this disease was and how to deal with it. Now i know the importance of protecting myself around such patients and how to properly manage their disease in my future practice as a paramedic.