Week 9

Week 9
Reflection:
Using the Gibb's Reflective Model, i will be reflecting on the practical session we had on the 28th of March, 2016.

Description: On the 21^st of March we had three OSCES. The first one involved setting up an IV line, cannulating the patient, and administering a medication bolus. The second one was providing BVM ventilations to an apneic patient. The third and final one was delivering oxygen using a non-rebreather mask. I followed the steps for all of these OSCEs correctly, and passed them all.

Feelings: I felt confident in my ability to perform these three OSCEs since we practiced them multiple times in the past. I got very happy and excited when I passed them all.

Evaluation: I did a great job and it was very good that I recalled everything I needed to do for each skill. I followed the steps in accordance to the OSCE sheet which was really good and lead me to pass.

Analysis: I practiced these three skills many times before and revised the OSCE sheets for them before coming to the exam. This helped me remember everything I needed to do and lead to me passing them all. This showed me that I am progressing and learning how to do the mentioned skills in a safe and effective manner.

Conclusion: Practice and repetition makes perfect. I still have not reached the stage where I am perfect at these skills. However, I have reached the standard expected from me and that is really rewarding. Passing the OSCEs thrilled me because it showed me that I am achieving my learning goals to become a good paramedic.

Action Plan: I plan to continue practicing these skills and to constantly read over their OSCE sheets. I intend to not settle after just passing the OSCEs, rather I want to continue training on these clinical skills until I am perfect at them.

 Video 1: Me performing IV cannulation and medication administration OSCE. 

Video 2: Me performing providing assisted ventilations to an apneic patient OSCE.

Learned Concepts

A cold is an infection of the mucus membranes of the respiratory tract caused by a rhinovirus. Colds and influenza are caused by viruses.
Defense against infections is as follows: Nonspecific external barriers -> Innate immune response -> Adaptive immune response.
Phagocytes are attracted by an inflammatory response of damaged cells. Inflammation is signaled by mast cells, which release histamine. Histamine causes fluids swelling at the site of injury. Also, part of inflammation involves a rise in temperature of tissues. This is to kill temperature-sensitive microbes.
Low fevers are beneficial for the body and should be left to run their course.
Interferons are proteins made and released by host cells in response to pathogens. This protein is produced by the immune system in response to infections.
Common cold is a general term for acute inflammatory disease of the upper airway tracts. It includes: Rhinitis, tonsillitis, pharyngitis, laryngitis, pharyngo-laryngitis.
Influenza, a respiratory virus, has symptoms including:

• Nasal obstruction
• Sneezing
• Sore throat
• Cough
• Sputum
• Headache
• Fever (characteristic)
• General malaise
• Muscle pains
• Arthralgia

Viruses causing the following respiratory infections are:

Corza: Rhinoviruses, Coronaviruses

Influenza: Influenza virus

Croup: Parainfluenza viruses

Bronchiolitis: RSV

Bronchopneumonia: Influenza virus, RSV, Adenoviruses

Common colds account for 1/3-1/2 of all acute respiratory infections in humans.

Image 1: Table comparing allergy, common cold, and flu.

Influenza has the same symptoms as the common cold in addition to rapidly rising fever, chills, and body and muscle aches.

Preventing H1N1 from spreading includes good personal hygiene, wearing PPE, environmental hygiene, exercise social responsibility, and maintaining a healthy lifestyle.

Complications of H1N1 include pneumonia caused by the influenza infection itself or bacteria. This complication can lead to death of the infected person.

Croup is the most common manifestation of parainfluenza virus infection. Other conditions that may be caused by parainfluenza viruses include: Bronchiolitis, pneumonia, and flu-like tracheobronchitis. 

Most common cause of severe lower respiratory tract disease in infants is influenza. Causes bronchiolitis, bronchopneumonia, and croup.

Inflammatory disorders of the larynx include acute simple laryngitis, chronic infection, laryngeal edema, and laryngeal-pharyngeal reflux disease (LPRD).

Some causes of laryngeal edema are angio-neurotic edema, thermal burn, trauma, nephritis, and heart failure.

Etiology of acute laryngitis is viral infection, vocal abuse, allergy, smoking, GERD, thermal/chemical burn, use of asthma inhalers, laryngeal trauma, and undue physical or psychological stress.

Presents as:

• Hx of upper respiratory tract infection
• Hoarseness, high pitched husky voice
• Dry, paroxysmal cough
• Sore throat
• Upon laryngoscopy: red, swollen supraglottic mucosa, swelling of true vocal cords, inspissated secretions between vocal cords.

Subglottic laryngitis presents in children below 3 years with rapid onset of stridor, barking cough, and low grade fever. Treatment of this condition is moist air with oxygen and supportive treatment. Must avoid sedatives in such cases.

Chronic laryngitis is chronic, non-specific inflammation causing irreversible changes to the laryngeal mucosa. Caused by: Viral infection, vocal abuse, allergy, smoking, and environmental pollution.

Chronic hyperemic laryngitis is presented as:

• Hoarseness
• Dry cough for more than 3 weeks
• Persistent clearing of throat
• Previous URTI/ GERD
• Upon laryngoscopy: Hyperemic laryngeal mucosa with sub-mucosal edema.

Treatment for this disease is medicated steam inhalation, systemic antibiotic, and avoidance of alcohol and tobacco.

Reinke's edema is the accumulation of fluid in Reinke's space between the vocal ligament and the overlying mucosa. Caused by irritants (alcohol, tobacco smoke), laryngeal allergy, and infection.

Clinical feature of Reinke's edema:

• Hoarseness of voice
• Stridor
• Early: increased convexity of medial cord margin
• Late: Pale, watery bags of fluid on superior surface of vocal cords. 

Angio-Neurotic edema is the recurring attacks of swelling of face, larynx, and extremeties caused by edema due to vasodilation and increased capillary permeability. Two types: Allergic and hereditary.

Etiology includes atopy, food, drugs, insect bites, physical stimulus (cold air, smoke), trauma, and emotional stress.

Laryngeal trauma most commonly caused by car accidents. Other causes include penetrating wound and gun-shot wound.

Signs and symptoms are: Stridor, bleeding, emphysema, hemoptysis, dysphagia, crepitation, and in severe cases, coma.
After the lecture we did the tutorial case study for week 9.

Image 2: My notes for week 9 tutorial.

Additional Readings

I read the additional readings and found good information on the tratment of croup.

For the treatment of croup nebulised racemic epinephrine may be administered. Administering one dose at a time has not been associated with any adverse effects and did not cause any significant increase in heart rate or blood pressure. Moreover, corticosteroids are used to treat such patients. Administration of corticosteroids has been found to reduce the rate of intubation by fivefold. The oral route for this drug has been found to be ideal in children (Bjornson & Johnson, 2008).

The corticosteroid recommended by the JRCALC(2013) is Dexamethasone.

Image 3: Information about Dexamethasone. Adopted from (JRCALC 2013).

References

Bjornson, C.L., & Johnson, D.W. (2008). Croup. The Lancet, 371, 329-339. doi: 10.1016/S0140-6736(08)60170-1

Join Royal Colleges Ambulance Liaison Committee. (2013). UK ambulance services: Clinical practice guidelines 2013(4^th edition). Bridgwater: Class Professional Publishing.

Biggest Impression

The three things that had an impression on me as a paramedic were learning how to deliver assisted ventilations using a BVM, providing oxygen via NRB mask, and the treatment of croup. All these skills are important and will prove useful in my future practice as a paramedic.