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Patients undergoing surgery for Graves’ disease should be treated with beta-blockers and rendered clinically and biochemi- cally euthyroid preoperatively with ATDs. Potassium iodide may be administered in the immediate preoperative period. If the patient needs urgent surgery, beta-blocker, ATDs, and potassium iodide should be used as long as possible to achieve or approach a euthyroid state prior to surgery. Subclinical Hyperthyroidism Patients with subclinical thyrotoxicosis may be asymptomatic or present with resting tachycardia or atrial fibrillation. The 10-year risk of developing atrial fibrillation in elderly patients with a TSH less than 0.1 mIU/L is three times higher compared to euthyroid patients. Elderly patients with subclinical thyrotoxicosis have an increased risk of all-cause and cardiovascular mortality, while young and middle-aged people manifest cardiac changes includ- ing increased ventricular mass and contractility and reduced dia- stolic function. The decision to treat subclinical hyperthyroidism is based on risk. If TSH is persistently less than 0.1 mIU/L, patients older than 65 years, patients with cardiac risk factors or disease, and those with osteoporosis should be treated. In addi- tion, patients with clinical symptoms of hyperthyroidism and postmenopausal women who are not treated with estrogens or bisphosphonates are treated if TSH is persistently lower than 108 J. Sandeep and J. V. Hennessey 0.1 mIU/L. When TSH is less than normal but above 0.1 mIU/L, treatment would be considered for patients over 65 years of age, patients who are symptomatic, and those with cardiac disease. Treatment with Amiodarone in Patients with Cardiac Arrhythmias Amiodarone is iodine rich (37% by weight) and concentrates in several tissues resulting in an effective half-life of more than 50 days. Amiodarone can cause both hypothyroidism and thyro- toxicosis. There are two types of amiodarone-induced thyrotoxico- sis (AIT). Type 1 AIT is a form of endogenous hyperthyroidism where there is overproduction of thyroid hormone and occurs in patients with underlying thyroid disease including Graves’ or mul- tinodular goiter. Type 1 AIT occurs more frequently in areas of iodine deficiency. Type 2 AIT is a form of thyroiditis where pre- formed thyroid hormone is released from the thyroid in an unregu- lated manner. Treatment for type 1 AIT includes antithyroidal drugs, potassium perchlorate (to block thyroidal iodine uptake), or surgery. Type 2 may be observed, and if mild, may be treated with glucocorticoids or if severe may be treated with surgery if not responsive to medical therapy. It may be difficult to differentiate type 1 from type 2 AIT, and a combination of antithyroidal drugs (MMI) and glucocorticoids is frequently used as the initial treat- ment. There is debate if amiodarone needs to be stopped when thyrotoxicosis occurs. As amiodarone is lipophilic and may not be cleared for 6 months or more after stopping the drug, discontinua- tion is not of short-term use. If treatment with amiodarone is criti- cal to controlling the arrhythmias, amiodarone should be continued. Hypothyroidism and Cardiac Disease Impact of Hypothyroidism on Cardiovascular Risk Factors Both overt and subclinical hypothyroidism (SCHypo) are asso- ciated with changes in lipid parameters and are considered risk 9 Thyroid Problems Encountered Specifically in Inpatients… 109 factors for cardiovascular disease. Total LDL cholesterol and apolipoprotein B levels are adversely affected by insufficient circulating thyroid hormone as decreased expression of the hepatic LDL receptor and reduced activity of cholesterol α-monooxygenase activity diminish cholesterol clearance. Other CV risk factors such as C-reactive protein and homocysteine are also elevated in the hypothyroid state. This risk profile may lead to the progression of undiagnosed coronary artery and vascular disease in patients with hypothyroidism. Additionally, the effec- tiveness and safety of treatment of dyslipidemia with statin med- ications, specifically myopathy, may be impacted by the presence of hypothyroidism. Cardiovascular Hemodynamics in Hypothyroidism Systemic vascular resistance (SVR) is increased and cardiac out- put declines. Thyroid hormone has a direct vasodilator effect on vascular smooth muscle and indirect effect by inducing endothelium- derived nitric oxide release. Both of these actions are impaired in mild and overt hypothyroidism which results in further increase in the systemic vascular resistance. Cardiac con- tractility is negatively affected leading to a reduction in stroke volume and decrease in heart rate which together lead to a reduc- tion in cardiac output. Additional changes include diminished stimulation of erythropoietin production decreasing plasma and circulating blood volume. Capillary permeability increases result- ing in gravity-d ependent edema and pericardial and pleural effu- sions which may further compromise both cardiac (tamponade physiology) and pulmonary function. Heart Failure and Arrhythmias in Hypothyroidism The impact of hypothyroidism on cardiac contractility may result in clinical cardiac failure, often characterized as diastolic dysfunc- tion that results in abnormal cardiac muscle relaxation. However, heart failure caused by hypothyroidism differs physiologically from heart failure caused by non-thyroidal causes. Despite reduc- 110 J. Sandeep and J. V. Hennessey tion in cardiac output, hypothyroid patients have normal arteriove- nous (AV) oxygen extraction as against patients with organic heart disease and heart failure who have increased AV oxygen extrac- tion. Patients with hypothyroidism are able to mount cardiac response to the exercise in terms of increasing the cardiac output and reduction in SVR as against patients with classic CHF. In addi- tion, signs of right heart failure are rare in hypothyroid patients, and they are able to excrete sodium load when compared with patients with CHF from organic heart disease. Exercise intolerance seen in hypothyroid patients is due to weakness of skeletal muscle and due to respiratory etiology rather than cardiac failure. As noted above, the presence of CAD risk factors potentially predispose these patients to atrial fibrillation (Afib) which further compromises optimal cardiac function. Recent data indicated that hypothyroidism may predict persistently symptomatic atrial fibril- lation impacting cardiovascular outcomes. A prolonged QT inter- val is commonly noted in hypothyroid subjects likely indicating a ventricular vulnerability to arrhythmia, while conduction defects across the AV node and through the ventricles are also reported. Amiodarone-Induced Hypothyroidism As a result of the substantial (37% by weight) iodine content of amiodarone, those with previously damaged thyroid glands due to autoimmune thyroid disease or 131-I ablation for Graves’ are especially susceptible to the Wolff-Chaikoff effect, thereby decreasing thyroid hormone production and lapse into hypothy- roidism after long-term treatment. Due to its prolonged half-life and the danger posed by the underlying arrhythmias that amiodarone so successfully treats, discontinuation of amiodarone is not usually undertaken as it is neither an effective solution to the hypothyroidism nor a prudent decision from a cardiac perspective. Diagnosis of Hypothyroidism Diagnosis requires measurement of TSH and free T4 (FT4) levels. There is no utility in measuring T3 or reverse T3 (rT3) if hypothyroidism is suspected. Caution should be exercised 9 Thyroid Problems Encountered Specifically in Inpatients… 111 in interpreting TSH levels (dopamine and glucocorticoids suppress TSH) and FT4 levels (change due to non-thyroidal illness [NTI]) in acutely ill patients. Overt primary hypothy- roidism is characterized as a clearly elevated TSH (greater than 10 uLU/L) and low FT4. Overt central hypothyroidism is recognized when TSH is suppressed or inappropriately nor- mal and FT4 is below the expected range. Subclinical hypo- thyroidism is defined as elevation of TSH with a normal FT4. TSH elevation should be reproducible to rule out the effect of non-thyroidal illness and greater than age-adjusted expected ranges. SCHypo is seldom definitively diagnosed in hospital- ized patients due to the impact of NTI on TSH levels. Antithyroid antibodies to thyroid peroxidase (TPO) or thyro- globulin (Tg-ab) are useful to document the presence of auto- immune thyroid disease, and TPO may predict an increased risk of progression to overt hypothyroidism in those with SCHypo. Treatment of Overt Hypothyroidism Treatment with levothyroxine (LT4) improves LDL cholesterol metabolism, diastolic hypertension, and cardiac dysfunction, accelerates heart rate, and delays the progression of atherosclero- sis. Additionally, prospective data clearly demonstrate that LT4 therapy will reverse the cardiac muscle lipid accumulation and reduction in cardiac output associated with short-term overt hypothyroidism. Due to the potential presence of underlying CAD in some subjects with prolonged duration of hypothyroid- ism, some caution in reestablishing the euthyroid state may be warranted. The full replacement dose of levothyroxine is generally 1.6–1.7 microgram/kg daily in patients with overt hypothy- roidism. However, this recommendation varies in those with SCHypo where residual endogenous thyroxine production is present. The cardiovascular system in patients with SCHypo clearly responds positively to LT4 when TSH is greater 10 mIU/L especially in those under 65 years of age. Out of an 112 J. Sandeep and J. V. Hennessey abundance of caution, lower initial replacement doses than those employed in young adults are advisable in the elderly and those with known CVD and titrated up slowly (start low and go slow). The recommended starting dose of levothyroxine in patients above 50–60 years of age is 50 microgram daily in the absence of known CAD and in those with known cardiac issues where initial doses of 12.5–25 microgram daily are rec- ommended. LT4 should be ingested fasting with water only 60 min before breakfast or other medications for optimal absorption. Following the institution of LT4 therapy, adequate time (4–8 weeks) should pass before reevaluation of thyroid function is carried out. Thyroid Hormone Treatment in Cardiac Failure and Patients Undergoing Cardiac Surgery It has long been felt that emergency coronary bypass surgery is considered safe in patients with hypothyroidism. Other reports raise concern about prolonged postoperative recovery from anes- thetics, ileus, and infections going undetected due to a lack of fever as well as atrial fibrillation of hypothyroid patients undergo- ing cardiac surgery. Preoperatively, a ll patients should be treated with adequate doses of thyroid hormone. Unless there are contra- indications such as bradycardia and advanced COPD, beta- blockers should also be given to reduce the risk of frequently encountered post-cardiac surgery atrial fibrillation. In patients with heart failure and normal TSH and T4, those with a low T3 concentration had more severe heart failure as assessed by New York Heart Association criteria. Short-term treatment with T3 in patients with cardiac failure has resulted in a predictable decrease in systemic vascular resistance and subse- quent improvement in cardiac output without adverse effects but is not generally suggested due to limited confirmatory data. There are no guidelines which recommend treatment with IV T3 in patients with cardiac disease undergoing bypass surgery with low T3 syndrome. Presently, we do not recommend treating patients with cardiac disease with IV T3. 9 Thyroid Problems Encountered Specifically in Inpatients… 113 Suggested Reading Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, et al. 2017 Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid. 2017;27(3):315–89. Bogazzi F, Tomisti L, Bartalena L, Aghini-Lombardi F, Martino E. Amiodarone and the thyroid: a 2012 update. J Endocrinol Invest. 2012;11(5):340–8. Burch HB, Cooper DS. Management of Graves’ disease: a review. JAMA. 2015;314(23):2544–54. De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet. 2016;388(10047):906–18. Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, American Thyroid Association Taskforce on Hypothyroidism in Adults, et al. Clinical practice guidelines for hypothyroidism in adults: cospon- sored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid. 2012;22(12):1200–35. Martin SS, Daya N, Lutsey PL, Matsushita K, Fretz A, McEvoy JW, et al. Thyroid function, cardiovascular risk factors, and incident atherosclerotic cardiovascular disease: the atherosclerosis risk in communities (ARIC) study. J Clin Endocrinol Metab. 2017;102(9):3306–15. Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. ATA hyperthyroidism management guidelines. Thyroid. 2016;26(10):1343–421. Sun J, Yao L, Fang Y, Yang R, Chen Y, Yang K. Relationship between sub- clinical thyroid dysfunction and the risk of cardiovascular outcomes: a systematic review and meta-analysis of prospective cohort studies. Int J Endocrinol. 2017;2017:8130796. Teasdale SL, Inder WJ, Stowasser M, Stanton T. Hyperdynamic right heart function in Graves’ hyperthyroidism measured by echocardiography normalises on restoration of euthyroidism. Heart Lung Circ. 2017;26(6):580–5. Udovcic M, Pena RH, Patham B, Tabatabai L, Kansara A. Hypothyroidism and the heart. Methodist Debakey Cardiovasc J. 2017;13(2):55–9. houstonmethodist.org/debakey-journal. Severe Hypercalcemia 10 Antonia E. Stephen and Johanna A. Pallotta Contents Introduction 116 Etiology 116 Presentation 117 Diagnostic Approach 118 Treatment 119 Summary 121 Suggested Reading 122 A. E. Stephen Harvard Medical School, Massachusetts General Hospital, Department of Surgery, Boston, MA, USA e-mail: [email protected] J. A. Pallotta (*) Harvard Medical School, Beth Israel Deaconess Medical Center, Department of

Medicine, Endocrinology and Metabolism, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 115 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_10 116 A. E. Stephen and J. A. Pallotta Introduction Hypercalcemia is a common clinical problem. The majority of patients with hypercalcemia are asymptomatic and are often diagnosed on routine laboratory studies. They do not typically require immediate treatment. In distinction to patients with mild hypercalcemia, patients with severe hypercalcemia are often symptomatic and usually require urgent admission and treat- ment. In addition to treating the acute hypercalcemia, the under- lying cause must be investigated and treated when possible, to avoid ongoing or repeated episodes of severe calcium elevation. In over 90% of patients, the cause of hypercalcemia is either pri- mary hyperparathyroidism or malignancy; other causes are far less common. The focus of this chapter is on the etiology of hypercalcemia and the presentation and treatment of severe hypercalcemia. Etiology The etiologies of hypercalcemia are primarily distinguished between those that are parathyroid (PTH)-dependent and those arising from non-PTH-dependent mechanisms (Table 10.1). Among all causes of hypercalcemia, hyperparathyroidism (excess PTH production) remains the most common. Included in this cat- egory are primary (adenoma, hyperplasia, or rarely carcinoma of the parathyroid glands) and tertiary hyperparathyroidism ( physiologic hypertrophy of the parathyroid glands). Among non- PTH- dependent etiologies, the most common cause is hyper- calcemia of malignancy. This can occur as a result of the excess production of PTH-related peptides (PTHrP), from osteolytic bone metastases, or from excess vitamin D production. Less com- mon causes of hypercalcemia include hypervitaminosis D, also known as vitamin D intoxication, where excessive vitamin D intake results in hypercalcemia, and granulomatous diseases ( sarcoidosis or tuberculosis). Other causes include thyrotoxicosis, pheochromocytoma, and medications such as thiazide diuretics 10 Severe Hypercalcemia 117 Table 10.1 Causes of hypercalcemia PTH dependent Primary hyperparathyroidism Adenoma Hyperplasia Inherited syndromes – MEN and hyperparathyroidism-jaw tumor syndrome Parathyroid carcinoma Familial hypocalciuric hypercalcemia (FHH) Non-PTH dependent Hypercalcemia of malignancy Paraneoplastic syndrome (PTHrP) Osteolytic metastases (IL-1) Excess 1,25 D production Milk-alkali (calcium-alkali) syndrome Vitamin D or A toxicity Granulomatous diseases (sarcoidosis, tuberculosis, fungal infections) Hormonal disorders (hyperthyroidism, acromegaly, pheochromocytoma, adrenal insufficiency) Medications (thiazide diuretics, lithium) Prolonged immobilization, parenteral nutrition and lithium. In general, severe hypercalcemia is almost always a result of hyperparathyroidism or malignancy. Presentation The majority of patients with hypercalcemia are asymptomatic. In general, symptoms of hypercalcemia usually present when the cal- cium level is >12 mg/dL. The presence and severity of symptoms may be related to the time course of the rise in calcium level. If the hypercalcemia is chronic, patients may have nonspecific and rela- tively well-tolerated symptoms such as fatigue, constipation, and depression. A more acute rise in the calcium level to the 12–14 mg/dL range will likely result in more noticeable symptoms such as muscle weakness, nausea, abdominal pain, polyuria/ 118 A. E. Stephen and J. A. Pallotta polydipsia, irritability, and changes in sensorium. Calcium levels of >13 mg/dL may result in cardiovascular complications noted on an electrocardiogram as a prolonged PR interval and a short- ened QT interval, a result of a shortened myocardial action poten- tial. Arrhythmias have been reported in patients with severe hypercalcemia. Diagnostic Approach The most important initial step in the evaluation of severe hyper- calcemia is repeating and confirming the laboratory test result and correcting the calcium level for the albumin to obtain an accurate calcium result (Table 10.2). This correction is done using the fol- lowing formula: corrected calcium (mg/dL) = measured total Ca (mg/dL) + 0.8 (4.0 − serum albumin [g/dL]), where 4.0 repre- sents the average albumin level. If the patient has prior calcium levels recorded, these should be reviewed to determine time course of the hypercalcemia. The level and chronicity of calcium elevation can be helpful in determining the cause of hypercalce- mia. Patients with primary hyperparathyroidism usually have milder and more chronic calcium elevations, compared with patients with hypercalcemia of malignancy. Once the level of hypercalcemia has been confirmed, an intact PTH level should be measured. This will then guide further workup and management. An elevated or high/normal PTH level is consistent with a diagnosis of primary hyperparathyroidism. Although the majority of patients with this diagnosis will have a PTH well above the upper limit of normal, some patients with primary hyperparathyroidism will have an intact PTH level in the normal range. If the level is in the high/normal range, then pri- mary hyperparathyroidism is still the most likely diagnosis, as the Table 10.2 Initial evaluation of patients with severe hypercalcemia 1. Repeat calcium level and correct for albumin 2. S erum PTH level to distinguish PTH-mediated versus non-PTH- mediated hypercalcemia 10 Severe Hypercalcemia 119 PTH should be suppressed in patients with an elevated calcium level for causes other than hyperparathyroidism. The PTH should be low in cases of non-PTH-dependent hypercalcemia. Most patients with PTH-dependent hypercalcemia have mild calcium elevations. There are circumstances, however, where PTH-dependent hypercalcemia can be more severe. If the patient has severe hypercalcemia and an elevated PTH, then the diagnosis of parathyroid carcinoma or a large parathyroid adenoma should be considered. These patients often have much higher PTH levels than most patients with primary hyperparathyroidism. The degree of hypercalcemia often, but not always, correlates with the PTH level. In turn, the size of the lesion can correlate with the PTH level. Patients with larger parathyroid tumors, benign or malig- nant, are more likely to have higher PTH levels and therefore be at higher risk for episodes of severe hypercalcemia. In patients with renal insufficiency, hypercalcemia can increase the severity because of decreased renal filtration of serum calcium. Severe hypercalcemia is most common among patients with a non-PTH-dependent mechanism, often malignancy. In these cases, the patient frequently has more advanced malignant dis- ease, and the diagnosis and cause of hypercalcemia may be quite obvious. Treatment The treatment of hypercalcemia depends primarily on the calcium level. Patients with mildly elevated levels (Ca < 12 mg/dL) often do not need treatment but should be instructed regarding factors that can exacerbate the hypercalcemia. These factors include dehydration/volume depletion, medications (thiazide diuretics and lithium therapy), prolonged bed rest or inactivity, and a high calcium diet (>1000 mg/day). It is important to instruct patients to maintain adequate hydration (at least six to eight glasses of water per day) and to consider contacting their physician if they are unable to maintain oral hydration due to illness. The treatment of moderate hypercalcemia (12–13 mg/dL) depends on the time course of the calcium elevation and if the 120 A. E. Stephen and J. A. Pallotta patient is experiencing symptoms. All patients who are acutely symptomatic should be admitted to the hospital and treated. If the calcium level is <13 mg/dL and the patient is not symptomatic, they do not necessarily require immediate treatment, but the cause of the hypercalcemia should be investigated and promptly treated to avoid further elevation in the calcium level. These patients should be instructed as outlined above regarding factors that could exacerbate the hypercalcemia and their calcium levels closely fol- lowed until the underlying cause is treated. Any patient who has symptomatic hypercalcemia or a calcium level of >13 mg/dL should be admitted to the hospital and treat- ment initiated to lower the calcium level. There are four available treatment approaches to lower the calcium levels: 1. Intravenous hydration to promote excretion of calcium 2. Calcitonin 3. Bisphosphonates 4. Denosumab The combination of intravenous hydration and calcitonin should lower calcium levels within hours, while the bisphospho- nates are effective within days. The intravenous hydration to expand intravascular volume and promote calcium excretion should be initiated first. The patient’s volume status should be closely assessed and monitored. The recommended infusion should start at 0.9% saline at twice the maintenance rate and the urine output monitored. The infusion rate can then be adjusted depending on the patient’s age, overall medical conditions, urine output, and calcium level. It is important to expand the intravascu- lar volume before a diuretic such as furosemide is given. Salmon calcitonin is used in the acute setting for the treatment of hypercalcemia. It is usually administered intramuscularly or subcutaneously. The recommended starting dose is 4 international units/kg every 12 h; this can be increased up to 6–8 international units/kg every 6 h as needed. Prior to giving calcitonin, a skin test should be done to rule out any allergy to the medication. Bisphosphonates are most effective in treating patients with malignancy-associated hypercalcemia. Bisphosphonates such as pamidronate and zoledronate inhibit osteoclast activity and t herefore decrease the release of calcium from the bone. These agents are 10 Severe Hypercalcemia 121 long-acting and should be used judiciously in patients with PTH- dependent hypercalcemia, as a curative operation may lead to hypo- calcemia if the source of excess PTH is successfully removed and the bisphosphonates are still active in the patient’s system. Bisphosphonates should never be given to patients with hypo- parathyroidism who develop iatrogenic hypercalcemia from over- treatment with calcium and vitamin D supplements. Since they lack parathyroid hormone, these patients are at risk for profound and persistent hypocalcemia with bisphosphonates. In addition, patients with renal failure should be given these agents cautiously and at a lower dose. Denosumab can be used when bisphosphonates are contraindi- cated (e.g. severe renal failure). As the serum calcium level is low- ered into the normal range, the cause of the hypercalcemia should be investigated and treated when possible. In the case of surgi- cally correctable primary hyperparathyroidism, surgery should be performed as soon as possible to avoid repeated episodes of severe hypercalcemia. An alternative for patients with hypercalcemia secondary to hyperparathyroidism is the relatively newer agent, cinacalcet. This is often an effective treatment in patients with an adenoma who are poor surgical candidates as well as for patients with inoperable parathyroid carcinoma. Once diagnosis is clarified, which will require further investigation, steroids are a therapeutic option for granulomatous disease and lymphoma mediated by 1,25-hydroxy-vitamin D production. It is also important to rule- out tuberculosis prior to administering steroids. Summary The most common causes of hypercalcemia in general are hyper- parathyroidism and malignancy. Severe hypercalcemia can result in either of these clinical circumstances, although the majority of patients with hyperparathyroidism have mild calcium elevations. Patients with calcium levels >13 mg/dL and any patient with symptomatic hypercalcemia should be admitted to the hospital and promptly treated, with the underlying cause addressed and corrected when possible to avoid future episodes of clinically significant hypercalcemia. 122 A. E. Stephen and J. A. Pallotta Suggested Reading Bilezikian JP, Cusano NE, Khan AA, Liu JM, Marcocci C, Bandeira F. Primary hyperparathyroidism. Nat Rev Dis Primers. 2016;2:16033. Mohammad KS, Guise TA. Hypercalcemia of malignancy: a new twist on an old problem. J Oncol Pract. 2016;12(5):435–6. Peacock M, Belzikian J. Cinacalcet HCL reduces hyperalcemia in primary hyperparathyroidism across a wide spectrum of disease severity. J Clin Endocrinol Metabol. 2011;96(1):E9–E18. Srividya N, Gossman WG. Hypercalcemia. StatPearls https://knowledge. statpearls.com/chapter/acls/23158/. Wisneski L. Salmon calcitonin in the acute management of hypercalcemia. Calcif Tissue Int. 1990;46(Suppl):S26–30. Hypocalcemia 11 Alan Ona Malabanan Contents Hypocalcemia Should Be Considered in Those with Muscle Cramping or Bone Pain, Cardiac Dysrhythmias, Seizure Disorders, and Perioral/Digital Paresthesias 124 A Total Serum Calcium Should Be Measured with a Concomitant Serum Albumin 125 A Free Ionized Serum Calcium from Venous Blood Gas Testing May Provide a Timelier Test Result than Total Serum Calcium 125 The Free Serum Calcium Decreases with Alkalemia and Increases with Acidemia 126 The Electrocardiographic QT Interval Is Prolonged in Those with Hypocalcemia 126 Post-parathyroidectomy and Post-t hyroidectomy Patients Should Be Monitored Postoperatively for Symptoms and Physical Signs of Hypocalcemia, as Well as an Estimate of Free Calcium 126 Hypocalcemia Should Be Evaluated with an Estimate of Free Serum Calcium (Free Ionized Calcium or Total Serum Calcium Corrected for Serum Albumin), Serum Phosphate, Serum Magnesium, Serum 25-Hydroxyvitamin D, and Serum Parathyroid Hormone (PTH) 127 A. O. Malabanan (*) Beth Israel Deaconess Medical Center, Harvard Medical School, Division of Endocrinology, Diabetes and Metabolism, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 123 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_11 124 A. O. Malabanan Symptomatic Hypocalcemia Is a Medical Emergency, Particularly When Acute and Should Be Treated with Intravenous 10% Calcium Gluconate (with EKG Monitoring) Until the Symptoms Resolve

127 After Emergent Treatment with Intravenous Calcium Gluconate, a Calcium Gluconate IV Drip Should Be Maintained (with EKG Monitoring) Titrating the Free Serum Calcium Estimate to the Lower Limit of Normal 128 Chronic Treatment of Hypocalcemia Includes Treating the Underlying Causes (Hypomagnesemia, Vitamin D Deficiency, Inadequate Calcium Intake, Hypoparathyroidism, Hypercalciuria) and, in Addition, May Include 500–1000 mg of Elemental Calcium (1250–2500 mg of Calcium Carbonate) tid Along with an Activated Vitamin D Analog Such as Calcitriol (0.25–0.50 mcg bid) 128 Serum Calcium, Albumin, Phosphate, Creatinine, and 24-h Urine Calcium and Creatinine Should Be Monitored Closely and Therapy Adjusted Accordingly 129 Thiazide Therapy Should Be Used with Extreme Caution in Those Also on Calcium and Calcitriol, Particularly if There Is Concomitant Chronic Kidney Disease 129 Potent Antiresorptive Therapy with Oral and Intravenous Bisphosphonates or Subcutaneous Denosumab Is Contraindicated in Those with Hypocalcemia 129 Long-Term Parathyroid Hormone (1–84 PTH Analog) Is Now Approved by the FDA for the Management of Chronic Hypoparathyroidism 132 Suggested Reading 132 Hypocalcemia Should Be Considered in Those with Muscle Cramping or Bone Pain, Cardiac Dysrhythmias, Seizure Disorders, and Perioral/ Digital Paresthesias Calcium is important for the proper functioning of several of the human body’s organ systems and cellular processes. As a divalent cation, it is important in maintaining an electrochemical gradient. 11 Hypocalcemia 125 Hypocalcemia is associated with tetany and muscle cramping. Latent tetany may be identified by eliciting Chvostek’s or Trousseau’s signs. Neurologic irritability, with hypocalcemia, is associated with oral and digital paresthesias as well as seizures. Hypocalcemia results in cardiovascular irritability with atrial and ventricular dysrhythmias and may also cause laryngospasm with respiratory arrest. Calcium is important, along with phosphate, for normal bone mineralization. Inadequate serum calcium will lead to osteomalacia and bone pain. A Total Serum Calcium Should Be Measured with a Concomitant Serum Albumin The most commonly measured serum calcium level is total serum calcium. About half of the total serum calcium is bound to albu- min or complexed with organic ions such as phosphate. The cal- cium unbound to albumin or complexed with organic ions is termed the free calcium, which is the physiologically important portion. Free calcium levels are therefore affected by albumin lev- els. Hypoalbuminemia will lead to a decrease in total serum cal- cium levels. If the albumin is less than 4.0 g/dl, the total serum calcium should be corrected by adding 0.8 mg/dl of calcium to every 1.0 g/dl of albumin below 4.0. A Free Ionized Serum Calcium from Venous Blood Gas Testing May Provide a Timelier Test Result than Total Serum Calcium A total serum calcium level may take hours to return, while a free ionized serum calcium from an arterial blood gas analyzer often takes minutes to return, related to the assay methodology used. For patients with rapidly declining calcium levels, a free ionized serum calcium from venous blood gas testing may have an advantage in being able to adjust therapy. Accurate ionized calcium results require proper specimen collection and timely processing. 126 A. O. Malabanan The Free Serum Calcium Decreases with Alkalemia and Increases with Acidemia Acid-base balance affects the negative charges on albumin. Acidemia (i.e., increased H+ ions) decreases them leading to decreased ionized calcium binding to albumin and increasing free calcium. Alkalemia (i.e., decreased H+ ions) increases them lead- ing to increased ionized calcium binding and decreasing free cal- cium. Respiratory alkalemia from hyperventilation will lower free calcium levels and may precipitate tetany or seizures. The Electrocardiographic QT Interval Is Prolonged in Those with Hypocalcemia The presence of QT prolongation confirms the risk of cardiovascu- lar sequelae of hypocalcemia and should prompt urgent evaluation and treatment. Since electrocardiographic assessment may produce a result even more quickly than a venous blood gas, this is the quickest way for assessing calcium status in a patient. Post-parathyroidectomy and Post- thyroidectomy Patients Should Be Monitored Postoperatively for Symptoms and Physical Signs of Hypocalcemia, as Well as an Estimate of Free Calcium The risk of hypocalcemia after thyroid or parathyroid surgery is dependent on the type of surgery performed as well as the skill and experience of the surgeon. Preoperative vitamin D deficiency may also increase the risk for postoperative hypocalcemia. Four gland exploration/subtotal parathyroidectomy and total thyroidectomy for thyroid cancer or Graves’ disease have an increased risk for hypocalcemia. Hungry bone syndrome post- parathyroidectomy is increased in those with severe primary or secondary hyperparathy- roidism associated with lower bone density and increased bone turnover. Prophylactic treatment with calcium and calcitriol, as well as correction of preexisting vitamin D deficiency, may reduce 11 Hypocalcemia 127 the risk for symptomatic hypocalcemia post-thyroidectomy. Postoperative calcium and parathyroid hormone may be helpful in guiding postoperative management. Assessment for a baseline Chvostek’s sign should be done before surgery as 10% of normal individuals may have a Chvostek’s sign. Hypocalcemia Should Be Evaluated with an Estimate of Free Serum Calcium (Free Ionized Calcium or Total Serum Calcium Corrected for Serum Albumin), Serum Phosphate, Serum Magnesium, Serum 25-Hydroxyvitamin D, and Serum Parathyroid Hormone (PTH) Once a low free calcium is confirmed, the laboratory evaluation of hypocalcemia can suggest its etiology and need for additional sup- portive treatment beyond calcium. PTH is responsible for increas- ing calcium release from bone to normalize serum calcium levels. At the same time, increased PTH causes phosphaturia and leads to hypophosphatemia. Ineffective PTH action may result from hypo- magnesemia, and hypomagnesemia may also impair PTH release. Severe vitamin D deficiency, especially if long- standing with depletion of bone calcium stores, may cause hypocalcemia. Hungry bone syndrome is characterized by low calcium, phos- phate, and magnesium resulting from the reincorporation of these bone mineral components after cure of the hyperparathyroidism. Symptomatic Hypocalcemia Is a Medical Emergency, Particularly When Acute and Should Be Treated with Intravenous 10% Calcium Gluconate (with EKG Monitoring) Until the Symptoms Resolve Seizures, tetany, cardiac dysrhythmias, paresthesias, laryngo- spasm/stridor, or prolonged QT interval should be treated urgently with intravenous calcium gluconate (with EKG monitoring). Calcium gluconate is used in preference to calcium chloride, due 128 A. O. Malabanan to calcium chloride’s vein irritation. One to two amps (10–20 mL) of 10% calcium gluconate may be infused over 10 min watching for bradycardia. Those with chronic kidney disease or on concom- itant digoxin therapy should be infused more cautiously. After Emergent Treatment with Intravenous Calcium Gluconate, a Calcium Gluconate IV Drip Should Be Maintained (with EKG Monitoring) Titrating the Free Serum Calcium Estimate to the Lower Limit of Normal Because free calcium is rapidly filtered into the glomerulus, serum calcium levels will drop without an ongoing source of calcium, and hypocalcemia will recur. With EKG monitoring, a calcium gluconate IV drip using 100 ml of 10% calcium gluconate in 1 L of D5W may be started at 30 ml/h titrating to symptoms, free cal- cium levels, or QT intervals. Free calcium levels should be moni- tored every 2–4 h. Chronic Treatment of Hypocalcemia Includes Treating the Underlying Causes (Hypomagnesemia, Vitamin D Deficiency, Inadequate Calcium Intake, Hypoparathyroidism, Hypercalciuria) and, in Addition, May Include 500–1000 mg of Elemental Calcium (1250–2500 mg of Calcium Carbonate) tid Along with an Activated Vitamin D Analog Such as Calcitriol (0.25–0.50 mcg bid) Underlying causes of hypocalcemia, such as hypomagnesemia, vitamin D deficiency, hypercalciuria due to loop diuretics, or use of potent antiresorptives such as bisphosphonates or denosumab, should be addressed. Hypomagnesemia may require intravenous treatment with magnesium sulfate (see Hypomagnesemia). Vitamin D deficiency can be treated with high-dose ergocalciferol (50,000 IU weekly × 8 weeks) followed by 2000 IU c holecalciferol 11 Hypocalcemia 129 daily, although those with gastric bypass surgery or intestinal malabsorption may require higher doses of 6000–10,000 IU daily. Bisphosphonates should be discontinued until the hypocalcemia is corrected, and dose reduction or cessation of loop diuretics should be considered (Table 11.1). Serum Calcium, Albumin, Phosphate, Creatinine, and 24-h Urine Calcium and Creatinine Should Be Monitored Closely and Therapy Adjusted Accordingly The target free calcium should be in the low normal range. The calcium-phosphate product should be maintained <55 mg2/dl2 to minimize the risk for soft tissue calcification. The 24-h urine cal- cium excretion should be maintained <250 mg/day to minimize the risk for nephrolithiasis. Thiazide Therapy Should Be Used with Extreme Caution in Those Also on Calcium and Calcitriol, Particularly if There Is Concomitant Chronic Kidney Disease Thiazides decrease urinary calcium excretion and together with calcium and calcitriol therapy may cause hypercalcemia. Because thiazides decrease urinary excretion of calcium, the hypercalcemia is more difficult to treat. Potent Antiresorptive Therapy with Oral and Intravenous Bisphosphonates or Subcutaneous Denosumab Is Contraindicated in Those with Hypocalcemia Bisphosphonates and denosumab inhibit osteoclast-mediated bone resorption and prevent calcium release from the bone, dis- rupting calcium homeostasis and causing hypocalcemia. As such, 130 A. O. Malabanan Table 11.1 Medications used for hypocalcemia Mechanism of Route of Medication action administration Dose (elemental calcium) Comments Calcium carbonate Source of calcium Oral 1250–2500 mg tid (500–1000 mg tid) Requires gastric acid to aid dissolution and absorption Calcium citrate Source of calcium Oral 2992–4488 mg tid (630–945 mg tid) Oral preparation of choice in those with achlorhydria Calcium acetate Source of calcium Oral 2001–4002 mg tid (507–1014 mg tid) Typically used as a phosphate binder Calcium gluconate Source of calcium Intravenous 1000–2000 mg for symptomatic (1000 mg/10 mL) hypocalcemia (93–186 mg) then 30 mL/h of 100 mL in 1 L D5W as infusion titrating to calcium. Calcium chloride Source of calcium Intravenous 500–1000 mg for symptomatic Give only as slow IV (1000 mg/10 mL) hypocalcemia (136–273 mg) injection due to vein sclerosis Ergocalciferol Vitamin D2 Oral 50,000–100,000 daily to weekly Fat soluble and long (50,000 IU) half-life, by prescription only Cholecalciferol Vitamin D3 Oral 50,000–100,000 daily to weekly Fat soluble and long half-life, OTC Calcitriol Activated Oral, IV 0.25–0.50 mcg twice daily Onset of action in 1–2 days vitamin D 11 Hypocalcemia 131 Hydrochlorothiazide Hypocalciuric Oral 25–50 mg twice daily Hyperuricemia, thiazide hypokalemia, and hyponatremia may result Chlorthalidone Hypocalciuric Oral 25–50 mg once daily Hyperuricemia, thiazide hypokalemia, and hyponatremia may result Amiloride Mild Oral 5–10 mg once daily Potassium-sparing diuretic; hypocalciuric may be used in diuretic combination with thiazides Parathyroid hormone PTH Subcutaneous 50–100 mcg once daily REMS necessary to (1–84) prescribe, osteosarcoma risk 132 A. O. Malabanan they are contraindicated in those patients with hypocalcemia or known hypoparathyroidism. Long-Term Parathyroid Hormone (1–84 PTH Analog) Is Now Approved by the FDA for the Management of Chronic Hypoparathyroidism Replacement therapy with once daily 80 mcg parathyroid hormone is now available and can decrease oral calcium and calcitriol requirements. However, its role in inpatient management of hypo- calcemia is not yet clear. Long-term safety is also unclear. Suggested Reading Cooper MS, Gittoes NJL. Diagnosis and management of hypocalcaemia. BMJ. 2008;336:1298–302. https://doi.org/10.1136/bmj.39582.589433.BE. Mannstadt M, Bilezikian JP, Thakker RV, Hannan FM, Clarke BL, Rejnmark L, et al. Hypoparathyroidism. Nat Rev Dis Primers. 2017;3:17055. https:// doi.org/10.1038/nrdp.2017.55. Mathur A, Nagarajan N, Kahan S, Schneider EB, Zeiger MA. Association of parathyroid hormone level with postthyroidectomy hypocalcemia: a sys- tematic review. JAMA Surg. 2018;153:69–76. https://doi.org/10.1001/ jamasurg.2017.3398. Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. 2016 American Thyroid Association guidelines for diagnosis and man- agement of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26:1343–421. https://doi.org/10.1089/thy.2016.0229. Witteveen JE, van Thiel S, Romijn JA, Hamdy NA. Therapy of endocrine disease: hungry bone syndrome: still a challenge in the post-operative management of primary hyperparathyroidism: a systematic review of the literature. Eur J Endocrinol. 2013;168:R45–53. https://doi.org/10.1530/ EJE-12-0528. Perioperative Evaluation 12 of Primary Hyperparathyroidism J. Carl Pallais Contents Confirm the Preoperative Diagnosis of Primary Hyperparathyroidism 134 Review the Indications for Parathyroidectomy 134 Review Preoperative Parathyroid Imaging Studies 135 Review the Surgical Approach 136 Determine Possible Association with Hereditary Syndromes 136 Obtain Biochemical Evidence of Surgical Cure 137 Monitor for Postoperative Hypocalcemia 138 Evaluate for Signs and Symptoms of Postsurgical Hypocalcemia 139 Evaluate for Biochemical Evidence of Hypoparathyroidism 139 Assess for Evidence of the Hungry Bone Syndrome 140 Prevent and Treat Hypocalcemia 141 Follow-Up After Discharge 142 Suggested Reading 143 J. C. Pallais (*) Brigham and Women’s Hospital, Division of Endocrinology, Department of Medicine, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 133 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_12 134 J. C. Pallais Confirm the Preoperative Diagnosis of Primary Hyperparathyroidism Primary hyperparathyroidism is confirmed by the findings of inappropriately elevated

parathyroid hormone (PTH) levels in the setting of hypercalcemia without renal failure. PTH-dependent hypercalcemia in the setting of prolonged renal failure could indi- cate tertiary hyperparathyroidism. Calcium levels should be cor- rected for serum albumin. Occasionally the PTH levels will be within the normal range despite hypercalcemia. Because elevated calcium levels normally suppress PTH secretion, “normal” PTH levels in the setting of hypercalcemia indicate inappropriately increased PTH secretion. In patients in whom previously normal calcium levels cannot be confirmed, measurement of 24-hour urine calcium is important to differentiate primary hyperparathyroidism from familial hypocalciuric hypercalcemia (FHH). The latter condition is a contraindication for parathyroidectomy as it is associated with a high risk of surgical failure. In these patients, hypercalcemia typically recurs with subtotal parathyroidectomy. Review the Indications for Parathyroidectomy Parathyroidectomy is indicated for patients with primary hyper- parathyroidism and symptomatic kidney stones or fragility frac- tures. According to the recent guidelines, asymptomatic patients with primary hyperparathyroidism should be considered candi- dates for parathyroidectomy if they have any of the following indications: • Age <50 years old • Calcium levels >1 mg/dL above the upper limits of normal • Abnormal renal function • Osteoporosis at any site (spine, hip, or distal wrist) • Presence of vertebral fracture on dedicated imaging studies • Presence of kidney stones on abdominal imaging • High risk of developing kidney stones on 24-hour urine analysis 12 Perioperative Evaluation of Primary Hyperparathyroidism 135 Some patients may require urgent parathyroidectomy if they develop hypercalcemic crisis. This is characterized by the rapid onset of hypercalcemia, usually with calcium levels greater than 14 mg/dL, and evidence of multiorgan dysfunction. Aggressive fluid resuscitation and medical management are required prior to parathyroidectomy. Parathyroidectomy can also be considered in patients with pri- mary hyperparathyroidism without any of these indications if there are barriers to long-term follow-up. Surgical intervention is the only definitive treatment for primary hyperparathyroidism and could obviate the need for long-term monitoring. Finally, parathyroidectomy can be considered in patients with primary hyperparathyroidism and no other indication if they are undergoing neck surgery for other reasons. Frequently this involves surgical evaluation of concurrent thyroid nodules. It is important to evaluate thyroid nodules in patients with primary hyperparathyroidism as the FNA results can impact the decision to undergo surgery or modify the surgical approach to parathy- roidectomy. Review Preoperative Parathyroid Imaging Studies Imaging studies are not part of the diagnostic plan for primary hyperparathyroidism, but they help the surgeon define the surgical strategy. The most commonly utilized localizing studies are cervi- cal ultrasounds, sestamibi parathyroid scans, and four-d imensional computed tomography (4D CT) scan. Cervical ultrasounds are relatively inexpensive, do not involve radiation exposure, and have the added benefit of detecting concomitant thyroid nodules that may impact the surgical strategy for parathyroidectomy. In 4D CT, multiple scans are obtained after administration of IV contrast and provide good anatomic detail for planning the surgery. It is important to remember that patients with negative imaging studies remain candidates for parathyroidectomy, particularly as the sensitivity of these tests are significantly lower in patients with multigland involvement. 136 J. C. Pallais Review the Surgical Approach Parathyroidectomy is carried out via bilateral neck exploration or a minimally invasive approach. The choice between these two sur- gical strategies is determined in large part by the results of the imaging studies and the experience of the surgeon. Bilateral parathyroid exploration has been the standard surgi- cal approach for parathyroidectomy with a high surgical success rate of >95%. This is the preferred approach for patients with multigland disease and those with discordant or non-localizing imaging studies. Approximately 85% of cases of primary hyper- parathyroidism are caused by a single adenoma. If a single ade- noma is confirmed on localization studies, a focused minimally invasive operative strategy with measurement of intraoperative PTH could be attempted. PTH has a short half-life, and intraop- erative monitoring helps to confirm resection of the culprit ade- noma while limiting the scope of dissection. Elevated intraoperative PTH values help to identify persistent disease. If multigland disease is discovered during surgery or an abnor- mal gland is not identified through a minimally invasive approach, then the surgery should be converted to bilateral exploration. Likewise, if intraoperative PTH levels do not drop appropriately after resection of an abnormal gland, conversion to bilateral explo- ration is recommended to avoid persistence of hyperparathyroid- ism. Unilateral parathyroidectomy has been associated with similar success rates as bilateral exploration in properly selected patients. Autotransplantation of normal parathyroid glands is occasion- ally attempted to preserve the function of glands that appear devascularized after surgical manipulation or in subtotal parathy- roidectomy with multigland involvement. Determine Possible Association with Hereditary Syndromes Approximately 5–10% of patients with hyperparathyroidism have an underlying hereditary syndrome, some of which are caused by mutations in known genes. These genetic syndromes∗ and their 12 Perioperative Evaluation of Primary Hyperparathyroidism 137 associated genes are listed below: ∗MEN, multiple endocrine neoplasia syndrome; HPT-JT, hyperparathyroidism-jaw tumor syndrome; and FHH, familial hypocalciuric hypercalcemia. • MEN1 (MEN1) • MEN2A (RET) • MEN4 (CDKN1B) • HPT-JT (HRPT2/CDC73) • Familial isolated hyperparathyroidism • FHH1 (CASR) • FHH2 (GNA11) • FHH3 (AP2S1) Identification of these syndromes should ideally be done preop- eratively as the diagnosis may influence the surgical strategy and may prompt screening for other associated features. Patients with heredi- tary syndromes associated with hyperparathyroidism tend to be younger, have multiple gland involvement, and have a greater likeli- hood of negative localization studies and hyperparathyroidism per- sistence or recurrence. Thus, screening for these syndromes should be considered in young patients with hyperparathyroidism, those with an affected first-degree relative, or patients that have other asso- ciated syndromic features. In a ddition, patients of any age should be considered candidates for genetic screening if they present in with multigland parathyroid disease or persistent/recurrent hyperparathyroidism following parathyroidectomy. Although parathyroidectomy is generally contraindicated for patients with FHH, the diagnosis may have been missed prior to parathyroidectomy if hypocalciuria was not identified or tested. Hypercalcemia typically persists/recurs after subtotal parathyroidectomy. These patients should not undergo repeat parathyroid operations. Obtain Biochemical Evidence of Surgical Cure The immediate goal of parathyroidectomy in patients with pri- mary hyperparathyroidism is to reestablish normal calcium homeostasis. Persistent disease is manifested as a failure to 138 J. C. Pallais achieve normocalcemia within 6 months of surgery. Operative failure may be predicted by inadequate decrease in intraoperative PTH levels. If normocalcemia is achieved for at least 6 months following parathyroidectomy, patients are considered to have had a surgical cure. Primary hyperparathyroidism that recurs after 6 months of normocalcemia following parathyroidectomy is con- sidered recurrent disease. Monitor for Postoperative Hypocalcemia Postoperative hypocalcemia is the most common endocrine complication following parathyroidectomy, occurring in nearly 50% of cases in some case series. Injury to the parathyroid glands, inadvertent resection of parathyroid tissue, damaged blood supply to the remaining parathyroid glands, or failed auto- transplantation can cause transient or permanent hypoparathy- roidism. In addition to functional hypoparathyroidism, the reversal of bone resorption with increased bone formation after parathyroidectomy causes a net influx of calcium into bones contributing to the fall of serum calcium levels. Typically, the hypocalcemia is transient because the bone disease is mild and the remaining parathyroid tissue recovers function within 1 or 2 weeks. In the hands of high-v olume parathyroid surgeons, per- manent hypoparathyroidism is relatively uncommon after initial parathyroid surgery with an estimated frequency of <4%. Severe hypocalcemia caused by hungry bone is a rare complication of parathyroidectomy. Hypocalcemia may be symptomatic or asymptomatic and may be associated with variable PTH levels. The duration and severity of hypocalcemia vary and may depend on the routine use of calcium and vitamin D supplementation, the degree of injury to the remaining parathyroid glands, the severity of the underlying bone disease, and preoperative clinical features. Patients with impaired intestinal absorption such as those with prior gastric bypass surgery, vitamin D deficiency, renal dys- function, or hypomagnesemia are at higher risk of developing postoperative hypocalcemia. 12 Perioperative Evaluation of Primary Hyperparathyroidism 139 Evaluate for Signs and Symptoms of Postsurgical Hypocalcemia Acute hypocalcemia may be associated with a spectrum of clin- ical manifestations. At the mild end of the spectrum, asymptom- atic biochemical findings may be the only manifestations. Severe findings include laryngospasm, neurocognitive dysfunction, papilledema, seizures, and heart failure. Neuromuscular irrita- bility is the most common manifestation of acute hypocalcemia. This includes perioral numbness, acral paresthesias, muscle cramps, stiffness, or carpopedal spasms. On physical exam, patients may have Chvostek’s signs and/or Trousseau’s sign, which are markers of latent tetany. Chvostek’s sign is the con- traction of the facial muscles in response to tapping the facial nerve which causes twitching of the ipsilateral lip. Trousseau’s sign is the development of carpal spam characterized by adduc- tion of the thumb, extension of the interphalangeal joints, and flexion of the MCP joints and wrist elicited by the insufflation of a blood pressure cuff above the systolic blood pressure for 3 min. Trousseau’s sign is more specific for hypocalcemia as Chvostek’s sign may be present in up to 10% of normal subjects. Hypocalcemia may also cause QTc prolongation and may be associated with dysrhythmias. Evaluate for Biochemical Evidence of Hypoparathyroidism The biochemical signature of hypoparathyroidism involves hypo- calcemia with suppressed PTH levels. Approximately 40% of the total circulating calcium is bound to albumin, with the unbound or free portion referred to as ionized calcium. Total calcium measure- ment should be corrected for albumin levels according to the fol- lowing formula: corrected calcium (mg/dL) = measured calcium (mg/dL) + 0.8 (4.0 – measured albumin [g/dL]). If hypocalcemia is confirmed by either corrected calcium mea- surement or ionized calcium levels, hypoparathyroidism is diagnosed if the PTH levels are inappropriately suppressed. 140 J. C. Pallais As hypocalcemia normally elevates PTH levels, PTH values within the normal range are still considered inappropriately low in the setting of hypocalcemia. PTH increases circulating calcium levels by stimulating cal- cium efflux from the bone, promoting reabsorption of filtered cal- cium in the kidney, and indirectly increasing intestinal calcium absorption by promoting the activation of vitamin D through the expression of 1-alpha hydroxylase in the proximal tubule. Suppressed PTH release due to the resection or injury of parathy- roid glands lowers serum calcium levels by reversing these physi- ologic processes. In addition, PTH is one of the primary regulators of phosphorus in the body and promotes urinary phosphate excre- tion thorough its effects on the NaPi transporters in the proximal tubules. In hypoparathyroidism, the serum phosphorous concen- tration tends to be in the high-normal or frankly elevated range due to impaired phosphate excretion. As low magnesium levels can impair PTH secretion and action, it is important to exclude hypomagnesemia as the cause of hypo- parathyroidism or as a contributor to the hypocalcemia. Assess for Evidence of the Hungry Bone Syndrome Patients with severe preoperative bone disease caused by chronic bone resorption mediated by elevated PTH levels may have severe and prolonged hypocalcemia following parathyroidectomy. The reversal of advanced bone resorption from the acute withdrawal of PTH is coupled with accelerated bone formation and causes a strong influx of both calcium and phosphate into the bone in these patients. This lowers the calcium levels despite a compensatory increase in PTH production by the remaining parathyroid tissue. The clinical markers of the hungry bone syndrome include per- sistent hypocalcemia and hypophosphatemia on postoperative day 3 following parathyroidectomy. The hypocalcemia typically nadirs 2–4 days after parathyroidectomy but may last up to sev- eral months. In addition to low serum phosphorous concentra- tions, associated biochemical features frequently include 12 Perioperative Evaluation of Primary Hyperparathyroidism 141 hypomagnesemia and occasionally hyperkalemia. Risk factors for developing the hungry bone syndrome include large volume of the resected adenoma, elevated preoperative blood urea nitrogen level, elevated preoperative alkaline phosphatase activity, older age, and preoperative radiographic findings of osteitis fibrosa or bone erosions. Occasionally, patients with bone disease caused by hyperthyroidism may also develop the hungry bone syndrome fol- lowing thyroidectomy. This must be a consideration for patients undergoing combined thyroid and parathyroid surgeries. Prevent and Treat Hypocalcemia Regular monitoring of calcium, albumin, phosphorus, magne- sium, and vitamin D levels and occasional PTH measurements are required after parathyroidectomy to confirm surgical cure and detect development of hypocalcemia. Oral calcium and vitamin D supplementation are commonly started immediately following parathyroidectomy to prevent hypocalcemia. Between 1.5 and 3

g of elemental calcium is typically given orally in divided doses in the postoperative periods for several days to weeks depending on the serum calcium and PTH concentrations. Aggressive vitamin D repletion with high-dose ergocalciferol or cholecalciferol can be considered in patients with preoperative vitamin D deficiency. Most cases of hypocalcemia are mild and can be treated with oral calcium and vitamin D supplementation in the outpatient set- ting. As the hypocalcemia worsens, the dose of elemental calcium is increased. For patients with achlorhydria or on proton pump inhibitors, the use of the calcium citrate formulation is preferred over calcium carbonate for improved calcium absorption. For symptomatic patients or those who have developed hypoparathy- roidism, calcitriol may be added to their regimen. Calcitriol is the bioactive form of vitamin D, has a faster onset of action than ergo- calciferol or cholecalciferol, and is more effective in stimulating intestinal calcium absorption. However, because of its greater potency, it has a narrower therapeutic window, and careful moni- toring is required to ensure that serum or urinary calcium levels do not become excessively elevated. 142 J. C. Pallais Patients with more severe hypocalcemia may require longer hospital stays as their hypocalcemia may represent a medical emergency. Intravenous calcium administration should be consid- ered for patients with moderate to severe symptoms of hypocalce- mia or those with corrected calcium levels <7.5 mg/dL or ionized calcium concentrations <1.0 mmol/L. The typical starting dose is 1–2 g of IV calcium gluconate administered over 10–20 min. This bolus dose translates to approximately 90–180 mg of elemental calcium. Following the IV bolus, a continuous infusion of cal- cium gluconate of approximately 50–100 mg of elemental calcium/h can be initiated for several hours until symptoms resolve. Transition to oral calcium and calcitriol can then be initi- ated. In hypoparathyroidism or the hungry bone syndrome, large calcium doses may be required to facilitate enteral calcium absorption. Calcitriol doses can range from 0.25 to 4 mcg per day. As magnesium depletion may impair PTH release as well as its action, aggressive magnesium replacement is required. In con- trast, phosphate administration is typically avoided in patients with hypophosphatemia and hypocalcemia as it can bind to cal- cium and further lower ionized calcium concentrations. In severe cases of the hungry bone syndrome with extreme hypophosphate- mia, phosphate repletion may be considered but cautious admin- istration is advised. Follow-Up After Discharge The discharge plan should include a timely follow-up visit for continued evaluation of calcium concentrations. An appoint- ment should be made for the patient within 1–2 weeks following surgery to measure the calcium and PTH levels and adjust the calcium and vitamin D doses. It is important that the patient is educated about the signs and symptoms of hypercalcemia and hypocalcemia and that they are able to contact their providers if they experience suggestive symptoms in order to have labora- tory levels checked. For patients with persistent or permanent hypoparathyroidism, calcium and vitamin D/calcitriol dosing is adjusted to keep calcium levels in the lower limits of normal to 12 Perioperative Evaluation of Primary Hyperparathyroidism 143 prevent hypercalciuria. Thiazide diuretics may be added if hypercalciuria develops. Selected patients with hypoparathy- roidism may be candidates for treatment with parathyroid hor- mone injections. Suggested Reading Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C, et al. Guidelines for the management of asymptomatic primary hyperpara- thyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metabol. 2014;99(10):3561–9. Jain N, Reilly RF. Hungry bone disease. Curr Opin Nephrol Hypertens. 2017;26(4):250–5. Stack BC Jr, Bimston DN, Bodenner DL, Brett EM, Dralle H, Orloff LA, et al. American association of clinical endocrinologists and American col- lege of endocrinology disease state clinical review: postoperative hypo- parathyroidism–definitions and management. Endocr Pract. 2015;21(6): 674–85. Udelsman R, Akerstrom G, Biagini C, Duh QY, Miccoli P, Niederle B, et al. The surgical management of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop. J Clin Endocrinol Metabol. 2014;99(10):3595–606. Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, et al. The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151(10): 959–68. Management 13 of Osteoporosis in the Inpatient Setting Marcy A. Cheifetz Contents Definition of Osteoporosis 146 Significance of Fragility Fractures 146 Fragility Fractures of the Hip 147 Fragility Fractures of the Vertebra 147 Inpatient Management of Fragility Fractures 148 Laboratory Evaluation 153 Continuing Pre-hospitalization Osteoporosis Medications as an Inpatient 154 Preventing Future Fractures 156 Follow-Up After Discharge 156 Suggested Reading 157 M. A. Cheifetz (*) Harvard Vanguard Medical Associates, Atrius Health, Department of Endocrinology, Chestnut Hill, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 145 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_13 146 M. A. Cheifetz Definition of Osteoporosis Osteoporosis is defined as a disease of low bone mass and abnor- mal bone microarchitecture that leads to decreased bone strength and increased risk of fragility fracture. The term “fragility frac- ture” indicates a fracture that would not occur when bone strength and quality are normal, such as after a fall from a standing height. Osteoporotic fractures are defined as fragility fractures that occur at the vertebrae, hip, wrist, humerus, or pelvis. Although it has been well established that osteoporosis can be diagnosed with a bone density test, it is not as well appreciated that osteoporosis can also be diagnosed clinically. A hip or vertebral fragility frac- ture is synonymous with a clinical diagnosis of osteoporosis. Fragility fractures become increasingly prevalent as people age. Worldwide, one in three women and one in five men over age 50 will experience a fragility fracture in their lifetime. Fragility frac- tures that are most commonly seen in the inpatient setting include fractures of the hip and vertebrae. Hip fractures are particularly prevalent among the elderly population, especially for those resid- ing in long-term care institutions who are most prone to imbal- ance and falls. Significance of Fragility Fractures Osteoporotic fragility fractures are associated with significant morbidity, as well as an increased risk of mortality. The osteopo- rotic fractures most associated with negative health outcomes are hip fractures and vertebral fractures. Hip fractures, in particular, are associated with significant morbidity and an increased risk of mortality. At 1-year post-hip fracture, mortality rates reach nearly 40% in men and 25% in women, and mortality rates have been shown to remain elevated for up to 5–15 years after the fracture. Increased mortality rates have also been seen after fragility frac- tures of the spine. A prior fragility fracture of the hip or vertebrae confers up to a fivefold increased risk of future fracture. For these reasons, prevention of future fracture is of the utmost importance. However less than 20% of patients admitted with 13 Management of Osteoporosis in the Inpatient Setting 147 fragility fractures of the hip or spine ultimately receive osteopo- rosis treatment. Fragility Fractures of the Hip The majority of patients who are admitted to the hospital with a hip fracture will require surgical intervention. Approximately 50% of hip fracture patients never regain their prior level of phys- ical function, and many do not return to independent living. A high percentage report chronic pain even after 1-year postfracture. Approximately half of all patients who present with a hip fracture have already had a previous fragility fracture. Fragility Fractures of the Vertebra Vertebral fragility fractures are a common occurrence in the older osteoporosis population. Vertebral fractures also can have signifi- cant adverse effects on quality of life, and mortality rates are also substantial, with some studies showing over 20% greater age- adjusted mortality rates in women with one or more vertebral fractures. Furthermore, vertebral fractures can cause or exacer- bate kyphosis, restrictive lung disease, and chronic pain. Although they may be triggered by a fall or trauma, fragility fractures of the spine can occur spontaneously without a known inciting event. Two-thirds of vertebral fragility fractures are asymptomatic. The third that are clinically symptomatic can present with severe pain and associated disability that may necessitate hospitalization. The majority of cases can be managed conservatively with institution of pain control measures and physical therapy, as tolerated. In cases where adequate pain control cannot be achieved, vertebral augmentation with either percutaneous vertebroplasty or balloon kyphoplasty may be considered. However, whether such proce- dures are truly effective remains controversial. Overall, manage- ment of the vertebral fracture patient often requires a multidisciplinary approach that may involve pain management, interventional radiology, neurosurgery, and physical therapy. 148 M. A. Cheifetz Inpatient Management of Fragility Fractures There are many interventions that can be instituted by the inpa- tient care team for patients with fragility fractures. Non- pharmacological interventions such as initiation of calcium and vitamin D for those not already taking supplementation should be standard of care to help ensure adequate mineral stores and reduce the risk of secondary hyperparathyroidism and osteomalacia. Additionally, ensuring adequate nutritional status is vital, particu- larly in the elderly population that may be more at risk for malnu- trition. It is also critical to identify an individual’s modifiable risk factors for falling to help potentially reduce the risk of recurrent falls and fractures in the future. Risk factors associated with fall- ing in the elderly population include arrhythmias, impaired gait and balance, impaired vision, and neurological or musculoskele- tal disorders. Interventions and treatments that address these com- mon comorbidities can have significant benefits on reducing future fracture risks. Similarly, close scrutiny of an individual’s medication list is critical to help identify and potentially discon- tinue or change medications that may alter mental status or bal- ance and contribute to fall risk. Involvement of physical therapy to help address a patient’s risk for falling and recommend fall- prevention measures that can be instituted as an outpatient is also an important aspect of the care of these patients. The initiation of pharmacologic treatment for osteoporosis should also be consid- ered in the inpatient setting after an acute fragility fracture (see Table 13.1). In the presence of a fragility fracture of the hip or spine, which is indicative of osteoporosis regardless of bone den- sity status, it is not necessary to obtain a bone density test before initiating osteoporosis treatment. Osteoporosis treatment can be instituted in the acute setting immediately after a fragility fracture and does not need to be delayed until the fracture heals. Bisphosphonates, such as alendronate, risedronate, and zole- dronic acid, are the most commonly utilized osteoporosis medica- tions for osteoporosis. Studies have shown that bisphosphonates significantly reduce the risk of future fracture by 50–70% at the spine and 40–50% at the hip over 3–5 years of treatment in patients with or without prevalent vertebral fracture. The Horizon 13 Management of Osteoporosis in the Inpatient Setting 149 Table 13.1 Acute fragility fracture pharmacologic therapy Continue When to resume if after acute stopped after acute Drug Start after fracture and when fracture fracture Comment Bisphosphonate Yes. Can be initiated within Yes – Discontinue in setting of atypical femur Alendronate 2 weeks of fracture fracture (AFF) Risedronate Zoledronic acid Anabolic Yes. Can be initiated within Yes – Avoid in setting of preexisting therapy 1 week of fracture, although hyperparathyroidism, hypercalcemia, Teriparatide data limited to case reports and nephrolithiasis, Paget’s disease of the bone, Abaloparatide small clinical trials history of skeletal malignancy, or history of radiation to skeleton SERM Not first line. Can be initiated No Only if and when Associated with increased DVT risk, which Raloxifene immediately after fracture in back to baseline may be exacerbated by immobility, and the absence of DVT but limited ambulatory status with small increased stroke risk. by lack of efficacy in as an outpatient Discontinue in setting of DVT, MI, stroke preventing non-vertebral or immobility. fractures (continued) 150 M. A. Cheifetz Table 13.1 (continued) Continue When to resume if after acute stopped after acute Drug Start after fracture and when fracture fracture Comment Anti-rank ligand Can be initiated immediately Yes – Should be discontinued in setting of AFF. Denosumab after fracture Should not be abruptly discontinued without transition to bisphosphonate due to risk of rebound vertebral fracture. Romosozumab Likely can be initiated Yes – Given association with increased CV risks, immediately after fracture but should be discontinued in setting of MI or data re: effects on fracture stroke. healing not yet available HRT Not first line No Only if

and when In oral forms, estrogen is associated with back to baseline increased DVT risk, which may be ambulatory status exacerbated by immobility. Discontinue in as an outpatient the setting of DVT, MI, stroke, or immobility 13 Management of Osteoporosis in the Inpatient Setting 151 Recurrent Fracture Trial, a randomized, controlled trial of yearly zoledronic acid administered to hip fracture patients within 90 days after surgical repair, showed a 35% relative risk reduction in rates of any new clinical fracture over the ensuing 2 years com- pared to placebo. Furthermore, in this same study, the group that received zoledronic acid experienced an almost 30% reduction in mortality from any cause, a particularly important finding given the known association of hip fracture with increased mortality. Additionally, there was no difference seen in the incidence of delayed union between the zoledronic acid group and the placebo group, suggesting that there is no evidence of impaired fracture healing when bisphosphonate therapy is initiated within 90 days of hip fracture repair. In a separate analysis, there was similarly no effect on healing seen with different timing intervals even when zoledronic acid was administered within 2 weeks of hip fracture repair. Other studies examining oral bisphosphonates such as alendronate and risedronate demonstrated similar findings, with no relationship seen between the use or timing of bisphosphonates on healing of femoral, humeral, or distal radius fractures even when administered within 2 weeks of the fracture event. Prior to administration of bisphosphonate treatment, particu- larly intravenous zoledronic acid, vitamin D deficiency must be corrected in order to avoid development of hypocalcemia. In the aforementioned Horizon Recurrent Fracture Trial, vitamin D lev- els were measured prior to zoledronic acid infusion, with levels below 15 ng/mL treated with a loading dose of vitamin D 50,000– 120,000 units orally or intramuscularly 2 weeks prior to the first infusion of IV zoledronic acid, followed by daily calcium 1000– 1500 mg and daily vitamin D 800–1200 IU thereafter. Due to the high incidence of vitamin D deficiency found in this population, the study protocol was ultimately changed so that all enrolled patients received a loading dose of vitamin D 2 weeks prior to the initial zoledronic acid infusion regardless of baseline vitamin D levels. In addition to vitamin D deficiency, renal dysfunction may also prove to be a limiting factor with the use of bisphosphonates, particularly in the hospital setting. Oral bisphosphonates should not be administered below an estimated creatinine clearance of 152 M. A. Cheifetz 30–35 ml/min, and intravenous zoledronic acid should not be administered below an estimated creatinine clearance of 35 ml/min. The anabolic agents teriparatide and abaloparatide have also been shown to be efficacious for the treatment of osteoporosis and osteoporotic fractures. Teriparatide, which is a recombinant form of PTH (1–34), and abaloparatide, which is an analog of PTH-r elated peptide (PTH-rp), both exert their anabolic effects through stimulation of the PTH receptor. The net effect of this stimulation is increased recruitment and activation of osteoblasts and enhancement of bone formation. In addition to their proven role in reducing the risk of vertebral and non-vertebral fracture, there has been growing evidence that these anabolic agents may also have beneficial effects on fracture healing. Several small studies and case reports of teriparatide have demonstrated effi- cacy in promoting more rapid callus formation and radiographic healing time in the acute fracture setting. Anecdotal reports have also shown positive effects of teriparatide in promoting healing in circumstances of delayed or nonunion fractures and in peri- prosthetic fractures. Furthermore, small studies have shown a possible role for teriparatide in promoting the healing of atypi- cal femur fractures. At the present time, data for the beneficial use of abaloparatide for promoting fracture healing is limited to animal studies. Because of reports of osteosarcoma development in rats given teriparatide and abaloparatide, anabolic agents are contraindicated in individuals with a history of radiation to the skeleton, Paget’s disease of the bone, bone metastases, or skeletal malignancies. Anabolic agents should also be avoided in patients with underlying hyperparathyroidism, hypercalcemia, and active nephrolithiasis. At the present time, all of the data supporting the utility of anabolic agents in the acute fracture setting come from small clinical trials or case reports, and neither of the currently available anabolic therapies have been officially approved for use in fracture repair. Larger prospective trials are needed to confirm the efficacy of anabolic therapies for the promotion of fracture healing. 13 Management of Osteoporosis in the Inpatient Setting 153 Other osteoporosis agents, such as denosumab, a human mono- clonal antibody against RANK-ligand, and romosozumab, a humanized monoclonal antibody to sclerostin, are not easily initiated in the inpatient setting but are similarly effective medica- tions that could be considered as alternative choices for treatment as an outpatient. Laboratory Evaluation All patients with fragility fracture should undergo a comprehen- sive laboratory evaluation to exclude secondary causes of osteo- porosis. General recommendations for screening labs include 25-hydroxyvitamin D, PTH, serum calcium, phosphate, creati- nine, eGFR, and TSH. Interpretation of vitamin D levels in the inpatient setting may be confounded by the severity of the under- lying illness. In the setting of critical illness, vitamin D defi- ciency has been found to be highly prevalent, and several meta-analyses have demonstrated an association between vita- min D deficiency and poorer outcomes. Vitamin D deficiency in the ICU population may relate to preexisting nutritional deficits or disease, but studies have shown that critical illness can also lead to dysregulation of vitamin D metabolism, further exacer- bating the deficiency. In the ICU settings, this is often further compounded by fluid resuscitation, interstitial extravasation, liver dysfunction, and renal insufficiency. In men, hypogonadism is also associated with development of osteoporosis, but testosterone should not be measured in the acute hospital setting due to an increased likelihood of falsely low lev- els. In cases of vertebral fracture, evaluation for multiple myeloma with measurement of serum and/or urine protein electrophoresis is also recommended. More extensive laboratory testing can be undertaken in the outpatient setting, including 24-h urine calcium measurement, to ensure calcium intake and absorption and to exclude hypercalciuria. 154 M. A. Cheifetz Continuing Pre-hospitalization Osteoporosis Medications as an Inpatient Patients who are admitted with an acute fragility fracture and are already taking osteoporosis medication can, in most cases, continue their medication as an inpatient. As previously discussed, bisphosphonates do not significantly interfere with fracture healing and therefore can typically be continued during hospitalization for an acute fracture. However, given their long-term retention in the bone, short-term discontinuation of bisphosphonate therapy, if necessary, is unlikely to have a significant negative impact on bone health. Furthermore, bisphosphonates should not be administered in the setting of creatinine clearance below 30–35 ml/min and should be discontinued in the setting of acute renal failure. Like bisphosphonates, denosumab does not impair fracture healing or increase the risk of nonunion when administered within 6 weeks before or after a fracture, according to results from the Freedom trial. Furthermore, discontinuation of denosumab without transition to a bisphosphonate leads to significant rebound bone loss that can be associated with spontaneous vertebral fracture and therefore should be avoided in the inpatient setting. Anabolic agents such as teriparatide or abaloparatide can typically be continued in the hospitalized patient after a fragility fracture unless significant hypercalcemia is noted. In that case, the medication should be held until the hypercalcemia resolves and then can be restarted on an every other day schedule as long as there is close follow-up of calcium levels post-discharge. Raloxifene is an oral selective estrogen receptor modulator that is given daily to some postmenopausal women with osteoporosis, although it is less commonly used than other osteoporosis medications, particularly in elderly individuals, due to associated increased risk of DVT and possibly stroke. In the acute setting after hip fracture and possibly after vertebral fracture, when patients are often immobile, raloxifene should be discontinued to minimize the risk of DVT. In the absence of other contraindications, it can be restarted as an outpatient, although switching to a more potent osteoporosis agent post-discharge would be advisable, particularly since raloxifene has not been shown to reduce the risk of hip fracture. Romosozumab, a humanized monoclonal antibody to sclerostin that has been recently approved for treatment of osteoporosis for those at high 13 Management of Osteoporosis in the Inpatient Setting 155 risk for fracture, is administered as a subcutaneous injection once a month for up to 12 months. There is currently no data available regarding its effect on fracture healing, but given its anabolic effects it is unlikely to interfere. Since it is given monthly, administration of romosozumab in the inpatient setting would only be required during prolonged hospital stays. Romosozumab has been associated with an increased risk of cardiovascular disease, and currently the labeling includes a black box warning stating that it may increase the risk of heart attack, stroke, and cardiovascular death. If a patient experiences a heart attack or stroke during treatment, romosozumab should be discontinued. Although osteoporosis medications can typically be continued after hospitalization for an acute fracture, one notable exception is in the case of a proven atypical femur fracture (AFF). Atypical femur fracture is a fracture of the femoral shaft that occurs after minimal or no trauma and is an extremely rare occurrence in patients receiving antiresorptive therapies, such as bisphosphonates or denosumab. The rates of AFF associated with the use of bisphosphonates in doses administered for osteoporosis treatment have been estimated at approximately 2 per 100,000 person-years after 2 years of bisphosphonate use. However, the incidence of AFF appears to increase with long-term use, with reports of 78 cases per 100,000 patient-years after 8 years of bisphosphonate exposure, most of these occurring after 5 years of use. In cases of suspected or proven AFF in a patient currently taking an oral bisphosphonate, such as alendronate, risedronate, or ibandronate, the medication should be immediately discontinued. AFFs have also been associated with denosumab use, although in the Freedom Extension Study, only one AFF was noted after 10 years of denosumab use. Similarly rare rates of AFF have been noted with romosozumab, although a causal link has not yet been definitively established. Since medications such as intravenous zoledronic acid or subcutaneous denosumab are given on a biannual or annual basis, cessation of therapy is not typically feasible in the inpatient setting, but future administration should be avoided if AFF occurs during treatment. In the case of denosumab, discontinuation leads to significant rebound bone loss and has been associated with an increased risk for spontaneous vertebral fracture; for this reason, discontinuation should be undertaken with caution and preferably with the involvement of an endocrinologist. 156 M. A. Cheifetz Preventing Future Fractures Despite the high prevalence of osteoporotic fractures in the elderly population and the high risk of future fracture in those who have already suffered a fragility fracture, the vast majority of patients who experience such a fracture are never identified as having osteoporosis or having started on osteoporosis medication. The inpatient setting represents a unique opportunity to identify indi- viduals as having osteoporosis and initiate interventions and anti- fracture treatment to help minimize future fracture risks. Many hospitals worldwide have instituted fracture liaison services (FLS) led by hospital-based coordinators to identify patients with fragility fracture and, using a multidisciplinary approach, facili- tate bone density testing, laboratory evaluations, initiation of osteoporosis therapy, and follow-up osteoporosis care as an out- patient. Studies of FLS programs have shown significantly higher rates of treatment initiation and significantly lower rates of recur- rent fracture and mortality in patients compared to patients receiv- ing usual care. Follow-Up After Discharge Many patients who have suffered a fragility fracture, particularly of the hip or spine, will require physical rehabilitation after discharge, and in some cases transfer to an inpatient rehabilitation facility may be necessary. Such decisions should be made on an individualized basis. All patients who have been admitted with a fragility fracture of the hip or spine should be set up for a follow- up visit with their primary care team for further evaluation and management of their osteoporosis after discharge. A bone density test should be arranged post-discharge. If osteoporosis treatment has not been initiated during the hospitalization, patients should be discharged with instructions to follow up with their primary care doctors to initiate osteoporosis treatment as an

outpatient. 13 Management of Osteoporosis in the Inpatient Setting 157 Suggested Reading Bone HG, Wagman RB, Brandi ML, Brown JP, Chapurlat R, Cummings SR, C et al. 10 years of denosumab treatment in postmenopausal women with osteoporosis: results from the phase 3 randomised FREEDOM trial and open-label extension. Lancet Diabetes Endocrinol. 2017;5(7):513–23. Camacho PM, Petak SM, Binkley N, Clarke BL, Harris ST, Hurley DL, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice guidelines for the diagnosis and treatment of postmenopasual osteoporosis–2016. Endocr Pract. 2016;22(9):1111–8. Colón-Emeric C, Nordsletten L, Olson S, Major N, Boonen S, Haentjens P, HORIZON Recurrent Fracture Trial, et al. Association between timing of zoledronic acid infusion and hip fracture healing. Osteoporos Int. 2011;22(8):2329–36. Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10):2359–81. Ip TP, Leung J, Kung AW. Management of osteoporosis in patients hospitalized for hip fractures. Osteoporos Int. 2010;21(Suppl 4):S605–14. Lamy O, Gonzalez-Rodriguez E, Stoll D, Hans D, Aubry-Rozier B. Severe rebound-associated vertebral fractures after denosumab discontinuation: 9 clinical cases report. J Clin Endocrinol Metab. 2017;102(2):354–8. Lyles KW, Colón-Emeric CS, Magaziner JS, Adachi JD, Pieper CF, Mautalen C, HORIZON Recurrent Fracture Trial, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357(18):1799–809. Molvik H, Khan W. Bisphosphonates and their influence on fracture healing; a systematic review. Osteoporos Int. 2015;25:1251–60. Ong T, Kantachuvesiri P, Sahota O, Gladman JRF. Characteristics and out- comes of hospitalised patients with vertebral fragility fractures: a system- atic review. Age Ageing. 2018;47:17–25. Roberts SJ, Ke HZ. Anabolic strategies to augment bone fracture healing. Curr Osteoporos Rep. 2018;16:289–98. Sànchez-Riera L, Wilson N. Fragility fractures & their impact on older peo- ple. Best Pract Res Clin Rheumatol. 2017;31:169–91. Wu CH, Tu ST, Chang YF, Chan DC, Chien JT, Lin CH, et al. Fracture liaison services improve outcomes of patients with osteoporosis-related fractures: a systemic literature review and meta-analysis. Bone. 2018;111: 92–100. Calcium Disorders 14 in End- Stage Renal Failure Including Those on Dialysis Alan Ona Malabanan Contents Calcium Metabolism in Chronic Kidney Disease (CKD) Is Characterized by Aberrations in Calcium and Phosphate Clearance, Decreases in 1-α-Hydroxylase Activity with Decreased Calcium Absorption, and Parathyroid Hormone Resistance . . . . . . . . . 160 Calcium Status in CKD Stages 3–5 Should Be Assessed with an Estimate of Ionized Calcium (i.e., Total Serum Calcium Corrected for Serum Albumin), Serum Phosphate, Serum Parathyroid Hormone, and Serum Bone-Specific Alkaline Phosphatase . . . . . . . . . 161 Calcium Disorders in CKD Should Be Managed in Close Coordination with the Patient’s Primary Nephrologist, Carefully Reconciling the Medications Being Taken as an Outpatient and Being Given in Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Hypocalcemia Should Be Managed as Previously Described for Chronic Hypocalcemia but Being Particularly Cautious About Avoiding Hypercalcemia, an Elevated Calcium-Phosphate Product, and Parathyroid Hormone/Bone Alkaline Phosphatase Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 A. O. Malabanan (*) Beth Israel Deaconess Medical Center, Harvard Medical School, Division of Endocrinology, Diabetes and Metabolism, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 159 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_14 160 A. O. Malabanan Secondary Hyperparathyroidism May Be Managed with Dietary Phosphate Restriction or Phosphate Binding, Adequate Calcium Intake, Activated Vitamin D, or Cinacalcet Use . . . . . . . . . . . . . . . . . . 163 Tertiary Hyperparathyroidism May Be Managed with Adequate Fluid Intake, Reducing Calcium and Activated Vitamin D Intake, Cinacalcet Use, or Parathyroid Surgery . . . . . . . . . . . . . . . . . . . . . . . . 164 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Calcium Metabolism in Chronic Kidney Disease (CKD) Is Characterized by Aberrations in Calcium and Phosphate Clearance, Decreases in 1-α-Hydroxylase Activity with Decreased Calcium Absorption, and Parathyroid Hormone Resistance Serum calcium is controlled by the interaction between the bone, the kidney, and the gut through the actions of dietary calcium, vitamin D, and parathyroid hormone. With the loss of kidney function, there is ultimately the loss of the 1-alpha-hydroxylase, lowering the production of 1,25-dihydroxyvitamin D and impair- ing gastrointestinal calcium absorption. However, aberrations in calcium metabolism occur before this critical loss of renal mass and 1-alpha-hydroxylase activity. The kidneys are also responsi- ble for phosphate clearance, important because of the marked effi- ciency of gastrointestinal phosphate absorption and the omnipresence of phosphate in our diet. With increased phosphate levels, fibroblast growth factor 23 (FGF-23) increases due to its role as a phosphaturic factor. FGF-23 inhibits the renal 1-alpha- hydroxylase (since 1,25-dihydroxyvitamin D increases phosphate absorption) and lowers 1,25-dihydroxyvitamin D levels. Parathyroid hormone (PTH) rises, as compensation, increasing bone turnover and release of calcium from the bone, to maintain calcium homeostasis. In addition, hyperphosphatemia may directly stimulate PTH secretion, since PTH is also a phosphaturic 14 Calcium Disorders in End-Stage Renal Failure Including Those… 161 factor. Worsening azotemia also results in PTH resistance, further requiring higher PTH levels to maintain calcium homeostasis. Calcium Status in CKD Stages 3–5 Should Be Assessed with an Estimate of Ionized Calcium (i.e., Total Serum Calcium Corrected for Serum Albumin), Serum Phosphate, Serum Parathyroid Hormone, and Serum Bone-Specific Alkaline Phosphatase Hypoalbuminemia in nephrotic syndrome may lower total serum calcium levels, so serum calcium levels should always be assessed with a concomitant serum albumin. The total serum calcium should be corrected for hypoalbuminemia (corrected serum calcium = total serum calcium + ((4.0 − Albumin) × 0.8)). Aberrations in acid-base status may necessitate a direct mea- surement of ionized calcium, since acidemia increases ionized calcium levels. Hyperparathyroidism is associated with bone and vascular disease and should be monitored. Appropriate ranges for PTH are typically above the normal reference range due to PTH resistance and a risk for adynamic bone disease with lower than optimal PTH levels. Bone-specific alkaline phospha- tase reflects PTH action on the bone and may help in individual- izing PTH targets. Optimal PTH ranges for those not on dialysis with CKD 3a to 5 are unknown. PTH has poor sensitivity and specificity in identifying high and low turnover. In addition, PTH has marked variability with regard to diet and diurnal changes. The Kidney Disease Improving Global Outcomes (KDIGO) guidelines have focused on following PTH trends rather than individual values and correcting vitamin D defi- ciency, hyperphosphatemia, high phosphate diet, and hypocalce- mia. For those with CKD 5D, PTH target range has been recommended at 2× to 9× the upper limit of normal since high or rising PTH levels are associated with increased metabolic bone disease, morbidity, and mortality. 162 A. O. Malabanan Calcium Disorders in CKD Should Be Managed in Close Coordination with the Patient’s Primary Nephrologist, Carefully Reconciling the Medications Being Taken as an Outpatient and Being Given in Dialysis Often patients receiving hemodialysis are followed in outpatient dialysis centers, and they have frequent lab testing as well as long- acting medications given in dialysis. It is critical to obtain these records and reconcile medication lists to plan appropriate man- agement. Direct communication with the patient’s outpatient pri- mary nephrologist is paramount both on admission and on discharge. Hypocalcemia Should Be Managed as Previously Described for Chronic Hypocalcemia but Being Particularly Cautious About Avoiding Hypercalcemia, an Elevated Calcium-Phosphate Product, and Parathyroid Hormone/Bone Alkaline Phosphatase Suppression Hypocalcemia is managed by ruling out pseudo-hypocalcemia related to hypoalbuminemia and ruling out vitamin D deficiency or hypomagnesemia as a cause. Treatment is focused on correct- ing vitamin D deficiency, assuring adequate calcium intake and then considering activated vitamin D analogues. Because the impaired kidneys may not be able to clear excess calcium or phos- phate, attention and care should be paid to avoiding hypercalce- mia and an elevated calcium-phosphate product. An elevated calcium-phosphate product increases the risk for metastatic calci- fication of soft tissues and, as mentioned in the chapter on hypo- calcemia, should be maintained <55 mg2/dl2. 14 Calcium Disorders in End-Stage Renal Failure Including Those… 163 Secondary Hyperparathyroidism May Be Managed with Dietary Phosphate Restriction or Phosphate Binding, Adequate Calcium Intake, Activated Vitamin D, or Cinacalcet Use Hypocalcemia and hyperphosphatemia are associated with increased mortality and vascular disease, as is secondary hyper- parathyroidism. The KDIGO guidelines suggest dietary phosphate restriction in the setting of hyperphosphatemia, making sure that other nutrient intake isn’t compromised. Guidance and teaching from a dietitian would be helpful. It is unclear what PTH target should be considered for patients with CKD not on dialysis. KDIGO recommends PTH targets from two times upper limit of normal to nine times upper limit for those on dialysis. For those with CKD G3a-G5 and rising PTH levels, addressing modifiable etiologies such as vitamin D deficiency, hypocalcemia, and hyper- phosphatemia is warranted. With hypocalcemia, calcium supple- ments and calcitriol, as outlined in the hypocalcemia chapter, would be indicated. If dietary phosphate restriction is insufficient to control phosphate levels, nonaluminum phosphate binders are recommended, with non-calcium phosphate binders such as sevelamer having some advantage over calcium-containing phos- phate binders. Activated vitamin D therapy and calcium-based phosphate binders should not be used in patients with hypercalce- mia. If serum calcium levels are high normal, paricalcitol and dox- ercalciferol may be preferred to calcitriol due to a lower tendency to raise serum calcium levels. Cinacalcet, a calcium sensing recep- tor agonist, may be helpful in lowering PTH if the above measures are unsuccessful. GI upset is a side effect. Cinacalcet should not be used in patients with hypocalcemia. Cinacalcet use might lower the incidence of mortality and cardiovascular events in older dialy- sis patients by lowering FGF-23 levels. Normalization of PTH and suppressing bone-specific alkaline phosphatase should be avoided to minimize the risk for adynamic bone disease. 164 A. O. Malabanan Tertiary Hyperparathyroidism May Be Managed with Adequate Fluid Intake, Reducing Calcium and Activated Vitamin D Intake, Cinacalcet Use, or Parathyroid Surgery Occasionally secondary hyperparathyroidism leads to worsening parathyroid hyperplasia and autonomy, eventually causing hyper- calcemia, most often after renal transplantation. Maintaining ade- quate fluid intake and lowering or stopping the calcium and activated vitamin D may control the hypercalcemia. Cinacalcet is often started at 30 mg p.o. daily with lab testing at least 12 h after dosing. If medical therapy is insufficient to control serum calcium levels or there is significant bone involvement, surgical therapy is indicated for parathyroid debulking. Suggested Reading Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 clinical practice guideline update for the diag- nosis, evaluation, prevention, and treatment of chronic kidney disease– mineral and bone disorder (CKD-MBD). Kidney Int Suppl. 2017;7:1–59. Moe SM, Chertow GM, Parfrey PS, Kubo Y, Block GA, Correa-Rotter R, et al. Cinacalcet, fibroblast growth factor-23, and cardiovascular disease in hemodialysis: the evaluation of cinacalcet HCl therapy to lower cardio- vascular events (EVOLVE) trial. Circulation. 2015;132:27–39. Parfrey PS, Drüeke TB, Block GA, Correa-Rotter R, Floege J, Herzog CA, et al. The effects of cinacalcet in older and younger patients on hemodi- alysis: the evaluation of cinacalcet HCl therapy to lower cardiovascular events (EVOLVE) trial. Clin J Am Soc Nephrol. 2015;10:791–9. Disorders of the Serum 15 Sodium Concentration Julian L. Seifter and Hsin-Yun Chang Contents Basic Physiology of Sodium and Water Balance 166 Osmoregulation of ADH 168 Relation Between Plasma Osmolality and Sodium Concentration 169 Relation Between Osmolality and Tonicity 170 Initial Approach to Dysnatremia 171 Clinical Features of Dysnatremia and Cell Adaptation 172 Diagnostic Approach to Hyponatremia 173 Is the Hyponatremia “True or Fictitious”? 173 Is the Hyponatremia Associated with H ypo-osmolairty 174 Is the ADH Activity Appropriately Suppressed? 175

Diagnostic Categories of Hyponatermia Based on the Extracellular Volume 175 Hypervolemic Hyponatremia 177 Hypovolemic Hyponatremia 178 Euvolemic Hyponatremia 180 J. L. Seifter (*) Brigham and Women’s Hospital, Department of Medicine, Boston, MA, USA e-mail: [email protected] H.-Y. Chang National Cheng Kung University Hospital, Department of Family Medicine, Tainan City, Taiwan © Springer Nature Switzerland AG 2020 165 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_15 166 J. L. Seifter and H.-Y. Chang Management of Hyponatremia 182 Diagnostic Approach to Hypernatremia 184 Hypervolemic Hypernatremia 184 Hypovolemic/Euvolemic Hypernatremia 185 Management of Hypernatremia 186 Suggested Reading 187 Abbreviations ACE Angiotensin-converting enzyme ADH Antidiuretic hormone ANP Atrial natriuretic peptide AQP2 Aquaporin type 2 AVP Arginine vasopressin CHF Congestive heart failure CRH Corticotropin-releasing hormone ECF Extracellular fluid FES Flame emission spectrophotometer ICF Intracellular fluid ODS Osmotic demyelination syndrome RAAS Renin-angiotensin-aldosterone system SIADH Syndrome of inappropriate antidiuresis hormone (SIADH) SNS Sympathetic nervous system Basic Physiology of Sodium and Water Balance The concentrations of Na+, the most abundant extracellular fluid (ECF) cation, and K+, the major intracellular cation, determine the osmolality of total body water. More than 90% of the total osmotic content of the ECF is accounted for by Na+ and its accompanying anions, principally Cl− and HCO − 3 . 15 Disorders of the Serum Sodium Concentration 167 Plasma osmolality can be seen as that of total body water since osmolality of almost all body compartments is the same; we then have the equation shown below: Extracellular Intracellular solutes Plasma osmolality Total body water 2 Na K    2 Na  Total body water  Therefore, plasma [Na+] ≃ (Na+ + K+)/total body water. Na+ content is determined by dietary intake and regulated excretion independent of water regulatory mechanisms in order to maintain an adequate blood pressure and plasma volume required for perfusion of tissues. The state of total body potassium is also a reflection of diet and regulated excretion that determines cellular volume. Since most cell membranes are highly permeable to water, the regulation of osmolality usually depends on water balance. Plasma [Na+] is kept within a narrow range of 135–145 mmol/ kg (~mEq/L); an even narrower range of ~2% difference in an individual is often observed. Despite constantly changing dietary intake of salt and water, this finely regulated homeostatic control is due to an important thirst mechanism and renal regulation by means of the rapid stimulated release of the posterior pituitary peptide hormone, arginine vasopressin (AVP) , when conserving water is required and the rapid degradation of AVP in states of water excess. In turn, adequate ability to concentrate urine to maximal levels in humans (~1200 mOsm/kg) requires intact tubu- lar functions of the kidney, adequate salt and protein diets to allow for urinary concentrating ability, and a complex system of countercurrent exchange and multiplication. The systems of regulating osmolality and extracellular volume (and therefore blood pressure) are mostly different, but they inter- sect in the setting of changes in volume expansion or depletion (Fig. 15.1). 168 J. L. Seifter and H.-Y. Chang Na+ Excretion Volume H2O Excretion & Reabsorption & Retention Osmolality R-A-S ANP ADH SNS >10% Thirst Volume depletion Fig. 15.1 The systems regulating osmolality and volume are mostly differ- ent but interact in the setting of changes in volume. ADH secretion is stimu- lated as systemic osmolality is raised above a threshold level of 285 mOsm/ kg. Over the physiologic range of effective circulating volume, ADH levels are determined almost entirely by plasma osmolality. However, extracellular volume depletion of 10% or greater also significantly influences ADH levels. Both increase in plasma osmolality and decrease in extracellular volume stimulate the “thirst center.” The sympathetic nerve system (SNS) and renin- angiotensin system (RAS) , on the other hand, respond to smaller decrements of extracellular volume changes. In excessive fluid loss, baroreceptors stimu- late sympathetic activity to the kidneys, triggering vasoconstriction mainly in efferent arterioles to maintain GFR as well as renin secretion and Na+ reab- sorption along nephron. In renin-angiotensin system (RAS), angiotensin II also causes vasoconstriction in efferent arteriole to maintain GFR and pro- motes aldosterone secretion so as to stimulate increased Na+ reabsorption. Atrial natriuretic peptide (ANP) can be seen as the counter regulatory system for the RAS, causing systemic vasodilation and increased Na+ and water excretion in response to extracellular volume expansion Osmoregulation of ADH The absence or presence of ADH is the major physiologic deter- minant of urinary water excretion or retention. ADH secretion is stimulated as systemic osmolality is raised above a threshold level of 285 mOsm/kg. Decreases in blood pressure and intravascular fluid volume also stimulate ADH release and thirst but in a less sensitive manner. In addition, there are other non-osmotic stimuli that activate ADH release, including hypoxemia, nausea, stress (pain, emotion, exercise), alcohol, serotonin, and multiple drugs. 15 Disorders of the Serum Sodium Concentration 169 ADH acts on renal V2 receptors to increase permeability to water in the collecting ducts, permeability to urea in the inner medullary collecting ducts, and reabsorption of NaCl by the thick ascending limb, distal tubule, and collecting duct. Increases in plasma osmolality or decrease in volume stimu- lates the “thirst centers,” which is located in the same regions of hypothalamus as involved with ADH secretion. Other thirst recep- tors are located in the oropharynx. Osmotic threshold for trigger- ing thirst is higher than that for ADH secretion (295 vs. 285 mOsm/ kg). ADH will be suppressed by hypotonicity once ADH thresh- old is reached. The secretion of ADH reduces water loss in urine in the setting of water deprivation, and the ADH threshold being lower than that of thirst prevents an otherwise continuous cycle of polyuria and polydipsia. In diabetes insipidus, ADH is either inadequate in concentration or absent. The major sign is potentially massive dilute urine production, which becomes serious if water consumption is not available. On the other hand, in the syndrome of inappropriate antidiuretic hormone secretion (SIADH) , inges- tion of water does not adequately suppress ADH, and the urine remains more concentrated than expected. Relation Between Plasma Osmolality and Sodium Concentration Osmolality is a measure of the number of particles present in solution and is independent of the size or weight of the particles. Plasma osmolality (Posm) can be estimated as the calculated osmolarity (Posm): Posm 2 Na   glucosemg / dL /18  blood urea nitrogen mg / dL / 2.8 The multiple of 2 for the plasma sodium concentration accounts for the osmotic contribution of its accompanying anions in the extracellular fluid. The concentrations of glucose and blood urea nitrogen (BUN) being divided by 18 and 2.8 are to convert the frequently measured units of mg/dL into mmol/L. 170 J. L. Seifter and H.-Y. Chang In healthy subjects, glucose and urea are both present in low concentrations and are ineffective osmoles because they can cross cell membranes. Therefore, sodium acts as the main effective osmole in plasma, and the equation can be simplified as Posm ≃ 2 × [Na+]. Hyponatremia can result from either loss of Na+ and K+ or increase in total body water due to retention of ingested or infused water. Solute losses from vomiting or diarrhea typically occur in fluids that are iso-osmotic to plasma, which do not lead to changes in plasma [Na+]. Only if the fluids are replaced with ingested water will hyponatremia occur because ECF depletion leads to non-osmotic ADH release. Therefore, the cause for nearly all cases of hyponatremia is abnormal water retention leading to excess water in relation to solute. On the other hand, continuous water loss, and sometimes sodium overload, accounts for the occurrence of hypernatremia. Relation Between Osmolality and Tonicity Plasma tonicity, also called the effective plasma osmolality, equals the sum of the concentrations of the solutes which have the capac- ity to exert an osmotic force across the membrane. It reflects the concentration of solutes that do not easily cross cell membranes and therefore determines the transcellular distribution of water between the cells and the ECF. Fluid expansion and depletion contributing to disorders of serum [Na+] are summarized in Table 15.1. Hyponatremia occurs when a defect in urinary dilution is combined with water intake that exceeds the ability to quantitatively excrete enough water, while hypernatremia develops when there is loss of water in excess of sodium without appropriate water intake or by expansion with hypertonic fluids. Note that both hyponatremia and hypernatremia can be associated with increased, decreased, or normal ECF vol- ume. This is because ECF depletion, which always accompanies Na+ loss, may be due to losses of Na+ as hypertonic fluid (hypona- tremia), isotonic fluid (normonatremia), or hypotonic fluid (hyper- natremia). The expansion syndromes similarly accompany gains 15 Disorders of the Serum Sodium Concentration 171 Table 15.1 Syndromes of fluid expansion and depletion ECF ICF Hematocrit [Protein] [Na+] volume volume Examples Expansion Na > H2O ↓ ↓ ↑ ↑ ↓ Hypertonic expansion (hypertonic NaHCO3 or NaCl infusion) Na = H2O ↓ ↓ – ↑ – Isotonic expansion (saline infusion) Na < H2O ↓ ↓ ↓ ↑ ↑ Hypotonic expansion (1/2 NS infusion) Depletion Na > H2O ↑ ↑ ↑ ↓ ↑ Hypertonic depletion (diabetes insipidus) Na = H2O ↑ ↑ – ↓ – Isotonic depletion (sweating, vomiting) Na < H2O ↑ ↑ ↓ ↓ ↓ Hypotonic depletion (salt- wasting) of hypotonic fluids (hyponatremia), isotonic fluids (normonatre- mia), or hypertonic fluids (hypenatremia). Initial Approach to Dysnatremia Direct history and initial physical examination often provide use- ful information and guide the subsequent diagnostic approach. For example, a history of fluid loss from vomiting, diarrhea, and 172 J. L. Seifter and H.-Y. Chang diuretic therapy, or signs of extracellular fluid volume depletion such as decreased skin turgor and orthostatic or persistent hypo- tension, may suggest hypovolemic state. Inadequate fluid intake or poor diet, presence or absence of thirst and polyuria, medical history consistent with malignancy, heart failure, recent surgery, and certain medication use including antiepileptics and antipsy- chotics may all direct toward determining the causes of dysnatre- mias and further management. Routine laboratory chemistries may provide certain information, e.g., renal dysfunction and hyperkalemia suggesting hypoaldosteronism. Further investiga- tion should include urine chemistries. Imaging may be necessary to detect or confirm associated etiology. Note that dysnatremias are often multifactorial and clinical evaluation should consider all possible causes. Clinical Features of Dysnatremia and Cell Adaptation The symptoms of dysnatremia are mainly neurological due to the effects on the central nervous system. In hyponatremia, a fall in plasma tonicity results in osmotic water movement from the ECF into the cells, including brain cells, and leads to neurologic dys- function. In hypernatremia, there is an osmotic water movement out of the brain cells due to increased plasma tonicity. Symptoms of dysnatremia are associated with the rapidity of the changes in the plasma sodium concentration. Nausea and malaise are com- mon in early stage, while severe symptoms including seizures, brainstem herniation, and coma may develop when dysnatremia is acute or if a chronic condition is corrected too rapidly. When encountering changes in plasma tonicity, the brain attempts to adapt to hyponatremia by losing intracellular solutes (potassium and organics, e.g., amines, polyols, amino acids, glyc- erophosphocholine) and to hypernatremia by increasing intracel- lular solutes. The process of cell adaptation may be completed in 1–2 days with major implications for therapy. Brain cell volume may normalize within 1–2 days despite the continued change in 15 Disorders of the Serum Sodium Concentration 173 osmolality and may change abruptly if osmolality is corrected instantly. This can explain why patients with chronic dysnatremia are less likely to develop severe neurological deficits upon presenta- tion but are predisposed to cerebral edema and seizures if encoun- tering overcorrection of plasma sodium concentration (> 8–10 mM/d). Diagnostic Approach to Hyponatremia Is the Hyponatremia “True or Fictitious”? Hyponatremia is defined as a serum sodium level of less than 135 mmol/L. Decreased serum sodium often reflects a hypotonic state; however, hyponatremia may also occur with iso-osmotic or hyperosmotic plasma. It is prerequisite to confirm hypotonic and exclude non-hypotonic hyponatremia (Fig. 15.2). Plasma osmolality Hypertonic Isotonic Hypotonic Acute or severe >290 mOsm/kg 275~290 mOsm/kg <275 mOsm/kg symptoms? • Hyperglycemia • Hyperproteinemia Consider Urine • Mannitol • Hyperlipidemia immediate Osmolality • Glycine treatment with • Maltose hypertonic saline < 100 mOsm/L > 100 mOsm/L • Primary polydipsia See Figure 3. • Beer potomania

• Low solute intake Fig. 15.2 Establish the type of hyponatremia by first measuring plasma osmolality, and obtain urine osmolality to assess ADH activity in the hypo- tonic hyponatremic patients. Note that a rapid decline in plasma sodium over 24–48 h is a medical emergency and requires acute intervention 174 J. L. Seifter and H.-Y. Chang • Iso-osmotic hyponatremia is caused factitiously by hyperpro- teinemia and hyperlipidemia, as solids that may contribute to more than the normal volume of plasma (>10%) and if the measurement is made by indirect potentiometry, a method of diluting of serum. The laboratory artifact is known as pseudohyponatremia. Excluding factitious hyponatremia requires a measure of serum osmolality or the Na+ concentration by direct potentiometry (undiluted sample) usually on a blood gas analyzer. Is the Hyponatremia Associated with Hypo-osmolairty The presence of solutes which do not penetrate cell membranes such as glucose (in the absence of insulin) and mannitol decreases plasma sodium by shifting water from intracellular to extracellu- lar space. A decrease in serum [Na+] of 2.4 mmol/L occurs for every 100 mg/dL increase in plasma glucose particularly when glucose is greater than 400 mg/dL. Estimates of the serum sodium concentration corrected for the presence of hyperglycemia can be obtained from the equations: Corrected serum  Na  measured Na  2.4 mg m glucose  100 g     dL      dL  100 mg     dL  Plasma osmolality can alsobe increased by certain solutes including urea, ethanol, methanol, and ethylene glycol. These sol- utes are cell membrane permeable and do not translocate water into the intra- or extracellular space. Their presence does not cause hyponatremia but can lead to a normal or high measured plasma osmolality in a hyponatremic patient from other cause. These patients should be approached as having a hypotonic disor- der given their decreased effective plasma tonicity. 15 Disorders of the Serum Sodium Concentration 175 Is the ADH Activity Appropriately Suppressed? • Obtain urine osmolality to assess ADH activity in the hypo- tonic hyponatremic patient. To evaluate hyponatremia, urine osmolality is used to assess ADH activity. The development of hyponatremia along with hypo-osmolality is often caused by underlying disorders affecting the renal diluting mechanism. Such patients have a greater than maximally dilute urine, which is 50–100 mOsm/kg, unless hypo- osmolality fails to fully suppress ADH release (the reset osmo- stat). When the urine osmolality is < 100 mOsm/kg, indicating maximally dilute urine, the hyponatremia is primarily caused by excess water intake or low solute intake. Psychogenic polydipsia and beer potomania are classic examples. This example demon- strates the difference between urinary dilution, a measure of con- centration, and excretion of quantitatively enough dilute urine, measured by free water clearance rate, in ml/min. Diagnostic Categories of Hyponatermia Based on the Extracellular Volume Ingestion of a normal diet in a healthy subject results in the excre- tion of approximately 600 mOsm of solute per day, which includes primarily sodium, potassium salts, and urea. If the minimum urine osmolality is 50 mOsmol/kg, the maximum urine output will be 12 L/day. In beer drinkers (beer potomania) or those on a very poor diet, there is little solute (low sodium, potassium, or protein) in the diet. Also the carbohydrate load in beer may further sup- press endogenous protein breakdown. Therefore, daily solute excretion may be less than 150 mOsm, and hyponatremia occurs if daily fluid intake exceeds 3 L/day. Patients with hyponatremia due to beer potomania and low solute intake respond rapidly to intravenous saline and a resumption of a normal diet. However, patients with beer potomania are at high risk of developing osmotic demyelinating syndrome (ODS) due to the associated hypokalemia, alcoholism, malnutrition, and potentially overcor- rected plasma sodium concentration. 176 J. L. Seifter and H.-Y. Chang Primary polydipsia occurs when more hypotonic fluid is con- sumed than excreted in a maximally dilute urine. It is characterized by increase in thirst and is most often seen in patients with psychi- atric illnesses. Changes in plasma osmolality play the most impor- tant role in regulating ADH secretion. Osmolality is sensed by osmoreceptors in the anterior hypothalamus, which shrink or swell in response to changes in osmolality. Decrease in plasma osmolal- ity will cause osmoreceptors to swell and thereby decrease ADH secretion. In primary polydipsia, the patients continue to drink until the thirst threshold, causing fall in plasma osmolality sup- pressing ADH secretion with diuresis and subsequently continued stimulation of thirst. An acute water load of 3–4 L may cause fatal hyponatremia even though the urine is maximally dilute. • Determine the patient’s volume status and obtain urine sodium concentration. In the patient with hypotonic hyponatremia whose urine is not dilute (>100 mOsm/L), an assessment of the ECF volume has been proposed to help further differentiate the underlying causes (Fig. 15.3). However, in clinical practice, a mixed process may occur, or a hypovolemic state often presents as clinical euvolemia, making such classification debatable. Measuring urine Na+ and K+ concentrations is therefore always essential. Calculations of electrolyte- free water clearance are recommended (CH2O = V – (UNa + UK)V/PNa). Note that since water is coming from TBW, both Na and K are required. This equation enables independent calculations of isotonic and free water excretion. It is helpful in diagnosis and treatment. For example, a positive CH2O and hypernatremia suggests diabetes insipidus. CH2O also improves management as it informs about ongoing urinary losses. While deficits are calculated based on an abnormal serum [Na+] and must be corrected at a safe rate, ongoing losses will lead to a defi- cit if not replaced quantitatively. Another advantage of calculating CH2O is in the choice of management strategy. Thus, if the urine was hypertonic in a hyponatremic patient, giving saline may make a patient with SIADH more hyponatremic. Also, in the same patient, a large negative value for CH2O predicts that fluid restric- 15 Disorders of the Serum Sodium Concentration 177 True hyponatremia with urine osmolality >100 mOsm/L ECF volume Hypervolemia Euvolemia Hypovolemia UNa <20 UNa >20 UNa <20 UNa >20 • Heart failure • Renal • Diarrhea • Renal losses • Cirrhosis insufficiency UNa >20 • Vomiting • Salt-losing deficiency • Nephrotic • Adrenal insufficiency • Nasogastric • Recent diuretics syndrome • Hypothyroidism suction • Hypoaldosteronism • SIADH • Extrarenal • Reset osmostat losses • Other causes of increased ADH secretion (drugs, pain, stress) Fig. 15.3 Determine the patient’s volume status and obtain urine sodium concentration for further diagnosis tion may be inadequate. In that case, treatment with a loop diuretic may be helpful to diminish the maximal urine osmolality, or cau- tious use of hypertonic saline may be required. When using a loop diuretic in a patient with hypertonic urine, it is necessary to recal- culate CH2O to assure success in creating hypotonic urine. Hypervolemic Hyponatremia When hyponatremia occurs with excess ECF volume, both total body sodium and total body water are increased, with total body water being increased to a greater extent. In this setting, the edem- atous state may be due to congestive heart failure (CHF), cirrho- sis, nephrotic syndrome, or advanced kidney disease. In CHF, cirrhosis, and nephrotic syndrome, a decreased effec- tive circulating arterial volume leads to increased ADH secretion. Aquaporin 2 (AQP2) water channels may also be increased, resulting in decreased water clearance. Urinary sodium level is often very low (may be < 10 mmol/L) in these cases, as renin- angiotensin- aldosterone system (RAAS) increases sodium reten- 178 J. L. Seifter and H.-Y. Chang tion. However, sodium retention can be obscured by diuretics, which are often used concomitantly to treat such patients. In advanced renal insufficiency, hyponatremia is associated with water intakes exceeding the ability to excrete equivalent vol- umes, and the minimum urine osmolality can rise to as high as 200–250 mOsmol/L. A decrement in GFR and the impairment of free water excretion with increase in thirst contribute to the reten- tion of ingested water and the development of a hypervolemic hyponatremic state. Hypervolemic hyponatremia due to CHF will often respond to improved therapy of the underlying cardiomy- opathy, e.g., following the institution or intensification of angiotensin- converting enzyme (ACE) inhibition. Hypovolemic Hyponatremia As noted earlier, plasma sodium concentration can be determined by: 2 Na K / Total body water The loss of sodium and possibly potassium may contribute to hyponatremia, if these losses are not accompanied by parallel decrements in total body water. When there are substantial fluid losses, from either renal or extrarenal sources, volume contraction stimulates secretion of ADH. If these losses are replenished with water or hypotonic fluids, hyponatremia will result. We know that over the physiologic range of effective circulating volume, ADH levels are determined almost entirely by plasma osmolality. However, volume depletion of 10% or greater will significantly influence ADH levels. Therefore, in the presence of hypovolemia, ADH is secreted with subsequent water retention even in the pres- ence of hypotonicity. On examination, a low jugular venous pres- sure, decreased skin turgor, orthostatic hypotension, and tachycardia may be noticed. A urinary sodium concentration of less than 20 mEq/L indicates a normal renal response to volume depletion by conserving sodium, and an extrarenal loss is sug- gested. Vomiting or diarrhea, or fluid losses into third spaces such 15 Disorders of the Serum Sodium Concentration 179 as burns or pancreatitis, can all lead to hypovolemia. The urinary sodium concentration can be as low as <10 mEq/L. However, in patients with vomiting and metabolic alkalosis presenting bicar- bonaturia, urinary sodium concentration can be greater than 20 mEq/L, while urinary chloride concentration will be low since bicarbonate anion dominates. Both the sodium and chloride con- centrations can be as high as 40 meq/L in hypovolemic hypona- tremic patients with renal salt losses, which is most commonly seen with diuretic therapy if the urine electrolytes are measured while the effect of the diuretic is still present. The variation in the hyponatremia risk relates to the site of action in different diuret- ics. Loop diuretics interfere with sodium chloride (NaCl) reab- sorption in the thick ascending limb of the loop of Henle by impairing the accumulation of NaCl in the medulla. Although the loop diuretic can increase ADH levels by inducing volume deple- tion, responsiveness to ADH is diminished because of the impair- ment in the medullary gradient. As a result, water retention and the development of hyponatremia will be limited. The thiazides, in comparison, act in the cortex of distal tubule and do not inter- fere with medullary function or with ADH-induced urinary con- centration in volume depletion. In addition to water retention, increased sodium and potassium excretion due to the diuretic as well as enhanced water retention can result in the excretion of electrolyte-rich urine with a sodium plus potassium concentration higher than that of the plasma and directly promote the develop- ment of hyponatremia regardless of water intake. Hyponatremia related to use of thiazides begins soon after initiation and is often evident within 14 days. Furosemide-related hyponatremia tends to occur after many months of therapy, often when an intercurrent illness develops in polydipsic patients. If urinary sodium concentration higher than 20 mEq/L accom- panies hyperkalemia and elevated plasma urea and creatinine, hypoaldosteronism should be suspected. Hypovolemic hyponatremia responds to volume restoration with isotonic normal saline – most importantly, the recognition of underlying etiology needs to be identified. It should be obvious that the urinary chemistries in hypovolemic hyponatremia and hypervolemic hyponatremia, as in CHF, are similar. The one hor- 180 J. L. Seifter and H.-Y. Chang monal difference in the plasma may be a high BNP (B-type natri- uretic peptide) in CHF, whereas it will be low in hypovolemia. Euvolemic Hyponatremia Euvolemic hyponatremia is the most heterogeneous and com- monly encountered hyponatremia in hospitalized patients. Patients may have slightly excessive volume in the absence of edema, and it may be hard to distinguish from hypovolemia. Urine chemistry again is vital to differentiation, and sodium is expected to be >20 mEq/L. Euvolemic hyponatremia can occur in any of the set- tings mentioned above and is seen in other scenarios. The ques- tion often arises as to why patients with water overload but not salt and water overload do not get edema. One reason is that only 6% of a water load expands the plasma volume as most water goes

into cells. By the time water was expanded enough to cause edema, life-threatening hyponatremia would develop. A second reason is that an acute water load expands the plasma volume enough to cause a mild, acute natriuresis. But distinctively the cause of edema in ECF expansion is raised intravascular volume and pressure due to the gravitational effect on the veins. The result is an increased intracapillary hydrostatic pressure gradient in dependent areas such as lower extremities. In contrast, hypo- osmotic expansion with water will affect oncotic forces through- out the body, and there will be no effect of gravity to increase Starling forces in dependent areas. Secondary adrenal insufficiency due to pituitary disease may lead to euvolemic hyponatremia, while decreased aldosterone in primary adrenal insufficiency causes hypovolemic hyponatremia. In either primary or secondary adrenal insufficiency, glucocorti- coid deficiency leads to co-secretion of corticotropin-releasing hormone (CRH) and ADH by the paraventricular nuclei in the hypothalamus. Impaired water excretion with reduced water delivery to the collecting ducts is also associated with glucocorticoid deficiency. Hydrocortisone replacement in these patients will reduce ADH secretion and therefore normalize its response to osmolality. 15 Disorders of the Serum Sodium Concentration 181 In patients with hypothyroidism, the cardiac output is often reduced and may be the non-osmotic stimuli to ADH release, while the concomitant reduction in GFR leads to diminished free water excretion. Hyponatremia in this case can be reversed by treatment with levothyroxine. The syndrome of inappropriate antidiuretic hormone (SIADH) is a common cause of euvolemic hyponatremia in hospitalized patients. The diagnosis is made mainly by excluding other causes and can be summarized in Table 15.2. In normal individuals, plasma ADH levels are very low when the plasma osmolality is below 280 mOsmo/kg, permitting the excretion of ingested water. ADH levels increase progressively as the plasma osmolality rises above 280 mOsm/kg, and the higher the plasma ADH, the more concentrated the urine. In most patients with SIADH, ingestion of water does not adequately suppress ADH, and the urine remains concentrated. Sustained increases in ADH limit distal renal tubular transport, thereby preserving a relatively hypervolemic state with hyponatremia. Such patients are not euvolemic but rather subclinically volume-expanded. Serum uric acid is often low (<4 mg/dL) in patients with SIADH, while hyperuricemia is often seen in patients with hypovolemic hyponatremia. Common causes of SIADH include pulmonary disease, central nervous sys- tem disorders, and malignancies, most commonly in small-cell lung carcinoma. Patients with euvolemic hyponatremia due to SIADH may respond to successful treatment of the underlying cause. However, not all causes of SIADH are immediately revers- ible, and pharmacologic therapy may be necessary at certain point. Oral tolvaptan, the ADH V2 antagonist, may be considered Table 15.2 Diagnostic criteria for SIADH Decreased serum osmolality (<275 mOsm/kg) Increased urine osmolality (>100 mOsm/kg) Clinical euvolemia Increased urinary sodium concentration (>40 mmol/L) under normal salt and water intake Absence of adrenal, thyroid, pituitary, or renal insufficiency or recent diuretic use 182 J. L. Seifter and H.-Y. Chang in significant and uncontrolled SIADH which is not responsive to the treatment with water restriction, oral furosemide, and salt tablets. The “reset osmostat” is sometimes considered a variant of SIADH, in which the threshold for ADH secretion is reset down- ward so that ADH is secreted at a lower value instead of beyond 280–285 mOsm/kg as in most individuals. Diagnosing reset osmostat is a diagnosis of exclusion. Individuals with reset osmo- stat should be able to concentrate and dilute the urine appropri- ately, and a water challenge should result in a dilute urine (<100 mOsm/kg), while a water deprivation test results in a con- centrated urine. Reset osmostat often occurs in pregnancy, malnu- trition, and neurologic conditions such as epilepsy and paraplegia. A patient initially diagnosed with SIADH will sometimes be proven with virtually reset osmostat when it becomes apparent that fluid restriction does not successfully raise the serum sodium level. Management of Hyponatremia The major considerations in managing hyponatremia are: 1. The presence or absence, as well as severity, of symptoms 2. The duration of the disorder 3. Recognizing the underlying cause Patients with acute hyponatremia (with hyponatremia developing within 48 h) may present with symptoms ranging from headache, nausea, or vomiting to lethargy, seizures, or even coma and are also at greater risk of developing permanent neuro- logic sequelae. Patients with chronic hyponatremia (present for >48 h) are less likely to have severe symptoms. The risk of sei- zures remains low until the serum sodium concentration falls below 115 meq/L, and rarely patients may even be awake and talking with a serum sodium of <100 meq/L. However, patients with chronic hyponatremia are at greater risk for osmotic demy- elinating syndrome (ODS) if plasma sodium concentration is 15 Disorders of the Serum Sodium Concentration 183 corrected by >8–10 mM within the first 24 h or by >18 mM within the first 48 h. In contrast, in acute hyponatremia, overly rapid correction is less of a concern since the brain has not yet adapted completely to the hypotonic environment. Clinically, it may be unclear which treatments should be applied or what increases in plasma sodium concentration we should pursue. While treatment can be diagnosis specific, a single infusion of 150 mL 3% hypertonic saline may be suggested to avoid further drop in plasma sodium concentration. Nevertheless, frequent monitoring of plasma sodium concentration during corrective therapy is always crucial because a variation in the volume and electrolyte content of the urine produced concomitantly may also have an impact. Aggressive therapy to rapidly raise the serum sodium with hypertonic saline is indicated when patients present with severe symptoms such as seizures or obtundation or acute hyponatremia even with mild symptoms. The goal of such therapy is to rapidly increase the serum sodium by 4–6 mEq/L over a period of several hours. Note that the increase in serum sodium should not exceed 8 mEq/L in any given 24-h period. Patients who are asymptomatic or have mild to moderate symptoms with even acute or severe hyponatremia (i.e., serum sodium ≤ 120 mEq/L) do not require emergent therapy, and the goal is to slowly raise the serum sodium and alleviate symptoms. In general, raising the serum sodium by 4–6 mEq/L should improve a patient’s symptoms. Calculating a proper dose of 3% saline can be reasoned as follows: 3% saline has 513 meq/L NaCl (~0.5 meq/ml). Total body water is ~50% body weight in kilogram. Therefore, giving 1 ml/kg body weight will raise the [Na+] by 1 meq/L. Thus, to raise the serum [Na+] by 1 meq/L over 4 h in a 70 kg man, one would give 3% saline at a rate of 70 ml/hr for 4 h. Once the corrective therapy has been established and initiated, treatment should be directed at the underlying disease. In the case of overcorrection of hyponatremia (raising the Na+ greater than 8 mEq/L/day), water can be given as D5W with an amount to lower the Na+ to a value appropriate for the time elapsed. In cases where large elecrolyte free water clearance may correct hyponatremia too rapidly (as after saline given to a patient with 184 J. L. Seifter and H.-Y. Chang hypovolemic hyponatremia) SC or IV DDAVP may be adminis- tered to clamp the urine output to low levels. Then the adminis- tration of 3% saline allows correction at an appropriate rate. Since 3% saline is ~0.5 meq Na+/ml and total body water is ~0.5 times the body weight, it follows that administering 3% saline at 1 ml/kg body weight will raise the serum Na+ by 1 meq/L. Diagnostic Approach to Hypernatremia Hypernatremia is defined as an increase in the plasma Na+ con- centration to >145 mmol/L, reflecting losses of water via both renal and nonrenal routes in excess of sodium and potassium. Net water loss accounts for the majority. In order for hypernatremia to occur, either ADH function or thirst mechanism must be impaired, and limited access to water is often involved. In those who are alert and have an intact thirst mechanism and adequate access to water, persistent hypernatremia should rarely occur. The higher the GFR, or proximal tubule sodium, glucose, or urea delivery, the higher the urine volume. A detailed history and physical examination often reveal the underlying causes of hypernatremia. In the elderly, it is often due to water losses without adequate replacement due to altered men- tal status or limited access. Still, further investigation may be nec- essary when etiology is unclear (Table 15.3). As in hyponatremia, hypernatremia must be considered along with ECF status. Hypervolemic Hypernatremia If hypervolemia is present, sodium gains from hypertonic fluid administration or mineralocorticoid excess must be considered. Urine sodium concentration, if obtained, is often >20 mmol/L. The urine may in fact be hypertonic, though rarely maximally concen- trated due to washout of the medullary solute gradient. However, the net hypertonic salt intake must exceed the net hypertonic salt output. It is often asked whether someone can survive by drinking 15 Disorders of the Serum Sodium Concentration 185 Table 15.3 Common causes of hypernatremia Dehydration (nonrenal loss) Insensible losses Gastrointestinal losses Primary hypodipsia Sodium gains Hypertonic sodium load Hyperaldosteronism Cushing’s syndrome Osmotic diuresis Glucosuria High urea in high-protein tube feedings Mannitol Water diuresis Central diabetes insipidus Nephrogenic diabetes insipidus ocean water. Sea water is about 1000 meq Na+ and Cl−. The bowel can only absorb isosmotically. Thus, drinking seawater will increase isotonic salt water reabsorption, but the remaining hyper- tonic salt will induce severe isotonic diarrhea. The total body water will decrease. But the serum Na+ will rise, dehydrating cells while expanding the ECF. The result is hypertonic expansion. Urine osm and tonicity will rise (high ADH) and polyuria will result. Hypovolemic/Euvolemic Hypernatremia There may be evident history of extrarenal losses, e.g., increased. insensible loss, gastrointestinal loss, or burn. Minimum volume of maximally concentrated urine with urine osmolality >700 mOsm/kg and urinary sodium concentration <10 mmol/L may further support the diagnosis. If the urine osmolality appears less than 300 mOsm/ kg, the patient is suspected with either central or nephrogenic diabe- tes insipidus, which can be distinguished by the administration of exogenous ADH (dDAVP), followed by monitoring of the urine osmolality and volume every 30 min over the next 2 h. 186 J. L. Seifter and H.-Y. Chang If the urine osmolality is intermediate (between 300 and 800 mOsmol/kg), the hypernatremia may be due to diabetes insip- idus or an osmotic diuresis. Such patients can be differentiated by measuring the total solute excretion. As mentioned earlier, inges- tion of a normal diet in a healthy subject results in the excretion of approximately 600 mOsm (600–900 mOsm) of solute per day. A value above 900 mOsm/day suggests a significant contribution from increased solute excretion, indicating osmotic diuresis resulting from possibly glucosuria, mannitol, or high solute loads. If an osmotic diuresis is not present, a workup to rule out diabetes insipidus should be performed. Management of Hypernatremia The water deficit in the hypernatremic patient can be estimated from the following formula:  Serum Na   Free water deficit Current total body water   1   140   Total body water is estimated by multiplying weight in kilo- grams by 0.6 for men and by 0.5 for women. The formulas estimate the amount of water required to have been lost to raise the serum sodium from a relatively normal level of 140 to the hypernatremic value. To correct the [Na+] would require replacing that amount of water. Chronic hypernatremia (>48 h) or hypernatremia of unknown duration should be corrected at a safe rate at which the serum sodium concentration should be lowered no more than 10 meq/L per day to avoid cerebral edema caused by excess fall in serum [Na+]. As for acute hypernatremia, serum sodium level should be corrected over the next 24 h. Concurrent electrolyte disturbances should not be ignored and must be replenished accordingly. Meanwhile, ongoing free water losses, including losses in sweat, stool, dilute urinary, or gastrointestinal tract, must be replaced as well. In addition, this formula does not include com- bined sodium and water loss, as in diarrhea or an osmotic diuresis. 15 Disorders of the Serum Sodium Concentration 187 Suggested Reading Adrogue HJ, Madias NE. Hypernatremia. N Engl J Med. 2000;342(20):1493–9. Ashraf N, Locksley R, Arieff AI. Thiazide-induced hyponatremia associated with death or neurologic damage

in outpatients. Am J Med. 1981;70(6):1163–8. Ayus JC, Caputo D, Bazerque F, Heguilen R, Gonzalez CD, Moritz ML. Treatment of hyponatremic encephalopathy with a 3% sodium chlo- ride protocol: a case series. Am J Kidney Dis. 2015;65(3):435–42. Chung HM, Kluge R, Schrier RW, Anderson RJ. Clinical assessment of extra- cellular fluid volume in hyponatremia. Am J Med. 1987;83(5):905–8. Hillier TA, Abbott RD, Barrett EJ. Hyponatremia: evaluating the correction factor for hyperglycemia. Am J Med. 1999;106(4):399–403. Hoorn EJ, Zietse R. Hyponatremia revisited: translating physiology to prac- tice. Nephron Physiol. 2008;108(3):p46–59. List AF, Hainsworth JD, Davis BW, Hande KR, Greco FA, Johnson DH. The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in small-cell lung cancer. J Clin Oncol. 1986;4(8):1191–8. Sahay M, Sahay R. Hyponatremia: a practical approach. Indian J Endocrinol Metab. 2014;18(6):760–71. Sanghvi SR, Kellerman PS, Nanovic L. Beer potomania: an unusual cause of hyponatremia at high risk of complications from rapid correction. Am J Kidney Dis. 2007;50(4):673–80. Sterns RH. Formulas for fixing serum sodium: curb your enthusiasm. Clin Kidney J. 2016;9(4):527–9. Sterns RH, Cappuccio JD, Silver SM, Cohen EP. Neurologic sequelae after treatment of severe hyponatremia: a multicenter perspective. J Am Soc Nephrol. 1994;4(8):1522–30. Sterns RH, Hix JK, Silver S. Treatment of hyponatremia. Curr Opin Nephrol Hypertens. 2010;19(5):493–8. Szatalowicz VL, Miller PD, Lacher JW, Gordon JA, Schrier RW. Comparative effect of diuretics on renal water excretion in hyponatraemic oedematous disorders. Clin Sci (Lond, England: 1979). 1982;62(2):235–8. Verbalis JG, Adler S, Schrier RW, Berl T, Zhao Q, Czerwiec FS. Efficacy and safety of oral tolvaptan therapy in patients with the syndrome of inappro- priate antidiuretic hormone secretion. Eur J Endocrinol. 2011;164(5): 725–32. Weisberg LS. Pseudohyponatremia: a reappraisal. Am J Med. 1989;86(3): 315–8. Inpatient Management 16 of Hyperkalemia Erika R. Drury and Bradley M. Denker Contents Obtain Whole Blood Potassium in the Setting of Hemolysis, Thrombocytosis, or Marked Leukocytosis 190 Evaluate Symptoms and EKG to Exclude Life-T hreatening Hyperkalemia 191 Order Calcium Gluconate (1–2 g IV) to Treat Severe Hyperkalemia 191 Order Insulin 10 Units Plus Glucose 40–60 g as IV Bolus or Albuterol Nebulizer 10–20 mg to Shift Potassium Intracellularly 192 Assess History, Physical Exam, and Other Laboratory Data to Determine the Source of Potassium Load and Defect in Renal Excretion 192 Order Intravenous Loop Diuretic (e.g., Furosemide 20–40 mg) in Patients with Normal or Mild Renal Impairment 195 E. R. Drury Division of Nephrology, Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA e-mail: [email protected] B. M. Denker (*) Beth Israel Deaconess Medical Center, Department of Medicine, Nephrology Division and Harvard Medical School, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 189 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_16 190 E. R. Drury and B. M. Denker Order a Low Potassium Diet 195 Discontinue Any Medications That Impair Renal Potassium Excretion 195 Order Oral Sodium Polystyrene Sulfonate (Kayexalate) 15–30 g One to Four Times per Day in Non-postoperative Patients 196 Obtain Nephrology Consultation for Hemodialysis in the Setting of ESRD, Advanced Renal Failure, or Patients with Rising Potassium Levels Not Responsive to Medical Therapy 196 Fludrocortisone May Be Used in Patients With Aldosterone Deficiency 197 Suggested Reading 197 Obtain Whole Blood Potassium in the Setting of Hemolysis, Thrombocytosis, or Marked Leukocytosis Pseudohyperkalemia refers to an elevation in potassium that occurs after the blood specimen has been drawn and does not represent true hyperkalemia. This should be suspected when there are no electrocardiographic changes such as peaked T waves a ssociated with elevated potassium levels (>6 mEq/L), when the laboratory measurements of potassium levels are widely varying, or when there is no apparent cause for the hyperkalemia. The most common cause of pseudohyperkalemia is hemolysis from the trauma of venipuncture, which leads to the release of potassium from hemolyzed cells. If the blood specimen has been hemolyzed, repeat the measurement. Patients with thrombocytosis (platelet count >500,000/mm3) may exhibit pseudohyperkalemia. A small amount of potassium moves out of cells when blood clots, but more potassium may be released in the presence of thrombocytosis. Ask for a measurement of the plasma (whole blood) potassium (from a heparinized blood sample) which will reveal the true in vivo potassium levels in these patients. Patients with marked leukocytosis (white cell count >100/mm3) may also exhibit hyperkalemia. Leukemic lymphocytes are fragile and may release potassium when exposed to heparin or shaken. To exclude these 16 Inpatient Management of Hyperkalemia 191 scenarios, whole blood potassium from a sample in a blood gas tube should be taken, or samples should be walked to the lab, respectively. If pseudohyperkalemia can be excluded, then further workup and management is indicated. Evaluate Symptoms and EKG to Exclude Life- Threatening Hyperkalemia The most dangerous effects of hyperkalemia are cardiac arrhyth- mias and ascending muscle weakness and paralysis. These usu- ally occur when the plasma potassium concentration is >7 mEq/L but can occur at lower concentrations if the hyperkalemia is acute or in the presence of hypocalcemia or acidemia. When plasma potassium levels are >6 mEq/L, order an electrocardiogram and place the patient on continuous telemetry monitoring. ECG changes associated with hyperkalemia begin with peaking of the T waves and shortening of the QT interval followed by widening of the QRS complex and the P wave and finally the appearance of the sine wave pattern followed by ventricular fibrillation or asys- tole. Rapid increases in serum potassium cause more pronounced cardiac toxicity (e.g., in acute renal failure). Ascending muscle weakness and flaccid paralysis usually occur only when the plasma potassium concentration is > 8 mEq/L but can occur at lower levels in patients with the genetic disorder hyperkalemic periodic paralysis. Order Calcium Gluconate (1–2 g IV) to Treat Severe Hyperkalemia Patients with a serum potassium concentration > 6.5 mEq/L and those with ECG changes or with muscle weakness require imme- diate treatment with measures aimed at reversing the effects of hyperkalemia followed by therapies to remove potassium from the body. Rapidly acting therapies include calcium, insulin, and β-agonists. Calcium does not lower serum potassium levels but lowers the myocyte membrane threshold potential and protects 192 E. R. Drury and B. M. Denker against the toxic effects of hyperkalemia. Give 1–2 g IV calcium gluconate (90–180 mg of elemental calcium) over 2–3 min. This acts within minutes but lasts only about 30–60 min, so repeated doses may be needed while potassium-l owering therapy is being administered. Order Insulin 10 Units Plus Glucose 40–60 g as IV Bolus or Albuterol Nebulizer 10–20 mg to Shift Potassium Intracellularly Insulin administration lowers the serum potassium concentration by driving it intracellularly. The usual regimen is 10 units of regu- lar insulin given with 25 g of glucose (i.e., one “amp” of D50). This will lower the potassium concentration by 1–2 mEq/L within 60 min and lasts up to 4 h. If needed, insulin and dextrose can be repeated every 2–4 h. Nebulized beta agonists (i.e., albuterol) also lead to redistribution of potassium intracellularly. Up to 10–20 mg of nebulized albuterol is needed to lower the serum potassium level, which is in contrast to the 2.5 mg albuterol dose that is used for bronchospasm. If albuterol is used, give at least five standard dose nebulizers. This acts within 30 min and lasts 2–4 h. While these rapidly acting therapies are given, measures aimed at removal of potassium from the body should be instituted. In patients with severely impaired renal function such as advanced chronic kidney disease or acute renal failure, dialysis is often needed. In patients with normal or only mildly impaired renal function, other methods of removing potassium may be employed which include loop diuretics and gastrointestinal cation exchangers. Assess History, Physical Exam, and Other Laboratory Data to Determine the Source of Potassium Load and Defect in Renal Excretion Once life-threatening hyperkalemia has been excluded or is being managed, a thoughtful approach to determining the etiology of the hyperkalemia will help guide the best treatment. Take a thor- 16 Inpatient Management of Hyperkalemia 193 ough history and review the patient’s laboratory values and medi- cations. In most cases, the etiology of the hyperkalemia is multifactorial, but an impairment in renal excretion is required for the development of hyperkalemia. First, assess for increased potassium release from cells. There are many factors that can contribute to hyperkalemia as a result of increased release from cells. In patients with metabolic acidosis, buffering of excess hydrogen ions leads to potassium shift out of the cell. Check an arterial or venous blood gas and measure the serum bicarbonate concentration. States of hyperglycemia and insulin deficiency lead to hyperkalemia, such as occurs in diabetic ketoacidosis (although often these patients are total body potas- sium depleted and will develop hypokalemia after treatment). Increased tissue catabolism as occurs with tumor lysis can lead to massive release of potassium into the extracellular space. Obtain laboratory tests that can suggest tumor lysis including uric acid, phosphorus, lactate dehydrogenase (LDH), and calcium. Evaluate for a history of fall or traumatic injury which leads to muscle cell necrosis and the development of rhabdomyolysis and elevated creatine phosphokinase (CPK) levels. Digitalis overdose can cause hyperkalemia as a result of inhibition of the Na-K-ATPase pump. For some of these conditions, measures aimed at correcting the abnormalities can help reduce the hyperkalemia. If a meta- bolic acidosis is present, treat the underlying cause (lactic acido- sis, diabetic ketoacidosis), and sodium bicarbonate may be used if the serum pH is <7.1. If hyperglycemia is present, correct this with appropriate insulin therapy. Second, assess for decreased urinary excretion of potassium. Reduced urinary excretion of potassium is the predominant driver for sustained hyperkalemia. Potassium excretion requires an adequate number of nephrons (GFR) and urine flow with dis- tal sodium delivery to promote urinary potassium excretion. Finally, aldosterone is required for potassium excretion. Estimation of the potassium concentration in the tubular fluid of the collecting duct, which reflects tubular potassium s ecretion, may be possible by calculating the trans-tubular potassium gra- dient (TTKG) ([urine potassium (mEq/L) × serum osm (mOsm/ kg)]/[serum potassium (mEq/L) × urine osm (mOsm/kg)]). 194 E. R. Drury and B. M. Denker Values of <7 may suggest inappropriate renal response to hyper- kalemia and aldosterone deficiency. However, many argue that the TTKG is not valid because the underlying assumption that osmoles are not reabsorbed in the medullary collecting duct is incorrect. Therefore, calculation of the TTKG should be used with caution and in combination with the entirety of a patient’s clinical picture. There are three major causes of reduced urinary potassium excretion: renal failure, effective arterial volume depletion, and hypoaldosteronism. To assess for acute or chronic renal failure, check for elevations in the serum urea nitrogen and creatinine. Hyperkalemia can occur in states of effective arterial volume depletion as potassium excretion requires deliv- ery of water and sodium to the distal tubule, which is impaired in these states. Look for physical examination findings of true volume depletion such as orthostatic vital sign changes, hypo- tension, tachycardia, and diminished skin turgor. Patients with hypervolemia secondary to heart failure or cirrhosis often exhibit effective arterial volume depletion, so exam findings of pulmonary edema and peripheral edema are helpful. In both of these states, urine sodium levels will be <20 mEq/L, unless a loop diuretic has been recently used. Finally, hypoaldosteron- ism is the result of either reduced aldosterone production or aldosterone resistance. Reduced aldosterone secretion can be caused by drugs such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), nonsteroidal anti-inflammatory drugs (NSAID(s)), calcineurin inhibitors, and heparin. Aldosterone antagonists such as spironolactone and eplerenone directly inhibit potassium excretion, while potassium-sparing diuretics such as amiloride and triamterene block the aldosterone-responsive epithelial sodium channel that is necessary for creating the lumen-negative potential necessary for potassium secretion. If these drugs are not present and a diagnosis of hypoaldosteronism is suspected, check morning plasma renin activity and aldosterone concentrations. Hyporeninemic hypoaldosteronism is characterized by low renin activity, whereas in primary adrenal insufficiency and in enzyme deficiencies, the plasma renin activity is elevated. Hyporeninemic hypoaldosteronism is also known as type IV 16 Inpatient Management of Hyperkalemia 195 renal tubular acidosis and can be seen in patients with diabetes and tubular disorders. Order Intravenous Loop Diuretic (e.g., Furosemide 20–40 mg) in Patients with Normal or Mild Renal Impairment Diuretics are used to increase potassium excretion in states of volume

expansion such as heart failure. Furosemide can be started at a dose of 40–80 mg IV twice a day, but higher doses may be needed in renal impairment. For patients who are not hypervolemic, loop diuretics can be given with an infusion of IV saline to maintain euvolemia and urine flow with distal sodium delivery. Oral loop diuretics can be effective at lowering potas- sium levels in chronic renal failure. Order a Low Potassium Diet In patients with normal renal function, increased intake of potas- sium is generally well tolerated and is not a cause of hyperkalemia unless potassium is ingested in large quantities (>160 mEq) and is given as an IV bolus or if excretion of potassium is impaired. Still, it is important to take a dietary history to assess for high p otassium intake that may be contributing to the persistence of hyperkale- mia. Dietary sources of high potassium include tomatoes, white potatoes, sweet potatoes, bananas, oranges/orange juice, raisins, and salt substitutes. Restrict potassium in the diet to no more than 2 g per day. Discontinue Any Medications That Impair Renal Potassium Excretion Regardless of the urgency of potassium-lowering therapy, any medications that can cause hyperkalemia should be stopped or at least held temporarily. Angiotensin-converting enzyme inhibitors, 196 E. R. Drury and B. M. Denker angiotensin II receptor blockers, and aldosterone receptor blockers should be stopped. Other medications that can cause hyperkalemia include potassium-sparing diuretics, heparin, NSAIDs, calcineurin inhibitors, sulfamethoxazole/trimethoprim (Bactrim), and beta receptor antagonists. Depending on the severity and etiology of hyperkalemia, consider holding these medications as well. Order Oral Sodium Polystyrene Sulfonate (Kayexalate) 15–30 g One to Four Times per Day in Non-postoperative Patients Gastrointestinal cation exchangers remove potassium via exchange with other cations. Sodium polystyrene sulfonate removes potassium via exchange with sodium. It can be given as a single 15–30 g dose and repeated up to four times per day. The onset of action is at least 2 h and the maximum effect may take 6 or more hours. There is a small risk of intestinal necrosis with sodium polystyrene sulfonate, particularly in patients with under- lying bowel disease and a bowel obstruction or who are postop- erative, and therefore the safety of sodium polystyrene sulfonate has been widely debated. Many advocate for its use only with life-threatening hyperkalemia when dialysis is not readily avail- able, while others use it routinely for control of hyperkalemia in CKD in the outpatient setting. With the development of newer cation exchangers including patiromer and zirconium cyclosili- cate, sodium polystyrene sulfonate use is decreasing. Obtain Nephrology Consultation for Hemodialysis in the Setting of ESRD, Advanced Renal Failure, or Patients with Rising Potassium Levels Not Responsive to Medical Therapy End-stage renal disease patients presenting with hyperkalemia usually need urgent hemodialysis. These patients often tolerate higher serum levels of potassium, but renal consultation should be 16 Inpatient Management of Hyperkalemia 197 ordered immediately to assist with the timing of dialysis. Gastrointestinal cation exchangers are often recommended if hemodialysis cannot be performed immediately. Patients with oli- guric or anuric acute renal failure will also need hemodialysis as loop diuretics are often not effective at promoting urinary potas- sium excretion. Temporizing measures described previously should be given while awaiting recommendations. Fludrocortisone May Be Used in Patients With Aldosterone Deficiency With demonstrated deficient aldosterone production, fludrocorti- sone can be used to correct the hyperkalemia. Start with an oral dose of 0.1 mg per day. Monitor for sodium retention, edema, and hypertension. Doses of up to 0.4 mg per day may be needed, par- ticularly in cases of hyporeninemic hypoaldosteronism. Suggested Reading Kovesdy CP. Management of hyperkalemia: an update for the internist. Am J Med. 2015;128(12):1281–7. Rose DB, Post DW. Hyperkalemia. In: Wonsciewicz M, McCullough K, Davis K, editors. Clinical physiology of acid-base and electrolyte disor- ders. 5th ed. New York: Mc-Graw Hill; 2001. Sterns RH, Grieff M, Bernstein PL. Treatment of hyperkalemia: something old, something new. Kidney Int. 2016;89(3):546–54. Weir MR, Rolfe M. Potassium homeostasis and renin-angiotensin-a ldosterone system inhibitors. Treatment of hyperkalemia: something old, something new. Clin J Am Soc Nephrol. 2010;5(3):531–48. Suspected Adrenocortical 17 Deficiency Anand Vaidya Contents Physiological Considerations 200 What Is a Normal Cortisol Level? 202 Primary and Secondary Adrenal Insufficiencies 203 Primary Adrenal Insufficiency 203 Secondary Adrenal Insufficiency 203 Clinical Presentation and Diagnosis 203 Primary Adrenal Insufficiency 203 Secondary Adrenal Insufficiency 205 Adrenal Insufficiency in Critically Ill Patients 206 Etiology 207 Treatment 208 Primary Adrenal Insufficiency 208 Secondary Adrenal Insufficiency 210 Stress Dosing 213 Suggested Reading 214 A. Vaidya (*) Harvard Medical School, Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 199 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_17 200 A. Vaidya Physiological Considerations The adrenal cortex synthesizes glucocorticoids and mineralocor- ticoids that physiologically regulate the acute response to stress, glycemic homeostasis, hemodynamic homeostasis, potassium and acid balance, immune function, organogenesis, parturition, and many other functions. Adult adrenal glands are approximately 4 g in weight and usu- ally 4 cm long and 2 cm wide and 1 cm thick lying on top of the superior pole of each kidney. On cross-sectional imaging (such as CT or MRI), they appear as thin and wispy structures that resem- ble a Mercedes-Benz symbol. The adrenal gland is divided into the cortex and the medulla: Cortex stems from mesenchymal tissue and synthesizes ste- roids. There are three histologic layers: zona glomerulosa (ZG) produces aldosterone, zona fasciculata (ZF) produces cortisol, and zona reticularis (ZR) produces DHEA and androstenedione. Medulla, which is the core of the adrenal, arises from neural crest cells and functions primarily to synthesize catecholamines. The regulation of cortisol and androgen synthesis is entirely dependent on ACTH. Aldosterone synthesis is also stimulated by ACTH; however, the synthesis of aldosterone is also potently stimulated by angiotensin II (thus activation of the renin- angiotensin system stimulates adrenal aldosterone) and by high extracellular potassium. Therefore, in contrast to cortisol syn- thesis, aldosterone synthesis is not dependent on ACTH. Adrenal androgens play a minor role in adult human physiology but are important for adrenarche, including the development of axillary and pubic hair. Cortisol is a glucocorticoid that binds to and acti- vates the glucocorticoid receptor (GR), but it is also a mineralo- corticoid that can potently activate the mineralocorticoid receptor (MR). Cortisol is the main glucocorticoid in human physiology and therefore is the dominant ligand for the GR. Activation of the GR raises blood glucose, increases blood pressure, suppresses immune activity/inflammation, increases 17 Suspected Adrenocortical Deficiency 201 appetite, and depresses mood. These physiologic actions explain the pathophysiologic manifestations of diseases with cortisol deficiency (adrenal insufficiency) and cortisol excess (Cushing syndrome). Aldosterone is a pure mineralocorticoid and only activates the MR, principally in the distal nephron but also in other tis- sues such as the colon, heart, and vasculature. Activation of the renal MR increases renal sodium reabsorption, which facilitates the retention of water and results in intravascular volume expan- sion. Activation of the renal MR also increases renal potassium and hydrogen ion excretion. Therefore, another key role of aldosterone is to ensure normal potassium homeostasis and acid-base status by regulating urinary potassium and proton excretion. Notably, cortisol is also a potent mineralocorticoid and can activate the MR. Although cortisol circulates in the blood in 100- to 1000-fold higher concentrations than aldoste- rone, MR over-a ctivation (such as in primary aldosteronism) resulting in sodium retention, volume expansion, high blood pressure, and hypokalemia is prevented by 11β-hydroxysteroid dehydrogenase type 2 (11βHSD2), which is co-expressed with the MR in the kidney, and functions to convert cortisol to the inactive cortisone. In this manner, 11βHSD2 inactivates the majority of cortisol before it can bind to and activate the renal MR. The classical control of the adrenal cortex involves commu- nications between the hypothalamus, pituitary, and adrenal. The hypothalamus secretes corticotropin-releasing hormone (CRH), which stimulates the secretion of ACTH from the corti- cotrophs of the anterior pituitary. Cortisol binds to peripheral GR but also the centrally expressed GR in the hypothalamus and pituitary. Therefore, cortisol negatively regulates CRH and ACTH. ACTH also stimulates aldosterone secretion from the adrenal cortex; however, the dominant secretagogues of aldosterone are angiotensin II and potassium. Therefore, the predominant axis that regulates aldosterone is the renin-angiotensin system. 202 A. Vaidya Aldosterone acts on the MR expressed in the distal nephron to increase sodium retention and thereby expand the intravascular volume to counter the initial insult of renal hypoperfusion. This closes the renin-angiotensin-aldosterone feedback loop. High extracellular potassium also stimulates adrenal aldosterone pro- duction, and in turn activation of the MR by aldosterone increases urinary potassium excretion in the distal nephron to close this feedback loop. One of the major roles of cortisol is to help the body defend against stress. Stress can be defined as any physical or emotional stress or any condition that is perceived to be a threat or fear. In this regard, the stress response is designed to permit physiologic changes that defend against stress. The perception of stress stim- ulates CRH via central nervous system inputs. Other stressors such as hypoglycemia, hypotension, pain, and fever all stimulate the hypothalamic release of CRH to activate the axis and result in increases in cortisol proportional to the degree of stress to counter these stimuli. Vasopressin (also called antidiuretic hor- mone [ADH]), can stimulate pituitary ACTH secretion, as can cytokines that are increased during infections or inflammatory conditions. Another major regulator of the hypothalamic-pituitary-adrenal axis is light, thus creating a circadian rhythm. From a diagnostic standpoint, this diurnal secretion of cortisol is one of the main reasons why the diagnosis of adrenal insufficiency can be challenging. What Is a Normal Cortisol Level? A robust and elevated peak morning cortisol suggests a normal functioning hypothalamic-pituitary-adrenal axis; however, deter- mining when that peak arises and should be measured is often the challenge, particularly in the inpatient setting. Specific thresholds will be discussed below in Diagnosis. 17 Suspected Adrenocortical Deficiency 203 Primary and Secondary Adrenal Insufficiencies The term adrenal insufficiency refers to an absolute or relative deficiency of adrenal cortical hormones (cortisol and/or aldoste- rone) with respect to the current needs of the body. Primary Adrenal Insufficiency Primary adrenal insufficiency (Addison’s disease) refers to the destruction or inhibition of the entire adrenal cortex, resulting in an inability to synthesize and secrete cortisol and aldosterone (as well as androgens). The main signs and symptoms of this condi- tion are due to the lack of cortisol and aldosterone. In the absence of negative feedback from cortisol, the hypothalamus and pitu- itary augment secretion of CRH, POMC, and as a result ACTH and melanocyte-stimulating hormone (MSH). Secondary Adrenal Insufficiency Secondary adrenal insufficiency refers to the destruction or inhi- bition of the corticotroph cells in the anterior pituitary. Secretion of ACTH will be relatively insufficient or completely deficient. In the absence of ACTH, the adrenal cortex is not stimulated, and adrenal steroidogenesis is inhibited. This is particularly evident for cortisol and androgens. Since aldosterone synthesis and secre- tion can continue to be stimulated by angiotensin II and potassium, secondary adrenal insufficiency is mainly a syndrome of cortisol insufficiency; aldosterone regulation continues unabated. Clinical Presentation and Diagnosis Primary Adrenal Insufficiency Primary adrenal insufficiency typically presents with marked or critical illness. General malaise and feelings of being unwell, 204 A. Vaidya gastrointestinal symptoms (nausea, vomiting, diarrhea, abdomi- nal pain), and, in severe circumstances, hypoglycemia and hypo- tension are hallmarks of the illness and may be ongoing and progressively worsening for months to years before the diagnosis is made. Aldosterone insufficiency makes these patients espe- cially vulnerable. In the absence of aldosterone, renal sodium reabsorption is not maximal, resulting in renal sodium wasting and progressive intravascular volume depletion. This can mani- fest as symptoms of lightheadedness and orthostasis (dizziness and lightheadedness upon standing from a seated position) and frankly low blood pressure (hypotension and circulatory col- lapse) and salt cravings. Diffuse hyperpigmentation of the skin, particularly marked surrounding scar tissue and on mucosal membranes (such as the buccal mucosa and vaginal mucosa), is attributed to the high circulating levels of MSH- and ACTH- stimulating melanocytes. Primary adrenal insufficiency can be diagnosed by simultaneously evaluating a cortisol and ACTH – a relatively low or frankly low cortisol levels and concomitantly marked elevations in ACTH.

Morning cortisol levels less than 5 mcg/dL confirm the diagnosis of adrenal insufficiency, along with a concomitant ACTH level that is at least twofold greater than the upper range of normal (but usually several hundred or even greater than a thousand, pg/mL). Further, the deficiency of aldosterone may result in hyponatremia, hyperkalemia, and a markedly elevated renin. Measuring a renin and aldosterone is recommended to assess the degree of mineralocorticoid defi- ciency in primary adrenal insufficiency. Patients with primary adrenal insufficiency will exhibit low serum aldosterone levels, despite low blood pressure and high potassium balance, and markedly elevated plasma renin activity. Performing a cosyntro- pin stimulation (measuring a morning cortisol level, then inject- ing 250 mcg of synthetic ACTH-like p eptide, followed by repeat cortisol measure at 30 and 60 min) can further confirm the diag- nosis. Because the pathophysiology involves destruction of the adrenal cortex, patients with primary adrenal insufficiency dis- ease exhibit markedly diminished cortisol stimulation when cosyntropin is injected. A failure to achieve a peak stimulated 17 Suspected Adrenocortical Deficiency 205 cortisol following cosyntropin of > 18 mcg/dL indicates adrenal insufficiency. Secondary Adrenal Insufficiency Secondary adrenal insufficiency can present with a wide variety of signs and symptoms. This is in part because aldosterone regu- lation is intact and therefore hemodynamic homeostasis may be intact. The clinical syndrome experienced by these patients reflects the degree of stress (physical or emotional) they are under and the disparity between how much cortisol they are able to produce and how much cortisol is needed at any given time. For example, a healthy patient with secondary adrenal insuffi- ciency and a relatively low cortisol may experience no symptoms or perhaps only mild weakness and fatigue. However, as the degree of stress the patient experiences increases (e.g., the devel- opment of a febrile illness like influenza or sustaining severe trauma and pain), the gap between the patient’s need for cortisol and ability to produce cortisol increases, and the clinical mani- festations become more severe. Ultimately, in the setting of severe stress or critical illness, these patients may develop a clin- ical syndrome that includes intravascular volume depletion and hypotension, resembling that of primary adrenal insufficiency. Secondary adrenal insufficiency is diagnosed by confirming an inappropriately low morning cortisol level (ideally < 5 mcg/dL) in combination with an inappropriately low ACTH. A suboptimal cosyntropin stimulation test (peak cortisol < 18 mcg/dL) can pro- vide further confirmation of the diagnosis of adrenal insuffi- ciency and insight into the chronicity of the problem. A robust and normal peak cortisol following cosyntropin indicates that the lack of ACTH is acute or subacute (hours, days, or a few weeks). A suboptimal response to cosyntropin suggests that the defi- ciency of ACTH is chronic (weeks to months); since ACTH is trophic to the adrenal cortex, prolonged deficiency results in atro- phy of the zona fasciculata and progressively diminished responses to cosyntropin. 206 A. Vaidya Adrenal Insufficiency in Critically Ill Patients Adrenal insufficiency in critically ill patients is often more chal- lenging to diagnose than in noncritically ill patients because critically ill patients (1) may not have normal circadian rhythms, (2) may have decreased metabolism and clearance of cortisol, and (3) may have reduced circulating binding globulins, thus lowering total cortisol but not necessarily free and bioavailable cortisol. An important response to critical illness is a rise in ACTH. Whereas some hypothalamic and pituitary hormones may exhibit a physiological suppression during critical illness, critical illness should result in a robust rise in ACTH and increased adrenal cortical stimulation. Therefore, theoretically, patients with critical illness should have appropriately elevated cortisol levels, in part because ACTH is elevated and also because cortisol metabolism is decreased. In patients who have markedly reduced concentrations of albumin, cortisol-binding globulin may also be decreased and, therefore, total cortisol levels may decline and correlation with presumed free cortisol levels may become more challenging. Measuring cortisol-binding globulin or free cortisol levels may be useful. However, because these assays are not routinely performed and may take days to weeks to return, they are not commonly used in the practical diagnosis and management of adrenal insufficiency. Rather, it is generally suggested that a critically ill patient with a relatively normal albumin of >2.5 g/dL and cortisol of <15 mcg/dL is indicative of adrenal insufficiency that may require glucocorticoid replace- ment therapy. In contrast, in a critically ill patient with more marked hypoalbuminemia (albumin <2.5 g/dL), a random corti- sol of <10 mcg/dL may indicate adrenal insufficiency. When a critically ill patient is hypotensive due to septic shock and resis- tant to vasopressor therapy, empiric treatment with glucocorti- coids without diagnostic testing may be considered as an emergency measure. 17 Suspected Adrenocortical Deficiency 207 Etiology Primary adrenal insufficiency, particularly in developed parts of the world, is most commonly autoimmune adrenalitis. It may occur in isolation, or as a part of a larger autoimmune polyglandu- lar syndrome. Other causes of primary adrenal insufficiency include bilateral infiltrative infections (such as tuberculosis and fungi), bilateral adrenal hemorrhage, infiltrative malignancies, bilateral adrenalectomy, congenital adrenal hyperplasia, adreno- leukodystrophy, and rarer genetic syndromes. Establishing the cause of primary adrenal insufficiency is important. A positive 21-hydroxylase antibody can provide reassurance for autoim- mune adrenalitis, whereas when the titer is negative, evaluation for other causes using serologic testing and/or imaging should be considered. The evaluation of other non-autoimmune causes should be considered on a case-b y- case basis depending on the practice location and pretest probability. Imaging of the adrenals can help identify hemorrhage, infiltrative infections, and malig- nancy. Suspicion for adrenoleukodystrophy can be confirmed with imaging and assessment of very long chain fatty acids. Evaluation for congenital adrenal hyper- or hypoplasia is best per- formed by measuring intermediate adrenal steroids. Certain med- ications can inhibit adrenal steroidogenesis transiently and result in a functional primary adrenal insufficiency: antifungal medica- tions, etomidate, and, rarely, heparin. Secondary adrenal insufficiency can be the result of any con- dition that interrupts or damages the hypothalamus and pitu- itary. These include principally benign pituitary or parasellar tumors and rarely primary or metastatic brain malignancy, infec- tion, hemorrhage, infiltrative diseases, and radiation that involved the hypothalamus or pituitary. The most common cause of sec- ondary adrenal insufficiency, however, is iatrogenic secondary adrenal insufficiency due to the frequent use of exogenous glucocorticoids (most often oral or intravenous but in some instances inhaled and topical as well). Opioid medications are also frequently used and in some instances can cause a transient suppression of ACTH. 208 A. Vaidya Treatment Primary Adrenal Insufficiency The treatment of primary adrenal insufficiency is focused on replacing the missing vital adrenal steroids: cortisol and aldoste- rone. Patients are typically treated with a glucocorticoid (such as hydrocortisone or prednisone) and in addition with a mineralocor- ticoid (such as fludrocortisone) to replace their deficiencies (Table 17.1). The choice of glucocorticoid can vary, but the most preferred option in adults is hydrocortisone (15–25 mg daily) in two divided doses, often the larger dose first thing in the morning and the smaller dose in the early afternoon. Hydrocortisone peaks within 1–3 h and nadirs within 5–7 h, thus providing an opportu- nity to give a physiologic regimen of glucocorticoid. A common glucocorticoid regimen is hydrocortisone 15–20 mg upon awak- ening and 10 mg between 12 and 2 pm. Some patients require a third smaller dose in the early evening. Prednisolone (3–5 mg daily) and prednisone (5–7.5 mg daily) are alternatives that can be given once or twice daily but have longer half-lives and therefore less physiologic profiles. Dexamethasone is not ideal since it has a very long half-life and the greatest risk for inducing Cushingoid effects. Efficacy of glucocorticoid dosing is determined by patient well-being, energy level, normal blood pressure, and electrolytes. Toxicity or signs of excessive glucocorticoid dosing are deter- mined by evidence of weight gain and other Cushingoid signs. All patients with mineralocorticoid deficiency should be treated with fludrocortisone, typically 0.05–0.15 mg once daily. The efficacy of fludrocortisone dosing can be monitored by observing normal blood pressure (without postural hypotension), normal sodium and potassium balance, and the lowering of the previously ele- vated renin levels. Patients should be instructed on how to remain well hydrated and consume sufficient dietary sodium, especially on warmer days when insensible loses of water and salt can be greater. 17 Suspected Adrenocortical Deficiency 209 Table 17.1 Treatment of primary adrenal insufficiency Minor-moderate Moderate-severe Maintenance illness illness or surgery Formulation/ Glucocorticoid: Double (fever If emesis and dose/action hydrocortisone >38 °C) or triple inability to take 15–25 mg in two (fever >39 °C) oral medications divided doses; glucocorticoid or fluids: alternatively dose for intramuscular or prednisolone 3–5 mg 2–3 days, intravenous daily or prednisone increase hydrocortisone 5–7.5 mg daily hydration with 50–100 mg and Mineralocorticoid: water and intravenous fluids fludrocortisone electrolyte-rich If major surgery 0.05–0.15 mg in a fluids with general single dose anesthesia, intensive care hospitalization, or delivery: 50–100 mg of intravenous hydrocortisone every 6–8 h and intravenous fluids If adrenal crisis: aggressive hydration with isotonic fluids, hydrocortisone 100 mg intravenous every 4–6 h Typical Hydrocortisone Double Intravenous example 15–20 mg in the hydrocortisone hydrocortisone morning and dose for 50–100 mg 5–10 mg in the early 2–3 days until Intramuscular afternoon and mild febrile hydrocortisone fludrocortisone illness abates 100 mg 0.10 mg in the morning (continued) 210 A. Vaidya Table 17.1 (continued) Minor-moderate Moderate-severe Maintenance illness illness or surgery Comment The dose of If symptoms do In addition to glucocorticoid and not abate or higher mineralocorticoid worsen, glucocorticoid can vary depending in-person dosing, hydration on the size of the evaluation with isotonic patient, daily activity should be fluids is a critical and workload conducted management (physical or other), element. For and other symptoms. patients unable to During exercise, maintain oral additional or higher hydration, doses may be intravenous required. A general hydration with rule of thumb to isotonic fluids minimize should be initiated supraphysiologic glucocorticoid effects is to establish the lowest dose of glucocorticoid that enables a good quality of life Secondary Adrenal Insufficiency The treatment of secondary adrenal insufficiency is focused on replacing glucocorticoids. Patients are typically treated with hydrocortisone or prednisone (Table 17.2). If the cause of second- ary adrenal insufficiency was iatrogenic glucocorticoid adminis- tration, then the goal of therapy should be to gradually taper the glucocorticoid down in hopes that the endogenous hypothalamic- pituitary- adrenal axis will revive and resume normal function. The precise tapering schedule can vary and should be created on a case-by-case basis and customized for the specific patient. The longer the exposure to supraphysiologic glucocorticoids, the more profound the inhibition of endogenous ACTH production and the longer the time to recovery. Symptoms of fatigue, orthostasis, and/or depression may be signs that they are experiencing relative 17 Suspected Adrenocortical Deficiency 211 Table 17.2 Treatment of secondary adrenal insufficiencies Minor- moderate Moderate- severe illness or Maintenance illness surgery Formulation/ Glucocorticoid: Double (fever If emesis and inability to take dose/action hydrocortisone 10–25 mg in two divided doses; >38 °C) or triple oral medications or fluids: alternatively prednisolone 1–5 mg daily or prednisone (fever >39 °C) intramuscular or intravenous 3–7.5 mg daily glucocorticoid dose hydrocortisone 50–100 mg and Mineralocorticoid: none for 2–3 days, intravenous fluids increase hydration If major surgery with general with water and anesthesia, intensive care electrolyte-rich fluids hospitalization, or delivery: 50–100 mg of intravenous hydrocortisone every 6–8 h and intravenous fluids If adrenal crisis: aggressive hydration with isotonic fluids, hydrocortisone 100 mg intravenous every 4–6 h Typical example Hydrocortisone 10–20 mg in the morning and Double Intravenous hydrocortisone 5–10 mg in the early afternoon or prednisone hydrocortisone or 50–100 mg 3–7.5 mg in the morning prednisone dose for Intramuscular hydrocortisone 2–3 days until mild 100 mg febrile illness abates (continued) 212 A. Vaidya Table 17.2 (continued) Minor- moderate Moderate- severe illness or Maintenance illness surgery Comment The dose of glucocorticoid can vary depending on the If symptoms do not In addition to higher size of the patient, daily activity and workload abate or worsen, glucocorticoid dosing, hydration (physical or other), and other symptoms. During in-person evaluation with isotonic fluids is a critical exercise, additional or higher doses may be required. should be conducted management element. For A general rule of thumb to minimize supraphysiologic patients unable to maintain oral glucocorticoid effects is to establish the lowest dose hydration, intravenous hydration of glucocorticoid that

enables a good quality of life. with isotonic fluids should be If the cause of secondary adrenal insufficiency was initiated iatrogenic glucocorticoid administration, then the goal of therapy should be to gradually taper the glucocorticoid doses to permit normalization of the hypothalamic- pituitary- adrenal axis. The precise tapering schedule can vary and should be created on a case-by-case basis and customized for the specific patient. The longer the exposure to supraphysiologic glucocorticoids, the more profound the inhibition of endogenous ACTH production and the longer the time to recovery 17 Suspected Adrenocortical Deficiency 213 adrenal insufficiency and should prompt consideration to slow the pace of the taper. Measuring a morning cortisol and ACTH, 24 h after the last dose of glucocorticoid, can provide insight into the status of the hypothalamic-pituitary-adrenal axis. Low levels of each suggest a profound suppression of the axis. A rise in ACTH with a low cortisol suggests an awakening of the pituitary cortico- trophs and stimulation of the zona fasciculata by supraphysiologic ACTH, following which a gradual rise in cortisol should follow- ing the subsequent weeks to months. A morning cortisol greater than 10 mcg/dL, but ideally >15–18 mcg/dL, indicates restoration of normal endogenous HPA axis function and a concomitant com- pletion of the glucocorticoid taper. In addition, serial cosyntropin stimulation tests can be performed during the taper to evaluate not only basal ACTH and cortisol levels but also the magnitude of the stimulated value, to either assess normalization of adrenal func- tion or provide data to estimate the progress and duration of the glucocorticoid taper. Most patients with secondary adrenal insuf- ficiency do not need mineralocorticoid replacement. Stress Dosing Stress dosing of glucocorticoids is important counseling that should be provided to all patients with adrenal insufficiency. During critical illness, febrile illness, trauma, and/or other physi- cal stressors, the glucocorticoid needs of the body may increase. Patients reliant on exogenous glucocorticoids must therefore anticipate this by increasing their oral glucocorticoid dosing. Patients should typically be advised to double or triple their glu- cocorticoid doses during these situations, for a duration of a few days. If the illness and increased glucocorticoid dosing extends beyond 2–3 days, patients should seek counsel from their physi- cians to determine the necessity of glucocorticoid increases and search for potential causes of the illness. Gastrointestinal illnesses are notoriously the most concerning. Viral gastroenteritis induc- ing vomiting or diarrhea can result in volume depletion and lack of absorption (or intake) of steroids. Patients with adrenal insuf- ficiency can quickly spiral into a hemodynamic crisis in these 214 A. Vaidya situations and should be instructed to either go to an emergency room for intravenous hydration and steroid injections or be capa- ble of self-injecting intramuscular hydrocortisone or dexametha- sone. Patients with primary adrenal insufficiency are more susceptible to adrenal crisis with gastrointestinal illness given their mineralocorticoid deficiency. Patients should all be advised to wear a medic-alert bracelet or necklace that indicates that they have adrenal insufficiency for emergency providers. It is generally advisable to prescribe for them intramuscular hydrocortisone (100 mg) or dexamethasone in case they are not in proximity of an emergency room during an adrenal crisis. Suggested Reading Boonen E, Vervenne H, Meersseman P, Andrew R, Mortier L, Declercq PE, et al. Reduced cortisol metabolism during critical illness. N Engl J Med. 2013;368(16):1477–88. Bornstein SR, Allolio B, Arlt W, Barthel A, Don-Wauchope A, Hammer GD, et al. Diagnosis and treatment of primary adrenal insufficiency: an endo- crine society clinical practice guideline. J Clin Endocrinol Metab. 2016;101(2):364–89. Gomez-Sanchez CE. Adrenal dysfunction in critically ill patients. N Engl J Med. 2013;368(16):1547–9. Guran T, Buonocore F, Saka N, Ozbek MN, Aycan Z, Bereket A, et al. Rare causes of primary adrenal insufficiency: genetic and clinical characteriza- tion of a large nationwide cohort. J Clin Endocrinol Metab. 2016;101(1):284–92. Hamrahian AH, Fleseriu M, AACE Adrenal Scientific Committee. Evaluation and management of adrenal insufficiency in critically ill patients: disease state review. Endocr Pract. 2017;23(6):716–25. Cushing’s Syndrome 18 Brandon P. Galm and Nicholas A. Tritos Contents Consider Testing for Cushing’s Syndrome if the Patient Has a Cluster of Suggestive Signs and Symptoms, Unusual Symptoms or Features for Age (e.g., Hypertension or Osteoporosis in a Younger Patient), a Pituitary Gland Mass, or an Adrenal Adenoma 217 Use of Exogenous Glucocorticoids Is the Most Common Cause of Cushing’s Syndrome in the General Population and Should Always Be Considered First in the Evaluation of Patients with Suspected Hypercortisolism 218 Endogenous Cushing’s Syndrome Can Be Caused by Lesions of the Pituitary Gland (“Cushing’s Disease”), Adrenal Glands, or Other Organs (Ectopic ACTH-Secreting Tumors) 219 Diagnostic Testing Should Be Optimally Deferred to the Outpatient Setting Unless the Patient Has Acute Manifestations or Severe Comorbidities Potentially Related to Hypercortisolism 220 B. P. Galm (*) Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA N. A. Tritos Harvard Medical School, Massachusetts General Hospital, Neuroendocrine Unit and Neuroendocrine & Pituitary Tumor Clinical Center, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 215 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_18 216 B. P. Galm and N. A. Tritos Confirm Pathologic, Autonomous Hypercortisolism as the First Step 220 Measure Plasma ACTH to Direct Further Investigations 221 Order a Pituitary-Directed MRI in ACTH- Dependent Cushing’s Syndrome 222 Order Adrenal Imaging in ACTH-Independent Cushing’s Syndrome 222 Assess and Manage Hypercortisolism-Related Consequences and Comorbidities 222 Refer for Tumor-Directed Surgery as First-Line Therapy for Cushing’s Syndrome 223 Consider Pharmacotherapy Prior to Surgery, if Surgery Is Contraindicated or Tumor Location Is Unknown, if the Patient Is Medically Unstable, or for Persistent or Recurrent Cushing’s Syndrome After Surgery 223 Consider Pituitary Radiotherapy in Persistent or Recurrent Cushing’s Disease or if Surgery Is Contraindicated 225 Consider Bilateral Adrenalectomy in Patients Who Have Refractory Cushing’s Syndrome 225 Minimize Glucocorticoid Exposure in Patients with Iatrogenic Cushing’s Syndrome 226 The Diagnosis and Management of Cushing’s Syndrome in Pregnancy Are Challenging but Tumor-Directed Surgery Remains First-Line Therapy and Can Be Life-Saving 226 Suggested Reading 227 18 Cushing’s Syndrome 217 Consider Testing for Cushing’s Syndrome if the Patient Has a Cluster of Suggestive Signs and Symptoms, Unusual Symptoms or Features for Age (e.g., Hypertension or Osteoporosis in a Younger Patient), a Pituitary Gland Mass, or an Adrenal Adenoma Consider testing for Cushing’s syndrome (CS) in the setting of a cluster of suggestive signs or symptoms (Table 18.1), although many are nonspecific when present in isolation, and in the setting of unusual symptoms or features for the patient’s age, such as unexplained hypertension or osteoporosis in a younger patient. The most discriminative (specific but not sensitive) features are reddish/purple striae > 1 cm wide, proximal Table 18.1 Features of Cushing’s syndrome Metabolic Cardiovascular Catabolic Central adiposity Hypertension Proximal Hyperglycemia/diabetes Myocardial infarction myopathy Hypertension Cardiomyopathy Bone loss Hypertriglyceridemia Stroke Striae Facial plethora Venous Ecchymoses Fat redistribution (dorsal fat thromboembolism Skin thinning pad, supraclavicular fullness, Weight loss facial fullness) Hypogonadal Mineralocorticoid Hyperandrogenic (women) Reduced fertility Hypokalemia Acne Low libido Metabolic alkalosis Hirsutism Irregular menses Hypertension Oligomenorrhea Edema Neuropsychiatric Others Pediatric Depression, anxiety Nephrolithiasis Decreased growth Emotional lability Infections velocity Mania Exophthalmos Altered timing of Changes in cognition Avascular necrosis puberty Lethargy Skin Insomnia hyperpigmentation Psychosis (ACTH-dependent) 218 B. P. Galm and N. A. Tritos myopathy, facial plethora, spontaneous ecchymoses, and dis- proportionate, central adiposity. Some patients, especially those with biochemically severe ectopic CS, may present in a cata- bolic state, with weight loss, muscle wasting, edema, and severe hypokalemia. In addition, consider testing for CS if the patient has an incidental pituitary gland lesion suggestive of an ade- noma. Most guidelines recommend that patients with an inci- dental adrenal lesion consistent with an adenoma should undergo testing for CS, usually with the low- dose 1-mg dexa- methasone suppression test (DST). Use of Exogenous Glucocorticoids Is the Most Common Cause of Cushing’s Syndrome in the General Population and Should Always Be Considered First in the Evaluation of Patients with Suspected Hypercortisolism The use of exogenous glucocorticoids is the most common cause of CS. This includes any route of administration, such as topical, inhaled, intra-articular, and rectal. Make sure to ask about joint injections (including the spine) over the last few months. Make sure to ask about strong cytochrome P450 (CYP450) inhibitors, especially ritonavir or cobicistat (antiretroviral therapy), as these increase the risk of CS with exogenous steroid use. Also ask about naturopathic or herbal supplements. Megestrol acetate (Megace®), an appetite stimulant, has glucocorticoid activity and can cause CS. Patients on exogenous steroids may appear Cushingoid with biochemical evidence of hypoadrenalism as a result of suppression of the pituitary-adrenal axis, including a low or undetectable serum cortisol level (if the exogenous gluco- corticoid has limited cross-reactivity with cortisol in the assay) and low plasma ACTH. Exogenous glucocorticoids may be detectable in urine specimens assayed by liquid chromatography tandem mass spectrometry, though this test is rarely needed in clinical practice. 18 Cushing’s Syndrome 219 Endogenous Cushing’s Syndrome Can Be Caused by Lesions of the Pituitary Gland (“Cushing’s Disease”), Adrenal Glands, or Other Organs (Ectopic ACTH-Secreting Tumors) Causes of endogenous CS are shown in Table 18.2. Table 18.2 Causes of endogenous Cushing’s syndrome ACTH- Pituitary Pituitary Females 3–5 times more, dependent (70%) adenoma peak 20–30s, 95% are (Cushing’s microadenomas disease; CD) Ectopic Small cell lung Peak 40–50s, especially ACTHa cancer smokers (10%) Carcinoids Peak 20–30s (bronchial, thymic) Othersb Rare, may have other paraneoplastic syndromes ACTH- Adrenal Adrenal adenoma Females 4–8 times more, independent (20%) (60%) peak 30–40s Adrenal Females 1–3 times more, carcinoma (40%) peak 40–50s, often large mass, may co-secrete androgens Bilateral nodular May be familial or adrenal associated with Carney hyperplasiac complex (<1%) aMay rarely be caused by ectopic CRH secretion (<1% of ACTH-dependent CS) bIncludes pancreatic neuroendocrine tumors, pheochromocytoma, medullary thyroid carcinoma, and others cIncludes bilateral macronodular adrenal hyperplasia and primary pigmented nodular adrenocortical disease 220 B. P. Galm and N. A. Tritos Diagnostic Testing Should Be Optimally Deferred to the Outpatient Setting Unless the Patient Has Acute Manifestations or Severe Comorbidities Potentially Related to Hypercortisolism Defer testing for CS to the outpatient setting, if possible (e.g., incidental adrenal or pituitary adenoma), as many tests may be difficult to interpret in the hospitalized patient and may not have been adequately validated in this population. Physiologic hyper- cortisolism (pseudo-Cushing’s syndrome) can be seen in severe obesity and in acute stress and illness, including depression, poorly controlled diabetes mellitus, and malnutrition, and 50–80% will have abnormal testing for CS. However, it is important to remember that patients with acute manifestations or severe comorbidities (such as sepsis, psychosis, or severe, unexplained hypokalemia with cachexia) that are suspected of being hypercor- tisolemic require urgent evaluation and management in the inpa- tient setting. Confirm Pathologic, Autonomous Hypercortisolism as the First Step Order the 24-h urinary free cortisol (UFC) (at least two collec- tions), late-night salivary cortisol (LNSC) (at least two samples), and/or the low-dose 1-mg DST. Urine creatinine and volume should be measured with UFC tests to ensure adequate collection and exclude high urinary volumes as an explanation for falsely elevated UFC. Consider measuring a plasma dexamethasone level during the DST to ensure adequate exposure during the test. The 2-day DST is usually deferred to the outpatient setting. At least two different tests should be positive before pathologic hypercor- tisolism is confirmed. Significant fluctuations of cortisol secretion can be seen, especially in the setting of cyclic CS. LNSC is rarely done in hospital due to the delayed turnaround time. Test charac- teristics are shown in Table 18.3. 18 Cushing’s Syndrome 221 Table 18.3 Initial tests used to evaluate for pathologic hypercortisolism (Cushing’s syndrome) False Test Cutoff Sensitivity Specificity False positives negatives 1 mg >1.8 μg/ 97–100% 80–90% Estrogens (OCP), CYP DST dL CYP inducersa, inhibitorsb rapid metabolizers UFC >ULNc 80–95% 90–95% Fluid intake >5 L/ Reduced day, some drugsd GFR LNSC >ULNc 90–95% 95–100% Tobacco or licorice use, altered sleep- wakefulness cycle Abbreviations: CYP cytochrome P450, DST dexamethasone suppression test, GFR glomerular filtration rate, LNSC late-night salivary cortisol, OCP oral contraceptive pill, UFC 24-h urinary free cortisol, ULN upper limit of normal aStrong CYP450 inducers include phenytoin, carbamazepine, rifampin, phe- nobarbital, ethosuximide, and pioglitazone bStrong CYP450 inhibitors include azole antifungals, ritonavir, fluoxetine, diltiazem, and cimetidine cUse the reference range provided by the laboratory, as assay types and cut- offs vary. Specificity for CS rises with greater UFC or LNSC elevations;

how- ever, the effects of acute illness on cortisol levels should also be considered when interpreting test results dCarbamazepine, fenofibrate (in some assays), licorice, and carbenoxolone Measure Plasma ACTH to Direct Further Investigations Once CS is confirmed, measure plasma ACTH to determine whether CS is ACTH-dependent or ACTH-independent. ACTH is optimally assayed in morning specimens. Ensure that ACTH is collected properly, as it is degraded quickly and needs to be placed on ice immediately after collection. CS is ACTH- dependent if ACTH is inappropriately normal or high (>20 pg/ mL), while it is ACTH-independent if ACTH is suppressed (<5 pg/mL) in a patient with active hypercortisolism. Intermediate levels (5–20 pg/mL) may represent either possibility but are more often ACTH- dependent. 222 B. P. Galm and N. A. Tritos Order a Pituitary-Directed MRI in ACTH- Dependent Cushing’s Syndrome Order a pituitary-directed MRI to investigate for a pituitary ade- noma, although this may miss 40–50% of small adenomas caus- ing CS. Recall that pituitary incidentalomas occur in ~10% of the general population. Unless there is an adenoma >6–10 mm, pro- ceed with inferior petrosal sinus sampling (IPSS) to distinguish pituitary from ectopic CS. The high-dose DST is also sometimes used but has low specificity (~67%), and results should generally be confirmed on IPSS. For ectopic CS, order CT of the chest, abdomen, and pelvis. If this does not identify a source, functional nuclear imaging (octreotide scan, FDG PET, F-DOPA PET, or gallium DOTATATE PET) may be required. Order Adrenal Imaging in ACTH-Independent Cushing’s Syndrome Order adrenal imaging (CT or MRI) to investigate for an adrenal mass. Recognize that adrenal incidentalomas occur in ~10% of the population but are more likely to be the source of CS when hypercortisolism is present and ACTH is suppressed. Patients with ACTH-independent CS and bilateral adrenal adenomatous lesions may require adrenal vein sampling to determine which lesion is the culprit. Also order adrenal androgens to assess for co-secretion, which is common in adrenal carcinomas; in con- trast, serum DHEA-S is typically below normal in adrenal CS due to adrenal adenomas. Assess and Manage Hypercortisolism-Related Consequences and Comorbidities Assess for the presence of hyperglycemia, hypertension, dyslipid- emia, and osteoporosis, and manage these as per usual. Assess for psychiatric disorders and consider referral to psychiatry if 18 Cushing’s Syndrome 223 appropriate. Offer appropriate vaccinations, especially for pneumococcus, influenza, and (preferably not during active hypercortisolism) herpes zoster. Hypokalemia from overstimulation of the mineralocorticoid receptor by excess cortisol (especially in ectopic CS) should be monitored and treated with potassium supplements and spironolactone or eplerenone. Consider prophylaxis for venous thromboembolism, especially perioperatively and in those at high risk. Consider prophylaxis for opportunistic infections, especially Pneumocystis, in severe CS (UFC > 5 × ULN). Refer for Tumor-Directed Surgery as First-Line Therapy for Cushing’s Syndrome When localization has been successful, surgery (transsphenoidal pituitary surgery, unilateral adrenalectomy, or resection of ectopic tumor) performed by an experienced surgeon is first-line therapy for those who are appropriate candidates. Control of hypercorti- solism and its associated comorbidities, especially when severe, should be considered prior to surgery. If the source of CS cannot be identified (especially in ectopic CS), bilateral adrenalectomy may be an option, especially in life-threatening severe CS or in those who have contraindications or are refractory to medical therapy. Consider Pharmacotherapy Prior to Surgery, if Surgery Is Contraindicated or Tumor Location Is Unknown, if the Patient Is Medically Unstable, or for Persistent or Recurrent Cushing’s Syndrome After Surgery Options for pharmacotherapy are shown in Table 18.4. For rapid control, patients are usually started on ketoconazole and/or metyr- apone (mifepristone may also be considered, if available). For very rapid control in life-threatening CS in the critical care set- ting, etomidate may be useful but requires close monitoring for sedation. Cabergoline or pasireotide may be more useful in 224 B. P. Galm and N. A. Tritos Table 18.4 Pharmacotherapy for Cushing’s syndrome Approximate Medication Mechanism of action efficacya Dosing Adverse effects Cabergoline Dopamine receptor 2 30–40% 1–7 mg/wk GI upset, orthostatic hypotension, potentially agonist cardiac valvulopathy in high doses Pasireotide Somatostatin receptor 20–40% 600–1200 μg sc GI upset, cholelithiasis, transaminitis, ligand bidc hyperglycemia/diabetes, prolonged QT Ketoconazole Inhibits several adrenal 50–75% 400–1600 mg/d, Transaminitis, hepatitis, drug interactions, enzymes divided bid–tid gynecomastia, hypogonadism (men) Metyrapone Inhibits 11β-hydroxylase 50–75% 500–6000 mg/d, GI upset, hirsutism, acne, hypokalemia, edema, divided tid–qid hypertension Etomidate Inhibits several adrenal 100% 3–5 mg load then Sedation; requires monitoring in intensive care, enzymes (dose- 0.03–0.1 mg/kg/h given via central line dependent) Mitotane Adrenolytic, inhibits 75–85% 250–8000 mg/d, GI upset, CNS effects, transaminitis, alters several adrenal enzymes divided tid–qid binding proteins, inhibits CYP 3A4, drug interactions, hypothyroidism, teratogenic Mifepristone Glucocorticoid receptor 40–60%b 300–1200 mg GI upset, abortifacient, hypokalemia, antagonist once daily hypertension, edema, endometrial thickening Abbreviations: CNS central nervous system, CYP cytochrome P450, GI gastrointestinal aAll estimates are approximate, as various studies used different outcomes for efficacy. Treatment escape may develop in some patients (~25% on cabergoline, ~10% on ketoconazole, ~5% on metyrapone) bAs cortisol and UFC are not meaningful while on mifepristone, efficacy is reported as improvement in diabetes or hypertension cA long-acting formulation of pasireotide (10–40 mg intramuscularly every 4 weeks) has also been tested and FDA-approved for the treatment of CS 18 Cushing’s Syndrome 225 less- severe pituitary CS but take longer to control hypercorti- solism than adrenally acting agents. Combination therapy can also be useful (efficacious in 70–90%), especially in severe or refractory CS. Monitoring while hospitalized is generally per- formed with serum cortisol (although UFC can be used), with a target of ~10–15 μg/dL (exact targets vary depending on assay). Do not monitor cortisol levels in patients on mifepristone. All agents can cause hypoadrenalism as an extension of their pharma- cologic effects. Only pasireotide and mifepristone are FDA- approved for treatment of CS. Consider Pituitary Radiotherapy in Persistent or Recurrent Cushing’s Disease or if Surgery Is Contraindicated Consider pituitary-directed radiotherapy (RT) for refractory, per- sistent, or recurrent CD, for patients with contraindications to sur- gery, or for large adenomas with residual tumor after surgical debulking. As RT may take months to years to become effective, other medical therapies may need to be used in the interim. Consider Bilateral Adrenalectomy in Patients Who Have Refractory Cushing’s Syndrome Consider bilateral adrenalectomy in patients who have refractory CS despite medical therapy, tumor-directed surgery, and/or RT. Bilateral adrenalectomy may also be helpful in severe, life- threatening CS and in patients where the primary tumor (includ- ing ectopic CS) cannot be found. Bilateral adrenalectomy is generally advisable in patients with bilateral ACTH-independent (macro- or micronodular) adrenal hyperplasia. Patients require lifelong glucocorticoid and mineralocorticoid replacement after bilateral adrenalectomy. Monitor for Nelson’s syndrome (cortico- troph tumor progression) with regular ACTH levels and pituitary MRI examinations in patients with CD who undergo bilateral adrenalectomy. 226 B. P. Galm and N. A. Tritos Minimize Glucocorticoid Exposure in Patients with Iatrogenic Cushing’s Syndrome In patients with iatrogenic CS, minimize the glucocorticoid doses as needed to treat the underlying illness. If possible, avoid ritona- vir or cobicistat in patients on long-term glucocorticoids. For those patients on long-term steroids who no longer require phar- macologic doses, prescribe replacement doses (equivalent of prednisone 3–5 mg/day), with appropriate stress-dose coverage at the time of surgery or acute illness, until recovery of the hypothalamic- pituitary-adrenal (HPA) axis occurs. Although practice varies, clinicians will often monitor morning plasma cor- tisol (prior to steroid dose) or perform ACTH stimulation testing to document recovery of the HPA axis. The Diagnosis and Management of Cushing’s Syndrome in Pregnancy Are Challenging but Tumor-Directed Surgery Remains First-Line Therapy and Can Be Life-Saving Making the diagnosis is critical as CS in pregnancy is associated with significant morbidity and mortality for the fetus and mother. Do not use the DST. Use the UFC with a higher cutoff of 2–3 × prepregnancy ULN, since cortisol secretion rates rise during healthy pregnancies above pregestational levels. The LNSC may be useful, but more data are needed on reference ranges. Adrenal causes are proportionately more common during pregnancy (~50% of CS), but ACTH may not be fully suppressed. Order an abdominal ultrasound as the initial imaging modality; unen- hanced MRI of the adrenals or pituitary may be performed in consultation with radiology. Tumor-directed surgery, preferably during the second trimester, should be undertaken if a source is identified. No pharmacotherapy is approved for use in preg- nancy; metyrapone has been used the most, but cabergoline may also be useful. Mifepristone is absolutely contraindicated as it is an abortifacient. 18 Cushing’s Syndrome 227 Suggested Reading Elamin MB, Murad MH, Mullan R, Erickson D, Harris K, Nadeem S, et al. Accuracy of diagnostic tests for Cushing’s syndrome: a systematic review and metaanalyses. J Clin Endocrinol Metabol. 2008;93(5):1553–62. Lacroix A, Feelders RA, Stratakis CA, Nieman LK. Cushing’s syndrome. Lancet (Lond, Engl). 2015;386(9996):913–27. Nieman LK, Biller BMK, Findling JW, Murad MH, Newell-Price J, Savage MO, et al. Treatment of Cushing’s syndrome: an endocrine society clini- cal practice guideline. J Clin Endocrinol Metabol. 2015;100(8):2807–31. Nieman LK, Biller BMK, Findling JW, Newell-Price J, Savage MO, Stewart PM, et al. The diagnosis of Cushing’s syndrome: an endocrine society clinical practice guideline. J Clin Endocrinol Metabol. 2008;93(5):1526– 40. Pivonello R, De Leo M, Cozzolino A, Colao A. The treatment of Cushing’s disease. Endocr Rev. 2015;36(4):385–486. Tritos N, Biller BMK. Medical therapy for Cushing’s syndrome in the twenty- first century. Endocrinol Metab Clin N Am. 2018;47(2):427–40. Adrenalectomy 19 Ole-Petter R. Hamnvik Contents Preoperative Evaluation 230 Review Indications for Adrenalectomy and Consider Appropriateness of a Biopsy 230 Ensure Completeness of Preoperative Endocrine Evaluation 231 Postoperative Management 233 Assess for Hormonal Deficiencies 233 Initiate Replacement Therapy 233 Educate the Patient About Adrenal Insufficiency if Present 234 Organize Follow-Up After Discharge 235 Suggested Reading 235 Abbreviation IV Intravenous O.-P. R. Hamnvik (*) Brigham and Women’s Hospital, Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 229 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_19 230 O.-P. R. Hamnvik Preoperative Evaluation Review Indications for Adrenalectomy and Consider Appropriateness of a Biopsy Most adrenal masses should not be surgically removed. Indications for unilateral adrenalectomy include: • Hormonally secreting adrenal adenomas (such as cortisol- producing or aldosterone-producing adenomas) • Pheochromocytomas • Adrenal masses that are suspicious for primary adrenocortical carcinoma, based on imaging characteristics such as irregular shape, size >4 cm, high unenhanced CT attenuation values (>20 Hounsfield units), irregular enhancement after contrast administration, etc. • As part of a radical nephrectomy for renal cell carcinoma or other rarer tumors such as Wilms tumor or neuroblastomas Bilateral adrenalectomy is usually only performed in the set- ting of ACTH-dependent Cushing syndrome where the source of the ACTH excess cannot be identified or controlled (such as in a widely metastatic ACTH-secreting malignancy). Adrenalectomy is usually not performed for non-adrenal can- cer with metastatic spread to the adrenal gland or for infections causing adrenal masses such as tuberculosis, fungi, etc. Therefore, a fine needle aspiration biopsy may be reasonable if there is concern for metastasis (such as in a patient with a known primary tumor) or infection (such as in a patient with systemic symptoms such as fevers, chills, weight loss, etc.). Biopsy should not be performed until pheochromocytoma has been ruled out biochemically. In addition, biopsy will not distinguish adrenocortical cancer from an adrenal adenoma (a full resection is required) and therefore is not indicated in suspected adreno- cortical cancer. 19 Adrenalectomy 231 The indication for surgery, the surgeon’s experience, and char- acteristics of the patient and the tumor will determine the surgical approach chosen by the surgeon. The standard approach for benign disease is laparoscopic transabdominal adrenalectomy or retroperitoneal endoscopic adrenalectomy. These approaches are used in the vast majority of adrenalectomies and are considered the standard of care for adrenalectomies for benign lesions, par- ticularly in patients who are otherwise at high risk for postopera- tive complications. Open transabdominal adrenalectomy is a more invasive surgical approach that allows the best exposure and visu- alization of the operative field; it is usually the preferred approach in cases of suspected malignancy where a more extensive resec- tion is needed. This includes cases of known adrenocortical carci- noma, suspected adrenocortical carcinoma (such as tumors >6 cm in size, tumors making multiple hormones, or tumors making adrenal androgens), and tumors with local invasion into surround- ing

structures. However, the open approach to adrenalectomy is associated with more pain and longer postoperative hospitaliza- tion than less invasive approaches, although this is a reasonable trade-off to allow more complete resection in cases of suspected malignancy. Ensure Completeness of Preoperative Endocrine Evaluation All patients with an adrenal mass should have an evaluation for hormonal hypersecretion by history, physical examination, and biochemical testing prior to surgery. If adrenalectomy is performed in a patient without an adrenal mass (such as in a rad- ical nephrectomy), an endocrine evaluation is not required unless the patient has an incidental adrenal mass noted on preoperative imaging. The history and physical examination should focus on symp- toms and signs of Cushing syndrome, primary hyperaldosteron- ism (mainly by assessing blood pressure), androgen excess, and 232 O.-P. R. Hamnvik pheochromocytoma. All patients with an adrenal nodule should have a biochemical assessment for Cushing syndrome (1-mg dexamethasone suppression test or late-night salivary cortisol level) and pheochromocytoma (plasma or 24-h urine metaneph- rines). Patients with hypertension or hypokalemia should also be assessed for primary aldosteronism with an aldosterone-renin ratio. When adrenocortical carcinoma is suspected, andorgen lev- els should be measured: primarily DHEAS, but also consider tes- tosterone and androstenedione. Males and post-menopausal females with features of estrogen excess should have estogen lev- els measured. Assessing the endocrine function preoperatively is essential to avoid unexpected intraoperative or postoperative complications. Patients who have preoperative cortisol excess from a cortisol- secreting adrenal adenoma are at risk for adrenal insufficiency postoperatively due to atrophy of pituitary corticotrophs and of the contralateral adrenal gland; they are also at higher risk of venous thromboembolism, hyperglycemia, hypertension, peptic ulcer disease, and infection. Perioperative management of these patients is discussed in Chap. 18 “Cushing’s Syndrome.” Patients with primary aldosteronism may need preoperative blood pres- sure control and hypokalemia treatment (often with a mineralo- corticoid receptor antagonist such as spironolactone) and are at risk for postoperative hypoaldosteronism with hyperkalemia and sodium wasting with hypotension, as discussed in Chap. 21 “Primary Aldosteronism.” Patients with pheochromocytomas should receive preoperative blockade of alpha- and beta- adrenergic receptors as well as volume expansion, as discussed in Chap. 20 “Pheochromocytoma and Paraganglioma,” to prevent uncontrollable intraoperative blood pressure swings. A finding of hyperandrogenism raises the likelihood that the lesion is an adre- nocortical cancer; benign adrenal adenomas almost never secrete androgens. 19 Adrenalectomy 233 Postoperative Management Assess for Hormonal Deficiencies Postoperatively, adrenal insufficiency may be an expected occur- rence, such as after bilateral adrenalectomy. These patients do not need any further hormonal assessment but should start hormone replacement as discussed below. In patients who have undergone unilateral adrenalectomy for a hormonally silent lesion, as assessed preoperatively, the likelihood of clinically apparent adre- nal insufficiency is low, and routine glucocorticoid replacement is therefore not indicated. However, biochemical adrenal insuffi- ciency on postoperative day 1 (defined by a morning cortisol below 94 nmol/L [3.4 μg/dL]) has been found in around 20% of patients and may represent suppression of the remaining adrenal from subclinical Cushing syndrome or an inadequate adrenocorti- cal reserve in the remaining adrenal. While routine postoperative testing for adrenal insufficiency in these patients is not currently standard of care, close monitoring of the patient’s clinical status (symptoms, blood pressure, electrolytes) should be performed, and there should be a low threshold to assess for adrenal insuffi- ciency. Postoperative endocrine monitoring of patients with secre- tory adrenal masses is discussed in Chap. 18 “Cushing’s Syndrome,” Chap. 20 “Pheochromocytoma and Paraganglioma,” and Chap. 21 “Primary Hyperaldosteronism.” Initiate Replacement Therapy Patients who undergo bilateral adrenalectomy, as well as those patients whose indication for unilateral adrenalectomy is a cortisol- secreting adrenal adenoma or adenocarcinoma, will have adrenal insufficiency postoperatively. Therefore, routine adminis- tration of glucocorticoids is indicated. For patients who have undergone bilateral adrenalectomy, an example of a postoperative hormone replacement strategy is the following: 234 O.-P. R. Hamnvik • Hydrocortisone 50 mg IV every 8 h on the day of surgery and postoperative day 1, with the first dose being administered intraoperatively after the second adrenal gland has been removed. • Then reduce the dose to 25 mg IV every 8 h on postoperative day 2. • On postoperative day 3, if the patient is tolerating oral intake, switch to oral hydrocortisone, 40 mg at 7 am and 20 mg at 3 pm for 1 day and then to 20 mg at 7 am and 10 mg at 3 pm thereafter. When oral intake is tolerated, oral fludrocortisone 0.1 mg daily is also added. • The dose can be weaned further after discharge based on patient symptoms, blood pressure readings and potassium levels. In patients who have undergone adrenal surgery for overt or subclinical cortisol excess, some practitioners prefer to wait with initiation of glucocorticoids until postoperative day 1 after ensur- ing that blood cortisol levels have dropped, confirming surgical cure of the disease. In patients with overt Cushing syndrome, higher supraphysiologic glucocorticoid doses and a slower taper are often needed as the patient can otherwise be very symptomatic from the rapid decline in glucocorticoid levels. Patients who undergo unilateral adrenalectomy for any indication usually do not require mineralocorticoid replacement with fludrocortisone, although they should be monitored for hyperkalemia and hypo- tension which are signs of hypoaldosteronism. Educate the Patient About Adrenal Insufficiency if Present All patients diagnosed with adrenal insufficiency should be informed about their diagnosis and taught how to prevent adrenal crises prior to discharge. This is discussed in further detail in Chap. 17 “Suspected Adrenocortical Deficiency.” 19 Adrenalectomy 235 Organize Follow-Up After Discharge Patients should have a follow-up appointment within 1–2 weeks with their surgeon for routine postoperative follow-up and to dis- cuss the results of the histopathologic examination of the adrenal specimen. Patients who are diagnosed with adrenocortical cancer or patients who are discharged on adrenal hormone replacement should have follow-up with an endocrinologist within 2–4 weeks to discuss whether adjuvant mitotane is indicated and to titrate the hormone replacement dose, respectively. Patients should have a contact number in case symptoms of adrenal insufficiency develop. Suggested Reading Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2016;175(2):G1–G34. Mitchell J, Barbosa G, Tsinberg M, Milas M, Siperstein A, Berber E. Unrecognized adrenal insufficiency in patients undergoing laparo- scopic adrenalectomy. Surg Endosc. 2009;23:248–54. Zeiger MA, Thompson GB, Duh QY, Hamrahian AH, Angelos P, Elaraj D, et al. The American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract. 2009;15(Suppl 1):1–20. Pheochromocytoma 20 and Paraganglioma Alejandro Raul Ayala and Mark Anthony Jara Contents Before the Admission 238 Preoperative Blood Pressure Control 239 Hydration 240 During Admission 241 Inpatient Diagnosis and Treatment 241 Confounders: Diagnostic Accuracy of Metanephrines 242 Localization of Pheochromocytomas/PPGLs 243 Opportunities to Explore Syndromic Pheochromocytoma: Hints of Genotype 244 Anesthesia in the Patient with Pheochromocytoma 244 Early Postoperative 245 Special Circumstances 247 Suggested Reading 248 A. R. Ayala (*) University of Miami, Miller School of Medicine, Department of Endocrinology and Metabolism, Miami, FL, USA e-mail: [email protected] M. A. Jara University of Miami, Miller School of Medicine, Division of Endocrinology and Metabolism, Miami, FL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 237 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_20 238 A. R. Ayala and M. A. Jara Before the Admission Because pheochromocytoma and catecholamine-secreting para- gangliomas (PPGLs) might have similar clinical presentations and are treated with similar approaches, many clinicians use the term “pheochromocytoma” to refer to both. The most common inpatient consultation often involves perioperative management of a patient previously diagnosed with a pheochromocytoma. However, catecholamine secreting tumors can also be diagnosed during a hospitalization for unrelated conditions or in the context of a hypertensive crisis. The clinical presentation of patients with PPGLs varies widely from no symptoms or minor discrete symp- toms to catastrophic life-threatening clinical conditions. In gen- eral, 50% of these patients are asymptomatic at presentation. This subgroup is much larger in those patients with incidentally dis- covered adrenal masses or those tested during family screenings. When symptomatic, patients may present with the following: • Pounding headache, approximately 90% of symptomatic patients. • Profuse sweating in 60–70%. • Palpitations that occurs in spells that last from several minutes to 1 h with complete remission of the symptoms between spells. The spells could occur either spontaneously or being provoked by a variety of physical or chemical triggers, such as general anesthesia, micturition, and medications (e.g., β-adrenergic inhibitors, tricyclic antidepressants, glucocorticoids). • Panic attack like symptoms. Approximately 50% of patients have paroxysmal hyperten- sion, often severe, while the remaining either have primary hypertension or are normotensive (5–15%). Other symptoms include tremors, pallor, dyspnea, weakness mostly generalized, and panic attack-type symptoms. On rare occasion, catechol- amine excess can result in decompensated heart failure and/or cardiogenic shock with features of stress-induced (Takotsubo) cardiomyopathy. 20 Pheochromocytoma and Paraganglioma 239 Preoperative Blood Pressure Control The main goal of preoperative management of a pheochromocy- toma patient is to normalize blood pressure, heart rate, and func- tion of other organs; restore volume depletion; and prevent a patient from surgery-induced catecholamine storm and its poten- tially devastating consequences. All patients with a biochemically positive pheochromocy- toma should receive appropriate preoperative medical manage- ment to block the effects of released catecholamines. Medical treatment should be started ideally 14 days preoperatively allowing for blood pressure and pulse normalization. Based on retrospective studies and institutional experience, target goals include a blood pressure of less than 130/80 mm Hg while seated and greater than 90 mm Hg systolic while standing and a heart rate target of 60–70 bpm seated and 70–80 bpm standing. The α-adrenergic receptor blockers are the first-choice agents having significant impact on surgical outcome as patients without α-adrenoceptor blockade experience significant periop- erative complications when compared with those on treatment. Phenoxybenzamine (a noncompetitive, α-adrenoceptor blocker) is most commonly used for preoperative blockade. The initial dose of phenoxybenzamine is usually 10 mg twice a day followed by 10–20 mg increments every 2–3 days until the clinical manifestations are controlled or further increases are limited by side effects. Generally, a total daily dose of 1 mg/kg is sufficient. Additionally, the prolonged action of phenoxybenzamine can contribute to hypotension in the first 24 h after tumor removal. Another option is to administer phenoxybenzamine by infusion (0.5 mg/kg·d) for 5 h a day, 3 days before the surgical intervention in those patients that are hospitalized. Prazosin, terazosin, and doxazosin are specific competitive alpha 1-postsynaptic blocking α-adrenoceptor blocking agents of shorter half-life that can also be used safely. Prazosin is administered in doses of 2–5 mg two or three times a day, terazosin in doses of 2–5 mg per day, and doxazosin in doses of 2–8 mg per day. These three medications could 240 A. R. Ayala and M. A. Jara potentially induce severe postural hypotension immediately after the first dose; thus, they should be given just as the patient is ready to go to bed. Thereafter, the dosage can be increased as needed; titration can be achieved more quickly with much less side effects compared with phenoxybenzamine. Beta-adrenoceptor blocking agents are needed when catecholamine- related or α-blocker-induced tachyarrhythmia occurs but should never be used before an adequate α-blockade has been established as unopposed alpha-receptor stimulation will cause increased vasoconstriction and might lead to hypertensive crisis. Calcium channel blockers may also be used preoperatively. The combination of extended-release verapamil (180–360 mg/ daily), sustained release nicardipine beginning with 30 mg twice daily, amlodipine beginning with 2.5-5 mg daily or extended release nifedipine beginning with 30 mg daily and specific com- petitive alpha 1-p ostsynaptic α-adrenoceptor blocking agents (i.e., doxazosin) may be particularly useful although there is little data to compare the efficacy of one treatment regimen over another. Calcium channel blockers do not cause hypotension or orthostatic hypotension during normotensive period and may also be used as the primary preoperative treatment of choice in normo- tensive patients with pheochromocytoma. These agents may also prevent catecholamine-associated coronary spasm; therefore, they may be useful when pheochromocytoma is associated with cate- cholamine-induced coronary vasospasm. Hydration Adequate oral hydration should be encouraged prior to admission. Catecholamines cause intense vasoconstriction through the

alpha-1 receptors, and initiation of α-blockade can lead to severe orthostatic hypotension. A patient may need 2–3 L of fluid orally or intravenously with 5–10 g of salt to increase the intravascular volume, reverse catecholamine-induced blood volume contrac- 20 Pheochromocytoma and Paraganglioma 241 tion preoperatively, and prevent severe hypotension after tumor removal. Serial hematocrit measurements give a guide to the effectiveness of volume expansion. Usually, a 5–10% fall in hematocrit is seen in well-prepared patients. During Admission Inpatient Diagnosis and Treatment The diagnosis of a pheochromocytoma in hospitalized patients can be challenging, mainly due to confounders that can result in non-tumoral catecholamine elevation. Coexisting conditions (heart failure, renal failure, and hypoglycemia) increase sympa- thetic activity and may result in a false-positive test. Interfering medications and psychiatric conditions should also be taken into account. Confirmatory biochemical testing should generally pre- cede imaging procedures because only solid evidence of excess production of catecholamines can justify performing expensive imaging procedures. However, a highly suspicious lesion (i.e., markedly hyperintense vascular tumor on T2 MRI images with no signal loss on out-of-phase imaging) should prompt immediate and incisive investigation. Imaging characteristics are particularly important during the evaluation of an incidentally discovered adrenal tumor (adrenal incidentaloma), since the tumor may be in the so called pre-biochemical phase (normal catecholamines/ metanephrines). Initial biochemical testing for PPGLs should include mea- surements of plasma-free metanephrines or urinary fractionated metanephrines by either mass spectrometry, liquid chromatog- raphy with electrochemical, or fluorometric detection (LC-ECD), as they have shown superior sensitivity and accu- racy compared to VMA and urine catecholamines. For mea- surement of plasma metanephrines, it is recommended to test the patient in the supine position and use of reference intervals established in the same position. An elevation of two to four times above the normal reference values often confirms the diagnosis with few exceptions. 242 A. R. Ayala and M. A. Jara Confounders: Diagnostic Accuracy of Metanephrines Plasma (free and total) metanephrines have similar sensitivities of 96% and 95% to urinary fractionated metanephrines. Both tests are equally recommended and combination of tests is not necessary. To avoid false positives, acetaminophen should be avoided for 5 days before blood sampling (HPLC assay). Caffeine intake and cigarette smoking should be discontinued for at least 24 h before a blood sample is obtained. The blood sample should be drawn in lavender or green-top tube, transferred on ice, and then stored at −80 °C until analyzed. The highest diagnostic sensitivity for plasma-free metanephrines is reached if the collection is performed in the supine position after an overnight fast and while the patient is recumbent in a quiet room for at least 20–30 min (Table 20.1). Table 20.1 Drugs that can affect the levels of plasma and urinary catechol- amines or metanephrines and affect test accuracy Medications Effect Tricyclic antidepressants amitriptyline, Increase plasma and urinary imipramine, and nortriptyline NA, NMA, and VMA SSRI Increased NMA Blockers atenolol, propranolol Increase plasma MA Caffeine, nicotine Increase plasma and urinary A and NA Calcium channel antagonists Increase plasma A and NA Amphetamine, ephedrine Increase plasma and urinary A and NA SNRI (venlafaxine) Increase NMA Adapted from Davison AS. Biochemical Investigations in Laboratory Medi- cine. Physiological effects of medications on Plasma/Urine metanephrines. Newcastle upon Tyne NHS Foundation Trust. http://www.pathology.leedsth. nhs.uk/dnn_bilm/Misc/Effectofdrugsonmetanephrines.aspx. (See Suggested Readings) NA noradrenaline, A adrenaline, NMA normetadrenaline, MA metadrenaline, VMA vanillylmandelic acid 20 Pheochromocytoma and Paraganglioma 243 Localization of Pheochromocytomas/PPGLs Localization of PPGLs is only done when there is biochemical diagnosis confirmation. CT or MRI may be used as the usual ini- tial imaging modalities for localization of PPGLs. These studies have high sensitivity but less than optimal specificity. These should be combined with functional imaging studies (nuclear medicine) to rule out extra-adrenal pheochromocytoma or meta- static disease. Gallium-68 PET/C is a promising agent that may offer further advantage in the localization of paragangliomas (Fig. 20.1). Clinical features suspicious for pheochromocytoma Rule out confounders: heart failure, renal failure, medications, caffeine WARD ICU In acute illness hyperadrenergic state, Biochemical testing: catecholamines and Plasma free metanephrines are rarely helpful metanephrines after 30 min of supine rest or 24 h Adrenal CT/MRI urinary fractionated metanephrines Normal Abnormal results results Positive Negative Repeat Elevation 2–3 testing during times above the symptomatic upper limit of episode normal Functional scanning Extradrenal tumor 18F-Dopa PET CT neck, CT chest Negative Ga-68 DOTATE PET Fig. 20.1 Algorithm 1 Biochemical and imaging diagnosis of catecholamine- producing tumors 244 A. R. Ayala and M. A. Jara Opportunities to Explore Syndromic Pheochromocytoma: Hints of Genotype Pheochromocytoma/PPGLs may be inherited and may have dis- tinct characteristic setting them apart from sporadic pheochromo- cytoma. Patients with syndromic lesions and/or positive family history should be tested for appertaining genes. Considerations should be made in patient presenting with: • PPGL at young age, usually before 40 years old • Positive family history • Multifocal PPGLs • Bilateral adrenal tumors Pheochromocytomas are associated with the following famil- ial syndromes: multiple endocrine neoplasia type 2 (MEN 2), von Hippel-Lindau disease (VHL), von Recklinghausen’s neurofibromatosis type 1 (NF 1), and familial paragangliomas (PGLs). Hospitalization represents a unique opportunity to identify such associated syndromic inherited conditions. Furthermore, the presence of family members providing support to the hospi- talized patient represents an opportunity to further explore famil- ial forms and to evaluate family members following appropriate consent. Anesthesia in the Patient with Pheochromocytoma Pheochromocytoma represents an important challenge for the anesthesiologist. By some estimates, 25–50% of hospital deaths of patients with unmanaged or unknown pheochromocytoma occur during induction of anesthesia or during operative proce- dures for other conditions, mostly related to lethal hypertensive crises, malignant arrhythmias, and multiorgan failure. Most patients with pheochromocytoma will require surgical interven- tion, and labile blood pressures, arrhythmias, and tachycardia 20 Pheochromocytoma and Paraganglioma 245 during and after surgery are not uncommon. Risks are much higher for patients with unrecognized pheochromocytoma who undergo anesthesia for unrelated surgery. Multidisciplinary pre- operative evaluation and medical management before surgery are important. Once the diagnosis is confirmed, medical management for sur- gery preparation is recommended as resecting a pheochromocy- toma is a high-risk surgical procedure. Preoperative cardiac evaluation should include an electro- cardiogram (ECG) to evaluate for possible ischemic changes and rhythm disturbances as damage to the cardiovascular sys- tem is the most likely to impact on outcomes in patient requir- ing anesthesia. A number of medications commonly used in anesthesia should be avoided or used cautiously in patients with pheochromocy- toma. Metoclopramide is associated with hypertensive crisis and adrenergic myocarditis with cardiogenic shock in patients with pheochromocytoma. Phenothiazine derivatives, including droper- idol, haloperidol, and chlorpromazine, can result in hypotension in patients with pheochromocytoma. Glucagon has been shown to release catecholamines from the tumor and also linked with hypertensive crisis (Fig. 20.2). Early Postoperative The postoperative management usually requires an intensive care unit admission as once the tumor is removed the withdrawal of catecholamine effect will result in hypotension. The incidence of hypotension is variably described as 20–70% in various reports and may somewhat be dependent on the use of nature of preop- erative alpha-antagonist and intraoperative hypotensive agents. Fluid replacement and vasopressor infusion might be necessary in some patients. After tumor removal, sudden catecholamine with- drawal can lead to severe hypoglycemia, and blood sugar moni- toring, at least for the initial 12–24 h of the postoperative period, is recommended. 246 A. R. Ayala and M. A. Jara Hemodynamics monitor blood pressure Blood glucose monitoring ICU admission Discontinuation of alpha Postopeative at least for 12–24h stimulation can lead to management hyperinsulinemia and hypoglycemia due to disappearance of B-cell suppression. Hydration IV fluids Discharge Instructions Inpatient-ward - Follow up appointment and contacts transfer - Laboratory assessment including BMP, 24 h urine free Blood pressure metanephrines in 2 weeks. monitoring Fig. 20.2 Algorithm 2 Postoperative management of pheochromocytoma 20 Pheochromocytoma and Paraganglioma 247 Special Circumstances The Pregnant Patient Pheochromocytoma has a reported incidence of <0.2 per 10,000 pregnancies. Although a rare disorder, untreated, it carries a risk of mortality for both mother and fetus. Pheochromocytomas have the ability to produce signs and symptoms that mimic other forms of hypertension, including the new-onset hypertensive syndromes in pregnancy, gestational hypertension, and preeclampsia. It may become overt during pregnancy because of increases in intra- abdominal pressure, fetal movements, uterine contractions, the process of delivery, an abdominal surgical intervention, and even general anesthesia. The diagnosis is based on the results of 24-h urinary fraction- ated metanephrines and/or plasma fractionated metanephrines. MRI without gadolinium is the preferred imaging modality for localization as it locates adrenal and extra-adrenal masses and requires no radiation. The management has primary goal to prevent hypertensive cri- sis. Medical treatment with α-blockers must be started as soon as the diagnosis is confirmed and should be given for 10–14 days. The drug of choice is phenoxybenzamine (pregnancy class C), followed by a β-blocker if necessary. Phenoxybenzamine crosses the placenta and may cause perinatal depression in the mother and transient hypotension in the neonate; however, it has been described as generally safe for the fetus. Methyldopa is not rec- ommended, because it may worsen the symptoms of pheochro- mocytoma. Cesarean section is the preferred mode of delivery since it appears to carry less risk of maternal death than vaginal delivery. The definitive treatment is surgery, and tumor resection can be completed either before 24 weeks, as second trimester is the safest period to do surgery during pregnancy, or a few weeks later after uterine involution. The ICU Patient Because critical illness results in a hyperadrenergic state, mea- surements of catecholamines and metanephrines are rarely helpful in the ICU setting. Furthermore, vasoactive amines and 248 A. R. Ayala and M. A. Jara antiarrhythmics may also interfere with diagnostic testing. Therefore, a CT of the abdomen with emphasis on the adrenal gland may be the most convenient test in this situation, as most pheochromocytomas are large (4–5 cm) and have distinct imag- ing characteristics. Renal Failure Measurements of urinary catecholamines and metabolites are less reliable if the patient has advanced kidney disease. In addition, serum chromogranin A levels have poor specificity in these patients. There is very limited literature in this regard. However, one study by Eisenhofer G et al. found that in renal failure, there are up to twofold higher plasma concentrations of catecholamines and free metanephrines. Suggested Reading Amar L, Bertherat J, Baudin E, Ajzenberg C, Bressac-de Paillerets B, Chabre O, et al. Genetic testing in pheochromocytoma or functional paragangli- oma. J Clin Oncol. 2005;23(34):8812–8. Barrett C, van Uum SH, Lenders JW. Risk of catecholaminergic crisis follow- ing glucocorticoid administration in patients with an adrenal mass: a lit- erature review. Clin Endocrinol (Oxf). 2015;83(5):622–8. Davison AS. Biochemical investigations in laboratory medicine. Physiological effects of medications on plasma/urine metanephrines. Newcastle upon Tyne NHS Foundation Trust. http://www.pathology. leedsth.nhs.uk/dnn_bilm/Misc/Effectofdrugsonmetanephrines.aspx. Eisenhofer G, Peitzsch M. Laboratory evaluation of pheochromocytoma and paraganglioma. Clin Chem. 2014;60(12):1486–99. Eisenhofer G, Rivers G, Rosas AL, Quezado Z, Manger WM, Pacak K. Adverse drug reactions in patients with pheochromocytoma: incidence, prevention and management. Drug Saf. 2007;30(11):1031–62. Lenders JW, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SK, Murad MH, et al. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. Endocrine Society. J Clin Endocrinol Metabol. 2014;99(6):1915–42. Manger WM, Gifford RW. Pheochromocytoma. J Clin Hypertens (Greenwich). 2002;4(1):62–72. Pacak K. Preoperative management of the pheochromocytoma patient. J Clin Endocrinol Metabol. 2007;92(11):4069–79. 20 Pheochromocytoma and Paraganglioma 249 Pacak K, Eisenhofer G, Ahlman H, Bornstein SR, Gimenez-Roqueplo AP, Grossman AB, et al. International Symposium on Pheochromocytoma. 2005 Pheochromocytoma: recommendations for clinical practice from the First International Symposium. Nat Clin Pract Endocrinol Metab. 2007;3(2):92–102. Primary Aldosteronism 21 Alejandro Raul Ayala and Mark Anthony Jara Contents Diagnostic Considerations 252 Inpatient Testing for Hyperaldosteronism 252 Factors Affecting Aldosterone/Renin Ratio 253 Special Considerations: Cortisol Co-secretion 254 Disease Subtyping 254 Treatment 255 Early Postoperative Period 255 Special Considerations 256 Primary Hyperaldosteronisms and Pregnancy 256 The Patient with Chronic Kidney Disease 257 Familial Hyperaldosteronism: Contact with the Family Members 258 Suggested Reading 260 A. R. Ayala (*) University of Miami, Miller School of Medicine, Department of Endocrinology and Metabolism, Miami, FL, USA e-mail: [email protected] M. A. Jara University of Miami, Miller School of Medicine, Division of Endocrinology and Metabolism, Miami, FL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 251 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_21 252 A. R. Ayala and M. A. Jara

Diagnostic Considerations Primary aldosteronism (PA) is the most common cause of endo- crine hypertension. Patients with PA have higher cardiovascular morbidity and mortality compared with age- and sex-matched patients with essential hypertension and the same degree of blood pressure elevation. Case detection screening should be considered in patients with: • Spontaneous hypokalemia, including patients treated with low-dose thiazide diuretics. However, there are patients with primary mineralocorticoid excess who are normokalemic and rarely some who are hypokalemic but normotensive. Only 9–37% of patients with primary aldosteronism are hypokalemic. • Severe or resistant hypertension to three conventional antihypertensive drugs (including a diuretic) or controlled BP (<140/90 mm Hg) requiring four or more antihyperten- sive drugs. • Patients with hypertension and adrenal incidentaloma. • Hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age (<40 years). • Hypertensive first-degree relatives of patients with PA. Inpatient Testing for Hyperaldosteronism The recommended case detection-screening test is the plasma aldosterone activity (PAC)/plasma renin activity (PRA). An elevated plasma aldosterone activity (PAC)/plasma renin activity (PRA) ratio and an increased PAC are required for the diagnosis of primary aldosteronism. • PAC is inappropriately high for the PRA, usually >15 ng/dL. • PAC/PRA ratio greater than 20. Collecting blood midmorning from seated patients following 2–4-h upright posture improves sensitivity. 21 Primary Aldosteronism 253 In the setting of spontaneous hypokalemia, plasma renin below detection levels plus plasma aldosterone concentration (PAC) >20 ng/dL, further confirmatory testing might not be needed. Confirmatory Testing Usually, elevated PAC/PRA ratio alone does not establish the diagnosis of primary aldosteronism, and the results have to be confirmed by demonstrating inappropriate aldo- sterone secretion, except in situations as spontaneous hypokale- mia, undetectable PRA or PRC, and a PAC >20 ng/dL. Otherwise, aldosterone suppression testing is needed with one of several tests (table of confirmatory test). The patient that presents with hypertensive crisis despite the use of multiple antihypertensives should be screened for primary hyperaldosteronism. Factors Affecting Aldosterone/Renin Ratio False Negatives Genrally limited to the mineralocorticoid recep- tor antagonists, spironolactone and eplerenone. While dietary salt restriction, concomitant malignant or renovascular hypertension, pregnancy, and treatment with diuretics (including spironolactone), dihydropyridine calcium blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor antagonists can stimulate renin, they generally do not have a sufficiently potent effect to interfere with diagnosing PA. False Positives Beta-blockers, alpha-methyldopa, clonidine, and nonsteroidal anti-inflammatory drugs suppress renin, raising the ARR with potential for false positives. False positives can also occur in patient with advanced age and renal disease. In general, medications other than the minetarlocorticoid antagonists do not need to be discontinued before ARR measure- ment. However, when the diagnosis is not clear, the interfering medications should be discontinued at least 2 weeks before ARR measurement; diuretics should be discontinued ideally 6 weeks before the test, although this is inconvenient, potentially harmful and rarely feasible. Some patients will require substitution of the 254 A. R. Ayala and M. A. Jara interfering medication during the w ashout period until the test is completed. Doxazosin and fosinopril can be used in hypertensive patients who need to undergo aldosterone and PRA measurement for the diagnosis of primary aldosteronism; amlodipine yields a small percentage of false-negative diagnoses, and beta-blockers may only have limited influence on the diagnosis of primary aldo- steronism as they lower PRA and PRC measurements and raise the PAC/PRA ratio, an effect that in most settings is not clinically significant. Other potassium- sparing diuretics, such as amiloride and triamterene, usually do not interfere with testing unless the patient is treated with high doses. Special Considerations: Cortisol Co-secretion There is an increasing awareness of cortisol co-secretion in the context of primary hyperaldosteronism resulting from adrenal tumors. Overt or subtle glucocorticoid hypersecretion may poten- tially interfere with diagnostic studies or result in secondary/ter- tiary adrenal insufficiency after surgical removal of the tumor because of contralateral gland suppression. Patients with adrenal tumors, including those with confirmed hyperaldosteronism, should also be evaluated for hypercortisolism with a 1 mg dexa- methasone suppression test. Disease Subtyping Once the diagnosis of primary hyperaldosteronism has been confirmed, unilateral adenoma or rarely carcinoma must be distinguished from bilateral disease. Disease subtyping is established using adrenal computed tomography (CT) and adrenal vein sampling (AVS) (algorithm). Adrenal vein sam- pling is used to distinguish between unilateral adenoma and bilateral hyperplasia, and it is recommended to confirm unilat- 21 Primary Aldosteronism 255 eral secretion for patients who would likely pursue surgical management. Treatment The curative treatment is surgical: unilateral laparoscopic adre- nalectomy for patients with documented unilateral PA or unilat- eral adrenal hyperplasia. Medical treatment is preferred in patients who are unable or unwilling to undergo surgery or who have bilateral adrenal disease. Mineralocorticoid receptor antagonists are the medical treatment of choice. Spironolactone is the primary agent at doses ranging from 25 to 400 mg/d, with eplerenone as an alternative. Antiandrogen side effects such as gynecomastia and diminished libido in men and menstrual disorders in women can result from spironolactone due to cross-antagonism of the sex steroid receptor. Eplerenone is more specific for the aldosterone receptor and therefore causes less unde- sired side effects but is less potent than spironolactone. In a study comparing these two therapies, spironolactone at doses ranging from 75 to 225 mg/d was more efficacious than eplerenone at doses between 100 and 300 mg/d for hypertension control. Biochemical cure following adrenalectomy as well as hemodynamic improve- ment is seen in over 90% of patients. Hypokalemia typically resolves immediately after surgery, and blood pressure reduction may take months, prompting a reduction in quantity of antihyper- tensive medications in most patients. Early Postoperative Period We suggest the measurement of aldosterone and PRA on the first and second postoperative day. A significant decrease in serum aldosterone levels is detected a few hours after adrenal clipping is performed during adrenalectomy, although plasma renin activity may take weeks to normalize. 256 A. R. Ayala and M. A. Jara In general, when the unilateral adrenalectomy is successful, aldosterone levels achieve a nadir within 24–48 h after the inter- vention, suggesting cure. After surgery, mineralocorticoid recep- tor antagonists should be withdrawn in the first postoperative day to avoid hyperkalemia. Antihypertensives should be administered base on the patient’s postoperative blood pressure readings. One should expect a significant reduction in the number of antihyper- tensives and dosing in most cases. On occasion, normotension is observed in the early postoperative period, particularly in younger patients with less severe preoperative hypertension, although blood pressure normalization may take up to a year to occur. Unless the patient is persistently hypokalemic, postopera- tive hydration should include normal saline without potassium with careful monitoring of renal function, as a decrease in GFR is often seen following resolution of hyperaldosteronism, a con- dition that results in glomerular hyperfiltration. Preoperative renal damage as revealed by elevated serum creatinine and microalbuminuria are significant predictors of postoperative hyperkalemia (hypoaldosteronism). Hence, the combination of worsening renal function and post- surgical hypoaldosteronism that occurs in cured patients treated with unilateral adrenalectomy may result in severe hyperkalemia, requiring close attention not only in the early postoperative period but also following discharge. Because the hypoaldosteronism may be prolonged, we recommend at least weekly electrolyte and renal function testing during postsurgical month, as a minimum. Special Considerations Primary Hyperaldosteronisms and Pregnancy Primary aldosteronism is uncommon in pregnancy, with only few cases reported in the literature, most of them due to aldosterone- producing adenomas. Primary aldosteronism can lead to 21 Primary Aldosteronism 257 intrauterine growth retardation, preterm delivery, intrauterine fetal demise, and placental abruption. The evaluation in the pregnant woman is the same as for non- pregnant patients. For case confirmation, however, the captopril stimulation test is contraindicated in pregnancy, but measurement of sodium and aldosterone in a 24-h urine collection is an option. Subtype testing with abdominal magnetic resonance imaging (MRI) without gadolinium is the test of choice. Computed tomography (CT) and adrenal venous sampling are contraindi- cated in pregnancy. Hypertension may improve or worsen in pregnancy due to the agonist/antagonist function of progesterone on the mineralocorti- coid receptor. The treatment depends on the case presentation including med- ical or surgical options: • Unilateral laparoscopic adrenalectomy during the second tri- mester in clear cases of tumors of >1 cm. • Spironolactone crosses the placenta and is a US Food and Drug Administration (FDA) pregnancy category C (Not proven safe in pregnancy), and eplerenone is an FDA pregnancy category B (There are no adequate and well-controlled studies in preg- nant women. Should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus). Therefore, standard antihypertensive drugs approved for use during pregnancy should be used. • Hypokalemia can be managed with oral potassium supplements. The Patient with Chronic Kidney Disease The diagnosis of primary hyperaldosteronism could be challeng- ing in patient with chronic kidney disease (CKD) as this may 258 A. R. Ayala and M. A. Jara disturb the renin-angiotensin-aldosterone system. The diagnosis of primary PA in the CKD population has not been established as plasma aldosterone concentration, PRA, and ARR can vary sig- nificantly in CKD. As CKD progresses, PAC increases, and the more advanced the CKD, the lesser the effect on PRA, giving rise to a higher ARR. Also in a study, primary aldosteronism patients accompanying chronic kidney disease had high serum aldoste- rone and ARR levels, low PRA, and no clear association of hypokalemia. Familial Hyperaldosteronism: Contact with the Family Members Familial hyperaldosteronism is a group of inherited conditions inhered in an autosomal dominant pattern. Three familial forms of PA have been described: • FH type I or glucocorticoid-remediable aldosteronism, usually associated with bilateral adrenal hyperplasia. • FH type II is not dexamethasone suppressible. • FH type III is caused by germ line mutations in the potassium channel subunit KCNJ5, mostly suspected in patient with mas- sive adrenal hyperplasia and children. The patient and their family should receive appropriate information as well as appropriate counseling for biochemical screening of family members; continuously updated databases of human genes and genetic disorders and traits like OMIM or MalaCards are excellent free educational resources (Fig. 21.1). 21 Primary Aldosteronism 259 - BMP once - Low plasma a week for Unilateral aldosterone four weeks.* adrenalectomy - Reassess BP - Reassess control and BP control Measure: antihypertensive (home Is - Plasma Aldosterone on regime monitoring) adrenalectomy day 2 post surgery Unilateral desired or the disease Preoperative Postoperative - Potassium level, patient a YES management management creatinine candidate? - Discontinue MRA to avoid hyperkalemia - BP control with PRN - Blood pressure antihypertensive (i.e Primary NO - Possiblecontrol: Start MRA hydralazine) aldosteronism persistent- Potassium - Hydration with normal confirmed disease,supplementation if saline (with potassium if Repeat hypokalemic. persistently hypokalemic) plasma Plasma aldosterone >5 aldosterone Start treatment with MRA ng/dl (PRA) and - Spironolactone: 50–400 mg/day Bilateral BMP in one - Eplerenone: if sides effects disease week. (gynecomastia,erectile dysfunction) 50–200 mg/day * May require prolonged monitoring for persistent contraltaeral adrenocorticol supression (hypoaldosteronism) MRA: Mineralocorticoid receptor antagonist BP: Blood pressure PRA: Plasma renin activity Fig. 21.1 Algorithm: inpatient management of primary hyperaldosteronism 260 A. R. Ayala and M. A. Jara Suggested Reading Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, Mantero F, Stowasser M, Endocrine Society, et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an Endocrine Society clinical prac- tice guideline. J Clin Endocrinol Metabol. 2008;93(9):3266–81. https:// doi.org/10.1210/jc.2008-0104. Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an endocrine society clinical practice guideline. J Clin Endocrinol Metabol. 2016;101(5):1889–916. https://doi.org/10.1210/ jc.2015-4061. Keuer B, Ayala AR, Pinto P. The role of intra- and postoperative serum aldo- sterone levels following adrenalectomy for primary aldosteronism. 64th Annual Meeting of the American Urologic Association (Mid-Atlantic Section), Washington, DC, October 12–15 2006. Mulatero P, Rabbia F, Milan A, Paglieri C, Morello F, Chiandussi L, Veglio F. Drug effects on aldosterone/plasma renin activity ratio in primary aldo- steronism. Hypertension. 2002;40(6):897–902. Parthasarathy HK, Ménard J, White WB, Young WF Jr, Williams GH, Williams B, et al. A double-blind, randomized study comparing the anti- hypertensive effect of eplerenone and spironolactone in patients with hypertension and evidence of primary aldosteronism. J Hypertens. 2011;29(5):980–90. https://doi.org/10.1097/HJH.0b013e3283455ca5. Rossi GP, Auchus RJ, Brown M, Lenders JW, Naruse M, Plouin PF, et al. An expert consensus statement on use of adrenal

vein sampling for the sub- typing of primary aldosteronism. Hypertension. 2014;63(1):151–60. https://doi.org/10.1161/HYPERTENSIONAHA.113.02097. Savard S, Amar L, Plouin PF, Steichen O. Cardiovascular complications asso- ciated with primary aldosteronism. A controlled cross-sectional study. Hypertension. 2013;62(2):331–6. https://doi.org/10.1161/ HYPERTENSIONAHA.113.01060. Stowasser M, Ahmed AH, Pimenta E, Taylor PJ, Gordon RD. Factors affect- ing the aldosterone/renin ratio. Horm Metab Res. 2012;44(3):170–6. https://doi.org/10.1055/s-0031-1295460. Young WF. Primary aldosteronism: renaissance of a syndrome. Clin Endocrinol (Oxf). 2007;66(5):607–18. Treatment of Hyperglycemia 22 in a Hospitalized Patient Without Hyperglycemic Emergency Rajesh K. Garg Contents Obtain HbA1c Unless Available Within Last 3 Months 262 Assess Preadmission Diabetes Status and Antidiabetic Treatment 262 Assess Current Nutritional Status 262 Assess Other Medications That May Affect Glycemic Status 263 Point of Care (POC) Blood Glucose (BG) Monitoring 263 Insulin Infusion in Critically Ill Patients, Intraoperatively or During Labor/Delivery 264 Critically Ill Patients in Intensive Care Units 264 Labor and Delivery 264 Order Correctional Insulin 265 Order Basal Insulin Therapy 265 Order Nutritional Insulin Therapy 266 Order Hypoglycemia Protocol 267 R. K. Garg (*) Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Coral Gables, FL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 261 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_22 262 R. K. Garg Continue Insulin Pump if Patient Can Manage the Pump: Otherwise, Switch to Basal Bolus Insulin 267 Review Blood Glucose (BG) Data Daily and Adjust Insulin Doses to Achieve Target BG Levels 268 Evaluate Diabetes Treatment at Time of Discharge 268 Follow-Up After Discharge 269 Suggested Reading 269 Obtain HbA1c Unless Available Within Last 3 Months All hyperglycemic patients should get an HbA1c at the time of admission. HbA1c helps in diagnosing new-onset diabetes or assessing the preadmission diabetes control. It also helps in advis- ing antidiabetic treatment at the time of discharge. Assess Preadmission Diabetes Status and Antidiabetic Treatment If possible, a detailed history including the duration of diabetes, type of diabetes, presence of complications of diabetes, and pre- admission diabetes treatment, especially the use of insulin, should be obtained. A focused physical examination assessing body weight, presence of neuropathy, and peripheral vascular disease should be conducted. Assess Current Nutritional Status Many hospitalized patients are rendered nothing per-oral (NPO) at the time of admission due to an impending surgery or a diag- nostic procedure or simply due to inability to eat. Make a note of the reason for NPO status and expected duration for this order. 22 Treatment of Hyperglycemia in a Hospitalized Patient… 263 Assess whether the patient will be able to swallow after lifting the NPO status and what type of foods are likely to be swallowed. Any special restrictions or additional requirements for food should be noted. Patients requiring special supplements in- between regular meals may require a modified insulin regimen. If a patient is getting enteral tube feed, note the content, rate, and times of tube feed. Similar data need to be collected for parenteral nutrition. Assess Other Medications That May Affect Glycemic Status Most hospitalized are likely to be receiving one or more medica- tions that can potentially affect BG levels. Most important medi- cations are agents like norepinephrine, dopamine, and glucocorticoids. If possible, medications for intravenous (IV) infusion should be prepared in glucose-free solutions rather than in dextrose water. Point of Care (POC) Blood Glucose (BG) Monitoring BG monitoring is often obtained using POC BG monitoring devices and is adequate for glycemic management in hospital- ized patients. However, in the intensive care unit (ICU) setting, arterial blood glucose monitoring may be available if blood oxy- gen is being monitored at the same time. In a patient eating regu- lar meals, BG monitoring should be ordered before meals and bedtime. In all other situations, blood glucose should be moni- tored at least every 6 h. More frequent monitoring may be appro- priate in critically ill patients or in a rapidly changing clinical situation. POC monitoring devices are less accurate at low BG levels. Therefore, any BG value less than 70 mg/dl should be confirmed by sending a sample for plasma glucose to the central laboratory. 264 R. K. Garg Insulin Infusion in Critically Ill Patients, Intraoperatively or During Labor/Delivery Critically Ill Patients in Intensive Care Units Most critically ill patients are NPO and have a rapidly changing clinical condition. The same may apply to some patients intraop- eratively. Therefore, insulin infusion is the preferred treatment for these patients. All hospitals with an ICU should have an approved insulin infusion protocol that the entire ICU staff are familiar with. It is always better to order continuous insulin infu- sion using hospital approved protocol. Blood glucose should be monitored every 1–4 h and insulin infusion rate adjusted using an algorithm that takes into account the current insulin infusion rate, current BG levels, and the rate of rise or fall of BG level. Blood glucose targets may vary from one hospital to another but are usually in a range of 100–180 mg/dL. As the clinical condition improves, patients should be transitioned from insulin infusion to basal bolus insulin therapy. In most hospitals, general floors are not equipped to administer insulin infusion. Therefore, it is important to switch to basal-bolus insulin before the patient leaves the ICU. Labor and Delivery Hyperglycemia during labor and delivery increases the risk of hypoglycemia in the newborn because of beta cell stimulation by glucose diffusing from the placenta. Therefore, tight glycemic control with BG target 70–110 mg/dL is recommended during labor and delivery. Most women with pregestational type 1 diabe- tes require insulin and glucose infusion to maintain glycemic con- trol. Women with type 2 diabetes and those with gestational diabetes may or may not require insulin infusion, but they need to be monitored hourly. 22 Treatment of Hyperglycemia in a Hospitalized Patient… 265 Order Correctional Insulin Correctional insulin therapy, also called sliding scale insulin therapy, is ordered for almost all hospitalized patients with hyperglycemia who are not on an insulin infusion protocol. There has been much criticism of using correctional insulin alone in a patient with diabetes. It leads to highly fluctuating blood glucose levels with high risk of both hypoglycemia and hyperglycemia. Moreover, in a patient with type 1 diabetes or insulin-requiring type 2 diabetes, using sliding scale insulin alone can be danger- ous because of the risk of diabetic ketoacidosis or hyperosmolar state. Therefore, correctional insulin therapy alone should be avoided, and it should be ordered along with basal or basal-bolus insulin therapy. However, in a non-insulin-dependent patient with mildly high BG levels after admission, it may be appropri- ate to order correctional insulin alone for 1–2 days while assess- ing the need for basal and nutritional insulin. Correctional insulin doses should be administered after each POC BG testing and, if possible, combined with nutritional insulin doses. Thus, insulin formulation used for correctional insulin should be the same as used for nutritional insulin. Correctional insulin doses should be administered in proportion to the total daily insulin doses: a lower scale for patients with total daily dose of insulin <40 units, medium scale for patients with total daily dose of insulin 41–80 units, and higher scale for those with total daily dose of insulin >80 units/day. Avoid using correctional insulin more fre- quently than every 4 h to prevent the stacking effect that often leads to hypoglycemia. Order Basal Insulin Therapy Most hyperglycemic patients should receive basal insulin ther- apy in the hospital. Basal insulin can be an intermediate-acting insulin used twice daily or a long-acting insulin used once daily. Long- acting insulin may be administered in the morning or at 266 R. K. Garg bedtime. The dose of basal insulin can be decided on the basis of preadmission insulin needs or current insulin needs if on IV insu- lin infusion or body weight. In a patient with good glycemic con- trol on insulin at home, total daily dose of insulin may be divided into 50% as basal insulin and 50% as the nutritional insulin need. In general, 80% of the preadmission basal insulin need is an appropriate starting dose. However, full dose or even a higher dose may be used if the admission HbA1c was high. In a patient coming off an insulin drip, insulin infusion rates in the last few hours may guide the basal insulin dose. However, if no informa- tion is available, weight-based basal insulin dose starting at 0.25 unit/kg is appropriate. Order Nutritional Insulin Therapy Once a patient starts receiving nutrition, insulin coverage is needed. Nutritional insulin coverage depends on the type of nutri- tion and it should be customized for each patient. If the patient is on an insulin infusion protocol, insulin infusion rates may be adjusted to cover all the nutritional insulin needs. For parenteral nutrition, regular insulin may be added to the IV nutrition. However, mostly the patients are switched to subcutaneous insu- lin when they start receiving enteral nutrition. In a patient eating regular meals, nutritional insulin doses may be assessed from the total daily dose of insulin and given as three equal premeal doses of a short-acting insulin. Nutritional insulin should be held if a meal is missed. It may be administered after a meal if oral intake is unreliable and reduced in proportion to the food intake. In a patient unable to eat regular meals but able to ingest semisolids or liquids, rapid-acting insulin is given before each meal. In a patient receiving tube feeds, rapid-acting insulin every 4 h or regular insulin every 6 h should be used during the duration of tube feeds. Often a much higher nutritional insulin coverage is needed with tube feeds than with regular meals. In a patient on bolus tube 22 Treatment of Hyperglycemia in a Hospitalized Patient… 267 feeds, a rapid-acting insulin dose at the time of each bolus of tube feed should be ordered. Order Hypoglycemia Protocol All patients on insulin should have an order for hypoglycemia protocol. Treatment for hypoglycemia should start at BG level <70 mg/dL. Any low BG value should be confirmed by sending a stat plasma glucose test unless the patient is symptomatic in which case treatment should be administered immediately. If patients are able to eat, give 4 ounces of juice, non-diet soda, or 8 ounces of nonfat milk. If unable to eat but an IV line is in place, give dex- trose 50% 1 ampule (25 g). If unable to take orally and no IV line is in place, give glucagon HCl 1 mg IM. Check BG every 15–30 min and repeat one of the three treatments till BG level is above 80 mg/dL. Continue Insulin Pump if Patient Can Manage the Pump: Otherwise, Switch to Basal Bolus Insulin Many patients with type 1 diabetes and some with type 2 diabetes may be using insulin pump before admission to hospital. Evaluate patients’ proficiency with insulin pump, their clinical condition to manage their own pump, and the availability of pump supplies. If all conditions are ideal, i.e., the patient is well educated about insulin pump use and clinically (mentally and physically) able to take care of pump and can provide all their supplies for the pump, insulin pump can be continued as inpatient. Basal rates may need to be lowered (generally to about 80% of home dose) to prevent hypoglycemia. If the patient becomes unable to manage pump at any time during hospitalization, he/she should be switched to basal bolus insulin. 268 R. K. Garg Review Blood Glucose (BG) Data Daily and Adjust Insulin Doses to Achieve Target BG Levels It is important to review BG data at least once daily and adjust insulin doses to achieve target BG levels and to prevent hypogly- cemia. Basal insulin should be adjusted to keep the fasting BG <140 mg/dL, and nutritional insulin should be adjusted to main- tain all other BG levels in 100–180 range. Insulin doses should be increased by 10–20% at a time to produce a meaningful effect. A rapid increase in insulin dose may be appropriate depending on the clinical condition and BG levels. Any BG value <100 mg/dL in the previous 24 h should lead to a decrease in insulin dose to prevent hypoglycemia. Any BG <70 mg/dL or symptomatic hypo- glycemia should lead to immediate reevaluation to prevent recur- rence of hypoglycemia. Evaluate Diabetes Treatment at Time of Discharge Clinical condition may

have changed during hospitalization necessitating changes to preadmission treatment for diabetes. Additionally, changes to diabetes treatment may be indicated due to poor preadmission diabetes control. In general, if HbA1c was <7% at time of admission, the patient should be discharged on the pre-hospitalization treatment. If HbA1s was 7–8%, adjust the pre- hospitalization treatment without making drastic changes to treat- ment. For example, doses of non-insulin agents or insulin may be increased or decreased, but avoid adding additional antidiabetic agents. An HbA1c >8% suggests that changes in treatment are needed but it depends on the glycemic goal for an individual patient. If a change in antidiabetic medications is made, the patient and the outpatient diabetes care provider should be informed of the change and the rationale for it, and a follow-up plan must be developed. 22 Treatment of Hyperglycemia in a Hospitalized Patient… 269 Follow-Up After Discharge Discharge plan should include a timely follow-up visit for contin- ued outpatient diabetes care. An appointment should be made for the patient to see their diabetes care providers within 7–30 days of discharge. Because glycemic control is expected to change after discharge, make sure that the patient is able to contact a diabetes care provider in case of high or low blood glucose levels. Suggested Reading American Diabetes Association. 14. Diabetes care in the hospital. Diabetes Care. 2017;40(Suppl 1):S120–7. Garg R, Hudson M, editors. Hyperglycemia in the hospital setting. New Delhi: JP Brothers; 2014. Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guide- line. J Clin Endocrinol Metabol. 2012;97(1):16–38. Hypoglycemia in Patients 23 with Diabetes Margo Hudson Contents Questions to Ask When a Patient with Diabetes Has Hypoglycemia in the Hospital 272 Defining Hypoglycemia in the Inpatient Setting 272 Detecting Hypoglycemia 272 Frequency of Hypoglycemia in Patients Treated with Insulin 273 Deleterious Effects of Hypoglycemia 274 Identifying Patients Most at Risk for Hypoglycemia 274 Insulin Action 276 Initial Dosing of Insulin to Avoid Hypoglycemia 276 What to Do When Hypoglycemia Occurs 279 Hospital Surveillance and Reporting: Glucometrics 280 Beyond Basal-Bolus Insulin: Glucose Control Without Hypoglycemia 280 Suggested Reading 281 M. Hudson (*) Brigham and Women’s Hospital, Department of Endocrinology, Hypertension and Diabetes, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 271 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_23 272 M. Hudson Questions to Ask When a Patient with Diabetes Has Hypoglycemia in the Hospital • Has the patient received insulin or sulfonylurea agent to cause hypoglycemia? • Does the patient have an underlying condition predisposing to hypoglycemia such as renal or hepatic failure or advanced age? • Was the insulin dose weight based or home dose? • Are eating habits different in the hospital compared to home? • Was prandial insulin mismatched to meal time or meal size? • Were continuous tube feedings or TPN held or decreased? • Was correctional insulin “stacked”? • Were glucose checks done at correct times? • Has there been a decrease in medications that cause hypergly- cemia such as glucocorticoids or vasopressors? • Does the hospital have systems in place to help detect, treat, and prevent hypoglycemia? Defining Hypoglycemia in the Inpatient Setting Inpatient hypoglycemia has previously been defined as any glu- cose <70 mg/dl (3.9 mmol/l) and severe hypoglycemia as glucose <40 mg/dl (2.2 mmol/l) independent of symptoms. However, as of 2017, the American Diabetes Association has modified the defini- tion which now applies to inpatients and outpatients. Level 1 hypoglycemia is any glucose ≤70 mg/dL which is sufficiently low to warrant acute treatment with fast-acting carbohydrate as well as to adjust therapy to prevent in the future. Level 2 hypoglycemia is any level <54 mg/dL (3.0 mmol/l) which is sufficiently low to be considered serious and clinically important. Level 3 hypogly- cemia is any glucose low enough to cause severe cognitive impair- ment which requires external assistance. Detecting Hypoglycemia Frequent glucose monitoring is required to detect hypoglycemia with use of insulin. Point of care (POC) testing provides immedi- ate actionable results. Glucose values obtained with venous 23 Hypoglycemia in Patients with Diabetes 273 blood draws sent to the lab are generally less helpful than POC because of the significant time delay for resulting as well as a tendency for glucose levels to decrease in the tube unless sodium fluoride has been added to inhibit glycolysis. However, some medical conditions such as extremes of hematocrit and periph- eral ischemia may render POC testing less accurate and require venous draws. With IV insulin protocols, monitoring should be done at least every 1–2 h. With subcutaneous insulin, monitoring is usually at least four times a day: at meals and bedtime when patients are eating and every 6 h when they are NPO. In the inpa- tient setting, it is important to remember that patients may not manifest usual symptoms of hypoglycemia because of concomi- tant use of drugs that mask symptoms or diminished cognition from underlying medical conditions, so vigilance is important in detecting hypoglycemia. Frequency of Hypoglycemia in Patients Treated with Insulin Rates of hypoglycemia vary by severity of underlying condition (critical or noncritical), type of glycemic treatment (intravenous insulin or basal-bolus insulin or sliding scale alone), and target glucose range. In the Normoglycemia in Intensive Care Evaluation- Survival Using Glucose Algorithm Regulation (NICE- SUGAR) study, patients in the ICU were randomized to IV insu- lin targeting glucose of 80–110 mg/dl or 140–180 mg/dl. Nearly 7% of the patients with the lower glucose targets had at least one episode of BG below 40 mg/dl which was significantly greater than the less than 1% rate in the patients in the higher target range. In another study on a general surgical ward, patients with diabetes were randomized to basal-bolus insulin or sliding scale alone with glucose target ranges of 100–140 mg/dl in both groups. In the basal-bolus group, the mean glucose was 145 mg/dl, and in the sliding-scale-alone group, the mean glucose was 175 mg/dl. Incidence of glucose <70 mg/dl was 23% in the basal-bolus group and 4.7% in the sliding scale group. And, a third study looking at insulin dosing found that rates of hypoglycemia are greater with total daily doses of insulin exceeding 0.6 units/kg/day compared to lower doses. The implication of these studies is not to use 274 M. Hudson sliding scale alone rather than basal-bolus or IV insulin but rather to use basal-bolus therapy or IV insulin with appropriate targets and methods for dose calculation. In order to reduce potential for hypoglycemia, most professional society guidelines suggest glu- cose target goals should be fasting 100–140 mg/dL, premeal <140 mg/dL, and random <180 mg/dL on the general medical ward and 140–180 mg/dl in the ICU setting. Deleterious Effects of Hypoglycemia Hypoglycemia in the inpatient setting is strongly associated with higher mortality. In a review of general ward patients with diabe- tes, each day with any BG <50 mg/dl was associated with an 85% increase in inpatient death, 65% increase in 1-year mortality, and 2.5 extra days of hospitalization. In another retrospective study, inpatients on insulin with an episode of hypoglycemia (BG <50 mg/dl) had an in-hospital mortality rate of 20.3% compared to 4.5% mortality rate in insulin-treated patients without hypogly- cemia. In the NICE-SUGAR study, ICU patients on the lower tar- get insulin drip protocol who had severe hypoglycemia (BG <40) had 79% higher mortality than patients on the same insulin drip protocol who did not experience hypoglycemia. In the subset of patients with diabetes, moderate hypoglycemia was associated with 58% higher mortality and severe hypoglycemia with 85% higher mortality than patients with diabetes who did not have hypoglycemia. Whether hypoglycemia is the driver of higher mortality or a marker of poor health, it is clear that it should be avoided if possible. Identifying Patients Most at Risk for Hypoglycemia Patients admitted to the hospital often have multiple medical problems. The elderly and patients with renal or hepatic failure are at high risk for hypoglycemia because of decreased gluconeo- genesis as well as decreased insulin metabolism. Another risk 23 Hypoglycemia in Patients with Diabetes 275 Table 23.1 High-risk 1. Change in nutrition situations for hypoglycemia (a) H olding TPN, tube feeds, or sudden NPO status (b) Patient off floor at meal time 2. Drop in steroid dose 3. Patients who are on pressors and iv insulin together who then have pressors decreased 4. Acute kidney or liver injury 5. Stress hyperglycemia treated with insulin when stress resolves group is patients with unusually high outpatient insulin doses (over 1 unit/kg/day total daily dose) which may indicate either noncompliance or excess caloric intake, both of which will be corrected in the hospital, and therefore giving 80% of the usual outpatient dose or recalculating with standard weight-based dos- ing may be prudent. Common inpatient situations that lead to an acute drop in insu- lin requirements are listed in Table 23.1. Change in nutrition is responsible for many episodes of hypoglycemia. Patients with insulin “on board” and who are on TPN or enteral tube feeds who have the feedings held or decreased or patients who are eating and are made NPO or do not eat a complete meal are particularly vul- nerable. Other common high-risk scenarios include patients on high-dose steroids who have the steroid dose dropped, patients on high insulin infusion rates due to vasopressors who have them tapered, and patients who develop acute renal, hepatic, or adrenal failure. Patients who are actually improving such as patients with sepsis or MI and secondary acute hyperglycemia (stress hyperglycemia) will see glucose levels drop and insulin require- ments decrease. Hypoglycemia should be anticipated in all these situations and insulin doses dropped preemptively to prevent hypoglycemia. When subcutaneous insulin has already been given, short-term IV glucose infusion may be necessary to avoid hypoglycemia. For patients on continuous tube feeds, for example, that are abruptly discontinued (e.g., patient pulls out NG tube), D5W at the rate of the tube feeds or D10 at half the rate of the tube feeds will usually 276 M. Hudson be adequate to avoid short-term hypoglycemia until beyond the period of active insulin action or the tube feeds can be restored. Communication between nursing and providers is essential to manage these situations that often are unpredictable. Insulin Action Medications that may contribute to hypoglycemia in the inpatient setting include drugs in the sulfonylurea class (glyburide, glipi- zide, glimepiride in the United States), meglitinides (usually repa- glinide), and all insulins. In general, use of oral agents is discouraged in the hospital because of unpredictable and pro- longed action, especially in the setting of hepatic or renal dys- function or interruption of nutritional patterns. Insulin is the most widely used medication to treat hyperglyce- mia in the inpatient setting because the many types of insulin offer a wide range of available action profiles to allow greater flexibility in dosing. However, insulin is also responsible for medication- induced hypoglycemia because of its narrow therapeutic window. Insulin action profiles are shown in Table 23.2. Patients are most at risk for hypoglycemia at the peak action of the insulin. When two types of insulin are used, hypoglycemic potential will be additive. Premixed insulin is not recommended in the hospital set- ting because the faster-acting and longer-acting components can- not be individually adjusted. When regular insulin is given IV either as a bolus or as a continuous drip, the impact is immediate and action can persist for up to an hour after the dose. Initial Dosing of Insulin to Avoid Hypoglycemia In patients naive to insulin who are admitted to the hospital, a framework for prescribing insulin is critical to assist in meeting glucose targets and avoid hypoglycemia. Weight; age; renal, hepatic, and pancreatic functions; and steroid use all impact insu- lin requirements. Generally insulin is prescribed using a combina- tion of intermediate- or long-acting insulin (basal) with short- or 23 Hypoglycemia in Patients with Diabetes 277 Table 23.2 Insulin action profiles (subcutaneously) Type of insulin Name Onset Peak Duration Rapid acting Aspart (Novolog) 5–15 min 1–2 h 4–6 h Lispro (Humalog) Glulisine (Apidra) Short acting Regular (Humulin R, 30–60 min 2–4 h 6–10 h Novolin R) Intermediate NPH (Humulin N, 2–4 h 6–12 h 12–18 h acting Novolin N) 30–60 min 2–4 h 6–8

h U-500 regular insulin (only for use in insulin-resistant patients) Long acting Glargine (Lantus) 2–4 h None 22–24 h Detemir (Levemir) 17–24 h Glargine (Toujeo) 6 h None 22–36 h Degludec (Tresiba) 1 h None 42 h Premixed NPH/regular (Humulin 30–60 min 2–12 h 12–18 h insulin 70/30, Novolin 70/30) Lispro protamine/lispro 5–15 min 1–2 h 12–18 h (Humalog 75/25, Humalog 50/50) Aspart protamine/aspart 5–15 min 1–2 h 12–18 h (Novolog 70/30) rapid-acting insulin (nutritional and correctional). The schema in Fig. 23.1 is a handy way to calculate the doses. For patients on TF or glucocorticoid treatment, consider using 60% of TDD as nutri- tional component rather than 50%. Correctional insulin (sliding scale) can be prescribed based on the calculated total daily dose so that if TDD is less than or equal to 40 units, use a correctional scale of 1 unit rapid-acting or short- acting insulin for every 50 mg/dl above goal. For TDD over 40 units a day, consider using 1 unit for every 25 mg/dl above goal. Correctional insulin is generally given with a rapid-acting insulin analog before meals and before bed in patients who are eating and with regular human insulin every 6 h in patients who are on continuous feedings, TPN, or NPO. Outside of hyperglyce- mic emergencies, correctional insulin should not be given more frequently than this to avoid hypoglycemia from overlapping the 278 M. Hudson a Baseline weight-based TDD 0.5 unit/kg/day, adjust by Estimate factors listed below Age > 70 years –0.1 unit/kg/day Renal insufficiency (eGFR < 45) –0.1 unit/kg/day Advanced Cirrhosis –0.1 unit/kg/day Pancreatic deficiency (chronic pancreatitis, cystic fibrosis, s/p –0.1 unit/kg/day pancreatectomy) HbA1c >10% +0.1 unit/kg/day Currently on glucocorticoids with equivalent of prednisone 40 mg/day +0.1 unit/kg/day or greater FINAL TDD estimate ? b TDD Basal Nutritional (40–50%) (50–60%) Example: 60 kg patient with TDD estimate 0.5 unit/kg/day 0.5 X 60 = 30 units TDD with 50% basal and 50% nutritional 30÷2=15 units basal and 15 units prandial (5 units AC) Fig. 23.1 (a) Step 1: initiation of insulin and determination of total daily dose (TDD). Use weight or if patients on insulin as outpatient consider 80% of home dose, but not to exceed 1 unit/kg TDD (b) Step 2: Components of insulin program: basal, nutritional, correctional. (Reprinted from Hudson M.S., Palermo N.E. Diabetes in Older Adults, pp. 1–18, In: Rosenthal R., Zenilman M., Katlic M. (eds) Principles and Practice of Geriatric Surgery, © 2017, with permission from Springer Nature. See Suggested Readings) actions of repeated doses, a phenomenon known as “stacking.” Some institutions give only “half” scale for bedtime correctional insulin to avoid potential for overnight hypoglycemia. 23 Hypoglycemia in Patients with Diabetes 279 What to Do When Hypoglycemia Occurs All hospitals should have protocols in place for managing acute hypoglycemia both on the general wards and in the ICU. Generally, treatment should be started in the hospital when glucose falls below 70 mg/dl. If possible, patients should be treated orally. A nursing protocol should be in place for treat- ment (Fig. 23.2). The art of managing hypoglycemia is to determine which insu- lin dose may be responsible for an episode of hypoglycemia and how much it should be reduced. Knowing the insulin action pro- file (see Table 23.2) is helpful. Generally the early morning glu- cose is the best reflection of the action of basal insulin, but this may not be the case if the patient is receiving rapid-acting insulin late at night (nighttime correctional scales) or overnight (e.g., with continuous enteral nutrition). Premeal or pre-bed hypoglyce- mia may reflect the rapid-acting insulin given with the previous meal. If the hypoglycemia is associated with a significant change in medical condition (stopping steroids, e.g., or acute renal failure), dose adjustments in the range of 30–50% may be necessary. However, if the patient is otherwise clinically stable, a simple cal- culation for adjusting insulin is to decrease the TDD of insulin by Treatment of Hypoglycemia 1. Give 15 g of sugar (no artificial sweetners) as 1/2 cup of fruit juice or 1 cup skim or 3 packs of sugar in water or 3 − 4 commercial glucose tablets (4–5 g glucose each). 2. Wait 15 min and re-test blood sugar. Retreat until glucose is at least over 70 mg/dl. 3. If the patient is unable to take orally for any reason (loss of consciousness, aspiration risk, etc.) glucose should be given IV generally 12.5–25 g of dextrose as D50 IV push. 4. If patient does not have an adequate IV to handle D50W push, then glucagon 1 mg IV or IM can be given. Fig. 23.2 Treatment of hypoglycemia 280 M. Hudson 10% for glucose values running 70–99 mg/dl and to decrease the TDD by 20% for any glucose value below 70 mg/dl. Hospital Surveillance and Reporting: Glucometrics Hospitals should have in place quality improvement programs to monitor glucose values generally and episodes of hypoglycemia specifically so that areas with recurrent problems can be identi- fied and causes addressed. The Society for Hospital Medicine has developed a national Glucose Control Mentored Implementation Program that hospitals can join to report their glucose values. The hospital can then be benchmarked against other institutions for metrics such as days with any glucose below 70 mg/dl. In this way, the institution can assess performance on a national level and hopefully find ways to improve patient care. For more information, go to http://dev.hospitalmedicine.org/Web/Quality_ Innovation/Implementation_Toolkits/Glycemic_Control/Web/ Quality___Innovation/Implementation_Toolkit/Glycemic/ Track_Performance/Introducing_Glucometrics.aspx Beyond Basal-Bolus Insulin: Glucose Control Without Hypoglycemia Because of concern for hypoglycemia and its potentially devastat- ing consequences, improvements on current basal-bolus treat- ment recommendations are being actively studied. A trial comparing basal-bolus insulin to basal plus correctional insulin (i.e., no scheduled mealtime insulin) showed similar average glu- cose values but less moderate hypoglycemia (<70 mg/dl) in the basal plus correctional treatment group. Other trials have looked at using DPP-4 inhibitors or GLP-1 receptor agonist agents in the inpatient setting, but these have not received general acceptance at this time. 23 Hypoglycemia in Patients with Diabetes 281 Suggested Reading American Diabetes Association. Diabetes care in the hospital. Diabetes Care. 2017a;40(Suppl 1):S120–7. American Diabetes Association. Glycemic targets. Sec 6. In Standards of medical care in diabetes–2017. Diabetes Care. 2017b;40(Suppl. 1): S48–56. Garg R, Hurwitz S, Turchin A, Trivedi A. Hypoglycemia, with or without insulin therapy, is associated with increased mortality among hospitalized patients. Diabetes Care. 2013;36(5):1107–10. Hudson MS, Palermo NE. Diabetes in older adults. In: Rosenthal R, Zenilman M, Katlic M, editors. Principles and practice of geriatric surgery. Cham: Springer; 2017. p. 1–18. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283–97. Rubin DJ, Rybin D, Doros G, McDonnell ME. Weight-based, insulin dose- related hypoglycemia in hospitalized patients with diabetes. Diabetes Care. 2011;34(8):1723–8. Society of Hospital Medicine. Quality & innovation. External sources & benchmarking/glycemic control implementation toolkit 2017 https:// www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_ Toolkits/Glycemic_Control/Web/Quality___Innovation/Implementation_ Toolkit/Glycemic/Track_Performance/external_sources_benchmarking. aspx. Turchin A, Matheny ME, Shubina M, Scanlon JV, Greenwood B, Pendergrass ML. Hypoglycemia and clinical outcomes in patients with diabetes hospi- talized in the general ward. Diabetes Care. 2009;32(7):1153–7. Umpierrez GE, Smiley D, Jacobs S, Peng L, Temponi A, Mulligan P, Umpierrez D, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care. 2011;34(2):256–61. Umpierrez GE, Smiley D, Hermayer K, Khan A, Olson DE, Newton C, et al. Randomized study comparing a Basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169–74. Hypoglycemia in Patients 24 Without Diabetes Rajesh K. Garg Contents Diagnosis of Hypoglycemia in Patients Without Major Acute or Chronic Illness 284 Diagnosis in Patients with Major Illness 284 Symptoms and Signs of Hypoglycemia 284 Causes of Hypoglycemia 285 Medications 285 Organ System Failure Like Cardiac, Renal, or Liver Failure 285 Sepsis and Adrenal or Pituitary Insufficiency Are All Associated with Hypoglycemia 285 Non-islet Cell Tumors 286 Antibody-Induced Hypoglycemia 286 Endogenous Insulin Production 286 Pseudohypoglycemia 287 Laboratory Investigations for Hypoglycemia 287 Prolonged Fasting Test 287 Mixed Meal Test 289 R. K. Garg (*) Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Coral Gables, FL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 283 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_24 284 R. K. Garg Differentiating Insulin-Mediated Versus Non-insulin-Mediated Hypoglycemia 289 Imaging Studies for Insulinoma 290 Treatment of Hypoglycemia 291 Suggested Reading 291 Diagnosis of Hypoglycemia in Patients Without Major Acute or Chronic Illness Symptoms and signs of hypoglycemia are often nonspecific. Therefore, Whipple’s triad must be satisfied to make a diagnosis of hypoglycemia. Whipple’s triad includes low blood glucose lev- els, the presence of symptoms or signs of hypoglycemia at the time of low blood glucose levels, and recovery from symptoms or signs by raising blood glucose levels. Diagnosis in Patients with Major Illness Sick patients may not feel symptoms or signs of hypoglycemia. Therefore, any blood glucose <55 mg/dL needs evaluation in a sick person. Spontaneous hypoglycemia in a sick person is often not caused by hyperinsulinemia. Both insulin-mediated and non- insulin- mediated hypoglycemia in the hospital setting are associ- ated with high mortality. Symptoms and Signs of Hypoglycemia Symptoms and signs of hypoglycemia can be divided into auto- nomic or neuroglycopenic. Autonomic symptoms and signs including hunger, palpitation, anxiety, tachycardia, tremor, pallor, and diaphoresis appear early as the blood glucose levels start going down. Neuroglycopenic symptoms and signs including behavioral changes, confusion, loss of consciousness, and seizures appear later and at much lower blood glucose levels. However, in 24 Hypoglycemia in Patients Without Diabetes 285 patients getting frequent hypoglycemic episodes, autonomic symptoms and signs may be suppressed, and as a result they may present with neuroglycopenic symptoms. Causes of Hypoglycemia Medications The most common medications that cause hypoglycemia are insu- lin or insulin secretagogues and alcohol. However, the list of drugs associated with hypoglycemia is long and ever growing. Check all current medications that a patient is taking that may cause hypoglycemia. However, the evidence regarding associa- tion between most drugs and hypoglycemia is rather weak. Therefore, in many cases, diagnosis of drug-induced hypoglyce- mia can only be made after excluding other causes. More often, drugs are a contributing factor to hypoglycemia caused by another major problem, like organ system failure. Organ System Failure Like Cardiac, Renal, or Liver Failure The liver is the main glucogenic organ with the kidney contribut- ing to gluconeogenesis to some extent. Therefore, hypoglycemia is common in the presence of liver failure, and the risk of hypo- glycemia increases in the presence of renal failure. Severe heart failure can cause hypoglycemia due to inanition and liver congestion. Sepsis and Adrenal or Pituitary Insufficiency Are All Associated with Hypoglycemia Major illness is evident in this setting. A high index of suspicion and targeted testing are needed to rule in adrenal and pituitary insufficiency. 286 R. K. Garg Non-islet Cell Tumors Tumors associated with hypoglycemic are mostly large mesen- chymal tumors that secrete IGF-II. In these cases, IGF-II level or its ratio to IGF-I is increased. However, a few reports of IGF-1 secreting tumors leading to hypoglycemia have also been published. Antibody-Induced Hypoglycemia Insulin antibodies can bind endogenous insulin and release it in large amounts periodically to cause hypoglycemia. Antibodies may also directly bind to insulin receptors and cause hypoglyce- mia. In the presence of antibody-induced hypoglycemia, insulin levels are often reported extremely high (>100 mU/L) due to the antibodies interfering with the insulin assay. C-peptide and proin- sulin levels can be high, normal, or low. Endogenous Insulin Production Insulinoma- and non-insulinoma-related hyperinsulinemia are rare but important causes of hypoglycemia. Insulinomas are often small, single, benign tumors with very low recurrence rate after resection. However, they may also occur as part of the MEN-1 syndrome where they can be multiple and have a high recurrence rate. Non-insulinoma-related hyperinsulinemia has been described most often after bariatric surgery. It is due to diffuse islet hypertrophy, sometimes with hyperplasia, also called as nesidio- blastosis. No single lesion can be identified in these cases, making treatment very difficult. Endogenous insulin secretion due to drugs like sulfonylureas or meglitinides must be ruled out before making a diagnosis of insulinoma- and non-insulinoma-related

hyperinsulinemia. 24 Hypoglycemia in Patients Without Diabetes 287 Pseudohypoglycemia Pseudohypoglycemia can happen in conditions with increased number of red or white blood cells. It may also happen when the blood sample is collected in a tube without an inhibitor of gly- colysis or when the processing of blood sample for glucose mea- surement is delayed. Laboratory Investigations for Hypoglycemia Laboratory investigations for hypoglycemia are necessary unless there is a clear cause of hypoglycemia, in which case it will resolve after the cause is addressed (Table 24.1). Investigations for the cause of hypoglycemia must be performed at the time of the condition. Induction of hypoglycemia may be necessary if the episodes of spontaneous hypoglycemia are infrequent. Blood glu- cose from finger-stick blood samples is appropriate for monitor- ing while waiting for a symptomatic episode of hypoglycemia. However, venous blood samples for the following laboratory tests should be collected at the time of hypoglycemia: glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate, and sulfonylureas. After collecting blood, patient should receive an IV injection of 1.0 mg glucagon, and then finger-stick and plasma glucose should be measured at 10, 20, and 30 min after the injection. Prolonged Fasting Test A prolonged fasting test is indicated when the patient complains of fasting hypoglycemia, but it is hard to observe an episode of spontaneous hypoglycemia. A prolonged fast test can take up to 72 h to be diagnostic. A sufficient amount of noncaloric, non- caffeinated beverages may be administered during the test in order to prevent dehydration. Although it can be started at any 288 R. K. Garg Table 24.1 Differential diagnosis of spontaneous hypoglycemia Diagnosis Laboratory tests Comment Endogenous High insulin, C-peptide, and Prolonged fasting may insulin proinsulin be required to induce production: Low beta- hydroxybutyrate hypoglycemia insulinoma and Response to glucagon diffuse islet cell Absence of insulin hyperplasia secretagogue drugs Exogenous High insulin Detailed history may insulin Low C-peptide and proinsulin reveal exogenous Low beta- hydroxybutyrate insulin use Response to glucagon Absence of insulin secretagogue drugs Drug induced: High insulin, C-peptide, and Detailed history sulfonylurea-like proinsulin including examination drugs Low beta- hydroxybutyrate of all drugs and Response to glucagon supplements is Presence of insulin important secretagogue drugs Non-islet tumors: Low insulin, C-peptide, and Presence of tumor producing IGF-II proinsulin may be obvious Low beta- hydroxybutyrate Response to glucagon Absence of insulin secretagogue drugs High IGF-II levels Non-insulin- or Low insulin, C-peptide, and Presence of obvious insulin- like proinsulin severe acute or chronic factor-related High beta- hydroxybutyrate illness condition: organ No response to glucagon system failure, Absence of insulin endocrine secretagogue drugs deficiencies Antibody Very high insulin levels Blood glucose levels mediated High or low C-peptide and highly variable. Other proinsulin autoimmune Low beta- hydroxybutyrate conditions may be Response to glucagon present Absence of insulin secretagogue drugs 24 Hypoglycemia in Patients Without Diabetes 289 time of the day in a patient admitted to hospital, it is best that the prolonged fast test be started in the morning because the majority of patients with significant underlying pathology are likely to become hypoglycemic within the first 8 h and appropriate testing would be possible before the night shift when access to staff and other resources may be limited. However, if hypoglycemia does not develop within 8 h, fasting should continue until the time of symptomatic hypoglycemia or up to 72 h before ending the fast. Patients should be closely monitored for signs and symptoms including mental status checks along with finger-stick blood glu- cose determinations. Low blood glucose values should be con- firmed by laboratory plasma glucose determination. The prolonged fast test should be ended when the patient is symptomatic with plasma glucose <55 mg/dL or the plasma glucose is <45 mg/dL even without symptoms or 72 h have elapsed. Laboratory investi- gations described in previous section should be obtained at this point before ending the prolonged fast test. Mixed Meal Test If hypoglycemia symptoms occur postprandially, a mixed meal test may be able to induce hypoglycemia and allow investigation at the time of hypoglycemia. In general, the meal should be simi- lar to the one that causes spontaneous hypoglycemia. However, if this not practical, a liquid nutritional formula may be used. The test should be conducted in the morning after an overnight fast. Blood glucose should be monitored every 30 min for 4 h. Blood glucose criteria for ending the test are similar to those for the pro- longed fast test. Differentiating Insulin-Mediated Versus Non-insulin-Mediated Hypoglycemia Diagnosis of endogenous hyperinsulinemia depends on demon- strating high insulin, high C-peptide, high proinsulin, low beta- hydroxybutyrate, and absence of sulfonylureas and meglitinides 290 R. K. Garg at the time of hypoglycemia. Because hypoglycemia should nor- mally suppress insulin and C-peptide levels, a plasma insulin level of ≥3.0 microU/ml and a C-peptide level of ≥0.6 ng/ml in the presence of hypoglycemia are considered abnormal. A proin- sulin level of ≥5.0 pmol/L is also highly suggestive of hyperinsu- linism due to insulinoma. If insulin levels are high in the absence of high C-peptide or proinsulin levels, exogenous insulin-induced hypoglycemia should be suspected. Insulin effectively suppresses ketone production, and a beta-hydroxybutyrate level of ≤2.7 mmol/L is indicative of an increased insulin-like effect. An increase in plasma glucose of at least 25 mg/dl after intravenous glucagon also indicates mediation of the hypoglycemia by insulin- like effect. Therefore, low beta-hydroxybutyrate and adequate response to glucagon in the absence of high levels of insulin sug- gest the presence of IGF. Insulin secretagogue drugs like sulfonyl- ureas and meglitinides cause hypoglycemia, and their presence should be ruled out before making a diagnosis of insulinoma or non-insulinoma hyperinsulinism. Non-insulin-mediated hypogly- cemia will be associated with low insulin, low C-peptide, low pro- insulin, high beta-hydroxybutyrate, and inadequate response to glucagon. In severely hypoglycemic patients, glucose require- ment >8 mg/kg/min (normal 4–6 mg/kg min) to maintain normo- glycemia suggests hypoglycemia likely due to excess of insulin or insulin-like growth factor secretion. Imaging Studies for Insulinoma Imaging for insulinoma should be ordered only when the bio- chemical diagnosis has been definitively made. The majority of insulinomas are <2 cm in size. Computed tomography or MRI can identify about 80% of insulinomas. When a lesion is not seen on CT scan or MRI scan, endoscopic pancreatic ultrasonography should be the next modality of imaging because it will detect most remaining insulinomas. Sometimes, an octreotide scan or gallium dotatate PET/CT scan may be ordered. When an insulinoma is not 24 Hypoglycemia in Patients Without Diabetes 291 visible on any of the imaging studies, hepatic venous sampling after selective arterial calcium injections may be required. In this method, calcium gluconate is sequentially injected into the splenic, gastroduodenal, and superior mesenteric arteries, and a twofold increase in insulin levels in the hepatic vein will localize the source of excess insulin to the tail of the pancreas, body of the pancreas, or head of the pancreas. Imaging using 18-FDG PET is of no proven value at this time. However, it may be useful in local- ization of the cause of non-insulin-mediated tumorigenic hypoglycemia. Treatment of Hypoglycemia Treatment of hypoglycemia depends on the cause of hypoglyce- mia, and it may be achieved by treatment of the underlying cause or surgical removal of the cause, e.g., discontinuing the offending drug, hormonal replacement, treating sepsis, or removing an islet cell tumor. In the short term, treatment of hypoglycemia or its prevention is important. Frequent oral feeding or intravenous glu- cose or glucagon may be needed. Most cases of insulinoma are cured after surgery. However, some patients with malignant insu- linoma- or non-insulinoma-mediated hyperinsulinism may need chronic treatment with diazoxide or octreotide or parenteral nutri- tion. Rare patients with nesidioblastosis may require partial or complete pancreatectomy to relieve hypoglycemia. The patient with an IGF-producing malignant tumor may also be difficult to treat. Patients with antibody-induced hypoglycemia may respond to glucocorticoids or immunosuppressive treatment. Suggested Reading Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ, Endocrine Society. Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metabol. 2009;94(3):709–28. 292 R. K. Garg Garg R, Hurwitz S, Turchin A, Trivedi A. Hypoglycemia, with or without insulin therapy, is associated with increased mortality among hospitalized patients. Diabetes Care. 2013;36(5):1107–10. Martens P, Tits J. Approach to the patient with spontaneous hypoglycemia. Eur J Intern Med. 2014;25(5):415–21. Salehi M, Vella A, McLaughlin T, Patti ME. Hypoglycemia after gastric bypass surgery: current concepts and controversies. J Clin Endocrinol Metabol. 2018;103(8):2815–26. Diabetic Ketoacidosis 25 and Hyperosmolar Hyperglycemic State Daniela V. Pirela and Rajesh K. Garg Contents Epidemiology 294 Diagnosis of DKA 294 Signs and Symptoms 294 Laboratory Tests 295 Diagnosis of HHS 297 Signs and Symptoms 297 Laboratory Tests 298 Management 298 Most Common Causes to Rule Out 298 IV Fluids 299 Insulin Therapy 299 Electrolytes 300 Monitoring 301 Criteria for Resolution 302 Complications 302 Transition of Care 303 D. V. Pirela Jackson Memorial Hospital/University of Miami Hospital, Division of Endocrinology, Diabetes and Metabolism, Miami, FL, USA R. K. Garg (*) Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine, Coral Gables, FL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 293 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_25 294 D. V. Pirela and R. K. Garg Disposition 304 Suggested Reading 306 Epidemiology According to the CDC data, there were 207,000 emergency depart- ment visits for hyperglycemic crisis in the year 2014. This amounts to 9.5 visits per 1000 persons with diabetes for DKA or HHS. However, these two entities represent an extreme on the spectrum of avoidable hyperglycemic emergencies in patients with diabetes; majority of patients are admitted with hyperglycemia along with another illness. Females, adolescents, ethnic minorities, and patients with high A1c are at higher risk of DKA or HHS. The incidence of DKA has gone up, at least 6% annually from 2009 to 2014 in all age groups. Although DKA is considered pathognomonic of type 1 diabetes, at least one-third of the DKA cases occur in patients with type 2 diabetes. HHS is less common and represents less than 1% of all diabetes-related admissions. Although generally seen in adults with type 2 diabetes, HHS is becoming more frequent among children and young adults. DKA causes almost 50% of all deaths in patients with type 1 diabetes under the age of 24 years. Inpatient DKA mortality is less than 1%, while for HHS, mortality is as high as 16%. Even though the mortality risk has declined, mortality and morbidity related to acute hyperglycemic emergencies remain high, and the health-care costs remain substantial, especially taking into account the increase in incidence. Diagnosis of DKA Signs and Symptoms Evolution of DKA is rather acute. Patients often complain of fatigue and osmotic symptoms like polyuria and polydipsia. Abdominal pain, nausea, and vomiting are present in up to two- 25 Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State 295 thirds of patients. The severity of symptoms depends on multiple factors including the severity of acidosis, dehydration, and age of the patient. Neurologic symptoms such as lethargy and stupor develop in half of patients when serum osmolarity reaches 320 mOsmol/kg; loss of consciousness occurs in less than 25% of patients. Presence of altered mental status and a serum osmolarity less than 320 should prompt additional neurologic workup. Abdominal pain is more common in younger patients and seems to be related to the severity of the metabolic acidosis, which inter- feres with gastric emptying. In the absence of metabolic acidosis or if abdominal pain persists despite resolution of DKA, pancre- atitis and other gastrointestinal disorders should be considered. Dry mucosa, decreased skin turgor, and low jugular venous pres- sure can be appreciated in most of the patients due to dehydration. The presence of tachycardia and hypotension correlates with the degree of dehydration. Patients may have a fruity odor to their breath due to the exhaled ketones as well as deep hyperventilation (Kussmaul respirations). Laboratory Tests To make a diagnosis of DKA, the triad of hyperglycemia above 250 mg/dL, ketonemia, and metabolic acidosis with elevated anion gap should be present. Plasma glucose is usually between 350 and 500 mg/dL when the patient presents to the emergency department. Some patients with DKA may present with only mild elevations of blood glucose levels. This is known as euglycemic DKA; this can be seen in

patients with prolonged starvation, alco- hol intake, insufficient insulin dose, and pregnancy and in patients using SGLT-2 inhibitors that lead to glycosuria, blunting the ele- vation of blood glucose level. Hyperglycemia is secondary to the deficit of effective insulin, the excess of counterregulatory hormones, and relative increase in insulin resistance. Insulin normally blocks ketogenesis by inhibit- ing lipolysis and the transport of free fatty acid derivatives into the mitochondrial matrix. Insulin deficiency leads to unrestrained lipolysis and mobilization of triglycerides and amino acids for 296 D. V. Pirela and R. K. Garg energy use instead of glucose. Increased levels of serum free fatty acids are converted to ketones bodies and acids which are mainly acetoacetic acid and beta-hydroxybutyric acid, both strong organic acids. Hepatic gluconeogenesis is stimulated by glucagon excess and excess of other stress hormones, while alanine origi- nated from muscle catabolism and glycerol from lipolysis provide the substrate. The metabolic imbalance is characterized by a low bicarbonate level, usually less than18 mEq/L, and the accumulation of keto acids in blood that cause a drop in the arterial pH to less than 7.3 with an elevation of the anion gap above 12. In DKA, keto acids become circulating unmeasured anions. In addition, lactic acid generated from tissue hypoxia contributes to unmeasured anions further increasing the anion gap. The anion gap is calculated by the following formula: Aniongap Sodium mEq / L Potassium mEq / L   Chloride mEq / L HCO3  mEq / L  The nitroprusside test can detect ketones bodies, more specifi- cally acetoacetate, in the urine. This test does not correlate with disease severity as it can be negative in severe ketosis when beta- hydroxybutyrate becomes the predominant ketone or when lactic acidosis coexists with the ketoacidosis interfering with the mea- surement of the acetoacetate. Serum ketone levels usually are done when urine ketone test is positive; however, due to the high false-negative and false-positive urine nitroprusside tests, direct measurement of serum beta-hydroxybutyrate is preferred. Hyperglycemia may cause non-hypotonic hyponatremia. Glucose is an osmotically active substance. Therefore, in the pres- ence of hyperglycemia, increased plasma osmolality induces water movement to the extracellular space leading to reduction of serum sodium levels which is also called dilutional hyponatremia. Therefore, corrected serum sodium level should be used to calcu- late an accurate serum anion gap. To correct serum sodium level, add 1.6 mEq/L to the measured serum sodium for each 100 mg/dL of glucose greater than 100 mg/dL. A normal measured sodium 25 Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State 297 level in the setting of hyperglycemic DKA is suggestive of pro- found hypovolemia. Serum bicarbonate is usually below 10 mmol/l and pH 6.8–7.3. Infrequently, the pH may not be sig- nificantly decreased due to compensatory hyperventilation, which will decrease the partial pressure of carbon dioxide. There is an increased urinary loss of potassium due to the glu- cose osmotic diuresis and the excretion of potassium keto acid anion salts which lead to deficit of the total body potassium. The metabolic acidosis, hyperosmolarity, and insulin deficiency cause a shift of potassium from intracellular fluid to extracellular fluid. Therefore, the serum potassium concentration is usually normal or even elevated initially. Once insulin therapy is introduced, potassium shifts back into cells which rapidly lower the potas- sium concentration and may lead to severe hypokalemia. At presentation, serum phosphate is usually normal or high because both insulin deficiency and metabolic acidosis cause a shift of phosphate out of the cells. However, there is a decreased phosphate intake and phosphaturia caused by osmotic diuresis that result in a net phosphate depletion. Thus, after volume and insulin replacement, hypophosphatemia ensues. Diagnosis of HHS Signs and Symptoms Hyperosmolar hyperglycemic state (HHS) presentation has a less acute presentation than DKA. Symptoms of polyuria, polydipsia, and weight loss are more evident and often start several days or weeks before the hospital admission. Blurred vision and progres- sive decline in mental status are also evident. Severe dehydration and high plasma osmolarity lead to mental obtundation and coma that are proportional to the degree and rate of the development of hyperosmolarity. Decreased skin turgor, dry oral mucosa, low jugular venous pressure, tachycardia, and hypotension are more evident in HHS compared to DKA. Rarely patients can develop abdominal pain. 298 D. V. Pirela and R. K. Garg Laboratory Tests The serum glucose concentration is much higher, frequently exceeding 600 mg/dL, but can be higher than 1000 mg/dL in HHS. The endogenous insulin production is sufficient to suppress ketogenesis. Therefore, ketone levels remain within normal lim- its, which means the pH, the serum bicarbonate, and the anion gap stay normal as well. The glycosuria leads to severe dehydration and an effective plasma osmolarity typically above 320 mOsmol/ kg. Hyponatremia is usually present through the same mechanism as in DKA and is sometimes more severe. Similar to DKA, the serum potassium concentration is usually normal, though in one- third of patients it is elevated up to 5.7 mEq/L on admission. After proper insulin therapy and fluid resuscitation, potassium shifts back into the cells uncovering the total body potassium deficit. Other laboratory results such as leukocytosis, increased BUN, and creatinine are proportional to the degree of hypovolemia. Management Most Common Causes to Rule Out • Medication nonadherence. • Infections. Obtain urine and blood cultures, chest radiograph, and other tests in selected cases. • Pancreatitis. Obtain serum lipase and amylase when pancreati- tis is clinically suspected. The result must be interpreted with caution because some increase in amylase can be associated with DKA itself. • Tissue ischemia such as cardiac ischemia and cerebrovascular accidents. Obtain cardiac enzymes and electrocardiogram, and perform neurologic assessment. • Concomitant medications. Look for medications that may have precipitated the acute hyperglycemic emergency including glucocorticoids, beta-blockers, thiazide diuretics, certain 25 Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State 299 chemotherapeutic agents, atypical antipsychotics, and SGLT2 inhibitors. • Severe dehydration. Mainly bedridden and elderly patients are in danger of having compromised access to water; this is exac- erbated by the altered thirst response in some of them. Newly diagnosed and even undiagnosed fragile patients, particularly residents of chronic care facilities, may be at risk of delayed recognition of hyperglycemic symptoms and severe dehydra- tion. Administration of insulin, without initial proper fluid replacement, may accentuate hyperosmolality by moving water intracellularly which further aggravate vascular collapse, hypotension, and even death. IV Fluids Intravenous fluid is the mainstay of management of hyperglycemic crises. Fluids improve the clinical and metabolic status by decreas- ing serum glucose through urinary clearance by improving renal perfusion and by intravascular volume expansion. Isotonic saline is initially infused at 500–1000 ml/h for 2–4 h, followed by the infusion of 0.9% or 0.45% saline at 250–500 ml/h depending on the serum sodium level, the state of hydration, and the urine out- put. In general, 0.9% saline is continued in patients with low serum sodium, whereas patients with normal or elevated serum sodium or hyperosmolarity should receive 0.45% NaCl. Intravenous dextrose (5% or 10%) is added once the plasma glucose level is between 200 and 250 mg/dL, to allow continued insulin administration until ketonemia is controlled while avoiding hypoglycemia. Insulin Therapy Insulin is key component of treatment of DKA and HHS. In gen- eral, DKA resolution occurs between 10 and 18 h after initiation of therapy, while HHS resolution can take longer. Intravenous 300 D. V. Pirela and R. K. Garg regular insulin has been the treatment of choice for the manage- ment of acute hyperglycemic emergencies, but the use of subcuta- neous insulin for mild-to-moderate DKA is becoming more common. The time of resolution seems to be equivalent with either option, but the use of subcutaneous insulin mitigates the burden on the nursing staff. Insulin reduces hepatic gluconeogen- esis and suppresses lipolysis and ketogenesis. Insulin therapy will shift extracellular potassium into the intracellular space. Therefore, to avoid severe hypokalemia, serum potassium should be more than 3.3 mEq/L when insulin therapy is started. An intravenous bolus of regular insulin at a rate of 0.1 unit/kg followed by a continuous infusion at a rate of 0.1 U/kg/h (5–10 U/h) vs no bolus and infusion of insulin at a rate of 0.14 U/kg/h has shown similar outcomes. The infusion rate should be adjusted per hour to ensure that serum glucose falls by at least 50 mg/dL/h. The insulin infusion rate may be decreased by 0.05 U/kg per hour until a rate of 0.5 U/h (minimum rate) is reached. Dextrose should be added to the intravenous fluids when the plasma glucose concen- tration reaches <200 mg/dL in patients with DKA and <300 mg/dL in patients with HSS. The insulin i nfusion should be continued to maintain a plasma glucose level of 150–200 mg/dL until ketoaci- dosis has resolved, as evidenced by normalization of pH and anion gap among those with DKA, and until mental status and the hyper- osmolar state are corrected in HHS cases. The use of insulin lispro or aspart in subcutaneous boluses seems to be as effective as IV regular insulin infusion and a safe alternative for patients in situations where insulin infusion is not practical. An initial bolus of 0.2–0.3 U/kg of rapid-acting insulin followed by maintenance boluses of 0.1–0.2 U/kg every hour to 2 h may be used. Once glucose is less than 250, consider reducing the maintenance boluses until resolution of the DKA. Electrolytes Potassium Therapy The initial insulin-deficit state, hypertonic- ity, and acidosis lead to a shift of potassium from the intracellular to the extracellular compartment in the setting of total body 25 Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State 301 potassium deficit of 3–5 mmol/kg. Fluid and insulin therapy pro- mote a rapid intracellular shift of potassium, which may result in hypokalemia with the risk of arrhythmia and even cardiac arrest. Hence, early IV potassium therapy should be initiated when the serum potassium level is below 5.0 mEq/L with the goal of main- taining a potassium level of 4–5 mEq/L during therapy. An excep- tion to this rule is the case of low urine output or severely decreased renal function whereby potassium should be given only if low and monitored carefully. Bicarbonate Therapy The use of bicarbonate in DKA is contro- versial. The current ADA guidelines recommend bicarbonate therapy for the severe metabolic acidosis with a serum pH <6.9. However, no study has shown benefit from the use of this therapy. Bicarbonate use has some potential side effects including cerebral edema, hypokalemia, rebound acidosis, hypoxia, and hypernatre- mia. In view of the lack of evidence of a therapeutic effect, it should generally be avoided. Phosphate Therapy Replace if serum phosphate is less than 1 mg/dL, especially in a patient with evidence of respiratory or cardiac distress. If the phosphate level is higher than 1 mg/dL, it usually will self-correct once the patient has resumed eating. There is no evidence of a beneficial effect of phosphate replace- ment, and aggressive intravenous phosphate therapy can cause hypocalcemia; therefore, in case of phosphate replacement, cal- cium levels should be monitored closely. Monitoring All patients should get frequent clinical and laboratory reas- sessment to ensure an adequate glycemic control, adequate urine output, and electrolyte correction and avoid fluid over- load. The main assessments include finger-stick blood glucose (every hour to prevent hypoglycemia) and at least basic meta- bolic panel (every 1–4 hours to monitor potassium levels and the anion gap). 302 D. V. Pirela and R. K. Garg Criteria for Resolution Criteria for establishing the resolution of DKA include a serum glucose ≤250 mg/dL and at least two of the following criteria: nor- malization of the anion gap, a venous or arterial pH ≥7.3, and a serum bicarbonate level ≥18 mEq/L. Ketonemia and ketonuria may persist for 24–36 h due to delayed ketone elimination. Patients who recover from ketoacidosis may develop a secondary hyperchloremic non-anion gap metabolic acidosis resulting from aggressive saline administration. The serum bicarbonate may not normalize immedi- ately for this reason as it is temporarily “replaced” by chloride. In HHS, resolution may be declared when a plasma glucose level ≤250 mg/dL and normal effective serum osmolarity <310 mOsmol/ kg are achieved in the setting of a restored baseline mental status. Complications Hypoglycemia: 5–25% of the patients with DKA develop hypo- glycemia. This is due to a significant percentage of patients pre- senting with hyperglycemic emergencies have a defective

adrenergic response to low blood sugar. Therefore, a lack of fre- quent monitoring, not adjusting the insulin dose appropriately and not adding dextrose-containing solutions when blood sugar is less than 200 mg/dL, can easily lead to hypoglycemia. Hypokalemia can occur when insulin therapy is started with serum potassium less than 3.3 mEq/L because of the mechanisms discussed in electrolyte management section. Cerebral edema is rare in adults. However, the mortality in children, where it is seen more often, can be as high as 20–40%. Fluctuation in the mental status, abnormal verbal or motor response to pain, decorticate or decerebrate posturing, cranial nerve palsy, and abnormal neurogenic respiratory pattern have been described. Onset is usually 4–12 h after starting treatment of DKA. The mechanism of cerebral edema is not well understood. Either mannitol 0.5–1 g/kg IV over 20 min or 3% saline fluid 5–10 ml/kg can be used. After initiating treatment, m onitoring for thrombosis, cerebral infraction and hemorrhage is indicated. 25 Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State 303 Rhabdomyolysis, more common in HHS than DKA, can lead to renal failure. Checking creatine kinase every 2–3 h in patients with myalgia, weakness, and dark urine is recommended. Transition of Care Transition to a subcutaneous insulin regimen is indicated when the acute metabolic derangement has resolved and the patient is alert and can start oral nutrition. For patients who remain critically ill (e.g., shock requiring pressor agents, mechanical ventilation) or will undergo additional interventions (e.g., sur- gery), insulin infusion therapy should be continued. The half- life of intravenous regular human insulin is less than 10 min. Therefore, when transitioning from IV insulin to subcutaneous insulin, abrupt interruptions of the insulin infusion should be avoided. An overlap for 2–4 h of the insulin infusion and sub- cutaneous basal insulin is absolutely necessary to avoid rebound hyperglycemia and possible reopening of the anion gap from ketoacidosis. To choose a subcutaneous insulin regimen for a patient with controlled diabetes, home insulin regimen can be restarted if appropriate. However, for patients with uncontrolled diabetes and insulin-naïve or newly diagnosed diabetes, insulin can be started at a total daily dose of 0.5–0.8 U/kg/dL, 50% administered as long-acting basal insulin and the other 50% in pre-meal boluses of rapid-acting insulin analogs trying to mimic normal insulin phys- iology. Long-acting insulin analogs seem to have a lower inci- dence of hypoglycemia compared to intermediate-acting insulin (neutral protamine Hagedorn, NPH). Evidence suggests that administration of insulin glargine at a dose of 0.25 U/kg within 12 h of initiation of intravenous insulin infusion may help prevent rebound hyperglycemia following acute management of DKA. Chronic hyperglycemia leads to structural and functional damage in the beta cells decreasing the secretion of insulin and also interferes with the action of insulin in the target tissue c ausing insulin resistance. Therefore once hyperglycemia improves, insulin sensitivity changes quickly, and insulin dose adjustment 304 D. V. Pirela and R. K. Garg may be required after recovery from acute illness, especially in those with renal or pancreatic insufficiency. Disposition With proper treatment, the average time to the resolution of anion gap acidosis is 3 h. If the hyperglycemic crisis itself resolves in the emergency department, these patients may be stable enough for general floor admission to continue subcutaneous insulin, pending improved volume status after resuscitation, closed anion gap, and ability to tolerate fluids by the mouth. Patients with severe DKA or HHS often require ICU admission for adequate treatment, obser- vation, and resolution of sepsis, hypoxia, altered mental status, hypotension, persistent tachycardia, severe acidosis, or electrolyte abnormalities. Acute comorbidities such as myocardial infarction or cerebrovascular accidents may also dictate disposition to an ICU. If the patient has to stay in the emergency department longer than expected, the patient can be managed in the proper-staffed observation unit, and the need of ICU admission can be obviated. It is important to evaluate the cause of acute hyperglycemic emergency and treat it to prevent recurrence. DKA is the initial presentation of diabetes in approximately 15–20% of adults and 30–40% of children with type 1 diabetes. Early identification of new-onset diabetes in the emergency department can prompt the timely inclusion of a multidisciplinary team including an endocri- nologist, dietitian, and social worker with ability to provide diabe- tes education and arrange outpatient follow-up appointment that can prevent future hospital admissions. Visual impairment can lead to inappropriate dosing of insulin specially when using vials of insulin preparation; in these cases, an insulin pen should be considered. For patients with severe visual impairment and, also, for patients with cognitive impairment, super- vised or assisted insulin injection should be arranged with home health care, family members, or assisted living facilities/nursing home admission to prevent readmission with hyperglycemic crisis. Lipodystrophy due to repetitive insulin injection in the same area and malnourished patients with low fat mass should be coun- seled about the appropriate technique and area to inject insulin. 25 Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State 305 In patients presenting to the emergency department with hyperglycemic emergencies due to medication nonadherence, especially in those with multiple recent readmissions, further questioning should aim to identify the reason behind the medica- tion noncompliance, which in most cases is due to socioeco- nomic issues. In about half of the patients presenting with DKA or HHS due to medication nonadherence, the underlying problem is an inabil- ity to afford medication. In the United States, insulin can be very expensive and almost unaffordable for patients without insurance. For these patients, early social worker involvement may help the patient find community resources for insulin availability. For patients with limited access to health care, for example, undocumented patients, the physician should be aware of inex- pensive options in the community such as state programs, health department free options, and local pharmacies where they can purchase insulin without prescriptions. When prescribing insulin, even patients with insurance can have difficulties obtaining the insulin brand prescribed. Depending on the insurance, prescribing the right brand of insulin with the lowest copayment for the patient can make a big difference in compliance and, therefore, can prevent the next episode of DKA or HHS (Table 25.1). Table 25.1 Differences between DKA and HHS DKA HHS Severe insulin deficiency with excess of Relative insulin deficiency and counterregulatory hormones, promoting inadequate fluid intake, leading gluconeogenesis, glycogenolysis, and to gluconeogenesis and ketone formation glycogenolysis Glucose levels usually 300–500 mg/dL >600 mg/dL Plasma osmolarity <320 >320 Ketones in blood and urine Absent Metabolic acidosis with anion gap Normal pH Elevated beta-hydroxybutyrate Absent Most common symptoms: abdominal Most common symptoms: pain, nausea, vomiting polyuria, polydipsia, and altered mental status Acute onset Subacute onset 306 D. V. Pirela and R. K. Garg Suggested Reading American Diabetes Association. Summary of revisions: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(Suppl 1):S4–6. https:// doi.org/10.2337/dc18-Srev01. CDC. New CDC report: More than 100 million Americans have diabetes or prediabetes. July 18, 2017. Available online https://www.cdc.gov/media/ releases/2017/p0718-diabetes-report.html. Crilly CJ, Allen AJ, Amato TM, Tiberio A, Schulman RC, Silverman RA. Evaluating the Emergency Department Observation Unit for the management of hyperglycemia in adults. Am J Emerg Med. 2018;36(11):1975–9. https://doi.org/10.1016/j.ajem.2018.02.027. Epub 2018 Feb 27. Echouffo-Tcheugui JB, Garg R. Management of hyperglycemia and diabetes in the Emergency Department. Curr Diab Rep. 2017;17(8):56. https://doi. org/10.1007/s11892-017-0883-2. Fayfman M, Pasquel FJ, Umpierrez GE. Management of hyperglycemic cri- ses: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Med Clin North Am. 2017;101(3):587–606. https://doi.org/10.1016/j. mcna.2016.12.011. Management of Preexisting 26 Diabetes and Gestational Diabetes During Hospitalization Gregory P. Westcott and Florence M. Brown Contents Differentiate Between Preexisting Diabetes and Gestational Diabetes 308 Definition of Gestational Diabetes (See Table 26.1) 308 Glycemic Targets (See Table 26.2) 310 Treatment Options 311 Patients with Gestational Diabetes 312 Patients with Type 1 Diabetes 313 Patients with Type 2 Diabetes 314 Diabetic Retinopathy 314 G. P. Westcott Beth Israel Deaconess Medical Center and Joslin Diabetes Center, Department of Endocrinology, Diabetes and Metabolism, Boston, MA, USA e-mail: [email protected] F. M. Brown (*) Joslin-Beth Israel Deaconess Medical Center Diabetes in Pregnancy Program, Joslin Diabetes Center, Department of Adult Diabetes, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 307 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_26 308 G. P. Westcott and F. M. Brown Special Situations 314 Diabetic Ketoacidosis 314 Betamethasone Therapy 315 Labor and Delivery 315 Glycemic Targets 315 Treatment Strategies 315 Postpartum 316 Postdelivery Insulin Requirements 316 After Discharge and Future Pregnancies 316 Suggested Reading 317 Differentiate Between Preexisting Diabetes and Gestational Diabetes When evaluating patients hospitalized during pregnancy, it is important to determine whether they have preexisting type 1 or type 2 diabetes, or whether they have gestational diabetes. Knowing their preconception diagnosis and treatment as well as the circumstances of their diagnosis provides insights into their current treatment and eventual postpartum care. Definition of Gestational Diabetes (See Table 26.1) As opposed to preexisting diabetes, gestational diabetes mellitus (GDM) is diagnosed during pregnancy. GDM screening is typically performed at 24–28 weeks of gestation when insulin Table 26.1 ADA diagnostic criteria for gestational diabetes Diagnosis of gestational diabetes Glucose in mg/dl One-step 75 g Fasting: ≥92, 1 h: ≥180, 2 h: ≥153 method One abnormal value required Two-step Step 1: 50 g Non-fasting: 1 h: ≥130 to ≥140 method Step 2: 100 g (institutional) Fasting: ≥95, 1 h: ≥180, 2 h: ≥155, 3 h: ≥140, usually two abnormal values required 26 Management of Preexisting Diabetes and Gestational… 309 resistance has increased and hyperglycemia is usually apparent upon testing. Diagnosing GDM has been controversial. Recommendations have shifted over time and differ by organization. The 2018 American Diabetes Association (ADA) guidelines propose two diagnostic protocol options: a one-step fasting 75 g oral glucose tolerance test (OGTT) and a two-step evaluation which includes a 50 g non-fasting screen followed by a fasting 100 g OGTT for those who screen positive. The one-step OGTT employs glucose cutoffs of ≥92 mg/dL fasting, ≥180 mg/ dL at 1 h, and/or ≥153 mg/dL at 2 h with one abnormal value indicating a positive test. The non-fasting 50 g screen, also called a glucose loading test (GLT), uses cutoffs which range from ≥130 mg/dL to ≥140 mg/dL at 1 h, depending on institutional guidelines. The subsequent fasting 100 g OGTT is positive when at least two (or one, depending on the guideline used) of the following cutoffs, proposed by Carpenter and Coustan, are met: ≥95 mg/dL fasting, ≥180 mg/dL at 1 h, ≥155 mg/dL at 2 h, or ≥140 mg/dL at 3 h. The Carpenter-Coustan cutoffs have been demonstrated to confer additional benefit with respect to pregnancy-induced hypertension, shoulder dystocia, cesarean delivery, and macrosomia compared to the less stringent criteria from the National Diabetes Data Group, which uses OGTT cutoffs 5–10 mg/dL higher than Carpenter-Coustan. The one-step method is a more sensitive method to detect gestational hyperglycemia, and data from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) trial suggested that there is a continuous relationship between maternal glucose and primary cesarean section delivery, neonatal hypoglycemia, birth weight over the 90th percentile, and cord C-peptide over the 90th percentile, and the one-step method is therefore the method endorsed by the International Association of Diabetes and Pregnancy Study Groups (IADPSG). The complexities of the debate between the one-step and two-step methods include discussions of changes in prevalence of diagnosis, effects of outcomes, and medical costs. Women at high risk of abnormal glucose metabolism should be evaluated during the first trimester. The 2018 ACOG Practice Bulletin expanded list of criteria for patients considered high risk are those with: 310 G. P. Westcott and F. M. Brown • High-risk race or ethnicity • Hypertension • HDL cholesterol less than 35 mg/dL or triglyceride level over 250 mg/dL • Polycystic ovarian syndrome or clinical conditions associated with insulin resistance such as acanthosis nigricans • History of cardiovascular disease • Obesity • GDM during a previous pregnancy • Previous baby with birth weight over 9 pounds • Glycosuria • Having a first-degree relative with diabetes • Impaired fasting glucose These women should be evaluated with the one-step fasting 75 g 2 h OGTT. A screening GLT is not indicated in this high-risk population, as the sensitivity of this test is approximately 80% and therefore may be negative in 20% of patients with GDM. Note that alternative measures may also be incorporated in determining fetal and maternal risk. An A1c value ≥5.9

during the first trimester is associated with congenital malformations, pre- eclampsia, shoulder dystocia, and perinatal death. Note that while an A1c ≤5.9 has a high negative predictive value for ruling out overt diabetes, it is not highly sensitive in diagnosing gestational diabetes. Therefore, screening should be reassessed at 24–28 weeks of gestation with either the one-step or the two-step method for women with A1c <5.9% on early screening. Glycemic Targets (See Table 26.2) Glycemic targets are the same regardless of whether the patient has preexisting or gestational diabetes. ADA and the American College of Obstetricians and Gynecologists (ACOG) accepted targets are <95 mg/dL fasting and postprandial targets of <140 mg/ dL at 1 h and <120 mg/dL at 2 h after a meal commences (typi- cally patients measure either 1 or 2 h postprandial blood glucose, not both). However, it is noteworthy that in the normal pregnant populations, mean ± SD for fasting blood glucose is 71 mg ± 8 mg/ 26 Management of Preexisting Diabetes and Gestational… 311 Table 26.2 Glycemic targets for pregnant women with diabetes Glycemic targets Glucose in mg/dl Antepartum ACOG and ADA 2018 Fasting: <95, 1 h PP: <140, 2 h PP: Joslin <120 Fetal AC ≥75th percentile (GDM Fasting: <95a or <99b, 1 h PP: <130 only) Fasting: 60–79, 1 h PP: 90–109 Labor and delivery 80–110 Postpartum Fasting: <100, 2 h PP: <140 PP postprandial aGDM bPreexisting DM dl, and post-meal blood glucose at 1 h is 109+/−13 mg/dl and at 2 h is 99.3 ± 10 mg/dl, which are considerably lower than the upper ranges of these targets. So, some institutions advocate low- ering the upper range of targets; for example, Joslin Diabetes Center recommends 1 h postprandial glucose target of 100– 129 mg/dl. For patients with gestational diabetes, more stringent glycemic targets should be considered in patients with a fetus whose Hadlock abdominal circumference (AC) is ≥75th percen- tile prior to 34 weeks of gestation. The fetal AC discriminates low and high risk for large-for-gestational-age newborns. When high- risk fetal AC growth is identified, lower glucose targets signifi- cantly reduce excessive fetal growth. Therefore, fasting glucose target of 60–79 mg/dL and 1 h postprandial target of 90–109 mg/ dL are recommended in these patients. Note that this guidance applies specifically to gestational diabetes, since there is no evi- dence to support similar adjustments in preexisting type 1 or 2 diabetes. In women with preexisting diabetes, these targets may be quite difficult to achieve without increasing the risk of signifi- cant hypoglycemia. Treatment Options There is considerable overlap between outpatient and inpatient management of diabetes during pregnancy. In addition to moni- toring blood glucose while fasting and at peak post meal, patients 312 G. P. Westcott and F. M. Brown diagnosed with gestational diabetes and preexisting diabetes are advised to adhere to consistent carbohydrate intake with small frequent meals, for example: 30 g of carbohydrates for breakfast and 45 g for lunch and dinner with 15–20 g snacks between meals and before bed. Fasting urine ketone measurement in the morning helps identify patients who are over-restricting carbohydrates. Counseling should be provided on the quality of the diet. To con- ceptualize a healthy diet, we recommend the “Healthy Plate” in which half the plate is filled with non-starchy vegetables, one- quarter with whole grains, and one-quarter with lean protein. Fats are derived primarily from plant sources. Low-impact exercise is also encouraged. Patients with Gestational Diabetes Patients with gestational diabetes who maintain blood glucose within target ranges with lifestyle interventions alone are classi- fied as having GDMA1. For patients who are unable to maintain glucose within target range without over-restricting carbohy- drates, insulin is recommended. If there is no history of preexisting diabetes, patients who require insulin to maintain target glucose concentrations are classified as having GDMA2. In gestational diabetes, the pattern of hyperglycemia should guide the choice of insulin. To reduce fasting hyperglycemia, NPH at bedtime is considered standard of care. Insulin analogues aspart and lispro can be dosed before the meal to manage postprandial hyperglycemia, typically via a fixed premeal dose that can be titrated to achieve glycemic target. As mealtime insulin doses are up-titrated to control postprandial glucose peak, hypoglycemia prior to the subsequent meal is common and should be prevented with a small snack 2–3 h after the meal. The use of oral medications during pregnancy has been contro- versial. Until recently, ACOG had endorsed the use of glyburide and metformin for gestational diabetes despite the fact that the FDA has not approved the medications for this indication, while the ADA has stated that insulin is the first-line therapy for GDM 26 Management of Preexisting Diabetes and Gestational… 313 and type 2 diabetes in pregnancy. ACOG has now also embraced this view and considers insulin the preferred treatment for diabetes during pregnancy. Because glyburide crosses the placenta, it can contribute to fetal hyperinsulinemia, and there is evidence that it increases the risk of macrosomia, preeclampsia, neonatal hypogly- cemia, and hyperbilirubinemia. Metformin crosses the placenta, has high failure rates, and achieves therapeutic levels in the fetus, and recently published data from the metformin in gestational dia- betes trial found that at 9 years, offspring of women who received metformin during pregnancy were larger by weight, arm and waist circumference, waist-to-height ratio, BMI, triceps skinfold, and MRI abdominal fat volume. Patients with Type 1 Diabetes Patients with type 1 diabetes typically continue their current regimen with either multiple-dose injections or insulin pump therapy. This includes basal insulin and mealtime insulin admin- istered as fixed doses or determined by a ratio of insulin to cal- culated carbohydrate intake in combination with correctional insulin based on a correction factor or sliding scale. Insulin detemir is non-inferior to NPH insulin for basal dosing based on results from a randomized controlled trial. Glargine is not rec- ommended in pregnant patients or in those planning a preg- nancy, as there is no randomized controlled trial outcome data comparing it to detemir or NPH insulin. There is a six- to eightfold increased affinity of glargine for the IGF-1 receptor, which is of hypothetical concern, although insulin does not cross the placenta and therefore is unlikely to contribute to increased fetal growth. Insulin analogues aspart and lispro are preferred for mealtime dosing as above. Glulisine and degludec have not been studied in pregnancy. Insulin requirements vary throughout pregnancy in all patients on insulin, increasing in the first 9 weeks of gestation, decreasing in weeks 9–16, increasing again until week 37, and then decreasing again in the final month until delivery. Patients with type 1 diabetes may also benefit from continuous glucose monitoring. 314 G. P. Westcott and F. M. Brown Patients with Type 2 Diabetes Patients with type 2 diabetes should be treated exclusively with insulin. There is inadequate safety data regarding the use of GLP-1 agonists, DPP-4 inhibitors, alpha glucosidase inhibitors, and SGLT2 inhibitors in pregnancy. Diabetic Retinopathy In women with preexisting type 1 or type 2 diabetes, a dilated eye exam should be performed in each trimester of pregnancy with the frequency of follow-up depending on the level of baseline reti- nopathy. The level of retinopathy and the timing of the last dilated eye exam should be determined in all hospitalized patients. For patients who require prolonged hospitalization, an ophthalmology consultation may be necessary. Special Situations Diabetic Ketoacidosis DKA may occur at lower glucose levels than what is typically seen in the nongravid state (<200 mg/dl) due to the flux of glucose from the maternal to the fetal circulation via glucose transporter-1 (GLUT-1), the lowered renal threshold for glucose leading to enhanced glycosuria due to reduced tubular reabsorption capacity and increased GFR, and the accelerated starvation state that contributes to ketonemia. Infection, insulin omission or failed delivery, or the use of medications such as terbutaline or glucocorticoids may predispose to DKA. When a patient is seen in triage or as an inpatient due to concern for DKA, insulin pump infusion issues should be ruled-out and insulin given by syringe or intravenously if needed, adequate hydration ensured, and electrolyte abnormalities corrected. Insulin drip protocols should be employed when necessary. Intravenous dextrose may be required to maintain mild hyperglycemia (150–200 mg/dl) to allow for adequate insulin infusion until the anion gap is closed 26 Management of Preexisting Diabetes and Gestational… 315 and the bicarbonate level has normalized. In a recent study, fetal demise occurred in 15.6% of DKA in pregnancy cases; the need for maternal ICU admission and higher serum osmolality were risk factors for fetal demise. Betamethasone Therapy Betamethasone is often given in the setting of preterm labor as it has been shown to reduce perinatal mortality and incidence of respiratory distress syndrome in infants delivered before 34 weeks. It is typically given in two doses of 12 mg 24 h apart. An algo- rithm developed by Mathiesen and others helps proactively adjust insulin dosing to prevent severe glycemic abnormalities. On the day of the first betamethasone dose, the evening insulin dose should be increased by 25%. All insulin doses should be increased (compared to baseline dose) by 45% on day 2, by 40% on day 3, by 30% on day 4, and by 10% on day 5. On days 6 and 7, insulin doses may be reduced toward original dosing, with the caveat that requirements may not return completely to pre-glucocorticoid dosing, as baseline insulin resistance has likely increased as the pregnancy has advanced. Labor and Delivery Glycemic Targets Careful monitoring of blood glucose during labor and delivery is required. Since intrapartum glucose levels affect the risk of neonatal hypoglycemia, the risk is lowest when maternal intrapartum glucose levels average <100 mg/dL while aiming for a range between 80 and 110 mg/dL. Treatment Strategies In the setting of planned induction of labor or preeclampsia requiring magnesium infusion, oral intake may be decreased or 316 G. P. Westcott and F. M. Brown eliminated for several hours. For patients with GDM or type 2 diabetes, basal insulin doses may need to be reduced or held, depending on the timing of expected delivery, and prandial doses likewise held or reduced based on intake status. For patients with type 1 diabetes, an intravenous insulin drip is preferred while the patient is NPO during labor, delivery, and immediately postdeliv- ery. An ideal insulin drip protocol will include insulin and dex- trose infusions that can be titrated hourly by nursing staff based on finger-stick blood glucose data. When oral intake is resumed, the transition back to subcutaneous insulin can be accomplished by overlapping basal (2 h) and prandial insulin (1 h) with the insu- lin drip. An insulin drip can also be used in patients with GDM or type 2 diabetes if intrapartum blood glucose is difficult to control. Postpartum Postdelivery Insulin Requirements Following delivery, there is a significant decrease in insulin resis- tance as placental hormones clear. Patients with GDM typically do not require insulin following delivery, and it should be discon- tinued. Patients with type 2 diabetes who were not on insulin prior to conception may also be trialed off insulin. Oral medications should be held as long as the patient is breastfeeding since these medications distribute to breast milk. Postpartum blood glucose can be monitored following delivery to confirm a return to normal levels (<100 mg/dL fasting and <140 mg/dL at 2 h postprandially). Patients with type 1 diabetes typically require a reduction of insulin doses to approximately 50% of preconception dose. Breastfeeding is considered beneficial due to increased insulin sensitivity and weight loss and should be encouraged for at least 6 months if possible. After Discharge and Future Pregnancies For patients with GDM, the postpartum period is a key opportu- nity for counseling regarding interventions to reduce the risk of 26 Management of Preexisting Diabetes and Gestational… 317 developing type 2 diabetes in the future. The risk of developing type 2 diabetes is approximately 50% at 5–10 years after delivery. Dietary and exercise modifications should be encouraged, and if preconception BMI was ≥25 (or ≥23 for Asians), a goal of 7% weight loss compared to preconception weight will reduce the probability of developing type 2 diabetes in the future. All patients with GDM should undergo a 75 g 2 h OGTT at 6 weeks postpar- tum to assess for impaired glucose metabolism or type 2 diabetes. They

should also be screened for GDM or undiagnosed type 2 diabetes early in subsequent pregnancies. Prior to discharge, patients with type 1 or type 2 diabetes should be advised to sched- ule appointments 2 weeks and 6 weeks postpartum with their out- patient endocrinologist as insulin sensitivity will be returning to baseline and insulin dosing may require adjustment. The 6 weeks postpartum visit should also include labs for A1c, creatinine, and urine albumin/creatinine ratio, and TSH should be checked given the risk of postpartum thyroiditis particularly in patients with type 1 diabetes and to monitor postpartum levothyroxine dosing changes in patients with type 1 DM who have concurrent chronic lymphocytic thyroiditis. Counseling on contraceptive options and the optimal timing of the next eye exam and endocrinology fol- low- up should be provided. Suggested Reading American Diabetes Association. 13. Management of diabetes in pregnancy: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(Suppl 1):S137–S43. Brown FM, Wyckoff J. Application of one-step IADPSG versus two-step diagnostic criteria for gestational diabetes in the real world: impact on health services, clinical care, and outcomes. Curr Diab Rep. 2017;17(10):85. Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 190: gestational diabetes mellitus. Obstet Gynecol. 2018;131(2): e49–64. Garcia-Patterson A, Gich I, Amini SB, Catalano PM, de Leiva A, Corcoy R. Insulin requirements throughout pregnancy in women with type 1 diabetes mellitus: three changes of direction. Diabetologia. 2010;53(3):446–51. 318 G. P. Westcott and F. M. Brown Harvard School of Public Health. Healthy eating plate & healthy eating pyra- mid. 2011. https://www.hsph.harvard.edu/nutritionsource/healthy-eating- plate. International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010;33(3):676–82. Joslin Diabetes Center. Joslin diabetes center and Joslin clinic guideline for detection and management of diabetes in pregnancy. 2017. https://www. j o s l i n . o rg / d o c s / P r eg n a n cy - G u i d e l i n e s _ 1 1 - 1 3 - 2 0 1 6 _ c o r- rected_1-11-2017.pdf. Kjos SL, Schaefer-Graf UM. Modified therapy for gestational diabetes using high-risk and low-risk fetal abdominal circumference growth to select strict versus relaxed maternal glycemic targets. Diabetes Care. 2007;30(Suppl 2):S200–5. Mathiesen ER, Christensen AB, Hellmuth E, Hornnes P, Stage E, Damm P. Insulin dose during glucocorticoid treatment for fetal lung maturation in diabetic pregnancy: test of an algorithm [correction of algorithm]. Acta Obstet Gynecol Scand. 2002;81(9):835–9. The HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991–2002. Inpatient Insulin Pump 27 Management Maria Vamvini and Elena Toschi Contents Insulin Pump Use in the Hospital in Non-critically Ill Patients 320 Assess Preadmission Diabetes Status 320 Patients Who Can Continue Using Their Insulin Pump 321 Assess Current Nutritional Status 321 Assess Other Medications That May Affect Glycemic Status 322 Medical Orders for Insulin Pump Treatment 322 Insulin Pump Management 323 Insulin Pump Use in the Hospital in Critically Ill Patients 324 Contraindications for Self-Administered Insulin Pump Therapy 324 Special Considerations Regarding Pump Therapy 325 Insulin Pump Use in the Hospital in Patients Undergoing Surgical Procedures 325 During Imaging Studies 326 In Diabetic Ketoacidosis 326 Peripartum 327 Transition from Continuous Subcutaneous Insulin Infusion (CSII) to Multiple Daily Injection (MDI) Insulin Regimen 327 M. Vamvini · E. Toschi (*) Adult Clinic, Joslin Diabetes Center, Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Endocrinology and Diabetes, Boston, MA, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2020 319 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_27 320 M. Vamvini and E. Toschi Use of Continuous Glucose Monitor (CGM) in the Hospital 328 In Non-ICU Patients 328 In ICU Patients 328 Sensor-Augmented Insulin Pump and Hybrid Closed-Loop System 329 Evaluate Diabetes Treatment at Time of Discharge 329 Follow-Up After Discharge 330 Suggested Readings 330 Insulin Pump Use in the Hospital in Non-critically Ill Patients Assess Preadmission Diabetes Status The hospital physician should obtain a detailed medical and diabe- tes history including duration of diabetes, type of diabetes, presence of any complications, and review of most recent A1c. If A1c has not been checked in the past 3 months, patient should have a repeat A1c checked at the time of admission. The type of insulin pump and insulin formulation (Humalog or Novolog) as well as pump settings including basal rates, insulin-to-c arbohydrate ratio/s (I:CHO), and the correction or sensitivity factor/s should be clearly docu- mented. Pump settings also include target glucose (see Table 27.1). Table 27.1 Insulin order for the self-administering insulin pump Name of Insulin Pump: Type of Insulin: Target glucose: Settings: Time Basal Time I:CHO Time CF/SF (U/hour) (U/g (U/mg/ carb) dl) MN–6 AM 0.6 MN–6 AM 1:10 MN–8 AM 1:50 6 AM–12 PM 0.8 6 AM–10 AM 1:8 8 AM–8 PM 1:35 12 PM–8 PM 0.7 10 AM–4 PM 1:10 8 PM–MN 1:50 8 PM–MN 0.5 4 PM–8 PM 1:12 Total basal X 8 PM–MN 1:15 27 Inpatient Insulin Pump Management 321 A focused physical examination assessing body weight and skin sites used for pump infusion set should be performed. The pump site should be inspected for possible pump site issues including ecchymosis, hypo- and hypertrophy, infection, and leaking. Careful assessment for diabetic neuropathy and vascular disease should be conducted. Patients Who Can Continue Using Their Insulin Pump Patients on insulin pump therapy are usually knowledgeable about insulin pump technology and management. These patients should be allowed to use their insulin pumps in the hospital set- ting if they are deemed physically, cognitively, and emotionally able to do so. Basal rates may need to be lowered (generally to about 80%) to prevent hypoglycemia. Patient and team should discuss insulin regimen changes recommended while in the hospital. Target glycemic goals may differ between staff team and patient and, therefore, both communication and documen- tation of recommended glucose targets are important for safe and satisfactory care. In non-critically ill hospitalized patients, both the American Diabetes Association (ADA) and Endocrine Society recommend goal for fasting and pre-meal blood glu- cose (BG) is <140 mg/dl and random glucose <180 mg/dl. For contraindications for insulin pump use, see section “Contraindications for Self-Administered Insulin Pump Therapy”. Assess Current Nutritional Status All patients with diabetes should follow a consistent carbohydrate meal plan while in the hospital. Many hospitalized patients are rendered nothing per oral (NPO) for a variety of reasons (impend- ing surgery or diagnostic procedures, gastrointestinal disease, inability to eat). It is important that the reason and anticipated duration of NPO status are documented. Any special dietary restrictions should be noted. If a patient is getting enteral tube feedings, note the content, rate, and times of tube feeds. Similar 322 M. Vamvini and E. Toschi data need to be collected for parenteral nutrition. Based on this information, insulin pump settings may need to be adjusted. In patients who are NPO, it is recommended that the basal rate should be decreased by 20–50%. In cyclical enteral tube feeding, basal rates may need to be increased 2 hours prior to initiation of the feeding cycle, initially by 20%, and then titrated upward as needed. In patients receiving total parenteral nutrition (TPN), basal rate may need to be adjusted depending on the amount of carbohydrates (dextrose) in each TPN bag. Assess Other Medications That May Affect Glycemic Status Most hospitalized patients are likely to be receiving one or more medications that can potentially affect their blood glucose levels. Most commonly used medications are the glucocorticoids. Basal rates as well as insulin-to-carb ratio and sensitivity factor should be adjusted to mitigate glucocorticoid-induced hyperglycemia. If possible, medications for intravenous (IV) infusion should be prepared in glucose-free solutions rather than in dextrose in water. Medical Orders for Insulin Pump Treatment In order to allow a given patient to continue using an insulin pump, a medication order for the insulin pump must be pro- vided by a licensed independent practitioner. A medication order to allow a patient to continue using an insulin pump includes acknowledgment that the patient has been assessed to be competent in operating the pump and that no exclusion criteria apply (see section “Contraindications for Self- Administered Insulin Pump Therapy”). The orders for the self- administering insulin pump should include type of insulin, basal rate, and bolus doses for meals (insulin-to-carb ratio) and for hyperglycemia correction (insulin sensitivity or correction factor) along with glucose targets (Table 27.1). The order 27 Inpatient Insulin Pump Management 323 should also dictate the frequency of blood glucose monitoring. It is optimal that an insulin pump order in the electronic medical record prompts the practitioner to obtain an endocrinology and nutrition consultation, if this is a possibility at a given institution. Insulin Pump Management If a medication order for insulin pump self-administration has been activated, the patient will be considered responsible for programming his/her insulin pump and changing the infusion set as per his/her own regimen (change infusion set is recommended every 2–3 days). Blood glucose should be checked at least four times a day before meals and before bedtime or every 4 hours for NPO patients. Documentation should be completed utilizing an insulin pump flowsheet (see Fig. 27.1). It is important that BG data are reviewed at least once daily by the treating team or endocrinologist for insulin dose adjustments. Basal insulin should be adjusted to keep fasting BG <140 mg/dL, and nutritional insulin should be adjusted to maintain all other BG levels in 100–180 mg/dl range. Insulin doses should be increased or decreased by 10–20% at a time to produce a meaningful effect. The insertion site should be assessed at every shift and if glu- cose values >250 mg/dl. All infusion sets shall be changed by the patient at least every 72 hours. It is good practice to record the date and time of the last infusion set change once the patient is admitted to the hospital. Indications to change infusion sets more frequently may include but are not limited to: • The site is erythematous, swollen, or warm to touch. • Bleeding at insertion site. • Discomfort at insertion site. • Unresolved delivery alarm alerts. • The patient has two consecutive blood glucose readings greater than 250 mg/dl which are refractory to correction boluses. 324 M. Vamvini and E. Toschi 1 2 3 4 5 6AM 7 8 9 10 11 12PM BG (mg/dL) 201 154 Carbs (g) 30 45 Meal Bolus (units) 3 4.5 Correction Bolus (units) 1 0 Basal (u/hr) 0.5 0.7 Fig. 27.1 Insulin pump flowsheet Insulin Pump Use in the Hospital in Critically Ill Patients It is recommended that critically ill patients not use their insulin pump. Instead they should be transitioned to intravenous insulin treatment. Intravenous insulin treatment should start as per usual in-hospital protocol. ADA recommends for most ICU patients glucose targets between 140 and 180 mg/dl. Contraindications for Self-Administered Insulin Pump Therapy • Acute change in conscious state/mental status as assessed by nurse or treating team • Some procedures involving anesthesia that alter the patient’s capability to manage the pump for longer period of time (>12 hours) • Inability to demonstrate competence with pump management • Risk of suicide or suicidal ideation • Recurrent or persistent episodes of hypoglycemia or hypergly- cemia • Patient refusal or inability to participate in pump management • Inability to procure their own supplies (reservoirs and infusion sets should be changed at least every 72 hours) • Unresolved pump failure 27 Inpatient Insulin Pump Management 325 • Unexplained hyperglycemia • Diabetic ketoacidosis and hyperglycemic hyperosmolar state • Unexplained, persistent hypoglycemia • Lack of pump supplies • Health-care decision or lack of trained health-care personnel on management of insulin pump therapy Special Considerations Regarding Pump Therapy Insulin Pump Use in the Hospital in Patients Undergoing Surgical Procedures In procedures and surgeries requiring moderate sedation or anes- thesia, patients have limited or no ability to operate the insulin pump independently throughout the perioperative period. In some cases, it is appropriate to discontinue the insulin pump and provide insulin therapy via an alternative route. Among rea- sons to consider stopping pump use are the length of the proce- dure, postoperative recovery time, and use of imaging perioperatively (i.e., MRI, CT scan, radiation therapy). When use of a self-administering insulin pump is

contraindicated or must be stopped, the patient may require either subcutaneous insulin via syringe or an insulin drip to maintain glycemic control for the duration of time that the pump is disconnected. Blood glucose monitoring is case dependent but may be done as frequently as 1–2 hours. In other cases, especially when patients undergo ambulatory or short-term surgical procedures lasting a few hours (≤ 2 hours), continuation of the insulin pump at a basal rate administration of insulin may be appropriate. In this scenario, basal rate should be reduced by 20–50% 2 hours pre-procedure and kept at this lower rate up to 4 hours postoperatively. Blood glucose monitoring during procedures is case dependent but may be done as frequently as 1–2 hours. In cases where an insulin pump is to continue while the patient is sedated or under anesthesia, the following is recommended: 326 M. Vamvini and E. Toschi • An order to continue the self-administering insulin pump at the basal rate is written by the primary team if the patient is under an observation status (non-inpatient) and has no existing order in place for the pump. • Blood glucose should be checked before the procedure/sur- gery, hourly during procedure/surgery and following proce- dure/surgery. • IV access is confirmed. • Documentation is completed utilizing the insulin pump flowsheet. • Insertion site is assessed pre- and post-procedure/surgery. If the insertion site is not ideally located due to the anticipated positioning of the patient, it is recommended that the patient should move the site to a more ideal location. Infusion site and tubing should be taped to secure placement and avoid dislodging during procedure. During Imaging Studies During imaging or procedures utilizing x-ray, the pump should be covered by lead apron. Prior to an MRI, insulin pump and metal infusion set, if used, should be disconnected from the patient in the MRI scanning suite (a minimum of 8 feet away from MRI machine) because of incompatibility with the MRI scanning envi- ronment. Interruption of insulin infusion should be overall less than 60 min, and blood glucose levels should be monitored. If duration of the imaging study is long and the pump needs to be discontinued for longer periods of time, the patient may require either subcutaneous insulin administration or an insulin drip to maintain glycemic control and avoid ketosis for the duration of time that the pump is disconnected. In Diabetic Ketoacidosis Insulin pump failure can lead to diabetic ketoacidosis. Pump mal- function can be due to dislodgement of the infusion set and block- 27 Inpatient Insulin Pump Management 327 age or leakage of the tubing system, all causing an interruption of insulin delivery. In patients with diabetic ketoacidosis, the insulin pump must be discontinued, and they should be treated with continuous intravenous insulin administration as per hospital protocol. These patients may be transitioned back to the insulin pump after resolution of the diabetic ketoacidosis when clinically stable and when the acid-base disorder is corrected. The intravenous insulin should be overlapped with the pump restart by at least 2 hours to allow for adequate insulin absorption. Frequent BG monitoring is needed for several hours after the pump is restarted to ensure adequate glycemic control. Peripartum Many women with type 1 diabetes are treated with an insulin pump during pregnancy. It is recommended that the insulin pump be disconnected peripartum. An intravenous insulin drip is pre- ferred while the patient is NPO during labor, delivery, and immediately post-delivery. During labor and delivery, the mater- nal blood glucose level should be kept between 80 and 110 mg/dl. After delivery, insulin requirement falls dramatically, and insulin rate should be decreased. For more details, see Chap. 26, “Management of Preexisting Diabetes and Gestational Diabetes During Hospitalization.” Transition from Continuous Subcutaneous Insulin Infusion (CSII) to Multiple Daily Injection (MDI) Insulin Regimen When use of a self-administered insulin pump or CSII is contra- indicated or must be stopped, the patient will require either sub- cutaneous insulin via syringe or an insulin drip to maintain glycemic control for the duration of time that the pump is dis- connected. When there is no indication for treatment with an insulin drip, insulin should be administered subcutaneously 328 M. Vamvini and E. Toschi through MDI. Because of varying absorption rates, subcutaneous insulin ideally needs to be initiated before discontinuation of the pump. Long- acting (basal) insulin should be administered at least 2 hours and rapid-acting insulin 30 minutes before disconnecting the pump. To transition to MDI insulin regimen, the basal dose should be calculated using the 24 hour basal dose of insulin delivered from the pump. The total basal daily insulin can be given as once-daily or twice-daily injections. Prandial insulin can be calculated as half of a patient’s usual total daily dose of insulin divided by three. Alternatively, the patient, if able, should be allowed to calculate the prandial insulin using his/her insulin-to- carbohydrate ratio from the pump setting. His/ her correctional insulin bolus should be calculated according to the insulin pump correction factor. Capillary blood glucose should be measured before meals and bedtime or every 4 hours if the patient is NPO. Use of Continuous Glucose Monitor (CGM) in the Hospital In Non-ICU Patients There are currently no guidelines for use of CGM in the inpa- tient setting. Some sensors need to be calibrated, and some of them are affected from commonly used drugs such as acetamin- ophen. There is also a lack of evidence on accuracy during hypoxemia, hypotension, or hypothermia. Therefore, sensor readings or trends may not be accurate in the hospital setting. Thus far, the use of this technology in hospital has been largely experimental. In ICU Patients Two CGM systems are FDA-approved for use in hospitals: GlucoScout® (International Biomedical) and OptiScanner 5000®. However, use of CGM in critically ill patients in the ICU 27 Inpatient Insulin Pump Management 329 is not currently recommended. Data from several ICU studies have been conflicting, and there is no clear evidence that use of subcutaneous CGM systems improves the glycemic control of critically ill patients in a clinically significant manner. More large- scale studies are needed to determine potential beneficial effects from CGM use in the ICU. Sensor-Augmented Insulin Pump and Hybrid Closed-Loop System Sensor-augmented insulin pump and hybrid closed-loop systems which feature CGM are now available. Sensor-augmented insulin pumps can suspend insulin delivery based on CGM sensor reading to prevent hypoglycemia. Hybrid closed-loop systems not only can suspend infusion temporarily to prevent episodes of hypoglycemia but can also adjust basal insulin delivery based on sensor reading. However, patients are still required to bolus prior to meals and administer correction boluses as needed to keep these systems operating correctly. Therefore, similar criteria should be used to evaluate if the patient can operate these pumps while in hospital. The sensor-augmented insulin pump and hybrid closed-loop systems should not be used in the ICU settings. Evaluate Diabetes Treatment at Time of Discharge Clinical conditions may change during hospitalization necessitat- ing changes to pre-admission treatment for diabetes. Additionally, changes to diabetes treatment may be indicated due to poor pre- admission diabetes control. If there is a plan to discharge the patient to a rehabilitation or skilled nursing facility, case management should determine the competence of the facility to manage an insulin pump. Prior to patient transfer, the facility will be required to provide their protocol for managing patients on insulin pumps. Discharge paperwork should include the insulin pump treatment plan and a 330 M. Vamvini and E. Toschi contingency plan for insulin management in case the patient is not be able to continue insulin pump therapy. If pump use is not recommended for any reason prior to dis- charge, then a multiple daily injection regimen with long-acting and short-acting insulin for meals and correction doses should be provided. Reasons to be discharged on MDI include patient preference, mental status changes precluding restarting CSII, and lack of additional supplies. Follow-Up After Discharge Discharge plans should include a timely follow-up visit for con- tinued outpatient diabetes care. An appointment should be made for the patient to see their diabetes care providers within 2–4 weeks of discharge. Because glycemic control is expected to change after discharge, make sure that the patient is able to contact a diabetes care provider in case of high or low blood glucose levels. Suggested Readings American Diabetes Association. Diabetes care in the hospital. Diabetes Care. 2017;40(Suppl. 1):S120–7. Garg R, Hudson M, editors. Hyperglycemia in the hospital setting. New Delhi: JP Brothers; 2014. Grunberger G, Abelseth J, Bailey T, Bode B, Handelsman Y, Hellman R, et al. Consensus Statement by the American Association of Clinical Endocrinologists/American College of Endocrinology Insulin Pump Management Task Force. Endocr Pract. 2014;20(5). Joslin Clinical Guidelines at https://www.joslin.org/info/joslin-clinical- guidelines.html. Kannan S, Satra A, Calogeras E, Lock P, Lansang MC. Insulin pump patient characteristics and glucose control in the hospitalized setting. J Diabetes Sci Technol. 2014;8(3):473–8. Mendez CE, Umpierrez GE. Management of type 1 diabetes in the hospital setting. Curr Diab Rep. 2017;17(10):98. Peters AL, Ahmann AJ, Battelino T, Evert A, Hirschn IB, Murad MH, et al. Diabetes technology—continuous subcutaneous insulin infusion therapy 27 Inpatient Insulin Pump Management 331 and continuous glucose monitoring in adults: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2016;101(11):3922–37. Thompson B, Korytkowski M, Klonoff DC, Cook CB. Consensus statement on use of continuous subcutaneous insulin infusion therapy in the hospi- tal. J Diabetes Sci Technol. 2018;12(4):880–9. Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, et al. Endocrine society. management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(1):16–38. Umpierrez GE, Klonoff DC. Diabetes technology update: use of insulin pumps and continuous glucose monitoring in the hospital. Diabetes Care. 2018;41(8):1579–89. Severe 28 Hypertriglyceridemia in the Hospitalized Patient Roselyn Cristelle I. Mateo and Om P. Ganda Contents Define Hypertriglyceridemia (HTG) 334 Risk Factors That Contribute to Elevated TG Levels 335 Physical Examination 336 Laboratory Work-Up 337 Evaluate Need for Insulin and/or Heparin Drip 338 Evaluate Benefit of Plasmapheresis 339 What Is a Safe Therapeutic Target? 339 What Are the Non-pharmacologic Means to Control HTG? 339 Determine the Appropriateness of Starting Fibrate Therapy 340 R. C. I. Mateo Joslin Diabetes Center, Department of Endocrinology, Beth Israel Deaconess Medical Center, Boston, MA, USA e-mail: [email protected] O. P. Ganda (*) Joslin Diabetes Center, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 333 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_28 334 R. C. I. Mateo and O. P. Ganda Determine Appropriateness of Starting Omega-3-Fatty Acid (OM3FA) Therapy 341 Determine Appropriateness of Starting Niacin Therapy 341 Determine Appropriateness of Starting HMG-CoA Reductase Inhibitors (Statins) 342 Evaluate Novel and Potential Therapies of TG-Lowering Agents 342 Suggested Readings 343 Define Hypertriglyceridemia (HTG) Clinical Practice Guidelines (CPG) from major professional societies, including the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP ATP III), National Lipid Association (NLA), American Association of Clinical Endocrinologists (AACE), and the Endocrine Society (TES), have proposed different criteria for the clinical diagnosis of ele- vated triglyceride levels under fasting conditions, as shown in Table 28.1. Severe HTG, usually >1000 mg/dl, accounts for 10–15% of cases of AP and often occurs in the setting of acute or chronic insulin deficiency. In most cases, AP requires emergency hospital- ization and can be fatal, if not treated promptly, due to severe Table 28.1 Criteria for high fasting TG NCEP ATP III NLA AACE TES Normal <150 mg/dL <150 <150 Normal <150 mg/dL Borderline 150–199 150–199 150–199 Mild 150–199 high High 200–499 200–499 200–499 Moderate 200–999 Very high >= 500 >= 500 >= 500 Severe 1000–1999 Very >= 2000 severe 28 Severe Hypertriglyceridemia in the Hospitalized Patient 335 hemodynamic changes, hypovolemia, and hypotension. AP due to HTG may follow more severe clinical course than that due to other causes. Risk Factors That Contribute to Elevated TG Levels Severe HTG levels are usually associated with genetic traits that are often combined with acquired risk factors such as overweight, physical inactivity, insulin resistance, metabolic syndrome, advanced chronic kidney disease (CKD), or uncontrolled diabetes mellitus (DM). The underlying genetic disorders include familial hypertriglyceridemia, familial dysbetalipoproteinemia, monogenic or polygenic chylomicronemia syndrome (FCS), acquired partial

lipodystrophy, and familial combined hyperlipidemia (FCH). Pregnancy, hypothyroidism, autoimmune disorders such as para- proteinemia or systemic lupus erythematosus, and certain drugs are also contributing factors to HTG (Table 28.2). Table 28.2 Medications that may affect TG levels Drugs Mechanism of action Thiazide, furosemide Modulate adipocyte differentiation leading to accumulation of plasma TGs in susceptible patients with certain genetic polymorphisms Beta blockers (particularly Peripheral vasoconstriction through atenolol, metoprolol, and peripheral β-adrenergic receptors can propranolol) increase insulin resistance, leading to lowering of HDL-C, and increased TG; induce decreased TG hydrolysis through a reduction in the muscle lipoprotein lipase (LPL) and endothelial dysfunction from peripheral vasoconstriction Estrogen Increase the hepatic secretion of VLDL (continued) 336 R. C. I. Mateo and O. P. Ganda Table 28.2 (continued) Drugs Mechanism of action Bile acid sequestrants (BAS) Activation of phosphatidic acid (cholestyramine, colestipol, phosphatase promotes hepatic TG colesevelam) synthesis and induces secretion of TG-rich VLDL. BAS also act as farnesoid X receptor (FXR) antagonists and activate liver X receptor (LXR), thus increasing TG levels Protease inhibitors, e.g., Increase in VLDL production and ritonavir and lopinavir intermediate-density lipoproteins (IDL); decreased activity of lipoprotein lipase and hepatic lipase; development of insulin resistance and abnormal expression of the apolipoprotein CIII gene Second-generation Cause weight gain, insulin resistance, antipsychotic medications such and worsening of the metabolic as clozapine, olanzapine, syndrome risperidone, and quetiapine Immunosuppressants Inhibit LPL, stimulate hepatic (interferon, tacrolimus, lipogenesis sirolimus, others) Isotretinoin Slows down the metabolism of triglyceride-r ich lipoproteins (TRL), such as chylomicrons, and remnant particles Physical Examination Relevant physical examination should include measurements of body mass index (BMI) and blood pressure (BP); assessment of carotid and peripheral pulses; palpation of the liver and thyroid; and inspection of palms, soles, and extensor surfaces of the arms, buttocks, trunk, and tendinous attachments. Clinical features may include eruptive xanthomas, lipemia retinalis, hepatosplenomeg- aly, focal neurologic symptoms such as irritability, and recurrent epigastric pain consistent with pancreatitis. Eruptive cutaneous xanthomas are filled with foam cells that appear as yellow morbil- liform eruptions that measure 2–5 mm in diameter, often with ery- 28 Severe Hypertriglyceridemia in the Hospitalized Patient 337 thematous areolae. Palmar crease xanthomas, typically seen in familial dyslipidemia syndrome, appear as yellow deposits within palmar creases. Lipemia retinalis is a characteristic milky appearance of the retinal vessels and pink retina. Samples of lipe- mic plasma develop a creamy supernatant when refrigerated overnight. Laboratory Work-Up Order a glucose test, thyroid function tests, and a renal panel and liver panel to detect or rule out diabetes, hypothyroidism, and renal and liver disease. Thyroid hormone plays a role in the regulation of the synthesis, metabolism, and mobilization of lipids. Patients with hypothyroidism have increased levels of total cholesterol, low- density lipoprotein cholesterol, apolipoprotein B, lipoprotein(a) levels, and triglyceride levels. Hypertriglyceridemia and reduction and dysfunction of high-density lipoprotein are also common lipid disturbances in chronic kidney disease, caused mainly by the decreased efficiency of lipoprotein lipase (LPL)-mediated very Low Density Lipoprotein-TG (VLDL-TG) lipolysis. The liver, too, plays a crucial role in the synthesis, secretion, catabolism, and storage of lipids and lipoproteins. Alcoholic and nonalcoholic liver disease affects lipid metabolism differently. High alcohol consumption can cause excessive synthesis of triglycerides, hypercholesterolemia, defective esterification of plasma cholesterol, and decreased level of high-density lipoprotein cholesterol. Order a fasting lipid panel including total cholesterol, HDL-C, direct LDL, and TG. Hemoglobin A1c should be ordered to assess control of diabetes in the appropriate patient. Patients with HTG may present with acute pancreatitis (AP) and relatively low amylase levels. This is brought about by inter- ference caused by triglyceride-rich lipoprotein (TRL) that can result in falsely low amylase levels. Centrifugation before labora- tory testing can remove chylomicrons from plasma and eliminate artifacts in lipemic specimens. HTG can also interfere with bio- chemical measurement of glucose, leading to falsely lower levels in these patients. 338 R. C. I. Mateo and O. P. Ganda The Endocrine Society not only recommends against the rou- tine measurement of lipoprotein particle heterogeneity in patients with hypertriglyceridemia but also recognizes that measurement of apolipoprotein B (Apo B) or lipoprotein(a) [Lp(a)] levels can be of value in assessing cardiovascular (CV) risk in selected cases, such as those with familial combined hyperlipidemia. Evaluate Need for Insulin and/or Heparin Drip HTG can contribute to adverse CV events, including acute coro- nary events, and AP. During AP episodes, insulin promotes synthe- sis and activation of lipoprotein lipase (LPL), thereby accelerating chylomicron degradation. Treatment with insulin infusion, along with hemodynamic support, can dramatically improve the hydro- lysis of chylomicrons and large VLDL particles in patients with DM and uncontrolled hyperglycemia. Heparan sulfate proteoglycan chains normally bind LPL to the capillary endothelium. Heparin, administered as a bolus dose, has a stronger affinity for the LPL binding site than heparan sulfate, leading to the dissociation of heparan-LPL complexes from the endothelium to the plasma. This surge of free LPL is then able to bind to and metabolize chylomicrons and VLDL at an accelerated rate, thus lowering serum TG levels. In case reports, heparin was used in conjunction with an insulin drip or if triglyceride lowering is insufficient despite Nil Per Os (NPO) status, intravenous fluids, and insulin infusions. If heparin is needed despite other interventions, it is safe to start with a standard weight-based infusion to keep the International Normalized Ratio (INR) at 1.5–2 times the upper limit of normal. However, the use of heparin should be limited to short term in order to limit the depletion of LPL stores. There have been numerous reports of the use of heparin and insulin for acute reduction of triglycerides, although there are no established guidelines for efficacy of these modalities, and heparin could pos- sibly be detrimental in the setting of hemorrhagic pancreatitis. In a nondiabetic patient with severe HTG, a bolus dose of regu- lar insulin (0.1 U/kg) given subcutaneously can decrease serum TG rapidly after a few hours. It has been shown in case reports to be effective either as monotherapy or in conjunction with heparin 28 Severe Hypertriglyceridemia in the Hospitalized Patient 339 drip. However, there is insufficient evidence for the benefits of this approach, compared to hemodynamic supportive measures alone. Evaluate Benefit of Plasmapheresis Plasmapheresis involves the removal of units of whole blood anti- coagulated with heparin followed by centrifugation to separate the blood into the cellular elements and plasma. The cellular ele- ments are then mixed with a replacement for the discarded plasma and reinfused. Various studies through the years have repeatedly concluded that plasmapheresis is an effective treatment for reduc- ing the serum TG concentration. However, due to the lack of ran- domized and controlled trials, it is currently unknown if plasmapheresis may improve morbidity and mortality in the clini- cal setting of HTG-AP. There are currently no consensus clinical guidelines in the management of HTG-AP. What Is a Safe Therapeutic Target? An elevated TG level is not a target of therapy per se, to prevent AP, except when very high (>= 500 mg/dL). When TG levels are between 200 and 499 mg/dL, the targets of therapy are non-HDL- C and LDL-C for CV risk reduction. When the TG concentration is very high (>= 500 mg/dL), reducing the concentration to <500 mg/dL to prevent AP becomes the primary goal of therapy. However, some guidelines have concluded that risk of AP decreases if plasma TG concentration is decreased to levels below 1000 mg/dL. Below this level, the treatment goal should be directed toward prevention of premature atherosclerosis. What Are the Non-pharmacologic Means to Control HTG? Alcohol consumption should be reduced or eliminated. Lifestyle therapy, including dietary counseling to achieve appropriate diet composition to include foods with low glycemic index, physical activity, and a program to achieve weight reduction in overweight 340 R. C. I. Mateo and O. P. Ganda and obese individuals, is recommended as the initial treatment of mild-to-moderate hypertriglyceridemia. For severe and very severe hypertriglyceridemia (>1000 mg/ dl), combining reduction of total dietary fat and simple carbohy- drate intake with prophylactic drug treatment to reduce the risk of AP is recommended. Dietary modification should decrease weight, overall energy intake and intake of all fat (including saturated, unsaturated, and trans fats), and refined carbohydrates. NCEP and NLA advise a carbohydrate intake of 55%–60% and a protein intake of 15%–20% of the daily dietary intake. However, reduction in total fat intake is the cornerstone of treatment for preventing AP and should be limited to less than 15–20% of total calories. Plasma TG response to diet and weight loss is about 25%, with marked variation among patients. Medium-chain triglycerides (MCTs) may be added to make up caloric intake in patients with recurrent AP, as MCTs are not dependent on LPL for hydrolysis. Determine the Appropriateness of Starting Fibrate Therapy Treatment with fibrates has been found to be cost-effective as both monotherapy and combination therapy for lowering TG in the prevention of AP. However, the role of fibrates in the prevention of atherosclerotic cardiovascular disease (ASCVD) outcomes in statin-treated patients with optimal LDL-C remains controversial, with some evidence supporting their role in ASCVD event reduc- tion in those with TG concentrations of 200–499 mg/dL and HDL-C concentrations <40 mg/dL. A more potent fibrate, pemafi- brate, currently not available, is undergoing a long-term clinical trial for ASCVD event reduction. Fibrates decrease triglyceride levels by 30–50%. Fibrates may act by multifactorial mechanisms including increased fatty acid oxidation, increased LPL synthesis, reduced expression of Apo CIII, decreased VLDL-TG production, and increased LPL- mediated catabolism of triglyceride-rich lipoproteins (TRL). 28 Severe Hypertriglyceridemia in the Hospitalized Patient 341 Determine Appropriateness of Starting Omega-3-Fatty Acid (OM3FA) Therapy Use of OM3FAs is an effective TG-lowering treatment option, frequently in combination therapy, in the prevention of AP in high-risk patients with TG levels ≥500 mg/dl. The long-chain marine OM3FA [eicosapentaenoic acid, C20:5n-3 (EPA), and docosahexaenoic acid, C22:6n-3 (DHA)] can lower fasting and postprandial TG levels in a dose-dependent fashion. Doses of roughly 3–4 g/d of EPA plus DHA are neces- sary to reduce HTG by 20–40%. OM3FAs are available by pre- scription in capsules that contain >90% of OM3FA in variable proportion of EPA and DHA. In contrast, over-the-counter prepa- rations of OM3FA have variable quantities of EPA and DHA ranging from 20 to 50%, depending on the products, and gener- ally are not recommended for this purpose. A recently completed large cardiovascular trial, REDUCE-IT, employed 4 g daily of pure EPA vs placebo in patients with type 2 diabetes, with or without preexisting CVD, with TG 150–499 mg/dl at baseline. All subjects were on statin therapy and optimally controlled LDL-C. In this trial, there was an impressive 25% reduction in major CV end points. However, the CV outcomes were unrelated to the magnitude of TG reduction. This study points to some unique CVD benefits of pure EPA. Determine Appropriateness of Starting Niacin Therapy Niacin therapy is recommended principally as an adjunct for reducing TG, if fibrates and OM3FA are not adequately effective. At doses of 500–2000 mg/d, niacin lowers triglycerides by 10–30%, increases HDL cholesterol by 10–40%, and lowers LDL cholesterol by 5–20%. Patients with glucose intolerance and those with DM on oral medications or insulin, who have moderate to good glycemic control, can safely use niacin at moderate dosage, as an adjunct to keep TG in safe range. 342 R. C. I. Mateo and O. P. Ganda However, niacin should not be used for ASCVD event reduc- tion in individuals aggressively treated with a statin due to an absence of evidence for additional CV benefits in those with well- controlled LDL-C (<70–80 mg/dl). In the pre-statin era, high- dose niacin was found to reduce plaque progression in several clinical trials, but given the adverse effects including worsening of glucose control at higher dosage, it is currently not recom- mended for CVD reduction. Determine Appropriateness of Starting HMG-CoA Reductase Inhibitors (Statins) HMG-CoA reductase inhibitors, also known as statins, have a weak TG-lowering effect. They should not be used as monother- apy for HTG. They can have a synergistic TG-lowering effect in combination with fibrates and may be considered in patients in whom HTG is not controlled on fibrates or other TG-lowering agents. In combination therapy of statins with fibrates, fenofibrate is preferred over gemfibrozil, to prevent the risk of myositis. Evaluate Novel and Potential Therapies of TG-Lowering Agents Apolipoprotein CIII inhibitors are a novel class of

drugs available for patients with familial chylomicronemia syndrome (FCS) for TG reduction. Apolipoprotein CIII (Apo CIII), which is primarily synthesized in the liver, is a key regulator of lipoprotein metabo- lism and plasma TG levels. It has a role in inhibiting the LPL- mediated hydrolysis of triglyceride-rich lipoproteins (TRL). It also affects the receptor-mediated hepatic uptake of remnants of TRL. It can also inhibit the activity of hepatic lipase at higher concentrations. Apo CIII is an independent risk factor for CVD and is associated with both impaired lipolysis and impaired clear- ance of TRL from the circulation. 28 Severe Hypertriglyceridemia in the Hospitalized Patient 343 Apo CIII inhibitors are second-generation, single-stranded, DNA-like antisense oligonucleotides designed specifically to bind to a specific RNA sequence. These then elicit degradation of the RNA through RNase H1 and allow the antisense drugs to selectively inhibit Apo CIII synthesis. Reductions in Apo CIII and TG levels have been reported in a small number of patients with the familial chylomicronemia syn- drome who were treated with Apo CIII inhibitors. These patients had defective LPL, and the mechanism of lowering of plasma TG levels was shown to be from an enhanced removal of TRL in a dose-dependent manner. These drugs are currently in phase III studies. Whether targeted reduction of Apo CIII will confer such a benefit in patients at high risk for CVD, including patients with DM and HTG, remains to be determined. Other novel approaches, in development, to reduce HTG include gene therapy for LPL deficiency and antibody-based therapies. Acknowledgments OG was partially supported by NIDDK grant # P30-DK036836. Suggested Readings Berglund L, Brunzell JD, Goldberg AC, et al. Evaluation and treatment of hypertriglyceridemia: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97:2969–89. Bhatt DL, Steg PG, Miller M, Brinton EA, Jacobson TA, Ketchum SB, et al. REDUCE-IT investigators. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019;380:11–22. Brahm AJ, Hegele RA. Chylomicronaemia--current diagnosis and future therapies. Nat Rev Endocrinol. 2015;11:352–62. Chait A, Eckel RH. The Chylomicronemia syndrome is most often multifac- torial: a narrative review of causes and treatment of the chylomicronemia syndrome. Ann Intern Med. 2019; https://doi.org/10.7326/M19-0203. Jacobson TA, Maki KC, Orringer CE, et al. National lipid association recom- mendations for patient-centered management of dyslipidemia: part 2. J Clin Lipidol. 2015;9:S1–122. 344 R. C. I. Mateo and O. P. Ganda Nakhoda S, Zimrin AB, Baer MR, Law JY. Use of the APACHE II score to assess impact of therapeutic plasma exchange for critically ill patients with hypertriglyceride-induced pancreatitis. Transfus Apher Sci. 2017;56:123–6. Rocha NA, East C, Zhang J, McCullough PA. ApoCIII as a cardiovascular risk factor and modulation by the novel lipid-lowering agent volane- sorsen. Curr Atheroscler Rep. 2017;19:62. Scherer J, Singh VP, Pitchumoni CS, Yadav D. Issues in hypertriglyceridemic pancreatitis: an update. J Clin Gastroenterol. 2014;48:195–203. Hypomagnesemia 29 Alan Ona Malabanan Contents Hypomagnesemia Should Be Considered in Patients with Hypocalcemia or Hypokalemia, Cardiac Dysrhythmias (Torsades de Pointes), Alcoholism, Diabetes, Diarrheal Illnesses, Renal Tubular Disorders and Use of Medications Associated with Hypomagnesemia such as Proton Pump Inhibitors, Diuretics, Cisplatin, and Amphotericin B 346 Serum Magnesium Does Not Reflect Total Body Magnesium Stores and a Total Body Magnesium Deficit May Exist Even with a Normal Serum Magnesium Level 347 A 24-Hour Urine Magnesium and Creatinine or a Fractional Excretion of Magnesium May Be Useful in Establishing the Etiology of Hypomagnesemia 347 A 24-Hour Urine Magnesium and Creatinine May Be Useful in Confirming Adequacy of Total Body Magnesium Stores 348 Hypocalcemia or Hypokalemia with Concomitant Hypomagnesemia Will Not Correct with Calcium or Potassium Therapy Alone 348 A. O. Malabanan (*) Beth Israel Deaconess Medical Center, Harvard Medical School, Division of Endocrinology, Diabetes and Metabolism, Boston, MA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 345 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_29 346 A. O. Malabanan A Concomitant Assessment of Urinary Calcium Can Help Identify the Portion of the Nephron Affected in Hypomagnesemia 349 Severe Hypomagnesemia (Mg <1 mEq/L) and Symptomatic Hypomagnesemia Should Be Treated with Intravenous Magnesium Therapy 349 Oral Magnesium Oxide Therapy Is Limited by Diarrhea and Often Intravenous Magnesium Sulfate Therapy Is Necessary 349 In Addition to Replacement Magnesium Therapy, Addressing the Etiology of the Hypomagnesemia Is Necessary to Maintain Magnesium Homeostasis 350 Suggested Readings 352 Hypomagnesemia Should Be Considered in Patients with Hypocalcemia or Hypokalemia, Cardiac Dysrhythmias (Torsades de Pointes), Alcoholism, Diabetes, Diarrheal Illnesses, Renal Tubular Disorders and Use of Medications Associated with Hypomagnesemia such as Proton Pump Inhibitors, Diuretics, Cisplatin, and Amphotericin B Magnesium is an important intracellular cofactor for a multitude of cellular processes, and deficiency can disrupt several organ sys- tems. The human body has approximately 25 g of magnesium, 50–60% of which is found in the bone. Magnesium homeostasis is maintained by balancing dietary magnesium absorption and urinary magnesium losses. Up to 60–70% of a dietary magnesium load is absorbed in the gut, the majority in the ileum, with its absorption aided by high gastric acidity. Intestinal magnesium absorption is not regulated. Diarrheal illnesses cause increased magnesium losses and disrupt intestinal magnesium absorption. Serum magnesium levels are controlled primarily through reab- sorption by the kidneys. Illnesses or medications causing diuresis, such as alcoholism, diabetes mellitus or insipidus, or diuretics, lead to increased urinary losses of magnesium. Proton pump inhibitors decrease intestinal magnesium absorption. Cisplatin and amphotericin B may cause renal tubular dysfunction leading 29 Hypomagnesemia 347 to urinary magnesium losses. Magnesium is important for para- thyroid hormone release and action, which can disrupt calcium homeostasis. In addition, it is a cofactor for the sodium-potassium ATPase, and deficiency leads to hypokalemia. As such, hypomag- nesemia may cause neuromuscular and cardiac irritability. Serum Magnesium Does Not Reflect Total Body Magnesium Stores and a Total Body Magnesium Deficit May Exist Even with a Normal Serum Magnesium Level Extracellular magnesium represents only 1% of the total body magnesium. As a result, serum magnesium is not an accurate measure of total body magnesium stores and cannot accurately demonstrate successful repletion of body magnesium stores. A test for red blood cell magnesium is available, but due to pro- longed turnaround time as well as artifact related to improper specimen processing, it is of limited utility in the inpatient setting. Magnesium treatment should be considered, even with a normal serum magnesium level, if there is hypocalcemia, hypokalemia, or drugs/conditions associated with hypomagnesemia. A 24-Hour Urine Magnesium and Creatinine or a Fractional Excretion of Magnesium May Be Useful in Establishing the Etiology of Hypomagnesemia Body magnesium is controlled by a balance between gastrointes- tinal magnesium absorption, skeletal magnesium storage, and uri- nary magnesium losses. Most cellular food (i.e., of animal or plant origin) have significant amounts of magnesium, which are typically readily absorbed, although there are concerns of decreas- ing magnesium content of the Western diet. Gastrointestinal dysfunction, either with increased motility leading to diarrhea or problems with absorption such as inflammatory bowel disease, will lead to decreased magnesium absorption. A daily 24-hour urine magnesium excretion, in the setting of hypomagnesemia, of 348 A. O. Malabanan more than 10–30 mg or a fractional excretion of magnesium (FEMg = ((UMg × PCr)/(0.7 × PMg × UCr)) × 100%) of >2% argues for renal magnesium wasting. A daily 24-hour urine mag- nesium excretion, in the setting of hypomagnesemia, of <10 mg or an FEMg <2% argues for gastrointestinal losses. A 24-Hour Urine Magnesium and Creatinine May Be Useful in Confirming Adequacy of Total Body Magnesium Stores Magnesium sufficiency will lead to increased urinary magne- sium losses. Diuresis, either from drugs or conditions, will lead to increased magnesium ultrafiltration and decreased reabsorp- tion of magnesium. Hungry bone syndrome, after parathyroid- ectomy, will increase the bone uptake of magnesium, as well as calcium and phosphate. The normal physiologic response to hypomagnesemia is an increase in renal reabsorption of magne- sium, so an inappropriately normal or high urinary magnesium points to a renal etiology of the hypomagnesemia. In addition, assessing a 24-hour urine magnesium after an intravenous mag- nesium bolus is helpful. A high 24-hour urine magnesium excretion indicates magnesium sufficiency, although this assessment is not typically practical in most hospitalized patients. Hypocalcemia or Hypokalemia with Concomitant Hypomagnesemia Will Not Correct with Calcium or Potassium Therapy Alone Magnesium is an important cofactor for the Na-K ATPase and is also important for parathyroid hormone release and action. Persistent or recurrent hypokalemia or hypocalcemia is frequently associated with magnesium deficiency, and consideration of magnesium repletion should be pursued even in the presence of normal serum magnesium. 29 Hypomagnesemia 349 A Concomitant Assessment of Urinary Calcium Can Help Identify the Portion of the Nephron Affected in Hypomagnesemia Conditions affecting the loop of Henle, such as loop diuretic use, Bartter’s syndrome, or nephrotoxins, will cause hypercalciuria in the setting of hypermagnesiuria. Conditions affecting the early distal nephron, such as Gitelman’s syndrome, are associated with hypocalciuria with hypermagnesiuria. Normocalciuria and hyper- magnesiuria (i.e., isolated magnesiuria) may be seen in mutations of the pro-epidermal growth factor (pro-EGF) gene or as a result of cetuximab therapy. Severe Hypomagnesemia (Mg <1 mEq/L) and Symptomatic Hypomagnesemia Should Be Treated with Intravenous Magnesium Therapy The presence of torsades de pointes should be treated emergently with 1–2 g of IV magnesium sulfate over 30–60 seconds. It may be repeated in 5–15 minutes if the arrhythmia does not resolve. For asymptomatic severe hypomagnesemia, 1–2 g of IV magne- sium sulfate may be given over 3–6 hours. For both situations, continuous IV magnesium sulfate infusion should be ordered (4–8 g magnesium sulfate over 12–24 hours in those with normal renal function and 50% dose reduction if chronic kidney disease). Oral Magnesium Oxide Therapy Is Limited by Diarrhea and Often Intravenous Magnesium Sulfate Therapy Is Necessary Oral magnesium acts as a laxative and at higher doses can cause diarrhea. Oral magnesium can be tried, at small doses (i.e., 250 mg), as tolerated. Small doses every few hours are much bet- ter tolerated than larger doses at one time. If the oral magnesium 350 A. O. Malabanan is not tolerated or there is already diarrhea, intravenous magnesium sulfate should be considered. Symptomatic hypomagnesemia, i.e., neuromuscular irritability or cardiovascular dysrhythmias, should be treated urgently with intravenous magnesium sulfate. An ongoing intravenous magnesium sulfate drip should be con- sidered in patients with normal renal function to help replete depleted intracellular magnesium. Table 29.1 shows magnesium preparations and elemental magnesium content. In Addition to Replacement Magnesium Therapy, Addressing the Etiology of the Hypomagnesemia Is Necessary to Maintain Magnesium Homeostasis The causes of hypomagnesemia are listed in Table 29.2 and involve either inadequate magnesium intake or absorption or excessive urinary magnesium losses. Assuring adequate intake Table 29.1 Magnesium preparations Route of % Elemental Preparation administration magnesium mg/mEq Magnesium sulfate IV 10% 100 mg/8.1 mEq (1 gm) Magnesium chloride PO 12% 64 mg/5.33 mEq (535 mg) Magnesium oxide PO 60% 241.3 mg/20.1 mEq (400 mg) Magnesium PO 5.4% 27 mg/2.25 mEq gluconate (500 mg) Magnesium PO 42% 500 mg/41 mEq hydroxide (1200 mg/15 mL) Magnesium citrate PO 16% 279 mg/23 mEq (1.745 g/30 mL) Magnesium lactate PO 12% 84 mg/7 mEq (Mag-Tab SR caplet) Magnesium PO 9.9% 61 mg/5 mEq L-aspartate (615 mg) 29 Hypomagnesemia 351 of magnesium and treating diarrhea is important. If the small intestine has been resected, a parenteral source of magnesium may be necessary. Proton pump inhibitor therapy may need to be discontinued and an alternative acid-lowering therapy substituted. Table 29.2 Causes of hypomagnesemia Inadequate intake Excessive urinary losses Redistribution Malnutrition Drugs Ethanol withdrawal Inadequate Diuretics Insulin absorption administration Diarrhea Aminoglycosides Hungry bone syndrome Short bowel Cisplatin (Platinol-AQ) Pancreatitis syndrome Celiac disease Amphotericin B Trisodium (Fungizone) phosphonoformate (Foscarnet) Inflammatory Tacrolimus (Prograf) Blood transfusion bowel disease in liver transplant recipients Laxative abuse Cyclosporine (Sandimmune) Drugs Cetuximab (Erbitux) Proton pump Pentamidine (Nebupent) inhibitors Genetic Primary tubular disorder Primary familial Primary renal wasting hypomagnesemia Renal tubular acidosis Diuretic phase of acute tubular necrosis Post-obstructive diuresis Post renal transplantation (continued) 352 A. O. Malabanan Table 29.2 (continued) Inadequate intake Excessive urinary losses Redistribution Hormone-induced Aldosteronism Hypoparathyroidism and Hyperparathyroidism Hyperthyroidism Genetic Gitelman’s syndrome Autosomal dominant hypercalciuric hypocalcemia Miscellaneous (Na-K- ATPase, HNF1B, KCNA1, EGF) Induced tubular losses Hypercalcemia Volume expansion Glucose, urea, mannitol diuresis Phosphate depletion Alcohol ingestion Suggested Readings Agus ZS. Mechanisms and causes of hypomagnesemia. Curr Opin Nephrol Hypertens. 2016;25:301–7. Ayuk J, Gittoes NJL. Treatment of hypomagnesemia.

content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Medication Routes ......................................... 525 Access of a Central Venous Access Device .............. 585 Preparation for Medication Administration .............. 525 Implanted Vascular Access Devices ......................... 585 Local Routes ........................................................... 526 Routes for Systemic Medications ................... 527 28. Blood Products Enteral Drug Administration ................................... 527 and Transfusion 598 Parenteral Drug Administration ............................... 530 Injections ....................................................... 534 History of Transfusions .................................. 600 Tools for Injections ................................................. 534 Blood Components ......................................... 601 Hypodermic Needle ................................................ 535 Routes of Injection .................................................. 537 Blood Products .............................................. 603 Packed Red Blood Cells .......................................... 603 27. Intravenous Access 552 Fresh Frozen Plasma ............................................... 604 Cryoprecipitate ....................................................... 604 Platelets .................................................................. 604 Intravenous Access and Paramedics ................ 554 Blood Groups and Compatibility .................... 604 Physiology Review ......................................... 554 Blood Grouping ...................................................... 604 Compatability ......................................................... 605 Medical vs Trauma ......................................... 554 Transfusion Terms ................................................... 606 Sources of Fluid Loss .............................................. 554 Identif ication and Management Past Medical History ............................................... 555 of Transfusion Reactions .......................... 606 Physical Examination for Dehydration ..................... 555 Transfusion-Associated Circulatory Overload .......... 606 Intravenous Fluids ................................................... 556 Allergic Reaction .................................................... 606 Tonicity .................................................................. 556 Febrile Non-Hemolytic Reaction ............................. 607 Intravenous Fluid Administration ................... 556 Acute Hemolytic Reaction ....................................... 607 Administration Sets................................................. 558 Bacterial Contamination .......................................... 607 Preparing the Intravenous Administration Set .......... 561 Transfusion-Related Acute Lung Injury ................... 607 Intravenous Access......................................... 562 Treatment of Transfusion Reactions ......................... 607 Peripheral Venous Access Devices ........................... 562 Transfusion Procedure and Documentation ..... 608 Categories of Venous Access Devices ...................... 563 Prior to Transfer ...................................................... 608 Needle Safety ......................................................... 563 During the Transfer ................................................. 608 Peripheral Site Selection ......................................... 563 After the Transfer .................................................... 609 Site Preparation and Disinfection ............................ 567 Venipuncture ........................................................... 568 29. Introduction to Continuous or Intermittent Infusion ......................... 570 Securing the Intravenous Catheter ........................... 570 Pharmacology 612 Adjusting the Infusion Rate ..................................... 571 Intravenous Injection ..................................... 573 Paramedic Pharmacology ............................... 614 Obstruction of Intravenous Flow ............................. 574 Historical Development Complications of Intravenous Infusions ................... 574 of Pharmacology ...................................... 614 Infusion-Induced Hypothermia ................................ 576 Sources of Drugs ........................................... 615 Removing Intravenous Access ................................. 576 Plants ..................................................................... 615 Intraosseous Access ....................................... 576 Minerals, Chemicals, and Salts ................................ 616 Anatomy and Physiology of the Long Bones ............ 576 Animal ................................................................... 616 Intraosseous Devices ............................................... 577 Synthetic ................................................................ 616 Indications and Contraindications ............................ 577 Genetic Engineering ................................................ 616 Intraosseous Placement ........................................... 577 Drug Terminology .......................................... 617 Medication Administration ...................................... 577 Drug Classif ication ........................................ 617 Phlebotomy .................................................... 577 Pediatric Phlebotomy .............................................. 578 Herbal Remedies ............................................ 619 Blood Cultures ........................................................ 579 Sources of Drug Information .......................... 619 Pediatric Intravenous Access ................................... 579 Historical Legal Developments in Central Venous Access ................................... 582 Pharmacology .......................................... 620 Types of Central Venous Access Devices ................. 582 Controlled Substances Legislation ........................... 620 Field-Placed Central Venous Access Device ............. 583 Drug Misuse versus Drug Abuse.............................. 621 xii Table of Contents Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. New Drug Development ................................. 622 Diuretic Agents ....................................................... 668 FDA IND Status ...................................................... 623 Vasodilator Therapy ................................................ 669 Patented Drugs........................................................ 623 Cardiac Glycosides ................................................. 670 Medicine Errors ...................................................... 624 Acute Heart Failure ................................................. 672 Catecholamines ....................................................... 672 Principles of Pharmacology ............................ 624 Pharmacokinetics ........................................... 624 31. Pharmacological Absorption .............................................................. 624 Therapeutics for Medical Distribution ............................................................ 627 Detoxif ication ......................................................... 628 Emergencies 682 Elimination ............................................................. 629 Pharmacodynamics ........................................ 629 Drugs That Affect the Central Drug-Receptor Interaction ....................................... 630 Nervous System ....................................... 684 Drug-Enzyme Interaction ........................................ 630 Blood-Brain Barrier ................................................ 684 Nonspecif ic Drug Interaction .................................. 630 Central Nervous System Sedatives ........................... 684 Biological Response ................................................ 630 Withdrawal from Central Nervous Adverse Drug Reaction ........................................... 630 System Depressants ............................................. 686 Allergic Reaction .................................................... 631 Pain Management........................................... 688 Idiosyncratic Reaction ............................................ 631 The Experience of Pain ........................................... 688 Concepts in Pain ..................................................... 688 30. Pharmacological Interventions Physiology of Pain .................................................. 689 for Cardiopulmonary Analgesics ..................................................... 689 Emergencies 636 Opiates ................................................................... 689 Non-Opioid Analgesics ........................................... 692 The Nervous System ...................................... 638 Convulsions ................................................... 694 The Central Nervous System ................................... 638 Anticonvulsant Medication ...................................... 694 The Peripheral Nervous System ............................... 638 Parkinson’s Disease ................................................. 696 Autonomic Nervous System .................................... 638 Drugs That Affect the Endocrine System ........ 697 Neurotransmission ......................................... 639 Hormones and Pharmacy ......................................... 697 Cholinergic Receptors ............................................. 640 Diabetes ........................................................ 698 Cholinergic Agents ................................................. 640 Drugs That Are Used to Treat Diabetes .................... 698 Anticholinergic Agents ............................................ 640 Drugs That Are Used to Treat Diabetic Adrenergic Neurotransmitters .................................. 641 Emergencies ........................................................ 698 Adrenergic Agents .................................................. 641 Hypoglycemia ......................................................... 699 Pharmacological Interventions during Drugs That Are Used to Treat Adrenal a Respiratory Emergency .......................... 644 Disorders ................................................. 700 Overview of Pulmonary Pathophysiology ................ 645 Synthetic Glucocorticoids ....................................... 700 Beta-Selective Drugs ............................................... 645 Mineralocorticoids .................................................. 701 Pharmacological Interventions during Antiadrenal Medications ......................................... 701 a Cardiac Emergency ................................ 647 Adrenal Medulla ..................................................... 701 Coronary Artery Disease ......................................... 647 Acute Coronary Syndrome ...................................... 652 Drugs That Are Used to Treat Ovarian Dysrhythmia ........................................................... 654 Disorders ................................................. 701 Estrogen Therapy .................................................... 701 Vaughn-Williams Antidysrhythmic Drug Classif ications ......................................... 657 Drugs That Are Used to Treat Pituitary Class I Drugs .......................................................... 657 Disorders ................................................. 702 Class II Drugs ......................................................... 659 Vasopressin ............................................................. 702 Class III Drugs ....................................................... 662 Drugs That Are Used to Treat Thyroid Class IV Drugs ....................................................... 662 Disorders ................................................. 702 Unclassif ied Antidysrhythmic Agents ...................... 663 Drugs That Are Used to Treat Anaphalaxis ..... 702 Heart Failure .................................................. 665 Antihistamines ........................................................ 703 Angiotensin-Converting Enzyme (ACE) Inhibitors ....666 Therapeutic Approaches to Heart Failure ................. 666 Drugs That Are Used to Treat Diuresis .................................................................. 667 Gastrointestinal Disorders ........................ 703 Table of Contents xiii Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Ulcer Medicines ...................................................... 703 Descriptive Analysis ............................................... 741 Emetics ................................................................... 704 Emergency Decision Making ................................... 742 Antiemetics ............................................................ 704 Determining the Isoelectric Line ............................. 742 Antidiarrheal .......................................................... 704 Identify the QRS Complex ...................................... 743 Laxatives ................................................................ 705 Determine Rhythm .................................................. 744 Drugs That Are Used to Treat Bleeding Calculate Heart Rate ............................................... 744 Disorders ................................................. 705 QRS Width ............................................................. 745 P Waves .................................................................. 746 Antihemophilic Drugs ............................................. 705 AV Relationships .................................................... 746 Anemia ................................................................... 706 Intervals ................................................................. 746 Drugs That Are Used to Treat Psychiatric Normal Sinus Rhythm .................................... 747 Disorders ................................................. 706 Sinus Tachycardia ................................................... 747 Psychosis ................................................................ 706 Sinus Bradycardia ................................................... 747 Anxiety ................................................................... 707 Sinus Dysrhythmia .................................................. 748 Antidepressant Medication ...................................... 707 Mania ..................................................................... 708 Out-of-Hospital ECG Monitoring Equipment................................................ 750 Drugs That Are Used to Treat Childbirth Emergencies ............................................. 708 At-Home ECG Monitoring ............................. 750 Eclampsia ............................................................... 709 Labor ...................................................................... 709 34. Diagonostic ECG— Drugs That Are Used to Combat Infection ...... 709 The 12-Lead 754 Antimicrobials ........................................................ 710 Antifungals ............................................................. 711 Chief Concern ............................................... 756 Antiprotozoal .......................................................... 711 Atypical Presentations of ACS ....................... 756 Antihelmintics ........................................................ 711 Rhythm Strip ................................................. 756 Drugs Used to Treat Cancer ........................... 711 Palliative Care ........................................................ 711 Origins of the Electrocardiogram ................... 757 Standard Limb Leads .............................................. 757 32. Principles of Precordial Leads ..................................................... 757 Augmented Leads—A More Complete Picture ......... 758 Electrocardiography 718 Acquisition of the 12-Lead ECG .................... 759 Diagnostic 12-Lead ECG versus Rhythm Anatomy ........................................................ 720 Monitoring .......................................................... 759 Cardiac Cycle ................................................ 721 12-Lead ECG Artifact ............................................. 759 Conduction System ................................................. 722 Patient Preparation ......................................... 760 Impulse Formation .................................................. 723 Electrode Placement ................................................ 761 Properties of Cardiac Cells ...................................... 725 Dextrocardia ........................................................... 762 Electrocardiographic Principles ...................... 726 12-Lead ECG Tracing .................................... 762 Leads ...................................................................... 726 Standard Leads ....................................................... 726 Electrocardiographic Assessment Waves ..................................................................... 727 of Left Ventricular Function ..................... 763 Intervals and Spaces ................................................ 728 Contiguous Leads ................................................... 763 Relationship to Coronary Arteries ........................... 764 33. The Monitoring ECG 734 Interpretation .......................................................... 764 12-Lead ECG Identif ication of Myocardial The Monitoring ECG ..................................... 736 Injury ....................................................... 765 Portable ECG Equipment ........................................ 736 Normal Depolarization and Repolarization .............. 765 ECG Tracing ........................................................... 736 Ischemic Patterns .................................................... 766 Monitor Features ..................................................... 737 Injury ..................................................................... 767 Monitor Adjustments ............................................... 737 Electrocardiographic Diagnosis Wire Systems .......................................................... 738 of Acute Myocardial Infarction ................. 769 Electrodes ...................................................... 739 Reciprocal Changes ................................................ 769 Electrode Placement ................................................ 739 R Wave Progression ................................................ 770 New Onset Left Bundle Branch Block ..................... 770 Systematic Approach to ECG Rhythm Right Bundle Branch Block ..................................... 771 Interpretation ........................................... 741 xiv Table of Contents Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Nondiagnostic ECG ................................................ 771 12-Lead ECG Interpretation .................................... 777 Alternative Etiologies for ECG Abnormalities ......... 772 Further 12-Lead ECG Interpretation ........................ 777 Special Case of Pericarditis ..................................... 773 Evaluation .............................................................. 781 Nonspecif ic ST Changes ......................................... 774 15-Lead ECG ................................................. 782 Approach to 12-Lead ECG Interpretation ....... 775 Calibration .............................................................. 775 Acronyms ...................................................... 787 Speed...................................................................... 775 Glossary ........................................................ 792 Diagnostic Quality .................................................. 775 12-Lead ECG Analysis ............................................ 775 Index ............................................................. 831 Table of Contents xv Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. EMS is a practice of medicine. . . . In medicine, there is an art and a science to everything. The science is what we need to do to improve our patient’s condition. In its purest form, what we do is based on rigorous scientifi c scrutiny and all the available evidence applicable to the conditions we treat. The art of medicine is how we apply the science to our patients in a way that maximizes the potential for an improved outcome. Ironically, the science is often much easier to master than the art. This is perhaps no more pronounced than in the ever-changing, often unpredictable world of EMS. One thing is very clear: A good practitioner must be accomplished at both the art and the science of medicine. Edward M. Racht, MD This is a fascinating time to work in emergency health care. EMS is undergoing tremendous evolution. Not only do we know more about the conditions we treat, but more and more of our clinical practices are now based on sound scientifi c evidence that applies specifi cally to our patient population. In the early days of EMS, we adapted evidence from inpatient studies or the laboratory environment and applied it to what we did in the fi eld. While that was certainly appropriate for much of what we did, the challenges of the fi eld and the unique environment of medical care outside the hospital created the need for very targeted research in out-of-hospital medicine. Fortunately, we have more academic initiatives focused on the fi eld than ever before in our brief history. The more we study, the more we learn. We also understand much more about the seemingly insignifi cant details that can have a dramatic impact on patient outcomes. Paying attention to those details and focusing on what’s truly important in the fi eld practice of medicine is another characteristic of the EMS evolution. For example, there are major changes in the way we attempt to resuscitate our patients. A very consistent, focused attention to perfusion is at the core of everything we do during resuscitation

attempts. While many would say we’ve always believed that to be true, the fact is we didn’t always focus on those details during patient care. During those critical moments of assessing and repairing altered physiology and broken anatomy, paying attention to details can often mean the difference between life and death. As we learn more about the amazing science of the human body and how it behaves when it’s “broken,” we appreciate that the best approach to management of illness and injury requires more than just memorizing facts. It requires us to put together everything we know, use all our available resources, and develop a plan of action that incorporates clinical care, different modes of transport, and different receiving facilities that have different capabilities. EMS, as a unique practice of medicine, is charged with making complex decisions in short periods of time, often with only limited data. The educational toolbox you hold in your hand will follow you throughout your career and guide you in making the tough calls. Our role in the Big Picture of Medicine is also evolving. The devastating and unfortunate events of September 11th and the emerging challenges of terrorism, intentional violence, and newer, unpredictable threats have forever focused the American public’s attention on the importance of emergency medical care. EMS providers must have the knowledge and ability to deal with an entire spectrum of out-of-hospital problems, ranging from the simple to the unimaginable. Because of the potential for rapidly changing scenarios, we as Paramedics must now know where to go to get the right information and how to rapidly access data we need to make our decisions. Our ability to rapidly deploy our resources throughout a xvi Foreword Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. community has also highlighted the value of using EMS providers and systems to disseminate emergency medications and immunizations in the event of a need for rapid public health interventions. As economic conditions change, our society is retooling healthcare delivery and our patients are using EMS in different ways than they have historically. While that creates some new stresses on EMS, it’s a vitally important part of our EMS culture. We are the safety net for many communities suffering from inadequate healthcare resources. Regardless of the number of facilities, patients still get sick and hurt. We should be very proud of our collective ability to care for our fellow human beings regardless of their ability to afford it or our community’s ability to provide it. It’s who we are. The newly promulgated Educational Standards are the result of thousands of hours of work from the most accomplished EMS educators, clinicians, and administrators in the profession. The standards provide us with a new approach to delivering the tools that perfect the out-of-hospital delivery of medical care. Rich Beebe, Jeff Myers, and their colleagues have done a spectacular job of presenting the latest evidence in a very comprehensible manner. As you embark on your educational journey to master the art and science of fi eld medicine, you will continuously discover the valuable educational approach of the Professional Paramedic Series. Volume I provides a solid foundation in the knowledge and clinical skills a Paramedic needs to expertly assess and treat patients. In Volumes II and III, the clinical material is presented in a unique way that facilitates the development of critical thinking skills (remember the art?). These volumes use an interrupted case format that narrows a patient’s chief concern into a paramedical diagnosis. Volume III also discusses the wide range of operational issues faced by the Paramedic and presents students with the many niches within EMS. In addition, the accompanying student resources and instructor curriculum provide additional cases and avenues to test student knowledge, further refi ne critical thinking skills, and enhance the teaching and learning experience. Throughout the learning process, students will not only understand what’s important, they will also learn how to think their way into the diagnosis and develop an approach that has the best opportunity to improve a patient’s condition. That is critical thinking. Enjoy. Enjoy this part of your journey. Enjoy taking care of people when they need you the most. Enjoy learning about the fascinating intricacies of the human body, and enjoy the impact you will have on people’s lives every day. Always remember how important your knowledge, skills, and compassion are for those at the other end of the 9-1-1 call. Edward M. Racht, MD Foreword xvii Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Intent of This Book nature of the Paramedic fi eld demanded a fresh You are about to embark on an exciting career as a approach. We wanted our textbook to challenge Paramedic! Within these pages we will present to you Paramedic students to think about the application of the knowledge, skills, and practical advice needed medical knowledge to fi eld practice. This approach to become a skilled and profi cient Paramedic. changed the focus of a Paramedic textbook from With a focus on future Paramedics and the being the center of a Paramedic’s education to Paramedics of today, the Professional Paramedic one in which it serves as an authoritative resource Series was designed as a comprehensive resource that implores the student to explore the current for Paramedic students during their education state of the science. and as a source for life-long learning. This series As part of our vision in writing this series, we seeks to prepare aspiring Paramedic students wanted to recognize the practice of paramedicine. in community colleges, universities, and other What is paramedicine? Paramedicine is a unique educational programs by not only providing the practice of emergency medicine that happens in knowledge needed to become a Paramedic, but the out-of-hospital setting. First described in the also developing the ability to think critically and EMS Agenda for the Future in 1996, paramedicine decisively when seconds count. Beyond the basic is the result of the growth of EMS over almost one foundation of information and skills, this series half of a century. It encompasses the complete helps the Paramedic student reach a higher level of roles and responsibilities of the Paramedic within understanding. For this reason, the series is also an the domains of health care, public health, and essential source for recertifi cation and continuing public safety systems. We offer this series as a education for practicing Paramedics. guide to prehospital emergency medical care and In January 2009, the new National EMS Education the practice of paramedicine, providing learners Standards were released to the EMS community, with a reference for the often complex, at setting an academic standard for all Paramedic times ambiguous, and always challenging fi eld of education programs. This series was specifi cally emergency medicine. developed with the National EMS Education We understand that often the best Paramedics Standards in mind, yet can also be used in Paramedic are those who start with a natural curiosity about programs that have not yet transitioned to the new emergency medicine and inquisitiveness about how standards. Each of the three volumes, as a series, that medical knowledge could be practically applied meet and exceed these new education standards in the streets. These students know it is important by not only teaching the essential information and to be street smart as well as book smart. This book skills, but also by preparing each student in how to seeks to help answer their questions through a think like a Paramedic. As Paramedics who started conversation with the student. in the streets and who continue to practice in the streets, we support the vision of the National EMS The Professional Paramedic Education Standards, and have created this aptly Series named Professional Paramedic Series. This series is designed to follow a logical progres- sion of learning, in which information and skills Why We Wrote This Book are presented fi rst in Volume I, followed by the As educators, we challenge our learners—the application of those skills in emergency situations students of this series—to be the best Paramedics in Volume II, and trauma and special response they can be. While there are other Paramedic considerations in Volume III. The framework of each textbooks available, we felt that the evolving book is practical in approach: introducing principles, xviii Preface Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. skills, and terminology; presenting a typical case; This volume is divided into six sections. walking through critical response steps; and again reviewing key concepts to ensure understanding for Section I: Framework For successful application on the job. Paramedic Practice The series is inclusive of all of the content areas All things must be built on a solid foundation, listed in the National EMS Education Standards and and the practice of EMS is no different. What contains material on most of the critical and emergent do Paramedics do, why do they do it, and how did disorders listed in the EMS core content, as well as many the fi eld develop? How are EMS systems put to- of the lower acuity conditions. This coverage helps gether and why? How do we remain safe at what ensure the student prepares for the National Registry we do? What is research, how do I read it, and or state Paramedic certifi cation examinations. More why is it important during my daily practice in the importantly, the series helps prepare the Paramedic street? The four chapters in this section answer student for professional Paramedic practice. these questions and examine these subjects in Volume I: Foundations depth. As the fi eld of paramedicine becomes more evidence based, understanding research and how it of Paramedic Care applies to our practice becomes more important. ISBN: 978-114283-2345-2 Section II: Ethics and Law in EMS The public as a whole—and each individual patient and family—entrusts Paramedics with their lives and expects them to provide appropriate care. Some situations pose a dilemma for the Parame-dic, whether it is with a patient, family member, partner, supervisor, or medical director. A strong sense of ethics, displayed by following accepted ethical and legal practices, helps Paramedics maintain the trust and privilege that is placed in them by society. Section III: EMS and Public Health Since September 11, 2001, the EMS community has recognized that there is a strong link between EMS and public health. In some areas of the United States, Paramedics are utilized to augment the public health system, whether as part of a response team to a public health emergency or to assist with day-to-day public health activities in areas of need. These chapters provide a foundation in the fi eld of public health and illness and injury prevention. This allows the Paramedic to fulfi ll these important roles To be able to make a diagnosis, the Paramedic in the healthcare system. must be well grounded in the basics of medicine including anatomy and physiology as well as pa- Section IV: Scientifi c Principles thophysiology. Volume I: Foundations of Paramedic The four chapters in this section provide a basic Care begins with the basics. This fi rst volume in the foundation in lifespan development, physiology, series introduces the fundamental information and pathophysiology, and medical terminology. These skills needed for success, as well as the

necessary areas again help lay a solid foundation for the tools to begin developing a professional approach to Paramedic to build upon in the later technical and emergency medicine and Paramedic care. clinical chapters. Preface xix Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Section V: Principles of Clinical Practice various diseases and disorders, from gynecological Communication with and assessment of the patient is concerns to neonatal resuscitation, from the essential to every encounter. Through this process, chronically ill to the victims of domestic violence the Paramedic gains the information needed to form and sexual assault. Each chapter walks you a differential diagnosis and develop an appropriate through a typical emergency that a Paramedic treatment plan for the patient. These seven chapters might encounter in the fi eld—each case associated provide the Paramedic with the base skills to obtain with the subject of the chapter–presenting an effective history and perform a thorough physical critical information that leads you to develop examination. a Paramedic’s diagnosis from the information provided. Section VI: Clinical Essentials It should be understood that each case repre- The fi nal section of this volume includes the essen- sents only one potential patient presentation. tial material regarding airway management, moni- To that end, we have included additional cases in the toring devices, intravenous access, pharmacology, accompanying Study Guide. It is the responsibility ECG monitoring, and acquisition that forms the of the student and the instructor to explore these basis for our assessment and treatment. This section other cases, and other real world examples, to fully provides the foundational material nece-ssary to appreciate other potential patient presentations. progress into the clinical chapters in Volume II. Even so, this cannot possibly cover the entire universe of potential patient presentations. This Volume II: Medical Emergencies, fact makes Paramedic emergency care exciting Maternal Health & Pediatrics and refreshing. These cases are intended to ISBN: 978-1-4283-2351-3 reinforce the commonalities of presentation As Paramedic students, you must learn to for the different disorders and syndromes that apply the skills introduced in the fi rst volume will permit the Paramedic to make a diagnosis, within Volume II of the series. Through introduction regardless of the individual patient-specifi c of an interrupted case approach, this book conditions. walks you through a wide range of emergency Volume II is divided into four sections: response situations, from cardiac emergencies to ■ Section I: Medical Emergencies ■ Section II: Maternal Health ■ Section III: Pediatric Medicine ■ Section IV: Special Patients Volume III: Trauma Care and EMS Operations ISBN: 978-1-4283-2348-3 Volume III highlights special response conside- rations and a broad range of operational medical topics needed to prepare readers with the complete spectrum of knowledge required to succeed as a Paramedic. These aspects of Paramedic practice help to make paramedicine unique and help make paramedicine a profession. Volume III is divided into four sections: ■ Section I: Trauma Care ■ Section II: Environmental Medicine ■ Section III: EMS Operations ■ Section IV: Emergency Incident Management xx Preface Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. and instructor within the classroom. By portraying realistic emergency situations that a Paramedic is likely to encounter on the job, the book introduces the student to the material in a meaningful manner. This presentation also encourages the decision-making process involved in making a fi eld diagnosis, and outlines a plan of treatment that meets the standard of care within the scope of practice for the patient—for prehospital care and transport to the hospital. Each case is designed to encourage a Paramedic thought process, relates to the subject under discussion within the chapter, and includes follow-up Case Study Questions at the end of the chapter. Case Study Questions: Please refer to the Case Study at the beginning of the chapter and answer the questions below. 1. W hat should be included in the radio report to the medical control physician? 2. H ow important was the fi rst-due report given by the Features fi rst member of the public safety team on-scene? Along with an appealing design, this series has many features intended to motivate the student to read CHEATED Method and learn the content and skills presented in each This method follows the standard medical intelligence volume. of a Paramedic (sometimes called “medic think”), and encourages students to engage in the critical Comprehensive Coverage thinking process needed for a proper fi eld diagnosis The complex depth and comprehensive breadth of and treatment—Chief concern, History, Examination, information required for a working knowledge of Assessment, Treatment, Evaluation, and Disposition. Paramedic practice, for Paramedic certifi cation, and, ultimately, for success on the job are all provided in Professional Paramedic an engaging and reader-friendly manner. Students Integrated throughout the book, this advice high- will be properly prepared for these challenges li23g45h7_t18s_ ch1t8h_p3e20 -33p5.irndod f 3e34ssional attitudes that signify the with evidence-based information presented within difference between a competent Paramedic and the content that meets and exceeds National EMS a profi cient Paramedic—one fellow Paramedics Education Standards. respect and look to as a leader. Key Concepts Presented in the beginning of each chapter, the key Professional Paramedic concepts set learning goals for students and prepare The professional Paramedic does not blame the readers for both the didactic and psychomotor skills presented in the chapter. patient for the disease. For example, tobacco smoking is now known to be a risk factor for lung Case Studies diseases such as emphysema and cancer. However, tobacco smoking was encouraged by the U.S. The case studies included in each chapter facilitate government in World War II and tobacco companies the conversation—both the internal dialogue within advertised that tobacco was an aid to digestion. the student and the dialogue between the student Preface xxi Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Street Smart Skill 23-5 King Airway Placement Street Smart tips, lessons learned by the authors while in practice in the fi eld, focus on practical information that can help new Paramedic students perform in less-than-ideal or unusual situations. Street Smart 1 Grasp tongue and jaw, lifting toward ceiling. Place tip of tube 2 Rotate the airway counterclockwise as it is advanced. To differentiate a pericardial rub from a pleural rub, toward oropharynx, approaching from the patient’s right. have the patient hold his breath. Pleural rubs are heard when the patient is breathing while pericardial rubs occur with each heartbeat. Cultural/Regional Differences 3 Advance until the orogastric port is at the level of the teeth. 4 Infl ate balloon, bag-ventilate the patient, and auscultate Important considerations are pointed out for respond- breath sounds. ing to patients of different cultural backgrounds. This prepares students for the diverse patient population that the Paramedic will encounter in emergency situa- tions. Understanding these cultural/regional differences increases the Paramedic’s effectiveness in the fi eld. 5 Slowly withdraw while listening until breath sounds are the 6 Confi rm placement and secure airway. loudest. Cultural / Regional differences Review Questions It should be noted that while younger and better Review Questions at the end of each chapter are educated patients prefer to share clinical decision helpful for evaluating student knowledge of the con- making, cultural and ethnic differences may decrease cepts presented in the chapter. Review Questions patient cooperation. This lack of cooperation should are followed by Case Study Questions that encourage not be viewed as resistance to care but rather as a students to apply critical thinking skills to the case trust in the Paramedic’s decision. studies that are presented at the beginning of each chapter. 10/2/09 12:41:26 AM Step-by-Step Skills References and an Photos and descriptions are combined to present critical information on the fundamental skills of Evidence-Based Approach Paramedic practice. Each skill is included at the end of The content each student learns must be substantiated the chapter to avoid interrupting the fl ow of learning, by science and medicine. Each chapter is thoroughly and is referenced in the applicable discussion within researched and includes documentation of references the chapter. that support the content presented in the chapter. Conclusion and Key Points References: Critical points in the chapter are covered and 1. Kelly CG. The ways and whys of documentation. Good provide a basis of review for the student. While documentation is more than what’s on a PCS form. Emerg Med the Conclusion provides an overall summary of the Serv. 2007;36(7):30. 2. Perkins TJ. Tell me a story. The importance of good chapter’s main theme, the Key Points provide a documentation. Emerg Med Serv. 2007;36(9):30, 32–33. bulleted list of important information that is helpful 3. Krentz MJ, Wainscott MP. Medical accountability. Emerg Med for study or review. Clin North Am. 1990;8(1):17–32. xxii Preface Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Professional Paramedic Series Curriculum Plan We are proud to present a robust curriculum plan for the Paramedic student and instructor. As part of this plan, we offer resources that work hand-in-hand with each volume in the series, serving to further enhance both the teaching and the learning experience. For the students, resources are available that will help them review important concepts through practical application, develop and practice critical thinking skills, and guide them toward further research and discovery. For the instructors, we offer tools that will help them effi ciently prepare for classroom instruction, manage and track student progress of didactic and skill requirements, keep informed of new advances in the EMS fi eld, and overall, engage students in learning both in and out of the classroom. For the Student Study Guides For the Instructor Volume I Study Guide, ISBN: 978-1-4283-2346-9 Instructor Resources (CD-ROM) Volume II Study Guide, ISBN: 978-1-4283-2352-0 Volume III Study Guide, ISBN: 978-1-4283-2349-0 Volume I Instructor Resources, ISBN: 978-1-4283-2347-6 Bridging the gap between knowledge and application, Volume II Instructor Resources, one Study Guide accompanies each volume to offer ISBN: 978-1-4283-2353-7 learners additional case studies for each chapter, Volume III Instructor Resources, along with multiple types of practice questions ISBN: 978-1-4283-2350-6 and activities required for comprehension of the material. The Instructor Resources for each volume are designed to help instructors effectively prepare Online Companions students to become well-rounded, street-smart Students are provided with FREE access to our Paramedics within the guidelines of the new National website with an Online Companion to accompany EMS Educational Standards. The Instructor Resources each volume. This website invites students to on CD-ROM includes tools that help instructors and further study and explore the concepts presented in administrators prepare their Paramedic program in a each volume. The website includes articles and up- timely and effi cient manner. Each CD-ROM includes to-date information on the EMS fi eld, related links the following features: to important industry organizations and resources, ■ Administration: This section includes information information related to national guidelines, illustrated on setting up the program, as well as practical glossaries, and bonus content. Each Online Companion advice for transitioning your program to the new

is uniquely designed to the corresponding volume in National EMS Educational Standards. In addition, the series, and contains information relevant to the it includes the following tools: topics covered within that volume. ● Equipment Checklist: The checklist provides Visit www.cengage.com/community/ems to access a resource for instructors to ensure that these Online Companions! they have the necessary tools for classroom Preface xxiii Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. revise them according to local practice variations and regional/state medical protocols. ■ PowerPoint Presentations: Correlated to the accompanying Lesson Plans, these presentations combine key points with photos, graphics, and video to serve as a basis for either interactive classroom instruction or as augmentation of an asynchronous distance learning program. ■ Computerized Test Banks: Containing over 1,000 questions and covering the content in each chapter, these Test Banks in ExamView format allow instructors to manage test administration in the classroom. Instructors may create or edit tests based on existing questions, edit questions, and add or delete questions to fi t local practice variations and regional/state medical protocols— all in this user-friendly program. ■ Teaching Sheets: Highlighting the Paramedic skills necessary for Paramedic practice, these Teaching Sheets provide a baseline for skills learning. Each Teaching Sheet provides a break- down of the critical principles for the skill, and is included in Word format to allow instructors to add specifi cs based on their local requirements and/or regional/state protocols and procedures. ■ Clinical Logs: Based on the Teaching Sheets, instruction and for setting up and running skill these Clinical Logs provide forms for tracking sequences. student accomplishment of prehospital (fi eld) ● Concept Maps: Highlighting the decision- and in-hospital (clinical) skills. These forms, making process, these Concept Maps offer complete with a signature page, are provided in a way for instructors to help students Word format to allow instructors to edit them in conceptualize ideas in the classroom and order to meet local requirements. develop the critical thinking skills necessary ■ Research and Discovery—Instructor Reference for determining a fi eld diagnosis. Each Concept Guide: Paramedicine, like medicine, has an ever- Map, utilizing a typical emergency scenario, changing body of knowledge. To remain current, walks students through the critical thinking the Paramedic must be a life-long learner. In steps used during an EMS response. addition to the listing of references that appears ● Correlation to National EMS Education at the end of chapters in each volume in the Standards and D.O.T Paramedic Curriculum: series, this Instructor Reference Guide provides These guides map out Paramedic content and additional resources—including articles, websites, provide students with the volume, chapter, organizations, and other reference materials—to and pages where this content is covered in fi nd information on specifi c topics. This ensures the Professional Paramedic Series. that instructors remain informed of current ■ Lesson Plans: Including an outline of each practices in the EMS fi eld. chapter, with correlations to the accompanying PowerPoint presentations, skill sheets, and helpful Online Companions teaching tips, these Lesson Plans provide a helpful Linked to the student Online Companions, these guide for classroom instruction. These plans are resources provide instructors FREE access to provided in Word format so that instructors may bonus content, including podcasts, articles on xxiv Preface Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. new information and technology, links to EMS During his tenure as a Paramedic Educator, community websites, information related to Mr. Beebe has served in the capacity as lecturer, national guidelines, and additional classroom instructor-coordinator, and Paramedic program materials. Each Online Companion is uniquely director. He continues to speak at local, regional, designed to the corresponding volume in the series, state, and national conferences on topics of and contains information relevant to the topics importance to both the EMT and the Paramedic. covered within that volume. Mr. Beebe is presently a clinical assistant pro- fessor at the State University of New York at Cobleskill and Paramedic program director for Web Tutor on WebCT and Blackboard Bassett Healthcare’s Center for Rural Emergency Providing a content-rich, Web-based teaching and Medical Services Education. learning aid, this tool helps to emphasize and clarify Mr. Beebe has been published in several journals, complex concepts, provides a forum for discussion, including the Journal of Emergency Medical Services and offers a venue for tracking course syllabus and and Fire-Engineering, as well as being a co-author other program-related activities. for Delmar’s Fundamentals of Basic Emergency WebTutor on Blackboard Course allows instructors Care, now in its third edition. to quickly and easily jump-start their on-line course Mr. Beebe has contributed to the previous editions development. Whether you want to Web-enable of the National Standard Curriculum for Paramedic, your class or put an entire course on-line, WebTutor Intermediate, and Basic; to the national EMS delivers! Education Agenda for the Future; to the national EMS Scope of Practice; and served as content leader for the National EMS Education Standards. Mr. Beebe About the Authors is also a charter member of the National Association of EMS Educators. Richard Beebe, MSEd, BSN, RN, NREMT-P Richard Beebe started his EMS career in 1974 as an Jeff Myers, DO, EdM, NREMT-P, FAAEM Explorer Scout with the Moyers Corners Volunteer Fire Dr. Myers has been involved in EMS for over 20 years, Department in upstate New York. Since obtaining his including 12 years in the prehospital environment and Emergency Medical Technician certifi cation in 1975, 18 years as an EMS educator. Dr. Myers began his EMS Mr. Beebe has continuously maintained his certifi cation journey in 1988 in upstate New York by volunteering and his practice. During his career Mr. Beebe has for his college ambulance (RPI Ambulance) and a local served in fi re/EMS, commercial EMS, volunteer EMS, community ambulance (North Greenbush Ambulance and as a municipal Paramedic. During that time, he Association). He began teaching in 1990 for the has served as a volunteer crew chief, a squad captain, Rensselaer County Ambulance and Rescue Association, and Paramedic supervisor. Mr. Beebe currently serves eventually becoming a state Certifi ed Instructor as a civilian Paramedic for the Guilderland Police Coordinator. Dr. Myers ran the EMT-Basic original Department, outside of Albany, New York. course in Rensselaer County for three years before Mr. Beebe has also been a critical care nurse leaving to attend medical school. During the early since 1985, having practiced for 10 years in both 1990s, he also served as a Rensselaer County Deputy the Emergency Department and the Intensive Care County EMS Coordinator for four years, responding Unit. During these years, Mr. Beebe developed to multi-ambulance and multi-agency incidents. His his knowledge of medicine and—perhaps, more fi eld experience includes volunteer, commercial, and importantly—an appreciation of the potential combination paid-volunteer agencies as a Paramedic impact that prehospital advanced life support could in upstate New York and in southern Maine. have on patient morbidity and mortality. Dr. Myers attended medical school at the Consistent with that belief, Mr. Beebe became a University of New England College of Osteopathic Paramedic in 1988 and, in hopes of advancing the Medicine in Biddeford, Maine. While in medical practice of his fellow Paramedics, started his career school, he continued to teach ACLS and BCLS classes as a Paramedic Educator. through the local hospital. Preface xxv Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Dr. Myers then moved to Buffalo, New York, Anthony Billittier, IV, MD, Commissioner of Health, completing his residency in Emergency Medicine at Erie County, New York; Assistant Professor SUNY-Buffalo in 2004. In his fi nal year of residency, Emergency Medicine, Department of Emergency he served as Chief Resident. He stayed at SUNY- Medicine, School of Medicine and Biomedical Buffalo for a two-year EMS Fellowship through the Sciences; Assistant Professor, Department of Erie County Medical Center and completed a Masters Social and Preventative Medicine, School of Public in Education at the University of Buffalo. He is board Health and Health Professions, State University of certifi ed in Emergency Medicine and a Fellow of the New York at Buffalo American Academy of Emergency Medicine. Jonnathan Busko, MD, MPH, EMT-P, Emergency He is currently on faculty at SUNY-Buffalo as a Physician, Eastern Main Medical Center, Bangor, clinical assistant professor and serves as the associate Maine system EMS medical director and EMS fellowship Steve Carson, BS, PA, CCEMT-P, Physician Assistant, director at the Erie County Medical Center. Dr. Army National Guard, Afghanistan Myers is an active member of the Specialized Medical Deborah Kufs, MS, RN, EMT-P, Interim Director, Assistance Response Team, western New York’s Paramedic Program, Hudson Valley Community physician response team, which is called upon to College, Troy, New York augment local EMS during MCIs, and special situations, Jeffrey Thompson, MD, Attending Physician, for example patient entrapment and providing Professional Emergency Services and Clinical tactical medical support. He is the assistant medical Instructor of Emergency Medicine, State University director for Rural Metro Medical Services of Western of New York at Buffalo, Buffalo, New York New York, based out of Buffalo, New York. Dr. Myers Brett Williams, MD, Florida Emergency Physicians, has several publications in peer-reviewed journals Orlando, Florida and is an author for Delmar Cengage Learning, writing Automated Defi brillation for Professional For the development of the art program in this and Lay Rescuers and Principles of Pathophysiology volume—the countless hours spent in preparation, and Emergency Care. He also produced and directed set up, and shooting of the photography appearing the Techniques in Airway Management DVD series. in this book, as well as the extensive research, Dr. Myers has spoken at several regional and national persistence, and acquisition of those “hard to fi nd” conferences on a variety of topics. For more photos and graphics—we express our gratitude to information on topics or to provide feedback on the the following individuals: textbook, please check out Dr. Myers’ website at Jon Behrens, AAS, EMT-P, Paramedic Instructor, http://ems-ed.photoemsdoc.com. State University of New York at Cobleskill Chris Lenaghan, Photographer, CML Media Services Abigail Reip, Photo Acquisition and Permission Acknowledgments Coordinator As with all of our projects, the Professional Para- Liana Dypka, Art Manuscript Development medic Series would not have been possible without the support, guidance, and participation of the con- tributors, reviewers, and advisory board members. Reviewers We owe these individuals our sincere thanks. To the reviewers, who provided an honest evaluation of the content in the book and continual guidance throughout development of this volume, we express Contributors our appreciation: During the development of Volume I: Foundations Melissa Alexander-Shook, Director of EMS Academy, of Paramedic Care, we were honored to have the University of New Mexico, New Mexico following contributors participate in researching, Steve Kanarian, Paramedic Instructor, Rockland writing, editing, and reviewing materials to Community College, New York ensure a comprehensive and accurate Paramedic Mike McLaughlin, Director of Health Occupations, guide: Kirkwood Community College, Iowa xxvi Preface Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. M. Jane Pollock, Extension Education Training From the

Authors Specialist, Emergency Medicine, East Carolina Beebe University, North Carolina Don Royder, Emergency Medical Services Program First, I would like to acknowledge my friends Coordinator, Texas Engineering Extension Service, and family, and particularly my wife Laura, whose Emergency Services Training Institute, Texas support has sustained me over the 10 years that it took to write this book. Thank you for your love. EMS Advisory Board I would also like to thank the professionals at Delmar/Cengage Learning who have helped support We offer special thanks to our Advisory Board this idea from its onset and continue to encourage Members, who take time out of their schedules to me to greater accomplishments. I would like to advise us on our training materials, the status of the thank Sandy, Benj, Erin, and particularly Jennifer, EMS fi eld, and to work with us as partners in striving the backbone of this excellent team. to meet the needs of the students and instructors of Finally, I would like to thank my students who, each today—and those of the future: and every year, challenge me to be the best Paramedic Scott Bourn, National Director of Clinical Programs, and educator that I can be and who, even to this day, National Resource Center, American Medical continue to inspire me. In the 30-plus years I have been Response, Colorado involved in EMS and EMS education, I have truly seen Deb Cason, Associate Professor, University of Texas EMS in general—and Paramedics in particular—evolve Southwestern Medical Center, Texas into a caring profession that we all can be proud of. Don Collins, Captain, Massport Fire-Rescue, Logan International Airport, Boston Myers Stephen Dean, Director, Corporate Training, Thanks and love to my family. This textbook (and Paramedic Plus, Oklahoma all my life’s projects) would not be possible without Joe Grafft, President, Customized Safety Training their support. Art Hsieh, Chief Executive Offi cer and Director of Education, San Francisco Paramedic Association, Delmar/Cengage Learning Team California For the team that always fi nds a way, every day, Mike Kennamer, Director of Workforce Develop- to turn an idea into a reality, we thank these ment, Northeast Alabama Community College, extraordinary people for their hard work, dedication, Alabama support, and creativity: Guy Piefer, Paramedic Program Coordinator, Borough of Manhattan Community College, City Janet Maker, Product Development Manager of Yonkers Fire Department, New York Jennifer Starr, Senior Product Manager Ed Racht, Vice President of Medical Affairs and Amy Wetsel, Editorial Assistant Chief Medical Offi cer, Piedmont Newnan Hospital, Jennifer Hanley, Senior Content Project Manager Georgia Erin Coffi n, Senior Marketing Manager Karla Rickards, EMS Training Coordinator, Unifi ed Shanna Gibbs, Marketing Coordinator Fire Authority, Salt Lake County John Rinard, Training Coordinator, TEEX, Texas Closing Thoughts A&M University In this time when the importance of quality John Sinclair, Fire Chief, Kittitas Valley Fire improvement is understood and appreciated, Rescue Emergency Manager, City of Ellensburg, we encourage students and instructors alike to Washington; Immediate Past Chair and communicate with us. Via these conversations, International Director, International Association all parties can improve their understandings. We of Fire Chiefs, Emergency Medical Services are all enriched through this communication. Section Mike Ward, Director of Emergency Health Services, Richard W.O. Beebe Jeffrey W. Myers George Washington Medical Center, Washington, [email protected] h ttp://ems-ed. DC photoemsdoc.com Preface xxvii Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. A ll things must be built on a solid foundation, and the practice of EMS is no different. What does a Paramedic do, why do they do it, and how did the fi eld develop? How are EMS systems put together and why? How do we remain safe at what we do? What is research, how do I read it and why is it important during my daily practice in the street? The four chapters in this section answer these questions and examine these subjects in depth. As the fi eld of paramedicine becomes more evidence based, understanding research and how it applies to our practice becomes more important. • Chapter 1: Roles and Responsibilities of the Professional Paramedic • Chapter 2: Introduction to Emergency Medical Service Systems • Chapter 3: Workforce Safety and Wellness • Chapter 4: Research and EMS 1 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The profession of paramedicine combines aspects of public health, public safety, and health care • Standards and scope of practice defi ne the Paramedic’s knowledge, skills, and attitudes • The Paramedic’s role is as a healer, clinician, and teacher • Quality assurance, Quality improvement, and continuing education enhance both the Paramedic’s individual practice and that of the profession as a whole • The Paramedic is a physician extender through stewardship, leadership, and followership Case Study: Traffi c was slowed around the accident site. As the two teens drove slowly by, each looked at the Paramedics who were providing and directing care of the victims. The fi rst teen stated, “They sure looked like they knew what they were doing.” The second teen added, “I wonder what else they do.” 2 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Roles and Responsibilities of the Professional Paramedic 3 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Although paramedicine is a relatively young profession compared to many others, it has found its footing as a unique part of the healthcare system. The Paramedic’s role has evolved from simply responding to emergencies to now practicing an expanded scope of practice as a physician extender. In this way, the Paramedic has proved to be a vital part of the public health and safety team. This chapter not only examines the origins of paramedicine but also how national education standards and accreditation of educational programs coupled with professional organizations have helped to validate paramedicine as a profession. The chapter also examines the Paramedic’s core values and his or her role as healer, clinician, and teacher. As the Paramedic’s scope of practice and community responsibilities continue to develop, quality assurance, quality improvement, and continuing educational programs need to be established. The Paramedic’s independent and interdependent role as a physician extender relies on leadership and stewardship. What Is Paramedicine? examinations and become licensed to practice paramedicine. All Paramedics understand the importance and the necessity Paramedicine is a special subset of medicine that Paramedics of giving back to their profession through teaching Paramedic provide in the out-of-hospital setting. Paramedics, as allied students. healthcare professionals, practice paramedicine under often The practice of paramedicine, like the practice of medi- austere conditions and with a minimum of equipment. cine, is constantly evolving. Professional Paramedics incor- Paramedic practice is both independent as well as interdepen- porate and apply new information and technologies in their dent. The universe of independent Paramedic practice includes practice. Through programs of competency assurance and pro- disaster planning, response readiness, scene management, and fessional development, offered in continuing education pro- emergency vehicle operations. Collaboratively, Paramedics grams, the Paramedic stays current with the profession. work interdependently with emergency physicians to bring The Paramedic’s professional identity revolves around the the highest level of medical care outside of the hospital. voluntary assumption of certain roles and responsibilities and While Paramedics traditionally have provided emergency a code of ethics. Once Paramedic status is attained, that person care as part of the emergency response system, Paramedics is a Paramedic and, regardless of other roles the person may also provide care during transportation between medical have in a lifetime, will always see himself as a Paramedic. facilities. Interfacility patient care often involves a high level of medical complexity and requires education above that of The practice of medicine is an art, not a trade; a the entry-level Paramedic. calling, not a business; a calling in which your heart Paramedicine is positioned at the intersection of health will be exercised equally with your head. care, public health, and public safety. Owing its existence to each, the Paramedic is cross-trained in each of these areas. As — William Osler, MD a result, a synergy occurs among the knowledge from these three areas and the result is paramedicine, a unique body of The professional Paramedic has many roles, the fi rst knowledge which is exclusive of its origins. of which is as a healer. Healing is an attempt to mollify the More than a vocation, paramedicine involves exten- effects of disease. In many instances the Paramedic is unable sive educational preparation, typically at a collegiate level, to effect a cure and strives instead to relieve pain and suffer- to attain the specialized knowledge necessary to become a ing. Healing is a process of helping people physically, men- Paramedic. Paramedic education is usually attained in an edu- tally, and spiritually endure their illness. As one of the healing cational program that is accredited by a body which includes professions, when the practicing Paramedic demonstrates professional Paramedics. empathy, respect, and a genuine interest in the patient, the Paramedicine is also an applied science. To attain profi - Paramedic is seen as a compassionate caregiver—a healer. ciency at patient care skills and apply the knowledge gained This ability to help the patient in distress to heal while provid- to care of patients, Paramedic students learn and work under ing medical care could be seen as the art of paramedicine. the watchful eye of preceptors. Upon completion of a pro- While Paramedics rarely cure a disease, the practice gram of study, Paramedics complete professional certifi cation of paramedicine is also based, in part, on the science of 4 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. medicine.1,2 The science of medicine focuses on cure and Table 1-1 Qualities of a Profession medical research is continually improving the treatment of • Extensive educational preparation patients with diseases. In turn, the medical treatments that • Accreditation of educational programs Paramedics provide are based, to the extent possible, on med- ical research. A professional Paramedic always keeps abreast • Mentoring of the medical science which has an impact on the practice.

• Certifi cation Paramedics are also stewards. As a shared practice that • Licensing originates in medicine, Paramedics are responsible for main- • Professional development taining the ideals of medicine and to practice in a manner • Professional societies that would bring honor to themselves and their physician • Code of ethics—professional boundaries colleagues. The right to practice paramedicine is given to Paramedics by physicians who understand the importance of collaborative practice. of education is typically provided in a college or university As members of the healthcare team Paramedics are also environment in accredited educational programs. During leaders. Paramedics are not leaders by virtue of their posi- their education, Paramedic students would need professional tion but by their ability to affect the behavior of other mem- models, or mentors to guide them along in their educational bers of the team to accomplish the goal of patient care. As a development. Upon successful completion of the original leader, the Paramedic may have to take on the role of teacher education, the Paramedic’s rite of passage into the profes- or patient advocate, but in every instance the patient’s welfare is foremost in the Paramedic’s mind.3 sion would be certifi cation and licensure. Once in the fi eld, the practicing professional Paramedics would be expected As the leader, the Paramedic also understands the impor- to maintain their education through competency assurance tance of followership. A Paramedic’s adherence to the phy- and professional development.5 Paramedics would also be sician’s orders, as well as those of other authority fi gures, expected to contribute to the profession through active par- is an example of followership. Followership is not offered ticipation with fellow Paramedics in an association or soci- begrudgingly but instead willingly, with an understanding of ety. Central to these professional associations or societies is a the importance of teamwork for patient care. code of ethics which helps defi ne the profession. Many quali- ties are common in all professions (Table 1-1). Currently Paramedics are required to obtain extensive Professional Paramedic educational preparation to acquire a unique body of knowl- edge. An increasing number of Paramedic programs are being offered in accredited programs provided at postsec- The role of patient advocate encompasses all of the ondary schools where Paramedic students also learn from Paramedic’s other roles and responsibilities. experienced preceptors during an internship. Plus, there is a growing trend toward licensing Paramedics. These efforts, and others, will help to shape and develop the Paramedic profession. Hallmarks of a Profession In the past, Paramedics were considered auxiliary healthcare providers, unlicensed care providers who received the major- Cultural / Regional differences ity of their training “on the job” (OJT) and were not con- sidered to be healthcare professionals. Classic examples of No national exam serves as a culminating point for healthcare professionals are physicians, nurses, and physician assistants. These groups are considered professional because entry into the profession of paramedicine as does they meet certain criteria to be considered a profession. the NCLEX for professional nursing. A tapestry of Paramedics have not yet met those criteria. However, the fi eld county, regional, and state requirements often create of paramedicine is in the process of professionalization. Some of the criteria for consideration as a healthcare diffi culties in transferring from one geographical area professional were discussed in the fourth report of the Pew to another. Health Professions Commission entitled, “Recreating Health Professional Practice for a New Century.”4 The section entitled, “Professional Characteristics of Allied Healthcare To assist current and aspiring healthcare professionals, Providers” describes what is needed for a group to be consid- the Pew Health Commission listed what were felt to be the 21 ered an allied healthcare provider. competencies that healthcare professionals needed to aspire To be considered an allied healthcare provider, Paramedics to in the twenty-fi rst century. Some of these are especially would fi rst need extensive educational preparation. This type germane to Paramedics (Table 1-2). Roles and Responsibilities of the Professional Paramedic 5 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 1-2 Partial List of the 21 Competencies National Registry of Emergency for Healthcare Professionals for the Twenty-First Medical Technicians Century from the Pew Health Commission The culmination of a Paramedic education should be certifi - • Embrace a personal ethic of social responsibility and service cation. A certifi cation is a formal process in which an outside • Exhibit ethical behavior in all professional activities organization, often an organization that represents the profes- • Provide evidence-based clinically competent care sion or the professional association, verifi es through written • Integrate population-based care in services into practice and/or practical examination the competency of an individ- • Improve access to healthcare for those with unmet health needs ual who wishes to enter the profession. This process seeks • Provide culturally sensitive care to a diverse society to ensure that the individual possesses the minimum level of • Use communication and information technology effectively and knowledge and skill required to practice that profession. appropriately The National Registry of Emergency Medical • Work in an interdisciplinary team Technicians (NREMT) presently provides a certifi cation process of practical testing and written examinations for the • Practice leadership certifi cation of Paramedics. Successful completion of the • Contribute to continuous improvement of the healthcare National Registry testing demonstrates that the Paramedic system has demonstrated a minimally acceptable level of profi ciency • Continue to learn and help others learn in the core elements. The National Registry was initiated by recommendation of the American Medical Association’s (AMA) Committee Education Systems on Highway Traffi c Safety, chaired by Dr. Oscar Hampton Jr. The committee included notable EMS authorities such as Key to a profession is the educational preparation required to Dr. J.D. “Deke” Farrington, author of the infl uential article enter that profession. In the past, the DOT National Standard “Death in the Ditch.” The National Registry of EMT was Curriculum has served as the basis for EMS education. Since formed in June 1970 and—under the leadership of its fi rst the creation and adoption of the fi rst EMT-A National Standard executive director, Rocco V. Morando—proceeded to meet its Curriculum (NSC) in 1969, the DOT NSC has served as both mission “to certify and register EMS professionals through- curriculum and a scope of practice in that EMS lacked any out their careers by a valid and uniform process to assess the other unifying documents. The document which will replace knowledge and skills for competent practice.” the NSC is the National EMS Education Standards. The stan- dards, together with the national core content and national scope of practice, identify the Paramedic’s knowledge, skills, National Association of Emergency and attitudes. Medical Technicians The National EMS Education Standards (NEMSES) pro- vide the foundation for that fi nal terminal objective of every The EMS profession is relatively young compared to other EMS education program—the graduation of a competent healthcare professions. While EMS has roots in the past, the entry-level Paramedic.6 emergence of EMS as a profession has occurred in less than four decades. Nevertheless, EMS has strived to meet its ide- Commission on Accreditation als and become recognized as a profession. of Allied Health One of the other attributes of a profession is a profes- sional organization or society that speaks on behalf of the Education Programs members. The National Association of EMT (NAEMT) is To ensure that Paramedic education programs adhere to these a professional organization, founded in 1975, whose mission educational standards, the Commission on the Accreditation is to represent the views and opinions of all prehospital care of Allied Health Education Programs (CAAHEP) charges the providers. As the voice of the profession, it has been lead- Committee on Accreditation of Educational Programs for the ing efforts to help professionalize EMS. Through its leader- EMS Professions (CoAEMSP) to investigate and report to ship, the NAEMT has been infl uential with the advancement CAAHEP. of EMS as an allied healthcare profession. The NAEMT has Accreditation of a Paramedic program is evidence of a liaisons with at least 28 federal agencies and professional satisfactory report from the CoAEMSP having been furnished organizations with interests in EMS. That list of collaborating to CAAHEP. At present, CAAHEP accredits over 2,000 edu- organizations includes the American College of Emergency cational programs in 19 healthcare professions. Physicians (ACEP), the National Association of EMS Beginning in 2012, the National Registry of Emergency Physicians (NAEMSP), the Advocates for EMS, the National Medical Technicians will only permit those individuals who Registry of EMT (NREMT), the International Association have completed their education in an accredited Paramedic of Firefi ghters (IAFF), the International Association of Fire education program to seat for the Paramedic national certifi - Chiefs (IAFC), the Emergency Nurses Association (ENA), cation examination. the American Red Cross (ARC), EMS for Children (EMSC), 6 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. the Federal Emergency Management Agency (FEMA), expressed when the provider recognizes the presence of the National Rural Health Association (NRHA), and the strong emotion and then responds to the patient in a support- Commission on the Accreditation of Ambulance Services ive manner. To be supportive, all the Paramedic need do is (CAAS), to name a few. imagine the feeling the patient is experiencing, be it anger or fear or hopelessness, and then acknowledge those feelings to National Institute of Medicine Report the patient in a simple statement such as, “This must be dif- The landmark National Institute of Medicine Reports entitled fi cult for you.” This simple offer of respect and support will “EMS at the Crossroads” and “Hospital Based Emergency be appreciated by the patient. Care: At the Breaking Point,” released in 2006, spoke of the Sympathy is the quality of suffering with the patient. While dysfunctional and fragmented emergency services in the United empathy is a quality to be practiced, sympathy can interfere States.7 These reports encouraged standardization of emergency with the patient–provider relationship. Sympathy is lending an services through processes such as national accreditation of emotional quality to the relationship that is neither wholesome the Paramedic programs, national certifi cation of Paramedics, nor professional and which can lead to burnout. The Paramedic and organized efforts at improving the delivery of patient care should strive to understand the patient’s feelings (empathize) through cooperation with other healthcare professions. but not take on the patient’s feelings (sympathy). Caring implies emotional vulnerability on the part of Core Values both the patient, who confi des in the Paramedic, and the Paramedic, who is trying his best to provide care, often under The clinical care provided by Paramedics, guided by evidence- trying circumstances. To be truly caring, the Paramedic must based science, is dictated by protocols, guidelines, and algo- be willing to also share his mistakes with the patient and rithms. But the human side of paramedicine—that aspect apologize if necessary. of EMS which makes it part of the patient care realm—is While the thought of apologizing for an error may seem dictated by another set of rules, the core values of a Paramedic abrasive or unwise to some, physicians and Paramedics are professional. Paramedics must possess these core values, increasingly accepting of the need to apologize. Simply stated, which complement and enhance their clinical skills and no matter how skillful or knowledgeable the Paramedic, mis- medical knowledge. Otherwise, Paramedics will be ineffec- takes will be made. The Institute of Medicine (IOM) 1999 tual as patient care providers. report estimated that between 44,000 and 98,000 patients will The key professional attribute and the fi rst core value of a die while in the hospital

from mistakes.8 Mistakes are a part Paramedic is caring. Caring is an expression of concern toward the of the practice of paramedicine and each mistake represents patient by the Paramedic and is foundational to the Paramedic– an opportunity for improvement. The Paramedic’s accep- patient relationship. To practice caring, some Paramedics tance of the mistakes and willingness to apologize will be have been taught to use the PEARLS model advanced by the important to the patient’s satisfaction with care.9 Whenever a American Academy on Physician and Patient. The letters in the professional standard of care is breached, or the outcome is PEARLS mnemonic stand for partnership, empathy, apology, unwanted or unexpected, a caring Paramedic admits the error respect, legitimization, and support. These are the qualities that and demonstrates caring when he apologizes. provide for a strong Paramedic–patient relationship. The fi rst step whenever an error is encountered is to inves- While in the past most patients willingly accepted a tigate why the error occurred. If there is no immediate expla- physician’s advice without question, patients today are less nation forthcoming, then the Paramedic should explain to the tolerant of this paternalistic approach. Patients now want to patient that an error occurred and, if appropriate, explain that be knowledgeable about their choices and to be involved in “I will fi nd out why” and get back to the patient later with their healthcare decisions. They want to partner with their an answer. healthcare provider. Paramedics who involve patients in If the decision is made to apologize, the Paramedic should their own care, in a partnership, are demonstrating an accep- choose an appropriate time and place—perhaps after patient tance of the patient’s wishes to be involved and in control. care has been turned over at the emergency department—and Paramedics who involve patients in decisions about their own explain the situation, stating that an error has been made. A care empower the patients to take more responsibility for skillful Paramedic listens to the family’s response and answers their own health. This Paramedic–patient cooperation tends their questions thoughtfully and after a moment’s refl ection. to improve the patient’s overall satisfaction with the care pro- Fundamental to the Paramedic–patient relationship is vided by the Paramedic. respect for the patient. Respect is based upon a nonjudgmen- Another key to quality patient care is empathy. Empathy is tal attitude toward the patient, regardless of the personal cir- an emotional understanding of the patient’s feelings; to be able cumstances. While many Paramedics are aware of prejudices to understand what it is like to walk in the other person’s shoes. about race or religion, the problem of economic prejudice Some refer to empathy as a good bedside manner. Paramedics is less recognized. Regardless of the social status or eco- can demonstrate their empathy through both action and words. nomic position that a patient holds at any one moment, the Like the teachable moment—that point in time when Paramedic should respect the patient as a person in need of the student is most susceptible to learning—empathy is best help and worthy of care. Roles and Responsibilities of the Professional Paramedic 7 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. On occasion some Paramedics have diffi culty under- the Paramedic, as a healer, supports the patient, both physi- standing the patient’s concerns, and may even cite “9-1-1 cally and spiritually, through an illness or injury. abuse” when speaking about these patients. Regardless of The role of the healer revolves around showing compas- the Paramedic’s attitude, these patients have a concern that sion. Dr. Bernard Lown, noted cardiologist and Nobel Peace prompted them to call for emergency medical services. The Prize winner, states in his book The Lost Art of Healing that caring Paramedic listens and seeks to understand the patient healing involves two aspects: preserving the personhood of and the patient’s concern, regardless of how seemingly insig- an individual and providing comfort measures. nifi cant the problem. This process of legitimization supports By its nature, illness is an attack upon an individual’s the patient and demonstrates caring. A patient who is put at sense of person, the individual’s personhood. Illness threat- ease is more cooperative with care and has a more positive ens the patient’s quality of life and perhaps even the patient’s regard for the Paramedic. life itself. Moreover, illness is something that the patient has Finally, the Paramedic demonstrates caring and compas- limited ability to prevent and little control over once it occurs. sion by offering the patient support and acting as a patient As a result of illness, the patient may feel helpless. This sense advocate. Being a patient advocate is important in a chaotic of helplessness leads to suffering. world where people are “lost in the process” and “treated like To help reduce suffering, the Paramedic need only show a number.” compassion. Compassion is an awareness of another’s suffer- ing. In some cases it only takes the Paramedic’s concerned The secret of the care of the patient is in caring for the presence (presencing) to help alleviate the suffering. The patient. importance of presencing is exemplifi ed by the common feel- ing often voiced by others that no one wants to die alone. By —Dr. Francis Weld Peabody— merely being there and showing compassion, the Paramedic Harvard Medical School—1925 helps to support the patient and, specifi cally, helps the patient validate himself and his sense of personhood. Another key to quality patient care is the attribute of Illness also brings pain. The Paramedic, as healer, can integrity. Professional integrity, described in more detail provide a range of comfort measures to the bedside. In some in Chapter 5 on ethics, involves an unabashed truthfulness cases that comfort measure is in the form of pharmaceutical with the patient which serves as a foundation for the patient– pain management. But in almost every case the Paramedic’s provider relationship. therapeutic use of touch helps to relieve the patient’s pain and Inherent within interpersonal communications is the con- provides comfort. Therapeutic touch has long been recognized cept of diplomacy. A thoughtful consideration of the words by nursing as an effective treatment for pain. Therapeutic spoken, to ensure that the message spoken does not have an touch involves one-on-one attention and human touch. unintended meaning, improves interpersonal understanding and, ultimately, patient care. Clinician While the science of emergency medical care can be A clinic is a place dedicated to the diagnosis and care of a learned from a book, the art of emergency medical service— patient. A clinician is the person who works in that place. combining the previously stated qualities in an effective It could be said that the Paramedic’s clinic is the back of an manner—is best learned by practice in the fi eld with a master ambulance, a place where the Paramedic assesses and diag- Paramedic. A professional mentor can help with the process noses a patient’s ailment. of socialization needed to create a professional Paramedic. A Paramedic’s diagnosis is a broad diagnosis made after A novice Paramedic subjected to intense socialization at the an assessment. During the assessment the Paramedic ascer- hands of seasoned professionals within a healthy EMS c ulture tains a symptom complex. This symptom complex is simply can quickly mature into a professional Paramedic. a list of abnormal conditions found by the Paramedic during the history of the present illness and the physical examina- Roles of a Paramedic tion. The Paramedic then, in turn, takes the symptom com- A Paramedic assumes many roles during the course of a plex, compares it to his knowledge of disease, and matches career. The primary roles are those of healer, clinician, and it to a known symptom pattern associated with a disease to patient advocate. As the Paramedic’s practice evolves, the arrive at a diagnosis. Paramedic may become involved as a researcher or a teacher. With only crude medical instruments and a limited time These changing roles keep a Paramedic engaged with the for history taking, the Paramedic’s diagnosis, sometimes profession and continuously striving to improve his practice. called a fi eld diagnosis, must be broad and comprehensive. Typically a Paramedic makes a diagnosis of a syndrome, Healer a group of signs and symptoms that signifi es a specifi c disease, or of a primary disorder of homeostasis, such as The Paramedic’s primary role is that of healer. A healer is hypoxia. a person who supports another during illness. From the old As a clinician, the Paramedic’s fi rst responsibility is to English “Haelan” meaning to make whole, sound, and well, treat disorders of homeostasis which threaten the patient’s 8 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. survival. The brain’s survival is paramount. The three essen- In some other circumstances, such as rural communities, tial conditions for the brain’s survival are adequate oxygen, or under special conditions such as an epidemic, it may be glucose, and perfusion. If the brain lacks any of these three appropriate to give Paramedics an expanded scope of prac- conditions, then the patient has a fundamental disorder of tice to supplement existing healthcare resources.11 cerebral function and manifests an altered mental status. The American College of Emergency Physicians, in a The approach to the assessment and treatment of these position paper on expanded scope of practice, specifi es sev- disorders is exemplifi ed by the mnemonic ABC. The patient eral conditions that must be met before Paramedics can per- is assessed for hypoxia, hypoperfusion, and hypoglycemia. form an expanded scope of practice.12 ACEP maintains that While this description is technically accurate, it is a gross all expanded scope of practice must be closely monitored, simplifi cation of a process which is expanded upon and dis- with intimate physician involvement and a rigorous quality cussed throughout this series. assurance process that has standards and mechanisms for The Paramedic, as clinician, keeps one invaluable rule remediation. ACEP, in its position paper, further states that foremost in the mind when treating the patient. That rule, such expanded scope of practice must fulfi ll a community simply stated, is “do no harm.” While some harm will always need, usually based on an assessment and plan of action, and come from a treatment or drug (e.g., the pain of a needle), the that the practice is legally permissible. harm is outweighed by the benefi t that the treatment or drug will have for the patient. The rule “do no harm” is intended Self-Evaluation and Continuous to cause Paramedics to pause and consider every treatment Quality Improvement intervention before proceeding. The Paramedic, as clinician, is always trying to improve the The decision to treat in the fi eld is multifactorial. In some practice of paramedicine. This is best accomplished by criti- instances it is more prudent to withhold certain treatments cal self-evaluation and planned action. For example, an often until arrival at the hospital where more experienced physi- quoted goal of EMS is the patient’s satisfaction. Patient sat- cians can make the judgment about which treatments to ini- isfaction may result from many factors including the provi- tiate. At other times, delaying treatment in the fi eld can be sion of high-quality emergency medical care, timeliness of detrimental to the patient. The concept of “do no harm” is response, or respect for the patient’s rights. An EMS system further discussed in Chapter 5 on ethics. objective would be an eight-minute response in 90% of calls The Paramedic, as clinician, understands that medicine is for EMS. It might also be in response to a patient demand a practice, meaning the science of medicine must

be matched for a timely response. If that objective is met then, to some to the patient to try to obtain a maximum benefi t for the extent, patient satisfaction with EMS should be higher. patient. In some instances that match is not perfect. Learning While an EMS system may periodically look at certain the right time to perform specifi c procedures or administer practice parameters, a superior EMS system is always in a particular medication is often a function of trial and error. It process of review and re-engineering, trying to refi ne the pro- takes practice. cess and improve the delivery of EMS. This approach is called The Paramedic, as clinician, understands that the prac- continuous quality improvement (CQI) and involves a pro- tice of medicine is fi rst and foremost about the patient. The cess that can be summarized as plan-do-check-act (PDCA). Paramedic understands that while the technology to treat This PDCA cycle is different than simply verifying compli- the patient is becoming truly amazing, the priority remains ance with established standards, or quality assurance (QA), to treat the patient as a person. The Paramedic under- because it has an action component. stands that the love of technology and the science of medi- Any system of self-analysis, whether it is QA/CQI or cine (philotechnia) comes second to caring for the person others, is dependent on the data collected. These information (philanthropia). systems can be real-time (i.e., direct observation of skills or Expanded Scope of Practice performances in the fi eld), but are often done retrospectively, after the fact, by a chart audit. For a chart audit to be reliable The traditional role of a Paramedic has been in the out-of- and dependable, it is important that Paramedics accurately hospital setting responding to medical emergencies. But as and completely describe the care given. As the saying goes, necessity has required, the Paramedic’s role has expanded in “If it wasn’t written down then it didn’t happen.” some limited situations and the Paramedic’s scope of practice has expanded as well. Driven by the increasing specialization of hospitals (i.e., Continuing Medical Education trauma centers), interventional cardiology centers, stroke Another responsibility of a professional Paramedic as clini- centers, children’s hospitals, and so on, and accelerated by the cian is to stay current with the state of the art. This is best nursing shortage, more Paramedics are becoming involved accomplished through continuing medical education which in specialty care transport (SCT). Paramedics who perform culminates in periodic recertifi cation. Paramedics also have SCT have training above that of the typical Paramedic. The a responsibility to re-register every two or three years. The fl ight medic is an example of a specially trained Paramedic re-registration is intended to ensure the public that the Paramedics who performs SCT.10 that serve them have remained competent as Paramedics. Roles and Responsibilities of the Professional Paramedic 9 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to a great deal of concern regarding the effectiveness of EMS by some. To counter these claims, Paramedics have turned to an evidence-based approach to the practice. Changes in prac- tice are now driven by research and the practice is becoming more reliable and valid in the process. Professional Paramedic The professional Paramedic is interested in research because it offers the opportunity to improve the effi ciency of paramedicine. Figure 1-1 EMS journals are a means to obtain information about the state of the art. Teacher However, the Paramedic understands the necessity of not Paramedics, in an effort to reduce injury and illness, have only maintaining minimal skills and an adequate knowledge started to educate the public. These opportunities to educate base, or competency assurance, but the need to continue the public sometimes occur during an emergency call, on a to remain current with the state of the art. Paramedics are one-to-one basis, or in public education programs. expected to keep abreast of new developments in the fi eld To be effective, this education must occur when the per- of medicine as they pertain to EMS through involvement in son, or the public, is ready to learn. This is called the teach- professional development. able moment. For example, a campaign to wear seat belts Attendance at state and national EMS conferences as may have more impact immediately following a fatal motor well as attending regional workshops help ensure that the vehicle collision involving teenaged drivers. At that moment Paramedic is continuing to develop and provide high-quality the public is sensitive to preventable death from motor vehi- emergency medical care. Alternatively, Paramedics often turn cle collisions. to their medical directors for guidance and education on new technologies. Another way to keep up with the profession is reading EMS trade journals (Figure 1-1). The best EMS trade journals have research that is peer-reviewed or articles that Professional Paramedic are refereed. Whenever research has been peer reviewed, that means A newer role for the Paramedic is that of health the article or research was critically appraised by experts in the educator. fi eld for validity. To be valid, the research has to objectively support its conclusion. In other words, the research must not be personal opinion, contain exaggerated statements, or make unjustifi able claims. Public Education However, articles are not peer reviewed per se but rather Public education is one means of garnering public support are refereed. Typically an editor will distribute an article to while simultaneously providing the public with the informa- a panel of expert Paramedics, in this case, and these expert tion they need about injury and illness prevention. A model Paramedics offer input. They edit the article and act as refer- public education system called PIER was developed by the ees. Then the article is returned to the author and the author National Highway Traffi c Safety Administration (NHTSA).13 is allowed to revise the article before re-submission. Often PIER stands for public information, education, and relations, the comments offered by these referees cite current research and incorporates the three aspects of public education. or best practices. The fi rst aspect, public information, pertains to infor- The commitment made by all Paramedics when they mation regarding people and events that the media tradition- attain that fi rst certifi cation is to remain current with the pro- ally communicates to the public. Many EMS agencies have fession through life-long learning. a public information offi cer (PIO) whose responsibility is to interface with the news media and to provide public Researcher information. The PIO must be cautious about not reveal- EMS practice in years past was based upon either in-hospital ing restricted personal health information (PHI), a violation practice, which sometimes did not fi t into the prehospital of the Health Insurance Portability and Accountability Act environment, or anecdotal experience. This approach has led (HIPAA) regulations, while simultaneously providing the 10 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 1-3 Public Education Activities Stewardship Public Information Because Paramedics work under the physician’s license, • Press conferences paramedicine is a shared practice with physicians. However, often a physician is not present when the Paramedic is taking • Newspaper announcements about weekly EMS activity care of the patient. Nevertheless the Paramedic is still repre- • Annual reports to government boards or councils senting the physician and the responsibilities of medicine. Public Education Therefore, in the absence of the physician, the Paramedic • CPR classes shares the physician’s responsibilities, including veracity, • Life-saving classes fi delity, benefi cence, avoidance of malfeasance, and jus- • Pediatric drowning education tice. These concepts are discussed in Chapter 5 on ethics. • Elderly fall prevention classes Whenever a Paramedic upholds noble traditions of medicine the Paramedic is acting in the role of a steward. Stewardship Public Relations is a weighty responsibility for the Paramedic. A Paramedic’s • Open house failure to properly conduct himself, as a physician would, • Blood pressure clinics often leads to confl ict between the Paramedic and physician and loss of medical privileges. news media the information that it is entitled to due to the Leadership freedom of the press. As the highest level of out-of-hospital EMS provider, The second aspect of PIER is public education. All edu- Paramedics are often thrust into the leadership role by virtue cation is an attempt to change behaviors. Public education, of their education. This traditional form of top-down man- from an EMS perspective, is an attempt to change the public’s agement (vertical leadership) was common in the immediate behavior toward medical emergencies. Examples of public post-World War II business world. It can be visualized as a education programs include CPR classes for citizens or pub- pyramid with a distinctive chain of command. lic access defi brillation (PAD) for school offi cials. However, enlightened Paramedics as leaders seek to The fi nal aspect of PIER is public relations. Public rela- “fl atten the pyramid” and work toward linking, or network- tions is less an effort to educate the public (though there can be ing, with the members of a public safety team. This horizon- overlap) as it is to garner the public’s support of Paramedics. tal leadership style demonstrates that the Paramedic values The public’s opinion of Paramedics can be directly translated the contributions of every team member. Horizontal leader- to support for new programs or support of public funding. ship emphasizes an “out and back” line of communication The Paramedic is involved in a number of public education instead of an “up and down” line of communication and can activities (Table 1-3). be visualized more like a wagon wheel. Patient Advocate In an information intensive era, horizontal leader- ship is an effective technique for knowledge management. Finally, the professional Paramedic is a patient advocate. Nevertheless, there still needs to be a nexus for control. Being a patient advocate means that the Paramedic defends Traditionally the Paramedic assumes that role, offering com- and supports the patient’s rights to health care. Whenever a mon direction and a strong vision to fellow EMS team mem- Paramedic acts to help a patient obtain needed health care bers as well as other public safety partners. he is acting in the advocacy role. A Paramedic is also acting The Paramedic, as leader, needs to have a sense of direc- in an advocacy role when she supports, through constructive tion and a strong personal vision of paramedicine. He must argument, the need for equipment that will improve patient also constantly refl ect upon the values common to a profes- care. Some would see reporting child abuse as a Paramedic sional Paramedic (ethics) and work to incorporate those val- acting in an advocacy role as well. ues into daily practice. Besides being a model of ethical behavior, the Paramedic Paramedics as Physician Extenders as a leader is also a coach. As coach the Paramedic teaches While physicians are educated in medical schools, it is the others, or trains the team, to work together to reach a com- state, through licensing legislation, that authorizes the physi- mon goal. cians to practice medicine. Most states have state statutes, The qualities of a good leader can be summed up in called a medical practice act, that defi ne medical practice. the 5 “C’s”: competence, command presence, choreogra- Many of these medical practice acts have a reference to phy, communications, and confl ict resolution. Competence physician extenders, allied health professionals who work goes beyond merely being technically profi cient at skills and under the license granted to the physician. Paramedics, as instead means having operational competence. Operational physician extenders, are among those allied healthcare pro-

competence includes knowing how the various team mem- fessionals who are permitted to perform limited medical pro- bers interact, knowing an organization’s policies and proce- cedures while under the supervision of a licensed physician. dures, and possessing situational awareness. Roles and Responsibilities of the Professional Paramedic 11 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Paramedic, as leader, has situational awareness. He It is inevitable that disputes about patient care will can read the scene and can detect both opportunity and threat. occur among team members. Without the authority given These opportunities include teaching moments, times for the in a traditional chain of command, the Paramedic must be team members to learn, without risk to either the team’s or masterful at confl ict resolution in order to maintain order the patient’s safety. This skill cannot be easily learned from and control. In high stress situations (i.e., those with a high books but rather is a result of witnessing master medics func- life hazard), it may be necessary for the Paramedic to assert tion in the fi eld. authority, issue a command, and offer to review the call Another quality of a good leader is command presence. later with the team. In those cases it is important for the Command presence can be defi ned as that ability to present Paramedic to institute an “after action review” and allow oneself as the person of authority. The Paramedic’s authority all parties to express their viewpoints and vent their emo- fl ows, in part, from the respect that the team has for the medi- tions. But if time permits, and it is not disruptive to patient cal director and the Paramedic’s role as the medical director’s care, the Paramedic may elect to listen to the suggestions of steward. other team members offered in civil discourse. During these Outwardly, the Paramedic’s appearance can demonstrate teachable moments learning can occur for all involved, confi dence, a key command trait. A clean pressed uniform including the Paramedic leader. and the “tools of the trade,” such as a stethoscope, give the Paramedic the appearance of a medical professional. A pro- Followership fessional appearance, along with a professional attitude, can Consistent with the concept of leadership is followership. substantially improve one’s command presence. Followership is a willingness to follow a leader’s direction Confi dence can also be manifest in one’s behaviors. The and to support the mission, putting aside personal ambitions. confi dent Paramedic walks purposefully toward the patient Every leader is a follower at some level. Inherent in the defi - with an eye toward the patient as well as the surrounding envi- nition of paramedicine is the willing submission to medical ronmental, i.e., situational awareness. Confi dence is further command. But followership is more than submission. demonstrated in purposeful speech with a low tone. Instead A Paramedic, as follower, understands the mission of yelling into the scene, instructions are pointedly given to (patient care) and is dedicated to that mission. The Paramedic, individuals by looking toward that individual and speaking an as follower, understands the team’s need for compliance (team unambiguous message in a directive manner. play) in order to achieve the team’s common goals. The good The next quality of a Paramedic leader is the ability to follower puts the needs of the team and the patient above organize the team’s efforts in order to deliver appropriate one’s own needs. interventions in a timely manner. This skill could be described A Paramedic, as follower, makes timely recommenda- as choreography. While algorithms are helpful with orga- tions to the leader. That includes respectfully disagreeing nizing patient care, acting almost like a pre-plan, on-scene with the leader when need be, if that is what is in the best conditions and other variables make it imperative that the interests of the team and/or the patient. Paramedic take an active role in leading the team down the A Paramedic, as follower, sets the example for others by treatment pathway. understanding the leader, anticipating the orders of the leader, To be truly effective, the Paramedic, as leader, must also and complying with those orders. Perhaps more importantly be a strong communicator. A key to success in teamwork is the Paramedic, as follower, knows when to take appropriate possessing excellent communication skills. The Paramedic action when no orders are forthcoming. must be articulate with both patients and family, speaking to Finally, the Paramedic, as follower, keeps the informa- them in terms that they understand while still being able to be tion fl owing to the leader and does not horde vital informa- conversant with fellow healthcare professionals, most notably tion. Through clear communications, all members of the team the emergency physician, in terms that they will understand. can provide the highest quality of care. 12 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Paramedicine is a pattern of thinking and behaviors, that outward manifestation of thinking, that is consistently applied in varying situations until a practice has been achieved. The art of paramedicine is the ability to apply that practice while maintaining focus, using one’s wits and creative abilities. Key Points: • Paramedic practice is both independent, • Roles and responsibilities describe a Paramedic’s encompassing specialized prehospital practices, and scope of practice. interdependent, through a working relationship with emergency physicians. • A superior EMS system is always in a process of review and re-engineering through continuous quality • The Paramedic is cross-trained in health care, improvement (CQI) and quality assurance (QA). public health, and public safety. • Involvement in professional development provides • The National EMS Education Standards, together the Paramedic with competence assurance, and with the national core content and national scope of allows the Paramedic to remain current with the practice, identify a paramedic’s knowledge, skills, state of the art as a life-long learner. and attitudes. • Changes in EMS are now driven by research, and the • Professional organizations or societies, such as process has become more reliable and valid to the the National Association of EMT (NAEMT), provide Paramedic practice. a voice for the profession and have been leading efforts to professionalize EMS. • In an effort to reduce injury and illness, the Paramedic has become a health educator. • The landmark National Institute of Medicine Reports entitled “EMS at the Crossroads,” and “Hospital • The professional Paramedic is also a patient Based Emergency Care: At the Breaking Point,” advocate. released in 2006, encouraged changes in the • As a physician extender, the Paramedic is delivery of patient care. authorized to practice under the license granted to • Caring is an expression of concern toward the the physician. patient and is foundational to the Paramedic— • The Paramedic serves as a model of ethical patient relationship. behavior. • A Paramedic may assume the role of healer, • A Paramedic leader is a strong communicator and clinician, and patient advocate. has the ability to organize a team’s efforts to • During the assessment, the Paramedic ascertains a deliver appropriate intervention in a timely manner. symptom complex. • The Paramedic, as a follower, is willing to follow a • The Paramedic, as clinician, keeps one rule in mind leader’s direction and support the mission. when treating the patient: do no harm. Roles and Responsibilities of the Professional Paramedic 13 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. How has the Paramedic’s role changed since 6. Describe how a Paramedic develops a the inception of the profession? Paramedic fi eld diagnosis. 2. What professional organizations or societies 7. How do continuous quality improvement serve as a voice for the Paramedic profession? (CQI), quality assurance (QA), and research How have they helped to advance EMS? improve the practice of paramedicine 3. Using the mnemonic PEARLS, explain how 8. What is the relationship between stewardship caring is the Paramedic’s fi rst core value. and the Paramedic as a physician extender? 4. Why is it important for the Paramedic to take 9. What leadership qualities should the Paramedic part in continuing education? exhibit? 5. How does the rule “do no harm” relate to a 10. How is being a good follower as important as Paramedic’s scope of practice? being a good leader? Case Study Questions: Please refer to the Case Study at the beginning of the 3. Discuss the importance of a science and chapter and answer the questions below: mathematics curriculum as the basis for 1. How would you counsel high school students Paramedic study. who are interested in EMS? 2. What could you say to someone who says, “I want to be a Paramedic but I only want to take care of trauma patients”? References: 1. Fan E, MacDonald RD, Adhikari NK, Scales DC, Wax RS, 5. Bartlett WD. Paramedic education and the development of Stewart TE, et al. Outcomes of interfacility critical care adult professional status: a prognosis. Paramed Int. 1979;4(1): patient transport: a systematic review. Crit Care. 2006;10(1):R6. 36–39. 2. Svenson JE, O’Connor JE, Lindsay MB. Is air transport 6. http://www.nemses.org faster? A comparison of air versus ground transport times for 7. National Academies Press. Hospital-Based Emergency Care: interfacility transfers in a regional referral system. Air Med J. At the Breaking Point (Future of Emergency Care). Washington, 2006;25(4):170–172. DC: National Academies Press; 2007. 3. American Academy of Pediatrics. Committee on Pediatric 8. Leape LL. Institute of Medicine medical error fi gures are not Emergency Medicine. American College of Critical Care exaggerated. Jama. 2000;284(1):95–97. Medicine. Society of Critical Care Medicine. 9. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, 4. Minarik PA. A vision for health professions regulation in the new Lawthers AG, et al. Incidence of adverse events and negligence millennium: recommendations from the Pew Health Professions in hospitalized patients. Results of the Harvard Medical Practice Commission. Clin Nurse Spec. 1999;13(6):306–309. Study I. N Engl J Med. 1991;324(6):370–376. 14 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 10. Gryniuk J. The role of the certifi ed fl ight Paramedic (CFP) as a 12. American College of Emergency Physicians. Expanded roles of critical care provider and the required education. Prehosp Emerg EMS Personnel. Revised April 2008. Available at: http://www Care. 2001;5(3):290–292. .acep.org/practres.aspx?id29444. Accessed May 4, 2009. 11. Hatley T, Ma OJ, Weaver N, Strong D. Flight Paramedic 13. Thoma T, Vaca F. National Highway Traffi c Safety Administration scope of practice: current level and breadth. J Emerg Med. (NHTSA) notes. PIER: public information, education, and 1998;16(5):731–735. relations for EMS injury prevention modules. Ann Emerg Med. 2004;43(4):521–524. Roles and Responsibilities of the Professional Paramedic 15 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially

affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The paradigm in EMS has shifted from ambulance transport to advanced prehospital care • Emergency Medical Services are incorporated into all levels of public life: local, state, and national • The EMS Agenda for the Future has redefi ned both the scope of practice and educational standards Case Study: The Paramedics were at the squad building and the group of them stared at the invitation. The local Emergency Physician’s Advocacy Group had invited a Paramedic to their next meeting to speak on the history of paramedicine, its scope of practice, its educational requirements, and its role in the local healthcare system. Who would go and represent them to their physician colleagues and what would they say, everyone asked. One thing was for sure, they wanted to put their best foot forward. 16 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Introduction to Emergency Medical Service Systems 17 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW What started out as the simple idea of transporting the sick or wounded to medical care has evolved into an integral component of our healthcare system in the United States. Its development—one that originated out of necessity—now plays a vital role in an ever-expanding system of health care. This chapter will not only outline the history and progression of EMS but also identify what defi nes EMS practices. The evolution of EMS in the healthcare system prompted the development of an EMS Agenda for the Future that establishes a clear vision for the future of EMS. This vision has been implemented by means of national core content, a defi ned scope of practice, and educational standards. With knowledge of how the EMS system is constructed and an understanding of the origin of its various components, a Paramedic can better appreciate the responsibility and function they have in the healthcare system. The Evolution of EMS overcrowding in inadequate housing and almost nonexistent sanitation systems.4,5 While medicine has been in existence since the beginning of recorded time, Emergency Medical Services (EMS) is a rel- Revolution in the Laboratory ative newcomer to the fi eld of medicine. Modern EMS, with During the early and mid-1900s, discoveries in the laborato- its specially trained EMS providers and a systems approach, ries brought about a revolution in medicine. Scientists used is generally considered to have started in the late 1960s and microscopes to identify the sources of many infectious dis- early 1970s.1–3 From these early beginnings EMS, and spe- eases and developed crude but effective treatments—using cifi cally Paramedics, have rapidly developed into one of the the scientifi c method—to treat these diseases. Word of these newest allied healthcare professions. medical breakthroughs was widely disseminated via journals A constant throughout the development of EMS is the such as the New England Journal of Medicine. The fi eld of close working relationship of EMS with other parts of the medicine began to change. healthcare system, particularly the emergency department. Almost overnight, county and state medical societies Therefore, to understand the evolution of EMS it is important were created and physicians gathered to discuss new devel- to fi rst review the history of American health care. opments in medicine in a climate of openness that fostered more medical research and established the beginning of mod- Historical Evolution ern medicine. of American Health Care Before the 1800s, health care was largely delivered by phy- Public Health Care Emerges sicians who traveled by mule to the homes of the sick and As great strides were being made against infectious disease, injured. In its day that level of health care was satisfactory for the delivery of health care also changed. For example, in 1906 the fl edgling republic. St. Luke’s Hospital in New York City opened its fi rst private As cities grew during the 1800s, largely due to a dra- pavilion. This change marked the beginning of a healthcare matic infl ux of European and Asian immigrants, the demand system.6,7 for more public healthcare facilities escalated. Forward think- Prior to that time there was no perceived advantage to ing physicians helped develop large urban hospitals to meet having patients cared for in the hospital setting rather than that demand. These hospitals (e.g., Massachusetts General in in the home where patients could receive equally good care. Boston and Bellevue in New York City) could care for hun- However, after the turn of the century—with the advent of dreds of patients, and allowed economies of scale (savings hospital laboratories equipped with powerful microscopes made from bulk purchases), which in turn made health care as well as expansive pharmacies fi lled with new cures— affordable to vast legions of poor and underserved persons. the hospital setting provided distinct advantages. These The physician in the 1800s, armed with only limited resources empowered the physicians to encourage patients experience and even more limited education—or no formal to be admitted into the hospital. Soon hospital admission for education at all—dealt largely with infectious diseases. Many illness, predominantly infectious diseases, became a public of these infectious disease outbreaks occurred because of expectation. 18 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Evolution of Medicine Following World War II and the successful introduction of modern antibiotics, the incidence of infectious diseases was waning. For example, smallpox was being eradicated due to the use of a new vaccine. Soon chronic diseases, such as cancer, stroke, and heart disease, were replacing infection as the leading killers. As a result, medicine began to concentrate less on infectious diseases and more on chronic diseases. Also during this time the development of medical sciences (biology, pharmacy, etc.) blossomed and the biotechnology industry—the marriage of medical science and technology— emerged in the health care industry. At the same time, the growth of widespread employer- provided health insurance permitted an increasing segment of the U.S. population to afford medical care. With the wide- spread availability of health insurance the healthcare industry was then fi rmly established. Also beginning in the 1980s, medicine began to integrate information technologies such as computers, and other bio- medical devices, into healthcare. The advancement of phar- maceutical research had also taken on revolutionary new directions, including the development of new bioengineered drugs. Partially as a result of the signifi cant advances in medi- cal science, healthcare costs have skyrocketed. For this rea- son the federal government, in part because of Medicaid Figure 2-1 Lillian Wald, RN, a pioneer in public and Medicare health programs, has taken a greater role in health. (Photo courtesy of American Nurses Association) healthcare policymaking in an effort to curb rising health- Street Settlement in New York City, a social services shelter, care costs. in 1793 and coining the term “Public Health Nurse.”10 Public Health Movement Public Health Service Paralleling the advances in medicine, and the development The federal Public Health Service actually evolved out of of healthcare systems, was the public health movement. The the need for health care for the maritime fl eet. The Public public health movement started in the early 1800s as a result Health Service roots can be traced to the creation of the of the smallpox, yellow fever, and cholera epidemics that rav- Marine Hospital Service in 1798. At that time, sailors paid aged the larger cities.8,9 20 cents a month to fund the Marine Hospital Service. The ser- During that time, quarantines and in-house confi ne- vice provided them with medical care if they should get sick ment were the only effective means of preventing the further away from home and while in a distant port of call. As the spread of disease. As a result of widespread illness, business public health movement grew, and pressure mounted on the and the manufacturing industries suffered and productivity federal government to provide service to the poor, the Marine was affected. Hospital Service became the federal Public Health Service. In order to temper the effect of illness and sick call outs The federal Public Health Service is a key portion on business a few wealthy patrons hired graduate nurses to of the Department of Health and Human Services today. care for the sick and the poor in Boston, Cincinnati, and With 5,700 commissioned health services offi cers and Washington, DC. These nurses, referred to as community 51,000 civilian employees, all led by the Surgeon General, nurses, worked tirelessly in the ghettos and tenements of the current United States Public Health Service provides major cities trying to improve sanitation and decrease mor- support to county and state Public Health Departments as bidity and mortality as a result of infectious disease. well as health care to medically underserved areas. Similar to modern-day Paramedics, these public health The United States Public Health Service (PHS) consists nurses would leave the safety of the hospital to go to workers’ of eight agencies, including the National Institute for Health homes and worksites. Some community nurses established (NIH), the Food and Drug Administration (FDA), the Agency clinics to advance sanitary practices in the home and improve for Toxic Substances and Disease Registry (ATSDR), and the maternal–child health, as infant mortality was particularly Centers for Disease Control and Prevention (CDCP). high in the inner cities. Lillian Wald, RN (Figure 2-1), an Current challenges to public health, including Lyme early social work pioneer, is credited with starting the Henry disease, West Nile virus, SARS, Avian fl u, and swine fl u, to Introduction to Emergency Medical Service Systems 19 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. name a few, have placed a renewed emphasis on public health However, credit for the concept of the modern ambulance medicine. is generally given to Dominique-Jean Larrey of Baudean, The mission of EMS is now seen as being more in step France. A surgeon, Larrey got a great deal of his training with the Public Health Service than previously thought. treating victims of the French Revolution during his stay at Relationships between Paramedics and the Public Health the Hotel Dieu, the premier French hospital in Paris. Larrey, Service’s physicians, nurses, scientists, and sanitarians are pressed into military service by the Prussians, was disturbed growing and evolving; especially in light of the threats of by the then-common practice of waiting for the battle to end pandemic fl u and natural disasters. before rescuing the wounded. Larrey went about creating a light carriage that could swoop into a battle, scoop up the wounded, and then rapidly transport them to the waiting sur- The History of Emergency geons at the “ambulance.” Those light two-wheeled carriages Medical Service that carried an attendant as well as a

driver were called les ambulance volantes, or fl ying ambulances. The transportation of the sick and injured has seen many The American Civil War utilized what could be described developments over the past millennium. The earliest exam- as weapons of mass destruction, such as rapid fi re or repeating ples may be seen in the Roman Empire. Romans would use rifl es and devastatingly accurate cannon fi re. These improved chariots to move battle-injured soldiers from the battle fi eld in weapons caused greater casualties and put greater demands the time of Caesar (100 A.D.). This innovation was followed on battle surgeons. While casualties were greater, medical by the fi rst hammock-wagon, a wagon designed specifi cally attention to these combat casualties improved and resulted for transporting the sick and injured, and a forerunner of the in many advances in fi eld care of wounded soldiers. And to modern ambulance, but the hammock-wagon was not created respond to the mass casualties sustained during these military until about 900 A.D. In their day these crude carriages and engagements, army surgeon Major Jonathan Letterman com- horse litters would carry one invalid patient to medical care pletely reorganized the military fi eld medical service, called at a distant physician, at a monastery, for example, but the long the Letterman plan, into what was to be the forerunner of the transfer over rough roads often proved to be more dangerous modern trauma system. to the wounded patient than the original battlefi eld wound. The Letterman plan called for “an act to establish a During the Spanish crusade of Ferdinand and Isabella uniform system of ambulances in the Armies of the United against the Moors in the late fi fteenth century, the use of States,” and was ratifi ed by the United States Congress in ambulancias, or mobile military hospitals, came into being. 1864. The act declared that ambulances were a special corp. These facilities, which were located closer to the battlefront, that needed personnel, in distinctive special uniforms, who helped provide more immediate care to the wounded. As a drove specially marked wagons, and answered to the head of result, this more timely medical intervention improved the the medical department of the army, a physician, and not the chances for a soldier’s survival from battle wounds. battlefi eld commander (Figure 2-2). Figure 2-2 Civil War ambulance accepting patients. (Courtesy of the Library of Congress, Selected Civil War Photographs, Photo No. LC-B8171-7636) 20 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. As a result of the shear number of casualties and the hor- York City provided ambulances staffed with an ambulance rible carnage of war there was a public outcry to control war- driver and a surgeon in accordance with a plan advanced by fare. In 1864, a convention was held in Geneva, Switzerland, Dr. Dalton. These ambulances responded to medical emer- to “civilize” warfare. The result was the Geneva Treaty. gencies throughout the City of New York. Among its many precepts, the Geneva Treaty established The practice of prehospital care rapidly advanced as the neutrality of all ambulance workers who wore the “Red new technologies were created to deal with the unique envi- Cross”—an icon created by the reversed colors of the Swiss ronment encountered in the civilian world as well as on the fl ag created in honor of the Swiss, who hosted the conven- battlefi eld. For example, the outbreak of World War I and the tion. In 1882 the United States Congress ratifi ed the Geneva invention of the motorized ambulance coincided, improving Convention accords. both the quality and the speed of ambulance transportation. In keeping with the accords of the Geneva Treaty, and Another example is the splint created by Sir Hugh Owen- with the help of Clara Barton (Figure 2-3), the American Red Thomas. Dr. Thomas invented an external fi xation and trac- Cross was formed and chartered by the Congress in 1881 “to tion splint, called the Thomas half-ring, which reduced the provide volunteer aid in time of war to the sick and wounded number of fatalities resulting from a traumatic fractured of the armed forces.”11,12 femur from roughly 80% to less than 20%. The American Red Cross differs from its European coun- The combination of advances such as the Thomas half- terparts because it was active during peacetime as well as ring splint, rudimentary fi rst aid treatments to stop bleeding, during war, responding during peacetime with disaster relief and the introduction of motorized ambulances substantially and humanitarian aid. Since the American Red Cross is not a reduced battlefi eld mortality during World War I. These bat- government agency, it offers neutral humanitarian service to tlefi eld advances, which were also adopted for the civilian victims of war. population, led to improved survival from trauma in general Around the same time as the appearance of the American during the same time. Red Cross, hospital-based civilian ambulance services started to appear in the United States. The fi rst hospital-based Emergence of Civilian EMS ambulance, the ambulance of the Commercial Hospital After World War I, citizens started to see the importance of of Cincinnati (later Cincinnati General), was started in an organized emergency medical service and subsequently 1865, followed by Bellevue Hospital ambulance in 1869. the fi rst volunteer rescue squad was formed in Roanoke, By 1891 Bellevue Hospital’s ambulance had responded to Virginia. The Roanoke Rescue Squad, lead by Stanley Wise 4,392 calls. Shortly thereafter, hospitals throughout New (Figure 2-4), started to provide emergency medical service to the citizens of Roanoke in 1921. After early successes with this model, community-based rescue squads began to spring up across the country. Many of these “independent” rescue squads (i.e., not hospital-based or commercial ambulance services) sprang from local volunteer fi re departments and heralded an era of volunteer ambulances. Changing Paradigms Before World War II, the ambulance was chiefl y seen as an expedient means to get a patient to a hospital. Following the successes of army “para-medical” personnel during World War II and the advent of a new treatment for cardiac arrest called “cardiopulmonary resuscitation” or CPR, it became apparent that the ambulance driver might be able to provide more than just a fast ride. In 1958, Dr. Peter Safar demonstrated the safety and effi ciency of mouth-to-mouth ventilation, using trained Baltimore fi refi ghters, on anesthetized medical residents. This idea of non-medical personnel performing medical pro- cedures was revolutionary in its day. The introduction of the lifesaving CPR technique quickly intrigued the public.13–16 The “can do” attitude in America led organizations such as the American Red Cross and the American Heart Figure 2-3 Clara Barton, founder of the American Association to conduct mass CPR and fi rst aid training for Red Cross. (Courtesy of the National Archives, the public in fi rehouses and rescue squad buildings across the Photo No. 111-B-4246, Brady Collection) country. By 1960, fi refi ghters in major cities like Columbus, Introduction to Emergency Medical Service Systems 21 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. From 1965 to 1966, two reports on highway safety were produced. One, by the National Academy of Sciences, enti- tled “Accidental Death and Disability: The Neglected Disease of Modern Society,” discussed shortfalls in the nation’s EMS system.18–20 The other, the report of the President’s Commission on Highway Safety, entitled “Health, Medical Care and Transportation of the Injured,” also echoed the prob- lems EMS was experiencing.21 In 1966, President Lyndon B. Johnson signed into law the National Highway Safety Act. This act provided for fed- eral funds as well as other improvements in highway safety.22 The Highway Safety Act, among its many provisions, created an EMS program within the Department of Transportation (DOT) and is seen as the fi rst federal commitment to EMS. Following the passage of the Highway Safety Act there was a fl urry of activity in emergency medicine. For example, The American College of Emergency Physicians was formed in 1968, a group consisting of physicians who specialized in emergency medicine. These early physicians, pioneers in emergency medicine, provided medical oversight and control to the growing EMS community. In support of the EMS community the federal DOT pro- duced the fi rst Emergency Medical Technician-Ambulance curriculum in 1969, a national standard curriculum for the training of ambulance drivers/attendants in new skills and life-saving techniques. Figure 2-4 Julian Stanley Wise, founder of the While the EMT curriculum was developed to deal with fi rst volunteer rescue squad. (Courtesy of the Julian vehicular trauma, cardiologists were dealing with another Stanley Wise Foundation) threat to Americans: the heart attack. Physicians, like Dr. Barnard Lown, noted that when certain drugs, such as lidocaine, were given during a heart attack there was a Los Angeles, Seattle, and Miami, to name a few, were trained decrease in the incidence of sudden cardiac death (SCD). to provide CPR. Another cardiologist, Dr. Paul M. Zoll (Figure 2-5), also Also in 1960, Asmund S. Laerdal, a Norwegian dollmaker, theorized that an electrical current passed through the heart created the fi rst “resusci-annie,” a manikin for CPR practice. could terminate the lethal dysrhythmia called ventricular With an acceptable simulator/manikin, the American Red fi brillation. And in 1956 Dr. Zoll delivered the fi rst external, Cross and the American Heart Association began to train the 750-volt, alternating current countershock to a fi brillating public in vast numbers. CPR training, along with American heart, which effectively stopped the dysrhythmia. Shortly Red Cross advanced fi rst aid training, became the standard thereafter defi brillators, now battery-powered direct current for ambulance drivers. (DC) defi brillators, were placed in service in many hospitals The White Paper and emergency departments. As America prospered, and medical care improved, it was Prehospital Coronary Care becoming increasingly apparent that prehospital care, par- Dr. J. “Frank” Pantridge, of Belfast, Ireland, noted that 90% of ticularly for motor vehicle trauma, was not keeping pace with young or middle-aged men who died from heart attacks did so the medical community. In 1960 President John F. Kennedy made the statement that “Traffi c accidents constitute one of the greatest, perhaps the greatest, of the nation’s public health Street Smart problems.”17 At that time, the majority of ambulance service was provided by a variety of tow truck operators, hospital sup- The defi brillators, some weighing over 100 pounds, ply companies, and funeral homes. To illustrate the point, in were placed on top of mobile carts which had a the 1950s and 1960s over 50% of ambulances in the United tendency to roll over, or “crash,” when pushed States were owned and operated by some 12,000 morticians. Funeral hearses were often used as ambulances as they were through the halls of the hospital; hence the term the only public conveyance that could transport a patient “crash carts.”23—25 horizontally on a stretcher. 22 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Image not available due to copyright restrictions Figure 2-6 Emergency Paramedics Jon Gage and Roy DeSoto. (Courtesy of Everett Collection, Inc.) his success with creating the television show Adam-12, Mr. Cindar approached then Captain James Page of the Los Angeles Fire Department and asked him if he would be the

technical advisor for a new “reality” television program to be called Emergency. The show was to be loosely based on the new Paramedic program. Subsequently, the crew of the tele- vision Squad 51 of the L.A. County Fire Department began to roll. These fi re department Paramedics, or fi re-medics, responded to all variety of emergencies, from fi res to special and technical rescue to every imaginable medical emergency, always rendering expert medical care in the fi eld. An entire generation of future Paramedics was raised watching the emergency medical care provided by Firefi ghter/Paramedics due to ventricular fi brillation. These deaths usually occurred Gage and DeSoto (Figure 2-6). within one hour of onset of initial symptoms. Realizing the potential of rapid defi brillation in the fi eld to reverse sudden EMS Act of 1973 cardiac death, Dr. Pantridge placed the “heart-shockers” into In 1973 Congress passed the EMS Act, Public Law 93-154, ambulances and staffed those ambulances with trained coro- an amendment to the Public Health Service Act of 1944, nary care nurses. which offered technical assistance to regions and municipali- The patient survival rates from sudden cardiac death ties.27 The EMS Act of 1973 delineated the 15 aspects of an were remarkable and Dr. Pantridge reported his success in the EMS system that needed improvement including education British medical journal Lancet in 1967. After reading of his (both public as well as provider), improved communications success with prehospital defi brillation, the American College (including public access), and system evaluation but offered of Cardiology invited Dr. Pantridge to speak at its annual con- little money to help make those improvements. vention the following year.26 After learning of Dr. Pantridge’s success, physicians Federal EMS Efforts in the 1980s at Ohio State University started their own version of the The 1981 Omnibus Budget Reconciliation Act took mon- mobile coronary care unit which they dubbed the “heartmo- ies previously earmarked for EMS and placed them under a bile.” The heartmobile continued to operate through Ohio broader rubric of preventive health money. The federal gov- State University until July 1971 until it became a part of the ernment provided the states with large “block” grants to fund Columbus Division of Fire as Squad 52. various programs including EMS. While the intention was to continue to fund EMS, the effect was to turn control of EMS Emergency Hits TV Screens funding over to the states. The states then choose how to spend Robert A. Cindar was interested in emergency medical ser- the allocated monies. Some states did not support funding for vices, and particularly the advent of the Paramedic. Following EMS to the same level as the federal government had. Introduction to Emergency Medical Service Systems 23 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 1500 B.C. Roman Wars 1950–1970 Korean and Vietnam Wars • Evidence of fi rst treatment protocols. • Mobile Army Surgical Hospitals (MASH) were developed during the • Romans and Greeks used chariots to remove wounded from the Korean and Vietnam confl icts in an attempt to save the most seriously battlefi eld. injured patients through a transportation-dependent method of triaging. 1797 The Napoleonic Wars • Transportation of wounded soldiers by helicopter to medical units, • Baron Dominique-Jean Larrey, Napoleon Bonaparte’s chief surgeon, used fi rst during the Korean War, was the genesis of modern constructed a horse-drawn carriage called the ambulance volante or aeromedical transportation. “fl ying ambulance.” • The HU-1 (Huey) helicopter used during the Vietnam War had a large 1860s The U.S. Civil War patient compartment to allow emergency care to begin while in • The fi rst ambulance service in the United States was developed by U.S. fl ight. Army surgeon Jonathan Letterman, who reorganized the Army Medical 1960s Development of an EMS System Corp to include ambulances, similar to Baron Dominique-Jean Larrey’s fl ying ambulances. • (1966) The National Academy of Sciences produced a white paper, “Accidental Death and Disability: The Neglected Disease of Modern • Clara Barton was a volunteer on the Civil War battlefi elds and saw the Society” for President Kennedy. It stated that, to that date, more mayhem fi rst hand. Returning from the Franco–Prussian War, where Americans had died on American Highways than in all of the she witnessed the good work of the Red Cross on the battlefi eld, she U.S. wars. founded the American Red Cross. • (1966) The National Highway Safety Act of 1966 encouraged states to 1865–1950 U.S. Ambulance Service begin organized EMS programs. • (1865) Cincinnati established the fi rst civilian ambulance service. • (1967–1968) The fi rst paramedic services were established in Miami, • (1869) New York City established an ambulance service with hospital Florida, using telemetry units designed by Dr. Eugene Nagel and interns riding in horse-drawn carriages designed specifi cally for the Dr. John Hirchmann. sick and injured. • (1968) St. Vincent’s Hospital in New York City established the • (1901) At the Pan American Expo in Buffalo, NY, the fi rst electric- fi rst coronary care unit in the United States, and Columbus, Ohio powered ambulance was demonstrated and used to transport people established mobile coronary units staffed with cardiology fellows from to the on-site hospital. OSU. Both soon replace physicians with advanced • (1910) One of the fi rst ambulances, called the “Invalid’s Car,” ran out trained EMTs. of Iowa Methodist Hospital, Des Moines, Iowa, staffed with a nurse • (1969) The fi rst nationally recognized EMT course was held in and resident from the hospital. Wausau, Wisconsin. Dr. J. “Deke” Farrington was the course • (1928) The Roanoke Life Saving and First Aid Squad was the fi rst medical director. volunteer rescue squad in the United States. • (1969) Dr. Leonard Cobb, Harborview Medical Center, and Seattle 1910–1940s The World Wars Fire Department established the Medic One paramedic program. • An unmodifi ed French fi ghter aircraft was used for air medical 1970s The Star of Life and Voice of EMS transport during the retreat of the Serbian army from Albania. • (1970) The National Registry of EMTs (NREMT), a national EMS • “Combat medics” cared for the wounded in the fi eld with advanced certifi cation organization that maintains a registry of certifi cations, procedures including intravenous solutions, crude antibiotics, and was established. intraosseous (bone) needles. • (1971) “Emergency!” debuted on television, putting a public face on • Improved systems for trauma care were established including fi eld EMTs and Paramedics providing expert medical care on the scene of hospitals and forward fi rst-aid stations. an accident. The show increased public awareness of EMS and possibly infl uenced government funding of EMS. • Mechanized ambulances with the characteristic Red Cross emblem on the side were used and the era of the ambulance driver had arrived. • (1973) Star of Life was adopted as the national EMS symbol, representing the six points of the complete EMS system: detection, 1950s Out of Hospital Medical Advances reporting, response, on-scene care, care in transit, and transfer to • American Red Cross took the lead in providing basic medical training, defi nitive care. The central staff with a serpent wrapped around it making classes such as Standard and Advanced First Aid the standard represents medicine and healing. of care for rescue squad members. • (1973) U.S. Congress passed the Emergency Medical Services Systems • Cardiopulmonary resuscitation (CPR) was taught to civilians for the Act (PL93-144), which identifi ed 15 essential components of an EMS fi rst time in the late 1950s and early 1960s. system and allocated federal funding for individual EMS regions to • (1958) Mouth-to-mouth ventilation was demonstrated by Dr. Peter address these components. Safar using volunteers from the Baltimore Fire Department, who • (1975) National Association of EMTs (NAEMT) was formed agreed to be paralyzed. to represent the needs of all EMTs to the public and • (1958) Dr. Joseph K. “Deke” Farrington, known as the Father of EMS, government. and Dr. Sam Banks started a trauma training course for the Chicago • (1979) American Ambulance Association (AAA), a representative Fire Department in what was to become the prototype of the EMT- organization for the ambulance service industry and legislation Ambulance course. affecting EMS, was founded. Figure 2-7 EMS Timeline. 24 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 1970s–Present Iraq War • (1986) The Comprehensive Omnibus Budget Reconciliation Act • With an advanced skill set, the 68W healthcare specialist (a.k.a. (COBRA) prevented patient “dumping,” or transferring patients Army medic) is prepared to treat combat casualties as well as incapable of paying for services. civilian combatants. • (1988) The National Highway Traffi c Safety Administration initiated • Development and deployment of special blood-stopping dressings, the Statewide EMS Technical Assessment program based on ten key one-handed tourniquets, and special surgical procedures for extremity components of EMS systems. injuries and burns. • (1990) The Trauma Care Systems and Development Act of 1980s–2000 Agenda for the Future—Education 1990 provided funding to states for trauma system planning, and Federal Funding implementation and evaluation, encouraging development of inclusive trauma systems. • (1981) The Omnibus Budget Reconciliation Act of 1981 consolidated EMS funding into state preventative health and health services block • (1993) The Institute of Medicine published “Emergency Medical grants. Funding under the EMSS Act is eliminated. Services for Children,” pointing out defi ciencies in the healthcare system’s ability to address the emergency medical needs of pediatric • (1984) Medical Priority Dispatching began in Salt Lake City, Utah. patients. • (1984) EMS for Children (EMS-C) program, under the Public Health • (1996) “The EMS Agenda for the Future” was released, outlining Act, was established, providing funds for enhancing the EMS system 14 essential attributes for future EMS development. to better serve pediatric patients. • (2006) The controversial report, “The Future of Emergency Care: • (1985) The National Research Council published “Injury in America: Emergency Medical Services at the Crossroads” was released by A Continuing Public Health Problem,” describing defi ciencies in the the Institute of Medicine. progress in addressing the problems of accidental death and disability. Figure 2-7 (continued) EMS Agenda for the Future Table 2-1 Statement from the EMS Agenda for the Future As shown in Figure 2-7, EMS has developed out of a long and rich history. In 1995, the National Association of State Emergency Medical Services (EMS) of the future will be community- Emergency Medical Services Directors (NAEMSD) and based health management that is fully integrated with the overall the National Association of EMS Physicians (NAEMSP), healthcare system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, with assistance from the National Highway Traffic Safety and contribute to the treatment of chronic conditions and community Administration (NHTSA), met to reflect upon the previ- health monitoring. This new entity will be developed from redistribution ous 25 years of EMS practice experience and to establish of existing healthcare resources and will be integrated with other their vision for the future of EMS. Their intention was to healthcare providers and public health and public safety agencies. It will guide EMS toward its own destiny. The product of those improve community health and result in more appropriate use of acute meetings was called the EMS Agenda for the Future healthcare resources. EMS will remain the public’s emergency medical safety net.28 (Table 2-1). The EMS Agenda for the Future suggests that EMS will be more intimately intertwined with public health, as well as EMS agencies should also strive to improve their opera- public safety, and continue to

evolve along with health care. tional preparedness. Proactive EMS agencies will look to The EMS Agenda suggested that public expectations and the leaders in the EMS industry and use their operational demands of EMS will remain high. These expectations will practices as benchmarks. These benchmarks will rapidly be fueled in part by increasing media attention by the press, become the standard of care and public offi cials will mea- television, and Internet as well as consumer demand. sure their EMS systems operations against the EMS stan- To meet those expectations, Paramedics and emergency dard of care. physicians are going to need to make better decisions regard- To survive in a world of ever tightening fi scal constraints, ing what care provides the best patient outcomes in the most and in order to remain the public’s “safety net,” EMS will cost effective manner. The standard of care that was formerly have to demonstrate its effi ciency and effectiveness and its provided may not be the best care that can be offered. In that willingness to adapt to improved medical technology. case, the public is going to demand performance improve- The EMS Agenda for the Future describes the attributes ment and cost effi ciency. of an effective and effi cient EMS system. The EMS Agenda In other words, EMS practice is going to have to become for the Future was reviewed by 500 EMS organizations and more evidence-based (i.e., supported by the medical research). individuals, who came to consensus about EMS excellence. In situations where the evidence is lacking, EMS should The panel that created the EMS Agenda for the Future listed review their experience and refl ect upon those practices that 14 attributes of EMS (Table 2-2) and noted that EMS needs have led to the most desirable outcomes and strive to replicate to continue to develop those 14 attributes if it is to reach its them. These practices are the so-called best practices. greatest potential. Introduction to Emergency Medical Service Systems 25 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 2-2 Attributes of an EMS System National EMS According to the EMS Agenda for the Future Core Content 1. Integration of Health Services 2. EMS Research National EMS 3. Legislation and Regulation Scope of Practice Model 4. System Finance 5. Human Resources 6. Medical Direction National EMS 7. Education Systems Education Standards 8. Public Education 9. Prevention National EMS National EMS 10. Public Access Certification Education Program 11. Communication Systems Accreditation 12 Clinical Care Figure 2-8 The fi ve essential elements of the 13. Information Systems EMS educational system. (Courtesy of National Highway 14. Evaluation Traffi c Safety Administration) National EMS Education Agenda One advantage of a national SOP is that there is a stan- dardization of EMS providers of four levels. The four levels for the Future of EMS providers described in the NEMSSOP include the In 1996 the National Highway Traffi c Safety Administration emergency medical responder (formerly the certifi ed fi rst convened a meeting of over 30 EMS organizations with the responder), the emergency medical technician (formerly the intent of implementing the educational portions of the EMS emergency medical technician–basic), the advanced emer- Agenda for the Future. The results of that meeting became gency medical technician (formerly the advanced emergency known as the national EMS Education Agenda for the medical technician–intermediate), and the Paramedic (for- Future.29 The Education Agenda set out to describe how merly the emergency medical technician–Paramedic). all EMS providers, including Paramedics, would be pre- The emergency medical responder (EMR) is an EMS pared for service in EMS by following a systems approach. provider who is expected to render lifesaving care with mini- The National EMS Education Agenda, a systems approach, mal equipment. This person may be the lone provider on scene established fi ve components that incorporated the essential for an extended period of time. For example, a member of the elements of an educational system and how these elements emergency response team at a plant or a security offi cer at a interacted in a system (Figure 2-8). shopping mall, would be an emergency medical responder. The fi rst component was the National EMS Core The emergency medical technician (EMT)–Basic is Content. The core content defi nes the entire universe of part of a team that responds to the emergency scene, typically disorders, diseases, syndromes, and skills that an EMS pro- aboard an ambulance, and is trained to provide initial care on vider might encounter and for which he would be expected to scene as well as medical care to the patient while in transit to provide emergency care (i.e., the domain of EMS practice). the hospital. Naturally, EMS physicians had a lead role in defi ning the The advanced emergency medical technician (AEMT) domain of EMS practice. To the extent possible, the core con- is an EMT with additional skills. These additional skills are tent tried to include those practices that had strong evidence skills or medications that have been shown to positively to support them or those that appeared in the 2004 practice impact patient survival (i.e., evidence-based practices). These analysis conducted by the National Registry of EMT. skills include the administration of a limited number of drugs The second component of the EMS Education Agenda as well as, among other things, supraglottic airway devices. for the Future was the National EMS Scope of Practice The highest level of EMS provider is the Paramedic. The (NEMSSOP) model.30 The scope of practice defi nes and Paramedic’s medical education includes advanced assessment divides EMS into four groupings. The National EMS Scope and diagnosis of syndromes and disorders and the treatment of Practice, created under the leadership of the National thereof. In many states a Paramedic can obtain an associate’s Association of State EMS Offi cials (NASEMSO), formerly degree or higher. known as the National Association of EMS State Directors Each level of EMS provider has knowledge and skills (NAEMSD), clearly defi nes four levels of EMS provid- that are clearly delineated. If an EMS provider was to per- ers. More importantly, it identifi es the knowledge and skills form a procedure that was not within one’s scope of practice required for each level (i.e., what is the scope of practice for then that individual could be accused of practicing medicine that level within the domain of EMS practice). without a license. 26 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Education Standards exclusive rights to perform a function or profession it is a In the past, the scope of practice for many EMS providers license. The use of the term “certifi cation” in this regard is was defi ned by the National Standard Curriculum (NSC) a semantic difference. The National Registry of EMT has a well written legal opinion on the matter on its website.33, 34 for EMS. A seminal document, created with the assistance of the NHTSA in the 1970s, the NSC quickly became the only In a growing number of states the certifi cation of the available source of information about the domain of prehos- National Registry of Emergency Medical Technicians pital emergency care (i.e., the scope of practice).31,32 (NREMT) is accepted as proof positive that the individual With a defi nition of both the core content of EMS and the being licensed is minimally competent to provide that level of scope of practice of EMS establishing the domain of EMS, care. Presently, the majority of states accept National Registry the National Association of EMS Educators (NAEMSE) certifi cation for licensure. set out to replace the NSC with the broader National EMS Education Standards. These National EMS Education Standards serve as the basis for EMS instruction and provide Street Smart direction for EMS educators regarding both the core content and the scope of practice. The original designation EMT-A (the A was for Accreditation ambulance) was changed to EMT-B (B for basic) National EMS Education Program Accreditation, like to emphasize that EMTs operate in many varied other educational program accreditations, assures students environments other than the ambulance. Currently, who enter an EMS education program that the education the letter B has been eliminated altogether. they are about to receive meets national standards. Perhaps more importantly, accreditation helps assure the public, who depends on the graduates of those educational programs, that the graduates will be competent providers. Mission of the EMS System Presently the Commission on Accreditation of Allied The fundamental mission of EMS has been to respond to a Health Education Programs (CAAHEP) accredits Paramedic medical emergency, provide on-scene care, and transport education programs. CAAHEP grants accreditation after patients to the closest appropriate medical facility. This mis- receiving a favorable report from the Committee on sion is exemplifi ed in the star of life, the symbol of EMS as Accreditation of Educational Programs for EMS Professions represented by the six points; detection, reporting, response, (CoAEMSP). CoAEMSP site visitors visit the program and on-scene care, care in transit, and transfer to defi nitive care.35 review the facilities, faculty, and courses of a Paramedic pro- To be effective, the EMS system must provide a coor- gram to determine if they meet the national accreditation dinated response of health and safety resources in a timely standards and then issue their report either recommending manner and be successful in mitigating the effects of illness for or against accreditation. For most healthcare profes- and injury. To attain this goal, EMS must have both horizon- sions, graduation from an accredited school or program is a tal linkage with other public safety agencies and vertical link- minimum requirement for entry to certifi cation examina- age with the rest of the healthcare system. tions. Eventually this will become the standard for Paramedic Through complementary relationships (i.e., horizontal education as well. linkage) with other emergency services, such as law enforce- ment and/or the fi re service, EMS can realize effi ciencies Licensure and Certifi cation through rapid response and treatment. All states, as a matter of state rights, license individuals for Take, for example, a citizen who experiences a cardiac practice in that state. Licensure permits an individual to prac- arrest. If a law enforcement offi cer (LEO) in a quick response tice a trade or a profession. Generally that license is issued system (QRS) were to arrive on-scene within minutes of the after demonstration of satisfactory completion of a course cardiac arrest, the offi cer could apply an automated external of education, usually called a certifi cation. By defi nition, a defi brillator (AED). Following the instructions of the AED, license precludes other non-licensed individuals from prac- and the lessons learned during CPR training, lifesaving care ticing in the profession or trade. If a non-licensed person was could be initiated. (LEO is used to categorize that large group to practice, then that person could be accused of “practicing of professionals that are involved in law enforcement, includ- without a license,” which might involve criminal and/or civil ing but not limited to constables, Sheriff ’s deputies, police penalties. offi cers, state troopers, border patrol offi cers, agents and In some cases the state not only licenses but also cer- investigators from the Federal Bureau of Investigation, Drug tifi es those individuals, through written and practical test- Enforcement Agency, and so on.) Immediately afterward a ing, before they are licensed. This has been cause for some basic life support (BLS) engine company from the fi re ser- confusion about the difference between licensure and certi- vice would arrive to support the LEO effort and provide addi- fi cation. Simply stated, any time

a state gives an individual tional skills and equipment, such as suction and oxygen. An Introduction to Emergency Medical Service Systems 27 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. advanced life support (ALS) ambulance would then arrive. computer-assisted dispatch (CAD) technology identifi es the The Paramedic would assume care of the patient, provide caller’s location as well. additional skills and equipment (such as intubation and venti- With the growing number of mobile cellular telephones lation), and transport the patient to the emergency department which cannot utilize the 9-1-1 technology, the early advan- for stabilization. Once stabilized in the emergency depart- tages of 9-1-1 location identifi cation may have been lost. The ment, the patient would be transferred to a coronary care unit Federal Communications Commission (FCC) is now working (CCU) for further treatment and evaluation by a team of car- with the telecommunications industry and has undertaken a diologists. The patient’s entry into this critical care pathway is special wireless project that permits identifi cation of a cellular an example of horizontal linkage between EMS and the rest telephone’s location within 125 meters. Telecommunications of the healthcare team. professionals, represented by the National Emergency This ideal system illustrates one example of the effec- Number Association, have been working to improve the pub- tiveness that can be realized from an integrated approach to lic’s access to EMS. emergency response by all public safety agencies. Communication Systems Legislation and Regulation A typical EMS communication starts at the public safety EMS at its core is a public service. As such, the public has access point (PSAP) when the professional telecommunicator, certain expectations of performance. To ensure that EMS is or dispatcher, answers the call and starts the emergency medi- available, states have enacted legislation that provides for the cal dispatch process. It ends when the Paramedic presents the existence of EMS and regulates its functions.36–38 patient over the radio to the medical control physician. In many states this enabling legislation describes the An overview of emergency communications under- various levels of providers and, more importantly, links the scores its importance. The emergency communications cen- practice of those providers with the state medical practice act ters alert the public of impending natural disasters or terrorist and physician oversight. Furthermore, these statutes typically attacks. From the simple color-coded terrorist alert used in the empower either the state health department or the state depart- Homeland Security Advisory System to the Emergency Alert ment of state with responsibility for EMS system oversight. System (EAS) that predates the Homeland Security Advisory At a larger, macro level, local, state, and federal govern- System, emergency communications professionals have been ment have an interest in EMS. EMS responds to and miti- alerting the public to potential danger for years. Keeping up the gates the consequences of a disaster as part of the larger tradition of watchfulness over our communities, telecommu- government response. For that purpose, government often nicators can now alert drivers of a child abduction, via Amber funds EMS disaster preparedness through grants and other alert, or dangerous persons with a special “be on the lookout mechanisms. (BOLO)” alerts via public signs and television announcements A further discussion of other medical–legal responsibili- using the Emergency Notifi cation System (ENS). ties is contained in Chapter 6 on the law and EMS. As technology improves, emergency communications takes advantage of these advances and incorporates them into Public Access the emergency communications system. There is a further discussion of emergency communications, both process and When a citizen is suddenly confronted with a potentially life- technology, in Chapter 18 on communications. threatening emergency, the person turns to EMS for help. To get that help, the citizen can use a variety of telecommunica- Architecture of EMS Systems tions devices but by far the most common means is to call on a telephone. The wide variety of EMS system confi gurations speaks to Previously the citizen had to memorize a seven-digit the ingenuity of EMS offi cials and system administrators number for that jurisdiction. This often led to confusion and whose planning refl ects the community’s capability to pro- mistakes, some that were fatal. The obvious answer was to vide EMS. have a universal number for emergencies. Britain has had a Contemporary EMS depends on a number of confi gu- universal number, 9-9-9, since 1937. However, the United rations of emergency responders—some fi re-based, some States did not see a universal number, 9-1-1, until 1967.39–42 municipal, some volunteer, some proprietary, and some When that famous 9-1-1 call was made from Haleyville, a combination of these—to ensure EMS is provided to the Alabama, in 1967, the era of modern telecommunications community. was ushered in. Early 9-1-1 service provided the public immediate access System Confi gurations to the local public safety access point (PSAP), as well as The predominant means of delivering EMS in the United automatic number identifi cation (ANI), so that a “call-back” States is via fi re-based EMS.43,44 The combination of trained could be performed if necessary. Since that time, basic 9-1-1 personnel, lifesaving equipment, emergency vehicles, and has been improved. Enhanced 9-1-1 is now in use. Not only strategically located stations make the fi re service an ideal does it provide rapid access to emergency services, but platform for the delivery of EMS. 28 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The fi re service has a long tradition of rescue and fi rst In still other cases, groups of physicians established aid. During World War II, in a time before self-contained ambulance services, such as the Physicians and Surgeons breathing apparatus, many early fi re services carried heavy Ambulance Service (P&S) of Columbia University. E&J or Emerson Resuscitators for use in reviving fi refi ghters Commercial ambulance services, or for-profi t EMS, and fi re victims overcome by smoke and fumes. Eventually, have long provided interfacility medical transportation as the fi re service started getting requests for “resuscitator” well as emergency medical services to patients. Many of runs. Despite the availability of this equipment, medical calls these commercial ambulance services originated from the remained infrequent until a few visionary physicians saw the funeral homes that previously provided the service. potential of fi re-based EMS. Today, commercial ambulance services provide EMS to Leaders in fi re-based EMS—such as Dr. “Deke” vast areas. Some companies (e.g., Rural-Metro and American Farrington of Chicago, Dr. Nagal of Miami, and Dr. Cobb of Medical Response) are so large that the company’s stock is Seattle—saw the advantages in fi re-based EMS and encour- sold in the market on the stock exchange. aged the fi re service to get involved in EMS. Today, many Following the example of the Roanoke Volunteer Rescue major cities operate fi re-based EMS services. For example, Squad in 1920, rescue squads sprang up across America. the Fire Department of New York (FDNY) operates the larg- These community-based EMS squads were independent est fi re-based EMS service in the United States and had of local fi re departments and largely staffed with volun- 1.2 million ambulance “jobs” or trips in 2007. teers. Pressured by a lack of volunteers today, many of these The International Association of Fire Chiefs (IAFC) and community-based ambulances have turned to paid crews. the International Association of Fire Fighters (IAFF) has However, the fact that these community-based ambulance supported the development of fi re-based EMS and has made services remain not-for-profi t differentiates them from com- EMS a major priority for the Fire Service (Figure 2-9). mercial ambulance services. Hospital-based EMS is another common EMS sys- Some citizens believe that the government should provide tem design. When the large urban hospitals—such as the EMS as part of its responsibilities for public safety. In those Commercial Hospital in Cincinnati or Bellevue in New York communities, a municipal EMS service was established as City—were started it became clear that these hospitals needed the third of three public safety departments (the other two ambulance service to bring invalid patients to the hospital. public safety services being law enforcement and the fi re ser- In some cases proprietors of local livery stables dedicated a vice). In some cases small cities and villages would cross- specially outfi tted carriage for the hospital to provide special train police offi cers as Paramedics to provide service and transportation. That tradition continues today in many large effi ciency. cities. New York City, for example, still has a large number of The military is decidedly the largest provider of emer- ambulances that respond from the “voluntary” hospitals. gency medical care (i.e., military emergency medicine) and Figure 2-9 A fi re service-based ambulance stands ready for an EMS call. (Image copyright 2009, Jenny Woodworth. Used under license from Shutterstock) Introduction to Emergency Medical Service Systems 29 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. has been providing EMS for a longer period of time than any or rotor aircraft from scenes or other facilities to defi ni- other EMS system. The healthcare specialist and corpsmen of tive care. Upon completion of advanced EMS education, today’s military care for some 1.37 million active service men with emphasis on critical care medicine and fl ight medi- and women alone. cine, fl ight Paramedics may test to become certifi ed fl ight Modern EMS in the armed forces can be traced back to Paramedics. surgeon Jonathan Letterman’s efforts to establish a system Frontier/rural Paramedics and woodlands search and of ambulances in 1864. In many respects the lessons that the rescue teams are tasked with providing patient care in wil- military has learned while providing emergency medical care derness areas. The Wilderness EMT (WEMT) has special on the battlefi eld have been translated to emergency medical training that fosters critical thinking as well as creativity in care in the civilian sector. an environment where supplies may be limited and patient transport to defi nitive care prolonged. Resource Management Paramedics who provide EMS in a rural setting often Resource management involves placing vehicles and person- have different circumstances and more diffi cult obstacles to nel in a position to provide the most expeditious response to overcome than their counterparts in the city. To prepare for an emergency. Some communities require, through contract these emergencies many Paramedics take the FarMedic® or regulation, a minimal response time. While there is not course, which is specifi cally directed to the farm emergency. a national standard response time, many EMS services have The FarMedic® course teaches how to care for a patient under accepted a 6- to 10-minute response time. This time is consis- an overturned tractor (Figure 2-10) and a number of other tent with cardiac arrest studies that indicate the greatest like- rural emergencies. lihood of return of spontaneous circulation (ROSC) is within Another area of EMS specialization is medical support 6 to 10 minutes of cardiac arrest.45–50 for special weapons and tactics (SWAT) teams. Despite care- Traditionally EMS was stationed in standing facilities ful planning and preparation, casualties do occur in these and many EMS services still utilize this fi xed-post staff- highly charged operations. Tactical EMS (TEMS) provid- ing method of resource distribution. Using squad buildings, ers are trained on how to provide care to the

wounded while ambulance bays, or fi re stations, ambulances respond from in hostile surroundings as well as maintain the health of the these centrally located stations to calls for emergency medi- SWAT team members on prolonged operations. cal service. Some EMS services have gone to a dynamic posting Information Systems method called system status management (SSM) or event- In the age of computers EMS began to incorporate informa- driven deployment. Instead of posting in fi xed locations, tion systems into patient care. From electronic patient care such as a fi re house, the ambulances or emergency response reports that are capable of being transmitted prior to the vehicles are “on-the-road” moving to new locations, or posts, arrival of the ambulance to integrated information systems that optimize response times. The decision of where to post that permit inter and intra-agency communications, EMS these resources is typically made after an analysis of histori- systems are embracing information technology. cal data of call volume and knowledge of geography and traf- Some new challenges have also been presented with this fi c conditions. new technology. Patient confi dentiality, a fundamental tenet Still other systems, trying to combine fi xed-post staffi ng of patient care, is at greater risk for inadvertent disclosure. with system status management, provide peak-load staffi ng. Recent federal legislation, the Health Insurance Portability During predictable hours of high demand, additional ambu- and Accountability Act (HIPAA), has placed conditions lances are placed in-service at strategic locations. upon all healthcare providers that protect patient privacy dur- ing claims processing, data analysis, utilization review, qual- Specialization ity assurance, and practice management.54–59 There is further discussion of information systems in Unique environments, certain occupations, and special cir- Chapter 19 on documentation. cumstances require specially trained Paramedics. Over a dozen subspecialties have been created in EMS. The following are short descriptions of some of the notable subspecialties. Integration of Health Services A growing subspecialty in EMS is the area of Specialty EMS does not operate independently but is a link between Care Transport (SCT). Called to transport sick and injured the public and the rest of the healthcare continuum. EMS can patients from outlying clinics and critical access hospitals be seen as one of the doors to health care, a system within a to tertiary care centers, such as trauma centers and cardiac system. The seamless transition of care from the streets to the centers, for example, these Paramedics perform critical care hospital ensures the continuation of quality medical care. interfacility transportation. A number of healthcare “stakeholders” depend on Many consider the fl ight Paramedic as the most highly EMS. Social service workers depend on the assistance of trained level of EMS provider.51–53 Flight Paramedics trans- Paramedics to report child abuse, domestic violence, and port critically ill patients in either fi xed-wing aircraft elder abuse. Trauma surgeons depend on Paramedics to 30 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 2-10 Disentangling a patient under an Figure 2-11 Radio communications permit the overturned tractor. (Courtesy of Chris Randall/Michigan physician to have direct access and control of the Rural Rescue, Inc.) Paramedic in the fi eld. expeditiously transport trauma patients to defi nitive care at Finance Systems the trauma center. Cardiologists have an interest in the pro- The means of fi nancing EMS systems is typically driven vision of advanced life support and stabilization of cardiac by community capabilities. For example, a fi re-based EMS patients in the fi eld, including the identifi cation of high-risk patients using 12-lead ECG.60–63 system may be supported, in part or in whole, from property taxes, whereas a volunteer EMS rescue squad may receive its funds from taxes collected in a special district similar to a Medical Direction fi re district. Other volunteer ambulances or fi re districts may In 1989, the American College of Emergency Physicians depend on community generosity by seeking donations. (ACEP) published a position paper, “The Principles of EMS The majority of EMS—be it commercial, hospital-based, Systems,” which called for strong physician involvement in or any other confi guration—is funded by billing a fee-for- prehospital medicine as well as the active participation of service. In a fee-for-service system, the patient is billed physicians in EMS.64 a charge that is customary for such a service in the area. Terms such as medical oversight and medical com- Payment for ambulance service may come from the patient mand illustrate the direct control that a physician has over a but is usually paid by the patient’s health insurance. Paramedic’s practice. One of the largest payers for EMS is Medicare. Medicare Medical oversight is present whenever a physician is reimbursement is paid according to a schedule established involved in the quality assurance/quality improvement pro- by the Centers for Medicaid and Medicare Services (CMS) cess and provides direction, either in the form of protocols which is part of the federal Department of Health and Human or education, to Paramedics. This medical oversight is often Services. retrospective and may be remedial in nature. Grants for special projects or research are also available Medical command implies a more immediate and direct to EMS services from government agencies or groups (e.g., involvement in patient care. The physician’s authority can the Centers for Disease Control and Prevention (CDC), the be exercised either on-scene or over-the-air at the time of an Maternal and Child Health Bureau, or the EMS for Children emergency, referred to as on-line medical control. Physicians program). can give medical direction via the base radio and exercise One of the diffi culties facing EMS is the inconsistency medical command (Figure 2-11). in funding. Driven by patient transportation, as opposed to More commonly, the physician’s authority is exerted the emergency medical care provided, payments have been through a written set of instructions, called protocols. The erratic and undependable. The CMS has attempted to modify protocols can be used by the Paramedic in specifi c situations the federal Medicare rules to account for not just transporta- in the absence of the physician.65–67 These preauthorized med- tion but emergency medical care as well. ical orders, or standing orders, are often given to Paramedics Some health insurance organizations have tried to elimi- in a fl owchart format called an algorithm. An algorithm is a nate payments by limiting the defi nition of a medical emer- logic tree that simply states: if this, then do that; if not this, gency to these conditions, listed in a discharge diagnosis, that then do this other thing. Algorithms can be useful during an without immediate care and treatment would result in harm to emergency when time is of the essence. the patient’s health. Any medical condition that does not fall Introduction to Emergency Medical Service Systems 31 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. under this defi nition and could have been treated later and at or governmental sources, such as state-run Medicaid or fed- less expense to the insurance company is thus not a covered eral Medicare programs. condition. This limited retrospective view of an emergency These insurers then gather groups of healthcare fails to take into account the patient’s fears and anxiety when providers—physicians as well as allied healthcare suddenly faced with an unknown illness or injury. providers—and obtain a reduced rate in exchange for a Many health insurance carriers have adopted a more guaranteed client base. These savings could only be pos- fl exible and a reasonable approach to defi ning an emergency. sible because of the economies of scale. The managed These organizations use the prudent layperson standard to healthcare insurance plan then mandates that patients seek establish medical necessity. The prudent layperson standard treatment from this preferred medical group, in essence simply places the proverbial “average person” in the situation managing the care that the patient will receive by provid- and asks if that average person would reasonably think, under ing medical care for the lowest price. those conditions, that this problem was an emergency.68–72 A multiplicity of managed care arrangements exist. This approach allows for the inclusion of human factors such However, generally managed care can be broken down into as fear and anxiety. three basic confi gurations. The fi rst and earliest system is the health maintenance National Healthcare Systems organization (HMO). The HMO provides payments to healthcare providers at a negotiated annual per capita rate. Medical care in the majority of the world is a government- These rates are based on practice history of the insured operated enterprise, a social welfare system of sorts which patients and helps to prevent fl uctuations in payments, thus ensures the health and well-being of the citizens within its making expenses, costs, and budgets more predictable. borders. The next confi guration is the preferred provider orga- Health care in the United States is more of a medley of nization (PPO), a modifi ed fee-for-service schedule, that private payment and public funds, private physicians, and permits patients to choose their healthcare provider from government-run treatment centers. This unique blend of dif- amongst a roster. Although there is increased fl exibility for ferent approaches to healthcare delivery has resulted in a the patient with the PPO, some limitations still exist in terms healthcare system that provides numerous opportunities, as of the patient’s choice of provider if not on the roster. well as remarkable ineffi ciencies. The last confi guration is called point of service (POS). Previously the majority of health care was provided on a POS has qualities of both an HMO and a PPO. In a POS pro- fee for service basis, or pay as you go, with a certain amount gram the patient is allowed to choose a healthcare provider of medical care provided gratis to the poor or uninsured. from amongst a list of preferred care providers (PCP) but However, the pressures of modern economics have generally may elect to see another “out of system” provider, without a encouraged all healthcare providers to embrace the concept referral, at a substantially higher copayment and/or deduct- of managed health care. ible, similar to a fee-for-service arrangement. The employer, Managed health care is a system where there is a pur- in turn, gets the advantages of cost savings whenever the chaser of services, such as a large corporation or the govern- patient/employee participates in the managed care program. ment. The purchaser in turn obtains health insurance for its The POS is gaining increasing popularity with patients and workers via private sources, such as Blue Cross/Blue Shield, employers alike. 32 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. From its early beginnings, when hearses were used as ambulances and the patient might be lucky enough to have an ambulance driver with basic fi rst aid training, EMS has evolved into a highly complex system of emergency responders who provide the public with an emergency medical safety net and who work as part of the larger healthcare system. Key Points: • Emergency Medical Services (EMS) became created to provide aid in a time of war to the sick recognized as part of the public health services in and wounded of the armed forces. the late 1960s. • Hospital-based civilian ambulance services began to • The historical evolution of

performance. Accountability Act) rules: federal and state enforcement. Med Prehosp Emerg Care. 1998;2(2):141–144. Interface. 1997;10(8):96–98, 101–102. 35. Alberts ME. The star of life. J Iowa Med Soc. 1972;62(8):431. 58. Kumekawa J. HIPAA: how our healthcare world has changed. 36. Doyle OJ. Federal EMS legislation. JEMS. 1997; Online J Issues Nurs. 2005;10(2):1. 22(9):26–27, 30. 59. Schoppmann MJ, Sanders DL. HIPAA compliance: the law, 37. Lipsky J. The need for EMS legislation. J Iowa Med Soc. reality, and recommendations. J Am Coll Radiol. 2004;1(10): 1978;68(3):85–86. 728–733. 38. McKenna W. Understanding EMS legislation. Emerg Med Serv. 60. Collins D. The prehospital 12-lead EKG: starting outside the 1988;17(5):52–55. emergency department. J Emerg Nurs. 1997;23(1):48–50. 39. Davenport J. Anatomy of a 911 call. Northwest Dent. 61. Cummins RO, Eisenberg MS. From pain to reperfusion: 2005;84(4):37–38. what role for the prehospital 12-lead ECG? Ann Emerg Med. 40. Isler C. Dial 911 for the coronary ambulance. RN. 1990;19(11):1343–1346. 1969;32(8):48–51. 62. Davis DP, Graydon C, et al. The positive predictive value of 41. Kimball KF. 911—the emergency number. Nebr State Med J. paramedic versus emergency physician interpretation of the 1971;56(2):68–70. prehospital 12-lead electrocardiogram. Prehosp Emerg Care. 42. McSwain NE, Jr. The effectiveness of 911. Ann Emerg Med. 2007;11(4):399–402. 1992;21(10):1242–1243. 63. Greiff SJ. Taking it to the street: advanced monitoring and 43. Greiff SJ. Fire-based EMS: the trend of the future? Emerg Med 12-lead EKGs in prehospital care. Emerg Med Serv. Serv. 1999;28(6):43, 45–46, 48 passim. 1998;27(9):47–48, 54–55. 36 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 64. John A, Brennan E. Principles of EMS Systems (3rd ed.). 69. Kucera WR. Narrow defi nition of “emergency” can spell American College of Emergency Physicians; Boston, MA: Jones “litigation.” Hosp Med Staff. 1978;7(9):21–27. and Bartlett, 2005. 70. Li J, Galvin HK, et al. The “prudent layperson” defi nition of an 65. Myers MB, Norwood SH. Standing orders for trauma care. J emergency medical condition. Am J Emerg Med. 2002;20(1): Emerg Nurs. 1994;20(2):111–117. 10–13. 66. O’Connor R. Paramedic standing orders. Del Med J. 71. Mitchell TA. Nonurgent emergency department visits—whose 1993;65(7):465–466. defi nition? Ann Emerg Med. 1994;24(5):961–963. 67. Schedler P. Standing trauma orders should also be cost-effective. 72. Schneider SM, Hamilton GC, et al. Defi nition of emergency J Emerg Nurs. 1994;20(5):346–347. medicine. Acad Emerg Med. 1998;5(4):348–351. 68. American College of Emergency Physicians. Defi nition of emergency medicine. Ann Emerg Med. 1994;24(3):553–554. Introduction to Emergency Medical Service Systems 37 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Paramedic wellness defi ned as more than absence of disease • The body’s responses to both positive and negative stresses • Stress management techniques for managing acute stress and chronic stress • Safety tips and stress management prevention strategies Case Study: “I can’t believe that I pulled my back on that last call,” said the young Paramedic. “Now what am I supposed to do? We’re expecting our fi rst baby and I’ve got the house payment and car payment. I can’t be out of work and I need the overtime!” 38 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Workforce Safety and Wellness 39 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW The health and wellness of the Paramedic goes beyond simply avoiding illness. It involves the social, spiritual, intellectual, emotional, and physical well-being as a part of a well-balanced lifestyle. The Paramedic encounters stress each day. This stress can have a harmful physiological effect on the body. It is important for the Paramedic to have built-in mechanisms for stress management and be familiar with the methods of crisis intervention to help prevent stress related illness. The Paramedic has many responsibilities, but perhaps the most important is personal safety. Focusing on the Paramedic’s response to emergencies and scene hazards, awareness is what can keep the Paramedic, his team, and the public safe. Safety is more than body substance isolation. Wellness Benefi ts of Wellness The concept of wellness could be thought of as merely the The benefi ts of wellness include a heightened sense of pur- absence of illness. However, this simplistic approach fails pose, an inner tranquility, as well as a physical being capable to take into account the complexity of human existence. of greater feats. Physical health is the most outward sign of Wellness is a multidimensional concept which includes wellness. Physically, the healthy body is more resistant to all aspects of a person—social, spiritual, intellectual, and injury (such as back injuries), as well as to illness. The body, emotional—as well as physical well-being (Figure 3-1). as a machine, functions better with a lower resting heart rate One defi nition of wellness, advanced by DePaul and blood pressure, more respiratory reserve, and generally University, is that wellness is an active process of becoming has a better cardiovascular capacity when it is healthy. Risk aware of, and making choices toward, a more successful exis- factors for all of the major diseases—cardiovascular disease, tence. This defi nition, intrinsically, implies that wellness is diabetes, and cancer—are reduced in healthy people. more than an absence of illness, which could be thought of as the lowest level of wellness. Paramedics who are aware of the Methods Used to Achieve Wellness practice of wellness are more likely to not experience illness Nutrition and to lead more productive lives. The components of physical health include a proper diet, one that provides the necessary nutrients, in the quantities suf- fi cient for life. A balanced intake of carbohydrates for quick energy, fats and proteins for body maintenance, as well as essential vitamins and minerals, can help the body main- Social tain optimal functionality. These nutrients can be obtained from the major food groups illustrated in the Department of Agriculture’s Food Pyramid (Figure 3-2). Foods, taken in the quantities indicated, can sustain a body and provide it with the materials and resources it needs to withstand the stresses Spiritual Physical encountered in emergency services. Food should always be eaten in moderation, with atten- Wellness tion paid to the type of foods being eaten. Excess amounts of fatty foods, for example, or excessive intake can lead to obesity. Obesity is a growing health crisis, second only to cigarette smoking as the leading cause of preventable death.1,2 Obesity can lead to a host of associated complications includ- ing diabetes and cardiovascular disease.3–6 Intellectual Emotional Medically speaking, a person is obese when his body mass index is 30 or greater.7 A common layperson defi nition of morbid obesity is 100 pounds over ideal weight. Over 60% of American men are obese by defi nition and therefore have Figure 3-1 The interconnectedness of wellness. an increased chance of illness, injury, and premature death. 40 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. PEACHES Grains Vegetables Fruit Milk Meat & Beans Figure 3-2 United States Department of Agriculture’s Food Pyramid with a new emphasis on exercise. (Courtesy of United States Department of Agriculture) Figure 3-3 Physical fi tness is essential to longevity in EMS. Street Smart health. Whether using free-weights (isometric) or resistance exercises (isotonic), strength training can lead to increased Specialized bariatric equipment is available to help muscle strength and fl exibility (Figure 3-3). This in turn transport patients with obesity. The Paramedic should can help reduce the incidence or the severity of on-the-job injuries, particularly back injuries. know how to obtain this equipment and use it to prevent personal injury. Stress Stress is a function of daily living, a result of the interaction between the person and the environment. During the course of a day, the human body is constantly being bombarded Exercise by stimuli. The body reacts to this stimuli accordingly. The Exercise is also essential to physical health. A combina- amount of stimulation results in a certain level of stress in tion of aerobic exercise (e.g., walking or jogging), as well the body. If the stress is manageable (i.e., tolerable within as strength training is considered optimal for maintaining the limits of a person’s physical, psychological, emotional/ spiritual, and intellectual capacity to respond to the stimuli), then it is a positive form of stress or eustress. Eustress can Professional Paramedic lead to improved health as well as a sense of fulfi llment or accomplishment. Alternatively, overwhelming stimuli can lead to unhealthy Some Paramedic employers contract with stress, which in turn can have a negative impact on the per- chiropractors, personal trainers, or health educators son. This is called distress. Distress is the result of the body’s with a specialty in injury prevention to conduct maladaptive reaction to stress. The stimulus causes the body to react in a self-protective manner. This “survival instinct,” assessments and teaching sessions in an effort to awareness of and the ability to respond to one’s surroundings, reduce back injuries. is immediate and uncontrollable. Workforce Safety and Wellness 41 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. When distress occurs, the body undergoes a reaction con- the vagus nerve. These functions are summarized as “feed trolled by the autonomic nervous system. The autonomic ner- and breed.” vous system can affect organ function throughout the body. The other autonomic nervous system responses are the Walter Cannon coined the term “fi ght or fl ight” to describe result of the sympathetic nervous system. Normally the sym- the generally adaptive response of the autonomic nervous pathetic nervous system includes those emergency responses system to stress. “Fight or fl ight” describes the body’s instinc- that are at “stand-by,” ready to provide the person with the tive response to a potential life threat. This primitive stress ability to fl ee (fl ight) or fi ght. Under normal conditions, the response may have been critical to the survival of primeval parasympathetic nervous system takes dominance, through man, but can be unhealthy today. vagal tone, and maintains homeostasis. However, under Modern man faces a host of new behavioral and emo- emergency conditions in which there is suffi cient stimulus, tional stressors beyond the mere physiologic stressors faced the epinephrine-based sympathetic nervous system assumes by early man. Modern

stressors include psychosocial pres- more dominant control of the organs’ functions.11,12 sures from family, coworkers complaints, and supervisors’ The sympathetic nervous system is greatly infl uenced demands. In addition, intellectual pressures to perform to by the brain’s cognition, that ability to comprehend stimulus, perhaps unrealistic expectations, as well as new physiologi- and thought, the ability to comprehend a stimulus’s meaning. cal stressors that include noise pollution from sirens wailing, When repeatedly overstimulated, perhaps by constant bom- can lead to distress. Distress can be caused by any stimulus bardment by stress-inducing stimuli, the body begins to show that creates a maladaptive response from the autonomic ner- the fatigue, a prelude to illness in many cases, in a condition vous system. called strain. Hans Selye, an endocrinologist, observing the impact The chief neurotransmitter in the sympathetic nervous of stress upon physiology, advanced his theory of the “gen- system is epinephrine. Epinephrine has organ-specifi c effects eral adaptation syndrome.” In his theory he suggested that that alter that organ’s function. For example, epinephrine all human experience creates stress, but it is how the per- attaches to beta-receptors in the heart to make it contract son responds to that stress that determines if it is eustress or more forcefully (inotropy) and more quickly (chronotrophy). distress.8–10 Selye believed that the power of the body to resist Simultaneously, epinephrine also attaches to alpha-receptors distress, over a prolonged period of time, was limited and that in the peripheral vasculature, leading to increased peripheral the body would eventually become exhausted and typically vascular resistance (PVR). manifest in mental or physical illness. The stimulation of both receptors, alpha and beta, by epi- nephrine released during a stimulus response causes the heart to beat faster and harder against a greater resistance (PVR). Symptoms of Stress The heart’s increased workload leads to cardiovascular The manifestations of a Paramedic’s pending exhaustion from complications if the stress is prolonged. stress can be divided into psychological, cognitive, behav- Stress can also cause abnormal contraction of skeletal ioral, and physiological signs and symptoms. muscles, contractions beyond their functional needs, lead- For some people, the psychological signs of distress include ing to muscle spasms, spinal column misalignment and an unreasonable irritability at seemingly minor annoyances, resultant backache, contraction of facial muscles leading to uncharacteristic angry outbursts, open or covert hostility, and headache, jaw clenching, nocturnal teeth-grinding (brux- a general restlessness. For other people, distress is manifested ism), and neck pain. Internally, the immune system, set on by depression, withdrawal, self-deprecation, as well as reduced high alert for potential bacterial invasion, eventually fatigues. self-esteem. The Paramedic may also manifest stress by hav- T-lymphocyte counts drop, resulting in immunosuppression ing uncharacteristic bouts of forgetfulness, reduced creativity, and, paradoxically, more infections. The signs and symptoms shortened attention span, and disorganized thought. of overstress, or distress, include persistent tachycardia, pal- The person under extreme stress may demonstrate pitations, hypertension, chest pressure, and chronic pain. uncharacteristic changes in behavior such as increased smok- Physical disorders associated with chronic high stress ing, aggressive behavior (e.g., road rage), increased alcohol include, from head to toe, migraine and tension headaches, or drug use, over-eating, and a general carelessness about and cardiovascular disorders, respiratory disease, ulcers, and coli- withdrawal from activities of daily living. All of these may be tis, as well as hypertension and cancer. signs of impending stress-induced crisis. Emotional and behavioral disorders are also associated Walter Cannon referred to the symptoms of stress as a with stress. These include anxiety, with associated panic “fi ght or fl ight syndrome” and all of the manifestations of attacks, depression, alcoholism, and conduct disorders. These stress, system by system, are all attributable to a heightened emotions, behaviors, and somatic complaints should alert fel- autonomic nervous system state. The autonomic nervous low Paramedics that the person is under stress and may or system’s function can be roughly divided into two portions. may not be coping well emotionally.13 The fi rst portion, the parasympathetic nervous system, is The human psyche is not immune to the effects of chronic responsible for the involuntary vegetative functions includ- stress either. The psychological defense mechanisms against ing digestion, heart rate, and the like, largely controlled by stress include projection, denial, and conversion, among 42 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. many others. When the individual’s coping mechanisms fail the individual can take action to eliminate the source of the to provide the relief needed, the individual may resort to mal- stress. This activity would constitute stress reduction. A job adaptative coping mechanisms. Examples of these maladapta- change or even divorce can be examples of stress reduction. tive coping mechanisms include substance abuse, alcoholism, If the source of the stress cannot be eliminated, then some smoking, and the use of other addictive substances. action must be taken to reframe the brain’s interpretation of the stimulus so that it is non-threatening. This technique, The Crisis Process called cognitive restructuring, provides hope for recovery A person is in crisis when he has experienced a threatening for some people with fatigue, strain, or stress. event but no longer has the capacity to respond, due to mental To understand the benefi ts of stress management, and/or physical exhaustion. The crisis process is somewhat Paramedics need to fi rst learn to recognize the early warning analogous to the transition from compensated to decompen- signs of stress, both immediate and long-term. Examples of sated shock. Anxiety, panic, and, in some cases, terror sets in the effects of long-term stress include recurrent headaches and the patient may become profoundly depressed or start to and unremitting fatigue. Part of managing stress is recogniz- manifest frank psychiatric symptoms. ing events that trigger stress and attempt to either eliminate Like the shock syndrome, the crisis process is reversible, them or respond to them differently. provided a crisis intervention is provided in time. The goals There are several effective models for stress manage- of crisis intervention start with stopping the acute process. ment, both short-term and long-term. For short-term stress Depending on the situation, this may be accomplished simply some EMS responders use controlled breathing or isotonic by removing the person from the source of the stimulus. Once exercise. Long-term methods of stress management are dis- removed, the downward spiral of emotions must be stopped cussed shortly. In every case, Paramedics need to become and the person’s thoughts and/or feelings can stabilize. In aware of their warning signs of impending stress and plan other cases it will take psychotropic medications and/or acute how they are going to respond to those stressors. crisis intervention to stop the crisis. With the acute symptoms While stress management is focused on the individual, managed, the goal of crisis management is to return the per- in this case the Paramedic, there are organizational benefi ts son back to independent functioning. to stress management training. In a cost–benefi t analysis, the One example of a crisis intervention approach used loss of time in stress management training is outweighed by for emergency services personnel is the SAFE-R model loss in sick leave, worker’s compensation, associated medical (Table 3-1). The letters in the SAFE-R model each stand for a costs, and employee turnover. Paramedics who learn how to step in the process. Stimulation reduction (S) is the fi rst goal manage their stress tend to have increased morale, decreased of crisis intervention using the SAFE-R model. Next, the confl ict with fellow workers and supervisors, reduced errors, facilitator would then acknowledge (A) the crisis and, using and enhanced performance while on-the-job. carefully chosen probing questions, facilitate (F) an under- Paramedics can learn a number of stress management standing of the situation. techniques that will help mitigate the long-term effects of After gaining the person’s attention, using empathy and stress.14–17 The majority of these techniques can be done therapeutic communications, the facilitator would explain (E) quietly, on-the-job, and without additional equipment. One the basic concepts of stress. The universality of stress would technique, autogenic training, stems from the practice of be emphasized and the facilitator would offer some plans autohypnosis fi rst advanced by Vogt in 1900. A form of for coping with the current situation. Finally, the facilitator “self-regulation” akin to biofeedback, autogenic training was would discuss a plan to return or restore (R) the person back developed in 1932 by Johannes Schultz as a means to train to independent function. the autonomic nervous system. Other stress management While the SAFE-R technique appears easy, as the say- techniques that emphasize the power of the mind–body con- ing goes, the devil lies in the details. Crisis interventions nection include progressive muscle relaxation and diaphrag- are best left to personnel trained in critical incident stress matic breathing. Some Paramedics have been trained in the management. use of mental imaging, which is useful for immediate stress relief, as well as meditation. Meditation has long been known Stress Management as a technique for stress reduction. Stress management is a process of coping with chronic stress in an effort to recover from its effects. In some instances, Specifi c Stressful Situations Acute Traumatic Stress Table 3-1 SAFE-R Model Witnessing horrifi c and disturbing events can generate intense S Stimulation reduction fear and a sense of helplessness in Paramedics. Unchecked, A Acknowledge the crisis these feelings can lead to acute traumatic stress. Acute F Facilitate E Explain traumatic stress is an unexpected and sudden stressful event R Return or restore which is unlike the stress of day-to-day EMS and understand- ably requires a different approach. Workforce Safety and Wellness 43 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. reports,” should be used to emphasize the successes on-scene. Professional Paramedic Disagreements regarding specifi c aspects of scene develop- ment should be reserved until later. During a debriefi ng, fi rst- line responders should be monitored, possibly including an Like medicine, the most effective critical stress exit physical examination. These post-event physicals can management is prevention-oriented. Planning for reveal signs of stress including sustained tachycardia, persis- the ability to provide humane relief during a major tent headaches, and hypertension. After a major incident all responders should be encour- incident provides the best opportunity to reduce aged to get rest, moderate their intake of alcohol, and reduce acute stress. their caffeine intake. Responders should also be encouraged to engage in self-affi rming activities such as spending time with family and friends or getting involved in a favorite When possible, a predeployment briefi ng that explains sport. the situation, and potential stressors that the Paramedic is about to encounter, can go far toward decreasing the shock Defusings and subsequent acute traumatic stress. For example, search On occasion, and because of the nature of the incident or and rescue predeployment briefi ngs should include a discus- based upon an observation of emergency services respond- sion of the possibility of the operation changing from one ers, it may necessary to order a defusing. A defusing is an of rescue to a recovery operation. Tempering the hopes of immediate intervention intended to avert acute stress reac- concerned rescuers can help to reduce the impact of a poor tions among the responders. Usually initiated within eight outcome, thereby protecting rescuers, without diminishing hours, a critical-incident response team (CIRT) is called the prospect of a rescue. in to meet with the affected personnel, typically front-line Clear delegation of authority and the assignment of responders. specifi c tasks can help to eliminate some of the confusion The purpose of a defusing is to quickly explore the event and helplessness that Paramedics will experience when and then educate

responders about the effects of stress. The confronted with a horrifi c situation. With proper guidance, lesson includes a discussion of signs and symptoms of acute command, and control, Paramedics can persevere against stress reaction as well as means of managing stress. If done incredible adversity. correctly, a defusing can either eliminate the need for further Incident command also needs to consider the mental critical incident stress debriefi ngs or enhance the productiv- and physical limitations of the emergency service respond- ity of future critical incident stress debriefi ngs. Crew leaders, ers under their command. Rotations to out-of-service in educated in debriefi ng techniques, can support their fellow order to take a rest break, eat some food, drink fl uids, and crew members (Figure 3-4). use lavatories, all part of rehabilitation, can help respond- Several criteria can establish the need for a critical inci- ers handle stress more effectively. It is also useful to have dent stress debriefi ng (CISD).18–20 Perhaps the most com- trained counselors who are observing for signs of stress and mon reason for a CISD is an extraordinary event-related can provide immediate interventions in the case of an acute occurrence. Examples of responder-related extraordinarily stress reaction. stressful events include a line-of-duty death, serious injury of a coworker while on-the-job, and post-event suicide of a fellow responder. Examples of event-related extraordinarily Street Smart stressful events include the traumatic death of a child or chil- dren; prolonged rescues, especially those that turn into a body recovery operation; and prolonged hostage situations.21–24 Whenever possible, the media should be restricted Dr. Jeffrey Mitchell, a leader in critical incident stress from the rehabilitation area. Reporters tend to use management, has identifi ed 10 critical incidents with high infl ammatory or untactful language in their questions potential for stress (Table 3-2).25 A CISD can be triggered by a request for CISD, often in order to achieve a desired effect or to prompt a from either an affected responder or an enlightened incident response. Unfortunately, ill-chosen or less than tactful commander. It can also be triggered by indirect personnel, words can have devastating effects upon emergency such as family members, who observe behavioral changes in services responders. the responder. Concerned coworkers, who are still witnessing signals of distress, such as constant ruminating after three weeks, can also request a CISD. A CISD is a private meeting, where only the CIRT and Demobilization is another opportunity to mitigate the responders are invited. Typically, rank holds no privilege effects of the acute stressors and to decrease the incidence of and conditions are established from the outset. This encour- acute traumatic stress reactions. Debriefi ngs, or “after action ages open dialogue among the CISD’s participants. With all 44 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 3-4 Defusing session led by a Paramedic. Table 3-2 High Potential Critical Incidents Following a CISD, a member of the CIRT may have identifi ed a responder manifesting symptomology consistent 1. Line of duty death with acute stress reaction who might benefi t from profes- 2. Suicide of a colleague sional psychiatric services. These psychiatric interventions, 3. Serious work-related injury provided immediately after the event, can potentially prevent 4. Multi-casualty incident long-term disability such as post-traumatic stress disorder. 5. High threat incident (terrorism) Post-Traumatic Stress Disorder 6. Severe traumatic injury to children 7. Close relationship with victim If symptoms of acute stress disorder do not resolve within a four-week period, then post-traumatic stress disorder 8. Excessive media exposure (PTSD) must be considered.26,27 The essential feature in 9. Prolonged operations post-traumatic stress disorder, per the American Psychiatric 10. Overwhelming events (disasters) Association’s (APA) Diagnostic and Statistical Manual, fourth edition (DSM-IV), is the development of “character- istic symptoms following exposure to an extreme traumatic stress involving direct personal experience of an event that responders and the CIRT assembled in one room, the CIRT involves actual or threatened death or serious injury, or other leader begins by making introductions. A typical CIRT has a threat to one’s physical integrity; or witnessing an event that mental health practitioner as well as emergency responders involves death, injury or a threat to the physical integrity of who are trained in critical incident stress debriefi ngs. Once another person.” the introductions are completed, the leader starts the process Symptoms of PTSD include persistent intrusive recol- of divining the facts, asking for thoughts and reactions, all in lections of the event and fl ashbacks. Chronic absenteeism a nonconfrontational atmosphere. may represent the Paramedic’s attempts to avoid anything Timing is important to a CISD. If responders are still associated with the psychological trauma. Paramedics who experiencing acute stress they will have a limited number of have experienced a violation of a key psychological assump- communication channels to handle incoming information. tion, such as safe return from duty, might have tendencies They will not be able to tolerate the ambiguity that may occur toward PTSD. during the discussion. The objective of every CISD, and the next step in the process, is education. Responders are fi rst taught about typi- Personal Injury Prevention cal or “normal” reactions to stress, asked to refl ect upon these Many individuals get involved with emergency services symptoms, then taught about means to manage the stress that because of the excitement and danger of a rescue, never really naturally accompanies any incident. thinking that they themselves might actually get hurt. To the Workforce Safety and Wellness 45 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Paramedic, nothing may be more stressful than personal Risk Management injury. Despite their best efforts to mitigate hazards, injuries Progressive EMS agencies have developed a plan for risk do occur. In many situations, these injuries could have been management, a plan that emphasizes safety and whose goal lessened, or eliminated altogether, with proper preplanning is to reduce Paramedic injury in an effort to promote a culture and a safety-conscious attitude on the part of Paramedics. of safety in their organization. The problem of emergency responder death and injury In those agencies, either a risk manager or a safety may have been brought to the forefront by a 1973 publica- committee identifi es known hazards and then tries to mitigate tion entitled America Burning. America Burning, a presiden- those hazards. These activities are consistent with require- tial white paper, brought to light the indifference to safety ments under the general duty clause contained within the in the fi re service.28 Subsequently, all emergency responders Occupational Safety and Health Administration’s (OSHA) have experienced an increased emphasis on safety, primar- regulations. ily through increased regulations and standards (Table 3-3). Through a study of the frequency of injury, the severity of Paramedics, both in and out of the fi re service, must be aware injuries, and the economic impact of those injuries (including of the standards and regulations that affect them. workers’ compensation claims), the risk management team Regulations are mandatory and carry the weight of law, identifi es trends and implements change (e.g., new regula- whereas guidelines and standards are voluntary and only tions, procedures, or protocols). The risk management team offer directions for safe practice. Other recognized sources of would then perform an audit and reassess the success of the standards include the American National Standards Institute change. This plan-do-check-act approach, the PDCA cycle, (ANSI) and the American Society of Testing and Materials is a form of continuous quality improvement and is the same (ASTM). However, when specifi c injuries increase in certain model used in business. areas lawmakers frequently turn to standards and guidelines for direction. Safety Back Injury The saying goes “safety starts at home.” Every Paramedic has The prevalence of back injury among Paramedics is high and a responsibility to help maintain the safety of both the station potentially preventable.29–31 A reduction in the incidence of and the emergency response vehicle (ERV). back injury can be realized if Paramedics adhere to a few Of immediate concern in the station is the problem of fi re basic back safety rules. In many cases, back injury occurs and life safety. EMS stations should serve as models of a safe because of improper lifting and carrying. building for the community. Sprinklers should be placed in A Paramedic should lift only those loads that can be car- all living areas and fi re extinguishers, as well as fi re alarms, ried safely. Many EMS agencies have guidelines regarding safe should be readily available. In addition, fi re escape routes lifting, often tied to a functional job description, and mandate should be posted and clearly visible and fi re drills should be that additional rescuers be called for heavy lifting. When lift- routinely practiced. ing any object—stretchers to jump kits—Paramedics should Another concern is falls that occur while on the prem- bend their knees, stoop down, and lift with their legs. Keeping ises. Wet fl oors and snow-covered walkways present a clear the object close to the body and in-line helps to reduce the and present danger. Precautions should be taken to eliminate chance of a back injury. Part of back safety is back health. or mitigate the danger if possible. Exercise, discussed earlier, helps to maintain the strength and Vehicle Safety fl exibility of the back and reduces the chance of injury. Paramedics depend on their emergency response vehicle (ERV) for protection during an emergency response. A Table 3-3 Sample of Safety Regulations combination of lights, refl ective surfaces, and sirens help and Standards Applicable to Paramedics to increase the visibility of EMS while on-scene. Therefore, • Safety Regulations within the Code of Federal Regulations (CFR) these safety devices should be regularly checked to be sure • Confi ned Space Rescue 29 CFR 1910.146 they are in working order. However, a greater danger may • Hazardous Materials Response 29 CFR 1910.120 exist from mechanical failure. High speed driving, sudden stopping, and multiple drivers driving in all kinds of condi- • Bloodborne Pathogens 29 CFR 1910.1030 tions combine to put an extraordinary stress on ERVs. • National Fire Protection Association Standards To prevent mechanical failure, and ensure a timely • Fire Department Infection Control NFPA 1581 response, EMS agencies should have a program of preven- • Hazardous Materials Awareness Competencies NFPA 472 tative maintenance (PM) for their ERV. As opposed to a • Centers for Disease Control and Prevention (CDC) traditional “wait until it breaks then fi x it” approach, a pre- • Guidelines for Exposure to Tuberculosis ventative maintenance program forestalls the incidence of • Guidelines for Hepatitis B Exposure failure, thereby decreasing the incidence of injury and poten- tial litigation. 46 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Emergency Response If the emergency responder is the fi rst emergency vehicle Paramedics are at greatest risk of personal injury during the on-scene then the vehicle should be placed in such a manner initial response to the scene of an emergency. Despite safe so as to protect the patient and the responders. Typically, the vehicle operation, collisions with other vehicles on the road ERV is staggered, out-of-line, from the vehicle ahead so that do occur. Every emergency vehicle operator (EVO) should a safety zone is created. practice caution when advancing

upon intersections. Many The ERV is now acting as a warning device, with its EMS agencies require all ERV to come to a complete stop, lights fl ashing, and as a physical barrier. To improve its func- when opposed by the red light, before proceeding. tionality as a barrier, the tires should be turned sharply, away When passing other vehicles, while running lights and from the pathway to the vehicle ahead. sirens, the EVO should expect the unexpected and be pre- If the scene is already protected by another emergency pared to drive evasively in order to avoid collision. Most responder, then most EMS agencies have a policy of parking states require emergency vehicles to pass on the left. Passing beyond the scene, parking in the direction of the most likely on the right runs the risk of having confused drivers suddenly destination hospital, and toward the route of intended exodus. turn into the path of the ERV. Parking in front of the scene helps reduce the exposure of the Paramedics should be on a heightened state of alert when second emergency vehicle to collision. multiple emergency vehicles are on the road. Unsuspecting Before approaching an unknown vehicle, headlights motor vehicle operators, seeing one emergency vehicle pass, should be turned on high and any available takedown lights may pull out into the path of the next emergency vehicle. or spotlights aimed toward the vehicle ahead. This lighting Police escorts are discouraged in many EMS systems for this helps to illuminate the interior of the vehicle as well as create reason. a safe working zone. If more than one emergency vehicle is traveling the same Some EMS systems require that the Paramedic radio route it may be prudent to change siren modes. There is a the license plate of the vehicle before it is approached. If the better chance that the motorists will hear two distinctly dif- plate comes back on a stolen vehicle the Paramedic is to wait ferent sounds and recognize that there is a second emergency for the arrival of law enforcement. vehicle. While a safe following distance increases the safety After selecting only the minimal equipment required of the chase vehicle, the wisdom of having two ERV respond- for an initial response, the Paramedic would approach the ing lights and sirens must be questioned. If it is plausible, the rear of the vehicle. Carrying additional equipment, such as chase vehicle should turn off its lights and siren, allowing the ECG monitors and so forth, is unnecessary and presents an fi rst ERV to be the fi rst responder to arrive on-scene. additional burden if the Paramedic has to fl ee suddenly. The A defensive driving attitude, or due regard for others Paramedic should choose to either approach the vehicle from on the road, can help to limit the number of motor vehicle the passenger side or to go around the back of the ERV and collisions. A number of emergency vehicle operator courses approach the vehicle from the driver’s side. The Paramedic and accident reduction programs are available to Paramedics. should avoid walking in front of the ERV headlights, back- Some insurance companies offer a reduction in premiums lighting his position and announcing his presence to the (personal and corporate) for participation in these programs. driver. Surprise is an important safety technique. With fl ashlight in hand, and carried away from the body, the Paramedic would examine the inside of the vehicle for Scene Hazards weapons as well as for the number of patients and then posi- Personal safety is the primary concern of Paramedics upon tion him- or herself behind the B-post of the vehicle. From arrival on the scene of an emergency. The responsibility for this venue the Paramedic can continue to inspect the interior scene safety is both an individual responsibility as well as of the vehicle’s occupant compartment for evidence of dam- a collective responsibility of the team. At larger incidents a age as well as weapons before proceeding with patient care. safety offi cer may be assigned to maintain safety. However, A Paramedic approaches a house call much differently at a small incident (e.g., a typical call for an emergency), than a road call for a motor vehicle collision. While houses overall responsibility falls to the offi cer-in-charge. vary, from the apartment in a high-rise development to the When approaching the scene of a motor vehicle colli- bungalow on a beach, the basic safety principles remain the sion, the driver and the Paramedic should slow the vehicle same for all and need only be modifi ed to the conditions on- and take a moment to get a “windshield survey” of the scene. scene. A current controversy in EMS concerns the style of Obvious hazards, such as a patient lying in the roadway or uniforms. Some EMS agencies advocate the button-down smoke and fi re, should be reportedly immediately as part of style of uniform that presents a clean image and portrays a the “fi rst due” report. It is safe practice to call out, by radio, or military bearing to the wearer. Other Paramedics argue that note somewhere in the cab of the ERV the license plate num- these uniforms make Paramedics look like law enforcement bers of the vehicle being approached. Some EMS agencies offi cers, especially to the distorted eyesight of a confused are not allowed to approach vehicles that are reported stolen or intoxicated patient (Figure 3-5). Patients could respond until law enforcement offi cers arrive. inappropriately, even violently, to this misperception. Workforce Safety and Wellness 47 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 3-5 Similarities between law enforce- Figure 3-6 Properly carrying equipment can ment offi cer uniforms and EMS uniforms. ensure the Paramedic’s safety. An alternative EMS appearance, dubbed the soft look, con- the Paramedic can take a moment to look and listen for evi- sists of polo-style shirts. These shirts, without the badges of dence of scene violence. authority, are argued to be safer. If there is no evidence of scene violence, the Paramedic The use of personal body armor while performing EMS should park the ERV either diagonal across the end of a drive- is another controversy in EMS. Some argue that body armor way, or backed into the scene. This position permits a hasty is necessary to protect Paramedics. Citing gun ownership sta- retreat if need be. tistics, body armor advocates believe that body armor is part Carrying only the minimum equipment needed, the of personal protective equipment (PPE). In opposition, other Paramedic should approach the house from an oblique angle Paramedics believe that wearing body armor will encour- if possible, cutting across the lawn if necessary. Potential age Paramedics to enter scenes that they would otherwise attackers assume the Paramedic will approach the house not have entered, under the false assumption that the body from the sidewalk or other walkways. If a fl ashlight is needed armor will protect them. Opponents of body armor argue that to illuminate the pathway, then it should be carried away Paramedics do not have a duty to enter into unsafe scenes. from the body and care should be taken to not backlight Like their approach to a motor vehicle collision, the Paramedic. Paramedics should slow their approach to a house call until Equipment bags should be slung over the shoulder, or both the driver and the Paramedic can get a windshield survey. carried by hand, where they can be slipped off and dropped Emergency lights should be extinguished well before arrival, in front of pursuers. If the equipment bag is slung over the so as to not alert the occupants of the impending approach of neck, attackers can grab the strap and drag the Paramedic to emergency responders. The ERV should be slowed to a near the ground. Paramedics must be sure to properly carry their stop at a 45-degree angle from the scene. From this vantage, equipment bag (Figure 3-6). 48 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. If possible, the EVO should remain in the vehicle, with perform a scene size-up before proceeding. Some Paramedics, the ERV running and the mobile radio on, while the Paramedic once they are inside the door, immediately step to the side, approaches the house. This permits the EVO to contact LEO with their back to the wall, and start asking family members if assistance is needed and to more quickly depart the scene. simple questions. Taking advantage of the moment, these If the residence is an apartment complex or similar struc- Paramedics perform a quick sweep of the room for deadly ture with an elevator, then the Paramedic should consider weapons and dangerous instruments.32–35 using the fi re service functions. Upon arrival at the intended Domestic violence calls are some of the most dangerous fl oor, the elevator alarm should be silenced and the elevator calls for LEO and Paramedics alike. When arriving on the locked. One Paramedic should approach the apartment door scene with a potential for domestic violence, the Paramedic is while another Paramedic surveys the scene for stairwells, fi re well advised to wait for the arrival of LEO before entering. If escapes, and other emergency exits. Once safe entry is made Paramedics have inadvertently entered into the scene of prob- into the apartment, the elevator can be released for regular able domestic violence, they should consider the severity of service. the patient’s injuries versus their personal safety, keeping their The Paramedic should verify the address, then approach safety foremost in their minds. If the scene is unsafe, and the the door from the door handle side; this cuts down on the Paramedic can get the patient into the relative safety of the ERV, Paramedic’s angle of exposure. Using the door’s jam as a bar- they should attempt to do so. If the scene is unsafe, the Paramedic rier, the Paramedic would position himself perpendicular to should immediately withdraw and call for assistance. the wall and loudly announce his presence, using the butt of a If Paramedics are attacked or feel they are about to be fl ashlight or similar object to knock on the door while shout- attacked they should immediately withdraw from the scene. ing out, “Ambulance!” or “Fire department!” These terms are Some Paramedics will throw the clipboard into the hands of generally understood by most citizens and cannot be confused a potential attacker, to confuse the attacker and to allow them with “police” or other terms. more time to escape. Entering the residence, many Paramedics suspend the The fi rst goal for Paramedics during a hasty retreat is to get EMS equipment bag and carry it in front of them, provid- two or more objects called cover between themselves and their ing a barrier to attacking dogs and/or an obstacle to pursuers. would-be attackers. Cover is any object that cannot be pene- Paramedics should request that all dogs be locked in another trated by a projectile, from bullets to frying pans. Examples of room, regardless of pleas from the family or innocent appear- cover include telephone poles and even fi re hydrants. The tires ances. Even small, apparently harmless dogs can attack if and engine block of the ERV also make good cover; however, they sense that the Paramedic is hurting their master. Paramedics are reminded that a bullet tends to follow the plane Whenever possible, two responders should enter the scene of the ground after it ricochets and can travel under an ERV. together. One responder acts as the contact

medic. The contact If cover is not immediately available then the Paramedic medic makes contact with the patient and begins patient care. will have to settle for concealment. Concealment is cre- This second responder acts in the role of the “cover medic.” ated by any object that blocks the pursuer’s vision of the The cover medic watches the scene for hazards. The cover Paramedic. However, concealment does not offer protection medic always keeps the “big picture” in mind, watching both and should be abandoned in favor of cover and retreat as soon the patient and the other people on scene. The cover medic as possible. should ensure that the doorway to the exit is never blocked. If possible, the cover medic should be stationed in the path to Special Operations the doorway, to ensure that it remains open. Often the cover Special operations, such as confi ned space rescue, vehicle medic carries the radio in case additional aid is needed. rescue, and water rescue, require special protective apparel The cover medic should also do a quick scan of the as well as training in its proper use. For example, a Paramedic scene to identify deadly weapons and dangerous instru- inside a vehicle should have, from head to toe, a helmet or ments. Deadly, or lethal, weapons are those objects that are, bump cap with strap, ear protection, eye protection, a fi re- by design, intended to infl ict death or disability (e.g., a pis- retardant turnout coat, leather or fi refi ghter-grade gloves, tol or a knife; Figure 3-7a). The defi nition of a dangerous overalls or bunker pants, and boots. instrument is more amorphous. A dangerous instrument is any object that could be used, under the right circumstances, to produce serious injury or even death. An example of a Infection Control dangerous instrument would be a box cutter or broken beer The ever-present danger on the scene of every EMS call is bottle (Figure 3-7b), both of which could produce serious infection. Paramedics have a good chance of preventing an lacerations. infection for themselves provided they have up-to-date immu- If a cover medic is not available then the Paramedic must nizations and use proper barrier protection. Immunizations perform a scene survey alone. The Paramedic should avoid considered standard in most EMS agencies include tetanus, tunnel-vision and, borrowing a term from the fi re service, diptheria, polio, and MMR (measles, mumps, and rubella). Workforce Safety and Wellness 49 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (a) (b) Figure 3-7 Deadly weapons versus dangerous instruments. Other common immunizations include the vaccination On-scene of a medical emergency, Paramedics utilize series for hepatitis B, offered free to Paramedics as part of a dress-up philosophy, meaning Paramedics add barrier the OSHA regulations regarding bloodborne pathogens, and devices for protection as the situation warrants. Practicing (in the future) smallpox vaccination. Many Paramedics also body substance isolation, Paramedics frequently don receive vaccination for infl uenza, not only to protect them- gloves before approaching the patient. In many cases, the selves, but to protect their infant and elderly patients who do patient’s chief complaint determines what additional barrier not recover as easily from these contagions. While, at pres- device is worn. Paramedics should be aware of commonly ent, there are no immunizations against tuberculosis (Tb) or used barrier protection for certain situations (Table 3-4). human immunodefi ciency virus (HIV), many Paramedics The list is not comprehensive nor should Paramedics limit obtain periodic testing, in order to obtain life-prolonging che- themselves to the listed devices if conditions warrant more motherapy in the event they are infected. protection. 50 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 3-4 Barrier Devices Used in Selected Activities Disposable Protective Task Gloves Gown Mask Eyewear Bleeding control Yes Yes Yes Yes Spurting blood Bleeding control Yes No No No Minimal blood Emergency childbirth Yes Yes Yes Yes Intravenous line insertion Yes No No No Endotracheal intubation Yes No Yes Yes Suctioning Yes No No No Measuring blood pressures No No No No Appropriate use of Body Substance Isolation (BSI) is recommended any time open skin or mucosa may be exposed to body fl uids.36–40 Source: This table is taken from the New York State Department of Health, Bureau of Emergency Medical Services, Recommendations for Body Substance Isolation. Infectious Disease Exposure Whenever blood or bodily fl uids from a patient are spilled, splashed, or dripped onto or injected into a Paramedic, an exposure to a potentially infectious material may have occurred. The prevention of exposure to blood and bodily fl uid is paramount and all efforts to provide equipment with built-in safety devices and for the proper disposal of sharps and other potentially infected materials should be given priority. Barrier devices, such as eye protection and gowns, should also be readily available and used in anticipation of a blood or bodily fl uid exposure (Figure 3-8). Whenever a potential exposure has occurred, the exposed area should be immediately blotted clear of visible blood or fl uids, then thoroughly washed with soap and water. If soap and water is not immediately available, the Paramedic should use a gelled alcohol cleanser, then (as soon as possible) use soap and water to cleanse the area. Blood or bodily fl uids inadvertently splashed into the eyes, nose, or mouth should be fl ushed away, using clean water. The Centers for Disease Control and Prevention (CDC) reports that there is no scientifi c evidence to support the prac- tice of applying antibiotics or squeezing fl uid from the wound to reduce or prevent the transmission of disease. Following agency guidelines, and after caring for the patient, the Paramedic should immediately report the expo- sure and seek medical treatment. Treatment may include Figure 3-8 Preparing for an intubation by fi rst obtaining a blood sample from both the Paramedic and the donning personal protective equipment. source patient, assuming the patient grants permission as well as post-exposure chemotherapy. fl uid contacts, and the chance of the Paramedic being infected Factors that combine to determine the risk of exposure to from a single blood contact with an infected patient. hepatitis B (HBV), hepatitis C (HCV), and human immuno- A great deal of concern is expressed about exposure to defi ciency virus (HIV) is a function of the number of infected HIV, but the CDC reports that the risk of HIV infection, even persons in the community, the type and number of blood or after needlestick with HIV-infected blood, is 0.3% (1 in 300). Workforce Safety and Wellness 51 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The risk for a splash of HIV-infected blood into the eye, nose, Using heavy-duty utility gloves, kitchen-type, the or mouth is less than 1 in 1,000.41–43 Paramedic should mix a 1:100 solution of bleach and water Following a call where potentially infectious material has (1/4 cup of bleach to a gallon of tap water) and wipe down been present, the equipment and the ERV should be decon- any contaminated surfaces. A ratio of 1:100 bleach is usable taminated. Decontamination of the emergency response for about 24 hours before it should be discarded. Many vehicle diminishes the potential for disease transmission EMS agencies prefer to mix a fresh solution before every and should be done as soon as practical. Moist blood should use. Soiled linens and the like, including soiled uniforms, be immediately blotted with a disposable towel at the time should be returned to laundry for proper cleaning and any of the spill, using a gloved hand. The towel should then be soiled dressing or other bloody materials disposed of in a red disposed of in a red biohazard waste container. More thor- biohazard waste container. ough cleaning should occur after the call. 52 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. An enlightened attitude about health and wellness, as well as a “heads-up” attitude about safety, contribute to a Paramedic’s wellness and ability to continue practicing paramedicine. Key Points: • Wellness is more than an absence of illness • The Paramedic may handle acute traumatic and incorporates all aspects—social, spiritual, stress differently than the layperson; therefore, intellectual, emotional, and physical being—of management may require a different approach. a person. • Some incidents may require a defusing, or an • A healthy body is more resistant to both injury immediate intervention intended to avert acute and illness. stress reactions among responders. • A proper diet, one that provides the necessary • A typical CIRT (Critical Incident Response Team) nutrients in suffi cient quantities, is one of the most has a mental health practitioner as well as important components of physical health. emergency responders who are trained in critical incident stress debriefi ngs. • Exercise is essential to a Paramedic’s physical health. • In many situations, injury can be lessened, or eliminated altogether, with proper preplanning • Stimulation results in stress in the body. The and a safety-conscious attitude on the part of the positive form of stress is eustress while the Paramedic. maladaptive reaction to stress results in distress. • A Paramedic’s responsibility is to maintain the • Behavioral and emotional stressors can negatively safety of both the station and the emergency affect the Paramedic’s emotions, way of thinking, response vehicle (ERV). and behavior. • Paramedics are at greatest risk of personal injury • The dominance of the sympathetic nervous during the initial response to the scene of an system in a chronically elevated state can bring emergency. about physical, emotional, and behavioral • Scene safety is an individual responsibility as well disorders. as a collective responsibility of the team. • Maladaptive coping mechanisms include substance • Whenever possible, two responders should enter abuse, alcoholism, smoking, or the use of other the scene together. One responder acts as the addictive substances. contact medic, interacting with the patient and • Analogous to decompensated shock, people are in beginning patient care, while the second responder crisis when they experience a threatening event acts in the role of the “cover medic.” but no longer have the capacity to respond. • Domestic violence calls are some of the most dangerous calls for law enforcement offi cers and • Stress management is a process of coping Paramedics alike. with chronic stress in an effort to recover from its effects. • Paramedic safety should be kept foremost in mind. • Paramedics can learn a number of stress • If attacked, the Paramedic should withdraw management techniques that will help mitigate the immediately. long-term effects of stress. Workforce Safety and Wellness 53 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not

materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • Immunizations and proper barrier protection offer • Any soiled dressing or other bloody materials Paramedics the best chance in preventing infection should be disposed of in a red biohazard waste for themselves. container. • The prevention of exposure to blood and bodily • Special operations, such as confi ned space rescue, fl uid is paramount. vehicle rescue, or water rescue, require special protective apparel as well as training in their • Contaminated surfaces should be wiped down with proper use. a cleaning agent. • Soiled linens or uniforms should be returned to laundry for proper cleaning. Review Questions: 1. What differentiates good stress from bad stress? 8. How does scene safety in the roadway of a 2. What are the signs and symptoms of stress? motor vehicle collision differ from the scene 3. Describe the physiological effects caused by stress. safety of a residential emergency? 4. How is the SAFE-R model used as a crisis 9. What is the responsibility of the cover medic? prevention tool? What should the Paramedic do when working 5. What are some stress management techniques alone? that are used by prehospital providers? 10. What steps should be taken by the Paramedic 6. How should a Paramedic lift a heavy load? prior to arrival that can help prevent exposure 7. How can the Paramedic reduce the risk of and/or infection? personal injury when responding to the scene of an emergency? Case Study Questions: Please refer to the Case Study at the beginning of 3. What stress management techniques could the the chapter and answer the questions below: Paramedic use? 1. What stress(es) is/are expressed by the young 4. In addition to back safety, what other illness Paramedic? and injury prevention techniques should the 2. Describe the body’s physiological responses to Paramedic employ? the stress(es). References: 1. Blackwell J. Identifi cation, evaluation, and treatment of 2. Beebe R. Size matters. Understanding morbid obesity & overweight and obese adults. J Am Acad Nurse Pract. its associated complications. Jems. 2002;27(1):22–28, 2002;14(5):196–198. 30–33. 54 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 3. Rashid MN, Fuentes F, et al. Obesity and the risk for mental health and emotional well-being. Br J Psychiatry. cardiovascular disease. Prev Cardiol. 2003;6(1):42–47. 2001;178(1):76–81. 4. Scaglione R, Argano C, et al. Obesity and cardiovascular risk: 24. Berger W, Figueira I, et al. Partial and full PTSD in Brazilian the new public health problem of worldwide proportions. Expert ambulance workers: prevalence and impact on health and on Rev Cardiovasc Ther. 2004;2(2):203–212. quality of life. J Trauma Stress. 2007;20(4):637–642. 5. Mensah GA, Mokdad AH, et al. Obesity, metabolic 25. http://www.sgsp.edu.pl/sos/mitchel/wyklady/stress.pdf syndrome, and type 2 diabetes: emerging epidemics and their Stress Management, Jeffrey T. Mitchell, PhD, CTS. cardiovascular implications. Cardiol Clin. 2004;22(4):485–504. 26. Foa EB. Psychosocial therapy for posttraumatic stress disorder. 6. Smith SC, Jr. Multiple risk factors for cardiovascular disease and J Clin Psychiatry. 2006;67 (Suppl 2):40–45. diabetes mellitus. Am J Med. 2007;120(3 Suppl 1):S3–S11. 27. Smith A, Roberts K. Interventions for post-traumatic 7. Bray GA, Bellanger T. Epidemiology, trends, and morbidities stress disorder and psychological distress in emergency of obesity and the metabolic syndrome. Endocrine. ambulance personnel: a review of the literature. Emerg Med J. 2006;29(1):109–117. 2003;20(1):75–78. 8. Selye H. Stress and distress. Compr Ther. 1975;1(8):9–13. 28. America Burning: Report of the National Commission on Fire 9. Seematter G, Binnert C, et al. Relationship between stress, Control. Chapel Hill: U.S. Government; 1973. infl ammation and metabolism. Curr Opin Clin Nutr Metab Care. 29. Mitterer D. Back injuries in EMS. Emerg Med Serv. 2004;7(2):169–173. 1999;28(3):41–48. 10. Selye H. The nature of stress. Basal Facts. 1985;7(1):3–11. 30. Powers DW, Wagner K. Getting back up from a back injury. 11. Arun CP. Fight or fl ight, forbearance and fortitude: the spectrum Emerg Med Serv. 2004;33(2):82–83. of actions of the catecholamines and their cousins. Ann N Y Acad 31. Terribilini C, Dernocoeur K. Save your back. Injury prevention Sci. 2004;1018:137–140. for EMS providers. Jems. 1989;14(10):34–35, 37–41. 12. Wortsman J. Role of epinephrine in acute stress. Endocrinol 32. Doyle TJ, Vissers RJ. An EMS approach to psychiatric Metab Clin North Am. 2002;31(1):79–106. emergencies. Emerg Med Serv. 1999;28(6):87, 90–93. 13. Crofford LJ. Violence, stress, and somatic syndromes. Trauma 33. Eckstein M, Cowen AR. Scene safety in the face of automatic Violence Abuse. 2007;8(3):299–313. weapons fi re: a new dilemma for EMS? Prehosp Emerg Care. 14. Verschuur M, Spinhoven P, et al. Making a bad thing worse: 1998;2(2):117–122. effects of communication of results of an epidemiological study 34. Dick T. Bar fi ght. A mental exercise in scene safety. Emerg Med after an aviation disaster. Soc Sci Med. 2007;65(7):1430–1441. Serv. 2003;32(3):38–39. 15. Hammer JS, Mathews JJ, et al. Occupational stress within the 35. Carlquist N. Five steps to scene safety. Emerg Med Serv. Paramedic profession: an initial report of stress levels compared 2007;36(2):82. to hospital employees. Ann Emerg Med. 1986;15(5):536–539. 36. Carrillo L, Fleming LE, et al. Bloodborne pathogens risk and 16. Stanzer M, Guarraci F, et al. Paramedic or EMT-basic partner? precautions among urban fi re-rescue workers. J Occup Environ Study evaluates preferred partner types & the effect of partners Med. 1996;38(9):920–924. on work-related stress levels. Jems. 2007;32(6):72–74. 37. DiGiacomo JC, Hoff WS, et al. Barrier precautions in trauma 17. Graham N. Done in, fed up, burned out—part 2: avoiding the resuscitation: real-time analysis utilizing videotape review. short career. Jems. 1981;6(2):25–31. Am J Emerg Med. 1997;15(1):34–39. 18. Caine RM, Ter-Bagdasarian L. Early identifi cation and 38. Madan AK, Rentz DE, et al. Noncompliance of health care management of critical incident stress. Crit Care Nurse. workers with universal precautions during trauma resuscitations. 2003;23(1):59–65. South Med J. 2001;94(3):277–280. 19. Bledsoe BE. Critical incident stress management (CISM): 39. Sadoh WE, Fawole AO, et al. Practice of universal precautions benefi t or risk for emergency services? Prehosp Emerg Care. among healthcare workers. J Natl Med Assoc. 2006;98(5): 2003;7(2):272–279. 722–726. 20. Neely KW, Spitzer WJ. A model for a statewide critical incident 40. Eustis TC, Wright SW, et al. Compliance with recommendations stress (CIS) debriefi ng program for emergency services for universal precautions among prehospital providers. Ann personnel. Prehosp Disaster Med. 1997;12(2):114–119. Emerg Med. 1995;25(4):512–515. 21. Sterud T, Ekeberg O, et al. Health status in the ambulance 41. http://www.cdc.gov services: a systematic review. BMC Health Serv Res. 2006;6:82. 42. Zanni GR, Wick JY. Preventing needlestick injuries. Consult 22. van der Ploeg E, Kleber RJ. Acute and chronic job stressors Pharm. 2007;22(5):400–402, 404–406, 409. among ambulance personnel: predictors of health symptoms. 43. Campos-Outcalt D. HIV postexposure prophylaxis: who should Occup Environ Med. 2003;60 (Suppl 1):i40–i46. get it? J Fam Pract. 2006;55(7):600–604. 23. Alexander DA, Klein S. Ambulance personnel and critical incidents: impact of accident and emergency work on Workforce Safety and Wellness 55 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Paramedics continually evaluate practices, protocols, and procedures • Connection between Paramedic practice and evidence-based practice • Different types of research appropriate for differing research questions • The research format and ability to identify errors • Ethical concerns associated with research • Types of research that can improve “the bottom line” Case Study: At a QA/QI meeting a Paramedic presents a case to her coworkers and medical director that introduces the need for medication- facilitated intubation (MFI). This developed after the Paramedic was presented with a patient who—due to the patient’s physical condition and medical emergency—could have been greatly aided by MFI. The Paramedic is charged with researching the topic and presenting her fi ndings at the next meeting. The Paramedic has been asked to examine the success or effectiveness of having MFI as an advanced airway skill at other agencies with MFI programs and to consult published research in an effort to support an evidence- based practice change. 56 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Research and EMS 57 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Hippocrates stated in his exposition “as to diseases, make a habit of two things—help or at least to do no harm” (Epidemics, Bk I, Section XI). Paramedics driven by the maxim “do no harm” often ask themselves if what they do truly helps, or if, at a minimum, no harm has been caused to the patient. Practice, Protocols, is defensible. A Paramedic practice is defendable if it estab- lishes evidence-based medical care is provided in specifi c and Procedures circumstances, such care can be independently evaluated by The question “does it help?” naturally leads to the question other Paramedics, it can be applied to a number of same or of where our practice, protocols, and procedures originated. similar circumstances, and it is the most effective means of Most current EMS practice parameters, protocols and proce- delivering desired patient outcomes. Such evidence-based dures, originated from anecdotal experience. These are the practice is more likely to weather the scrutiny of cautious result of apparently successful previous practices and of intu- public offi cials and alert community leaders. itiveness (i.e., this ought to work). In situations where science did not exist to support a Evidence-Based Practice practice, Paramedics and medical directors often used an Emergency medical service in general—and Paramedic prac- analogy to think through a situation (i.e., this worked for this tice in particular—are being attacked by some critics who say other problem in the past and the present situation is simi- that EMS is costly to the public and an ineffective means to lar). Experienced Paramedics call this “common sense” while delivering patient care. Paramedic educators refer to it as “pattern recognition” (i.e., To survive in the current cost-cutting environment comparison of similarities).1 Paramedics must prove that their practice is valuable. Unfortunately, some EMS practices have been driven by Paramedicine must prove that Paramedics can decrease correction of earlier misadventures. Practice improvement morbidity (e.g., through decreased hospital stays or length arrived at by conscious decision (i.e., by committee) is no of stays) and/or decrease mortality and should therefore be more reliable because it is simply the group’s combined anec- seen as valuable.5–7 dotal experience. To transform a practice to evidence-based practice, either As a result, Paramedic practice is often more likely to through updated protocols or continuing education, the fi rst be a function of what does not harm the patient. This form step is to look at the research that already exists. of practice can be ineffective and leads to the practice of While EMS research is still limited at this time, defensive medicine as well as the misdirected application of Paramedics can look to the research of other allied health resources. professions, such as medicine, nursing, respiratory care, and

The best way to determine effective Paramedic prac- so on, for support of paramedic practice. tices is to look at those practices from a scientifi c vantage. A literature search for research pertaining to shared prac- Use of the scientifi c method, the acquisition of knowledge tice issues (e.g., safety in medication administration) may through objective observation and considered reasoning, cor- reveal previous clinical research on the subject that could rects previous misconceptions and integrates new conceptual potentially be applied to the practice of paramedicine. frameworks for Paramedic practice.2 The application of the Similarly, Paramedics can look to the research of other scientifi c method will lead to the improvement of patient professions, such as business and education, for evidence- care. based practices. For example, operational issues, such as For example, scientifi c research created the paradigm effective human resource allocation, have already been shift in trauma care that concludes that limited resuscitation researched by hospital administrators and major businesses. (i.e., permissive hypotension) may be more advantageous Unfortunately, these studies can suggest solutions that to the patient than previously thought. Also, in the past it are impractical in the out-of-hospital setting or are cost pro- seemed logical that survival chances for trauma patients were hibitive for EMS. Furthermore, the practice of out-of-hospital increased by replacing blood loss with intravenous solutions care is unique in many cases and there may be no analogous in a 3:1 ratio. Well-designed studies have demonstrated the studies from other allied health professions to draw upon. fallacy of that thinking and Paramedics have adjusted their The best support for Paramedic practice is research done in trauma care accordingly—saving lives in the process.3,4 the prehospital setting, by Paramedics, physicians, and others While every EMS call can be unique, the purpose of sci- interested in advancing prehospital patient care. Details on entifi c EMS research is to establish a Paramedic practice that how to start EMS research follows shortly. 58 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Performing a Literature Search Most medical libraries, and many university libraries, The fi rst step in utilizing research to create evidence-based have a reference librarian. The reference librarian is trained practice is to ask key questions. These key questions should in research techniques and can help the Paramedic develop a focus on topics that are important to the Paramedics’ practice. search strategy to identify which articles will be most helpful. An example of a question is: “Does pediatric intubation by Paramedics improve patient outcomes?” Reviewing the Literature After deciding on the question, the Paramedic should After obtaining relevant research articles, the Paramedic perform a search of the current literature that is available on needs to identify the kind and type of research that was per- the topic of interest. By reviewing the published reports of formed in the study. research, called the literature, the Paramedic may fi nd stud- Currently, the most common kind of EMS research in the ies on the topic or studies that ask a question that is similar to literature is retrospective research. A question is raised and the question at hand. Paramedics look at past practice patterns, typically from doc- High-quality EMS research, when completed, is pub- umentation on the patient care reports, to determine effective lished in various academic journals or works. Unlike the versus ineffective practice. popular press, these journals are peer reviewed.8–11 Retrospective data analysis is often used in performance A peer-reviewed journal accepts submissions for publi- improvement. The danger of retrospective studies are the cation and circulates them to other experts in the fi eld for numerous variables involved in the particular patient sce- inspection and critical analysis. This process is called refer- narios that could account for the patient changes and which eeing. This intradisciplinary review provides readers with a are not controlled. For example, if the rate of ventilation in a degree of confi dence that what they are reading meets the cardiac arrested patient treated by Paramedics is being mea- profession’s standards and is a scholarly work. sured, how does the researcher know that every Paramedic However, even when a work has been properly vetted counts respirations the same way or that every Paramedic there may still be some errors. In medicine the saying goes, even counts respirations, perhaps leaving out the respiratory “One study does not make a practice.” It is important that a rate in the documentation by stating that manual ventila- Paramedic carefully read the entire study to see if the same tion was performed with a bag-valve-mask assembly? As a conditions exist in his or her system such that the study results result, randomness could be an explanation for the results. can reasonably be applied to that practice. Data dredging (data mining) is conducting research The most effective means of performing a literature search without a scientifi c question in mind (i.e., without a pre- is a computerized search. The most inclusive search engine for defi ned hypothesis). The application of mathematical tests of medicine is the electronic search engine called MEDLINE, “statistical signifi cance” to data and trying to observe pat- formerly the paper “Index Medicus®.” MEDLINE provides a terns in that data, and then attempting to form a cause and list of most published medical research that is searchable by effect conclusion, is not scientifi c research.16 key words or medical subject headings (MeSH).12–15 The most scientifi cally valid research is prospective Other research search engines that can also be used include research. In prospective research, an attempt is made to PubMed, a search engine of the National Library of Medicine account for all predictable or known confounding variables, (http://www.ncbi.nlm.nih.gov/pubmed/); the Cumulative to control those variables, and then add a treatment. If change Index to Nursing and Allied Health (CINAHL – http://www occurs then it may be reasonable to conclude that the treat- .ebscohost.com/cinahl/); as well as the Educational Resources ment may have caused that change. Information Center (ERIC – http://www.eric.ed.gov/). Even a The gold standard for research is the double-blinded ran- search of popular search engines like Google® scholar can be domized clinical trial (RCT).17,18 This technique is a prospec- helpful. tive scientifi c study that controls known and unknown variables Hypothetically, a Paramedic could fi nd dozens of cita- (which could result in spurious results), leaving only one vari- tions on a subject, especially if the key words have broad able to be manipulated. Subjects are then chosen at random to application, like the subject of pediatric intubation. be included in either the experimental treatment group or in To separate the “wheat from the chaff,” the Paramedic the control group (the control group receives standard treat- should review the research study’s abstract. The abstract ment). The key is that the treatment group, those who receive is an abbreviated “executive” summary that hits a study’s the experimental treatment, are subjects chosen at random.19 highlights. The results of the treatment of the experimental group After reading the abstracts, and eliminating non-related subjects is then compared to the results of the control group. articles, the Paramedic should take the reduced list of studies Ultimately a conclusion is drawn. and review the studies directly. With the reference informa- The use of statistically equivalent groups (i.e., patient pop- tion (i.e., author’s name, journal name, journal volume num- ulations having all the same characteristics [variables] except ber, and research title) in hand, the Paramedic may elect to the one being tested) lends credence to the claim that the pro- either go directly on-line to read the article or proceed to a cedure/medication/and so on worked as predicted and did not medical library. occur as a result of random chance or some other variable. Research and EMS 59 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Clinical Trials utility in a case study may be the development of theories of In a clinical trial (i.e., experimental medical research), sub- causation, leading to further research. jects are assigned at random to either the treatment group or There is precedent for case reports, such as case law. Case to the non-treatment group (i.e., those receiving standard care law has been used for hundreds of years to support decisions [control group]). which are based on decisions made by an earlier court. Like To limit bias, the participants may not be aware of which case law, case reports may be used in a court of law, or by a treatment group they are in. In a single-blind study, the sub- Paramedic in front of a medical director, to defend a decision ject does not know which group he is in. In a double-blind in a highly unusual circumstance.27 study, both the researcher and the participants are unaware of In dealing with instances of rare diseases, such as Ebola which group the subject is in.17,20,21 virus, or an exceptional event, such as a plane crash, the case Research often uses inactive drugs, called placebos, report may be the only means of educating other Paramedics or ineffective devices, called shams, that appear similar to as to the nature and scope of the atypical problem. the actual drug or device in order to create blinding for the Another example of descriptive research is a cross- participants.22–24 sectional survey. The cross-sectional survey is essentially a snapshot of a certain aspect of a population at a given moment Statistical Evidence in time that the researcher is interested in. It is obtained by means of observation, usually utilizing a written tool such The key to utilizing experimental research is to understand as a survey. A cross-sectional survey can look at a specifi c the statistical methods used to either confi rm the hypothesis population and a specifi c disease, for example. or reject it. The National Health and Nutrition Examination Survey Classical hypothesis testing compares the results of two (NHANES) conducted by the Centers for Disease Control treatment groups, statistically, in order to obtain a degree of and Prevention has established the prevalence of obesity in confi dence that the treatment actually caused the effect. the United States and might be used to help support the deci- Always skeptical, the researcher’s fi rst assumption is that sion to purchase a bariatric ambulance. By using an analysis the effect was not caused by the treatment but rather by ran- of a cross-sectional survey, Paramedics can use the preva- dom chance. With this assumption that the null hypothesis lence of certain diseases, conditions, and so on, to determine is true (i.e., the treatment did not cause the desired effect but operational, medical, and educational priorities. rather random chance could account for the change), the prob- The results of a cross-sectional survey of one popula- ability is calculated. The probability of random chance causing tion may not be applicable to another patient population. the changes, rather than the treatment, is called the p value. Furthermore, any descriptive study, like the cross-sectional An acceptable p value is arbitrarily assigned by the researcher survey, does not prove a cause and effect relationship between prior to the start of the study and is symbolized as . various variables. The calculated p value is then compared to the selected . The fi nal descriptive study is the ecological study, also If the p value is less than the  value, the alternative hypothe- sis is accepted, and is considered “statistically signifi cant.”25 called a correlational study. This type of research design serves to provide information about trends and rates of dis- Traditionally, in the medical community  values of 0.05 ease within a population. Often cited

as X number of cases are considered the standard for probabilities.26 In other words, of Y disease per 1,000 or per 100,000 of Z population, the if the p value in a study is less than 0.05 then this result may ecological study results are often quoted to emphasize the be considered to mean that the treatment caused the intended prevalence of a disease and therefore the need for research effect and that the researcher is willing to accept the notion grants or funding for special projects. that there is a 5% chance that the improvement in outcome occurred by random chance. Observational Studies The observational study, in contrast to the descriptive study, Types of Research asks a question and poses a simple explanation or hypothesis. To have a scientifi cally valid result from an observational Generally, research can be broken down into three types: study, it is necessary to control extraneous confounding vari- descriptive studies, observational studies, and experimental ables that could account for the desired change. studies. One such method of observational study is the case- control study. In the case-control study, the Paramedic would Descriptive Studies compare the cases—those patients with the disease—to The descriptive study simply states the prevalence of a con- the controls—those patients without the disease—and then dition and is often illustrative of a problem, without trying to examine the procedures performed on both to see if there was offer an explanation. an association between outcomes. A case report or case series is an example of a descriptive For example, a case-control study might look at both study. By reporting interesting or unique cases, Paramedics patients who died and those who survived a cardiac arrest to can help other Paramedics gain insight into a problem. The see if there was a difference in the medications administered 60 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to the surviving patients that could have made a statistical For example, an ST segment elevation on an electro- difference (i.e., not attributed to chance). cardiogram (ECG) tracing suggests myocardial infarction. Similar to a case-control study, a cohort study examines However, some African Americans have naturally occur- patients who have been exposed to a treatment and compares ring ST segment elevations on their ECG tracing. To state to them to a group that was not exposed to the same treatment. an African American male that this elevated fi nding was sug- The patients are followed to determine outcomes. gestive of a myocardial infarction would be a false positive. For example, a group of patients (such as pediatric One cause of a false negative is the limitations that a study patients) would be divided into two groups—intubated ver- group’s size places on the experiment. The number of partici- sus not intubated—and then a review of outcome data (i.e., pants in a treatment group, abbreviated N, may not be large the patient care report) would be analyzed to determine if one enough for the statistical difference to become evident and sup- group had a statistically better outcome. port the alternative hypothesis. This should not be interpreted to mean that the opposite is true (i.e., that the null hypothesis Experimental Studies is true). Instead, the evidence may have been inconclusive. Classic research starts with a suggested explanation why The results of small studies should be viewed as suspect something occurs or could occur. For example, a hypothesis and lacking power. The power of study (i.e., the ability to might be that administration of oxygen to cardiac patients attribute the changes to the treatment rather than chance) is improves long-term survival for cardiac patients. increased whenever there is an increase in the number of sub- With the hypothesis in mind, the researcher uses the jects (i.e., sample size) in the study. experiment to test, under controlled conditions, if a treatment created the predicted change. Meta-Analysis When considering the results of the research, the In some cases it is diffi cult to obtain a large population of researcher understands that there can be two plausible expla- study subjects, or the event being studied is relatively rare. To nations why the change occurred. The fi rst explanation is overcome the problem of reduced statistical power, a meta- that the treatment did not create changes (i.e., any changes analysis may be performed. are purely random and coincidental). This hypothesis is In a meta-analysis, the results of several similar small called the null hypothesis. An alternative hypothesis, that studies are combined and a statistical hypothesis test is the treatment is a plausible explanation for a change, is also applied. Of course, differences in subjects and methods used considered. in the individual studies must be taken into account before a Then a statistical test is applied to the outcome data to conclusion can be made.29 For the results of a meta-analysis to determine which hypothesis is most likely correct. The results be considered valid, it is important that the original research of the statistical analysis either support the null hypothesis or studies are methodologically sound. the alternative hypothesis. Prehospital Research Errors in Research Contributing to prehospital research can be as easy as being A common error made in an experiment is to reject the null willing to participate in the study. While the person doing the hypothesis and accept the alternative hypothesis when in fact lion’s share of the data collection and analysis is usually cited it is not supported. This is called a type I error. as the lead author, it takes a team to accomplish the goal. A type I error, also called a false positive, assumes a treat- Studies can be as simple as a descriptive study or as ment effect where none exists. An example of a false positive complex as a double-blinded randomized clinical trial. would be the assumption that the administration of oxygen In every case participants in a study should carefully con- to a patient with carbon monoxide poisoning increased the sider the study’s hypothesis before committing to making a patient’s oxygen saturation. contribution. Alternatively, incorrectly failing to reject the null hypoth- At its core, every research project should minimally “do esis is called a type II error, or a false negative. A type II no harm” and should reasonably be expected to improve error is a failure to observe the change created by the treat- the patient’s condition.30 If it is lacking either of these two ment when one did occur.28 qualities, the study should be considered suspect and perhaps An example of a type II error might be ascertaining a unethical. patient’s blood sugar was low and concluding that treatment Such a critical review of every clinical trial is consistent is required and subsequently administering glucose, when in with the Paramedic’s ethical responsibility for benefi cence fact the glucometer is out of calibration and producing erro- toward patients.31–33 neous low readings. In terms of patient care and test results, a false nega- Ethical Concerns tive would give patients false reassurance that treatment was The world was witness to the atrocities carried out in Nazi effective while a false positive may either lead to a wrong concentration camps, including the inhumane medical stud- conclusion or may ignore that the patient’s condition could ies that were performed, allegedly in the name of science. have an alternative explanation. Following the exposure of these medical studies, during the Research and EMS 61 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Nuremberg trials at the end of World War II, the world scien- is comprised of individuals who are not directly involved in tifi c community adopted a set of ethical research rules called the research and who can make an objective decision based the Nuremberg code. on the merits of the data. The Nuremberg code is a set of guiding principles that limit the scope and nature of experiments using human subjects.34–36 The United States government, using the Institutional Review Board 10 principles of the Nuremberg code, created the National To protect the rights of patients, and to protect patients from Research Act of 1974. This act, found in the Code of Federal unscrupulous researchers, proposals for research are typi- Regulations Title 45 Volume 46, speaks to three themes. cally evaluated by an Institutional Review Board (IRB). An The fi rst theme is the respect for the person’s freedom IRB is an independent ethics committee that is tasked with and dignity as manifested by informed consent. Implicit in ensuring that human rights are not violated and the standards that respect is the patient’s right to make an informed choice of medical research are upheld. as to whether to participate.37–39 An IRB review is mandatory for any federally funded In the past, some convicted criminals would be granted research. The activities of these IRBs are monitored by the privileges or even amnesty if they were willing to partici- Offi ce of Human Rights Protection of the Department of pate in questionable research. By the nature of incarceration, Health and Human Services (HHS).43,44 these individuals could not reasonably be expected to make an informed decision that was free of coercion. Emergency Circumstances The second principle actually speaks to the problem of In some cases, such as during an emergency, it would be imprac- diminished autonomy. Any person who is mentally incapable tical to obtain informed consent from either the patient or a of making an informed decision (e.g., by virtue of age or infi r- legally authorized representative (such as a healthcare proxy, mity) could not willingly consent to participate in research if one was available). Recognizing this problem, the United (21 CFR 50.24). For example, a child could not consent to States Code has an emergency exception (21 CFR 50.24). participate in a study by virtue of age. However, a parent may This exception for patient consent has been applied to make the decision whether the child can participate. This is numerous clinical trials. If a patient is incapable of consent- known as substituted judgment. The concept is that a respon- ing due to the medical condition, a form of consent similar to sible person is substituting her judgment for the child. The implied consent may be utilized. parent might determine that if the child had the ability to con- Regulations currently require that the public be informed, sent and understood the potential good that could come from through various mechanisms of disclosure such as newspa- such research, the child would agree to participate. per advertisements or television spots, of clinical trials. This The third principle of ethical research deals with disclosure attempts to establish informed consent before the the question of justice. In other words, one group of people emergency and advise the population of their right to refuse should not bear all the risks of research when the benefi ts to participate in the research. of said research would benefi t all persons in the larger society. The Tuskegee syphilis project would be an example of injustice in research.40–42 In the Tuskegee research, poor Professional Paramedic African American males who contracted syphilis were observed to determine how the disease progresses. This con- The professional Paramedic should read more about tinued even after antibiotics were developed that could have cured the participants and prevented signifi cant complications these concepts in the Belmont Report, written by the of syphilis. National Commission for the Protection of Human Research should not be permitted to begin or continue if Subjects of Biomedical and Behavioral Research in researchers reasonably believe that death or permanent dis- ability could occur. In every

instance, sensible safeguards 1979 (available at http://ohsr.od.nih.gov/guidelines/ should be in place to prevent injury and protect the patient. belmont.html). Part of this obligation is a willingness to terminate the clinical trial if it can be shown that continuation of the experi- ment could cause more death or disability than pre-existing standard treatments. Economic Research Conversely, if patients receiving the experimental treat- Some professional practice questions do not directly involve ment are showing marked improvement over those receiving patient care but rather matters of operational effi ciency or standard treatment then standard treatment must be stopped cost. Again, research can help to answer the questions. and the new experimental treatment offered. These research designs are called economic analysis. To ensure this last standard, many clinical trials have a The classic economic analysis is the cost-benefi t ratio. A Data and Safety Monitoring Board (DSMB). The DSMB simple cost-benefi t analysis asks the question of whether it is 62 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. advantageous (i.e., cost-effective) to take a particular action encourages introspection and courage—the courage to or make a change in a procedure. accept change. Business has many statistical methods of determining By questioning current practices, the Paramedic avoids cost-effectiveness. These same methods can often be applied paradigm blindness. Paradigm blindness can be summed to EMS. up by the phrase “because we have always done it this way.” Paradigms can sometimes become barriers to innovation Absence of Research and improvement. Lacking good research to support a practice or procedure, Best practices, by defi nition, speak to improvement— Paramedics often turn to what is referred to as best practice. improvement of self and the profession. This concept, A best practice, a term borrowed from business, suggests continual self-improvement, is best represented by the that one method of delivering care is the most effective, and Japanese concept of kaizen. Kaizen is not only a business therefore a superior, means of providing care.45 principle but a professional attitude for Paramedics. The use of best practices has two distinct advantages. Kaizen emphasizes process and system thinking. Kaizen First, it requires a comparison of one Paramedic’s practice is evident when Paramedics participate in performance against the practice of others. This head-to-head comparison improvement committees and multi-agency planning. Research and EMS 63 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. For Paramedics to attain and maintain professional status in the healthcare industry, it is important to continually ask the question, “Does what we do really help?” Paramedics must be prepared to change fi eld practice as evidence, borne of research, demonstrates new and improved means to improve patient care. Key Points: • Paramedic practice, protocols, and procedures research examines past practice patterns originated from anecdotal experience. By relying to determine effective versus ineffective solely on pattern recognition or “common practices. Though useful, the reliability of sense,” Paramedics ultimately practiced retrospective studies is limited due to the defensive medicine. The use of the scientifi c numerous variables that may be present but method to acquire scientifi c-based information are not accounted for. has helped to correct previous misconceptions and integrate new conceptual frameworks into • By accounting for predictable or confounding Paramedic practice. variables, prospective research is the most scientifi cally valid type of research. The gold • Paramedics and medical directors are moving standard for research methodology is the double- forward from anecdotal-based procedures and blinded randomized clinical trial. This method protocols toward evidence-based practices. provides a high degree of scientifi c validity These practices are proven to be logical, because only one variable is manipulated. independently evaluated, applicable to a number of same or similar circumstances, and • In clinical trials, the control group is given a are the most effective means of delivering placebo or sham, while the experimental group improved patient outcomes. Advantages of is given the actual treatment. A statistical evidence-based practice include more cost- analysis can then be applied to the data to effective practices by quantifying how effective evaluate whether the treatment caused the certain practices are in delivering patient care. desired effect or if the effect occurred by The fi rst step in moving toward evidence-based chance. The p value is assigned to provide practice is searching existing research of other statistical evidence that a treatment had the allied health professions by performing a literature desired effect(s). search. • Generally, research can be broken down into • In performing a literature search, the fi rst step three types of research: descriptive studies, is to ask a question important to the Paramedic observational studies, and experimental practice. Reviewing abstracts can narrow your studies. search for a specifi c topic. Because “one study does not make a practice”, it is important that • Descriptive studies are studies that involve several studies relating to a topic be reviewed. close or focused examination of a condition or A computerized search of peer-reviewed academic problem that exists. Though not critical of asking journals provides the greatest access to past “why,” or offering an explanation, descriptive research as well as the most current information studies work to gather valuable and relevant available. information about the condition or problem at hand. Found in case law, case reports offer insight • Retrospective studies are the most common type into a problem through discussion of a particular of research found in EMS literature. This type of event or occurrence. 64 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • Further descriptive studies include cross-sectional several similar studies and applying a statistical surveys. Often utilizing a written tool, such as a hypothesis test for the variable being studied. survey, data is collected to investigate a specifi c idea. Cross-sectional surveys have the benefi ts of • Outlined in the National Research Act of 1974, the examining specifi c populations or diseases that can U.S. government established three principles that be applied to a local or national level. address ethical concerns of scientifi c research. The principles exist to protect participants against • Often called a correlational study, an ecological inhumane and unethical practices. study serves to provide information by objectively examining trends and rates. By gathering and • The fi rst principle outlines the importance for any analyzing data or reports, both cross-sectional and study participant to be informed about the study’s ecological studies can provide powerful statistics to hypothesis so as to make an informed choice as to support a scientifi c question. whether to participate or not. • Observational studies ask a simple question or • The second principle addresses the problem of hypothesis and account for variables in the diminished autonomy or the ability to consent. topic of study. Normally in a case-control study, A participant may not be able to willingly consent two or more specifi c groups are compared (for example, due to age, infi rmity, or mental and analyzed. A researcher would examine ability). the procedures (for example, to identify any • The third principle speaks to maintaining justice similarities or differences that can be associated for the participants. The idea of fair treatment between group outcomes regarding a particular for both the control and experimental groups is situation or condition). A cohort study is similar in outlined. To ensure justice is upheld, many methodology; however, instead of examining the clinical trials have Data and Safety Monitoring treatment or procedures used in specifi c cases, Boards. These boards take an objective approach a specifi c population is analyzed for statistical to evaluating the merit of experimental signifi cance of treatment. methodology and data collected. In the case • of any federally funded research and for most All scientifi c studies essentially begin with a other research projects, even before research question. In an experimental study the investigation begins a proposal must be submitted to an is focused on answering why something occurs or Institutional Review Board. This independent could occur. Null and alternative hypotheses are ethics committee reviews the proposal for any always formed and variables are limited to the one violations of ethics. variable being manipulated. • • Professional practice questions do not always If the alternative hypothesis is accepted but is not involve patient care, but can be used to perform supported with suffi cient scientifi c evidence, a type economic research. This research provides I error or false positive result occurs. In contrast, valuable information through cost-benefi t a failure to observe a change may lead to a false analysis. negative or type II error. This may be caused by a limited sample size or may occur in a study that has • In the absence of research, Paramedics turn to best a low statistical power. practice as a way of determining the best method • or most effective way of providing patient care. To be confi dent the data represents changes due to the manipulated variable, (for example, • Best practice encourages the comparison of treatment) and not simply because of chance, practices against others as well as encouraging the a larger sample size must be studied. One way examination and constructive criticism of current researchers overcome this is by performing a meta- practices. Questioning one’s own practice helps analysis. This is done by combining the results of one avoid paradigm blindness. Research and EMS 65 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. What are the three origins of EMS practice? 8. What are type I and type II errors in 2. What are the steps to the scientifi c method? experimental research? 3. Describe the process of creating an evidence- 9. Explain the ethical concerns and what should based practice. be done to safeguard participants of clinical 4. Explain how to perform a literature search. trials. 5. What are the types of research and how do 10. Describe the advantages of a double-blinded they differ? randomized clinical trial. 6. What are the pitfalls of retrospective data analysis? 11. How can researchers overcome the problem 7. What type of information is discovered by a of reduced stat power? researcher from descriptive studies? 12. What is best practice and what are its advantages? Case Study Questions: Please refer to the Case Study at the beginning in favor of an MFI protocol for diffi cult airway of the chapter and answer the questions below: management. However, after several months an 1. Looking back at the task given, investigating the important question was brought up about the effectiveness of MFI in the prehospital setting, use of one of the medications in an MFI as it was would retrospective or prospective research not statistically used very much. How would you studies be more helpful? design a research proposal for an experimental 2. Contacting other agencies and speaking with study that would evaluate this question? personnel is much different than gathering 5. What

is the argument behind the statement, information via published reports. What is the “One study does not make a practice”? difference between the two? 6. What are some questions that you should have in 3. What errors in research would you have to be mind when evaluating the validity or reliability of aware of when researching to ensure reliability a research study? and validity? 7. Evaluate the importance of obtaining an 4. You presented your research and both the objective review of research studies methodology medical director and QA/QI committee are concerning ethics. References: 1. Theodoridis S, Koutroumbas K. Pattern Recognition (3rd ed.). 4. Dubick MA, Atkins JL. Small-volume fl uid resuscitation for the Boston: Academic Press; 2006. far-forward combat environment: current concepts. J Trauma. 2. Gauch H. Scientifi c Method in Practice. Cambridge: Cambridge 2003;54 (5 Suppl):S43–S45. University Press; 2003. 5. Johnston S, Brightwell R, et al. Paramedics and pre-hospital 3. Mackinnon MA. Permissive hypotension: a change in thinking. management of acute myocardial infarction: diagnosis and Air Med J. 2005;24(2):70–72. reperfusion. Emerg Med J. 2006;23(5):331–334. 66 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 6. Mason S, Knowles E, et al. Effectiveness of Paramedic 29. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control practitioners in attending 999 calls from elderly people in Clin Trials. 1986;7(3):177–188. the community: cluster randomised controlled trial. BMJ. 30. Department of Health and Human Services’ Part 46 Protection of 2007;335(7626):919. Human Subjects [see 46.116, (a),(3)]. 7. Davis DP, Peay J, et al. The impact of aeromedical response to 31. Pitkin RM, Branagan MA. Can the accuracy of abstracts be patients with moderate to severe traumatic brain injury. Ann improved by providing specifi c instructions? A randomized Emerg Med. 2005;46(2):115–122. controlled trial. JAMA. 1998;280(3):267–269. 8. Gitanjali B. Peer review—process, perspectives and the path 32. Pitkin RM, Branagan MA, et al. Accuracy of data in abstracts of ahead. J Postgrad Med. 2001;47(3):210–214. published research articles. JAMA. 1999;281(12):1110–1111. 9. Van Rooyen S, Godlee F, et al. Effect of blinding and unmasking 33. Al-Marzouki S, Evans S, et al. Are these data real? Statistical on the quality of peer review: a randomized trial. JAMA. methods for the detection of data fabrication in clinical trials. 1998;280(3):234–237. BMJ. 2005;331(7511):267–270. 10. Jefferson T, Wager E, et al. Measuring the quality of editorial 34. Weindling P. The origins of informed consent: the peer review. JAMA. 2002;287(21):2786–2790. International Scientifi c Commission on Medical War 11. Jefferson T, Rudin M, et al. Editorial peer review for improving Crimes, and the Nuremburg code. Bull Hist Med. 2001; the quality of reports of biomedical studies. Cochrane Database 75(1);37–71. Syst Rev. 2007;2:MR000016. 35. Marrus MR. The Nuremberg doctors’ trial in historical context. 12. http://www.nlm.nih.gov/medlineplus/ Bull Hist Med. 1999;73(1):106–123. 13. http://www.ncbi.nlm.nih.gov/sites/entrez 36. Annas GJ, Grodin MA. The Nazi doctors and the Nuremberg 14. http://scholar.google.com/ code: relevance for modern medical research. Med War. 15. http://www.emedicine.com/ 1990;6(2):120–123. 16. Smith GD, Ebrahim S. Data dredging, bias, or confounding. BMJ. 37. Fisher JA. Procedural misconceptions and informed consent: 2002;325(7378):1437–1438. insights from empirical research on the clinical trials industry. 17. Lachin JM, Matts JP, et al. Randomization in clinical trials: Kennedy Institute of Ethics Journal. 2006;16(3):251–268. conclusions and recommendations. Control Clin Trials. 38. Palmer BW, Savla GN. The association of specifi c 1988;9(4):365–374. neuropsychological defi cits with capacity to consent to 18. Eddy DM. Practice policies: where do they come from? JAMA. research or treatment. J Int Neuropsychol Soc. 2007; 1990;263(9):1265, 1269, 1272 passim. 13(6):1047–1059. 19. Rosenberger W, Lachin J. Randomization in Clinical Trials. New 39. Evans K, Warner J, et al. How much do emergency healthcare York: Wiley-Interscience; 2002. workers know about capacity and consent? Emerg Med J. 20. Day SJ, Altman DG. Statistics notes: Blinding in clinical trials 2007;24(6):391–393. and other studies. BMJ. 2000;321(7259):504. 40. Thomas SB, Quinn SC. The Tuskegee Syphilis Study, 1932 to 21. Friedman L, Furberg C, Demets D. Fundamentals of Clinical 1972: implications for HIV education and AIDS risk education Trials. Berlin: Springer; 1998. programs in the black community. Am J Public Health. 22. Weihrauch TR. Placebo effect in clinical trials. Med Klin 1991;81(11):1498–1505. (Munich). 1999;94(3):173–181. 41. Katz RV, Kegeles SS, et al. The Tuskegee Legacy Project: 23. Kienle GS, Kiene H. The powerful placebo effect: fact or fi ction? willingness of minorities to participate in biomedical J Clin Epidemiol. 1997;50(12):1311–1318. research. J Health Care Poor Underserved. 2006;17(4): 24. Harrington A. The Placebo Effect. Cambridge: Harvard 698–715. University Press; 1999. 42. http://www.cdc.gov/tuskegee/timeline.htm 25. Weinberg CR. It’s time to rehabilitate the p-value. Epidemiology. 43. Belmont Report: Ethical Principles and Guidelines for the 2001;12(3):288–290. Protection of Human Subjects of Research. Federal Register 26. Whitley E, Ball J. Statistics review 4: Sample size calculations. Document 79-12065. Crit Care. 2002;6(4):335–341. 44. Bankert E. Institutional Review Board. Boston: Jones & Bartlett 27. Sinclair M. Precedent, super-precedent. George Mason Law Pub; 2005. Review (14 Geo. Mason L. Rev. 363), 2007. 45. Bodmer W. Principles of scientifi c management. FASEB J. 28. Singh G. A shift from signifi cance test to hypothesis test 1993;7(9):723–724. through power analysis in medical research. J Postgrad Med. 2006;52(2):148–150. Research and EMS 67 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. As a Paramedic, the public as a whole and each individual patient and family entrusts us with their lives to care for them appropriately. Some situations provide dilemmas for the Paramedic, whether it is with a patient, family member, partner, supervisor or medical director. A strong sense of ethics as well as following accepted ethical and legal practices helps allow the Paramedic to maintain the trust and privilege that is placed in us by society. • Chapter 5: Ethics and the Paramedic • Chapter 6: The Law and Paramedics 69 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Conduct and responsibility derived from guiding principles as well as cultural and religious beliefs • Duty-based ethics founded on principles, not consequences • Bioethics and their application to day-to-day decision making • The idea of what is “right” • Awareness of patient dignity, privacy, and autonomy • Understanding how ethical principles, and their proper application, can help resolve ethical dilemmas Case Study: The Paramedics were called to the home of a 43-year-old man with a history of lung cancer. He was semiconscious with labored breathing. His ex-wife produced an advanced directive stating that he did not want extraordinary means to keep him alive. His mother produced a handwritten will that stated he would accept oxygen and pain medication and any means to deliver them. Many family members were present and they began taking sides and telling the Paramedics what to do. 70 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Ethics and the Paramedic 71 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Although it is easy to think that the Paramedic operates solely on protocols and guidelines, without thought to real human consequences, a Paramedic’s clinical decision making also has a strong ethical component. This chapter evaluates the question of what is “right,” versus what is “correct” and draws from two ethical models of decision making. The Paramedic’s decisions must also follow established human and legal rights and moral obligations. Paramedics may be asked to apply ethical principles to real life ethical concerns such as end-of-life decisions. To make educated and responsible clinical decisions, the Paramedic should have a well-rounded understanding of the EMS code of ethics. Ethics Defi ned exist. The ethics of a Paramedic entering into either one of these two workplaces can be affected by the culture present. Ethics, from the Greek “ethos” meaning character, is a sys- James O. Page, founding editor of the Journal of tem of guiding principles that govern a person’s conduct. Emergency Medical Services, spoke to the problems of a neg- Paramedics use ethical principles to help guide them to ative EMS culture in his article entitled “A Call for a Cultural make the right decision in a specifi c situation such as the one Revolution,” written after he witnessed the care provided to depicted earlier. his family.1 Mr. Page emphasized that the problem, as he saw Factors that can affect a person’s ethics are cultural infl u- it, was not just with the individuals whose behaviors were ences and religious beliefs. Religion provides people with a unprofessional, but in an EMS system that permitted—even description of what is right and what is wrong. Broadly, these encouraged—this type of behavior, thereby creating an EMS religious beliefs can be applied to a Paramedic’s practice. system with a negative culture. Many Paramedics obtain personal direction from these reli- Some Paramedics’ personal code of conduct, their moral- gious beliefs when confronted with an ethical dilemma. ity, is a mere refl ection of the culture where they work. The The culture in which a person lives can also have a great infl uence of others, a so-called worldview, has a signifi cant impact on that person’s ethics. In this context, culture means impact upon most people’s decision making and can replace those unique activities and symbols that make one group’s the individual Paramedic’s ethics. condition different from another’s. Culture can include the Alternatively, other Paramedics have carefully considered way a group of people dress, as well as their unique language and adopted a personal system of beliefs (i.e., professional and special rituals. ethics) which is based upon higher principles, discussed When discussing the concept of culture, images of shortly. It takes a strong personal belief system and a strong exotic places and people with strange customs may come sense of morality to withstand the ethical challenges from a to mind. However, a workplace can also have a culture. For negative culture. example, EMS has a distinctive culture. Paramedics who wear distinctive uniforms separate themselves from the rest of the public. Paramedics also develop phrases and termi- Medical Ethics nology that is often only understood by another Paramedic. Medical ethics pertains more specifi cally to how Paramedics Paramedics have certain special rituals

and rites of passage, behave in regard to patients. The term bioethics was originally often marked by educational achievement, such as obtaining coined by Van Rensselaer Potter. When speaking of bioethics clinical privileges. he was referring to a set of guiding principles for the medi- In some EMS organizations, the prevalent culture cal practitioner. Bioethics is a form of applied ethics—that is, includes a sense of a higher purpose. For example, the job ethics applied to the medical situation. Bioethics is used in is viewed as performing a valuable service to the commu- day-to-day decision making by Paramedics in the fi eld. nity which is manifested by a positive regard for the patient. Bioethics came to prominence during the 1960s when These Paramedics obtain positive meaning from their jobs, questions about health care and the implications of medical thus enriching their own lives. The culture of the workplace advances, such as in vitro fertilization and abortion, were could be said to be a positive one. forcing theologians, physicians, lawyers, and legislators to Alternatively, if the prevalent attitude among a group of consider the morality of certain medical procedures. Paramedics is that EMS is just a “job” and patient care is an Bioethics holds that an unconsidered decision that onerous task to be endured, then a more negative culture may results in harm to the patient is unethical. However, the 72 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. answers to questions regarding patient care are often not as be necessary to perform a painful needlestick. Teleologically clear as they might fi rst appear. Topics of great controversy, speaking, the benefi t of the medication far outweighs the such as pediatric intubation, have advocates on both sides, harm of the needlestick. each with valid arguments supporting their position. The Generally speaking, the intrinsic good of acts performed role of bioethics is to help guide the Paramedic to make an by Paramedics should prevent and control disease, relieve ethical decision. pain and suffering, and generally prolong life. These acts One means of coming to the answer is to have Paramedics should clearly outweigh any suffering, pain, or inconvenience come to a consensus. When the majority of Paramedics to the patient. agree to a specifi c conduct or course of action, determining However, when the decision to perform a procedure is that it does more good than harm, then the act is considered complicated then the Paramedic should weigh the outcomes to be ethical. This ethical relativism is in play at all times. or consequences of performing the act against not performing Ethical decisions change over time as new conditions, tech- the act and then make a decision that maximizes the intrinsic nologies, and knowledge alter the situation’s fundamental good. This approach to ethical decision making is called act- conditions. utilitarianism. In a number of situations, there is already a consensus Underlying this foundation is an implicit understanding as to the ethics concerning a certain conduct. For example, that the Paramedic cannot increase her own happiness at the Paramedics agree that diverting drugs for personal use is patient’s expense. For example, starting an intravenous access unethical. In instances when that conduct occurs, the profes- on the basis of some future good, such as the Paramedic can sion has a responsibility to take action. Action must be taken keep profi cient with obtaining intravenous access by practice, against the offender to prevent a reoccurrence. would be an ethical violation. If the conduct has risen to the level of criminality then Paramedics have a responsibility to report that crime to the proper authorities. If the conduct is less egregious, but still unethical, then the Paramedic may have a duty to report the Street Smart conduct to management and/or civil authorities, such as a state EMS offi ce. The decision to withhold a treatment in favor of Foundations for Value Judgments transporting the patient to an emergency When confronted with an ethical confl ict the Paramedic must department where a more experienced physician make a decision as to what action to take. He must make a can perform the skill could be seen as a utilitarian judgment as to which course of action is the correct course of action in terms of right or wrong. That decision mak- act, provided no harm came to the patient due ing requires that the Paramedic make a value judgment. to the delay. Several models are available to help the Paramedic make that decision. Deontological Model of Ethics Other Paramedics maintain that the consequences of an act Street Smart are relatively unimportant. Their position is that it is more important that decisions be driven by principles. Some Paramedics, in order to avoid controversy, This approach, the deontological approach, acknowl- may elect to not make a decision, deferring to edges that harm may occur but that Paramedics must perform their duty. Deontology is duty-based ethics in which the deci- medical direction or to another Paramedic. Even a sion as to whether an action is right or wrong is based on non-decision is a decision—the same ethical dilemmas principles and not upon the consequences. still exist. A situation that demands action by any person in that situation, as a matter of duty, is called a universal law. An example of a universal law would be for one Paramedic to stop another Paramedic from committing an act of violence Teleological Model of Ethics to a patient in restraints. The teleological model of ethics simply states that the end There are some universally agreed upon principles to justifi es the means. This approach implies that, even though which Paramedics and physicians alike subscribe; for exam- some harm may occur, in the end if the outcome is good then ple, the duty to “fi rst, do no harm;” primum non nocere. the behavior is ethical. For example, Paramedics do not want Observance of this rule would be an example of a deontologi- to hurt their patients, yet to reverse a drug reaction it may cal approach to ethical decision making. Ethics and the Paramedic 73 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. as privilege in another. An example is the difference in the Professional Paramedic freedom of speech in the United States versus the People’s Republic of China. Human rights are easier to understand than natural or Almost all religions and cultural systems refer to a personal rights as they are based on a commonly desired belief that is commonly called the “golden rule.” human condition (i.e., freedom from want, freedom from Also referred to as the ethic of reciprocity, this pain, and freedom from suffering). Human rights involve concept speaks to a basic human right to be treated universally accepted standards of justice. A patient’s human rights cannot be abridged by a with decency. Key to the golden rule is that a person Paramedic without risk of severe social repercussions. These attempting to live by this rule treats all people, not societal remedies are usually in the form of substantial civil just members of one’s own group, with consideration. penalties or criminal prosecution. Patients also enjoy some legal rights. These are rights afforded them by the government in the form of laws, stat- utes, ordinances, and regulations. These legal rights can be Virtue Ethics affi rmative rights in which the person can do something. For example, in the patient’s bill of rights the patient has a right A somewhat middle ground approach, virtue ethics, does not to self-determination, such as the right to choose treatment or depend on consequence-driven decisions or duty-driven deci- choose not to have treatment. sion making, but upon virtues. These legal rights can also take the form of a prohibition Virtue ethics suggests that a “right-thinking” person will which prohibits others from performing an action affecting make the best decision for the patient based upon a predeter- the individual. For example, a person has the right to be free mined set of virtues. The fundamental quality of a virtuous from unreasonable searches. The Bill of Patient Rights was person is to act without regard to the consequences to oneself recently adopted by the U.S. Congress (Table 5-1). or to some abstract duty, but rather to act altruistically for the sole benefi t of the patient.2 Mores and Paramedics The source of one’s virtues can be intrinsic, meaning that What some individuals might argue is a human right is more the virtues come from within the person. Examples of virtues of a social norm. A social norm is a rule of conduct that include compassion and kindness. These internalized values regulates the interaction between people but is not specifi c are often the result of values instilled in a child by a parent to one individual. Mores are a social custom rather than a during the child’s upbringing. They are considered by some to universally accepted standard of justice and do not rise to the be innate qualities for a Paramedic. level of a right. Generally a more is a collective agreement An extrinsic source of virtues comes from external among a group of people on how they will behave in a group sources such as religion. Sometimes called divine command and with one another. A more can be thought of as a social ethics, extrinsic ethics can be based upon the Bible’s Ten contract that states the involved parties will all act in a similar Commandments or Buddha’s Four Noble Truths and Eight way, or face the condemnation of the collective. Paths to Righteousness. In both cases, a higher authority has Professional groups, including Paramedics, may adopt predetermined what qualities a virtuous person would have certain mores, or moral obligations, that go beyond the and calls upon the person to display those virtues through basic human rights which every patient enjoys. For example, correct action. if an off-duty Paramedic fails to stop at the scene of a serious motor vehicle collision to offer aid, the action or omission Personal Rights and Moral Obligations may not be illegal, but other Paramedics might consider such The defi nition of a personal right can be somewhat nebu- an act immoral. Some would assert that the Paramedic has a lous and hard to defi ne. However, an individual knows when moral obligation to stop. However, the patient does not have he or she has been deprived of that right. A right could be a right to care from an off-duty Paramedic. loosely defi ned as something to which a person is entitled based on the society’s sense of fair play. Rights are not social Foundations of Bioethics expediencies that can change as conditions change. Rights The Hippocratic Oath has stood as the foundation for bioeth- are not privileges because privileges depend on the goodwill, ics for over 2,500 years.3–5 The Hippocratic Oath defi ned those or cooperation, of others. Rights are immutable and universal ethical principles that a physician was to follow. Inherent in to all people who are designated as possessing them. Some the Hippocratic Oath are the concepts of benefi cence and people refer to them as natural rights. Natural rights are a non-malfeasance. function of existing in the societal group. Because rights are Over time, various philosophers, such as Immanuel Kant, defi ned by the society, the existence of rights will vary. An have refi ned the subject of medical ethics. In the eighteenth example of a natural right in the United States is the freedom century, Thomas Percival developed the fi rst medical code of expression. What is a right in

one country may be seen of ethics, which was adopted by the American Medical 74 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 5-1 Patient Bill of Rights The ideal of human dignity suggests that every Paramedic also has a duty to be nonjudgmental. To be nonjudgmental, • The Right to Information. Patients have the right to receive accurate, the Paramedic must resist coming to a decision about some- easily understood information to assist them in making informed one based on an artifi ciality such as poverty or race. Prejudice decisions about their health plans, facilities, and professionals. has no place in paramedicine. • The Right to Choose. Patients have the right to a choice of health In support of this concept, the National Association care providers that is suffi cient to assure access to appropriate high-quality health care including giving women access to qualifi ed of EMT code of ethics states, “The Emergency Medical specialists such as obstetrician-gynecologists and giving patients with Technician provides services based upon human need, with serious medical conditions and chronic illnesses access to specialists. respect for human dignity, unrestricted by consideration of nationality, race, creed, color or status.”7 • Access to Emergency Services. Patients have the right to access emergency health services when and where the need arises. Health plans should provide payment when a patient presents himself/ Patient Autonomy herself to any emergency department with acute symptoms of Another tenet central to bioethics is the concept of patient suffi cient severity “including severe pain” that a “prudent layperson” autonomy, the patient’s ability to control her person and her could reasonably expect the absence of medical attention to result personal destiny through decision making. Followed to its in placing that consumer’s health in serious jeopardy, serious logical conclusion, patient autonomy implies that patients impairment to bodily functions, or serious dysfunction of any bodily organ or part. could decide to do nothing about a fatal illness, a decision that might lead to their own demise. This would be accept- • Being a Full Partner in Health Care Decisions. Patients have the right to fully participate in all decisions related to their health care. able provided that the patient is capable of understanding and Consumers who are unable to fully participate in treatment decisions understood the ramifi cations of such a decision. have the right to be represented by parents, guardians, family Paramedics might otherwise intervene in the previously members, or other conservators. Additionally, provider contracts described case, objectively for the good of the patient, if it should not contain any so-called “gag clauses” that restrict health were not for the respect that all medical professionals have for professionals’ ability to discuss and advise patients on medically patient autonomy. It is understood that the patient’s wishes, necessary treatment options. even without the power to act upon them, would be hollow if • Care Without Discrimination. Patients have the right to considerate, it were not for a Paramedic’s respect for autonomy. The sanc- respectful care from all members of the health care industry at all tity of patient autonomy is foundational to medicine. times and under all circumstances. Patients must not be discriminated against in the marketing or enrollment or in the provision of health Privacy care services, consistent with the benefi ts covered in their policy and/ or as required by law, based on race, ethnicity, national origin, religion, Privacy, a condition of being secluded from the view, opinion, sex, age, current or anticipated mental or physical disability, sexual or intrusion by others, is another foundation of the patient– orientation, genetic information, or source of payment. physician relationship. All healthcare providers zealously pro- • The Right to Privacy. Patients have the right to communicate with tect their patients’ privacy so that patients may feel at liberty health care providers in confi dence and to have the confi dentiality to discuss their medical conditions with health professionals. of their individually-identifi able health care information protected. If a Paramedic was to violate a patient’s privacy, then Patients also have the right to review and copy their own medical the patient might not be forthcoming with needed medical records and request amendments to their records. information in the future. Such an unauthorized disclosure • The Right to Speedy Complaint Resolution. Patients have the would not only compromise present patient care but also have right to a fair and effi cient process for resolving differences with a chilling effect on future patient care. their health plans, health care providers, and the institutions that serve them, including a rigorous system of internal review and an The issue of a patient’s right to privacy in an electronic independent system of external review. age where personal information can be transmitted to others • Taking on New Responsibilities. In a health care system that at the speed of light has become one of national concern, as affords patients rights and protections, patients must also take evidenced by HIPAA federal regulations.8–10 Paramedics must greater responsibility for maintaining good health. remain vigilant and attempt to prevent disclosure of private medical information, whether accidental or intentional, in order to maintain the trust of patients. Association in 1846.6 That code of ethics still stands and Veracity includes such corollary concepts as respect for human dig- nity, patient autonomy, privacy, and justice. Veracity is not just about truth but an adherence to truth- fulness. When a Paramedic practices being truthful with all Respect for Human Dignity of her patients, making it a habit to be truthful, then that It almost goes without saying that Paramedics must fi rst have Paramedic can be said to have veracity. This truthfulness is a respect for human dignity. Human dignity is not just about essential if the Paramedic wants to establish a therapeutic patient autonomy and the patient’s right to self-d etermination. relationship with the patient. For the purpose of treatment, Human dignity addresses the right of every person to be patients reveal facts about themselves that they would not treated respectfully, regardless of his or her station in life. reveal to anyone else. Ethics and the Paramedic 75 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. These revelations are so critical to the physician–patient rare medicine or allocating limited resources on the scene of relationship that the courts, without extraordinary reason, a multiple casualty incident (MCI). cannot ask the physician to willingly violate that trust. The In some of these instances, a random selection criterion courts have reasoned that if such a trust was violated then is applied, while in others a standard such as likelihood of a patient might not confi de essential aspects of medical his- medical benefi t is applied. In every situation, a recognized tory to the physician. Without that trust patients might not standard has to be applied in order to be fair and just. ever seek medical attention. The fallout of a violation of such a fundamental aspect of the physician–patient relationship EMS Code of Ethics could lead to widespread illness and untreated injury. Many healthcare professions, including EMS, have adopted A devotion to the truth, a physician’s veracity, burdens a code of ethics. A code of ethics serves as a standard for the physician with a duty to maintain this relationship until the profession and a basis by which practitioners facilitate the patient’s death—and perhaps beyond. This duty creates a resolution of ethical dilemmas. Many associations, such as legal bond (a fi duciary relationship) between the physician the National Association of EMT (NAEMT), have a code of and the patient. ethics (Table 5-2). Fidelity Inherent within the concept of veracity is the idea of fi del- Moral Rules ity. Fidelity is the obligation of the physician, and therefore and Particular Circumstances the Paramedic, to keep the promises that are made to the patient. Infi delity leads to mistrust and a general deteriora- Certain trying situations (for example, end-of-life decisions tion of veracity that is counterproductive to the therapeutic and triage) call upon a Paramedic’s morals and ethics. Using relationship. the framework of ethical decision making, described earlier, the Paramedic can come to an ethical decision. Benefi cence The other pillar of a physician–patient relationship is the con- Ethical Obligation cept of benefi cence. Benefi cence implies that the physician’s The public has come to expect that its emergency medical actions are acts of mercy and charity, a good act performed services system is its “public health safety net.” As such, it for people at a time of need. has placed the ethical burden on EMS systems to respond to The quintessential model of benefi cence is the Good all calls for help. Samaritan. The story of the Good Samaritan is that the Good The response to these calls should be immediate and not Samaritan cared for another who was injured on the roadside, complicated by concerns of fi nances. While fi nancial limi- not out of obligation but out of compassion. tations may affect a community’s ability to sustain an EMS Non-malefi cence system, the individual Paramedic should not be burdened with these fi nancial concerns. The Paramedic’s duty should Included in every act of benefi cence is the idea of non- be simple: respond to all calls for help. malefi cence. While similar, these two concepts are not the same. Benefi cence means that an act of good is performed whereas Allocation of Scarce non-malefi cence means that no act of harm will be done. The medical concept of “fi rst, do no harm” is an exam- Medical Resources ple of the application of the principle of non-malefi cence.11,12 Physicians and bioethicists have had many discussions regard- Harm (for example, in the form of a fever) which results from ing the distribution of limited resources. An example of an the physician’s inaction is not the physician’s responsibility. allocation of a scarce medical resource is allocation of organs The patient understands this. Although the patient depends for transplantation. Paramedics are similarly confronted with on the physician’s mercy and charity to prevent this harm, it the same ethical issues when they are on-the-scene of a MCI is understood that this can only be asked for, not demanded. and must allocate the scarce medical resources. However, the Paramedic, like the physician, is responsible Most Paramedics rely on the concept of medical utility for any harmful acts performed and can be held liable (malfea- to resolve this ethical dilemma. Simply put, medical utility sance). It is therefore important that the Paramedic be p rudent, assumes that those with the best prognosis should be treated relying on tested or proven methods of treatment when caring with the limited resources. Those with a likelihood of medi- for a patient, rather than risk creating harm. There is a greater cal benefi t are treated fi rst, whereas those who are expected duty not to injure others than there is to benefi t them. to succumb to their injuries and for whom medical treatment would be futile are left to be treated last.13–17 Justice In this situation, medical utility, a form of act- Justice, the application of the concept of fairness, implies utilitarianism, provides suffi cient guidance for Paramedics impartiality in the administration of rewards. In the case of to act. A problem arises, however, when a fellow emergency medicine, justice might be involved in the distribution of a responder, such as a fi refi ghter, is injured (Figure 5-1). 76 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in

part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 5-2 National Association of Emergency Medical Technicians Code of Ethics EMT Code of Ethics As adopted by the National Association of EMTs Professional status as an Emergency Medical Technician and Emergency Medical Technician-Paramedic is maintained and enriched by the willingness of the individual practitioner to accept and fulfi ll obligations to society, other medical professionals, and the profession of Emergency Medical Technician. As an Emergency Medical Technician-Paramedic, I solemnly pledge myself to the following code of professional ethics: A fundamental responsibility of the Emergency Medical Technician is to conserve life, to alleviate suffering, to promote health, to do no harm, and to encourage the quality and equal availability of emergency medical care. The Emergency Medical Technician provides services based on Figure 5-1 Firefi ghter with injuries on-scene. human need, with respect for human dignity, unrestricted by consideration of nationality, race creed, color, or status. transportation would improve operational effi ciency and there- The Emergency Medical Technician does not use professional fore serve a greater good. Others might argue that treating knowledge and skills in any enterprise detrimental to the public well being. and transporting the fi refi ghter represents a problem of bias The Emergency Medical Technician respects and holds in confi dence and, perhaps more importantly, a breakdown of the concept of all information of a confi dential nature obtained in the course of medical utility. The key to such ethical problems is to balance professional work unless required by law to divulge such information. The Emergency Medical Technician, as a citizen, understands and benefi ts with burdens and determine the moral behavior. upholds the law and performs the duties of citizenship; as a professional, the Emergency Medical Technician has the never-ending responsibility Ethics and EMS Research to work with concerned citizens and other health care professionals in Following the discovery of the Nazi atrocities of human promoting a high standard of emergency medical care to all people. experiments that were exposed during the Nuremberg tribu- The Emergency Medical Technician shall maintain professional nals following World War II, there was a strong call for a competence and demonstrate concern for the competence of other members of the Emergency Medical Services health care team. formal code of ethics for medical researchers. In 1947 the An Emergency Medical Technician assumes responsibility in defi ning Nuremberg code for the ethical conduct in the use of humans and upholding standards of professional practice and education. for experiments was advanced and accepted by many coun- The Emergency Medical Technician assumes responsibility for tries. Enhancements to this original landmark document were individual professional actions and judgment, both in dependent and passed in the Helsinki Declaration of 1964 and in subsequent independent emergency functions, and knows and upholds the laws guidelines passed by the World Health Organization. which affect the practice of the Emergency Medical Technician. Currently, all medical research, including EMS research, An Emergency Medical Technician has the responsibility to be aware of and participate in matters of legislation affecting the Emergency is governed under the federal regulation 45 CFR 46.111 as Medical Service System. well. Medical research is monitored by the U.S. Department The Emergency Medical Technician, or groups of Emergency Medical of Health and Human Services. The Department of Health Technicians, who advertise professional service, do so in conformity with and Human Services requires that all medical research be the dignity of the profession. presented to an Institutional Review Board (IRB) for accep- The Emergency Medical Technician has an obligation to protect the tance. An IRB consists of experts from the fi elds of theology, public by not delegating to a person less qualifi ed, any service which sociology, psychology, and medicine.18 The IRB is respon- requires the professional competence of an Emergency Medical Technician. sible for reviewing all aspects of a proposed research project The Emergency Medical Technician will work harmoniously with and sustain confi dence in Emergency Medical Technician associates, the in terms of the potential psychosocial impact and ensure that nurses, the physicians, and other members of the Emergency Medical all human subject research is ethical. Services health care team. Before any research is accepted by an IRB, the researcher The Emergency Medical Technician refuses to participate in unethical must demonstrate that the risks to the subjects are minimized procedures, and assumes the responsibility to expose incompetence or and any risks are proportional to the potential gain or benefi t, unethical conduct of others to the appropriate authority in a proper and that subject selection is unbiased, and that informed consent professional manner. is obtained from each subject. Written by Charles Gillespie M. D. Adapted by the National Association of Emergency Medical Technicians, 1978. End-of-Life Decisions End-of-life decisions are complicated by the defi nition of Some Paramedics would argue that triaging a fellow emer- death. Is death the absence of a heartbeat and breathing (clin- gency responder to the highest classifi cation serves a social ical death), as the ancients believed? Or is death the absence utility, since the presence of an injured fi refi ghter on-scene of life; that is, those factors that make us uniquely human, would be disruptive to operations. The fi refi ghter’s immediate such as consciousness, wakefulness, and awareness. Ethics and the Paramedic 77 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Current technologies permit a patient to be in a persistent Ethics Committees vegetative state (PVS), a permanent state of unconsciousness, Many healthcare organizations have established an ethics with an intact brainstem that still produces a heartbeat and committee, a committee which can help individuals, including breathing. Most medical authorities agree that biological death Paramedics, deal with common ethical concerns. An example (death of the human) occurs when the brain is dead. To estab- of when an ethics committee might help a Paramedic would lish death, most physicians apply the Harvard Medical School be with the development of palliative care protocols that pro- criteria: unresponsiveness, lack of movement, no refl exes, and vide for appropriate comfort and pain relief at the end-of-life a fl atline EEG. without hastening the patient’s death. Also, guidance could Paramedics encounter patients who are near-death and be provided as to whether it is appropriate to administer oxy- are sometimes confronted with the question of end-of-life gen to a patient with a Do-Not-Resuscitate (DNR) order. decisions. Without guidance from the patient, in the form An ethics committee typically has the same make-up as of advanced directives, or the presence of a healthcare proxy, an IRB. Generally its mission is to foster awareness of ethi- the Paramedic may be called on to make the decision to cal concerns that might arise during patient care and to guide start CPR. practitioners, including Paramedics, with decision making. Under the conditions described, and barring the presence Other organizations that deal with issues of medical ethics of signs of death (i.e., signs that would indicate medical futil- include the Institute of Society, Ethics and the Life Sciences, ity, such as rigor mortis or rigor lividity), the Paramedic is formed in 1969 and based in Hastings-on-the-Hudson, and generally compelled to perform CPR and leave the end-of- the Kennedy Institute of Ethics, established at Georgetown life decision to the family and the physician at a later time. University in Washington, DC. 78 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Paramedics are confronted with ethical dilemmas and with health-related questions which raise ethical issues. An understanding of ethical principles, and their proper application, can help the Paramedic to resolve these ethical dilemmas and allow the Paramedic to continue to provide care without hesitation. Key Points: • Ethics is defi ned as a system of guiding principles inalienable, such as the freedom of expression. that govern a person’s conduct. Cultural and Human rights involve universally accepted standards religious beliefs can strongly affect a person’s of justice, such as freedom from pain and suffering. ethics. There are even workplace cultures in EMS, Legal rights come in the form of laws, statutes, which can have a positive or negative infl uence on ordinances, and regulations. Moral obligations may how Paramedics view their responsibility. It takes a go beyond the basic human rights of the patient, strong personal belief system and a strong sense of such as the obligation for an off-duty Paramedic to morality to withstand the ethical challenges from a stop at the scene of an accident and offer assistance. negative culture. • Human dignity addresses the right of every person • Bioethics is a form of applied ethics (i.e., ethics to be treated respectfully, regardless of his or her applied to the medical situation) and is used in day- station in life. Paramedics must respect human to-day decision making by Paramedics in the fi eld. dignity, and therefore be nonjudgmental. When the majority of Paramedics agree to a specifi c conduct or course of action, saying that it does • The sanctity of patient autonomy is foundational more good than harm, then the act is considered to to medicine. Patients have the ability to control be ethical. their personal destiny through decision making, given that they are capable of understanding the • Generally speaking, the intrinsic good of acts ramifi cations of their decision. performed by Paramedics should prevent and control disease, relieve pain and suffering, and • The patient’s privacy must be maintained in order generally prolong life and clearly outweigh any to sustain patient trust. suffering, pain, or inconvenience to the patient. • When Paramedics practice being truthful with all • Deontology is duty-based ethics where the decision of their patients, making it a habit to be truthful, if an action is right or wrong is based on principles then those Paramedics can be said to have veracity. and not upon their consequences. A situation that This truthfulness is essential if there is to be a demands action and for which all persons, as a therapeutic relationship between the Paramedic matter of duty, should act unconditionally is called and the patient. To maintain patient trust, the a universal law. Paramedic must also practice fi delity, keeping the promises made to the patient. • Virtue ethics suggest that a “right-thinking” person will make the best decision for the patient based • Benefi cence assumes an act of good is performed, upon a predetermined set of virtues. This person whereas non-malefi cence means that no act of harm will be able to act altruistically for the sole benefi t will be done. It is important that the Paramedic be of the patient. prudent, relying on tested or proven methods of treatment, when caring for a patient, rather than • The defi nition of what is “right” can vary. Generally, risk creating harm. There is a greater duty not to a right is a sense of fairness. Natural rights are injure others than to benefi t them. Ethics and the Paramedic 79 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions

require it. • In the case of medicine, justice—the application • Paramedics are sometimes confronted with the of the concept of fairness—might be involved in question of end-of-life decisions. Without guidance the distribution of a rare medicine, or to ration from advance directives or a healthcare proxy, and out limited resources on the scene of a multiple unless there are signs of death (i.e., rigor mortis casualty incident (MCI). The concept of medical or rigor lividity), the Paramedic generally performs utility assumes that those with the best prognosis CPR and leaves the end-of-life decision to the family should be treated with the limited resources. and physician at a later time. • A code of ethics serves as a standard for the • An ethics committee’s mission is to foster awareness profession and a basis by which practitioners of ethical concerns that might arise during facilitate resolution of ethical dilemmas. patient care and to guide practitioners, including • Paramedics, in their decision making. There is a formal code of ethics for medical researchers. An Institutional Review Board • An understanding of ethical principles, and their reviews proposed research projects, ensuring proper application, can help the Paramedic to they meet certain ethical criteria before they resolve ethical dilemmas and allow the Paramedic can be carried out. to continue to provide care without hesitation. Review Questions: 1. What infl uences a person’s ethics? 8. How is benefi cence different than 2. What encompasses the term “bioethics,” coined non-malefi cence? by Van Rensselaer Potter? 9. What concept is demonstrated when limited 3. What is necessary for an act to be considered resources are applied to select people? ethical or unethical? 10. Explain the role of ethics in EMS research. 4. How does the teleological foundation of ethics 11. What professions make up an ethics committee differ from the deontological model? and what is its overarching purpose? 5. How can the defi nition of what is “right” vary? 12. When confronted with an end-of-life decision, 6. What are the foundations of bioethics? when is it appropriate for the Paramedic not to 7. What is veracity, and how is it related to fi delity? perform CPR? Case Study Questions: Please refer to the Case Study at the beginning of the 3. Many educational programs for healthcare chapter and answer the questions below: providers require a course in ethics. Should 1. How would you decide what care to provide for Paramedics be required to complete such a the patient in the case study? course? Why or why not? 2. What model of ethics supports your decision? 80 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. References: 1. Page JO. The Paramedics: An Illustrated History of Paramedics 10. Buppert C. Safeguarding patient privacy. Establish department in Their First Decade in the U.S.A. Kfar Sava: Backdraft compliance with new federal regulations on individually Publications; 1979. identifi able health information. Nurs Manage. 2002;33(12):31–35. 2. Miller DG, Pellegrino ED, Thomasma DC. The Christian Virtues 11. Meskin LH. Non-malefi cence: do no harm! J Am Dent Assoc. in Medical Practice. Washington DC: Georgetown University 1992;123(6):8, 11. Press; 1996. 12. Hoyt D. Prehospital care: do no harm? Ann Surg. 3. Yeager AL. On Hippocrates. Either help or do not harm the 2003;237(2):161–162. patient. Bmj. 2002;325(7362):496. 13. Marco CA, Schears RM. Prehospital resuscitation practices: 4. Doherty DJ. Contemporary medical ethics. Would Hippocrates a survey of prehospital providers. J Emerg Med. 2003;24(1): approve—or even understand? Postgrad Med. 1985;77(3): 101–106. 212–216. 14. Van der Hoeven JG, Waanders H, Compier EA, van der Weyden 5. Cameron NM. Bioethics and the challenge of the post-consensus PK, Meinders AE. Prolonged resuscitation efforts for cardiac society. Ethics Med. 1995;11(1):1–7. arrest patients who cannot be resuscitated at the scene: who is 6. Baker et al.The American Medical Ethics Revolution: How the likely to benefi t? Ann Emerg Med. 1993;22(11):1659–1663. AMA’s Code of Ethics Has Transformed Physicians’ Relationships 15. Battistella FD, Nugent W, Owings JT, & Anderson JT. Field triage to Patients, Professionals, and Society. Baltimore: The Johns of the pulseless trauma patient. Arch Surg. 1999;134(7):742–745; Hopkins University Press; 1999. discussion 745–746. 7. http://www.naemt.org/about_us/emtoath.aspx 16. Hawkins ML, Treat RC, Mansberger AR, Jr. Trauma victims: 8. Ouellette A, Reider J. Practical, state, and federal limits on the fi eld triage guidelines. South Med J. 1987;80(5):562–565. scope of compelled disclosure of health records. Am J Bioeth. 17. Sharma BR. Triage in trauma-care system: a forensic view. J Clin 2007;7(3):46–48. Forensic Med. 2005;12(2):64–73. 9. Banks DL. The Health Insurance Portability and Accountability 18. Garvin C, Landrum RE. (Ed.). Protecting Human Subjects: Act: does it live up to the promise? J Med Syst. 2006; Departmental Subject Pools and Institutional Review Boards. 30(1):45–50. New York: American Psychological Association; 1999. Ethics and the Paramedic 81 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The origins of case law • Civil and tort laws and the elements of a lawsuit • The complexity of patient consent (both legal and ethical concerns) • Understanding of patient rights • Principles of advanced directives • Acts and laws that impact the Paramedic as an employee Case Study: A Paramedic has been subpoenaed to give an affi davit as part of a pretrial investigation into the death of a 45-year-old man. The plaintiff is suing the hospital for malpractice and the untimely death of the patient. The patient was brought to the emergency department by EMS with the complaint of chest pressure and shortness of breath. It is claimed that the patient had to wait 15 minutes to be seen by a physician and had gone into sudden cardiac arrest and died. The lawyers for the plaintiff are looking into the prehospital care given by the Paramedic. The Paramedic’s assessment, diagnostic workup, and course of treatment all followed standard protocols. However, despite the Paramedic’s best efforts to inform the patient of the necessity for intravenous access, the patient refused, insisting on hospital personnel to perform such treatments. The prehospital care given by the Paramedic was found to have been within the Paramedic’s scope of practice despite the patient’s unresolved symptoms upon arrival at the emergency room (ER). 82 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Law and Paramedics 83 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW The Paramedic is expected to have a commanding knowledge of human physiology, symptomology, and pharmacology, but there is a more sobering side to paramedic practice that even the most knowledgeable Paramedic cannot overlook; the legal side. The legal side of EMS affects almost every Paramedic action from their duty to act to how Paramedics conduct themselves in the fi eld. This chapter examines the origins of case law and the divisions between criminal and civil law. The Paramedic must train for the unknown, and should not wait to be caught in the middle of a legal case before becoming familiar with the legal side of the profession. Paramedics should not have a defensive approach, living in fear of being sued; rather, they should develop a preventative approach through a sound understanding of the law. Often the Paramedic’s focus is placed on roles and responsibilities; however, in an almost reverse way of thinking the complexity of patient rights must also be examined and understood. Paramedics must also have an understanding of the legal basis of their actions when managing the day-to-day situations of patients with mental health issues, as well as patients who refuse care. Origin of Law Government units or departments have also been formed, under statutory authority, and charged with various functions In the past, when a transgression occurred against a king, the to carry out the business of government. These departments, accused would be brought before the king and be allowed during the performance of their duties, often fi nd it necessary to plead his case. The king would then make a decision, to regulate the conduct of citizens pursuant to their rule- pronounce sentence, and issue an edict (i.e., a public making authority through the establishment of rules. These declaration equivalent to law that prohibited others from rules, or regulations, while not being statutory law, carry the performing similar acts under certain penalty for such acts).1 same force as law. It was in this manner that the rule of law began. Any reported violation of a regulation would need to be Over time, when the numbers of cases became too investigated and then determined, or adjudicated, in a court numerous for the king, the king would appoint a magistrate having authority (i.e., jurisdiction). When a regulation is (i.e., his majesty’s administrator) to handle the minor cases. violated an administrative court generally has jurisdiction. These magistrates would judge the worthiness of a case When a violation of a departmental regulation occurs, the and render judgment. They would also make a notation of department (the petitioner) brings charges against the alleged the resolution to report to the king as well as to preserve the wrongdoer (the respondent). The respondent is notifi ed to appear decision for future reference. in administrative court and respond to the charges. A hearing Over time a considerable number of these judicial cases would then be conducted before an administrative law judge were documented and became case law. These case laws (ALJ) to discuss the merits of the case. A decision would then be were arranged in order of date and jurisdiction (i.e., codifi ed) rendered by the ALJ. While serious, these cases frequently held for ease of reference. When another magistrate came across less severe penalties for the individual, as opposed to criminal a similar case and needed guidance or wished to render a penalties, because it was a violation of a regulation rather than similar judgment, the magistrate would refer to this case law. of a statute. However, the penalty may have a signifi cant impact By using case law in this manner, the courts helped to assure upon the respondent’s job or profession. fairness under the law.2 Without a king to issue edicts or a dictator to impose his decrees, democracy required a new means of establishing Criminal Law versus Civil Law public policy. Duly elected legislators representing the people of a particular area of the governing state would create new Criminal Law laws, called statutes. Using these statutes, the government One of the purposes of criminal law was to replace personal could govern the population and offenders of the law could vendettas and blood feuds between groups of people with be prosecuted under a judicial system. This is the general a general condemnation of an act by a sympathetic public. structure of the government in the United States today.3 By removing the aggrieved victim from the process, and 84 Foundations of

Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. replacing her with the state as prosecutor, successive acts of A tort is a civil or private wrongful act, other than a vengeance were prevented and order was maintained. breach of contract, resulting in some type of injury or harm A crime could therefore be defi ned as an act done in (not necessarily physical injury).4 A tort involves some type of violation of a person’s duties to the community and for which duty which arises by law. Duties and responsibilities relating the written law requires the person to provide satisfaction, often to contracts arise from the relationship as a result of the in the form of restitution and loss of liberty, to the community. agreement or contract. Those contract issues are not torts. Crimes were defi ned and codifi ed in the criminal law. The Several different types of torts are relevant to a Paramedic. outraged community would rise up and, in its capacity as the An intentional tort occurs when the Paramedic intentionally state, demand prosecution of the individual. Therefore, when and affi rmatively performs an act which causes harm to a person is charged with a crime the prosecutor is the state the patient. An assault (a threat of violence) or a battery (e.g., the State of Montana v. Joe Citizen), and the person is (unwanted touching) are examples of intentional torts. tried in a criminal court. (Depending on the severity of the act, an assault and battery Dependent on the severity of the crime, a citizen could can separately constitute a crime and be prosecuted under the be tried in a local city or town court before a justice, for a criminal law.) Another example of a claim of intentional tort violation or infraction of the law, or before a judge in a county that has been lodged against a Paramedic is the charge of false or state court, for a misdemeanor or felony charge. imprisonment (a restriction of movement or a confi nement There are two separate criminal court systems; one for that abridges the patient’s right to freedom, such as by the use the states and one for the federal government. The federal of restraints). government has courts to adjudicate crimes involving federal Paramedics have certain public expectations placed upon laws. In addition, each state has state courts to adjudicate them in regard to their conduct and behavior. This public crimes involving violations of state laws. trust involves an understanding between the patient and Each state also has courts which determine appeals from the Paramedic that the patient will be treated with dignity the decisions of trial level state courts. An appeal is a request and respect in the same manner a physician would treat the for the appellate court to change the decision issued by the patient. If the Paramedic violates that trust, then the patient trial level court. The federal court system also has courts may bring a lawsuit against the Paramedic for any damages which determine appeals from trial level federal courts. In sustained. some situations, due to the type of issue presented, decisions Lawsuits against Paramedics more frequently involve of state courts may additionally be challenged in the federal carelessness and an allegation of negligence, a failure of the appeals courts. The highest court in the United States is the Paramedic to exercise the degree of care that a prudent person U.S. Supreme Court. Thus, U.S. Supreme Court is the last would exercise. court of appeal. Negligence is further divided into simple negligence, the lack of ordinary care that a reasonably prudent person under the same or similar circumstances would exercise, and gross negligence. Gross negligence involves intent on the part Street Smart of the Paramedic to willfully, or with reckless disregard for the patient, cause harm to the patient. Separately, egregious Many insurance providers/carriers will not protect or conduct of this type might also give rise to criminal charges pay claims for Paramedics whose conduct rises to the which might be leveled against the Paramedic by the district attorney, acting on behalf of the state. level of criminality. Negligence, either simple or gross, that occurs during patient care can give rise to a charge of malpractice, a variation of negligence. Examples of malpractice are discussed later in Civil Law the chapter. In order to resolve confl icts between individuals and to help maintain the peace, the states and the federal government Elements of a Tort Action have provided a forum in which persons and businesses can adjudicate allegations of civil wrongs which are not of a For a tort of malpractice to be actionable (i.e., to be the basis criminal nature. Every state, as well as the federal government, for a lawsuit), it must have the four elements of a tort. The has civil courts to provide for resolution of disputes involving elements of a tort are described in the following text. civil law. Common matters of civil law include contracts (an Duty to Act agreement between parties that is alleged to have been The fi rst element of a tort is a duty to act. Generally speaking breached), torts (claims involving a duty and allegations of a Paramedic has a duty to act whenever the Paramedic is injury, often due to negligence), estates, trusts, wills, real called to perform patient care (i.e., the Paramedic is “on estate matters, commercial matters, and grievances against duty”). The duty arises from her employment or volunteer the government. status as a Paramedic. Generally, a citizen does not have a The Law and Paramedics 85 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. duty to act toward a patient requesting assistance, regardless of training, unless that person is acting in the capacity as an Street Smart EMS provider or there is an expectation of the person to act in that role by virtue of job description. However, once a duty has been undertaken, or an Every state in the United States has enacted either a assignment accepted, then the patient can reasonably expect Good Samaritan law or volunteer protection act that that the Paramedic will continue care until care can be turned protects those who, in good faith, attempt to render over to another patient care provider with the same or higher aid to the sick or injured when off-duty. Of course, training.5 If the Paramedic were to prematurely terminate the Paramedic–patient relationship before the other provider there is an assumption that the patient wants the care assumed responsibility for patient care, thus interrupting being provided. patient care and resulting in harm to the patient, the patient could charge the Paramedic with patient abandonment. Abandonment occurs as a result of an overt action—for example, when a Paramedic walks away from the patient Breach of Duty without turning over care to another provider who has the Assuming that the Paramedic has a duty to act, the next same or higher level of training. However, if a Paramedic element to determine in the lawsuit would be if the Paramedic were to stop and render aid and then left the patient in order to committed a breach of duty. A breach of duty occurs when summon further assistance, this would not be abandonment as a Paramedic fails to perform patient care in conformance the Paramedic is attempting to make reasonable arrangements with the standard of care. The standard of care is that to provide for continued patient care. care and treatment that another Paramedic with the same or Finally, it would not be abandonment if a Paramedic similar training would have rendered in the same or a similar were to render aid, such as CPR, until becoming physically situation. exhausted and incapable of providing further aid. The standard of care is established in court during a lawsuit by the testimony of expert witnesses who would explain the standard of care as relating to the situation Good Samaritan Act in question. The expert would refer to local or regional Most Paramedics have no duty to respond to medical treatment protocols, authoritative textbooks and perhaps, emergencies when off-duty. However, in an effort to encourage quality assurance standards. healthcare professionals such as physicians, nurses, and Once the standard of care is established, the plaintiff ’s Paramedics to render aid during public emergencies, many lawyer would then establish that there was a material breach state legislatures have created Good Samaritan statutes.6 of that standard. The Bible story of the Good Samaritan is found in the A Paramedic may make an error in one of two ways. An Gospel according to Luke (10:25–27). The biblical parable error of commission is the performance of an act which is tells of an injured traveler who is cared for by a well-meaning alleged to be improper or wrong. An error of omission is a stranger. The Good Samaritan doctrine was established from failure to do something which she should have done. If the this story. Paramedic performed an inappropriate procedure (e.g., gave In the spirit of the Good Samaritan, legislatures have a fl uid bolus to a head-injured patient), then the charge would enacted laws that protect well-meaning healthcare providers be malfeasance. who, having no duty to respond, do nonetheless come to If the Paramedic performed the correct procedure but the aid of an injured person. These laws protect them from did so incorrectly, then the charge would be misfeasance. liability for negligent acts which are performed in the course For example, if a Paramedic performed an endotracheal of providing such assistance. intubation on an apneic patient and the endotracheal tube Good Samaritan laws do not provide immunity (exemption was placed in the esophagus instead of the trachea, then from being sued) from lawsuits. Rather, the Good Samaritan the plaintiff would make an allegation of misfeasance. acts provide the Paramedic with a legal defense to counter Finally, a Paramedic can fail to perform the correct or a complainant’s claim of negligence. The Paramedic is still required procedure, which would be an error of omission. required to go to court and demonstrate that he or she was For example, defi brillator batteries are typically checked on acting in the capacity of a Good Samaritan. a routine basis. If a Paramedic were to arrive on-scene of a Good Samaritan laws also may not apply when the cardiac arrest and the defi brillator failed because of a dead Paramedic involved created the situation. For example, if an battery, the family of the deceased could make an allegation off-duty Paramedic was to be involved in a motor vehicle of nonfeasance. collision he would likely not be considered a Good Samaritan In every instance, in order to fi nd negligence the and might be liable if he does not provide assistance, minimally Paramedic must have performed incorrectly.8 The Paramedic calling for rescue.7 He might not enjoy the protections of the must have either affi rmatively committed an error or failed to Good Samaritan act if he was expected to render fi rst aid. act appropriately (omission). 86 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Damages act to the injury, the patient, as plaintiff, cannot prove that the Paramedic is

negligent. It is not enough that a mistake was made. For the mistake to be actionable, the patient must have experienced some injury or harm from the error. The legal concept de minimis non curat et lex is applied to frivolous lawsuits where the patient Street Smart did not experience any substantial injury. The term translated means: “the law has not a cure for trifl es.” One eight-year study of lawsuits against EMS providers Damages are compensation for having suffered some injury or loss. Compensatory damages include both economic in an urban 9-1-1 system indicated that the majority and non-economic damages. Economic damages are concrete of lawsuits involved negligent operation of an and can easily be calculated. In other words one can put a emergency response vehicle. fi xed price on the loss. Economic damages include such things as the cost of repair, reimbursement for lost wages, and medical expenses. Non-economic damages are compensation for intangibles that one cannot put a fi xed price on. These Borrowed Servant Doctrine include compensation for pain and suffering, loss of life, injury to a part of the body, and loss of companionship. EMS practice dictates that the Paramedic with the highest Another type of damages are punitive damages, which level of education or experience is responsible for patient can also be levied by the court against the Paramedic. care. Therefore, the Paramedic is responsible for directing Punitive damages are akin to a civil fi ne that is intended as and supervising any patient care performed by any other a punishment for egregious conduct or to send a message to EMS providers on the team with lower levels of training. others so as to deter such conduct by others in the future. In those circumstances, called the borrowed servant doctrine, the Paramedic is not only accepting assistance from Proximate Causation those EMS providers but is also accepting responsibility for the actions and the errors of those providers. Therefore, the The saying goes that bad things happen to good people and Paramedic’s failure to supervise a subordinate, who in turn it is unfortunate that patients are forced to endure hardships makes an error and causes harm to befall the patient, leaves as a result of misfortune. But the presence of an injury and the Paramedic liable for the assistant’s actions. the commission of an error do not always equal cause and This legal principle, respondeat superior, Latin meaning effect.9 “let the master answer,” is well established in case law. A tort requires that there be a duty, a breach of that duty, Whenever a Paramedic permits another EMS provider and an injury as a proximate result. Thus, the plaintiff must to care for a patient, the Paramedic assumes vicarious prove that the Paramedic’s actions were the proximate cause liability for the actions of that provider. Take the case where of the injury.10 the Paramedic, while caring for a minor injury, allows the This is often diffi cult to prove. In many instances, the ambulance driver to drive at high rates of speed with lights injury may already have been present. For example, a patient and siren on. If the ambulance was to have a collision and who experienced a spinal cord injury during a motor vehicle harm the patient, the public, or the occupants of the other collision may have experienced that injury at the moment vehicles, the courts might hold the Paramedic vicariously of impact (i.e., primary injury). However, the patient may liable for the harm caused because the Paramedic did not complain that the injury did not occur at the moment of instruct the driver to turn off the warning lights and siren or impact but as a result of rough or inappropriate handling of slow to a reasonable speed. the patient by the Paramedic. The plaintiff would assert that the Paramedic’s actions may have caused the injury. Alternatively, the patient may assert that the injury The Process of a Civil Lawsuit occurred at the time of the collision but the injury was made When a patient feels that he has been harmed by the worse (i.e., secondary injury) by the Paramedic. In those Paramedic’s actions (i.e., an actionable cause), the patient cases, the patient might argue that the Paramedic should share generally approaches an attorney. The attorney initiates the responsibility for damages with the patient or the individual legal proceedings in hopes of obtaining a payment for the who caused the accident. This is called contributory damages the patient sustained. negligence. In this situation, the Paramedic would only be The attorney would serve (cause to be delivered) papers, responsible for a percentage of the damages that were levied called a summons and complaint, on the Paramedic. The by the court. summons and complaint identifi es some of the specifi cs of In other instances, there may be no way to prove that the matter and asks the defendant (the Paramedic being sued) the Paramedic’s actions created the harm, despite the fact to respond to the allegation contained in the complaint. it can demonstrated that the Paramedic erred and that the Attorneys usually hire a person, called a process server, patient is injured. Without proximate causation linking the to deliver the summons and complaint to the defendant. In The Law and Paramedics 87 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. the situation where a reasonable effort has been made to recognized by the court, verify the Paramedic’s identity. The serve the defendant, and the defendant refuses to accept the Paramedic then swears that the copy of the PCR is a true papers, then the courts can rule that the papers be served in a and accurate copy of the original. If using a notary public is different manner. permitted, then it may not be necessary for the Paramedic Once the matter is pending in court, the plaintiff or to appear in court to authenticate the document. defendant could then ask the court to make a decision based As a part of the pretrial investigation, the Paramedic may on the facts asserted only in the papers that had been fi led in be requested to give a sworn written statement, called an court. The judge, acting as fact fi nder, might then arrive at a affi davit, which attests to facts involving the case. fi nding in favor of the plaintiff and grant the plaintiff ’s request In a more formal proceeding prior to the trial stage, for damages. Alternatively, it is also possible the judge might the Paramedic may also be called to a deposition, which determine that judgment should be awarded to the defendant usually occurs in an attorney’s offi ce. During a deposition, Paramedic and dismiss the lawsuit. This determination by the the Paramedic swears to an oath. Then the plaintiff ’s attorney judge solely on the papers without conducting a trial is called asks questions while a stenographer takes minutes of the summary judgment. proceedings. A judge is generally not present during a It is in the Paramedic’s best interests to accept the papers deposition. The deposition allows the plaintiff ’s attorney to and contact his own attorney to avoid being in default. Failing obtain testimony in an out-of-court setting that will assist in to appear in court or to contest the lawsuit can result in a preparing the case. The testimony given at the deposition may summary judgment being entered against the Paramedic. or may not be presented later during the trial. Most malpractice insurance carriers require that any The purpose of the pretrial discovery phase is to provide Paramedic served with papers contact the insurance carrier both parties with suffi cient information to decide how to within a specifi ed period of time. This allows the insurance proceed with the case. It is possible that the attorney will carrier to contact an attorney to represent the insured learn that the Paramedic is not a party who should be sued. Paramedic. If the Paramedic’s employer is providing the Paramedics have been removed as a named party in a lawsuit insurance coverage, then the insurance company seeks to during this phase. protect the interests of both the Paramedic’s employer and If the case has merit, the defendant (i.e., the Paramedic) the insurance company. In some cases, the Paramedic may and the Paramedic’s attorney may decide that a trial would have his own malpractice insurance coverage. In that case, be counterproductive, inordinately diffi cult or expensive and the Paramedic must contact that insurance carrier. agree to pay the plaintiff a sum of money, called a settlement, to the plaintiff in order to conclude the matter. Pretrial Discovery Quality Assurance and Discoverability In an effort to determine the truth in a matter, the defendant’s attorney (the Paramedic’s lawyer) and the plaintiff ’s attorney Atypical patient presentations and/or differences in the (the patient’s lawyer) will undertake specifi c prescribed legal knowledge base of individual Paramedics can lead to less than proceedings. desirable practice in the fi eld on occasion. Quality assurance/ One action may be to issue a subpoena, which is a improvement (QA/QI) is an effort to improve patient care legal command or direction issued by the court to appear at through uniformity and reliability with the standard of care. a certain place, such as the offi ce of the plaintiff ’s attorney QA/QI is often accomplished through retrospective or the courthouse, at a particular time. The subpoena may analysis of the PCR. Disclosure of any defi ciencies in the direct the Paramedic to appear personally and it can also PCR, in a court of law, would have a chilling effect upon the demand that certain pertinent fi les and records be brought QA/QI process. with the Paramedic. Failure to respond to a subpoena may In an effort to encourage EMS care, vis-á-vis through the subject the Paramedic to legal sanctions including a charge QA/QI process, many states have adopted laws that protect of contempt of court. these QA/QI results from disclosure during the discovery In some instances, the patient may simply authorize, process. through a written release of information, that the Paramedic’s patient care report (PCR) be released to the attorney. If this Immunity and Defense report is released, the Paramedic is not required to appear at Immunity is a special privilege which, as used in the civil law, that time. means that the person or entity with immunity is exempt or Every report must be authenticated before it can be cannot be sued or held responsible for torts. The idea is that entered into the court’s record as evidence. To authenticate it is in the public interest that these entities not be sued. The the PCR, for example, the Paramedic may be given a copy practice of governmental immunity stems from old case law in court and asked to testify that the item is a true and that essentially stipulates that a citizen of the crown cannot accurate copy or that it is the original document. Another sue the king. means of authenticating the PCR that may be acceptable in Governmental immunity (also called sovereign some instances is to have a notary public, a person who is immunity) means that the government is exempt from liability 88 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. for torts committed by its employees except to the extent that water in the drug vial. Later a patient in pain received the it has consented by statute to be sued. substituted sterile water and suffered harm (pain) because As is relevant to the Paramedic, immunity

is usually there was no drug in the vial. granted when the Paramedic is required by law to report a The incidences of summary dismissal and summary crime, called mandatory reporting, and the Paramedic does judgment are both low because there are usually issues of so in good faith. Paramedics may be required to report child fact to be decided at trial. Judges also tend to prefer that each abuse, sexual assaults, gunshot wounds, certain communicable party has its opportunity to present its case in court. diseases, and animal bites. In fact, the failure to report these The best defense against a successful lawsuit is to conditions, as required by law, may leave the Paramedic with practice within the Paramedic’s scope of practice, to practice some personal liability for failing to report. to the standard of care within the EMS system, to observe States have limited or restricted their immunity over the the patient’s rights, and to document one’s actions completely years. It is more infrequent that EMS employees of state, local, and thoroughly.12 or federal government are granted governmental immunity. Patient Consent Motions in Court Paramedics have both an ethical and legal responsibility to During a trial, both the plaintiff and the defendant can request preserve the patient’s right to self-determination. In 1914 that the judge accept a motion. A motion is a request to the Supreme Court Justice Benjamin Cardozo said “every human judge for some action (i.e., dismiss the case, order a party to being of adult years and sound mind has a right to determine do something, postponement, cease and desist orders, etc.). what shall be done with his own body.”13 When a Paramedic A motion can be verbal, but is most often a written request helps to preserve this right it encourages patient autonomy, that contains pertinent points for the judge to consider. which in turn can lead to a more open dialogue and more For example, the attorney for the defendant, the rational decision making by the patient. Paramedic, may make a motion for summary dismissal based The importance of preserving patient autonomy cannot be upon the facts in the case, stating that the facts of the case are overstated. One of the leading causes of lawsuits by patients clear and without dispute. A lawsuit may also be dismissed against physicians, as reported in a National Academy of if the time from the occurrence of the incident to the time of Sciences study, was the lack of rapport between patient and fi ling the lawsuit has exceeded the statute of limitations. The physician leading to increased mutual mistrust. statute of limitations simply states that a plaintiff (usually the Patient-oriented medical care has not always been the patient) cannot commence a lawsuit after a certain amount of policy in medicine. In the past, physicians, in a form of time has passed. benevolent paternalism, expected patients to comply with The statute of limitations is handled differently in the case their instructions without question and to leave the medical of a child. Typically, the state permits the child to reach an age decisions to them. of majority, between 18 and 21 years of age, and then adds The landmark 1972 case Canterbury v. Spence may have the additional time to permit the lawsuit to be commenced. changed the nature of the physician–patient relationship. Therefore, in a pediatric case, it may take 10 years or more During that case the judge decided “it is the prerogative of before a case is commenced and more time for it to be fi nally the patient, not the physician, to determine for himself the resolved.11 direction in which his interests seem to lie . . .” The defendant’s attorney may also request summary Implicit in this statement is the concept of patient dismissal, claiming that the court does not have jurisdiction education and self-disclosure.14 The trend in medicine is now in the matter. Jurisdiction is usually established early in the toward more patient involvement in decisions that directly case. If there is a jurisdictional problem in that the plaintiff affect the patient. This is now viewed as a matter of right. commenced the lawsuit in the wrong place, then the case may be dismissed in that court. However, a new case would likely then subsequently be commenced in a different court or court Disclosure system which would have jurisdiction. One of the fundamental precepts of patient consent is The plaintiff ’s attorney may request a summary judgment disclosure. Disclosure is an open dialogue between patient awarding judgment to the patient based solely on the papers and provider in which the provider tells the patient about the submitted to the court. The concept of negligence per se is procedure, including its attendant risks, and recommends a case where summary judgment might be granted for the the procedure to the patient. It is therefore implicit that the plaintiff. Negligence per se occurs when the Paramedic Paramedic will get the patient’s consent, or authorization, committed a criminal act, and the patient was injured as a result before continuing with the procedure. of that criminal act. The assumption is that the Paramedic’s An issue crucial to disclosure is the extent of the negligence fl ows from the criminal act. An example of information required to be disclosed. The Paramedic should negligence per se might be the case where a Paramedic was provide the patient with information that is material to the diverting narcotics for personal use and substituting sterile situation at hand. For example, the patient should be informed The Law and Paramedics 89 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. how the procedure will help the patient. As an example, before Voluntariness starting an intravenous access, the Paramedic could explain The patient’s consent must be voluntary and the patient cannot to the patient that having an intravenous access allows the be coerced into consenting. However, a limited explanation Paramedic to administer drugs more quickly. of the procedure by the Paramedic, without an offer to ask The patient should also be told of the risks that can questions or to withdraw permission, might be construed to reasonably be expected as a result of the procedure. This is be coercion. The patient in the back of an ambulance is left called foreseeable harm. It is not necessary to provide the with few options. For example, the patient cannot get up and patient with an exhaustive explanation of the risks of the leave when the ambulance is moving and may feel compelled procedure or medication. The patient should be provided a to agree with the Paramedic. The Paramedic should make short list of the most common reactions or consequences every effort to ensure that the patient is comfortable with the (e.g., pain at the insertion site of an IV). decision made. Immediately following the explanation, the Paramedic should offer to answer any questions the patient may have. The Paramedic should also advise the patient that he or Permission she can withdraw permission, or withdraw consent, for the Following the explanation and an opportunity for the patient to procedure at any time. ask questions, the Paramedic should then ask for permission to proceed. In most cases the permission is going to be verbal. Understanding Every effort should be made to have the permission confi rmed by another person, a witness, who can attest to the patient’s For a valid legal consent to occur, the patient must be of capacity, the explanation’s content, and the patient’s consent. sound mind (possess the intelligence and presence of mind) to The Paramedic would then follow-up the verbal understand what is being said to her.15 An explanation offered permission with a notation on the PCR. to an incoherent patient who then consents is not informed consent. Inherent in the concept of informed consent is that BARNACLE the patient must have the capacity to understand what is being offered. Some Paramedics use the mnemonic BARNACLE to ensure If the patient is under the infl uence of drugs or alcohol, that they have completed all of the necessary steps in obtaining that patient may not have the capacity to consent. A question an informed consent (Table 6-1). arises when a patient has had a few drinks but is not The (B) in BARNACLE stands for benefi ts. Were the intoxicated. In those situations, the Paramedic is advised to benefi ts of the procedure explained to the patient? Next, contact medical control for direction before proceeding. were the alternatives (A)—for example, that consent can Other medical conditions can also impair a person’s ability be withdrawn—explained to the patient? Then, were the to think, and therefore consent. Fever-induced delirium, acute reasonably foreseeable risks (R) explained to the patient as stress reaction, medication-facilitated impairment, and organic well as the nature (N) of the procedure? Then, was the patient brain syndromes are just a few of the medical conditions that given satisfactory answers (A) to the patient’s questions? The can preclude a patient from making an informed decision. patient should be advised that he can withdraw his consent The patient must also have the legal capacity to (C) at any time. If the patient does withdraw consent, what understand what is being offered.16 Therefore, capacity is not are the reasonable consequences if he lacks (L) the treatment? only a matter of the patient’s mental state but age as well. Finally, were all explanations (E) offered in terms that the In general, the patient must be of legal age (i.e., the age patient could understand? of majority) in order to consent. In most states the age of majority is 18 years of age, though some states have set the Emergency Exception age of majority at 21 years old. In some cases, the delay created by a lengthy explanation There are some notable exceptions to the age of majority might compromise the patient’s health. In those cases it is and ability to consent.17 Adolescents below the legal age of majority can consent to limited health care. For example, they can consent to treatment for venereal diseases, drug Table 6-1 BARNACLE abuse, and birth control. Otherwise, these youths must have B Benefi ts of procedure parental permission, discussed further in the chapter, before A Alternatives to procedure they can receive health care, including EMS. The reasoning R Risks of procedure for these special exceptions is that laws provide for them due N Nature of procedure to societal determinations that they are in the best interest of A Answers to patient questions C Consent to rights of patient a greater public good: fewer teenage pregnancies, a decrease L Lack of treatment consequences in sexually transmitted disease (STD), and decreased drug E Explanations understood addiction. 90 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. understood that, provided the Paramedic is practicing to the decisions about health care. Even if the decision is poor, in standard of care, the patient would want that care. An example terms of negative consequences, the patient still has the right would be intravenous access. Intravenous access, seen on to make that decision. television and in the hospital, is so commonplace that patients can reasonably expect to understand that an IV will be started Types of Consent by a Paramedic, and that the patient understood the benefi ts Expressed Consent and risks of such a procedure when 9-1-1 was called. While an emergency exception may clearly be of benefi t In a typical medical environment, such as a hospital or to the patient during a crisis, not every call for EMS

is an doctor’s offi ce, before performing any medical procedure emergency. Therefore, a Paramedic should practice obtaining the physician must provide a complete verbal explanation, or informed consent whenever possible and reasonably practical. written justifi cation, to the patient and then obtain a written or verbal consent from the patient. Obviously, this takes time Therapeutic Privilege as well as requires an alert and aware patient. Thus, it is not always practical during an emergency. In rare instances, it is acceptable to withhold information During an emergency, a patient allows a Paramedic to from a patient for the patient’s benefi t. For example, it may initiate care and indicates consent by either gesture or verbal be inappropriate to disclose unhappy news to a depressed acknowledgment. Or, if the patient does not object to receiving patient who has threatened suicide. The case of Canterbury care, then expressed consent is assumed.18 v. Spence established that when the disclosure poses a threat When practical, a Paramedic is well-advised to try or detriment to the patient, then disclosure is contraindicated and obtain a verbal consent for specifi c procedures, such from a medical point of view. as starting an intravenous access, and particularly for At fi rst glance, this may appear to be a form of parentalism, uncommon procedures such as elective cardioversion. A discussed earlier, but the key difference is that the deception request for permission, accompanied by a simple explanation, has a therapeutic value to the patient in and of itself. Examples can improve patient compliance and decrease the risk of of the use of therapeutic privilege include the use of placebos, misunderstanding. medically inert drugs and shams, and procedures performed The essential aspect of patient consent is the fact that the that are not helpful or harmful to the patient. patient is informed of the benefi ts and risks of the procedure and then makes a rational decision based on that information. Waiver of the Right to Consent Whenever a patient can make an informed consent it Some patients will summarily waive their right to consent, strengthens the physician–patient relationship. permitting the Paramedic to treat the patient’s condition to the standard of care. A statement such as “do what you think Implied Consent is best” is an example of a waiver of the right to consent. This When a patient is unconscious and unable to speak for himself, waiver should be noted in the PCR, verbatim if possible, and then Paramedics can treat the patient under the doctrine of witnessed by another EMS provider. implied consent. Under implied consent, it is assumed that the patient would consent if awake and capable of consenting. Advantages of Consent Implied consent is assumed even if the patient was Consent protects the patient’s right to choose (autonomy) and refusing care moments before going unconscious because it thereby strengthens the trust between provider and patient. is thought that the patient, suddenly faced with the reality of When important patient care decisions are made jointly, it his mortality, would have changed his mind. increases the patient’s responsibility as well as protects the Implied consent is not applicable if there is a healthcare proxy Paramedic’s tolerability for a poor outcome. or an advanced directive available; both are discussed later in the Informed consent, as opposed to no consent, also chapter. In those cases, the consent from the healthcare proxy decreases the danger of complaints about fraud, deception, or must be obtained. Otherwise, the express wish of the patient, duress. These charges, once levied, are hard to deny without outlined in the advanced directive, is to be honored. the presence of an informed consent. Perhaps more importantly, consent can also have a Involuntary Consent therapeutic benefi t in and of itself. Patients naturally fear the When a law enforcement offi cer (LEO) places a person in unknown; informed consent provides them with reassurance, custody, that person no longer has the freedom of movement. decreasing their anxiety of the unknown in the process. The This condition makes the person necessarily dependant upon therapeutic impact of knowledge to an anxious patient can the offi cer for his or her safety and welfare, including health reduce some of the negative physiological consequences of care, while in custody. sympathetic stimulation generated by fear. During a life or limb emergency an offi cer can provide Finally, the American Hospital Association’s Patient’s consent for the person in custody (e.g., a prisoner). This Bill of Rights states that the patient has the right to make type of consent is called involuntary consent.19 Involuntary The Law and Paramedics 91 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. consent is usually reserved for true emergencies; the police adults who have children entrusted to their care can, and are power to provide consent is not generally invoked for minor expected to, seek medical attention for the injured or ill child emergencies or elective procedures. in an emergency. This status is called loco parentis. The patient who is under the control of mental health If there is no parent, relative, guardian, or duly- offi cials is in a similar circumstance. Some, but not all, empowered adult present, then the child can be treated in mental health patients are admitted involuntarily; that is, they a modified form of implied consent called the emergency are mandated into treatment. In those cases, permission for doctrine. The emergency doctrine holds that if the parent treatment is obtained from mental health offi cials, not the was present the parent would want the child treated and patient, in another form of involuntary consent.20 transported to the hospital. The emergency doctrine is usually invoked only in cases of life or limb-threatening Emancipated Minors emergencies. Every effort should be made to contact the In some special circumstances patients who are below the age parent, guardian, or responsible adult to obtain consent. of majority are permitted to give informed consent, provided In rare cases, a parent may refuse treatment and they are capable of understanding the consequences of their transportation for a child. The diffi culty lies when the parent decisions and that they are not impaired by alcohol or drugs. refuses care beyond reason and the child is in obvious need This special class of youths is called emancipated minors. of such care. Paramedics should not become confrontational In some states youths under the age of 18 may get married with the parents but continue to gently, but fi rmly, insist that with parental permission. Once married, the husband and a physician see the child. If the parent still refuses, it may be wife are considered to be adults and are treated, for purposes necessary to involve a law enforcement offi cer and invoke of health care, as emancipated minors. A similar situation is child protective laws. created when adolescents under 18 years of age enlist in the In these limited cases, the offi cer may take protective armed forces. custody of the child, citing child protective laws, and the In the majority of states, once an adolescent female is a offi cer will give permission to treat and transport the child mother she is treated as an adult. These teen-aged mothers pursuant to a form of involuntary consent. In this case, are capable of consenting for treatment for both themselves the parents may be charged with child abuse or neglect by and their children and are considered emancipated minors. appropriate authorities. However, every effort should be An adolescent, living away from home and without made to reason with the parent before such a heavy-handed support from the family, may also petition the court for status approach is taken. as an emancipated minor. Once the court decree is issued the adolescent can consent to health care. Medical Restraint Pediatric Consent Paramedics may encounter a patient experiencing a behavioral emergency, abnormal or bizarre behavior Children, by virtue of their age, are usually unable to consent, that may include violence or threats of violence. except for the very limited healthcare services that were Paramedics, unsure of the cause of the behavior (e.g., discussed earlier. A parent or legally appointed guardian must drug intoxication,toxicological emergency, or psychiatric provide consent for them. emergency), may need to institute a medical restraint Obtaining consent from a parent to treat a child is the and treat and transport the patient against his or her will. same as obtaining consent to treat an adult. The parent must Each state usually has a mental health law which be capable of understanding the consequences of a decision provides for the involuntary restraint and transportation to accept the treatment, the risk/benefi t, as well as the of a mentally disturbed person to a medical facility for consequence if treatment is refused. treatment. The applicable law may provide for whether or However, the Paramedic must be prepared to answer not a law enforcement offi cer can or must be present. When more questions about the procedure and may need to confronted with such a situation, the Paramedic should use include the child in the discussion, depending on the child’s every persuasion to encourage the patient to go voluntarily: developmental age. a “talk ’em down before taking ’em down” approach. In a situation in which the patient does not want to go Pediatric Consent without a Parent voluntarily, it may be necessary for either the Paramedic or Problems occur when a child is hurt and no parent is the offi cer to invoke the mental health law and to restrain a immediately available to consent to the child’s treatment and patient in order to protect the patient from himself or herself transportation. or to protect others from the patient. If the child has been left in the custody and care of another The American College of Emergency Physicians (ACEP), adult (e.g., a schoolteacher) then that adult has the authority in their position paper on the use of restraints, states that to provide consent. Parents are frequently asked to complete these emotionally disturbed patients, who are usually either permission slips, slips that permit the school’s agents (e.g., homicidal or suicidal, need to be treated with respect while teachers, coaches, and aides) to act in the parent’s stead. These under these trying situations and afforded as much dignity as 92 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 6-1 Proper use of extremity restraints in opposing directions. possible. Furthermore, restraints should be applied humanely with only the minimum amount of force needed to effect the medical restraint. In some instances it is better to leave the actual act of physical restraint to police offi cers who are trained in restraint procedures. Once restrained, handcuffs and other police restraint devices should be removed as soon as is practical. They should be replaced with other more humane restraint devices, such as padded-leather restraints, wide-band cravats, and the like. Regardless of the restraint device used, the Paramedic should be trained in the use of that device. Following restraint, it is imperative that the Paramedic periodically reassess the patient and document the continued need and use of restraints. The least restrictive, but effective, restraint should be used (Figure 6-1). Positional Asphyxia Sometimes during a restraint a patient will become so agitated and combative that he will enter a state of excited delirium. When in excited delirium the patient will be tachycardic, hypertensive, and have hyperpyrexia. In some instances, the condition is worsened by the presence of sympathomimetic drugs such as methamphetamine or cocaine. Patients in a state of excited delirium who have been restrained and then placed face down

rapidly tire from the restricted breathing. They become hypoxic, a process called positional asphyxia, and then subsequently go into cardiac arrest. While positional asphyxia is uncommon, there have been “in-custody” deaths of patients who have been physically restrained and placed face down. This is especially so if the patient has been “hog-tied” (ankles and wrists tied together behind the back) (Figure 6-2). Figure 6-2 Patients should NOT be “hog-tied.” The Law and Paramedics 93 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. While the exact etiology of this cardiac arrest has been be taken will ultimately rescind their refusal when the patient debated, most healthcare providers agree that restraining senses the genuine concern on the part of the Paramedic. a patient face down poses a signifi cant risk of positional Many EMS agencies have a standard refusal of care form, asphyxia and subsequent cardiac arrest. Whenever possible, crafted by attorneys, for use in the fi eld (Figure 6-3). To be the restrained patient should be placed face up or supine and effective as a form of notifi cation, the patient should receive a not “hog-tied.” copy of the RMA form. Most agencies also require a witness to the patient’s signature. Refusal of Medical Assistance While any adult can serve as a witness, the best witnesses are those who are not interested parties (i.e., someone who Every patient has a right to refuse care. Inherent in the right does not stand to benefi t fi nancially from a lawsuit). A witness to refuse medical care is the understanding that the patient is essentially assuring that the refusal was obtained without must fi rst be able to consent to care before he or she can duress and that the signature is authentic, not that the patient refuse care.21 In the case where the patient can consent, understood the explanation offered. and yet still refuses care, the Paramedic needs to carefully proceed with a refusal of medical assistance (RMA). Against Medical Advice An exploration of the reason for refusal can sometimes reveal issues or problems that can be easily resolved. For Some patients refuse care in opposition to all logic when example, some patients lack insurance and are concerned confronted with a clear and immediate danger to their health. about their ability to pay for the services they need. It is These patients are deciding, against medical advice (AMA), important that they understand that their health supersedes to not go to the hospital.22 In those cases the Paramedic is any fi nancial considerations and arrangements can always be advised to contact medical control for direction and advice. made to ensure that the patient can get the help that is needed. In some instances, the patient may still be permitted to Most hospitals and many EMS services are obligated, by refuse care but the input of the physician often provides the federal law, to provide free service to impoverished people. patient with the incentive to accept care and transportation.23, 24 If the patient remains resistant, the Paramedic should Also, the Paramedic then has the knowledge that he or she did proceed with a complete description of the illness or injuries all that could be done to convince the patient to seek medical that he or she has sustained and the potential complications care immediately. that could arise if the illness or injuries are not treated. However, the situation is different in the case of children. A seriously ill or injured child needs to be seen by a physician. If the parents refuse to permit the child to be seen, and it is clearly a life-threatening situation, then a police offi cer Street Smart should be summoned to the scene. The offi cer may have to take the child into protective custody in order to get the child In many cases, an injury or illness, unchecked, can to treatment. lead to permanent disability and even death. Some agencies require that Paramedics list the foreseeable Destination complications, including death, on the PCR. The Generally, patients are transported to the closest appropriate Paramedic must then ask the patient to read the PCR medical facility. If there are several reasonable options within out loud and then sign it. The “death warrant,” as approximately the same distance, then the patient is often given the choice of hospitals. it is commonly known, serves several functions. For Increasingly, hospitals are becoming more specialized one, the patient must be able to read and understand and the appropriate medical facility may not be the closest or the English language. Asking for the text to be read the patient’s choice. Under a restricted set of circumstances or aloud establishes that the patient both read and conditions, a patient may be diverted from the closest hospital to a hospital equipped to handle the patient’s particular understands the foreseeable consequences of refusal. emergency. The fi rst example of a specialty center may have been the trauma center. A trauma center has some very unique capabilities If the patient remains adamant in her refusal of treatment which permit it to provide the highest level of care for certain and/or transportation, then the Paramedic should advise the traumatic injuries. In general, Paramedics are permitted to divert patient of alternatives. Alternatives may include seeking to these trauma centers based upon authority granted within a set private medical care and calling EMS again if desired. of state, regional, or local protocols. Finally, it is important that Paramedics offer assistance With the likely future development of specialty care to the limit that the patient will accept. Frequently, patients centers, at some point Paramedics may divert to such who initially accept a bandage and then permit vital signs to specialty hospitals as cardiac care centers, with interventional 94 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Rensselaer County Emergency Medical Services REFUSAL OF MEDICAL CARE, TREATMENT, AND/OR TRANSPORTATION PCR NUMBER: ________________ DATE: ________________ TIME: ________________ PATIENT: I understand that competent persons maintain the right to refuse medical care, treatment and/or transportation. I, ________________________________________________, hereby acknowledge that I have been advised by members of the ___________________________________________[AGENCY], that they recommend that I receive medical care, treatment and/or transportation to a hospital emergency department for further evaluation by a physician. I further understand that I may refuse medical care, treatment and/or transportation, but do so at my own risk. I do not have any known physical or mental condition that would prohibit me from making an informed, competent, and intelligent decision to refuse the medical care, treatment and/or transportation that has been offered and recommended. THE RISK ASSOCIATED WITH REFUSAL MAY INCLUDE POSSIBLE LOSS OF LIMB OR LIFE I HAVE ALSO BEEN ADVISED THAT IF I DEVELOP ANY MEDICAL COMPLAINTS OR SYMPTOMS, I SHOULD IMMEDIATELY CONTACT AN AMBULANCE, HOSPITAL EMERGENCY DEPARTMENT, OR MY PHYSICIAN. I hereby release ________________________________________[AGENCY], its, offi cers, agents, personnel, and employees from any and all claims, causes of action or injuries, of whatsoever kind or nature, arising out of or in connection with my refusal of medical care, treatment and/or transportation. Patient’s Signature: ________________________________________________ Date: _________________________ Patient’s Name (print): ______________________________ Patient’s Age: _______ Patient refused signature: _______ FOR MINORS OR PERSONS WHO HAVE GUARDIANS: I am the patient’s legal guardian. My relationship to the patient is _________. I am hereby acting on behalf of the patient, ________________________________________[PATIENT’S NAME]. I have read the above information and refuse medical care, treatment and/or transportation on behalf of the patient. Guardian’s Signature: ____________________________________________ Date: _________________________ Guardian’s Name (print): ______________________________ Guardian’s Full Address: ___________________________ ___________________________ WITNESS: I, _________________________________________, witnessed members of the ______________________ ___________________________[AGENCY] recommend to the patient medical care, treatment, and/or transportation to a hospital emergency department for further evaluation and attention. I further witnessed the above-named patient (or patient’s guardian) decline such medical care, treatment, and/or transportation. Witness Signature: _____________________________________ Date: _________________________ Witness Name (print): ___________________________________ Witness’ Full Address: ___________________________ Occupation: _____________________________ ___________________________ EMS PROVIDER: I, ___________________________________________[EMS PROVIDER], have offered and recommended to __________________________________________[PATIENT’S NAME OR GUARDIAN’S NAME], emergency medical care and treatment, including transportation to a hospital. The patient (or patient’s guardian) has refused my recommendation for medical care, treatment, and/or transportation. I have fully explained the reasons for medical care, treatment, and/or transportation to the patient (or patient’s guardian). I have also explained this form to the patient (or patient’s guardian) and have requested that he/she personally read it. The patient (or patient’s guardian) has expressed to me an understanding of the information contained herein and did not have any questions regarding the content of this form. The patient (or patient’s guardian) did not appear to me to be suffering from any illness or injury nor any condition that would affect his/her ability to refuse medical care, treatment, and/or transportation. The patient (or patient’s guardian) is alert and oriented to person, place, time, and situation. EMS Provider Signature: ______________________________________ Date: _________________________ Provider Certifi cation Level / NYS ID Number: ______________________ Police Agency Present: NO _____ YES _____ Police Offi cer’s Name: ____________________________ Police Agency Name: ______________________________ Figure 6-3 An example of a refusal of medical assistance form. (Reprinted with permission of Rensselaer County Emergency Medical Services) The Law and Paramedics 95 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. cardiology capabilities, and stroke centers, with rehabilitation The state of Missouri interceded, stating there was no facilities, for example. “clear and convincing evidence” that Ms. Cruzan did not Diversion should only occur under express authority of want to live this way. The appeals for this decision went all medical control and when the patient has been fully appraised the way to the U.S. Supreme Court, who upheld the lower of the risks associated with refusing to go to the specialty courts’ decision. hospital. Subsequently, several of Ms. Cruzan’s friends came forward and testifi ed, under oath, that they had had conver- Advanced Directives sations with Ms. Cruzan in the past and that she indicated she would not want to live in a persistent vegetative state. The development of new life-saving technologies is accom- Had Ms. Cruzan made her intentions known to others panied by questions about the quality of life in terminal earlier, or in a more defi nite manner (e.g., in a written letter), illness and prolongation of suffering.25 These advances have the controversy would have been averted. coincidentally occurred at a time when patient autonomy The Cruzan case helped to establish the concept of is increasingly being asserted. Together, the two trends have advanced directives, a central tenant in the right to die combined to create a confl ict between paternalistic physicians movement. Advanced directives, written declarations of who have always had dominion over life and death decisions patient intent during specifi c circumstances, are designed and the patient’s wishes regarding the quality of his or her life. to provide guidance when a patient is threatened with an Several landmark cases have had a tremendous impact existence in a persistent vegetative state or affl icted with a upon these decisions, changing the entire fabric of medical terminal illness. decision making in the process. Case of Karen Ann Quinlan Principles of Advanced Directives Four core principles are included within the concept of Karen Ann Quinlan was found unconscious following advanced directives. These principles

provide a foundation suspected ingestion of barbiturates and alcohol at a party. which sustains an advanced directive. Following mouth-to-mouth resuscitation, Ms. Quinlan The fi rst principle is that competent people can refuse recovered but remained in a persistent vegetative state (PVS). medical treatment, even at their own peril. This statement Her family, witnessing her body waste away and given no affi rms the patient’s right to self-determination. hope for a recovery to a meaningful life, requested that the Next, the interests of the state are subordinate to the will mechanical ventilator supporting her be removed and that of a competent patient. If the competent patient, meeting Ms. Quinlan be allowed to die peacefully, in other words, all of the conditions of consent described earlier, makes a “death with dignity.” decision about his or her health care, then that decision is The state took the position that such an act, removal of inconvertible. the ventilator, would cause her death and therefore constitute The third principle supports making healthcare decisions criminal homicide. The state sought to prevent the family in a healthcare setting as opposed to a court room. The idea is from removing Ms. Quinlan from the ventilator. that the best patient care decisions are made by a partnership The family felt that Ms. Quinlan, a devout Catholic, of physician and patient and that the courts are used only would not want to live by these extraordinary means, and when an impasse is reached. that decisions on her behalf were a private family matter. The The fourth principle states that if a patient lacks the family also felt the state’s position constituted an invasion of ability to make decisions, then the patient may assign privacy (i.e., the patient’s right to self-determination). a surrogate decision maker in her stead. A surrogate The New Jersey Supreme Court ruled in favor of the decision maker has the responsibility to know the patient’s family, stating that the family’s right to privacy extends to preferences and must place the patients’ wishes before the matters of life and death. Ms. Quinlan was removed from the surrogate’s wishes. This level of understanding usually ventilator, started to breathe spontaneously, and survived for involves a personal dialogue between the two individuals almost a decade. and frequently results in a written statement that helps to The importance of the Quinlan case was that it recognized support the decision maker. the patient’s right to make life and death decisions and If the surrogate decision maker knows the patient’s preserved the patient’s autonomy. That case helped initiate wishes, then, in certain situations, the surrogate makes the right to die movement. the decision in a process called substituted judgment. If the surrogate decision maker does not know the Case of Nancy Cruzan patient’s wishes for the specifi c situation that he or she is Nancy Cruzan was a young woman left in a persistent vegetative being presented with, but does know the patient’s wishes state (PVS) following head injuries sustained in a motor for similar situations, then the surrogate must make a vehicle collision. Faced with the prospect of a bleak future, decision on the presumption of what is in the patient’s best the family wanted Ms. Cruzan’s tube feedings stopped.26 interest. 96 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Patient Self-Determination order (sometimes called a Do-Not-Attempt-Resuscitation Act of 1990 (DNAR) order). Paramedics are expected to honor a DNR order and In 1990, following the public’s growing insistence that the not commence cardiopulmonary resuscitation (CPR), patient should control the personal healthcare decisions, defi brillation, or other advanced life support measures when Congress passed the Patient Self-Determination Act presented with a DNR. (PSDA).27 The confusion lies in which treatments are life-sustaining Regulations within the act required hospitals to provide versus life-prolonging. The provision of supplemental oxygen notice to all patients that they have several rights. First, the (e.g., via a partial rebreather mask) is generally considered to patient has a right to participate in and direct her own health be life-sustaining and therefore acceptable. However, assisting care. Next, the patient has the right to refuse medical and/ ventilations with a bag-valve-mask assembly is thought to be or surgical treatments, up to and including the use of life- life-prolonging and therefore unacceptable. saving or life-preserving technologies. The patient also has It is important that Paramedics establish with their a right to prepare an advanced directive, and the hospital medical directors, beforehand, which treatments are life- should assist the patient with preparing an advanced sustaining and which are life-prolonging. directive. Finally, the hospital has a duty to assist the patient There is general agreement that the provision of pain with those decision-making activities such as preparation of medication, for the purpose of palliative care, is life-sustaining advanced directives, designation of a healthcare proxy, and and therefore acceptable. All forms of comfort measures assistance with the institution’s policies on how to utilize (i.e., palliative care, including suctioning, repositioning, and those rights. analgesia) are considered humane and merciful. Types of Advanced Directives Physician’s Order The intention of an advanced directive is to give the patient of Life-Sustaining Treatment control over her own body and to provide guidance to others Physician’s Order of Life-Sustaining Treatment (POLST) on how to proceed with healthcare decisions. In addition, is a more detailed description of the patient’s wishes, placed these advance directives afford healthcare providers some in the form of a physician’s order. This program was started in immunity from criminal or civil prosecution for making Oregon in 1991 as an answer to the issues that routinely occur decisions or taking actions on the patient’s behalf. in patients who may have a DNR order, but who have not yet There are several advanced directive instruments which progressed into cardiopulmonary arrest. Most states in the meet these objectives. The fi rst, and perhaps original, United States only allow Paramedics to honor DNR orders advanced directive instrument is the living will. The living once the patient has become pulseless and apneic. They will, drawn up by a patient, and perhaps an attorney, details also do not allow Paramedics to honor living wills or other the patient’s wishes regarding specifi c healthcare decisions. advanced directives. The advantage of the POLST program A living will might preclude certain treatments using is the forms that are generated through a discussion between terms such as “extraordinary treatment,” “heroic measures,” the patient and their physician that address specifi c situations and “artifi cial life support.” The use of these imprecise including utilizing artifi cial hydration, nutrition, intubation, terms has led to confusion and are ineffective if death is antibiotics, and other medical therapies. Many states that not imminent. The states of New York, Massachusetts, and have instituted POLST programs allow Paramedics to follow Michigan have rejected the use of living wills as the language these orders. therein was not “precise and convincing.” These states and many others preferred the creation of a durable power of attorney for health care (DPAHC). A DPAHC is a surrogate Confi dentiality decision maker, one who uses substituted judgment to guide the patient’s healthcare decisions. An aspect of patient trust and provider veracity is the patient’s The healthcare proxy, the title for the person who has assumption of confi dentiality. Inappropriate disclosure of a DPAHC, has a responsibility to review the medical record, sensitive patient information would be a failure on the part of to consult with healthcare providers, and to give consent to the Paramedic and may well have a chilling effect on future either initiate or to refuse care. Paramedic–patient relations. For this reason Paramedics share patient information only with those on a need-to-know basis. The duty of maintaining patient confi dentiality stems Do-Not-Resuscitate Orders from a person’s right to privacy. In the past, this was more of At some stage during the progression of a terminal disease a professional duty than a legal right. However, current laws the patient, or healthcare proxy, may decide that any artifi cial protect a patient’s confi dentiality to a greater extent. life support would be futile and that death is inevitable. In A breach of confi dentiality should not be confused those cases, the physician, after consultation with the patient with libel or slander. Libel occurs when a falsehood which or healthcare proxy, will issue a Do-Not-Resuscitate (DNR) is damaging to a person’s reputation is written or printed The Law and Paramedics 97 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. and then disseminated to the public. Slander occurs when Health Insurance Portability defamatory lies about a person are told to others. Libel and and Accountability Act slander involve the telling of an un-truth, whereas a breach of confi dentiality is an act of unauthorized disclosure of private The U.S. Congress passed the Health Insurance Portability and personal patient information. Both libel and slander are and Accountability Act (HIPAA) in 1996.28, 29 HIPAA provides actionable in a court of law. for criminal penalties for inappropriate disclosure of patient information. It also establishes a number of protections for Breaches of Patient Confi dentiality the patient’s right to privacy. HIPAA was enacted, in part, to stem the electronic transmission of patient information to A patient’s confi dentiality can be broken under some very unauthorized parties. specifi c circumstances. The American Medical Association HIPAA restricts the distribution of confi dential patient (AMA) acknowledged this in a position paper which says information to only those with a legitimate interest, such that a physician may breach a patient’s confi dentiality when as consulted healthcare professionals, those providing required to do so by law. patient treatment, coding and billing offi ces, and specifi c As stated earlier, the courts hold the physician–patient managerial functions, such as quality assurance and relationship in high regard. Before making a decision to utilization review.30 Patient information may be used abridge a patient’s rights to privacy, the courts weigh the good for training and education provided that all identifying of the community and the protection of the physician–patient information is removed or the patient consents. relationship versus the individual’s rights. The disclosure is HIPAA also requires that every healthcare agency, then limited to that which is necessary to the issue so as to including EMS, appoint a privacy offi cer. The privacy offi cer protect the patient’s privacy rights. is responsible for patient record security, record security Situations in which a Paramedic might be compelled by awareness training of all employees, as well as implementing law to disclose confi dential patient information may include a privacy protection plan within the agency. gunshot wounds, contagious diseases, and/or child abuse and In the future, Paramedics may be required to provide those cases where it is necessary to protect the welfare of patients with a notice of privacy practices for the EMS agency. another individual or the community. Laws in each state or That may include information about what confi dential patient jurisdiction may vary and the Paramedic should be familiar history is considered to be protected health information with applicable statutes that may impact him or her. (PHI). Limited Disclosure Disclosure to Law Enforcement The number of people who are directly, or indirectly, On occasion, law enforcement offi cers will request specifi c connected to the care of one patient is incredible. Literally information about a patient. In most cases, the disclosure dozens of people, from bedside caregivers to support services, of confi dential patient information to another could be a to utilization review, billing, and quality assurance, all have violation of the HIPAA regulations. Generally, the offi cer access to

a patient’s confi dential record. should be provided with information which is required by law. The concept of legitimate interest comes into play when The patient’s name and address can be shared but all other deciding if patient information should be shared. A Paramedic requests for information should be denied until the patient should only provide confi dential patient information to those signs a release of information or a subpoena is served.31 who have a need to know, and then only to the extent that that is needed. For example, an admission clerk does not need to know the patient’s HIV status, yet does need to know if the Employment Law patient has been previously admitted. A notable portion of The Paramedic, whether career or volunteer, is an employee people in the medical chain will need confi dential patient of the EMS agency. As such, the Paramedic is afforded certain information (Table 6-2). protections as a result of Congressional acts. The following is a gross overview of those laws which may pertain to the Table 6-2 Information Dissemination Paramedic. Other laws, both local ordinances and state statutes, may also apply to the Paramedic. Therefore, every • Paramedic Paramedic is advised to become aware of the relevant legal • ER MD and RN environment and seek legal counsel when appropriate. • Billing clerk • Utilization reviewer Americans with Disabilities Act • Infectious disease RN Congress passed the Americans with Disabilities Act • Public health service (ADA) to protect those citizens who had suffered hardship • CDC or discrimination from employers. The ADA prohibits • Media—reporting outbreak discrimination based on disability in hiring, promoting, training, and retiring. To be included in the class of protected 98 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. persons, the individual must have a permanent disability process. Most complaint processes start with an internal which limits full participation in the activities of daily living investigation of the inappropriate conduct and end with a (ADL). resolution that can vary from counseling and reassignment The ADA does not imply that, for example, the hearing- to termination. impaired person must be hired as a Paramedic. Clearly, some jobs require specifi c skills and capabilities. These skills and Amendments to Title VII capabilities are generally described in the position’s functional Since its passage through Congress, Title VII has had several job description. The tasks described therein are those that are amendments added. One of them, the Age Discrimination in needed to perform the function and exclude rare or marginal Employment Act (ADEA), prohibits the discrimination of job functions. those over the age of 40. Another, the Equal Pay Act, requires Perhaps more importantly, the ADA establishes that that pay be based on seniority or merit and not personal reasonable accommodations must be made, whenever preference. possible, which would permit the disabled person to function. EMS and the Fair Labor Standards Act (FLSA) have New technologies are ever increasing the capacity of disabled come into confl ict from time to time. The FLSA is intended citizens to perform varied and vital functions, many within to guarantee that all employees are paid the minimum wage EMS. as well as receive overtime for working extended hours past the normal workweek. Title VII Over the years, employers have created a large number Title VII, the Civil Rights Act, provides the employee with of work patterns and arrangements in order to meet the certain rights (e.g., freedom of religious expression, etc.). public’s demand for round-the-clock EMS coverage. These Recently, a great deal of notoriety has been given to the right arrangements include on-call pay, per diem pay, stipends, and of employees to be free of sexual harassment. the like. Some of these arrangements had to be modifi ed to Sexual harassment can be as blatant as demands of sex meet the requirements of the FLSA. in exchange for career advancement, a quid pro quo. In many cases, the charge of sexual harassment stems from a Family and Medical Leave Act perception of a “hostile working environment.” A hostile The Family and Medical Leave Act (FMLA) requires working environment is one that is intended to humiliate that employers with more than 50 employees provide or intimidate the worker because of gender. Examples of a their employees 12 weeks of unpaid leave for purpose of hostile working environment include displays of sexually childrearing. explicit pictures, uninvited kissing or embracing, or fl agrant Many employers have embraced the FMLA by creating sexual humor. family leave policies, believing that employees who are Every EMS agency should have a policy forbidding afforded the opportunity to establish their families and then sexual harassment and that policy should include a complaint return to work will be happier and more productive. The Law and Paramedics 99 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The acts, laws, and regulations which affect a Paramedic are intended to either protect the Paramedic or to provide for the patient’s protection. Careful attention to these laws, both in letter and in spirit, will help the Paramedic provide safe and effective care. Key Points: • Case law is developed from compiled case decisions • Good Samaritan laws protect healthcare providers and assures fairness through consistent application from liability for negligent acts that are performed of the law. in the course of providing assistance when there • is no duty to act or respond. Although these laws Different units or departments carry out various do not provide immunity from lawsuits, the Good functions of government. Each department may Samaritan acts do provide the Paramedic with be regulated by rules or regulations that are not legal defense to counter a complainant’s claim of statutory laws but carry the same force. negligence. • Criminal law is a violation of a person’s duties to • Standard of care is the care and treatment that the community; therefore, the prosecutor is the another Paramedic with the same or similar state and the case is tried in a criminal court. training would have rendered in the same or similar • An appeal is a request for the appellate court to situation. change the decision issued by the trial level court. • Malfeasance is the performance of an inappropriate • Civil law is the system of law concerned with private procedure. disputes between members of the community. • Misfeasance is the situation when a Paramedic • A tort is a civil or private wrongful act, other than a performs the right procedure but performs it breach of contract, resulting in some type of injury incorrectly. or harm (not necessarily physical injury). • Nonfeasance is the failure to perform the correct • Simple negligence is the Paramedic’s failure to or required procedure, which would be an error of exercise the degree of care that a prudent person, omission. under the same or similar circumstances, would • Damages are compensation awarded to the patient exercise. for some injury or loss. • Gross negligence involves intent on the Paramedic’s • The Paramedic is responsible for directing and part to willfully or with reckless disregard cause the supervising the patient care performed by any other patient harm. EMS providers on the team with less training than • For a tort of malpractice to be actionable against the Paramedic. a Paramedic, it must have the four elements of • The process of a civil lawsuit begins with the tort. First, the Paramedic must have a duty to Paramedic being served papers by a process server. act. Second, it must be shown that the Paramedic breached his duty (standard of care). Third, there • The purpose of the pretrial discovery phase is to is actual harm or damages as a result. Fourth, provide both parties with suffi cient information to proximate cause of harm must be shown. decide how to proceed with the case. 100 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • Immunity is usually granted when the Paramedic • If the child has been left in the custody and care is required by law to report a crime, called of another adult, that adult has been given loco mandatory reporting, and the Paramedic does so in parentis and has the authority to provide consent. good faith. • In rare cases, a parent may refuse treatment and • A motion is a request to the judge for some action. transportation for a child. If the parent still refuses • to give consent after attempts to convince him care The best defense against a successful lawsuit is to is needed, it may be necessary to involve a law practice within the Paramedic’s scope of practice, enforcement offi cer and invoke child protective laws. to practice to the standard of care within the EMS system, to observe the patient’s rights, and to • Paramedics may encounter a patient experiencing completely and thoroughly document one’s actions. a behavioral emergency. In a situation in which the • patient does not want to go voluntarily, it may be The signifi cance of patient consent is that the necessary for either the Paramedic or the offi cer patient makes a rational decision based on to invoke the mental health law and to restrain the information that the Paramedic provides. patient in order to protect the patient from himself • To obtain a valid legal consent, the patient must be or herself or to protect others from the patient. of sound mind and have the capacity to understand what is being offered. • Following restraint, it is imperative that the Paramedic periodically reassess the patient and • The patient’s consent must be voluntary and the document the continued need and use of restraints. patient cannot be coerced into consenting. The least restrictive, but effective, restraint should be used. • In rare instances disclosure is contraindicated from a medical point of view if the disclosure poses a • In the case where the patient can consent, and yet threat or detriment to the patient. still refuses care, the Paramedic needs to carefully proceed with a refusal of medical assistance (RMA). • Consent protects the patient’s right to choose, The Paramedic should proceed with a complete decreases legal charges against providers, and can description of the illness or injuries that he or she have a therapeutic benefi t in and of itself. has sustained and the potential complications that • could arise if the illness or injuries are not treated. A law enforcement offi cer can provide involuntary consent during a life or limb emergency when a • Paramedics should offer assistance to the limit that patient is in custody. Similar circumstances apply to the patient will accept. patients who are under the control of mental health offi cials. • Generally, patients are transported to the closest • appropriate medical facility. Circumstances may Emancipated minors are those youths under the age occur necessitating diversion from the closest of 18 who are married, enlisted in the armed forces, hospital to a hospital equipped to handle the or have petitioned and have legal documentation of patient’s particular emergency. emancipation. Also, once an adolescent female is a mother she is capable of consenting for treatment • High-profi le

primary care treats individuals. of public health to infl uence family health and planning. Because of its community focus, public health concentrates Through education, promotion of well-baby visits, childhood on the detection of community-wide disease and the creation immunization programs, and freestanding clinics, infant of programs for injury prevention. mortality has dropped 90% from 1900 to the present and Public health helps to reduce the cost of health care, maternal mortality has dropped 99%.4,5 through prevention and/or reduction of injury and illness, Paramedics may recognize the effects of these efforts over and therefore provides signifi cant economic benefi ts to the decades in terms of injury from motor vehicle collisions. the community. Many people believe that public health Improvements in motor vehicle safety through improved is rightfully a function of government. Governments, in motor vehicle engineering (e.g., seat belts and airbags) and general, are formed to secure the people’s welfare and help improved road design (e.g., civil engineering) have resulted ensure a population’s prosperity. Therefore, public health can in a marked decrease in mortality and morbidity in motor be viewed as a matter of national security in that the country’s vehicle collisions. health provides for that country’s social stability. Injury Surveillance Impact of Public Health Injury and illness detection is the fi rst step in injury and Prevention Programs illness prevention. Based upon research and statistical data concerning the incidence of a disease or the prevalance In the past, the spread of infectious diseases (such as of an injury, public health offi cials can make judgments smallpox and the plague) was rampant and mortality from about the need for new prevention programs or the revision these diseases was very high.3 In some instances, public of an existing prevention program. Therefore, for public offi cials would attempt to enforce public health measures, such as quarantine, in an attempt to halt the transmission of these diseases, with varying degrees of success. However, Table 8-1 Examples of Paramedic Public the result of these “after the fact” measures was premature Health Initiatives death, evidenced by an average life expectancy of 30 years. Pedestrian safety Bicycle lanes and sidewalks In the last century, the average life expectancy in the Bicycle safety Helmet patrols (ice cream tickets) western world has steadily increased to the point where it is over SIDS Back to sleep programs 70 years in most industrialized countries. This improvement Drowning prevention Pool inspections can be attributed to a combination of improvements in Child passenger safety Childseat inspections preventive medicine and to broad public health measures such as sanitation systems and water purifi cation plants. Food safety Health inspections 120 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. health offi cials to make good decisions they need accurate Table 8-2 National Centers for Injury information (surveillance). This process, surveillience and Prevention Programs prevention, is consistent with the “plan-do-check-act” cycle of quality improvement. 1. University of Alabama 2. University of California at Los Angeles (UCLA) Early Efforts at Injury Surveillance 3. University of California at San Francisco One of the early champions for public safety and injury 4. Harvard School of Public Health prevention was Ralph Nader. Nader and his associates, 5. University of Iowa referred to as Nader’s raiders, would investigate and report 6. Johns Hopkins University School of Hygiene and Public Health to the public items and goods that they deemed unsafe. 7. University of North Carolina These early efforts amounted to surveillance of a problem 8. University of Washington, Harborview Medical Center and a recommendation for action to reduce or eliminate the 9. University of Pittsburgh, Center for Injury Research and Control problem. One problem Nader was concerned about was the 10. Colorado State University high incidence of mortality caused by ejection from a motor vehicle. Largely as a result of Nader’s vigorous lobbying of the the pressing trauma conditions at that time.This information government and industry, cars were required to have case- is also used to create injury prevention programs focused on hardened steel pins, later called Nader pins, installed in car the specifi c trauma issues encountered in a given region. door locks. These Nader pins prevented passengers from being ejected during a motor vehicle collision, and have therefore saved countless lives. Nader’s infl uence in injury EMS and Injury Prevention prevention serves as an example of one group’s ability to have As a part of an approach to provide comprehensive prehospital a positive impact on the community’s health through injury care, Paramedics have been increasingly involved in public surveillance and action. health efforts. Injury prevention programs, in particular, have involved Paramedics. Trauma Surveillance In 1996, the National Highway Safety and Traffi c While Dr. “Deke” Farrington’s article “Death in a Ditch” and Administration (NHSTA) helped to create a consensus the 1966 white paper “Accidental Death and Disability: The statement regarding EMS and injury prevention. That Neglected Disease of Modern Society” brought the problem statement, “Role of EMS in Injury Prevention,” affi rmed the of trauma to the forefront, it took another white paper, position of EMS as a legitimate source for injury prevention “Injury in America: A Continuing Public Health Problem” to education.8 It was hoped that the consensus paper, sent out emphasize the lack of injury prevention.6,7 for peer-review to some 300 leaders in the EMS community, Written by the National Academy of Sciences in 1983, would help to shift some of the focus of EMS toward injury “Injury in America” emphasized that injury prevention is more prevention and health promotion. cost-effective than injury treatment. As a result, Congress EMS was specifi cally identifi ed as a vehicle for this injury dedicated funding to injury surveillance and prevention. prevention campaign because of its unique advantages. EMS Subsequently, the federal Centers for Disease Control was agencies are, at their essence, community-based organizations tasked with injury surveillance and created the Division of which blend public safety with public health to provide a Injury Control, which is now called the National Centers for service, EMS.9–11 In their role as EMS providers, Paramedics Injury Prevention and Control and the name of the federal enjoy the public’s respect. This high-credibility affords them Centers for Disease Control was changed to the Center for an effective platform from which to educate and to support Disease Control and Prevention. changes, especially regarding injury prevention. There are 10 national injury prevention and control Injury Prevention Theory centers across the country (Table 8-2), each with a focus on regional injury interests, and all are a part of a national and the Haddon Matrix network of injury prevention programs. Starting in 1963, William Haddon, Jr., the fi rst director of the Injury statistics are also compiled in the National Trauma NHSTA, started work on an injury prevention matrix, an easily Registry, which is maintained by regional trauma centers. This understood concept map of injury casuation and prevention. registry is an invaluable source of data regarding trauma and Using a model similar to one used for disease, Haddon plotted trauma trends. Selected data fi elds, called a data set, are gleaned the factors that cause injury across a horizontal X-axis and the from the patient care record (PCR) produced by Paramedics. stages of an injury process along the Y-axis. The result was an High-performing EMS agencies typically consult the injury prevention matrix. trauma registry for valuable information regarding topics for Each square in the Haddon matrix represents an continuing medical education and professional development opportunity to intervene and either prevent or mitigate the in order to keep current and ensure Paramedics are prepared for effects of traumatic injury. The matrix helps people recognize Illness and Injury Prevention 121 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. that the Paramedic is not limited to affecting traumatic injury The fi rst intervention point for prevention would be only after an injury occurs. It emphasizes that there are other elimination of the offending agent. While in some cases, such opportunities to affect traumatic injury. The horizontal X-axis as handguns, this may appear unreasonable, consider the case contains the elements host, agent, and environment, taken that was made for nuclear disarmament. That is, the ability from the Public Health Model. In the case of injury, the host to possess the weapons exists but there is a decision not to is the patient and the host’s characteristics are those human possess them. factors, such as alcohol intoxication, which come into play If the agent (i.e., the hazard) cannot be eliminated, then during an injury. perhaps it can be reduced to a non-lethal level. For example, The agent is the source of the injury. In broadest terms, it a pharmacist is only allowed to fi ll a limited prescription is the source of the mechanical (kinetic), chemical, electrical, of tricyclic antidepressants. This limited number of pills thermal, or radiation energy that, when infl icted on someone, dispensed helps to ensure that less than lethal doses are readily causes trauma. For example, a handgun would be the agent of available to the potentially suicidial patient with depression. injury in a pediatric gunshot wound. If the hazard cannot be eliminated or reduced, then The fi nal X-axis component is the environment. The perhaps the hazard can be contained in order to prevent its environment consists of those circumstances which have release or use. For example, pools have long been recognized an impact on the trauma. The environment can be further as an attractive nuisance to children. Many accidental subdivided into social environment and physical environment. drownings have occurred in unsupervised pools. An example The physical environment, in the case of pediatric gunshot of containment of this hazard would be to assemble fences, wounds, would be the presence of a handgun in the home. with padlocked gates, around pools. This containment The social environment would be the combination of the measure is mandated by law in many communities. adult’s attitude regarding handgun ownership, laws pertaining If the hazard cannot be eliminated, nor reduced, nor to handgun registration, and the child’s innate curiosity. contained, then perhaps the rate of release can be slowed, and/ Marked along the Y-axis are the stages of injury: pre- or distributed over time, in order to decrease the impact of the event, event, and post-event. These stages correspond with the event. Airbags and padded steering wheels are designed to three levels of medicine: primary care, secondary care, and dissipate the energy in a collision across both a larger area as tertiary care. Table 8-3 illustrates a Haddon matrix, using the well as over a longer time. problem of accidental shootings in the pediatric population If the hazard cannot be eliminated, nor reduced, nor and interventions as an example. These interventions are only contained, nor slowed, then the only alternative is to eliminate theoretical. The appeal of the Haddon matrix is that it allows— the target (i.e., the host). A case in which the host, the patient, and almost encourages—free-thinking (i.e., “thinking outside is eliminated is highways are closed during snow emergencies. of the box”) about solutions to public health problems. A declared snow emergency, enforced with the force of law, prevents motorists from even being on the highway under Injury Countermeasures potentially dangerous conditions. In 1970, Haddon produced another paper on injury prevention, In some cases, if the host can be removed, then protecting entitled “On the Escape of Tigers: An Ecological Note.” The the host is the best option. Safety engineers have created paper precisely detailed the 10 levels of countermeasures many barrier devices, ranging from simple gloves to soft that could be effective in reducing

injury. Starting from pre- body armor, to protect the host (people) from injury. incident (i.e., preventative medicine) and proceeding through If contact between the agent and the host is inevitable, to post-incident or clinical medicine, Haddon lays out the then modifi cation of some basic quality of the agent could logical points for effective intervention in injury prevention. be considered. For example, enlarging the size of baseballs Table 8-3 Haddon Matrix for Accidental Pediatric Shootings Problem Statement: CDC reports, in the year 2000, that there was a 58% increase in the number of gun accidents in the pediatric population aged 0–4 years of age, or 1,200 accidental pediatric shootings. Host Agent Physical Environment Social Environment Children age 0–4 Handguns loaded Home bedside United States Right to bear arms Pre-incident Gun safety education Trigger locks Gun lock boxes Gun regulation Incident Pediatric shooting Restriction Gun alarms Gun ownership Body armor Fully automatic Education classes Post-incident Pediatric GSW EMS Automatic confi scation Trauma systems Community statistics Pediatric GSW education 122 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to what we now call the softball decreased the incidence of on injury prevention is seat belt safety seminars. Following orbital fractures in children playing baseball. public education campaigns about the importance of seat In addition, modifying the host (the patient) to be more belt use, the use of seat belts remains highest in younger resilient to injury can help to decrease the injury’s incidence or drivers. Older drivers, taught to drive when seat belts were severity. For example, many healthcare plans offer employee not mandatory, have been more resistant to change. exercise programs to improve the health of their participants The third E, law enforcement, is actually a form of learning. and increase the participants’ resilence to injury and illness, Law enforcement provides punishment for nonconformance thereby diminishing the effect of the hazard/agent. with safety regulations, a form of operant conditioning. If injury cannot be prevented and yet is foreseeable, then Enforcement of safety regulations, such as speed limits, and systems for the rapid detection, treatment, and evacuation the resultant punishment of fees and fi nes provide the host to defi nitive treatment need to be in place. This essentially with a powerful incentive to change behavior. describes the mission of EMS. The fourth and fi nal E is economic incentives. It is also However, improvement in these systems can increase the a form of education—positive operant conditioning. Efforts effi ciency and the effectiveness of EMS. An example of an to behave safely or to correct behaviors are encouraged by improved means of detection is the addition of technology positive feedback, in the form of economic reward. For for location identifi cation of cellular telephone users. This example, some EMS systems distribute tickets for ice cream can improve the communications specialist’s ability to send cones to children seen wearing bicycle helmets. Another needed help. OnStar® is one system available in motor vehicles example might be a rebate after the purchase of a child’s car that detects and reports—through impact sensors, cellular seat or a smoke detector. technology, and global positioning systems—the location and extent of a motor vehicle collision back to a public safety Assessment access point (PSAP). Finally, efforts to improve tertiary care and rehabilitation Whenever Paramedics or an agency become involved in will diminish the long-term impacts of injury. Prostethetics, primary injury prevention, using any of the previous strategies, used to treat wounded soldiers of the Irag war, have improved they are improving the quality of health in their jurisdiction. tremendously and offer an improved quality of life to these Therefore, like all EMS activities, injury prevention is veterans. included in the quality improvement cycle. The fi rst portion of the PDCA cycle of quality improvement is planning. Several key questions should be answered before Injury Prevention Strategies implementation of the initiative as the answers may affect Injury prevention strategies are ways to go about the decision-making process. Every suggested improvement, implementing Haddon’s countermeasures.12 These can whether it is implementing an educational program or include engineering safety into products or processes, purchasing a product with an engineered safety feature, needs educating people about the dangers, increasing or improving to be weighed in a cost-benefi t analysis. The cost, whether enforcement of laws and regulations which promote safety, fi nancial or otherwise, must be considered in light of the and providing economic incentives for people to use safer potential benefi t to be gained from the proposed change. products or processes. For instance, is the cost of the product (for example, a self- Paramedics, when trying to brainstorm injury prevention protecting intravenous catheter) worth the benefi t of reduced strategies for inclusion in Haddon’s countermeasures, needlestick injuries which can cost, by some estimates, can consider four basic strategies, the “4-E’s,” of injury as much as $5,000 per incident? Would one potentially prevention. preventable needlestick injury pay for the increased costs of The fi rst E, engineering, refers to the addition of safety the new intravenous catheters? devices during the engineering phase of product design that Intrinsic within the cost-benefi t analysis is the question will prevent injury. The creation of needleless intravenous of acceptance by the user. A safer device that is not used administration sets is an example of safety engineering. In offers no benefi t. For example, workers must use the safer this case, the injury, accidental needlesticks, is eliminated device in order to prevent injuries. OSHA recognized this fact through a pre-incident intervention which affects the agent. when it required the participation of nonmanagerial front-line The next E, education, requires that the educator change employees in the decision-making process for utilization of the behavior of the host, the population, in a substantial personal protective equipment (29 CFR 1910.1030(c)(1)(v). manner. To affect such change, educators usually must Also taken into consideration during planning is the energize learners, through motivational speaking, to change concept of equity. Safety changes (e.g., workplace routines) behaviors that may have already been engrained into their lives. must be equitable. Equity is a concept of fairness or Understandably, the impact of injury prevention is greatest evenhandedness. To be accepted, any change must appear to when the learner has not already learned the behavior and be equitable to all parties concerned. is just initially learning the “correct” behavior, the one that Changes that are broadly applied to all individuals would will decrease injury. An example of the impact of education be said to have horizontal equity. For example, the blood Illness and Injury Prevention 123 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. alcohol level of 0.08 is considered the limit in most states for Teaching Injury Prevention driving while intoxicated. This legal limitation is an example of an effort to prevent alcohol-related collisions by reducing Paramedics appreciate that every call for an injured person the threshold for law enforcement. The change is then applied has the potential for being a moment to refl ect on the activity to everyone. that caused the injury and consider how to prevent that injury However, in some instances it is more appropriate in the future. That moment is called the teachable moment. to provide an injury prevention program to one group A teachable moment might be defi ned as the time when of people who are unduly affected by a problem. This the patient has a heightened awareness of a problem and is unequal treatment, preferential or targeted treatment, tends receptive to information.The positive impact which prevention to improve the health of that specifi c group. However, it can have to prevent future injury can be mentioned. also tends to reduce the burden carried by the rest of Use of this opportunity to teach, to change the behavior the population in the form of higher taxes or insurance of another person, must be carefully considered. Ill-chosen premiums. This type of injury prevention program would words can sound accusatory and produce an effect opposite create vertical equity. For example, if statistics demonstrate of the intended effect. The patient may perceive the well- a higher number of accidental shootings among children in intentioned words of a Paramedic as victim blaming. Victim low-income households, then public health programs could blaming is counterproductive to the goal at hand, preventing be justifi ably organized to emphasize prevention within a similar occurrence in the future, and tends to cause hostile that population. feelings. For example, lecturing a patient with emphysema When Paramedics are planning injury prevention about the ill effects of smoking at a time when the patient programs, they should be sensitive to the problem of stigma. is short of breath is both ill-advised and counterproductive Stigma is a negative connotation attached to participation in to the goal of smoking cessation. It would be better if the a program, such as labeling and public embarassment. For Paramedic were to offer supportive and nonjudgmental care example, a prevention program that asks drug abusers to to the patient at the present time and then leave the card of a come forward and be identifi ed before participation in a drug smoking cessation program with a family member. treatment program may not meet with much acceptance by the intended benefi ciaries. The potential participants may be concerned about persecution and public ridicule as well as labeling. The success of Alcoholics Anonymous is owed, in Professional Paramedic part, to the anonymity that participants are provided while they recover. Many behaviors are culturally related. The The fi nal question concerns the feasibility of any proposed professional Paramedic should recognize that changing changes. In some instances, prevention programs require the reallocation of scarce resources, including personnel and a behavior may be better accomplished through funds. The reallocation of essential resources requires the Paramedic cultural or religious networks. The goal is enlightened thinking of EMS leaders who can see the long- assisting the patient, not the Paramedic’s glory. term benefi t of such programs. Unfortunately, the realities of politics often interfere with these programs. As a result, many prevention programs—both local and federal—have fallen EMS Injury Prevention Programs due to budget cuts and other immediacies. Some Paramedics may still be hesitant about getting involved in public education for injury prevention, citing concerns Implementation about this “new” role. But these Paramedics should be aware To lead successful injury prevention programs, EMS leaders that other Paramedics have been remarkably successful with must fi rst get Paramedics to invest, intellectually and public education campaigns in the past. A model for EMS spiritually, in these programs. The changing safety paradigm success in injury prevention is the EPIC medic program in in EMS, placing personal safety above all else, is helping San Diego.13 The San Diego Paramedics created an injury Paramedics see the benefi ts of injury prevention programs. prevention project entitled Eliminate Preventable Injuries Chapter 3 on personal well-being emphasized the impor- of Children (EPIC). Using a combination of home safety tance of safety and injury prevention. Paramedics, cognizant assessments, pool safety inspections, child passenger of their roles as models for their community, may minimal- seat safety education, and several other initiatives, these ly demonstrate those safety habits that they would have the Paramedics have strived to make their community a safer public emulate. For example, passing motorists who see a environment for children. Paramedic wearing a seat belt, driving with headlights on The success of programs like the EPIC medic program during the daytime, or using headlights along with windshield has not gone unnoticed by their peers and the community wipers, may imitate the Paramedic’s action. These injury

alike. For example, the EPIC Paramedics were awarded the prevention efforts can have a positive impact. Nicholas Rosecrans Award, a national award recognizing 124 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 8-1 The EPIC team receiving the Nicholas Rosecrans Award for excellence in injury prevention. (Courtesy of EPIC medics; photo by Jeff Lucia) excellence in injury prevention in EMS (Figure 8-1). The or process evaluation, includes statistics on attendance, Nicolas Rosecrans Award is given to agencies or individuals among other items, and explains how the program was for community work with injury prevention. Specifi cally, this implemented. This information is vital to a later analysis prestigious award may be given to those agencies or persons of cost versus benefi t. In some cases, the outcome may be who have either established or expanded a comprehensive acceptable even though more effi cient or effective means of injury prevention program, promoted injury prevention achieving that goal are available or possible. within the EMS community, improved the delivery of EMS The measurement of ends, or outcomes evaluation, is to injured patients, or successfully created collaborations or a matter of comparing the level of injury or illness before partnerships with other public safety organizations to advance and after the program. The initiative is evaluated to determine injury prevention. whether the program made a difference. For example, data about rates of injury in motor vehicle collisions following a seat belt campaign can be obtained from patient care records (PCR) Outcomes or trauma registry statistics. Statements about the success or Action without refl ection cannot be said to be effective, for failure of injury prevention programs rest on the result of the there is no measurement of the change. Statements about outcomes evaluation. For example, Pinellas County EMS in the effectiveness of an injury prevention program require Florida established a pool safety campaign after a series of verifi cation. A process of evaluation, the checking portion in drownings. Kicking off with a media campaign to announce the PDCA cycle, is an integral part of any injury prevention the campaign, the Paramedics of Pinellas County performed program. public education programs, pool safety inspections, and the The measurement of any success, including success in like. Following the campaign, Pinellas County EMS was able injury prevention, is typically data-driven. The measurement to show a 43% reduction in drowning.14 These kinds of hard should involve both the means and the end. Measuring means, numbers tend to impress the public and politicians alike. Illness and Injury Prevention 125 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. With the specter of Avian fl u, the epidemic in obesity, and the proliferation of drug-resistant diseases, there will be many opportunities for Paramedics to work with public health in a strategic alliance that can be synergistic and provide the best outcome for the public. Key Points: • Public health is based on the premise that, as a • The fi rst director of the NHSTA developed an injury community, it is easier to prevent disease or injury prevention matrix based on the factors that cause than provide treatment. With public health, the injury and the stages of an injury process. The concentration lies on the detection of community- matrix emphasized that there is an opportunity for wide disease and the creation of programs for the Paramedic to affect traumatic injury before injury prevention. injury occurs. • Current public health prevention initiatives include • In another paper on injury prevention, Haddon family planning, smoking cessation programs, detailed 10 logical points or countermeasures for workplace safety, and motor vehicle safety. These effective intervention in injury prevention. An initiatives are areas of focus because they have example of Haddon’s logic that is pertinent to been shown to result in signifi cant mortality for the paramedicine is that, if injury cannot be prevented public. and yet is foreseeable, then systems for the rapid • detection, treatment, and evacuation of defi nitive In order for public health offi cials to make treatment need to be in place. good decisions, they need accurate information or surveillance. Ralph Nader pioneered early • The “4-E’s”—engineering, education, law surveillance efforts by investigating and reporting enforcement, and economic incentives—are basic to the public about items and goods that were strategies that the Paramedic can use when deemed unsafe. The Paramedic can appreciate brainstorming injury prevention strategies for improvements on motor vehicle safety that resulted inclusion in Haddon’s countermeasure of injury in the marked decrease in mortality and morbidity prevention. in motor vehicle collisions. • Injury prevention is included in the quality • Stemming from several documents that emphasized improvement cycle. For each suggested the lack of injury prevention and the notion improvement, a cost-benefi t analysis should that prevention is more cost-effective than be made. Equity should also be taken into injury treatment, the National Centers for Injury consideration, as well as any stigma that may be Prevention and Control were established. These associated with the program. The feasibility of any centers, along with the National Trauma Registry, proposed changes should be assessed. gather data regarding injury interests. • Implementation and the success of injury prevention • The National Highway Safety and Traffi c programs depend on how much the Paramedic invests Administration (NHSTA) helped to increase intellectually and spiritually into the program. The the Paramedic’s involvement in public health changing safety paradigm in EMS, placing personal efforts. This is in part because EMS agencies are safety above all else, is helping Paramedics see the community-based organizations, which affords benefi ts of injury prevention programs. them an effective platform for community education and injury prevention. • An appropriate teachable moment might be defi ned as the time when the patient has a heightened 126 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. awareness of a problem and is receptive to evaluation. These statements about the success or information given by the Paramedic. failure can be used to determine how effi cient or • effective the process was and how effective the An evaluation process is an integral part of any program was overall. injury prevention program. The measurement should include the process evaluation and the outcomes Review Questions: 1. Why is EMS an excellent vehicle for injury 7. Identify the four components of the quality prevention programs? improvement cycle. 2. What agencies compile injury statistics and why? 8. What do EMS providers need to invest into 3. What does the Haddon matrix emphasize? an injury prevention program for it to be 4. What is the fi rst point of injury prevention? successful? 5. What injury prevention point is similar to the 9. Describe a teachable moment. mission of EMS? 10. Why should the evaluation of an injury 6. How are the 4-E’s used in brainstorming injury prevention program measure both the means prevention strategies? and the end? Case Study Questions: Please refer to the Case Study at the beginning of the 2. Identify where the patient in the case study chapter and answer the questions below. currently is and brainstorm ideas for assisting 1. Using the Haddon matrix, identify the host, him in quitting/reducing his smoking. agent, and environment in the case study. Also identify the pre-event, event, and post-event. References: 1. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The 5. Garrett E, ed.,et al. Infant Mortality: A Continuing Social burden and costs of chronic diseases in low-income and middle- Problem. Aldershot: Ashgate Pub Co; 2007. income countries. Lancet. 2007;370(9603):1929–1938. 6. Council N, Sciences D, Sciences N. Accidental Death 2. Novick L. Public Health Administration: Principles for and Disability: The Neglected Disease of Modern Society. Population-Based Management. Sudbury, MA: Jones and Bartlett Washington, DC: National Academies Press; 2000. Publishers; 2004. 7. Council N, Medicine I. Injury in America: A Continuing Public 3. Bollet A. Plagues and Poxes: The Impact of Human History on Health Problem. Washington, DC: National Academies Press; Epidemic Disease. New York: Demos Medical Publishing; 2004. 1985. 4. Thompson JB. International policies for achieving safe 8. Garrison HG, Foltin G, et al. Consensus Statement: The Role of motherhood: women’s lives in the balance. Health Care Women Out-of-Hospital EMS in Primary Injury Prevention, Consensus Int. 2005;26(6):472–483. Illness and Injury Prevention 127 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Workshop on the Role of EMS in Injury Prevention. Arlington, 12. Christoffel T, Gallagher S. Injury Prevention and Public Health: VA: Final Report; 1995. Practical Knowledge, Skills, and Strategies. New York: Jones & 9. Garrison HG, Foltin GL, Becker LR, Chew JL, Johnson M, Bartlett Pub; 2005. Madsen GM, et al. The role of emergency medical services 13. Krimston J, Griffi ths K. EMS champions of injury prevention. in primary injury prevention. East Carolina Injury Prevention Highlights from some of the best injury-prevention programs in Program. Prehosp Emerg Care. 1997;1(3):156–162. the United States. Jems. 2004;29(11):80–84, 86, 88 passim. 10. Griffi ths K. Best practices in injury prevention: National award 14. Kirkwood HA. Before the call comes in. EMS and injury highlights programs across the nation. Jems. 2002;27(8):60–74. prevention. Jems. 1995;20(6):21, 23. 11. Kinnane JM, Garrison HG, Coben JH, Alonso-Serra HM. Injury prevention: is there a role for out-of-hospital emergency medical services? Acad Emerg Med. 1997;4(4):306–312. 128 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The four chapters in this section provide a basic foundation in lifespan development, physiology, pathophysiology, and medical terminology. These areas again help lay a solid foundation for the Paramedic to build upon in the later technical and clinical chapters. • Chapter 9: Lifespan Development • Chapter 10: Basic Human Physiology • Chapter 11: Principles of Pathophysiology • Chapter 12: Medical Terminology 129 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Human development from conception to childbirth • The psychosocial theories of nature vs. nurture • The continuous state of physical, cognitive, and psychosocial development from young to old • The impressionable time of middle childhood and the health concerns that face adolescents • Moral development and

facing adult responsibilities • A greater understanding of acceptance of the stages of dying Case Study: The Paramedics were called to the home of a 13-year-old male with diffi culty breathing. When they arrived they were introduced to Erik. His cold had worsened and he was having some diffi culty breathing. While one of the Paramedics began interventions, the other planned to obtain a history. As he began with questions about allergies and medication, he realized he didn’t know much about what 13-year-olds can do. He made a mental note to review human growth and development. It was like being back in Paramedic school. . . . 130 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Lifespan Development 131 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW The Paramedic may encounter patients ranging in age from newborns to over a hundred years of age. The Paramedic’s emphasis is often placed on how to treat the patient medically. This chapter discusses human development. Knowing the patient’s age can dictate a Paramedic’s approach to assessment and care (for example, the difference between a fussy 3-year-old and an elderly person who is making an end-of-life decision). This chapter discusses the physical, cognitive, and psychosocial development of people from birth to death. Personal Development it. Each theorist has brought a unique perspective to the study of psychosocial development. Paramedics will encounter patients of all ages. Understanding the patient’s developmental stage will help the Paramedic Psychosexual Theory adjust his approach accordingly and to connect more therapeutically with the patient. Sigmund Freud advanced one of the fi rst psychosocial A person’s development can be divided into three developmental theories in the late 1800s.1 Freud attached great components. The fi rst and outwardly most evident is the patient’s importance to sexuality and linked a person’s psychosocial physical development, those bodily changes that occur not just development to sex. Freud suggested that human psychic during one’s youth but throughout life. The second change is development was linked to physical growth, specifi cally where the person’s mental or cognitive development and includes the the sexual energy was centered, and that human development development of reasoning, the ability to think, and memory. was therefore biologically controlled. Freud suggested that Cognitive development also includes language acquisition, during childhood a person’s sexual energy shifted from the that human characteristic which permits communication. The oral to the anal to the genital regions as each become a focus third aspect of personal development is a person’s emotions, in the person’s personal life. the affective self. This aspect of development is the result Fundamental to Freud’s theory are the ideas of id, ego, and of internal psychological dynamics and external societal superego. A person’s id consisted of the person’s biological infl uences. The affective portion of the person represents the needs, such as water and food. A person’s id also contained psychosocial aspect of a person’s development. the will to live and the drive to reproduce, the libido. Inherent The changes in a person’s patterns of thinking, feeling, in the id is the concept of pleasure; that is, people will do and physical growth are all part of the person’s development. what is pleasurable and avoid what is not pleasurable. Each of these elements affect the person, to varying degrees, Eventually a person would develop an ego, a conscious over the course of a lifetime. These changes, coupled with state that controls the id. The ego is that personal sense of self life experience, combine to create the person that he or she as a physical being interacting in the world. The ego tempers has become. the id with reality. For example, while sex is pleasurable (a function of the id), if it were to be pursued to the exclusion of all other social interaction then the ego would prevent that. Theories of Personal Development Finally, in early childhood the person would develop a superego, those societal values that run counter to the id. Several theories have been advanced over the years to explain The superego works to suppress the id and forces the ego human development over a lifespan. These theories take into to consider moral behavior. Freud postulated that it was account the physical, mental, and psychosocial aspects of a the ego that kept the confl ict between id and superego to a person and try to provide a meaningful explanation of the minimum. changes that commonly occur. Psychosocial Theory Theories of Psychosocial Erik Erikson, a student of Freud’s psychosexual theory, dismissed the centrality of sexuality in favor of the effect Development of social infl uences on the person. Erikson felt that people The fi rst and most widely known theorist of psychosocial develop because of social pressures to conform and co-exist. development was Sigmund Freud. Having laid a framework Erikson’s view of psychosocial development stressed the for understanding the human psyche, others—such as role of the ego in direct confl ict with Freud’s theory, which Erikson, Skinner, and Piaget—have sought to improve upon stressed the role of the id. 132 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. In essence, Freud’s theory stressed the physical of theories, and an even greater abundance of debate, the developments and supported the idea that nature controlled argument lives on. one’s development. Erikson stressed the social infl uences and supported the idea that nurturance had a greater impact upon personal development.2 This is the classic nature vs. nurture Conception to Childbirth argument. At the moment of sexual climax, millions of spermatozoa are Erikson’s theory was also more comprehensive and deposited into the vaginal vault and begin the journey through included eight stages. Erikson’s theory takes into account the cervix and into the fallopian tubes. When the spermatoza the entire span of a person’s lifetime, adding three stages reach the egg, called an ovum (Figure 9-1), one will penetrate of adulthood to Freud’s fi ve stages of psychosexual and fertilize the ovum. development. The fertilized ovum, now called a zygote, starts to divide Confl ict is the pivotal event that moves people through the repeatedly. During this early stage the zygote will form various stages of Erikson’s psychosocial development. Each a hollow, fl uid-fi lled ball or blastocyst. The cells inside of stage is represented by the critical confl icts. For example, the blastocyst will form the human, whereas the cells on Erikson believed that the young person must resolve confusion the outside will form a protective covering that eventually over one’s role in life to form a personal identity. develops into the placenta. Behaviorism While this development has been occurring, the zygote has been traveling down the fallopian tubes and into the While Pavlov’s experiments with dogs, where he was able uterus. At the end of the fi rst week, the zygote implants into to condition dogs to salivate when a bell was rung, set the the uterine lining. The amnion, which makes amniotic fl uid, stage for a new developmental theory called behaviorism, and the chorion, which will make the placenta, start to form B. F. Skinner’s operant conditioning took center stage. along with the zygote. The placenta will provide the infant Skinner believed that human behavior is simply a function with nutrition through the umbilical cord, which connects of an interaction, positive and negative, with the social the mother and child (Figure 9-2). environment. In about 30% of pregnancies, the zygote fails to implant Expanding on behaviorism, Albert Bandura, another and the pregnancy is spontaneously aborted.5–7 This is referred American psychologist, suggested that people learn in to as spontaneous abortion. three ways: by direct instruction, direct experience, and In the weeks following the implantation, the zygote, now observation. Bandura’s social learning theory suggested that called an embryo, is rapidly dividing and laying down the people developed through learning. foundations for all of the major organ systems. During this All three of these theorists—Pavlov, Skinner, and period of time, from conception to the end of the ninth week, Bandura—took the approach that life experiences (nurturance) the infant is at greatest risk for fetal malformation. Potential are the dominant infl uence in a person’s psychosocial causes of fetal malformation are toxic substances or agents, development.3,4 called teratogens. Examples of teratogens include illegal drugs such as cocaine, alcohol, and infections such as rubella Cognitive Development Theory (measles) and toxoplasmosis. Women who drink alcoholic Cognitive development theorists looked at how the mind was beverages while pregnant can potentially cause a number developed. Jean Piaget, an early cognitive theorist suggested of birth defects, collectively referred to as fetal alcohol that people develop in a building block fashion, one learned syndrome.8–14. behavior building upon another. Piaget suggested that people learn schemes (ways to deal with the world) upon which Genetics and Human Development they build new schemes. The earliest schemes are primitive refl exes. A person’s intelligence is a function of the ability to Every person alive is the result of the union of two sex create new schemes to successfully adapt to the environmental gametes: a spermatozoa and an ovum. Each gamete brings conditions in which a person fi nds himself. This process of 23 chromosomes, a double helix of DNA, into the mix. assimilation (integrating new information into a preexisting Together, these chromosomes provide an individual’s genetic matrix) along with accommodation (the changing of make-up, the genotype. The subsequent division of the cell, preconceptions to allow for new information) was the source called mitosis, continues until a person is created. The visible of human development over a lifespan. outward expression of the chromosome, the phenotype, is therefore the result of the genetic infl uences of both the Topics in Human Development parents. If the gametes each bring an X-chromosome to Central to all discussions of lifespan development is the the union, then the individual will be female. If one of the argument of whether genetics are dominant in a person’s spermatozoa brings a Y-chromosome to the union, then the development or whether the environment and society play a person will be a male. Each chromosome provides genes. greater role in human development. Despite the abundance These genes determine the physical characteristics which Lifespan Development 133 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Acrosomal (head) cap Sperm Acrosome Head Polar body Condensed Zona nucleus pellucida Neck Cell membrane Mitochondria Cytoplasm Nucleus Middle piece Nucleolus Corona radiata made up of epithelial cells Ovum (1/125 of an inch in diameter) Flagellum Principal piece End-piece Figure 9-1 The sperm and fertilized ovum. Placenta Some genetic diseases are linked to the sex chromosomes Umbilical Intrauterine cord cavity (i.e., sex-linked transmission). If both parents contribute that abnormal chromosome, then the child will have the disease. Examples of sex-linked diseases include sickle- cell disease, Brugada syndrome, Huntington’s disease, and Marfan syndrome. If the child has one sickle-cell disease gene,

then the child will be a carrier but will not have the disease. If the child has both genes, then the child will have the disease. Pregnancy After the ninth week, the pregnancy is generally viable. Amniotic Amniotic The embryo, called a fetus, will come to term in about the fluid sac ninth month. The stages of a pregnancy are evenly divided into trimesters, each of which has specifi c characteristics. Figure 9-2 Fetus in utero attached to placenta by The fi rst trimester, the germinal period, is a period of the umbilical cord. high hazard. The second semester sees rapid growth in the fetus and the fi rst signs of life, fetal movements called comprise the individual. If one parent’s genes control the quickening. During the fi nal trimester, at the twenty- child’s characteristics, then that gene is said to be dominant. sixth week, the pregnancy reaches the point where, if the If one parent’s chromosome is not dominant, but instead pregnancy were to terminate prematurely, the infant would is recessive, then the recessive gene will not control the be viable. characteristic. For example, if a blue-eyed mother mates A number of other factors also combine to increase infant with a brown-eyed father and brown eyes are dominant, mortality, including advanced maternal age (greater than 35), then the child will have brown eyes; note eye coloring is not domestic violence (approximately 8% of pregnant women are that simple. battered), and poor health, including a lack of prenatal care 134 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Amniotic cardiac shunts (the foramen ovale and the ductus arteriosus) fluid to reverse blood fl ow and then close.15–17 Amniotic sac Internal os Cavity Street Smart of cervix External os Before labor Early effacement In the fi rst few minutes to one hour after birth, the infant is referred to as newly born. Thereafter, the child is referred to as a neonate for the remainder of the fi rst 28 days of life; this defi nition somewhat changes depending on the source. After the neonatal period, and through the fi rst year, the child is called an infant. The term “baby” is generally considered a Complete effacement Complete dilation lay term. Figure 9-3 Childbirth. Street Smart and poor nutrition. As a result, the most dangerous time in any human’s existence is the time from the moment of conception Less than 10% of the newly born require some form of until birth. active resuscitation. Simple techniques, such as drying the infant, are usually suffi cient to stimulate the Childbirth newly born to breathe. Childbirth, the culmination of nine months of growth and development, begins when the uterus starts to contract in a process called labor (Figure 9-3). These strong rhythmic contractions begin to push the fetus into the birth canal and The Infant dilate the cervix through a process of widening and thinning. This process takes approximately 12 hours on average. It The fi rst year of an infant’s existence revolves around eating, can range from one hour, called a precipitous delivery, to 24 sleeping, and growing. Initially, the infant spends eight hours hours or more. in full rest (non-REM sleep), another eight hours in REM The infant, with its head engaged in the birth canal, sleep (dreaming), and the rest of the time in varying amounts begins a rapid passage down the birth canal in the second of quiet alertness, drowsiness, and distress. stage of delivery. The delivery of the infant may take upwards At about the fourth month, the infant’s sleep/wake cycle of an hour, barring any complications. starts to approximate that of an adult and the child’s response The third and fi nal stage of the delivery is the delivery to the environment starts to become more determined. of the placenta, which marks the end of the pregnancy. Initially, the infant has only primitive survival refl exes, such as the sucking refl ex and the swallowing refl ex. The Newly Born At the moment of delivery the newly born must undergo Physical Development dramatic physiological changes in order to adapt to The average newborn weighs between 3 to 3.5 kg at birth and extrauterine life. During this transition period, the newly will almost triple that weight in the fi rst year of life. Most born’s cardiopulmonary system switches from dependence newborns typically drop between 5% to 10% of their birth on the mother, via the placenta, to independence. weight in the fi rst week due to a combination of fl uid loss During the fi rst minute of life the umbilical blood and consumption of brown fat; brown fat is special baby fat fl ow diminishes, raising carbon dioxide levels, which in used to generate heat. Normally, if the newborn is feeding turn stimulate the newly born’s fi rst breath. The increase in properly, the newborn should regain this weight and surpass intrathoracic pressure, from the air-fi lled lungs, causes the the birth weight by the end of the second week of life.18,19 Lifespan Development 135 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 9-1 Comparison of Vital Signs Between Newborn and 1-Year-Old Infant Street Smart Vital Signs Newborn 1-Year-Old Heart rate (BPM) 120–160 100–120 The common cold could be potentially deadly to an Respirations (BPM) 40–60 20–30 infant as most infants breathe through their nose, i.e., Blood pressure (mmHg)  60 70–100 obligate nose breathers. With stuffy nasal passages the infant must struggle to breathe.24,25 Fortunately, At the moment of birth, the newborn is challenged to most infants obtain passive immunity, passed on adapt to the world outside of the womb. At that moment from the mother, for the fi rst six months. Respiratory the newborn’s heart is racing, between 100 and 160 beats infections are minimized during this critical period.26 per minute, but soon settles to a sustained tachycardia around 120 beats per minute. In like fashion, the newborn’s respirations are between 40 and 60 breaths per During the fi rst six months of life, the infant experiences minute but become increasingly slower over the first year dramatic neuromuscular development. The primitive refl exes until they stabilize at about 20 to 30 breaths per minute (e.g., the Babinski refl ex) start to wane at about six months as (Table 9-1). the motor neurons within the spinal cord mature (Figure 9-4). This neurological development starts in a head-to-toe (i.e., cephalocaudal) fashion and from an inward-to-outward (i.e., proximodistal) fashion. During the assessment of the infant, the Paramedic Street Smart should be attentive to the presence of infantile refl exes.27–29 Upon observation of a healthy infant’s general appearance, the Newborns are very prone to hypothermia because of a Paramedic should note an infant who is interactive with the combination of a large head and a large body surface environment, whose limbs move when stimulated, and who has a strong sucking and gagging refl ex. An infant in trouble area to weight ratio, which encourages more radiant has limp extremities and a “Raggedy Ann” appearance. heat loss. Newborns have a special reserve of brown Most infants, when the Paramedic claps his hands, will startle fat, about 5% by body mass, which helps the newborn and extend both of their arms. This is called the Moro refl ex. An absent Moro refl ex on one side may indicate a neurological generate heat. Premature newborns do not have this disorder, such as hemiplegia, or perhaps a fractured clavicle. brown fat and are more prone to hypothermia than Other primitive or infantile refl exes include the rooting full-term newborns.20-23 refl ex, in which the infant turns toward the cheek that is stroked, and the sucking refl ex. Both of these refl exes are present at birth and help the infant with breastfeeding. The next refl ex is the palmar grasp refl ex. The palmar Maintaining ventilation represents one of the greater grasp refl ex is seen when the infant’s hands grasp an object challenges for an infant. The combination of a narrower pressing against the palm. Another refl ex is the tonic neck airway, which is more easily obstructed, and the fact that an refl ex, in which turning the infant’s head to the side causes infant is an obligate nose breather (i.e., primarily breathes the ipsilateral arm to straighten and the contralateral arm to through the smaller nasal passages) makes partial airway bend, in the classic fencing posture. Both of these refl ex tests obstruction more likely and breathing more diffi cult. are tests of the motor neurons of the upper nervous system. Once air has passed the upper airway into the lungs, The Babinski refl ex, a fanning of the toes and extension of there are fewer alveoli to exchange oxygen to meet the high the great toe caused by stroking the lateral soles of the feet, is metabolic rate and oxygen demand of the infant’s body. To a test of the lower motor neurons. compensate for the mismatch between demand and capacity, the infant increases the respiratory rate. This is not an effective mechanism yet because of the combination of horizontal Street Smart ribs, which decrease expansion, and weak accessory muscles which force the diaphragm to act as the primary muscle of When a person is in a coma, these primitive refl exes respiration. The diaphragm is limited in its ability to sustain a may reappear. Thus, when a family member holds the rapid respiration. Compounding the problem is the increased hand of the unconscious patient she may think that heat loss, from rapid respiration, which in turn increases the metabolic demand upon the body to produce heat. The infant the patient is intentionally grasping the hand when in can quickly fatigue and then experience respiratory distress fact it is a primitive refl ex. and failure. 136 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 9-4 Infant refl exes. Lifespan Development 137 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. At about the time the posterior fontanel closes, at three A smile is often an indication of a person’s affect. Until to four months, these primitive refl exes start to wane. By the around three months of age, infants smile refl exively, meaning time the anterior fontanel closes, in nine months to a year, all they smile randomly and without apparent provocation. The of these refl exes should be gone. infant older than three months will start to demonstrate The infant experiences the greatest amount of growth emotional expressivity through a social smile. A social during this period of time. Bones grow, infl uenced by factors smile is a refl ective smile (in response to someone smiling such as growth hormone, genetics, and the infant’s general at the infant). It is not a refl exive smile caused by an external health. The infant becomes physically stronger

as the muscle stimulus (e.g., the proximity of a person’s face). Often social mass increases correspondingly. smiling is accompanied by vocalizations such as cooing or by As the infant gains control over the larger muscle groups, lip movements called mouthing. the infant will raise the chest off the fl oor and then crawl. The continued social interaction between infant and Later the infant will stand and move about, grasping objects parents is the start of the process of socialization. As the to help with balance while walking. This is called cruising. infant becomes more connected, psychoemotionally, to Eventually, the child will walk unassisted. the mother, the infant is learning behaviors which will affect Each new skill represents another objective the infant the child’s social competence later in life. Further parent–child has accomplished while moving toward maturity. Taking an interaction, such as assistance with simple psychomotor tasks age-related average, Arnold Gesell distributed these different (a process called scaffolding), helps to further develop both tasks across a timeline, called developmental milestones. the infant’s psychomotor skills and the infant’s social skills. The developmental milestones represent a typical child’s A test of an infant’s social skills is the ability to development and are used to gauge an individual child’s withstand parental separation. During a medical emergency development against a norm. the Paramedic may need to examine the child at a location separate from the mother. This tends to elicit separation Cognitive Development anxiety in the infant.30,31 The infant may be observed to reach An infant obtains knowledge of the world through sensory out to the mother, or to grasp the mother fi rmly and resist input, which the infant brain tries to make sense of. Initially, separation. One theory suggests that the infant has no concept the newborn uses his primitive refl exes as building blocks. of time. Thus, when a mother leaves the child for even a Then, future experiences are assimilated into the old schemes, minute, the child—who depends on the mother for survival— thus building all new schemes. feels abandoned and instinctively cries for the mother. As the During this phase, the infant begins to acquire language infant develops, the infant will be comforted by memories of skills. Starting with cooing (simple vowel sounds), the infant the mother and self-soothing activities such as thumb sucking proceeds to preverbal gestures (e.g., pointing). The child then during periods of isolation. utters his or her fi rst words at about 12 months. From that During this early period of socialization, autism is often point, and for the remainder of the fi rst two years, speech discovered. Autism is a developmental disorder which includes develops rapidly and the infant’s vocabulary expands to over impaired social interactions, an absence of separation anxiety, 200 words, mainly consisting of labels of people or things. and problems with both verbal and nonverbal communications. Failure to manifest early signs of socialization, such as refl ective Psychosocial Development smiling, may be indicative of autism. The fi rst psychosocial task encountered by an infant is bonding. Bonding is a process that establishes a lasting nurturing relationship between a mother and child. While bonding may begin during pregnancy, it is a reciprocal Street Smart relationship that involves both mother and child. Many factors can infl uence bonding including physical While an infant’s crying is distressing to most, the separation from the infant, diffi culty in delivery, and absence Paramedic understands that this is the infant’s way of of breastfeeding. The Paramedic can be witness to this communicating. Infants cry because they are angry, bonding behavior, such as mutual gazing, refl ective smiling, and response to touch. Absence of these bonding behaviors in pain or discomfort, or have a basic need which is (i.e., poor bonding) may be refl ective of poor maternal care unfulfi lled. The cry of an infant in pain occurs without and even child abuse. any moaning and is followed by breath holding.32–34 During this formative year, an infant’s temperament becomes manifest. For example, the infant may be easy, diffi cult, or slow-to-warm-up. The majority of infants are cheerful and adapt to change readily. The slow-to-warm-up Parent–Child Relationships infant appears inactive, maybe even in a negative mood, and The importance of a Paramedic understanding the parent– adjusts slowly to changes. The diffi cult infant does not accept child relationship can be pivotal to a positive therapeutic changes and is demonstrative in his disapproval of change. encounter. Dr. Diana Baumrind has suggested in her typology 138 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. of parenting that there are four styles of parenting, each with Preschool Children: a different impact on a child’s psychosocial development. The child development literature has suggested that the impact of Early Childhood these parenting styles, both negative and positive, is evident The early childhood years, from age 2 to 5, are a period of as early as the preschool years. extraordinary growth. For each year of growth the child, Each of these parenting styles will have an impact upon now called a toddler, will add fi ve pounds and three inches the child’s social competence and psychosocial development. of height. The spinal column starts to lengthen and the In some cases, the parenting style is predictive of the problem internal organs start to ascend under the protection of the behaviors. Each of these parenting styles revolves around the thoracic cage. emphasis, or de-emphasis, of nurturance. Nurturance is the The toddler’s pulmonary system continues to grow as quality of caring and concern. A nurturing parent provides terminal airways continue to branch, alveoli develop, and clarity of communication, makes demands for maturity, and hemoglobin levels climb to near adult levels. Perhaps most maintains parental control. The last element, parental control, remarkably, the toddler’s nervous system is almost completed seems to be pivotal in describing a parenting style. in its development. The peripheral nervous system is myeli- Permissive, or indulgent, parents tend to give control over nated, allowing for the development of fi ne motor skills, and to the child by not establishing boundaries or routines. While the brain has attained almost 90% of its adult mass. these parents tend to display affection to their children, they While such factors as genetics and wellness can affect fail to consistently enforce or clarify rules, presenting the child a child’s height and growth, all children should become with mixed messages. Permissive parents tend to accept all larger and taller. Those who fail to grow, exhibiting failure of a child’s behaviors, both good and bad, without judgment. to thrive, may be under severe psychosocial pressures or Children of permissive parents tend to perform poorly in the have nutritional defi cits. Paramedics need to identify these structured environment of the school and have problems with toddlers and encourage the parent to seek medical attention authority. However, they have higher self-esteem and better for the child. social skills than children of other parenting styles. In contrast, the authoritarian parent always needs to be in Physical Development control and tends to demand high levels of maturity. Strict rules are the norm and the display of affection is rare. Authoritarian During these early preschool years, a child learns to run, parents tend to focus on negative behaviors. Children of jump, hop, and throw. These complex motor activities are an authoritarian parents tend to be anxious and withdrawn, with outward manifestation of the growing neuromuscular system poor social skills, but perform moderately well in school. (Figure 9-5). Children of authoritarian parents also tend to have higher At or about 3 years of age, children will learn how to levels of depression. As a result of their upbringing, the toilet themselves. Within another year, children learn how to interaction between Paramedic and child can be diffi cult as dress themselves. The 6-year-old child should have developed these children are generally mistrustful of adults. enough motor dexterity to be able to tie a shoe. The authoritative parent, sometimes referred to as At this age, the impact of sex can be fi rst noted. Males the democratic parent, has all four qualities in balance. tend to be slightly better at skills emphasizing force or power Authoritative parents establish rules, hold children responsible whereas females tend to be better at fi ne motor skills, such for adhering to those rules, and provide explanations of as balancing and foot movements. Most toddlers, because expectations to the child. Authoritative parents focus on of improved eye-to-hand coordination, enjoy games such positive behaviors. They try to catch their children being as puzzles or coloring with crayons. These activities can good. Children of authoritative parents tend to be happy, self- be solitary or enjoyed in groups. When engaged in group confi dent, and independent, to the point of genuine openness activities, toddlers tend to identify with other same sex to other adults. children and begin to model their behaviors based on the The last parenting style could almost be called a non- behaviors of others of the same sex. parenting style: the uninvolved parent. These indifferent The play “pals” that toddlers are often placed with are parents have little commitment to parenting. Children of other siblings. It is during this play period that sibling rivalry indifferent parents tend to have low tolerance for frustration will be seen. Sibling rivalry is a form of competition, for and exhibit problems with impulse control. This group of parental approval or attention, between brothers and/or sisters. children is a particular problem for Paramedics as they also Sibling rivalry can, at times, involve unacceptable behaviors tend to be aggressive, to the point of committing violence. such as aggression or “acting out.” In general, sibling rivalry From a Paramedic’s perspective, it may seem reasonable should be viewed as the toddler’s effort to establish herself to withdraw from a situation in which a child is aggressive. as a person and to establish her place within the family However, the more constructive approach is to remain hierarchy. While not entirely preventable, toddlers can be steadfast. The Paramedic can acknowledge the behavior as taught that violence is not an acceptable means of resolving being unacceptable, without becoming aggressive in either disagreement and that there are other more positive ways to words or action, and all the while remain authoritative. get attention. Lifespan Development 139 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 9-5 Motor skill development: Child. Cognitive Development Here again, the differences between the sexes become The early childhood individual is in a preoperational stage of more evident. Females tend to ask questions and make cognitive development, as per Piaget’s studies. The thinking is requests more indirectly than males, while maintaining more concrete and the child cannot think in terms of abstracts. The eye contact. Females also tend to use more nonverbal cues result is that these children will take what the Paramedic says such as body language. literally. Therefore, the Paramedic should carefully construct statements in order to avoid misinterpretation and confusion. Psychosocial Development As time progresses, the children develop more symbolic Play has a pivotal role in human development at this age. thought, which helps them remember experiences. Psychoanalytic theory suggests that play provides children an As symbolic thought develops, so does mathematical opportunity to gain mastery and demonstrate autonomy for reasoning. Young children understand that the numbers, the purpose of self-satisfaction. names, and objects in a set are related (i.e., 1  one  a dog). Cognitive theory suggests that play develops in readily Young children struggle to learn concepts such as ordinality identifi able stages, starting with functional play. Functional (that

numbers occur in an order) and cardinality (that the last play is focused on performance, usually of a simple repeated number represents the sum of the set of objects). movement, such as dribbling a ball or shooting a basket. Also critical at this point in a young child’s development The next level of play is constructive play. In constructive is language acquisition. Going beyond the 300 or 400 play, the child takes common objects and attempts to build learned earlier, the young child now learns how to apply things. Construction of objects permits the child to move into syntax, the rules of grammar, and semantics, the meaning the next phase of play, pretend play. Pretending to substitute of words. The focus of this language development is upon oneself into another character or role permits the child the the practical application of language to social and personal opportunity to expand horizons without threat; lines like relationships. “after all, it wasn’t me, it was my dolly,” might be heard. 140 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Eventually, children become involved in games with rules A person’s language skills (many children are—or learn to at about the fi fth year. Games encourage an understanding of be—bilingual at this age), musical skills (such as playing an interpersonal relationships as well as the relation of abstract instrument), logical skills (manifest in math or chess), and concepts to the real world. kinesthetic skills (such as demonstrated in Figure 9-6) may become apparent. Perhaps the most important intelligence a child learns at this age is the ability to form close human bonds School-Aged Children: as well as a social self (personal and interpersonal skills). Middle Childhood Psychosocial Development Middle childhood is centered on education, the school years, and The stage of middle childhood can be one of great upheaval for personal development. The infl uence of family starts to wane in the individual. There are many challenges to the psychosocial the face of growing social involvement and peer pressure. self such as knowing who the child is. The child develops a Physical Development sense of self and a desire to succeed and achieve. Peers, school, and family are modifi ers of the child’s sense School age signals a slowing in physical growth for a child. of self and often come into confl ict with one another. Erikson’s Girls may grow to be taller than their male counterparts for a psychosocial theory states that middle childhood is a time in time until boys enter puberty. Mortality is traditionally lower which children are concerned about their capacity to do good during this time, with viral illnesses being the largest source work (industry versus inferiority) and show initiative. of sickness. Children often manifest their differences in achievement motivation during this period. Some are learning oriented, Cognitive Development and are focused on attaining competence in an area of study. During middle childhood, children are more interactive with These children are intrinsically motivated. Other children are their environment. They experiment, test, and generally assess more interested in pleasing others (extrinsically motivated) their life condition and developing concepts about it. and have a performance orientation. During this time, the child starts to focus on objects and events. The child is able to focus on and comprehend the complexity Peer Relations of multifaceted problems. Piaget refers to this as the concrete According to Piaget, children in middle childhood overcome operational stage.35 Children in this stage are able to understand their egocentrism (i.e., focus on oneself) and start to relate to such concrete operational concepts as spatial relations, nature of others more in terms of common interests, goals, and so on. time, and the sequential nature of certain activities. Parents have a lesser infl uence in this matter, as they are not Gardner advances the theory by stating that the multiple viewed as peers, and friends start to take on a greater role in intelligences of a person become evident during this stage. shaping the person’s personality. Figure 9-6 Children learn balance and coordination by riding bicycles. Lifespan Development 141 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 9-7 Children tend to gravitate to same sex friendships. Initially, these children are interested in same-sex friends, Gender Identity almost to the exclusion of the opposite sex, and form close During the school-age years, children start to attach a friendships (Figure 9-7). Females tend to form close and intimate gender-role identity to themselves; that sense of being a friendships of one other same-sex friend at this age (dyads) male or a female. It is diffi cult to establish which factor has while males tend to include a larger circle of acquaintances. a greater infl uence on a child’s gender-role identity—genetic A child who forms friendships easily is viewed as popular. infl uences, hormonal factors, or social factors—but it can In addition, popular children are seen as confi dent, good- be a confusing time for a child. In some cases the child’s natured, and energetic. Physical traits that support athleticism psychological assignment of gender may be in confl ict with help a child gain popularity and social acceptance. the child’s biological sex assignment. A child may attempt to Conformity to the group is stressed during this time and maintain androgyny for a time (having both masculine and peer pressure can cause children to make rash decisions which feminine qualities), in an effort to understand the mental and run counter to their personal values or the values taught to physical changes within themselves, while others experiment them by their parents. This experimentation can be healthy, if with one and then the other gender role. not taken to extremes, as it encourages independent thought Regardless of a child’s gender-role identity, it is important about values and morals. that the Paramedic remain nonjudgmental in this matter and Divorce focus on the patient’s medical condition. Dr. Judith Wallerstein, in her landmark work entitled “The Unexpected Legacy of Divorce,” described the problems Adolescence of trust and intimacy that children experience because of Adolescence could best be described as a stormy transition divorce.36 Divided loyalties, inconsistent discipline, and long from childhood to adulthood. Societal concerns, such as periods of tension and discord can come together to produce educational preparation versus industry, have culminated a fear of intimacy, lowered expectations of authority fi gures, in child labor laws, compulsory education, and a separate and a sense of powerlessness in a child. judicial system for juveniles. Each is a response to an issue These fears can be problematic if the Paramedic is treating faced by adolescents. a child with divorced parents. Confl icts may arise during even routine physical assessments and a war of wills may occur. Despite the Paramedic’s good intentions, the child may not be Physical Development willing to accept care and will resent efforts to provide that The most remarkable changes in the human physique, the care, to the point of becoming violent. The Paramedics can body habitus, occur in adolescence. Entering into puberty, only resort to tact and diplomacy and a willingness to accept males and females see dramatic sexual changes in their what the child will permit. physical bodies. 142 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. For males, the development of facial hair, enlargement “comfort” foods, instead of healthier choices, leading to of the penis, and the fi rst ejaculation represent milestones in weight gain beyond growth. They then become obese. their passage to manhood. The United Nation’s World Health Organization (WHO) For females, the development of breasts, the widening of called obesity the “global health epidemic” in 1998 and the hips, and the fi rst menarche (period) represent milestones stated that at that time the health of 6 million children was in in their passage to womanhood. jeopardy because of obesity. The health risks associated with The timing of puberty is widely variable, with some obesity are impressive: type 2 diabetes mellitus, secondary females experiencing menarche at age 12 while some males hypertension, accelerated coronary artery disease, and do not experience ejaculation until age 18. stroke. Females who are early maturing are very concerned At the other extreme of teenage weight problems is about their physical appearance and are often confronted anorexia nervosa. Anorexia nervosa is a psychiatric illness with social situations for which they are not, psychosocially involving problems with self-image and is characterized by speaking, prepared. self-starvation and bulimia, binge-eating and then purging Late maturing males may appear immature and therefore via laxatives or vomiting. Anorexia nervosa affects about 1 lack social grace and self-confi dence, but are actually at more in 1,000 young women or 1% of adolescent girls. If untreated, liberty to develop a unique personality, unfretted by social anorexia nervosa can be fatal.41 pressures. Teenage Suicide Adolescent Health Concerns At increased risk for premature death from trauma, secondary The opportunities for freedom, and the accompanying to increased risk-taking behaviors and a false sense of experimentation, coupled with the use of inhibition-reducing invulnerability, teenagers are also at higher risk of death from drugs, such as alcohol, can potentially create unhealthy suicide. situations for adolescents. The Paramedic should keep these While death from motor vehicle collisions and homicide health concerns in mind when treating adolescent patients. are still competing for the distinction of most common cause of death for young people age 12 to 22, suicide is still Sex and the Adolescent in the top three causes of teenage death. Teenage suicide is frequently the result of a high-stress event (e.g., death of a The advent of sexuality brings the risk of sexually transmitted peer) and/or inadequate coping mechanisms. About 20% to diseases. It has been estimated that 25% of adolescents leaving 25% of adolescents report signs of depression at one time or high school will have, or have had, a sexually transmitted another during adolescence. Among adolescents, 8% report disease. A combination of early sexual maturing, early sexual suffering from debilitating or clinical depression. Suicide is activity, drug and/or alcohol use (lowering inhibitions), and the third leading cause of death for teenagers age 15 to 19.42–44 inadequate instruction about the use of contraceptives results Therefore, Paramedics should take all teenage depression and in a high rate of teenage pregnancy and an epidemic of suicide attempts seriously. sexually transmitted diseases (STD) in adolescents.37–39 Over the last two decades, the number of cases of chlamydia has risen almost 300% and it is estimated that there Cognitive Development will be one million new cases of genital herpes simplex virus The cognitive development of the adolescent revolves around type 2 (HSV-2) each year. It is thought that young women using logic to solve problems, seeing the possibilities rather are more susceptible to STDs because epithelial cells, which than the realities, and engineering new ideas. To turn a phrase, are more susceptible to infection by STDs, extend over the adolescents start to see problems as “less black and white and vaginal surface of the cervix and the cervix is unprotected by more as gray.” cervical mucosa. These epithelial cells later retract in an adult Piaget referred to this stage of intellectual development woman, exposing the cervical mucosa. as the formal stage. Formal thinking

involves the application Genital human papillomavirus (HPV), genital warts, of logic to abstract ideas to solve problems. This formal is the most common sexually transmitted disease among thinking allows the individual to fi nd meaning in seemingly sexually active adolescents. Genital human papillomavirus confusing data and to apply problem-solving techniques to has been connected to the incidence of cervical cancer.40 resolve confl ict. There is currently a vaccine for HPV and it is hoped that its use will decrease the number of cervical cancer cases. Psychosocial Development Adolescents return to egocentrism, a stage previously Obesity encountered in early childhood. Impressed with their Chaotic schedules, the ease and availability of “junk foods,” newfound abilities to reason logically and think abstractly, and peer pressure contribute to poor teenage nutrition. On they formulate idealisms without regard for practical reality. one extreme is the national epidemic of teenage obesity. During this time, adolescents turn their attention to Adolescents seeking solace in food eat carbohydrate-high morality and their own moral development. Kohlberg divided Lifespan Development 143 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 9-8 Adolescence is a time of growth and experimentation. the process of moral development into six stages and three The highest level of moral development, and the sixth levels. stage, is principle-based morality. Having developed a strong The fi rst level is preconventional morality. This is the set of internal principles (e.g., guiding missions), these fi rst stage of moral development and is simply avoidance adolescents conform to their principles rather than face self- of pain. To a person at this level, the morality of an act is condemnation. defi ned by the positive or negative outcome (i.e., pain and Teenagers are challenged to develop their social self, punishment). Notably, obedience is a function of punishment. their intellectual self, their moral self, and their sexual self Advancing to the next stage, the hedonistic phase, the person into a socially acceptable personage (Figure 9-8). conforms less to avoid punishment but more to attain or gain an advantage. Level two is simply conventional morality. Stage three, Early Adulthood conventional morality, involves being seen as a “good person” by Early adulthood is a period of striving and accomplishment. friends and family at its lowest stage. Conduct is geared toward It is punctuated with peak life events such as marriage and that goal. The advanced version of conventional morality, stage childbirth. four, is also called a “law and order” morality. People at this A fundamental decision made by most young adults is stage conform to the rules for the sake of the rules. whether to go to college or to start work. Women are more The third level of moral development is postconventional likely to go to college and more likely to complete college morality. People at the lowest stage of postconventional within the traditional four-year cycle. Men are more likely to morality are concerned with abstract concepts such as justice go to work or start college but not complete it. and democratic principles. Their moral beliefs tend to be more The young adult immediately entering the workforce fl exible, in concert with the society in which they exist. will fi rst enter a period of self-exploration, in preparation for 144 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. work, then try to fi nd an organization or business to enter same-sex friend, and then expect that confi dence to be shared into. Unions, like the guilds before them, offer these young exclusively. Young men tend to establish same-sex friendships adults opportunities to train as apprentices. Apprentices have based on common activities, such as sports. the advantage of gaining competence on the job as well as Regardless of sexual orientation, most young people are learning organizational rules and mores. seeking a monogamous relationship with a signifi cant other person. According to Dr. Robert Sternberg, love has three Physical Development aspects or components: intimacy, passion, and commitment. The majority of people, both male and female, reach Utilizing these three components, Sternberg has described their peak height in their early twenties, and their health seven combinations, each a variation of love: friendship, is generally at its peak as well. Unfortunately, obesity—a infatuation, empty love, romantic, companionate, fatuous, growing problem to children and adolescents—is also more and consummate love. common in young adults, with over one-half of all adults For example, intimacy without either passion or being overweight. commitment is friendship. Infatuation, on the other hand, As an adolescent reaches maturity, and the age of is passion without intimacy and commitment. Arranged consent, unhealthy decisions can be made regarding such marriages are an example of empty love, where there is potentially devastating behaviors as tobacco smoking, alcohol commitment but no intimacy or passion. Sternberg goes on to consumption, and unprotected sex. These behaviors may be describe romantic love, companionate love, and fatuous love. seen as outlets from the stress of everyday pressures. Some The greatest and deepest love has all three components— stress can be negative, such as distress or stress caused by intimacy, passion, and commitment—and is a complete form creditors trying to collect on unpaid bills. Other stress can be of love. positive (eustress), such as the birth of a child. Regardless of the type of stress, all stress can be seen as Marriage either a chance for harm or as a challenge and the body responds accordingly. The sympathetic nervous system responds by an Hypothetically, marriages are an equal partner relationship adrenaline release which leads to hypertension and tachycardia. in which shared concerns and responsibilities help form the Persistent or sustained stress eventually takes a toll on the body bond. In a conventional relationship, the male is the head and the mind, resulting in effects such as hypertension, immune of the household and sole provider, whereas the woman system disorders, and mental disorders. is the homemaker and mother. This form of relationship is rapidly waning in the face of growing single-parent Cognitive Development households and equal partner relationships, in which both parties work and make the home together. It should be Young adults tend to explore the world and seek out new noted that one-third of men and one-fi fth of women are experiences which engender questions about themselves, the single by choice and that singlehood is a viable alternative people with whom they associate, and the world in general. for some people. Young people explore their world through interaction with While marriage is a relative constant in a young adult others, engaging in dialectical thinking (i.e., discovering the person’s life, so is divorce. Divorce occurs in about 50% of truth through dialogue and appreciating that there may be fi rst marriages and most divorces occur in early adulthood.45 multiple perspectives). And while 82% of divorced people eventually remarry, Psychosocial Development with about one-half of those marriages ending in divorce, there is a growing lack of commitment in the institution of Entering young adulthood, many people are engaged in fi nding marriage. the “ideal mate,” that special someone with whom to share common goals and aspirations. Erikson refers to this stage as the choice between intimacy and isolation. Inherent in this Parenthood process is a social clock. A social clock can be thought of as In general, most young adults have less preparation for a set of expectations, placed on the individual by society, to parenthood than they did for their livelihood. The resulting complete certain tasks (e.g., marriage and childbirth) within strain between the expectations of happiness from parenting a predetermined time (young adulthood). Young adults who and the reality of parenting (felt largely by the mother) fail to accept the social norm are seen as outcasts and tend to places an additional burden upon the relationship. As a become self-absorbed in isolation. result, many mothers become single parents and have to depend upon extended families for support and assistance. Love and Friendship Paramedics should understand that single mothers may The differences between the sexes become more evident have limited resources and that EMS is one of the few when it comes to how they look at friendship and love. Young social supports readily available during a time of acute women are inclined to reveal deep personal feelings to a distress. Lifespan Development 145 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to have hormone replacement therapy. While hormone Cultural / Regional differences replacement therapy can help to reduce menopausal symptoms as well as the incidence or severity of osteoporosis (a loss of calcium from the bones secondary to a decrease in Paramedics should be sensitive to the fact that 5% hormones), hormone replacement therapy also increases the of married adults cannot, or do not want to, have risk of cancer, particularly breast cancer.46–48 children. Prying questions, in an effort to make pleasant conversation about what a Paramedic may think is a neutral topic, may be met with anger or silence, affecting the Paramedic–patient rapport. Street Smart A younger woman may undergo a hysterectomy or oophorectomy, for medical reasons, and will then have a surgically induced menopause. Thereafter, Middle Adulthood these women will not only be incapable of Middle adulthood could be characterized as a period of producing offspring, but are at an increased risk of maximal productivity as well as a period of readjustment and realignment. Middle adulthood is also a period of physical cardiovascular disease. decline and changes in interpersonal focus. Physical Development The impact of aging, which commenced in young adulthood, Cognitive Development begins to manifest in more obvious ways. Changes related Dr. K. Warner Schaie’s sequential studies have indicated that to age include a decrease in strength, which peaked in the while intelligence (the ability to think) peaks at different person’s thirties, and a loss of muscle mass. The most outward ages for both men and women, all intellectual abilities show signs of aging—graying of the hair; loss of hair; weight gain, decline at about age 68. The declines are modest in most called the “middle-aged spread”; and wrinkled skin—all cases. Signifi cant loss of intellectual capacity does not occur signal the onset of aging. until age 80. Perhaps more disconcerting to the middle-aged adult, and What is different between the intellect of a young of importance to Paramedics, is the loss of sensory acuity. adult and a middle-aged adult is information processing. Most adults by age 50 will need to wear corrective lens, as the Young adults have the ability to process new information in lens within the eye thickens and is less able to accommodate novel situations (a fl uid intelligence) whereas middle-aged for vision. Reading documents, such as permission forms and adults begin to solidify their understandings (crystallized consents, is more diffi cult without glasses. Hearing loss is intelligence). Crystallized intelligence is the person’s ability also reported in middle-aged adults. to use long-term memory (experiences and skills) to resolve problems. This dichotomy is represented in the comments of Climacteric young adults who claim middle-aged adults are “too rigid in their thinking” and middle-aged adults who complain young Climacteric is an age-related decrease in sex hormone adults do not take advantage of their “wisdom,”—that is, the production that occurs in both men and women. While men middle-aged person’s

intelligence and experience. experience a gradual decline in the number and the viability The rapidly changing complexity of the world has forced of sperm as a result of decreased testosterone production, adults, in record numbers, to return to school. These adult men have been known to sire children at age 80. learners are either changing careers, to meet the demands of Women experience a more dramatic decline in their repro- an overchanging market, or reinforcing their present career ductive capabilities. A decline in sex hormone production— choice through life-long learning. Schools that understand estrogen and progesterone—results in menopause, the the difference between fl uid and crystal intelligence are inability to conceive. By defi nition, menopause is the able to respond appropriately to the learning needs of each cessation of a woman’s menses for an entire year. However, population of students. many women go through a prolonged period of intermit- tent and irregular menstrual periods until hormone levels stabilize. Psychosocial Development The symptoms which often accompany these fl uctuating The quintessential milestone of middle age is the “mid-life hormone levels—such as hot fl ashes, night sweats, vaginal crisis.” The mid-life crisis is in actuality a readjustment from dryness, and insomnia—are distressing. Some women elect young adulthood, with marriage and children, to middle-aged 146 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. existence. Central to the concerns of a middle-aged adult is active and vivacious senior citizens. Most Americans ranging the idea of legacy. Legacy implies that life had meaning—that from age 65 to 84 years of age have suffi cient health to allow the dream of young adulthood has come to fruition. Erikson them to perform their activities of daily living independently, characterized this stage of life as an issue of generativity including dressing, feeding, and caring for themselves. versus stagnation. Middle age is therefore a time of reassessment and Life Expectancy realignment. If the person is at ease with the progress, then The National Center for Health Statistics and the United States the person may choose to reprioritize, rededicate, and renew. Bureau of the Census reports that, on average, a person who Other persons, overwhelmed by the failure of their dreams, has reached the age of 65 in 2000 can expect to live another can spiral into depression, anger, and frustration, which can 18.9 years and that a child born in the year 2000 could expect develop into crisis—even suicide. to be alive at least 86.9 years. Aging Parents This increased life longevity—29 more years of life in 2000 when compared to a person born in 1900—is the result At a time when many middle-aged adults are seeing their of a number of factors. These include improved sanitation, children become adults, and are looking forward to the better health care, and improved nutrition, as well as reduced “empty nest,” they are confronted with aged parents in need death rates in children and young adults. of care. Children of aged parents, particularly daughters, are The most widely circulated theory for senescence is the often expected to care for their parents. wear and tear theory. It is assumed that after years of exposure For some middle-aged adults, the strain of caring for to the elements, toxins, free radicals, and pollution, the human aged parents, especially if they lack fi nancial means, results body simply breaks down over time. Others have postulated in frustration, anger, and, in rare cases, elder abuse. that the human body has a gene that starts the aging process, ensuring a turnover in the species. For whatever reason, aging has signifi cant effects upon the body. Professional Paramedic Physical Development A quick system-by-system review of organ systems quickly The professional Paramedic recognizes that aging is demonstrates the impact of aging (Figure 9-9). The most visible vestige of a person is skin. The skin of an elderly person not a disease but a developmental event beginning wrinkles and sags as a result of a decrease in subcutaneous before birth. connective tissues. The bones of an elderly person also tend toward demineralization, a process called osteoporosis, leading to spontaneous fractures and falls. While the cardiovascular system as well as the cardio- Late Adulthood pulmonary system are in decline, worsened by cardiovascular Late adulthood is somewhat synonymous with being elderly. disease, it is the sensory system that fares worse. Cataracts, The traditional defi nition of an elderly person is anyone glaucoma, and loss of hearing are common to all elderly. who is 65 years old or older. This arbitrary cut-off is a poor Not a single organ system in the body is spared the ravages marker for the onset of senescence, the breakdown in the of aging. Each organ system, according to the genetic make- body’s ability to monitor for organ system failure and to up of an individual (sometimes called a person’s constitution) repair those organs, which is inherent in the concept of being fails over time. elderly. People less than 65 years of age may have symptoms of senescence whereas others with a chronological age of 80 Cognitive Development years may in fact have the health of a 50-year-old. The changes in mental functioning are generally related to However, the fact remains, regardless of any cut-offs in the health of the person, not to age. It is not inevitable that age, that the human population is aging. In 1900 only about every elderly person will become senile. 1% of Earth’s human population was greater than 65 years of When discussing an elderly person’s mental state, it is age. By 1992 that number had jumped to 6%, or 342 million important to differentiate dementia from delirium. Delirium people. An estimated 2.5 billion, or 20%, of the human is a sudden change in mental function. It is an acute brain population will be older than 65 years by the year 2050. syndrome, which is usually associated with reversible Paramedics may consider the elderly to be frail or feeble, metabolic derangements (e.g., hypoxia, or the toxic effects based upon their interactions with a limited percentage of of medications). the entire population of the elderly (i.e., the approximately Senile dementia is the result of irreversible damage 1.5 million residents in nursing homes). This stereotypical to the brain that typically is manifest over a longer period view of the elderly, called ageism, is self-defeating for the of time (e.g., a series of brain attacks, such as strokes).49–51 Paramedic and fails to recognize the large population of A common cause of dementia is Alzheimer’s disease, a Lifespan Development 147 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 9-9 With age comes physical decline. gradual degenerative disease of the brain characterized by extent possible, over living conditions and the availability of confusion, forgetfulness, and ending with coma and death. companionship (Figure 9-10). While passive senile dementia can occur, due to a loss of brain cells, the majority of elderly patients are in good Death and Dying health and any acute alteration in mental function should be As one ages, one is faced with the inevitability of death. immediately investigated for a potentially reversible cause. Most aging people begin to plan for it. An acceptance of the inevitability of death should not be confused with a desire Psychosocial Development to die. The fi nal stage of human development, per Erikson, is integrity However a desire to die and suicide are closely linked versus despair. Efforts to maintain one’s dignity and using to aging. Unfortunately, a large number of elderly persons, one’s wisdom for the greater good will lead to feelings of particularly males, are clinically depressed, never seek or integrity, whereas chronic poor health and substandard living obtain the assistance they need, and commit suicide.52,53 conditions may cause an elderly person to fall into despair. Depression in the elderly, like delirium, is a potentially Most elderly persons want to be self-suffi cient and reversible mental illness which should be confronted and live as independently as possible. In the past, options were dealt with immediately. generally limited to living at home while being assisted by When a terminal disease threatens an elderly person’s adult children or living in a nursing home. New assisted- life, the person will begin the dying process. Kubler-Ross living centers, where meals are prepared for the residents; identifi ed fi ve stages of dying in her landmark work on adult-care programs; and at-home, long-term care programs death and dying. While these fi ve stages are presented in a have provided much-needed steps between independent linear order, they can occur in variations. Some people may living and the nursing home. The key to satisfaction with manifest all of the stages and some may only undergo a few these living arrangements is control of the individual, to the of the stages.54,55 148 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. refusal to seek more medical attention to seeking the opinion of multiple physicians. The next stage of dying is anger: anger at the world, anger at God, anger at family. Self-reproach is sometimes heard from a patient in anger. The next stage of dying is bargaining. These patients will attempt to bargain with God, promising to stop sinful behaviors or to do some extraordinary good. The patient eventually falls into a depression. Depression is the natural acceptance of the inevitable and the start of mourning. Patients who are depressed should be given support and observed for signs of suicidal thought. In time, and in many cases there is not enough time, a patient will reach the fi nal stage, acceptance. Acceptance of death is a reasonable conclusion when faced with the facts of the patient’s situation. Paramedics are, on occasion, called to help care for dying patients. In many instances all that is asked of the Paramedic is to honor a Do-Not-Attempt-Resuscitation (DNAR) order or to follow the wishes of a healthcare proxy who is speaking on the patient’s behalf. In some instances, EMS may be called to Figure 9-10 Companionship is important to the scene of a dying person to administer comfort measures, the elderly. called palliative care, such as morphine sulfate. Sometimes this happens at the request of a hospice nurse. Hospice is a concept of care which differs from mainstream medicine. Traditional medicine’s mission is The fi rst stage of dying is denial, a refusal on the part of largely curative, whereas hospice medicine is focused on the patient, or the patient’s family, to accept what is happening. providing for the physical, emotional, and spiritual needs of Behaviors seen in patients in denial may range from a fl at a terminal patient. Lifespan Development 149 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. From conception to the crypt, a person undergoes dramatic changes over the span of an entire lifetime. Understanding these changes, and their impact upon the person,

helps the Paramedic empathize with the patient’s situation. It also allows the Paramedic to adjust patient care to the patient’s stage of life development in order to help ensure a more therapeutic outcome. Key Points: • Understanding the patient’s developmental stage • From the moment of conception to the end of will help the Paramedic adjust his approach the ninth week, the newly developed embryo accordingly and to connect more therapeutically begins the formation of the major organs. At this with the patient. The three components of point in time the infant is at high risk for fetal development are (1) physical, (2) mental or malformation. Potential causes of malformation cognitive, and (3) emotional or the affective self. include illegal drug use, alcohol consumption, and • severe infections during pregnancy. Sigmund Freud’s psychosocial developmental theory attached great importance to sexuality and • The female gender is a result of both gametes linked the psychosocial development of a person to contributing an X chromosome. The male gender sex. Fundamental to Freud’s theory are the ideas is a result of the male gamete contributing a Y of a person’s id, ego, and superego. Freud’s theory chromosome. The child’s physical appearance is stressed the physical developments and supported due to the genetics of both parents. Chromosomes the idea that nature controlled one’s development. can be considered dominant or recessive, with the • dominant contributor controlling the phenotypic or Erikson stressed the social infl uences and supported physical appearance. the idea that nurturance had a great impact upon personal development. Confl ict is the pivotal event • Sex chromosomes can also be linked to genetic that moves people through the eight stages of diseases. If the child carries both genes then he or Erikson’s psychosocial development. she will have the disease. If the child has only one • gene linked to the disease, the disease will not be Pavlov, Skinner, and Bandura took the approach expressed, but he or she will be a carrier. that life experiences (nurturance) are the dominant infl uence in a person’s psychosocial development. • A developing embryo, now called a fetus, will • come to term in about nine months. The stages of Jean Piaget suggested that people develop in a pregnancy are divided into trimesters. building block fashion by developing schemas, one learned behavior building upon another. This • Childbirth occurs in three stages. The fi rst stage process of assimilation, along with accommodation, begins when the uterus starts to contract in a is considered the source of human development process called labor. The second stage is the over a lifespan. infant’s movement down the birth canal, and the • third and fi nal stage is the delivery of the placenta. The path of fertilization begins at the moment of sexual climax and ends with the fertilization of the • During the fi rst minute of life the umbilical blood female ovum by a single spermatozoon. The newly fl ow diminishes, raising carbon dioxide levels, fertilized ovum or zygote begins to develop in the which in turn stimulate the newly born’s fi rst fallopian tubes as it travels down to the uterus. The breath. The increase in intrathoracic pressure, placenta is formed from zygotic cells and provides from the air-fi lled lungs, causes the cardiac the fetus with nutrition though the umbilical cord. shunts—the foramen ovale and the ductus 150 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. arterious—to reverse blood fl ow and then close. become larger and taller. Those who fail to grow, The newborn’s pulse is between 100 and 160 beats exhibiting failure to thrive, may be under severe per minute, and respirations are between 40 to 60 psychosocial pressures or have nutritional defi cits. breaths per minute. Paramedics need to identify these toddlers and • encourage the parent to seek medical attention for The Paramedic should recognize that infants can the child. quickly fatigue and experience respiratory failure due to an easily obstructed airway, compensation • The growing neuromuscular system in a toddler is for increased oxygen demand, weak accessory made evident by the toddler’s ability to perform muscles, and loss of heat. more complex motor activities. The toddler is in • the preoperational stage of cognitive development The developmental milestones represent a typical and is not able to think abstractly. Young children child’s development and are used to gauge an also develop mathematical reasoning and language individual child’s development against a norm. acquisition. During the fi rst six months the infant displays primitive refl exes. During the assessment of an • Physical growth slows during the middle childhood infant the Paramedic should be attentive to the stage, although the child is more interactive with presence of infantile refl exes. Infantile refl exes may his environment. In this concrete operational include the Moro refl ex, palmar grasp refl ex, and stage, the child is able to understand such concepts Babinski refl ex. as spatial relation, nature of time, and the • sequential nature of certain activities. The multiple Cognitively, primitive refl exes continue to develop intelligences of a person may also become evident. as the infant assimilates experiences into old schemas, thus building new schemas. The infant also • Middle childhood is also a time when the child begins to acquire language skills. The Paramedic develops a sense of self and a desire to succeed may witness bonding or behavior such as mutual and achieve. At this age children begin to relate gazing, refl ective smiling, and response to touch. to others more in terms of common interests and This behavior is the beginning of psychosocial goals. With less infl uence by parents, peers take on development between a mother and child. a greater role in shaping the person’s personality. • The continued social interaction between infant • During the school-age years, children start to and parents is the start of the socialization process. attach a gender-role identity to themselves, that During this early period of socialization, autism is sense of being a male or a female. Regardless of a often discovered. child’s gender-role identity, it is important that the • Paramedic remain nonjudgmental in this matter and Parenting methods may be divided into four styles focus on the patient’s medical condition. with an emphasis—or de-emphasis—on nurturance. The styles include the permissive or indulgent • The most remarkable changes in the human parent, the authoritarian parent, the authoritative physique, or body habitus, occur during adolescent parent, and the uninvolved parent. physical development. Entering into puberty, males • and females see dramatic sexual changes in their The child raised by the uninvolved style of parenting physical bodies as they develop secondary sex may be more aggressive, to the point of violence. characteristics. When the Paramedic is faced with a situation in which the child is aggressive, the Paramedic should • Unhealthy situations can arise as adolescents seek acknowledge the behavior without becoming out opportunities for freedom. Because of a desire aggressive in either words or action, all the while to experiment, adolescents may engage in drug remaining authoritative. use and explore their sexuality in unsafe ways. • The advent of sexuality brings the risk of acquiring During the period of early childhood, from ages 2 to sexually transmitted diseases. 5, there is extraordinary growth where all children Lifespan Development 151 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • Chaotic schedules, the ease and availability of “junk of the few social supports readily available during foods,” and peer pressure contribute to poor teenage a time of acute distress. Paramedics should also nutrition and a national epidemic of teenage obesity. be sensitive to the fact that 5% of married adults The health risks associated with obesity include cannot, or do not want to, have children. type 2 diabetes mellitus, secondary hypertension, accelerated coronary artery disease, and stroke. At • Middle adulthood can be characterized as a period the other extreme of teenage weight problems is a of maximal productivity as well as a period of psychiatric illness called anorexia nervosa. readjustment and realignment. Middle adulthood is also a period of physical decline and changes in • There is an increased risk of premature death interpersonal focus and information processing. among teenagers secondary to engaging in increased risk-taking behaviors and having a false sense of • The quintessential milestone of middle age is the invulnerability. However, teenagers are also at “mid-life crisis,” and central to the concerns of higher risk of death from suicide. a middle-aged adult is the idea of legacy. Legacy implies that life had meaning, and that the dream • Cognitive development of the adolescent enters of young adulthood has come to fruition. Middle- the formal stage and revolves around using logic to aged adults are also confronted with aged parents in solve problems, as well as seeing problems as “less need of care. black and white and more gray.” The psychosocial development involves a return of egocentrism, a • Late adulthood is somewhat synonymous with being stage previously encountered in early childhood. elderly, but is marked by the onset of senescence. During this time, adolescents turn their attention to Most Americans ranging in age from 65 to 84 have morality and their own moral development. suffi cient health to allow them to independently perform their activities of daily living. However, due • Early adulthood is a period of striving and to the stereotypical view of the elderly that exists, accomplishment that is punctuated by fundamental called ageism, the Paramedic may fail to recognize decisions, like going to college or entering the the large population of active and vivacious senior workforce, and peak life events such as marriage citizens. and childbirth. • Improved sanitation, better health care, and • The majority of people, both male and female, improved nutrition, as well as reduced death rates reach their peak height in their early twenties, in children and young adults, have all contributed and their health is generally at its peak as well. to increased life longevity. The effects of physical However, obesity is becoming more common and aging include osteoporosis, cardiovascular and the risk for developing unhealthy behaviors still cardiopulmonary decline, and a decreased sensory remains. system. • Cognitive development of young adults includes • Changes in mental functioning among the elderly exploration of the world through interaction with are generally related to the person’s health, not to others and seeking out new experiences that age. Delirium is a sudden change in mental function, engender questions about themselves, the people which is an acute brain syndrome that is usually with whom they associate, and the world in general. associated with reversible metabolic derangements • such as hypoxia. Senile dementia is the result of Psychosocial development of young adults involves irreversible damage to the brain that typically is fi nding that special someone with whom to share manifested over a longer period of time, such as common goals and aspirations. These goals and Alzheimer’s disease. While passive senile dementia aspirations may include marriage and parenthood. can occur, the majority of elderly patients are in • Paramedics should understand that single mothers good health. Therefore, any acute alteration in may have limited resources and that EMS is one mental function should be immediately investigated for a potentially reversible cause. 152 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not

materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • The goal of most elderly persons is to be self- is asked of the Paramedic is to honor a Do-Not- suffi cient and live as independently as possible. Attempt-Resuscitation (DNAR) order or to follow the Independence can be maintained at assisted-living wishes of a healthcare proxy who is speaking on the centers, through adult-care programs, and at-home. patient’s behalf. • Depression in the elderly, like delirium, is a • Hospice medicine is focused on providing for potentially reversible mental illness that should be the physical, emotional, and spiritual needs of a confronted and dealt with immediately. When a terminal patient. In some instances, EMS may be terminal disease threatens an elderly person’s life, called to the scene of a dying person to administer the person will begin the dying process marked by comfort measures, called palliative care (such as what is referred to as the fi ve stages of dying. morphine sulfate), sometimes at the request of a • hospice nurse. Paramedics are, on occasion, called to help care for dying patients. In many instances, all that Review Questions: 1. Describe the main points for each theory of 9. What are some health risks that teenagers face psychosocial development put forth by Freud, and why are they more prone to engage in Erickson, Skinner, and Piaget. unhealthy behavior? 2. How is the gender of a fetus determined? 10. What confronts an adult when he or she reaches 3. Explain how two parents, both with recessive middle age? genes for a disorder, can potentially have a child 11. Why is the stereotypical view of elderly people that will have the disorder. inaccurate? 4. What are the stages of childbirth? 12. What factors have helped to increase our life 5. What are some developmental milestones for expectancy? infants and toddlers? 13. Differentiate between delirium and dementia. 6. Describe the four different types of parenting. 14. What are the fi ve stages of dying per Kubler- 7. At what stage of development is there Ross? extraordinary growth and development? 15. Discuss the importance of palliative care and 8. Starting with concrete thinking, what is the the effects of hospice. progression of cognitive development of a child through young adulthood? Case Study Questions: Please refer to the Case Study at the beginning of the • Physical development chapter and answer the questions below. • Cognitive development 1. Based on lifespan development, what • Affective development expectations should Paramedics have for the following considerations in a 13-year-old male? Lifespan Development 153 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. References: 1. Erikson E. Identity and the Life Cycle. New York: W. W. Norton 19. Brown JE, Murtaugh MA, Jacobs DR, Jr., Margellos HC. & Company; 1980. Variation in newborn size according to pregnancy weight change 2. Greenberg-Edelstein R. Nurturance Phenomenon: Roots of by trimester. Am J Clin Nutr. 2002;76(1):205–209. Group Psychotherapy. 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AHA guidelines for 36. Blakeslee J, Lewis S, Lewis J, Wallerstein J. The Unexpected cardiopulmonary resuscitation (CPR) and emergency Legacy of Divorce: A 25 Year Landmark Study. Westport, Conn.: cardiovascular care (ECC) of pediatric and neonatal patients: Hyperion Books; 2000. Pediatric basic life support. Pediatrics. 2006;117(5):e989–1004. 37. Johnson HL, Erbelding EJ, Zenilman JM, Ghanem KG. Sexually 18. Ehrenkranz RA. Early, aggressive nutritional management for transmitted diseases and risk behaviors among pregnant women very low birth weight infants: what is the evidence? Semin attending inner city public sexually transmitted diseases clinics in Perinatol. 2007;31(2):48–55. Baltimore, MD, 1996–2002. Sex Transm Dis. 2007;34(12): 991–994. 154 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 38. Gray-Swain MR, Peipert JF. Pelvic infl ammatory disease in 47. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, adolescents. Curr Opin Obstet Gynecol. 2006;18(5):503–510. Kooperberg C, Stefanick ML, et al. Risks and benefi ts of estrogen 39. McKinzie J. Sexually transmitted diseases. Emerg Med Clin plus progestin in healthy postmenopausal women: principal North Am. 2001;19(3):723–743. results from the Women’s Health Initiative randomized controlled 40. Rambout L, Hopkins L, Hutton B, Fergusson D. Prophylactic trial. Jama. 2002;288(3):pp. 321–333. vaccination against human papillomavirus infection and disease 48. Rossouw JE, Prentice RL, Manson JE, Wu L, Barad D, Barnabei in women: a systematic review of randomized controlled trials. VM, et al. Postmenopausal hormone therapy and risk of Cmaj. 2007;177(5):469–479. cardiovascular disease by age and years since menopause. Jama. 41. Sodersten P, Bergh C, Bjornstrom M. Prevalence and recovery 2007;297(13):1465–1477. from anorexia nervosa. Am J Psychiatry. 2008;165(2):264–265. 49. Kirshner HS. Delirium: a focused review. Curr Neurol Neurosci 42. Steele MM, Doey T. Suicidal behaviour in children and Rep. 2007;7(6):479–482. adolescents. Part 1: etiology and risk factors. Can J Psychiatry. 50. Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in 2007;52(6 Suppl 1):21S–33S. elderly patients: evaluation and management. Mayo Clin Proc. 43. Steele MM, Doey T. Suicidal behaviour in children and 1995;70(10):989–998. adolescents. Part 2: treatment and prevention. Can J Psychiatry. 51. Borja B, Borja CS, Gade S. 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Gynecol Endocrinol. 2007;23(7):391–397. Lifespan Development 155 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Cellular physiology and the need for homeostasis • Fluid movement as dynamic driven by concentrations and hydrostatic pressure • The body’s general adaptation syndrome • Cell-mediated sympathetic and parasympathetic responses • The body’s thermoregulatory mechanism • The cell’s ability to adapt to variable conditions Case Study: “Hey, take a look in today’s paper. Remember that man from the auto crash two weeks ago? He died!” The Paramedics remembered the man. He was in a serious auto crash and had suffered some serious injuries. On-scene, it took a while before they could get him out of the car so he could be properly ventilated with a bag–mask assembly. He kept asking for a glass of water during the extrication and thought he could get up and walk away. They got a couple of large IVs into him. By the time he was transferred to the hospital, he had a blood pressure of 100/80 and a heart rate of 100. “Wonder what happened to him?” 156 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Basic Human Physiology 157 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if

subsequent rights restrictions require it. OVERVIEW The systems of the body work together to carry out the body’s functions. These systems can be broken down into individual organs, then to specifi c tissues, and further into specialized cells. This chapter begins with a look at cellular physiology and the process of maintaining an internal equilibrium. This balance or homeostasis is seen throughout systems of the body in response to internal and external stimuli. For the Paramedic, this includes the sympathetic and parasympathetic responses of the nervous system, the body’s thermoregulatory mechanism, and the cell’s ability to adapt to variable conditions. Physiology Resisting homeostasis are a myriad of external factors, such as cold and heat, lack of food, and infectious diseases. The study of the body’s functions, in its normal human Abnormal internal conditions, broadly called diseases, also condition, is called physiology. Different from anatomy, challenge homeostasis. The body must overcome them in order which studies human form, physiology studies the physical, to maintain homeostasis. Because these factors are always mechanical, and biochemical processes that go on inside the changing, the human body is in a constant state of fl ux, resisting body every day (i.e., how the body works). This chapter is and adapting to external and internal conditions, while trying to a brief overview of human physiology, with an emphasis maintain normalcy within a certain set of acceptable parameters on physiology that may have particular importance to the called a range. Because of this ever-changing internal milieu, Paramedic. some scientists and physicians have suggested that the more correct term for this process would be “homeodynamics,” in Cellular Milieu recognition of the ever-changing conditions. The sum of the biological processes within the body— The human body is actually a complex association of circulation, ventilation, and so on, through symbiosis— independent cells which, together, form tissues. The tissues support the cells of the body. in turn become organs, and ultimately all the cells comprise a person. Therefore, a person’s overall well-being is dependent on the health of all of the person’s constituent cells. Cellular Physiology To survive and thrive (i.e., to be healthy), cells need an environment, a milieu, that has (1) water, the most The outside of a cell is made up of a cell wall membrane, abundant substance in the body; (2) food stuffs, in the form a porous semipermeable dual layer lipid–protein matrix. of glucose, amino acids, and fatty acids; and (3) oxygen. All Inside the cell is an internal fl uid called cytoplasm, which of these essential elements must be maintained in an internal is primarily water and organelles, subunits with a specifi c environment where there is suffi cient heat and acidity for cellular function(s). biochemical reactions, or metabolism, to occur and life In the center of the cell is the fi rst organelle, the nucleus, processes to go on. which contains chromosomes and DNA. These are the blueprints for cellular protein production and reproduction. Homeostasis Outside of the nucleus, but inside the cytoplasm, are lysosomes, tiny sacs that contain enzymes which can break One of the primary functions of the human body is to maintain down proteins. Lysosomes can break down foreign proteins a relatively even state of temperature, acid load, oxygenation, in bacteria, called antigens, or the cell’s own chromosomes. blood glucose, and so on, for internal life processes. When the The largest organelle in the cell is the mitochondria. goal is achieved it is called wellness, a state of physiologic Inside the mitochondria, glucose is transformed into the equilibrium free of disease. The body’s process to attain this energy source adenosine triphosphate (ATP), which is used state of internal equilibrium is called homeostasis. to power the rest of the cell’s functions. This function, the Coined by Cannon in 1939, the term “homeostasis” production of ATP, earned the mitochondria the nickname of attempts to describe the processes that the body undertakes the cell’s “powerhouse” (Figure 10-1). to try to maintain a constant state of equilibrium.1 Key to For the all important mitochondria to work properly, the understanding the complex concept of homeostasis is an body must maintain a complex set of conditions—including understanding of the regulatory mechanisms that the body fl uid balance, acidity, oxygenation, and temperature. The utilizes to help to maintain homeostasis, namely the endocrine body depends on the nervous system, the endocrine system, system and autonomic nervous system. and the immune system to maintain that crucial balance. 158 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Ribosomes Centriole Lysosome Nucleolus Nucleus Rough endoplasmic reticulum Golgi Mitochondrion apparatus (complex) Plasma membrane Smooth endoplasmic reticulum Figure 10-1 Cross-section of a typical cell. Sodium Potassium Pump requiring the complex interactions of other organs required in aerobic metabolism. To make adaptations to the constantly changing conditions Under ideal conditions, and in the presence of suffi cient that exist within the body, the cells need energy. For the cell, glucose and oxygen, the cell uses oxygen in the next step that energy is in the form of adenosine triphosphate (ATP). of its metabolism, a process called aerobic metabolism, to The phase of glucose metabolism does not utilize oxygen create ATP from glucose (Figure 10-2). and is called anaerobic metabolism. During anaerobic During this process, the body uses eight different enzymes metabolism, the cell changes glucose into pyruvate acid, to divide glucose, a process called glycolysis (glycol- – which is in turn converted into lactic acid by an enzyme called “sugar”; -lysis – “to divide”), to create a chemical called lactate dehydrogenase (de- – “without”; hydrogen; -ase – pyruvate. Pyruvate and oxygen enter into the citric acid or indicating an enzyme). Krebs cycle, another complex series of changes facilitated by Although anaerobic metabolism is relatively ineffi cient enzymes, and there they undergo a process that creates ATP. in that it only yields two ATP, or about 2% of the energy that The end result of this chemical reaction creates carbon is available from glucose if oxygen were to be used, it is 100 dioxide (CO ), water (H O), energy (in the form of ATP), times faster than aerobic metabolism. For this reason, cells 2 2 and heat from the carbohydrate glucose. Aerobic metabolism that need quick energy in a short amount of time (i.e., skeletal produces about 36 ATP for the cell to use as energy compared muscles) use anaerobic metabolism. to the 2 ATP produced from glucose during anaerobic Interestingly, red blood cells (erythrocytes) that carry metabolism. oxygen cannot use the oxygen they carry. They depend on anaerobic metabolism and save the oxygen for the cells of the body instead. Glucose Storage Anaerobic metabolism only yields two ATP but can still When glucose is abundant, such as after a meal of release 619 kCal of heat. This amount of heat is comparable carbohydrates, any glucose which is not needed immediately to the amount of heat released by aerobic metabolism by the body is stored in the liver and muscles as a dual molecule (696 kCal). Thus, anaerobic metabolism can help keep the called glycogen (glycol- – “sugar”; -gen – “create”). When body warm (a very important factor discussed later) while not glucose levels fall, then the body liberates some glucose from Basic Human Physiology 159 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Glucose (C6H12O6) Glycolysis O2 67% Cytoplasm Pyruvic acid Citric acid cycle Electron-transport chain 2 lactic acid + 2 ATP Anaerobic respiration 6CO2 + 6H2O + 38ATP Interstitial Aerobic respiration Fluid Intravascular Fluid 26% (blood plasma) 7% Figure 10-2 First aerobic then anaerobic metabolism. Cerebrospinal Fluid (less than 1%) these glucose stores. These two bonded glucose molecules Figure 10-3 Distribution of water in the body. (glycogen) are broken down by an enzyme called glucagon into individual glucose molecules. In the absence of other readily available glucose stores, remaining fl uid is extracellular water which is in one of two the body can use other food sources to create glucose, a types. Interstitial fl uid is the fl uid between cells. It is about process called gluconeogenesis (glycol- – “sugar”; neo – 16% of the TBW, or 11 L. The second type of extracellular “new”; genesis – “creation”). For example, the body can water is fl uid found in the blood, which is called intravascular release glucose from fats, and in the process leave fatty acids fl uid. It is primarily made of plasma and constitutes about 4% behind. In extreme cases when glucose is not readily available, of the TBW or 3 or 4 L. (For clarifi cation, the blood volume the body can even break down muscles, liberating proteins in in the 70 kg male is about 6 L but only a portion of the blood the process. These proteins are then further broken down into is plasma, the rest being formed elements.) amino acids and glucose, leaving urea behind. Anatomists in the past referred to the volume of fl uid The process of aerobic metabolism is dependent upon inside the cells (intracellular) as the fi rst space, the volume of many organ systems working together in synchrony in order fl uid in the bloodstream (intravascular) as the second space, to be effective. To make ATP, the mitochondria needs ideal and the volume of blood in between the cells (the interstitial conditions of temperature and acidity. The body temperature space) as the third space. must be maintained at a fairly constant range of 99.6°F / While these volumes of fl uid in each compartment 1°F by a complex system of cooling and heat preservation are illustrative of the general distribution of fl uids within which uses bodily fl uids in the same way as an automobile the body, it should not be thought that fl uid levels between engine uses radiator fl uid. Acidity is also maintained by body compartments are static. In fact, there is a constant a complex system of dilution and diuresis (Greek “to pass movement of fl uids between compartments, an ebb and fl ow urine”). Central to maintaining both of these conditions is of living sustaining water laden with glucose, oxygen, and fl uid balance. other chemicals necessary for life. This is also known as nutritional fl ow. Fluid Balance Fluids can move from outside to inside the cells and from compartment to compartment by diffusion or osmosis. What The body is primarily made up of water—some 50% to 55% controls the amount of fl uid transferred from one compartment of total body weight (TBW) in women and 55% to 60% of to another is either the pressure behind the fl uid or the salts TBW in men.2 The water within the body can be divided into or the proteins in the fl uid of the other compartment. In both two portions or compartments. The water that is within the cases, nature is trying to reach a balance between the amounts cells is intracellular water and the water that is outside of of solutes in the two compartments. the cells is extracellular water. For example, when the interstitial fl uid volume is low, The majority of body water is intracellular. This amounts such as during dehydration, then fl uids are drawn out of the to about 35% to 40% of the TBW, or 25 liters (L) in the intravascular compartment into the interstitial space. This average 70 kilogram (kg)/154 pound male (Figure 10-3). The pressure created by the force behind the volume of water is 160 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.

Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Extracellular Intracellular Fluid Fluid called the hydrostatic pressure. An analogy can be made to Alternatively, when a fl uid has less water and more the garden hose. A garden hose can fl ow so many liters of salt (electrolytes), then the solution is called hypertonic. water per minute (lpm) and this fl ow can be measured as a A hypertonic fl uid on the other side of a semipermeable pressure (mmHg). Interestingly, as the circumference of the membrane will pull fl uids into itself (Figure 10-4). The opening narrows, such as when one places a thumb over the military has made limited use of hypertonic solutions during end of the hose, the pressure increases but the volume of fl uid resuscitation of wounded soldiers who have hemorrhaged (lpm) remains the same. However, when the hose is narrowed and are in need of intravascular volume replacement. to a critical point, about 70% to 90%, then the volume starts The capillary membrane, however, is relatively permeable to decline. Therefore, when the capillary hydrostatic pressure to electrolytes, such as sodium chloride. For this reason, is greater than the tissue hydrostatic pressure, which is near electrolytes in the blood, for example, do not create a great zero, then fl uid freely moves, or diffuses, across the capillary deal of osmotic pressure. However, capillary membranes are wall and into the tissues. semipermeable to proteins. These proteins can be found in Resisting this infusion of fl uids into the interstitial both the intercellular and extracellular space, including the space is the tissue’s hydrostatic pressure. This pressure is a intravascular space. These proteins create a force similar to combination of factors including maximal interstitial fl uid osmotic pressure called oncotic pressure. volume and compliance of the tissue (i.e., its elasticity). In short, the tissues have mechanisms that stop the free infusion Hypotonic (Hyposmotic) of fl uids once the tissues are adequately hydrated; adequate (low extracellular solute conc.) hydration being a function of the cells’ needs at the time. water flows in Constantly draining the tissues (the interstitial space) is the venous system and the lymphatic system. The venous system does the bulk of the elimination of the fl uids from the interstitial space. The lymphatic system acts as a storm sewer of sorts, ridding the tissue of excess fl uid beyond what the venous system can drain. Therefore, any backup of the venous system, or blockage of the lymphatic system, can result in dramatic fl uid buildup in the tissues called edema. As a result of this constant fi lling of the interstitial space Isotonic with nutrient-laden fl uids and the subsequent drainage of (same solute conc. in and out) those tissues, a fl ow is created. Another factor in this fl ow no net flow of water is osmotic pressure. Osmosis occurs whenever a semi- permeable membrane exists and there is a concentration of a substance, typically salt, on one side. Since the salt cannot cross a semipermeable membrane, water diffuses across the semipermeable membrane to try to balance the solution. If the solution being infused into the bloodstream has the same amount of salt (solute) and water (solvent) as the solution on the other side of the capillary membrane, then osmosis will not occur. Such a fl uid is said to be a balanced solution. Another name for a balanced solution is an isotonic solution (iso- – “equal”; tonic – “tension”). An example of Hypertonic (Hyperosmotic) (high extracellular solute conc.) a balanced solution that is used for intravenous infusions water flows out, plasmolysis is “normal saline”; termed “normal saline” because it has approximately the same amount of saline (sodium chloride 0.9%) as exists in blood and is therefore isotonic.1,3,4 Therefore, when a fl uid has more water and less salt (electrolytes) than the solution on the other side of a semipermeable membrane, then the fl uid is labeled hypotonic. In an effort to obtain a balance of concentrations, the water from the hypotonic solution will cross the membrane until the two solutions are balanced (i.e., equal parts water and salt). An example of a hypotonic solution is 5% dextrose in sterile water (D W). Since there is more water in intravenous D W 5 5 Figure 10-4 Effects of isotonic, hypotonic, than in the interstitial space, the water passes into the tissues. and hypertonic fl uids across a semipermeable This is useful when treating dehydration. membrane. Basic Human Physiology 161 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Hydrostatic (blood) Temperature Regulation Artery pressure Vein The enzymes within the cells operate best in a narrow temperature range of 98.6°F / 1°F. All endothermic (i.e., warm-blooded) animals create heat during cellular Capillary metabolism and use that heat to maintain a relatively constant core temperature. However, at least 90% of all cellular metabolism is used to maintain that heat production, leaving little for other life processes.8 While this may seem like an enormous cost, the benefi t is that it permits people to move about freely regardless of the environmental conditions. However, this ability to adapt to conditions is not unlimited. If too much heat builds up in the body’s core, a condition Colloidal Osmotic called hyperthermia, then the cell walls become more fl uid- Pressure (COP) like and cannot maintain their integrity. If there is too little Artery Oncotic pressure Vein heat, a condition called hypothermia, then the cell walls become gel-like, almost crystalline, and all cell wall activities stop. Thus, the body takes measures to both accumulate heat as well as dissipate heat. Capillary The anterior hypothalamus regulates the body’s temperature, acting as a thermostat and controlling heat loss mechanisms. With a set point of approximately 99°F, if 25 mmHg the body gets warmer than 99°F the hypothalamus engages drawing fluid into capillary certain heat loss mechanisms including rapid breathing, sweating, and vasodilatation. Vasodilatation is perhaps one of the most effective Figure 10-5 The effects of oncotic and heat-dissipating mechanisms that the body has. Controlled hydrostatic pressure upon intravascular volume. by the parasympathetic nervous system, surface capillaries under the skin react to dissipate the heat. Surface capillaries normally hold about 300 mL of blood but can be dilated to accommodate as much as 3,000 mL of blood. This causes the The most common intravascular protein is albumin, skin to act as a massive radiator to allow heat to dissipate by principally made in the liver. Albumin creates about 70% of conduction, convection, and radiation.9,10 the oncotic pressure. The remainder is provided by formed If the body should start to cool, then the hypothalamus elements such as red blood cells (erythrocytes). Together can either increase heat production by causing shivering, these blood proteins are called colloids and the pressure that an involuntary contraction of muscles, and/or by vasocon- they produce is called colloidal osmotic pressure (COP). striction. Alpha receptors of the sympathetic nervous system Whenever COP is high fl uids are pulled out of the tissues cause peripheral vasoconstriction by contracting the capillary and into the intravascular space. Whenever COP is low (e.g., sphincters (round muscles) that control the blood fl ow in the when albumin levels are low during liver failure) fl uid leaks capillary bed. Vasoconstriction can reduce blood fl ow in from the intravascular space and into the interstitial space, a the skin from 300 mL to as little as 30 mL for short periods process called third spacing (Figure 10-5). of time. Street Smart Street Smart When a patient is developing edema (e.g., from heart Understanding blood shunting in hypothermia explains failure), the condition may be described as “third why trauma patients often do not bleed signifi cantly spacing.” While the patient’s total body weight is when out of doors, but begin to bleed in earnest when increased due to retained fl uid, the patient can moved to the relative warmth of the back of the actually be intravascularly depleted.5–7 ambulance. 162 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Temperature and Stage One: ALARM the Oxyhemoglobin Curve When stressors are threatening or perceived to Increased body temperature (i.e., a fever) has been maligned be threatening, the body activates physiological by laypersons as being harmful to the body. Nothing could changes that ready it for fight or flight. be further from the truth. Fever is actually benefi cial to the healing process at many levels. The hypothalamus, located in the brain, controls the mean temperature of the body and maintains it at a steady Stage Two: RESISTANCE state of approximately 99.6°F. During an infection, poisons The fight-or-flight response occurs. Long-term from the bacteria, called endotoxins, stimulate chemical coping with stressors depletes adaptive energy, mediators (such as interleukin and interferon) to affect the resulting in exhaustion. hypothalamus. In essence, these chemical mediators reset the hypothalamus thermostat, thereby causing it to raise the body’s temperature. Stage Three: EXHAUSTION These pyrogens (fever producers) therefore create a pyrexia (Greek—fever) which makes the environment When the body has used up its adaptive energy and can no longer cope with stressors, it breaks hostile to bacteria, increases motility of macrophages, and down in disease, collapse, or death. enhances phagocytosis (cell eating) of bacteria by white blood cells.11–13 The increased temperature also moves the oxyhemoglobin Figure 10-6 The stages observed in the general dissociation curve to the right, improving oxygen off adaptation syndrome. loading to the cells. Also, metabolism is increased at the site of a localized infection vis-á-vis Hoff’s law where a 1°C temperature rise results in a 13% increase in metabolism. The fi rst stage of the general adaptation syndrome is While fever can be helpful in mild infections, in the the alarm stage. During this stage, the body responds to the case of a severe systemic infection high fever can lead to stressor via the central nervous system. The next stage is the delirium and/or convulsions. One possible cause of these stage of resistance in which the body attempts to reestablish convulsions is cerebral hypoxia. While hemoglobin readily homeostasis, utilizing the endocrine and/or the immune releases oxygen to the cells whenever the tissues are acidotic system. The fi nal stage is exhaustion or recovery. Exhaustion or hyperthermic, hemoglobin picks up less oxygen in the occurs when the body’s response is insuffi cient to meet the lungs. Tissues that are sensitive to even small drops in oxygen challenge of the stressor (Figure 10-6). saturation of hemoglobin, such as nervous tissue, will suffer Stress that overcomes the body’s innate defenses, and from the resultant systemic hypoxia. leads to exhaustion, is termed distress and heralds the onset of disease. However, not all stress is harmful. Stress is a condition Stress of daily living. Daily stress essentially keeps body defenses on guard for larger stress threats. This daily stress is called Stress and Cellular Response eustress. An example of stress being purposefully introduced Environmental conditions, both internal and external, are is the vigorous physical training in military boot camps. This constantly changing and therefore can cause an imbalance activity prepares the body for the physical challenges or within the body (i.e., a disruption in the homeostasis of stressors that await the soldier on the battlefi eld. the body). These constantly changing conditions, called From a physiologic perspective, stress creates a physical stress, cause the body to respond in an effort to regain

or chemical disturbance at the cellular level. However, to homeostasis. the layperson stress implies a psychological origin. There is In 1946 Hans Selye noted this physiologic response in a connection between the body’s response to psychological lab rats while injecting them with an ovarian extract. He stress and the resulting physiological response. Any emotional quickly noted the physiologic response was not limited to stress (e.g., fear or joy) can trigger the same response as a injections only but to cold and injury as well. Selye labeled physical stress. these noxious stimuli as stressors. As might be assumed, the body goes through the three Selye noted that when a person was stimulated with a stages of the general adaptation syndrome whether the stressor suffi cient stressor there was a predictable progression of is physical or psychological. This includes the fi nal stage, responses by the body. These responses occurred in stages, exhaustion, and the beginning of certain disease states. There and involved the central nervous system, the endocrine is ample evidence that persistent psychological stress upon system, and the immune system. Selye labeled the body’s the body can lead to hypertension, coronary artery disease, predictable pattern of response to these stressors as the strokes, asthma, stomach ulcers, obesity, and impotence, to general adaptation syndrome.14,15 name just a handful of stress-related diseases. Basic Human Physiology 163 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Stress and the Autonomic Lacrimal gland Midbrain Nervous System Paravertebral and nasal septum Medulla chain The autonomic nervous system controls the moment-to- ganglion Eye moment functions of most of the organs within the body and is composed of two divisions: the sympathetic and the Parotid parasympathetic nervous systems. Some have compared gland the sympathetic nervous system to the accelerator on a car and the parasympathetic to the brake. This analogy is not accurate. The better analogy for the parasympathetic Submandibular nervous system would be the idle adjustment on the and sublingual carburetor.16 salivary glands Many organs have dual innervations from these two divisions of the autonomic nervous system and the dominance T1 Trachea of one division over the other is a function of the body’s needs T2 Heart at the time. T3 The effects of the parasympathetic system can be grossly Lung T4 characterized as the “feed and breed” regulation of the organs. T5 The parasympathetic nervous system increases digestion in Celiac ganglion T6 Stomach the gut, slows the heart rate down, and causes erections in T7 males. The control of the parasympathetic nervous system is Pancreas maintained primarily by the vagus (Latin – wander) nerve, T8 the 10th cranial nerve, through its many branches. T9 Small intestine The sympathetic nervous system is reactive, stimulated T10 Liver Spleen by stressors, and promotes protection of the body. For this T11 reason, the responses of the body’s organs to stimulation from Adrenal gland T12 (medulla) the sympathetic nervous system has been described as “fi ght L1 or fl ight.” L2 The sympathetic nervous system (Figure 10-7), origin- Large ating from the thoracic–lumbar region (thoracolumbar Superior intestine division) of the spinal cord, causes a litany of bodily mesenteric responses. ganglion Neurotransmitters Kidney Both the sympathetic and parasympathetic systems affect Inferior organ function by their virtual connection at the motor mesenteric ganglion endplate. It is a virtual connection because neurons do Urinary bladder and genitals not physically contact the organs that they innervate, the neurons being separated by a gap called the synapse. The nervous signal is transmitted across this synapse by a Figure 10-7 Sympathetic nervous system. chemical messenger called a neurotransmitter to awaiting chemical receptors across the synapse called neuroreceptors (Figure 10-8). The sympathetic nervous system, at the motor endplates, creating an electrical transference across the cell wall uses the neurotransmitter norepinephrine, or adrenaline membrane that propagates the nervous signal or stimulates (ad- – “above”; renal – “kidneys”; -ine – for hormone). The the affected organ. transmission of a nervous signal using adrenaline as the The parasympathetic nerve uses the neurotransmitter neurotransmitter is called an adrenergic transmission. acetylcholine. Originally acetylcholine was called vagus- In a typical sympathetic nervous system transmission, schtuff by German physiologists because it was released by an electrical stimulus releases norepinephrine from storage the vagus nerve and affected the heart rate. The transmission in pockets, or vesicles, within the neuron that travel to the of a nervous signal using acetylcholine as the neurotransmitter synapse. The chemical neurotransmitter norepinephrine at the motor endplate is called a cholinergic transmission then travels across the synapse to occupy neuroreceptors on (Figure 10-9). the next neuron. These neurotransmitters cause increased Note that acetylcholine is the prime neurotransmitter for permeability of the affected neuron, specifi cally to potassium, all preganglionic fi bers of the autonomic nervous system. 164 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Presynaptic neuron Ciliary ganglion Direction of conduction Cranial nerve III Midbrain of nerve impulse Cranial Vesicles containing nerve VII Medulla neurotransmitters Mitochondrion Pterygopalatine Synaptic ganglion cleft Submandibular ganglion Cranial nerve IX T1 Otic ganglion T2 Cranial nerve X T3 Lung T4 T5 Heart T6 Postsynaptic Receptors on postsynaptic neuron membrane bound to neurotransmitter T7 Liver Figure 10-8 Neurotransmission across T8 a synapse. T9 Stomach T10 Paramedics are interested in the postganglionic neurons, T11 those that connect with the target organs, of the autonomic nervous system. Pancreas T12 Small Spleen There are different neurotransmitters in the different por- intestine L1 tions of the nervous system throughout the body: monoamine L2 class neurotransmitters like norepinephrine, dopamine, hista- mine, and serotonin; amino acid class neurotransmitters like glycine and gamma aminobutyric acid (GABA); and neuro- Large intestine peptide class neurotransmitters like endorphins. These are just some examples of the over 30 major neurotransmitters in the body. Many current drug therapies affect these neurotrans- Kidney mitters by simply supplanting or blocking them. Atropine, for example, blocks the neurotransmitter acetylcholine and thus impairs the parasympathetic nervous system conduction. S2 Urinary Neuroreceptors bladder and S3 genitals Pelvic nerves Each division of the autonomic nervous system joins with the S4 target organs at the motor endplate via neuroreceptors. Each Figure 10-9 The innervations of the division has two neuroreceptors. parasympathetic nervous system. The parasympathetic nervous system has nicotinic and muscarinic receptors, named after the fi rst chemicals that initially were used to stimulate them. in onset and short in duration, causing a sodium infl ux and Nicotinic receptors are found in the central and peripheral local depolarization. nervous system as well as the neuromuscular junction with The other parasympathetic neuroreceptors, muscarinic skeletal muscles. Certain paralytic drugs, like curare and receptors, are slower and indirectly open ion channels that succinylcholine, are nicotinic antagonists. They act by blocking cause depolarization. Muscarinic receptors, by defi nition, are the nicotinic receptors and are called neuromuscular blocking more sensitive to muscarine, a naturally occurring chemical agents. Cholinergic stimulation of nicotinic receptors is quick found in mushrooms, than to nicotine. Basic Human Physiology 165 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The effects of muscarine poisoning, from poisonous they are more active on the beta adrenergic receptors than 2 mushrooms, provides a clue to the location of muscarinic beta adrenergic receptors. 1 receptors. The symptoms of muscarine ingestion are contained A certain class of drugs that imitate epinephrine, called within the mnemonic SLUDGEM: Salivation, Lacrimation sympathomimetic, will affect adrenergic neuroreceptors. (tearing of the eyes), Urination, Defecation, Gastrointestinal However, each has a predilection for one of the specifi c pain, Emesis (vomiting), and Miosis (pinpoint pupils). While adrenergic receptors. For example, norepinephrine is these symptoms can be severe, the stimulation of muscarinic more active with alpha adrenergic receptors. Because receptors in the heart, affecting cardiac contraction, and alpha adrenergic receptors affect peripheral vascular beds, the lungs, causing bronchial constriction, can be more life norepinephrine is effective in states of massive vasodilation threatening. such as septic shock.20–22 The sympathetic neuroreceptors are also divided into two Isoprenaline hydrochloride (isoproterenol) is almost types of receptors. These receptors, called alpha receptors exclusively a beta adrenergic receptor stimulant and increases and beta receptors, are further divided into type 1 and type 2 heart rate (chronotropy) and strength of contraction (inotropy), receptors. Alpha adrenergic receptors are primarily making it useful in treating cardiogenic shock.23–25 1 involved with excitation. They are located in the peripheral vascular beds, on the arteriole side, and control the sphincters (round muscles) of the bladder, intestine, and the iris of Stress and the Endocrine System the pupil. The endocrine system can also be stimulated by stress. When the Stimulation of alpha receptors results in constriction endocrine system is activated by stress there are two effects. 1 of the precapillary sphincters of the peripheral vascular Initially, the sympathetic nervous system stimulates the bed, resulting in a displacement of blood volume to the core medulla of the adrenal glands, an endocrine organ, to secrete circulation, a phenomenon known as shunting. The result the hormone, adrenaline. Adrenaline is physiologically and is that the skin, drained of blood, appears pale. Vasomotor chemically the same as the neurotransmitter epinephrine regulation may be one of the most important functions of the (EP). Circulating adrenaline then goes to the liver and muscles sympathetic nervous system, ensuring perfusion to the body’s where it stimulates glycolysis of glucogen stores and liberates core organs. The shunting of blood, during crisis, provides for glucose into the bloodstream. increased blood fl ow to the vital organs of the heart, lung, and Simultaneously, the sympathetic nervous system brain, while decreasing the chance of excessive hemorrhage stimulates the release of corticotrophin-releasing factor (CRF) from external trauma.17–19 from the hypothalamus. In turn, CRF stimulates the pituitary Alpha adrenergic receptors are found in the gland to release several important stress hormones including 2 gastrointestinal tract where they decrease bowel motility, via antidiuretic hormone (vasopressin), from the posterior relaxation of the smooth muscles within the intestinal walls. pituitary gland, and adrenocorticotropic hormone (ACTH), Paramedics are generally more interested in the from the anterior pituitary gland. effects of the beta adrenergic receptors because they Vasopressin is a powerful vasopressor, a chemical affect the heart and lungs. Beta adrenergic receptors are that causes vasoconstriction particularly on the arterioles. also subdivided into beta adrenergic receptors and beta Vasopressin’s fi rst action is to prevent diuresis by 1 2 adrenergic receptors. vasoconstricting the distal arterioles in the kidneys and Beta adrenergic receptors are found in abundance preventing diuresis.26–28 This helps to maintain blood volume, 1 in the heart, though not exclusively, as there are beta which is especially important if one is hemorrhaging. 2 adrenergic receptors in the heart as well. Beta adrenergic At the same time adrenocorticotropic hormone (adreno- – 1 receptors cause the muscle of the heart, the myocardium, to “adrenals”; cortico – “cortex”; -tropic – “affecting”) stimulates beat harder (i.e., inotropy) and stimulate the heart to beat the cortex of the adrenal glands to secrete cortisol. Cortisol faster (i.e., chronotropy) as well. Beta adrenergic receptors is a glucocorticoid hormone that stimulates the production 1 are also found in the kidneys where they cause the secretion of glucogen from amino acids and fatty acids contained in of renin, which is converted into angiotensin, a powerful lipids, a process called glyconeogenesis (gluco- – “glucose”; vasoconstrictor. The addition of angiotensin increases neo- – “new”; genesis

– “creation”). Cortisol helps to ensure the shunting of blood to the core organs (i.e., the heart, that there are adequate levels of glucose circulating in the lungs, and brain), which was started by alpha adrenergic bloodstream once the immediately available glucose from the 1 receptors. liver is exhausted. Beta adrenergic receptors act upon the smooth Other hormones also excreted during times of stress 2 muscles found in the bronchial walls, the level of the terminal include endorphins, naturally occurring opiates within the bronchioles, and cause bronchodilation. The original body that reduce the perception of pain, and growth hormone. bronchodilator was racemic epinephrine (EP), which was a Growth hormone or somatotropin (soma- – “body”; tropin – potent bronchodilator that also caused unintended tachycardia. “affecting”) affects the metabolism of carbohydrates, proteins, Newer bronchodilators are more beta-specifi c, implying that and lipids. 166 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Stress and the Immune System Hypertrophy The last leg of the neuro–endo–immune axis of the stress Hypertrophy is an increase in either the weight or functional response is the immune system. The major organs of the capacity of a tissue or organ beyond what is normal. It should immune system—the thymus, spleen, and lymph nodes— not be confused with hyperplasia, which is an actual increase are directly innervated by the nerve fi bers of the autonomic in the number of cells. Cells that hypertrophy cannot normally nervous system. divide to increase their numbers and therefore must increase in The hypothalamus, located in the brainstem, acts size to accommodate demands upon them. The classic example through the pituitary gland and then the adrenal gland to is the bodybuilder who undergoes resistance training to create modulate the immune response. The now-activated adrenal enlarged, or hypertrophied, biceps muscles. A more pertinent glands increase levels of glucocorticosteroids, which in example would be myocardial hypertrophy (i.e., an enlarged turn suppress white blood cells, the macrophages and the heart), where the heart has to overcome hypertension. monocytes. An important function of the immune system may be Cell Replacement to alert other organs, through the release of infl ammatory Metaplasia is replacement of one adult cell type with another mediators such as interferon, of an impending systemic threat, type of adult cell. For example, tobacco smoke causes a be it from infection, cancer, or trauma. This mechanism is decrease in the number of cilia in the bronchial airways and discussed more fully in the section on systemic infl ammatory an increase in the number of mucus-producing goblet cells. response syndrome. Metaplastic cell changes are typically due to chronic irritation and may develop into precancerous cells. Hyperplasia (hyper- – “increase”; genesis – “creation”) Cellular Adaptation is an abnormal increase in the number of cells due to frequent cell division/reproduction which causes the tissue or organ Cells live in a highly volatile environment where changes to increase in size. Examples of common hyperplasia are in conditions, such as acidity or temperature, are constant callouses on the hands and benign prostatic hyperplasia, more even as the body strives to maintain homeostasis. Even the commonly known as prostate enlargement, which commonly availability of basic materials—such as glucose, oxygen, affects men over 50 years of age. proteins, carbohydrates, and fats—for metabolism and Some cellular hyperplasia is physiologic. Breast reproduction are highly variable. In order to survive in such enlargement during pregnancy is an example of a hormone- a hostile environment, cells must adapt to the conditions. driven hyperplasia. Cells must overcome those hostile conditions or be overcome Some cellular hyperplasia is compensatory. For example, themselves. Cells have developed some unique methods after the surgical removal of a portion of the liver, a procedure of adaptation. called a hepatectomy, the various human growth factors encourage the liver to regenerate itself.33,34 Some cellular hyperplasia can be pathologic. A form of Atrophy hyperplasia that is of concern to women is lobular carcinoma Atrophy is the reduction of cells. A physical loss of cells as in situ (carcinoma – “tumor”; in situ – “in place”). While a result of the normal changes of aging or simple disuse is the word “tumor” is thus included within the term “lobular considered physiologic, a natural development of cells. An carcinoma in situ,” it seldom progresses to invasive cancer. example of physiologic atrophy is the reduction in uterus However, the woman is at great risk for other types of mass following childbirth. Cell atrophy can also be the result breast cancers. of disease, or pathologic. For example, the atrophy can be A tumor, a form of hyperplasia, is an abnormal mass of due to diminished blood fl ow. cells which result from excessive cell division but serve no Muscle atrophy secondary to disease can be broken down useful purpose in the body. Tumors may be benign (kind, in two general categories: (1) atrophy due to a neuromuscular no danger) or they may be malignant (disposed to do evil). disease and (2) atrophy due to diseases that affect the muscles Malignant tumors are always cancerous; in fact, the term directly. Examples of diseases that cause problems at the “malignancy” means cancer. Cancer is not a single disease neuromuscular junction include poliomyelitis, amyotrophic but a collection of over 100 varieties of malignancies. lateral sclerosis (Lou Gehrig’s disease), and Guillain-Barré. Primary muscle wasting diseases include muscular dystrophy Dysplasia and other congenital diseases. Cells in the body are in a constant state of turnover, with new The most common sources of muscle atrophy, secondary cells replacing old cells. When there are too many new, or to disuse, are stroke (cerebrovascular accident), spinal cord immature, cells that are not functional then dysplasia has injury with resulting paralysis, and peripheral neuropathy occurred. In some instances (e.g., cervical cancer), the presence secondary to diabetes mellitus.29–32 of dysplasia is an early warning of future malignancy. Basic Human Physiology 167 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Apoptosis rapidly dividing cells (e.g., the epithelial cells of the skin or bowels). Removal of cells that have been damaged by To prevent intrinsic biochemical errors from accumulating virus or damaged by exposure to radiation or toxins is also within a cell, or to simply replace old worn out or senescent benefi cial. cells, all of the cells in the body are programmed to commit Apoptosis can also be a pathological condition when suicide. This process of planned cell death, called apoptosis it is stimulated by DNA damage caused by oxygen-free (Greek – apo- –“from”; ptosis – “falling”), is controlled by radicals. Oxygen-free radicals have been implicated in genes in the nucleus and involves a systematic disassembly of neurodegenerative diseases, such as amyotrophic lateral the cell. Approximately 10 billion cells die every day, without sclerosis, Parkinson’s disease, and Alzheimer’s disease. endangering other cells, so that new, more perfect cells can replace them.35–37 Apoptosis can also be stimulated by stress conditions, an important comorbid factor. Apoptosis serves several vital functions, such as maintaining relatively even numbers of cells among 168 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Ar eview of the conditions necessary to maintain cellular viability or wellness, and thus human life, shows that physiology is a complex process. The body’s failure to maintain that internal milieu, through a dynamic, ongoing process called homeostasis, leads to illness and disease. Key Points: • Physiology is the study of the body’s functions in • Aerobic metabolism utilizes oxygen and glucose its normal human condition. Functions include the under ideal conditions to fi rst carry out glycolysis physical, mechanical, and biochemical processes that produces pyruvate. Pyruvate and oxygen then that are carried out inside the body. Together cells enter the Krebs cycle that generates 36 ATP. The form tissues that in turn become organs and the products for both forms of metabolism are carbon organ systems that ultimately comprise a person. dioxide, water, and energy in the form of ATP. • The essential elements water, glucose, amino acids, • Glucose that is not needed for immediate use is fatty acids, and oxygen are used in biochemical stored in the liver and muscles as glycogen. When reactions. Together these biochemical reactions there is a demand for glucose, glycogen can be become the body’s metabolism that is carried out in broken down into individual glucose molecules order for life processes to occur. by the enzyme glycagon. For a cell to carry out • aerobic metabolism, the body must maintain ideal To achieve a state of wellness, the body must temperature and acidity. The body can use other maintain a physiologic equilibrium. The body’s food sources to carry out gluconeogenesis if there is process to attain this state of internal equilibrium an absence of readily available glucose. is called homeostasis. Though in a constant state of fl ux, the body uses regulatory mechanisms to • Water comprises the greatest percentage of our maintain temperature, acidity, oxygenation, and total body weight and can be found in two basic fl uid balance within a certain range. compartments: intracellular and extracellular. The • majority of body water is intracellular. Extracellular The cell is made up of an outer semipermeable water is found in either interstitial fl uid or membrane that encompasses cytoplasm and intravascular fl uid. organelles. The nucleus is a membrane organelle containing DNA that provides the blueprints for • Fluid volumes are not static. They can move from cellular reproduction and protein synthesis. outside to inside the cells and from compartment • to compartment by diffusion or osmosis. In the past Found outside the nucleus but inside the cytoplasm the volume of fl uid inside the cells (intracellular) are several organelles that serve different was considered as the fi rst space, the volume of functions. Lysosomes can break down the cell’s fl uid in the bloodstream (intravascular) as the own proteins and foreign proteins called antigens. second space, and the volume of blood in between Mitochondria transform glucose into the usable the cells (the interstitial space) as the third space. energy source adenosine triphosphate (ATP). • • Fluid distribution from one compartment to another Anaerobic metabolism occurs without the use of is controlled by hydrostatic pressure and the oxygen and yields only two ATP. Though it generates concentrations of dissolved salts or proteins. Fluid a small amount of ATP, the process is much faster fl ow is restricted by hydrostatic pressure, which than aerobic metabolism and releases a greater is the combination of factors including maximal amount of heat energy. Basic Human Physiology 169 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. interstitial fl uid volume and compliance of the very benefi cial for mild infections, high fevers tissue, or elasticity. during severe infections can lead to delirium or • convulsions. The venous system serves to eliminate fl uids from the interstitial space while the lymphatic system • Stress is the constant change in

the environmental drains excess fl uid not carried away by the venous conditions within the body. General adaptation system. A dramatic fl uid buildup in the tissues syndrome is the body’s response to environmental, called edema can develop from a backup of the chemical, and physical changes that disrupt venous system. homeostasis. • Osmosis is the diffusion of water through a • General adaptation syndrome comes in three stages: selectively permeable membrane. The amount the alarm stage, the resistance stage, and the of solute (salt) dissolved in water (solvent) exhaustion stage. Stress that exhausts the body’s determines the osmotic pressure. Osmotic pressure defenses is termed distress. Everyday stresses that is dependent on the concentration of salt on one help the body’s defenses stay on guard are called side of a membrane. This pressure determines the eustresses. Any psychological stress can in turn net movement of water across the membrane by trigger a physical stress such as cardiac, respiratory, osmosis. or gastrointestinal disease. • Saline with 0.9% sodium chloride is an isotonic • The autonomic nervous system is divided into the solution because it has approximately the same sympathetic and parasympathetic nervous system. concentration of salt that exists in blood. A The sympathetic nervous system, originating from hypotonic solution is a fl uid with more water and the thoracic and lumbar region, is described as the less salt than a solution on the other side of a body’s “fi ght or fl ight” regulator. The sympathetic semipermeable membrane. Conversely, a hypertonic nervous system is highly reactive and promotes solution on one side of a semipermeable membrane protection of the body. has less water and more salt than the other solution. • The parasympathetic nervous system, originating • from the vagus nerve, opposes the effects of the Warm-blooded animals have a constant core sympathetic nervous system. It is characterized as temperature of 98.6°F / 1°F. To some extent, the body’s “feed and breed” regulator and controls this temperature remains constant through a large bodily processes such as digestion in the gut, range of environmental conditions. This heat is slowing of the heart rate, and erection in males. created by cellular metabolism and is controlled by the anterior hypothalamus. The most effective heat • Both the sympathetic nervous system and the loss mechanism controlled by the hypothalamus parasympathetic nervous system are virtually is vasodilation. This dilates the skin surface connected to their affected organs by way of a capillaries, allowing heat to dissipate. Under synapse. Nervous signals travel across the synapse hypothermic conditions, vasoconstriction is used to by a chemical messenger called a neurotransmitter. increase heat production. Neuroreceptors await across the synapse to receive • the signals. Pyrexia, or fever, is an essential part of the healing process. Endotoxins, or bacterial poisons, affect the • Norepinephrine or adrenaline is used by the hypothalamus by raising the body’s temperature, sympathetic nervous system as a neurotransmitter producing a fever. An increase in body temperature that creates a transmission called an adrenergic creates an unfavorable environment for bacteria. transmission. Norepinephrine is released by It increases macrophage motility and signals the electrical stimuli and travels across the synapse defense of white blood cells. to occupy the neuroreceptors and the receiving • neutron. This neurotransmitter then causes an A rise in body temperature also increases increase in permeability of the neuron to potassium, one’s metabolism vis-á-vis Hoff’s law. Though stimulating the affected organ. 170 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • Acetylcholine is used by the parasympathetic after being stimulated by the sympathetic nervous nervous system as a neurotransmitter which creates system. In turn, CRF stimulates the pituitary gland a transmission called cholingeric transmission. to release an antidiuretic hormone (vasopressin). There are over 30 major neurotransmitters in the This vasopressor vasoconstricts to prevent diuresis. body, some being categorized within the monamine class, the amino acid class, and the neuropeptide • Simultaneously, ACTH stimulates the adrenal glands class. These neurotransmitters can be blocked by to secrete cortisol. Cortisol is a hormone that the use of simple drug therapies such as atropine. stimulates the glyconeogenesis process to ensure adequate circulation of glucose in the bloodstream. • The neuroreceptors of the parasympathetic nervous system are nicotinic and muscarinic receptors. • The major organs of the immune system are Nicotinic receptors are found in the central the thymus, spleen, and lymph nodes. The nervous system, peripheral nervous system, and hypothalamus regulates the immune system through neuromuscular junction within skeletal muscles. the adrenal gland by increasing the production The stimulation of this neuroreceptor has a quick of glucocorticosteroids. The glucocorticosteroids onset and is short lived. Muscarinic receptors, in suppress white blood cells, macrophages, and comparison, are much slower. monocytes. • The neuroreceptors of the sympathetic nervous • Cells constantly live in highly variable conditions system are divided into alpha1 and alpha2 and which they must adapt themselves to by developing beta1 and beta2. Shunting occurs when the alpha1 very unique methods. receptors are stimulated. The sphincters of the • Atrophy is the reduction of cells due to aging, peripheral vascular beds are constricted and disuse, or disease. Muscle atrophy is broken down the blood volume rushes to the core circulation. into neuromuscular disease and diseases that affect Shunting ensures good perfusion to the body’s the muscles directly. Secondary to disease causing core organs while decreasing chances of excessive muscle atrophy are stroke, spinal injury, and bleeding from external trauma. Alpha2 receptors peripheral neuropathy. relax the smooth muscles of the intestinal walls, causing a decrease in bowel motility. • Hypertrophy is an increase in tissue or organ weight • beyond normal limits. Myocardial hypertrophy is Beta1 receptors are found in the heart and cause an enlarged heart, making hypertension an issue to its muscles to beat harder and faster. Beta1 overcome. receptors are also found in the kidneys where they aid in the shunting of blood due to the secretion • Metaplasia is the replacement of one adult cell type of angiotensin, a vasoconstrictor. Beta2 receptors with another. Hyperplasia is an abnormal increase cause bronchiodilation by acting upon the smooth in cell number due to cell division that causes an muscles of the bronchial walls. increase in tissue size. Some cellular hyperplasia • is physiologic, or hormonally driven. Some cellular Sympathomimetic drugs are a class of drugs that hyperplasia is compensatory due to a removal of imitate epinephrine. These drugs affect adrenergic cells. Tumors can be either benign or malignant. receptors, with each drug affecting a specifi c type of receptor. • Dysplasia occurs when cells are nonfunctional due to • an overabundance of new cells. This can be an early The endocrine system can also be activated by warning of cancer. stress. During times of stress, the adrenal gland, an endocrine organ, fi rst secretes adrenaline. After • Apoptosis is the process of planned cell death. Its being stimulated, this hormone travels to the liver functions include maintaining even cell numbers and where it stimulates glycolysis. At the same time, removing damaged cells. Apoptosis can also be a corticotropin-releasing factor (CRF) is released harmful condition due to oxygen-free radicals. This may cause neurodegenerative disease. Basic Human Physiology 171 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. How does understanding the body’s regulatory 9. Name the stages of the general adaptation mechanisms help to defi ne homeostasis? syndrome. 2. Describe the parts of the cell. 10. What is the difference between distress and 3. Compare and contrast aerobic and anaerobic eustress? metabolism. 11. Would it be possible for acetylcholine to carry 4. If more glucose is taken into the body than is out an adrenergic transmission? Why or needed, where and how is it stored in the body? why not? 5. How does increasing the salt concentration 12. What are three types of neuroreceptors? of a solution on one side of a semipermeable 13. Describe the functions that alpha and beta membrane affect the net movement of water? receptors are involved in. 6. Why is edema called third spacing of fl uid? 14. What is the effect of stress on the endocrine 7. Describe the body’s mechanism of system? thermoregulation. 15. Compare atrophy to hypertrophy. 8. How is fever benefi cial to the healing process? Case Study Questions: Please refer to the Case Study at the beginning of the 2. What effect does stimulation of the sympathetic chapter and answer the questions below. nervous system have on blood vessels? 1. Explain the importance of preventing heat loss 3. Explain why a seriously injured patient may in a patient who has suffered a severe injury. request a drink of water. References: 1. Cannon WB. The Wisdom of the Body. New York: Norton; 1932. 6. Young ME, Flynn KT. Third-spacing: when the body conceals 2. Martinoli R, Mohamed EI, Maiolo C, Cianci R, Denoth F, fl uid loss. Rn. 1988;51(8):46–48. Salvadori S, et al. Total body water estimation using bioelectrical 7. Perel P, Roberts I. Colloids versus crystalloids for fl uid impedance: a meta-analysis of the data available in the literature. resuscitation in critically ill patients. Cochrane Database Syst Acta Diabetol. 2003;40 (Suppl 1):S203–S206. Rev. 2007;4:CD000567. 3. Gala GJ, Lilly MP, Thomas SE, Gann DS. Interaction of sodium 8. Rolfe DF, Brown GC. Cellular energy utilization and molecular and volume in fl uid resuscitation after hemorrhage. J Trauma. origin of standard metabolic rate in mammals. Physiol 1991;31(4):545–555; discussion 555–546. Rev. 1997;77(3):731–758. 4. Orlowski JP, Abulleil MM, Phillips JM. The hemodynamic 9. Sessler DI, Moayeri A, Stoen R, Glosten B, Hynson J, McGuire and cardiovascular effects of near-drowning in hypotonic, J. Thermoregulatory vasoconstriction decreases cutaneous heat isotonic, or hypertonic solutions. Ann Emerg Med. 1989;18(10): loss. Anesthesiology. 1990;73(4):656–660. 1044–1049. 10. Song CW, Chelstrom LM, Haumschild DJ. Changes in human 5. Gunnar WP, Merlotti GJ, Barrett J, Jonasson O. Resuscitation skin blood fl ow by hyperthermia. Int J Radiat Oncol Biol Phys. from hemorrhagic shock. Alterations of the intracranial pressure 1990;18(4):903–907. after normal saline, 3% saline and dextran-40. Ann Surg. 11. Haahr S, Mogensen S. Function of fever in infectious disease. 1986;204(6):686–692. Biomedicine. 1978;28(6):305–307. 172 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 12. Blatteis CM. Fever: is it benefi cial? Yale J Biol Med. 27. Meybohm P, Cavus E, Bein B, Steinfath M, Weber B, Hamann 1986;59(2):107–116. C, et al. Small volume resuscitation: a randomized controlled 13. Ryan GB. Infl ammation and localization of infection. Surg Clin trial with either norepinephrine or vasopressin during severe North Am. 1976;56(4):831–846. hemorrhage. J Trauma. 2007;62(3):640–646. 14. Selye H. The general adaptation syndrome and the diseases of 28. Tsuneyoshi I, Onomoto M, Yonetani A, Kanmura Y. Low- adaptation. Practitioner. 1949;163(977):393–405. dose vasopressin infusion in patients with severe vasodilatory 15. Goldstein DS, Kopin IJ. Evolution of concepts of stress. Stress. hypotension after prolonged hemorrhage during general 2007;10(2):109–120. anesthesia. J Anesth. 2005;19(2):170–173. 16. Appenzeller O, Oribe E. The Autonomic Nervous System. 29. Trudel G, Uhthoff HK. Muscle atrophy in stroke patients. Arch Amsterdam: Elsevier Publishing Company; 1997. Phys Med Rehabil. 2003;84(4):623; author reply 623. 17. Little RA, Stoner HB. Body temperature after accidental injury. 30. Giangregorio L, McCartney N. Bone loss and muscle atrophy Br J Surg. 1981;68(4):221–224. in spinal cord injury: epidemiology, fracture prediction, and

18. Fahim M. Cardiovascular sensory receptors and their regulatory rehabilitation strategies. J Spinal Cord Med. 2006;29(5):489–500. mechanisms. Indian J Physiol Pharmacol. 2003;47(2):124–146. 31. Baldi JC, Jackson RD, Moraille R, Mysiw WJ. Muscle atrophy 19. Van Corven EJ, van Rijswijk A, Jalink K, van der Bend RL, is prevented in patients with acute spinal cord injury using van Blitterswijk WJ, Moolenaar WH. Mitogenic action of functional electrical stimulation. Spinal Cord. 1998; lysophosphatidic acid and phosphatidic acid on fi broblasts. 36(7):463–469. Dependence on acyl-chain length and inhibition by suramin. 32. Andersen H, Gjerstad MD, Jakobsen J. Atrophy of foot Biochem J. 1992;281 (Pt 1):163–169. muscles: a measure of diabetic neuropathy. Diabetes Care. 20. Groeneveld AB, Girbes AR, Thijs LG. Treating septic shock with 2004;27(10):2382–2385. norepinephrine. Crit Care Med. 1999;27(9):2022–2023. 33. Kobayashi M, Ogata T, Araki K, Hayashi T. Human 21. Singer M. Catecholamine treatment for shock—equally good or liver regeneration after major hepatectomy. Ann Surg. bad? Lancet. 2007;370(9588):636–637. 1992;216(5):616. 22. Vincent JL, De Backer D. Inotrope/vasopressor support in sepsis- 34. Yamanaka N, Okamoto E, Kawamura E, Kato T, Oriyama induced organ hypoperfusion. Semin Respir Crit Care Med. T, Fujimoto J, et al. Dynamics of normal and injured human 2001;22(1):61–74. liver regeneration after hepatectomy as assessed on the basis 23. Mueller HS. Inotropic agents in the treatment of cardiogenic of computed tomography and liver function. Hepatology. shock. World J Surg. 1985;9(1):3–10. 1993;18(1):79–85. 24. Eichna LW. The treatment of cardiogenic shock. 3. The use of 35. Beutler E. The relationship of red cell enzymes to red cell life- isoproterenol in cardiogenic shock. Am Heart J. 1967;74(6):48–52. span. Blood Cells. 1988;14(1):69–91. 25. Worthley LI, Tyler P, Moran JL. A comparison of dopamine, 36. Kay M. Immunoregulation of cellular life span. Ann N Y Acad dobutamine and isoproterenol in the treatment of shock. Intensive Sci. 2005;1057:85–111. Care Med. 1985;11(1):13–19. 37. Taylor RC, Cullen SP, Martin SJ. Apoptosis: controlled 26. Farrow S, Banata G, Schallhorn S, May R, Mers A, Cadaret L, demolition at the cellular level. Nat Rev Mol Cell Biol. et al. Vasopressin inhibits diuresis induced by water immersion 2007;9:231–241. in humans. J Appl Physiol. 1992;73(3):932–936. Basic Human Physiology 173 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The interplay between modifi able and nonmodifi able risk factors and disease and its impact on mortality • Impact of physical and chemical injury on cell physiology • Infectious disease and the body’s response to pathogens • The concept and etiologies of shock using the Hinshaw–Cox classifi cation • The pathophysiology of shock and the body’s response • Biochemical changes and cellular death Case Study: The Paramedics responded to a man who had collapsed. Upon their arrival, they found him unconscious with a slow pulse and agonal breathing. Despite their best resuscitative efforts, he had no vital signs when they transferred him to the hospital, yet they continued CPR during the transport. Both Paramedics were perplexed when the ED physician requested the transplant team. What organs would be available now? Wasn’t the man dead? 174 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Principles of Pathophysiology 175 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW There is a physiological cause for every illness or disorder that the Paramedic encounters. Although it’s not the Paramedic’s job to determine the exact cause of the disease, it is the Paramedic’s job to recognize the signs and symptoms and treat the patient appropriately based on an assessment. This chapter provides the background knowledge the Paramedic needs to better understand the disease process and treatment. After examining disease risk factors, the focus is on how the body is impacted by injury and its response to pathogens. Although the Paramedic should be familiar with the signs of shock, he or she should also know the pathophysiology causing the body’s response to determine its etiology. Often the Paramedic’s treatment reverses the pathogenesis of an illness or disorder. Pathophysiology Defi ned poverty, lack of immunizations, and so on, which infl uence the incidence of disease. For example, poor sanitation, poverty, Pathos (Greek - “to suffer”) is the prefi x added to physiology, and overcrowding make cholera infection one of the leading the study of the normal human condition, to make the causes of death, or mortality, in the world.1,2 term pathophysiology. The origins of the term defi ne The many causes of cellular death due to disease can pathophysiology: to study the causes of suffering in the normal be categorized as either known causes or unknown causes. human condition. While the causes of disease are numerous, Unknown causes of cellular death are primarily due to an they share a few common mechanisms, making the study of incomplete understanding of the disease and/or because of pathophysiology somewhat easier. a lack of evidence of the disease. The “Black Death” is one This chapter is a discussion of those mechanisms and the example of an unknown cause of cellular death. Typically, body’s reactions to illness or injury. Discussions of the many the cause of an emergent disease is unknown until scientists illnesses and ailments of humans, related to specifi c organs, have a suffi cient number of cases to study so as to identify or systemic pathology, is contained in all of the chapters the source. A more recent example is the Severe Acute that follow. This chapter will serve as the foundation for Respiratory Syndrome (SARS) epidemic. Initially the cause understanding those chapters while the previous physiology of SARS was unknown; however, it has now been identifi ed chapter serves as the foundation for understanding this as a coronavirus, the same type of virus that causes the chapter. common cold.3–5 Disease: Defi ned Disease can be defi ned as an abnormal change in the function Known Causes of Disease of cells, tissues, or organs. An example of each is cancer in The known causes, or etiologies, of cellular injury can be cells, emphysema in tissues, and acute myocardial infarction broken down into two categories: the extrinsic (external) causes in organs. These changes interfere with homeostasis of the and the intrinsic (internal) causes. Extrinsic causes include body, making the body ill at ease—or literally diseased (dis- – chemical causes, physical causes, infection/infl ammation, “not”; ease – “rest”). and metabolic imbalances. The intrinsic (internal) causes are Paramedics are often more interested in the pathogenesis causes such as genetic derangements. (patho- – Greek “suffering”; genesis – “beginning”) of a Of the three general chemical causes of cellular injury, disease, the sequence of events—at the molecular and cellular hypoxia is ranked number one and receives the largest portion level—that lead to organ dysfunction. By understanding of a Paramedic’s attention. Other chemical causes of cellular these underlying conditions, treatment can be directed toward injury include the creation of free radicals and toxins. removing the cause and not just treating the symptoms. The physical cause of cellular injury is trauma. Trauma encompasses any mechanical injury, heat or cold injury, Etiologies of Disease radiation, electrical injury, or barotrauma. At the molecular level, there can be metabolic derange- All diseases have an assumed origin, an etiology. In the case ments (an extrinsic cause) and genetic derangements (intrinsic of an infection the etiology is a microbe. cause) that lead to disease. Inappropriate immunological res- The occurrence of disease has many other compounding ponse, the so-called autoimmune response, and an exaggerated factors, such as malnutrition, overcrowded living conditions, infl ammatory response can also cause disease. 176 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Street Smart Cultural / Regional differences Physicians are currently thinking that trauma Vaccination against smallpox was discontinued patients who survive from the fi eld may die while in the United States, as the disease had been in the intensive care unit from an inappropriate eradicated throughout the world. There is a concern infl ammatory response.6–8 that terrorists might use infectious diseases, like smallpox, against human populations who have lost their resistance or who were never vaccinated against the disease.9,10 Risk Factors Frequently, medical professionals will speak of the incidence Some risk factors are conditions that predispose a person of a disease, the incidence being the number of new cases per to another disease. For example, African Americans have a standardized group per time. An example would be 1 case per higher incidence of hypertension. Hypertension has been 100,000 per year of x disease. directly linked to an increased risk of coronary syndrome The incidence of disease (prevalence) is not the same secondary to the disease of atherosclerosis. as the risk of a disease. Risk, the likelihood that a situation could lead to harm—that is, that the person would contract a Age as a Risk Factor disease—is a function of an individual’s life circumstances. Outward signs of aging include wrinkles, secondary to loss of And everyone’s life circumstances are different. the underlying layer of fat, and gray hair. These signs indicate the Every person has some risk factors that tend to make presence of the changes of aging that are occurring within that person more or less vulnerable to a disease as compared the body. The multitude of hormonal, biochemical, and to another person. Some risk factors are functions of the physiologic changes that accompany aging combine to make human condition and are therefore modifi able. Others are the elderly person more at risk for all diseases in general. In nonmodifi able risk factors which are, essentially, a fact of life addition, specifi c diseases, such as dementia, are age-related. for the individual. An example of nonmodifi able risk factors is heredity. Modifi able Risk Factors Heredity is a signifi cant risk factor. If a woman has breast The term “modifi able” would seem to indicate that the person has cancer then her offspring are at risk for breast cancer. It is some control of the existence of factors. In some cases, such as thought that more diseases can be partially or completely tobacco smoking, obesity, and alcohol consumption, the person explained by genetics. With the unraveling of the DNA does have control over these risk factors. However, eliminating mystery by the Human Genome Project, some 35 diseases these risk factors is seldom as simple as it might appear. have been directly linked, or at least partially attributed to, Some risk factors are a function of one’s lifestyle or genetic origins. Cystic fi brosis, a disease of the lungs, is due occupational choices. These modifi able risk factors are called to a malfunctioning gene. Sickle-cell anemia, a disease of red environmental risk factors. Farmers, for example, inhale blood cells, also has a genetic origin. dust from moldy hay that leads to a pulmonary disease called Another nonmodifi able risk factor is a person’s gender. farmer’s lung. Wearing a simple dust

mask can help to modify For example, the overwhelming majority of patients with or eliminate the risk of acquiring farmer’s lung. breast cancer are women, though breast cancer is a reality for a small subset of men. There are a number of other gender- related diseases (e.g., prostate cancer) that are exclusive to one gender. There are other diseases that tend to be more Professional Paramedic prevalent in one gender. In some cases, gender helps protect a person from disease, as is the case with acute coronary The professional Paramedic does not blame the syndrome. A person’s race may be a risk factor, especially in cases patient for the disease. For example, tobacco of infectious disease. For example, Europeans were generally smoking is now known to be a risk factor for lung more resistant, and therefore had a lower risk of contracting diseases such as emphysema and cancer. However, smallpox due to centuries of exposure to smallpox. This risk tobacco smoking was encouraged by the U.S. is considered lower when compared to the fi rst Americans who had no exposure experience with smallpox until the government in World War II and tobacco companies arrival of Europeans. They suffered staggering losses of life advertised that tobacco was an aid to digestion. due to smallpox. Principles of Pathophysiology 177 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Prognosis unsuspecting and physically weakened patients. This can occur simply because a healthcare professional failed to wash his or The expected outcome from a disease is called the prognosis. her hands or take proper infection control precautions.12–14 A good prognosis, or the likelihood of recovery and survival, Iatrogenic disease does not end with infections. Every or a poor prognosis, which suggests death or disability, is a medical intervention carries with it some risk of harm to the culmination of modifi able risk factors (such as nutrition), patient and the potential to cause disease. Patients, as was nonmodifi able risk factors (such as age), and the availability of discussed in Chapter 6 on medicolegal responsibilities, have treatments. For example, a middle-aged male who experiences a right to know about these risks and to make an informed sudden cardiac death in an airport has a better prognosis than decision (i.e., informed consent). the same male stricken while in a rural community, owing to the rapid availability of automated external defi brillators in airports. Disease as a Process The origin and development of a disease follows an ordered Iatrogenic Disease sequence of events at the cellular, biochemical, and molecular Iatrogenic (iatro- – “physician”; genic – “cause”) disease is a level, which is called its pathogenesis. Thus, the disease has previously known cause of disease that was introduced to the predictable effects upon the patient. When a patient becomes patient as a result of medical intervention.11 diseased, one of three outcomes is inevitable: recovery, death, The classic example of an iatrogenic disease was described or survival with remission. by Dr. Ignaz Semmelweis, the father of microbiology. For cells, recovery means a return to a former functional While attending to patients at Vienna General Hospital, capacity. For a person, recovery means a return to health. To Dr. Semmelweis noted a connection between childbed fever be cured, the patient must have no remnant of the disease. (then referred to as puerperal fever) and the dirty hands of Recovery does not necessarily mean that the patient is birth attendants. He immediately ordered that hands be unchanged. Some patients recover with physical or chemical washed with “chlorine liquida,” a chlorinated lime solution changes remaining after the encounter with the disease; these (calcium hypochlorite). As a result, the death rate from changes are called residuals. Scars, called poxmarks, are a puerperal fever immediately dropped after the institution of visible residual left after recovery from the disease smallpox. this simple intervention. Unfortunately, fellow physicians Hemiplegia (hemi- – “half ”; plegia – “paralyzed”) is a failed to heed his advice until the emergence of the germ residual that can remain after a stroke. theory some 40 years later. Some people learn to co-exist with their disease having Death from a hospital-acquired infection, called a learned to compensate for their disease. Often with the help nosocomial infection (in this case, childbed fever), was the of medications, a patient may become asymptomatic. direct result of medical intervention. Hippocrates, in his Periodically patients will decompensate and become treatise “Epidemic,” advised aspiring physicians that their symptomatic. These episodes in which a chronic disease fi rst responsibility was to “do no harm,” an edict that has been returns, or fl ares up, is called an exacerbation. Asthma, a maintained to this day. chronic disease of the airways, is largely managed by the use Drug-resistant strains of diseases, grown in the hospitals of bronchodilators and anti-infl ammatory drugs. Occasionally, and the intensive care units, can be easily transmitted by the patient will experience an exacerbation of his or her unwitting healthcare professionals, including Paramedics, to asthma, usually triggered by some stimulus. This patient will present to EMS emergently with an acute exacerbation of the chronic disease asthma. In some cases, after a person has become diseased, the body’s defense, or medical treatment, may force the disease Professional Paramedic into a non-active state called remission. Remission does not mean the patient has been cured, but rather that the disease Whenever a medical intervention is being considered, has been stopped. the Paramedic must consider the risk/benefi t of the Some diseases, particularly certain infections, become dormant (Latin – “to sleep”) and remain in a state of procedure before making a decision. Even with the biological rest. These diseases remain dormant until favorable best of intentions and using the best techniques, conditions exist for them to reanimate. Tuberculosis is an iatrogenic disease—which can be caused by an excellent example of a disease that can infect a person and infi ltration of an intravenous line—will occur in every then remain dormant. It remains in spore form for years—and even decades—only to re-infect the person when the person Paramedic’s practice. The key is to identify and is aged or debilitated.15 consider the risk, monitor for its occurrence, and Ultimately disease will kill everyone. When a body’s mitigate its harm as soon as possible. defense mechanisms become overwhelmed, and the body cannot compensate, the patient will succumb to disease and 178 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. death will ensue. The process of death is described at the end Fick Principle of this chapter. Morbidity and Mortality Oxygenation Physicians, nurses, and allied health professionals monitor the Ventilation Lungs incidence of disease (called the morbidity) and death rate (or mortality) for trends. Awareness of these leading indicators Heart of disease (i.e., death and disability) provide healthcare Respiration professionals an opportunity to prepare for outbreaks of Circulation these diseases and to properly treat the population when an outbreak occurs. Epidemiology deals with the study of the causes, distribution, and control of disease in populations. Advances in epidemiology permit public health authorities to stockpile needed antibiotics, medicines, and the like in anticipation of epidemics and other public health emergencies. In the United States, the federal Centers for Disease Control and Prevention (CDC), located in Atlanta, Georgia, has taken the lead in this area and regularly disseminates epidemiological information through its publication of Morbidity and Mortality Reports (MMR). These reports appear both on-line and in print.16 Chemical Causes of Cell Injury Chemical causes of cellular injury can be divided into hypoxia (the leading cause of cell injury and death), free oxygen radicals, and toxins, which include poisons. Each of these sources of cellular injury is unique because it works Cellular primarily at a biochemical level, the foundation level of respiration cellular physiology. Figure 11-1 The Fick principle. Hypoxic Injury The classic cause of cell injury is low oxygen concentrations, The fi rst element of the Fick principle addresses the a condition called hypoxia. Hypoxia causes cells to redirect availability of oxygen in the ambient air going into the lungs. their metabolic processes to anaerobic respiration in an effort Lack of oxygen, due to an oxygen poor environment, can lead to sustain the cell. While this response can be effective for a to hypoxia and is categorized as hypoxic hypoxia. time, eventually anaerobic metabolism proves insuffi cient to The next element in the Fick principle is ventilation. sustain the cell. Even high fl ow oxygen via nonrebreather mask is useless if the airway is compromised. Hypoxia and Dr. Fick With oxygen-laden air in the lungs, the process of Key to effective cellular metabolism is the ready availability respiration can occur. Respiration depends on an intact of oxygen for the cells. The process of getting oxygen to the capillary–alveolar interface. An interruption of blood fl ow cells is outlined by the Fick principle (Figure 11-1). Fick, in (e.g., by a pulmonary embolism) or alveolar fi lling (e.g., his monograph Medical Physics, described the function of the pneumonia) will interfere with respiration and create hypoxic lungs; the hemodynamics of the body, including the work of hypoxia. the heart; and the properties of the gasses oxygen and carbon An adequate volume of circulating red blood cells is dioxide. The Fick principle can be summed up in fi ve key needed to carry the oxygen to the various organs of the body. concepts: oxygenation, ventilation, respiration, circulation, The volume of red blood cells is expressed as the percentage and cellular respiration. of red blood cells in the blood and is called the hematocrit. The Fick principle places hypoxia at the center of disease A low hematocrit, or other red blood cell abnormality, can and makes the resolution of hypoxia the fi rst priority in the lead to oxygen deprivation at the cellular level. This is called treatment of disease. Too little oxygen in the blood perfusing anemic hypoxia. the cells causes hypoxemia (hypo- – Greek “under”; ox – With the hemoglobin loaded with oxygen, the body now “oxygen”; -emia – “blood”) and leads to disease. must move the blood about the body via the circulatory system. Principles of Pathophysiology 179 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Problems of circulation can lead to oxygen deprivation at the and tissues. The key is to provide oxygenation via perfusion cellular level and is called ischemic hypoxia. Examples of to the affected cells before the lysosomes swell. circulation problems include occlusion of blood vessels, such These near-miss events are not completely harmless. as a deep vein thrombus, or heart failure. During the course of reperfusion, products of incomplete Finally, the cells must be able to accept the oxygen; that is, metabolism (hydrogen peroxide and other reactive oxygen oxygen must be able to be diffused across the cell membrane chemicals) are created.17 The analogy of a smoldering fi re is and utilized in the Krebs cycle. The inability of the cells to useful. A smoldering fi re results in products of incomplete accept or use oxygen, such as in cyanide poisoning, is called combustion such as cyanide, which are dangerous. In the same histoxic hypoxia. manner, the reactive oxygen chemicals which are products of Paramedic practice involves preventing hypoxia by incomplete metabolism, such as hydrogen peroxide, wreak supporting the

different elements of the Fick principle. For havoc in the cell. example, the administration of oxygen via nonrebreather face Reactive oxygen chemicals consist of an electrically mask supplements the available oxygen in the air. Intravenous uncharged atom with an unpaired electron. This unpaired fl uids help to support circulation. electron is unstable, by nature, and looks for another electron with which to pair up and thus stabilize. Unfortunately the ACLS View of Hypoxia reactive oyxgen chemicals tend to either pair up with amino Some Paramedics simplify the causes of cellular hypoxia acids within the DNA, causing their destruction, or pair up by referring to problems with the pipes, the pump, or the with lipids in the cell wall, a process called lipid peroxidation, fl uid—a familiar mantra in Advanced Cardiac Life Support which also results in destruction. (ACLS). As a result, these reactive oxygen chemicals fragment Problems of the pipes include vasodilatation, such as that DNA, thus impairing the cell’s ability to make proteins and which occurs with neurogenic shock and anaphylactic shock to reproduce itself. They may also cause cell wall damage, (discussed later). Problems with the pipes can also include making the cell walls more permeable to sodium. Increased leaky pipes which may occur during severe infections. intracellular sodium leads to cell swelling and autolysis (auto- – Problems with the pump include acute myocardial “self ”; lysis – “divide”). infarction leading to pump failure (cardiogenic shock). Also, an impaired heart cannot meet the body’s demands for perfusion, which is called heart failure. Street Smart Problems with fl uids imply problems with the oxygen- carrying capacity of the blood itself. This can be caused by a One therapy that has been given consideration is condition called anemia. the co–administration of drugs called antioxidants Ischemic Cascade during a resuscitation. Antioxidants, like vitamin C When cells are deprived of oxygen, and subsequently convert and vitamin E, absorb reactive oxygen chemicals to anaerobic respiration, a cascade of biochemical changes and effectively neutralize them before they can start to take place which can eventually lead to cell death. do damage.18 The fi rst step in the pathogenesis of hypoxia is called ischemia. The cells, fully dedicated to anaerobic respiration, rapidly deplete available glucose. Lactic acid, the by-product Toxins of glycolysis, is all that then remains. Some substances are so lethal that they are called poisons. As With an abundance of acid present, the cytoplasm pH little as a few micrograms of these substances can kill a person. drops rapidly and cellular proteins start to denature. At this However, any substance taken in excess—even water—can be point the cell is injured and recovery is questionable. toxic to the body. The defi nition of a toxin is any substance As the cell’s proteins continue to denature, the lysosomes capable of causing cell injury and death, and that includes within the cell swell and burst, releasing proteases, which poisons. Toxins injure cells by one of two basic mechanisms: hasten the cell’s destruction. The now dead cell is said to by direct reaction with the cell or through metabolites. have necrosis (Greek for dead). If a large number of cells are Metabolites are the by-products of drugs and chemicals involved, then the term infarction is applied. after the cell has reacted with them. The biochemical changes that occur in the cell can convert a previously harmless drug or Reperfusion Injury and Free Radicals chemical into a toxin. For example, acetaminophen is harmless Acute interventions during a medical emergency can reverse to the liver until after the liver metabolizes it. Thereafter, hypoxia and prevent permanent injury and even infarction. excessive amounts of metabolites of acetaminophen can build Emergency interventions that have an impact on the Fick up to toxic levels, causing liver necrosis.19–21 principles of oxygenation, ventilation, respiration, circulation, Toxins that affect the cells directly usually react and cellular respiration can reestablish perfusion to the cells with a molecular component of the cell. By mutating or 180 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. neutralizing that molecule the toxin impairs the cell’s Initially, in the case of heat exhaustion, the body is unable function, thereby injuring the cell. By way of example, to compensate for the heat load that it is being exposed to the poison cyanide works by inactivating an enzyme, and most of the emergency medical care is supportive of the cytochrome oxidase, which is needed in cellular metabolism body’s efforts to correct it. When the heat becomes excessive, for the cell to use oxygen in the mitochondria.22 Without this the lipid–protein cell membrane starts to liquefy. This allows enzyme the mitochondria cannot make ATP. In essence, sodium and water into the cell, as well as intracellular cyanide suffocates the cell by making the abundantly proteins such as enzymes, and DNA starts to break down. available oxygen useless. These conditions lead to cell death. Concurrent conditions that result from heat stroke include Physical Causes of Cellular Injury rhabdomyolysis (rhabdo- “rod like”– “”; myo – “muscle”; -lysis – “split”), a breakdown of muscle, and myoglobulinuria Those forces that exist outside of the body, in the physical (myo- – “muscle”; globin – “protein”; -uria – “urine”), a world, can cause injury to the body and the cells within. condition in which the protein products of muscle breakdown Such forces include mechanical forces, referring to those clog the kidneys. This leads to renal failure. injuries sustained by physical force or violence; extremes of The opposite situation, hypothermia and cold-related temperature; radiation, including electromagnetic radiation; injury, can lead to some localized injury (Figure 11-3) as a and changes in atmospheric pressures. result of freezing and coagulation of the microcirculation, as well as the potential for more systemic injury. When the Mechanical Injury body’s core temperature drops, cells suffer hypothermic Mechanical injury is due to abrupt and sudden physical injury from two mechanisms. forces acting upon the body, such as friction, blunt force, The first mechanism of injury is a disturbance in the or penetrating force. This mechanical injury is referred to ion concentrations of the cell, particularly sodium. As the as trauma (Figure 11-2). These traumatic injury-producing cell wall starts to gel, eventually becoming crystalline, forces tend to either stretch, tear, or crush tissues. Examples the sodium–potassium pump fails and sodium and water of traumatic injury, ranging from superfi cial to deep, are rush in. If the hypothermia is reversed in a timely fashion, abrasions, lacerations, punctures, and fractures. the result will be edema. Cellular death can also occur. Even as the cells start to cool, the cells continue Heat or Cold Injury with metabolism. This slowed metabolism is akin to the The body has excellent mechanisms for keeping itself smoldering fi re and smoke analogy used earlier. Partial within the range of normal temperatures needed for cellular products of metabolism—the reactive oxygen chemicals and metabolism. When these mechanisms fail, cellular metabolism particularly the oxygen-free radicals—start to accumulate. is affected and cells die. Examples of some heat-related These chemicals have their greatest potential for cellular diseases include heat cramps, exhaustion, or heat stroke. injury during the reperfusion stage or recovery phase. Figure 11-2 Trauma as a source of mechanical injury. (Courtesy of David J. Reimer Sr.) Principles of Pathophysiology 181 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 11-4 Burn injury. Therefore, the exposure to sunlight (visible light) is actually Figure 11-3 Frostbite as a result of cold injury. exposure to celestial radiation. There are many sources of photons and all can cause photo burns. Another form of electromagnetic radiation is radio frequency radiation (RFR), or radio waves. Contact with a Burn Injury noninsulated source of radio waves, such as a microwave Burn injury (Figure 11-4) involves exposure to large amounts antenna, can cause burns. However, RFR (including of energy from sources along the electromagnetic spectrum. microwaves) are generally non-ionizing. The danger of radio Burns can be caused by fi ve sources of electromagnetic energy: frequency radiation is with the production of thermal energy. thermal (infrared), radiation (gamma), light (ultraviolet), Electrical energy, the movement of electrons, is what radio, and electricity. powers the cell’s metabolic processes (i.e., electron transport). The most widely known source of thermal burns is However, when massive amounts of electron energy enter the direct contact with fi re. However, other sources of thermal tissues then injury will occur. The cells suffer from thermal energy—such as superheated steam, boiling liquids, and burns as well as electrolysis (electro- – “electron”; lysis – heated objects—can also cause thermal injury. “divide”). The buildup of thermal energy occurs as a result of Sources of nuclear radiation (e.g., uranium or plutonium) the fl ow of electricity overcoming resistance from the tissues can also cause burns. Radiation exposure can be divided and creating heat, called joule heat as a by-product of that into particulate exposure (i.e., alpha and beta particles), and reaction. electromagnetic energy in the form of X-rays and gamma More problematic can be electroporation, the effect of rays. The electromagnetic energy exposure (Figure 11-5) is electrical current passing through the tissue. The effect of considered to be more dangerous. electricity upon the lipid–protein layer of the cell membrane Intense light, which includes the light of the sun, contains is to denature the proteins that are in the cell’s pores. The photons (Greek – light) and are represented by the symbol end result is that sodium and water rush into the cell and the of gamma. High-intensity photons are called gamma rays. cell lysis. 182 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Electromagnetic Spectrum 10–13 cm 10–9 cm 10–6 cm 10–4 cm 1–2 cm 1 cm 1 km Visible Microwave Gamma ray Ultraviolet X-ray Radio Infrared Figure 11-5 Electromagnetic spectrum. Mechanism of Injury and eardrums. It occurs in the same manner that slapping an The major mechanism of injury for a burn is either direct heat air-fi lled paper bag destroys the paper bag. transfer or ionization. Heat placed in direct contact with the cells There is also indirect barotrauma secondary to dissolved denatures their proteins. That is, it breaks down the protein’s gasses. Gasses such as oxygen, carbon dioxide, and nitrogen complex folded structure. This can be seen when the clear liquid are dissolved in blood. When there is increased pressure, such protein of an egg white is cooked on a griddle. The egg white as occurs during deep sea diving, then the gasses compress. coagulates, becoming solid and turning white. As the diver ascends, the gasses “come out of solution” and Ionization, on the other hand, strips away electrons, leaving take up volume in the bloodstream, causing occlusions. At highly reactive chemicals to break down chemical bonds and the same time, the volume of air within the lungs expands alter cellular chemistry. High levels of ionization lead to (Boyle’s law) thereby overpressurizing the lungs and creating conditions such as radiation poisoning or sun poisoning. Low a risk of a ruptured lung or pneumothorax (Figure 11-6). levels of ionization, particularly the penetrating radiation of Barotrauma is not restricted to diving incidents only. The gamma rays, can alter amino acids in the DNA and cause same pathophysiological processes in decompression illness long-term complications. occur in

mountain sickness. The likelihood of long-term complications from ionizing radiation exposure, the stochastic effects, is a function of the length (duration of time) of exposure and/or the strength of the radiation. Ionizing radiation is thought to cause cancers in individuals. Frequent exposure to radiation, such as sunburns while sun tanning, can lead to an increased susceptibility to cancer. Exposure to ionizing radiation can also cause birth defects and cancer in subsequent generations, called the teratogenic effect, as a result of changes in the structure of Heart that all important protein, the DNA. Tension pneumothorax Barotrauma Barotrauma is physical damage to tissues, an injury caused Mediastinal by an imbalance between pressures in the environment and shift those within the body. The pathophysiology of barotraumas revolves around the fact that gasses, in the air or within the blood, are more compressible, or distensible, than the surrounding tissues. The classic example of direct barotrauma is injury due to the shock wave of an explosion.23–25 During an explosion there is a rapid rise in atmospheric pressure that can cause Figure 11-6 Tension pneumothorax possibly mechanical damage to any air-fi lled organs such as the lungs secondary to barotrauma. Principles of Pathophysiology 183 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Metabolic Disorders Nutritional defi ciencies can lead to metabolic derangement and disease. Scurvy, for example, is an ancient disease, having been recorded by the Egyptians in 1559 B.C., which became more problematic when early sailing voyages became prolonged. In 1520 Magellan lost more than 80% of his crew to scurvy while trying to circumnavigate the globe. British Navel Surgeon Sir James Lind linked scurvy with a defi ciency of vitamin C, ascorbic acid, in 1746. He immediately ordered citrus fruit, known to be high in vitamin C, aboard every British Navy ship; hence the origin of the British sailors’ nickname “limeys.” Nutritional excess can also lead to disease. The current epidemic of obesity in America (Figure 11-7) has led to an increase in obesity-related disease, such as diabetes mellitus, as well as an increase in obesity-linked diseases such as sleep apnea and Pickwickian syndrome. Genetic Disorders The existence of genetic diseases has been recognized for Figure 11-8 This child with Down syndrome is centuries. These disorders were described as running in a encouraged to develop psychomotor skills. (From family. What was missing was an understanding of why these Down Right Beautiful 1996 Calendar, Marijone’s Designer disorders ran in families. Abnormalities in a person’s genes Portraits) can cause a genetic disorder. Within the DNA, genes carry the blueprint for protein production which is the life work of most cells. These proteins are essential to cell health. rejoinings at new locations, called translocations; extra If the DNA sequence of one gene is altered, called a copies of chromosomes; or missing copies of chromosomes mutation, then protein production can be altered. Examples leads to genetic disorders. Down syndrome is a common of monogenic disorders include Marfan syndrome, sickle- genetic disorder linked to having three copies of the 21st cell anemia, and cystic fi brosis. chromosome.26,27 A child with Down syndrome (Figure 11-8) In some instances the entire chromosome is structurally may have a fl attened nose and widely spaced eyes. defective. Gross breaks in some chromosomes with subsequent However, most genetic disorders are complex and involve a combination of environmental and multiple genetic mutations. Many chronic diseases—such as Alzheimer’s disease, heart disease, arthritis, and obesity—are thought to have genetic underpinnings. Not all genetic differences necessarily lead to disease. In fact, some genetic changes may be evolutionary in nature. In an incredible case of genetic detective work, it has been discovered that some people cannot contract human immunodefi ciency virus (HIV), the cause of AIDS. The reason is because of a genetic mutation which prevents the white blood cells from creating the receptor, CCR5, that permits the HIV virus to gain entrance into the white blood cell. Infection The majority of deaths during recorded history have been due to infectious diseases. Infectious diseases, referred to in ≥30% 10%–14% medical circles as pathogens, stem from a number of sources. 25%–29% <10% Listed from smallest to largest, they are prions, viruses, bacteria 20%–24% No data (Figure 11-9), fungi, protozoa, and helminthes (worms). All 15%–19% of these microorganisms are parasites, dependent on the host for survival. Figure 11-7 Obesity in the United States. Infectious diseases have three pathogenic mechanisms. (Courtesy of Centers for Disease Control and Some infectious agents (e.g., herpes simplex) replicate Prevention) themselves inside the host cells. Eventually these 184 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 11-9 Common microorganisms that can cause disease. (Courtesy of Centers for Disease Control and Prevention Public Health Image Library) microorganisms destroy the cell’s structural integrity, thereby killing the cell, which is a direct cytopathic effect. The microorganisms are then released to infect other cells or other potential hosts. Other microorganisms are dangerous to the host because they produce a toxin that is harmful (poisonous) to the Figure 11-10 Patient experiencing an allergic cell. Toxins can be categorized as either being exotoxins reaction. (Courtesy of Robert A. Silverman, M. D., Clinical or endotoxins. Exotoxins are proteins that are produced by Professor, Department of Pediatrics, Georgetown University, bacteria and released into the interstitial fl uid where they are Georgetown, MD) absorbed, because they are highly soluble, into surrounding the body has a disproportionate response to a foreign protein cells. Exotoxins can be cell specifi c. For example, the toxins or polysaccharide, an antigen (anti- – “not”; gen – “self ”) and that produce tetanus and botulism affect nervous tissue whereas the results are life-threatening to the patient. This exaggerated the toxins of the streptococcus bacteria affect vascular tissue. immune response, called an anaphylactic response, can lead Some bacteria produce toxins by their death. These to severe airway compromise and/or cardiovascular collapse toxins, called endotoxins, are the result of the breakdown of secondary to relative hypovolemia. This may be exemplifi ed the bacteria’s cell wall membrane.28,29 Endotoxins are complex by a patient with an allergic reaction (Figure 11-10). substances made up of polysaccharides or phospholipids In the case of the autoimmune response, described and are attracted to other cell wall membranes. The bacteria earlier, the body sets upon itself and starts to destroy normal Clostridium tetanus produces a phospholipase (phospholipids cells along with infected cells. Autoimmune response has make up cell wall membranes and the suffi x -ase means been implicated in the diseases multiple sclerosis, diabetes enzyme) which breaks down cell walls. mellitus, scleroderma, Crohn’s disease, lupus erythematosus, Finally, some infections are dangerous because they rheumatoid arthritis, and gluten sensitivity. trigger an immune response that causes damage to the host, an autoimmune response. For example, the causative agent Effect: Systemic Defense of rheumatic fever, streptococcus, triggers an undifferentiated immune response that destroys healthy tissue (frequently the The body’s defenses to disease start with general nonspecifi c heart valves) in the process. barriers and end with targeted cellular attacks against the offending disease. If these defenses are overwhelmed, then Immune Reactions the patient is diseased. Patients with disease go into shock, a condition of deranged Immune reactions can be classifi ed as either exaggerated metabolic functions that have systemic effects described later immune responses or autoimmune responses. In the fi rst case, in this chapter. The shock syndrome, a predictable pattern of Principles of Pathophysiology 185 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. signs and symptoms, can either culminate with recovery or any remain alive, they are carried to the acidic environment of death. The Paramedic’s mission is to support the body in its the stomach to be destroyed. Note that external bodily fl uids struggle against shock. such as perspiration, tears, and ear wax are either mucus- like, trapping potentially infectious materials, or contain the Nonspecifi c Defenses enzyme lysozyme. While the analogy is not glamorous, the truth is that the body Like the skin, the internal organs can be protected from is essentially two hollow tubes, with one tube being a cul de foreign invaders by mechanical means such as regurgitation, sac. The outside of the tube is covered by skin, the largest defecation, menstruation, and urination. organ of the body. Skin is a barrier to physical attack by trauma, chemicals, and so on and from biological attack from Infl ammatory Response microorganisms such as fungus, bacteria, and virus. If the nonspecifi c defenses of the skin or the mucosa are The key to the skin’s effectiveness as a barrier lies breached and internal cells and tissues are injured, the in the fact that the outermost layer of skin is dead. Most second-string defenders, the infl ammatory system, responds. microorganisms depend on the host cells being alive. The The infl ammatory system is made up of white blood cells and layers of dead epithelial cells, contained in the epidermis, chemical intermediaries that act as messengers. prevent infection from reaching the live cells deeper in the A variety of causes can stimulate the infl ammatory tissue. Barrier devices, such as gloves (Figure 11-11), are response. Causes include infections that lead to systemic in- simply adjuncts to the fi rst defense, the skin. fections; trauma, such as burn trauma; anaphylactic reactions; But the defense does not stop there. Sebaceous glands complications of childbirth; and eclampsia, to name just a few. excrete acidic (pH 3–5) secretions—lactic acid and fatty acids—which act as a biochemical barrier and create a hostile Infl ammation: Acute Phase environment for fungi and bacteria. Finally, if any infection obtains a foothold in the skin it is Forward scouts, the mast cells contained in the bloodstream, only temporary. Skin is sloughed off, or mechanically abraded, are triggered by trauma, hypoxia, toxins, or any source of continuously, and replaced as quickly. The combination of cellular injury. They respond from the bloodstream almost these three mechanisms culminates in a very effective barrier immediately. Outwardly, the response of the infl ammatory defense against outside sources of disease. system is visible as redness (rubor), swelling (tumor), pain Internally, the body is lined with mucous membranes that (dolor), and warmth (calor) at the injury site. cover the pulmonary tree, the cul de sac mentioned earlier, and Looking beneath these outward manifestations, a complex the gastrointestinal tract that extends the length of the human process of infl ammation is revealed. Mast cells, containing torso. Mucous membranes secrete mucus, a sticky liquid that granules of chemical mediators like histamine and serotonin, entraps foreign invaders, such as bacteria. Bacteria-laden break down or degranulate, releasing their contents into the mucus in the lungs is either expectorated, and thus sputum surrounding interstitial fl uids (Figure 11-12). may be infectious, or ingested, where the bacteria meet their The chemical mediators histamine and serotonin cause fate in the stomach’s acid. vasoconstriction of the smooth muscle in the surrounding Infectious trespassers in the oropharynx are fi rst greeted arterioles, thereby limiting the spread of injury. They also by lysozyme-carrying saliva, which breaks down cell walls. If dilate the postcapillary venules, resulting in swelling and pain. Dilation of the capillary beds is important because it increases the permeability of the capillary walls and allows more white blood cells to migrate out of the blood and

into the interstitial space surrounding the cells. The collection of white blood cells and fl uids is called an exudate. Mast cells also release two chemical messengers: chemotactic factors, which attract specifi c leukocytes (white blood cells) to the injury site. These chemotactic factors— neutrophil chemotactic factor and eosinophil chemotactic factor of anaphylaxis (ECF-A)—bring out the workhorses of infl ammation—neutrophils and eosinophils—during the early stages of the infl ammatory response. Neutrophils destroy bacteria by engulfi ng them in a process called phagocytosis (Figure 11-13). Then the neutrophils break down the bacteria with their lysosomes. Eosinophils destroy parasitic infestations, such as helminthes Figure 11-11 Barrier devices, such as gloves, (worms), and release enzymes that slow the infl ammatory support the body’s own nonspecifi c defense, the response.30 Chief amongst these enzymes is histaminase, an skin. enzyme that breaks down histamine. 186 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Allergen (e.g., cigarette smoke, pollen, bee sting, etc.) IgE antibodies attach IgE antibodies to Mast cell Lower Mast cell airway degranulates T cells Airway Macrophages damage/ constriction/ mucous Eosinophils plugging Triggers acute inflammatory mediators Produce mucous plugging, airway edema and constriction, and damage airway lining. Figure 11-12 Mast cell degranulation. Infl ammation: Prolonged or Chronic vascular permeability and smooth muscle contraction later in Mast cells also create chemical mediators such as the infl ammatory response. leukotrienes (slow acting substances of anaphylaxis— If the infection is persistent (i.e., greater than 24 hours), SRS-A). Leukotrienes produce chemical effects which are then monocytes, which later become macrophages, come to similar to histamine and help to prolong the infl ammation, if the aid of the neutrophils and a similar process continues.31 necessary. Leukotrienes could be considered as long-acting At this stage the body typically mounts a fever response. histamine. The fever is induced by chemicals from the neutrophils and Perhaps most notable to the patient is the presence of the macrophages, which are released after exposure to the prostaglandins, a chemical mediator released from the mast bacterial remains (endotoxins). cell that creates the sensation of pain. However, the primary The cellular remnants of this battle, containing dead and function of prostaglandins is not to create pain but to increase dying leukocytes and bacterial remains, either migrate to the Principles of Pathophysiology 187 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Bacterium Support for Infl ammation: The Coagulation System The term “coagulation” evokes thoughts of blood clots and hemorrhage. However, during the infl ammatory response the coagulation system acts to entrap fl uids (exudates) and foreign bodies (Figure 11-15). Bacterium Both endotoxins (via the extrinsic pathway) and kinins (via engulfed the intrinsic pathway) can stimulate the coagulation cascade to begin. Circulating prothrombin, a plasma protein, is converted into thrombin, which in turn is converted into fi brinogen and then fi brin. The resulting fi brin net prevents the spread of the infection to adjunct tissues by essentially walling off the site. Perhaps as important as preventing the spread of infection, the fi brin net keeps the offending microorganisms confi ned Enzymes destroy Products absorbed to a smaller area for phagocytic action by neutrophils and bacterium by cell macrophages. Finally, the fi brin net serves as scaffolding for Figure 11-13 Neutrophils engaged in scar formation and healing. phagocytosis of an invading bacteria. (Diagram by Support for Infl ammation: Ruth Lawson, Otago Polytechnic, licensed under the Creative The Kinin System Commons Attribution-Sharealike versions 3.0, 2.5, 2.0 and 1.0) Another class of circulating plasma proteins is the kinin group, made up of chains of amino acids. Like the skin’s surface as pus or are carried away in the lymphatic coagulation cascade, kallikrein is activated and converted system as purulent exudate. If the purulent exudate is walled to bradykinin in a cascade. However, kallikrein is present off in a specifi c area, then it is called an abscess. Abscesses in sweat, tears, saliva, urine, and feces and can be converted can be diffi cult to resolve without a surgical procedure such into bradykinin. as incision and drainage (I&D).32 Support for Infl ammation: The Complement System The complement system, as the name suggests, supports and controls the infl ammatory response. Plasma proteins circulate Antigen in the blood and make up almost one half of the blood Antibody C1 complex proteins. The other half of the blood proteins are albumin. The blood proteins comprise the complement system and can be activated by either one of two mechanisms. C2a and C4b fragments The fi rst mechanism includes the classic pathway, an immune complex, in which an antibody (e.g., IgG or IgM) has Classical pathway C3 convertase attached to an antigen and stimulates the complement system. Alternative pathway The activated plasma proteins of the complement system act C3 hydrolysis as anaphylatoxins, increasing the degranulation of mast cells and attracting other white blood cells (leukocytes) to the site. C3b and C3a fragments The plasma proteins mark resistant bacterium by attaching fragments of themselves to the bacterial cell wall, a process called C3b cleaves C5 into opsonization, thus enhancing the impact of the leukocytes. C5a and C5b With the second mechanism, the alternative pathway, toxins Cell swells secreted by the bacterium or fungi stimulate the complement and bursts system and cause all of the same effects as the classic pathway. In some cases the body does not recognize the bacteria C5b, C6, C7, C8 and cannot mount an effective antigen–antibody defense. In and C9 together form those cases, the complement system creates a membrane the membrane attack complex attack complex (MAC), which attaches itself to the cell’s walls and forms a tube from the outside to the inside. The tube allows water to enter the cell, the cell to swell, and the Figure 11-14 The complement system creating cell to lysis (Figure 11-14). a membrane attack complex. 188 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Vessel cut Hemorrhage Aggregation of platelets Prothrombin Fibrinogen Red Cells Thromboplastin Red cells Thrombin Platelets enmeshed in fibrin Figure 11-15 Coagulation. Bradykinin is similar to histamine in its actions. It causes Five types of immunoglobulins have been identifi ed: vasodilation, increased permeability of the vascular bed, and IgA, IgD, IgE, IgG (gamma globulin), and IgM, and each works with prostaglandins to produce pain. Bradykinin was immunoglobulin fi ts into the surface of an antigen in a key and fi rst discovered in Brazil by three pharmacologists working lock fashion, linking them together. The result of this union is with snake venom which caused circulatory collapse. to either neutralize bacterial toxins or activate the complement Using this early work, scientists developed a new class of system. Complement proteins then cause the swelling and antihypertensive drugs called ACE inhibitors. rupture of the cells via membrane attack complexes. If the same antigen is introduced again, circulating Immune Response memory cells will recognize the antigen and plasma cells will start to release antibodies. This phenomenon is called The immune response is the body’s specifi c defense against humoral immunity. substances that are not part of the body (by defi nition, antigens). Antigens can be exogenous, from outside of the T Lymphocytes body, and enter the body by injection, ingestion, or inhalation. Antigens can also be endogenous, from within the body (e.g., Originating in the bone marrow with B lymphocytes, a virus that has replicated within a cell). Whatever the source T lymphocytes travel to the thymus where they mature and of the antigen, the body’s immune system reacts. exit the thymus immunocompetent (i.e., capable of providing Lymphocytes within the body respond to the site of immunity) and travel to the lymphatic system. Once in the injury and, depending on the type of lymphocyte, incapacitate lymphatic system, specifi c cytotoxic T lymphocytes, or killer the antigen. B lymphocytes, from bone marrow, produce T cells, attack antigens which antibodies could not bind to. antibodies that then attack the cell. T lymphocytes, from the They form an antigen–antibody complex (i.e., antigens for thymus gland, recognize the antigen and attack it directly. which the patient does not yet have immunity). Cytotoxic T cells can release lymphokine, a chemical that attracts macrophages, or they can release cell-killing toxins. B Lymphocytes Some even release interferon, a glucoprotein that inhibits cell After an infection, some remaining B lymphocytes remain growth. in contact with the antigen. This contact stimulates the Helper T cells bind to macrophages or B lymphocytes B lymphocyte to divide. The resulting clones can either have a and together produce a protein (interleukin) which stimulates memory of the antigen, called memory cells, or they become more production of both B and T lymphocytes. The plasma cells. Plasma cells generate antibodies, a type of resulting activity of T lymphocytes produces cell–mediated protein globulin called immunoglobulins. immunity. Principles of Pathophysiology 189 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Outcomes: Shock Syndrome with severe infections and during anaphylactic reactions, to name a few causes. Whenever a Paramedic approaches a patient, the quintessential The fi nal classifi cation of shock, obstructive shock, question in the Paramedic’s mind should be, “Is the patient in dealt with the physical impairment of forward blood fl ow shock?” Shock is of great signifi cance in emergency medicine. despite an effective pump, an adequate blood volume, and a While seemingly a simple question to answer, the defi nitions normal vasculature. Examples of obstructive shock include of shock are as different as the causes of shock. massive pulmonary clots, embolism, and a collapsed lung The common layperson defi nition of shock might be any (pneumothorax), which proceeds to crush the heart as well. condition that could potentially lead to death. In 1862, Samuel Recently a fi fth classifi cation has been added, endocrine Gross, a surgeon, described shock as the “rude unhinging shock. Endocrine shock recognizes the importance of of the machinery of life.” John Collins Warren made the hormones in maintaining homeostasis. The classic endocrine statement that shock is but “a momentary pause in the act of shock is hypoglycemic shock. death.” If asked to defi ne shock, a Paramedic might describe a Regardless of the etiology of shock or its classifi cation, state of hypoperfusion and inadequate tissue circulation, and all shock leads to cell injury. Cellular injury is generally owed this would be technically correct. Yet all of these defi nitions to ischemia, whether it is from a lack of oxygen (hypoxia) or are insuffi cient for the Paramedic’s purposes. glucose (hypoglycemia), the creation of infl ammation as well A better defi nition of shock is the “body’s inability to as free radical injury. provide the necessary substrates, oxygen and glucose, for example, to the cells for cellular life and the inability of the Pathophysiology of Shock body to maintain homeostasis.”33–36 This defi nition emphasizes the body’s complexity and The body’s homeostatic mechanisms engage at the fi rst sign interaction and the

singular importance of maintaining the of hemodynamic instability in an effort to maintain adequate viability of cells. The importance of identifying shock to a tissue perfusion. Chemoreceptors in the carotid arteries Paramedic’s practice cannot be overemphasized. Failure to and the medulla oblongata, as well as baroreceptors in the identify declining trends in the vital signs and subtle signs aortic arch and the carotid arteries, sense variations in blood of hypoperfusion can lead to missed rescues and increased pressure, oxygenation, and acidosis. This early hemodynamic morbidity and mortality. Shock deserves aggressive treatment instability activates the sympathetic nervous system and starts from the moment subtle signs are identifi ed. the body’s compensatory mechanisms, which compensate for shock.38–40 Classifi cations of Shock Henri Francois Le Dran, a French surgeon, fi rst originated Organs in Shock the term “choc,” meaning jolt or impact, when describing the The earliest organs to suffer in shock are the organs of the fatal syndrome that was associated with gunshot wounds. The gastrointestinal system. Hypoperfusion of the gut leads term was later expanded to include any lethal deterioration in to erosions of the stomach (erosive gastritis), irritations a patient’s condition. of the pancreas (pancreatitis), cessation of peristalsis As time progressed, additional etiologies besides trauma (paralytic ileus), and fi ne hemorrhage of the bowel (colonic for the shock syndrome were identifi ed. These included severe hemorrhage). infections and shock of a cardiac origin. In 1972 Hinshaw and The next set of organs—the liver, spleen, and kidneys— Cox advanced a universal system for inclusion of all causes enjoy the protection of the thoracic cage and are important of the shock syndrome. to short-term survival. These are often referred to as core The Hinshaw–Cox shock classifi cation included four organs. major categories. The fi rst, hypovolemic shock, included The fi rst organs to be affected by hypoperfusion are shock that arose from trauma (hemorrhagic shock) but also the paired kidneys which attempt to conserve volume and included other etiologies where there was a loss of circulating produce small amounts of urine (i.e., oliguria), sometimes blood volume.37 less than 0.5 mL/kg per hour. This conservation of volume is The next category of shock was cardiogenic shock, or mainly created by sympathetic stimulation and angiotensin shock of a cardiac origin. Cardiogenic shock could include that combine to create vasoconstriction. The net effect of diseases of the muscle (e.g., cardiomyopathy), diseases of prolonged hypoperfusion is acute renal failure (ARF) the coronary arteries, and diseases of cardiac conduction. secondary to tubular ischemia. Whatever the cause, there has to be a failure of the heart as The liver also fails, a condition called shock–liver, and is an effective pump. associated with massive ischemic changes that peak in one to Originally called vasogenic shock, the classifi cation was three days and resolve in three to ten days, provided the cause renamed distributive shock, a term that is more descriptive of the shock has been resolved.41,42 Systemically, the loss of of the problem of poor blood distribution. Distributive shock liver function leads to decreased blood proteins, especially included shock caused by the widespread vasodilatation seen albumin. 190 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Without albumin in the bloodstream to help maintain Eventually, a mismatch occurs between the increasing work colloidal osmotic pressure (COP), intravascular fl uids leak of breathing and the muscle impairment from ischemia, into the third space, creating total body edema or anasarca resulting in respiratory failure. (ana- – “throughout”; sacra – “fl esh”). Impaired gas exchange at the alveolar level causes an Blood proteins created from the liver are also critical to the infl ammatory response. The resultant leaky pipes of the coagulation cascade. Blood clotting factors are stimulated by alveolar capillaries spill into the alveolar space, fi lling it with the infl ammatory response. After initial blood clotting factors exudate that is appreciated as rales (crackles) by the Paramedic. are partially consumed by massive coagulation throughout the The combination of alveolar edema, from infl ammation and body, the remaining clotting factors are insuffi cient to protect pulmonary hemorrhage, from disturbed coagulation causes the body, a condition called disseminated intravascular adult respiratory distress syndrome (ARDS).47,48 coagulation (DIC). As time progresses, the resulting difference between the The paradox of DIC is that the patient’s body forms amount of lungs fi lled (alveolar ventilation) and the capillary clots where they are not needed, leading to localized tissue circulation (pulmonary perfusion) results in a mismatch, ischemia. The patient does not form clots where they are termed a V/Q mismatch. Blood, now unoxygenated, bypasses needed, which leads to hemorrhage. whole sections of the lung, a process called shunting, Splenic injury can be either direct parenchymal injury, producing systemic hypoxia from acute respiratory failure. such as blunt trauma, or cellular injury induced by ischemia that leads to impaired cellular or humoral immunity. Heart Subsequent dysfunction of the immune system leaves the Hypovolemia (from hemorrhage), vasodilatation (from patient prone to massive infections and life-threatening sepsis sepsis), and hypoxia all drive the heart to try to compensate (Greek – putrefaction). and maintain cardiac output, which equals stroke volume Sepsis involves the widespread activation of both the times heart rate. infl ammatory response as well as the coagulation cascade The primary mechanism is sympathetic stimulation, an and generally indicates the body’s failure to control the adrenergic surge which races the heart and increases the blood infection.28, 43–46 The subsequent massive shift of fl uids into pressure. Catecholamines, such as adrenaline/epinephrine, third space, with resulting anasarca, leads to hypotension, work to support the sympathetic nervous system. hypoperfusion, and widespread cellular ischemia. The sympathetic nervous system, in turn, starts to Systemic infections involving the whole body which lead constrict capillary sphincters, effectively closing off capillary to sepsis can cause multiple organ dysfunction syndrome beds, thereby shunting blood to the core organs. The order of (MODS), a failure of two or more organ systems. the shunting, sometimes called the pecking order of shock, MODS can also be caused by an uncontrolled infl ammatory starts with the fetus. The mother’s body will sacrifi ce the response from any disease. Diseases could include pulmonary fetus in order to save the mother; hence, the EMS axiom “to embolism, electrocution, and complications of childbirth, save the baby, you have to save the mother fi rst.” such as amniotic embolism. The alpha receptors of the sympathetic nervous During infection, MODS is the fi nal step in a process system then close down the skin, leading to pale, cool, and known as systemic infl ammatory response syndrome clammy skin. Then the gastrointestinal tract is closed down, (SIRS). The evolution of SIRS is localized infection leading producing nausea. Thereafter, the remaining core organs are to systemic infection leading to sepsis, then on to septic shock affected. and MODS. The sympathetic nervous system also stimulates the vital organs through the beta receptors. Adrenaline/epinephrine Shock: Vital Organs stimulates the beta receptors in the two lungs to breathe 2 The differentiation of decompensated and irreversible shock faster (tachypnea) and to breathe deeper (hypernea), may be academic for Paramedics because the timetable for increasing available oxygen to balance the oxygen demand recovery from ARF, DIC, MODS, and SIRS is often days of the tissues. or weeks. What may have more utility to the Paramedic is The heart’s beta receptors are stimulated by the 1 distinguishing shock that affects the vital organs: the lungs, sympathetic nervous system to increase the heart’s strength heart, and brain. of contraction (inotropy) as well as the rate of contraction (chronotropy). Lungs A factor working against the heart is the health of the The fi rst system to respond to hypoperfusion, to shock, is the coronary arteries. Coronary arteries can be narrowed by pulmonary system. Increased acid production from anaerobic chronic infl ammation or occluded by a blood clot (thrombus) respiration stimulates chemoreceptors in the carotid artery in a condition called acute coronary syndrome (ACS), and in the medulla oblongata. The resulting tachypnea (rapid leading to coronary ischemia. For this reason, and as a matter breathing) and hyperpnea (deep breathing) increases the of practice, ACS should be suspected as a comorbid factor in work of breathing for the muscles, particularly the diaphragm. high-risk patients with shock syndrome.49–51 Principles of Pathophysiology 191 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. In a corollary to ACS, increased demands upon the The leading theory of decompensated shock involves heart can induce tachydysrhythymias. Both tachycardias of the body’s production of acid, both carbonic acid (respiratory a ventricular origin and those of a supraventricular (supra- – acid) and lactic acid (metabolic acid). This acid accumulates, “above”; ventricles – Latin “belly” of the heart) do not permit called an acid load, to the point that tissues are acidotic. adequate ventricular fi lling time, affecting cardiac output The round muscles of the capillary sphincters, that have (CO  SV X HR) adversely. The target heart rate should be until that moment been shutting down capillary beds and less than 150 beats per minute. shunting blood to core organs, can no longer remain closed Conversely, heart rates that are too slow can also reduce in an acidotic environment and the muscles relax. The result cardiac output, adversely affecting the patient’s hemodynamic of this relaxation is massive vasodilatation and a relative status. Vagally mediated bradycardias occur with head hypovolemia as blood leaves the central circulation for injuries, with neurogenic shock, in end-stage hemorrhage the periphery. shock, and under certain conditions with acute coronary Another theory, either working alone or in concert with syndrome. The resultant cardiac output is insuffi cient to meet the acid load theory, states that catecholamine depletion (loss demands and global ischemia occurs. The target heart rate of the neurotransmitters of the sympathetic nervous system) should be greater than 50 beats per minute (BPM). leads to relaxation of capillary sphincters and a rapid decline Finally, during sepsis or hemorrhagic shock, toxic in peripheral vascular resistance. circulating myocardial depressant factors cause myocardial The last theory suggests that there is a decrease in depression. Also, there is a decrease in the strength of sympathetic tone due to loss of perfusion to the central myocardial contraction (inotropy), which results in profound nervous system. The signifi cant fi nding in all three conditions hypotension as well. is the sudden loss of peripheral vascular resistance (closed capillary beds that shunt blood to the core) and subsequent Brain loss of blood pressure and perfusion to the core organs. The brain requires an almost steady state of perfusion to ensure adequate oxygen and glucose because neurons are Axioms of Shock Treatment extremely sensitive to any ischemia or hypoxia. The brain Paramedic care largely revolves around making a tentative needs a mean arterial blood pressure (MAP) of approximately fi eld diagnosis of shock syndrome based upon the symptom 50 to 60 mmHg to maintain adequate perfusion, and the complex and then directing treatments toward supporting the brain is highly adaptive in its efforts to maintain perfusion. patient’s body in its efforts to maintain homeostasis. Without adequate perfusion, suffi cient oxygen and/or The traditional approach to treatment follows the same glucose becomes unavailable and brain damage starts to line as assessment: airway, breathing, and circulation. The occur. therapeutic goals, following this ABC system, are universally Starting with irreversible damage in the cerebral cortex, applicable to all forms of shock and are as follows. ischemic changes will start to progressively affect all areas of First, it is important to provide and optimize the unloading the brain. Outwardly, the manifestations of these changes will of oxygen at the cellular level. The

provision of supplemental include symptoms of anxiety and urgency before descending oxygen, as needed, is essential in order to prevent hypoxia. into feelings of doom and confusion, with concomitant Perhaps more importantly, ventilation must be assured. combativeness followed by unconsciousness. Ventilation is critical in the acid–base balance mechanisms. Maintenance of cerebral perfusion is the target goal of Profound acidosis, respiratory or metabolic, not only shifts all Paramedics. Every effort is made to either support the the oxyhemoglobin curve, but also causes capillary sphincter brain directly, via oxygen and/or glucose administration, or relaxation and massive vasodilatation. to support auxiliary organs, such as the heart and lungs, in The next goal is the maintenance of an adequate order to support the brain. circulatory pressure for perfusion. The end goal is to maintain adequate cerebral perfusion pressure (CPP). Cerebral Decompensated Shock perfusion pressure is the difference between the mean arterial Decompensated shock is the end-stage of a series of pressure (MAP) and the intracranial pressure (ICP). Its range cumulative physiologic derangements typically involving one should be greater than 10 to 15 mmHg in adults. The normal organ system which goes on to affect the entire body. Affected CPP range is 70 to 100 mmHg, and when the CPP falls to are the infl ammatory system and the complement system, less than 50 mmHg acutely, or 70 mmHg for a prolonged leading to coagulation, and culminating in a pathological period of time, the brain suffers ischemia secondary to process called the shock syndrome. hypoperfusion.53–55 Key to survival from shock is the maintenance of In the out-of-hospital environment, it is diffi cult to perfusion to the vital organs, particularly the brain. The monitor some of these values. Therefore, Paramedics focus body, through the sympathetic nervous system, attempts to on monitoring the mean arterial pressure, when automated maintain perfusion, but reaches a break point where it fails.52 noninvasive oscillometric technique is available, or the pulse This failure has been attributed to several mechanisms. pressure (systolic pressure minus diastolic pressure) when 192 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. auscultatory manual sphygmomanometry is used. Then, starts to shrink and fragment and the cell undergoes the fi nal making a reasonable estimate of the ICP, the Paramedic processes of necrosis, a cascade of cellular changes that lead measures the MAP, typically in a range of 50 to 150 mmHg, to death. and estimates the CPP. After the lysosomal rupture, there is a free effl ux of The average ICP in a conscious and alert adult is calcium. The effl ux of calcium joins unused phosphate, approximately 10 to 15 mmHg. When the patient starts to from the remains of the ATP, and precipitates (i.e., falls become confused or drowsy (a Glasgow Coma Scale (GCS) out of solution) as a solid mass. At this point, the cell has of 13 to 15) then the ICP is approximately 20 mmHg. If the experienced irreversible hypoxic injury. Free oxygen patient’s GCS drops to 8 or less, then the ICP is approximately radicals, such as hydrogen peroxide, perforate the cell wall 30 mmHg. These values assume that the patient has not been membrane, making it defective. Finally, the combination of medicated with sedatives such as diazepam. mitochondrial damage, leading to the release of oxygen-free The importance of oxygenation and ventilation cannot radicals, and cytoskeletal damage, as seen on the cell wall be overemphasized enough. Hypoxia and hypercapnia membrane, cause the cell to fragment. (increased carbon dioxide) levels raise cerebral blood fl ow (CBF), which in turn raises intracranial pressure. Hypoxia Patterns of Necrosis is poorly tolerated and hypercapnia, in the form of carbonic acid (respiratory acid) with values greater than 45 mmHg When a mass of cells within a tissue or organ die there are should be avoided.56–60 characteristic changes that affect the remaining tissues. When Next, cardiac function should be maximized, in large muscle cells die, such as in myocardial infarction, the skeleton part to maintain the MAP in a range that supports adequate of the cell remains and the tissue remains fi rm.62,63 This state cerebral perfusion pressures. Typically, the fi rst objective is to is called coagulative necrosis. normalize the heart rate within the range of 50 to 150 BPM, Coagulative necrosis permits the dead cells to act with 60 to 80 BPM being optimal.61 as a scaffolding for other tissue, but the tissue no longer If the MAP remains suboptimal, then the use of functions. In the case of an acute myocardial infarction, vasopressors, such as dopamine, may be needed to support the affected portion of the muscle mass is considered to be the sympathetic nervous system. Vasopressors should be akinetic (without motion) and does not contribute to the titrated, keeping the CPP and the MAP in mind. heart’s work. The fi nal goal should be to redistribute blood fl ow to Cells that are largely lipid in content, such as the neurons ensure perfusion of vital organs. The kidneys help to maintain of the brain, simply liquify upon death and leave a pool in intravascular volume by reducing urine output and by their place. This process is called liquifactive necrosis. When utilizing the renin–angiotensin–aldosterone mechanism. This a patient experiences a series of small ischemic strokes, the mechanism helps ensure not only that there is reabsorption dead tissue undergoes liquifactive necrosis and leaves a small of sodium at the kidneys but also that adrenal epinephrine cavity, called a lacuane (Latin – lacuna). release increases. When tissues die from ischemia (e.g., the toes of a patient From a prehospital point of view, the need is to provide with diminished distal circulation secondary to complications optimal intravascular volume, particularly preload (the of diabetes mellitus), tissues undergo gangrenous necrosis. In volume of venous blood entering the heart during diastole), to this type of gangrene, called dry gangrene, the affected portion optimize stroke volume and cardiac output. This is achieved generally blackens and then simply falls off the body. through intravenous infusions of crystalloid- or colloid- If a secondary infection sets in, resulting in toxin- containing solutions. producing bacteria such as clostridium, then the condition These goals are not in treatment priority order. Rather, is called wet gangrene. Wet gangrene can lead to systemic they should be individualized to each patient. It should be infections and systemic infl ammatory response syndrome. clear that the overarching mission is to support the body while If the tissues involved are invaded by anaerobic bacteria, it tries to provide oxygen delivery to the vital organs. typically secondary to wounds, then gasses form and the gangrene is called gas gangrene. Gas gangrene must be Pathological Cell Injury aggressively treated with antibiotics, for without treatment gas gangrene is invariably fatal. Cellular injury, due to any of the previously discussed causes, can be reversible in the early stages. Reversible cellular injury is characterized with cellular swelling, from an accumulation Death of sodium and water, and changes in the cell wall membrane When the body’s compensatory mechanism fails to maintain called blebs, which have the appearance of bubble wrap homeostasis, and the cells of the body are irreversibly injured, commonly used for packing. fi rst the tissues, then the organs, and then the organism There comes a point when the lysosomes rupture, will die. Somatic death (soma—“body”) is the death of the emptying their contents of enzymes, which begin to autolysis organism. There are specifi c changes within the body that are proteins (i.e., denature the proteins). Eventually the nucleus associated with death, referred to as postmortem changes. Principles of Pathophysiology 193 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Initially, the patient experiences what is called 12 hours the entire body is rigid and afterwards (about 36 clinical death, the absence of vital signs. Clinical death hours after clinical death) the breakdown of the proteins is characterized by unresponsiveness to loud verbal and returns the body to a fl accid condition.64–66 painful stimuli, absence of breathing, and an absence of a The second mortis is livor mortis. Livor mortis, or central pulse. Barring any restrictions to the contrary, cardio- lividity, is a condition caused by relaxation of the vascular pulmonary resuscitation is usually indicated. bed and a pooling of blood in dependant portions of the Although a patient may be dead, it is possible for some body.67,68 All bleeding stops and fl uids start to drain from the tissues or organs to still be alive. These tissues and/or organs body. Often the most notable changes occur when the fl uids can be harvested for transplantation if the remaining living drain from the face, leaving gaunt cheekbones and a peaked tissue is removed quickly. nose with a beak-like appearance. In certain circumstances the patient is beyond The third mortis is algor mortis. Algor mortis is the resuscitation. These patients have undergone biological body’s natural cooling. As the body’s metabolic processes death. Biological death is associated with irreversibility, cease, so does the production of heat. On average, the body meaning that any resuscitative efforts would be futile. cools about 1ºF to 1.5ºF an hour until the body reaches room Biological death is usually associated with an absence of temperature, usually about 24 hours.69–71 brain activity, as evidenced by an electroencephalogram. The presences of the three mortis, as well as the The patient is termed brain dead. This defi nition has limited signs of clinical death, are often felt to be suffi cient to utility to Paramedics. withhold resuscitative efforts. Some EMS systems include Paramedics rely on other signs to determine biological other conditions, such as decapitation, incineration, and death. Initially, Paramedics confi rm clinical death and then hemicorporectomy (amputation at the waist) for inclusion in proceed to confi rm biological death. Paramedics use the fi ndings their criteria for obvious death. of the three “mortis” to help confi rm biological death. When the body has undergone putrefaction, it is The fi rst mortis (Latin – death) is rigor mortis, a stiffening assumed that the patient is dead. Putrefaction is a process of the muscles. Muscles stiffen following anoxia (a- – of decomposition within the body characterized by greenish “without”; ox – “oxygen”; -ia – “state”) from acid buildup in discoloration, secondary to hemolysis of blood, and slippage of the tissues that interferes with the release of the contractile the skin from the skeleton, due to breakdown of subcutaneous protein actin from myosin. Initially, the short muscles of the fat. Putrefaction starts between 24 and 48 hours after clinical body (e.g., the muscles of the jaw) are affected. In about death. 194 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. From birth to death, disease is a constant in the human condition. The study of pathophysiology, the study of the suffering of the human condition wrought by disease, provides Paramedics with an understanding on how to intercede and reduce suffering through medical therapeutics. Key Points: • Pathophysiology is the study of the causes of • Paramedics work to prevent hypoxia by supporting suffering in the normal human condition. the elements of the Fick principle. • Disease is an abnormal change in the function • Ischemia is the fi rst step in the pathogenesis of of cells, tissues, or

organs which in turn interferes hypoxia, followed by injury and then death. with homeostasis. • A toxin is defi ned as any substance capable • All diseases have an origin or etiology. of causing cell injury and death. • Each person has certain risk factors—some • Metabolites are the by-products of drugs and modifi able and some not—that make that person chemicals after they interact with a cell. more or less vulnerable to a disease. • Outside forces such as trauma, extreme • Modifi able risk factors are factors over which a temperature, radiation, and atmospheric pressures person has some control. can all cause injury to the body and its cells. • Nonmodifi able risk factors include family • During heat emergencies, the body has diffi culty (genetics), aging, and gender. compensating for excessive heat. • Prognosis is the expected outcome from a disease. • Burns can be caused by fi ve sources of • electromagnetic energy: thermal, radiation, light, Iatrogenic disease is produced as a consequence of radio, and electricity. medical intervention. • Nosocomial infection is death from a hospital- • A burn uses the method of either direct heat transfer or ionization as its mechanism of injury. acquired infection. • Pathogenesis is the origin and development of • Stochastic effects are the long-term complications a disease followed in a sequential order at the from exposure to ionizing radiation. Teratogenic cellular, biochemical, and molecular level. effects are the harmful effects of ionizing radiation on future generations. • Exacerbation of a disease may occur where the disease returns or fl ares up. In remission, the • Low temperatures, or hypothermia, lead to disease may be forced into a nonactive state. impaired cell walls. • Morbidity (the incidence of disease) and mortality • Barotrauma is physical damage to tissues due (death rate) are constantly monitored for trends. to pressure imbalances between those in the environment and those in the body. A common • Hypoxia is a low oxygen concentration in the body. condition found in the prehospital setting is a pneumothorax. • The Fick principle can be summed up in fi ve concepts: oxygenation, ventilation, respiration, • Either a defi ciency of nutrition or excess circulation, and cellular respiration. of nutrition can lead to metabolic disease. Principles of Pathophysiology 195 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • A genetic disorder is an abnormality in a person’s • The pecking order of shock is the order of shunting genes which may be passed on through future which begins with the fetus. The skin is then closed family generations. down, followed by the gastrointestinal tract. The • core organs are the last to be affected. Infectious diseases stem from prions, viruses, bacteria, fungi, protozoa, and helminthes, all of • In order to adequately perfuse the brain, a mean which are parasites. arterial blood pressure (MAP) of 50 to 60 mmHg • is needed. Cerebral perfusion pressure can be Skin is the body’s fi rst defense against physical, estimated from mean arterial pressure. chemical, and biological attacks. • • Decompensated shock is the body’s inability to Mucous membranes line the internal “tubes” of the maintain perfusion. body with mucus, engulfi ng any foreign predators. • • Attention to airway, breathing, and circulation is Various acids and saliva create another line of necessary in all forms of shock. defense. • Mechanical defenses include regurgitation, • Hypoxia and hypercapnia can result in increased intracranial pressure. defecation, menstruation, and urination. • The infl ammatory system defends the body when • Vasopressors such as dopamine are used to maximize cardiac function and to support the nonspecifi c, external defenders are weakened. sympathetic nervous system during times when the • Complement, coagulation, and kinen proteins mean arterial pressure is suboptimal. support infl ammation. • Cellular injury can be reversible. • The immune response is an internal, specifi c method of defense. • Cellular injury occurs in steps: swelling, cell wall changes, lysosome changes, cellular death. • The immune response consists of B lymphocytes (humoral immunity) and T cells (cell-mediated • Coagulative necrosis occurs when muscle cells die immunity). but remain fi rm. • Shock is the body’s inability to provide the • Liquifactive necrosis occurs when lipid cells liquify necessary substrates to the cells, which makes the when they die. body unable to maintain homeostasis. • Dry gangrene occurs when tissues die from • The Hinshaw-Cox shock classifi cation system ischemia. includes four categories: • Wet gangrene forms when secondary infections 1. Hypovolemic invade the ischemic tissues. 2. Distributive 3. Cardiogenic • Gas gangrene forms when the tissues are invaded 4. Obstructive by anaerobic bacteria. • The body begins compensating for the shock state • Somatic death is the death of an organism. by activating the sympathetic nervous system. • • Death occurs in stages. Multiple organ dysfunction is a failure of two or more organs due to total body systemic infection • Clinical death is when a person no longer has vital leading to sepsis. signs. • The Paramedic must identify shock affecting the • Biological death is the absence of any brain core organs. activity. 196 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. Defi ne pathophysiology. 8. Describe how hypoxia impacts cellular function 2. How is a tentative fi eld diagnosis helpful to the and the resultant consequences. Paramedic in the treatment of a patient? 9. Describe how trauma impacts cellular function 3. What is the difference between a disorder and and provide an example of resultant harm. a syndrome? 10. Initially, how does the body respond to an 4. List several modifi able and nonmodifi able risk infection on the skin? (Hint: Think of the three factors. cardinal signs.) 5. Choose one modifi able risk factor and discuss 11. What are the four classifi cations of shock using its impact on an associated disease. the Hinshaw–Cox descriptions? 6. What is meant by the term “iatrogenic disease”? 12. How does the sympathetic nervous system 7. What term is used to describe the crossover support the body in shock? from recovery toward death? Case Study Questions: Please refer to the Case Study at the beginning of 2. What type of death has been described with the the chapter and answer the questions below. absence of vital signs? 1. Describe the changes that occur in cells as 3. Why might some organs in a deceased individual perfusion ceases. still be viable for transplant? References: 1. Atkins D. Reports of Hospital Physicians and Other Documents 8. Plank LD, Hill GL. Sequential metabolic changes following in Relation to the Epidemic of Cholera of 1832. New York G. & induction of systemic infl ammatory response in patients C. & H. Carvill; 1832. with severe sepsis or major blunt trauma. World J Surg. 2. Guerrant RL, Carneiro-Filho BA, Dillingham RA. Cholera, 2000;24(6):630–638. diarrhea, and oral rehydration therapy: triumph and indictment. 9. Nafziger SD. Smallpox. Crit Care Clin. 2005;21(4):739–746, Clin Infect Dis. 2003;37(3):398–405. vii. 3. van der Hoek L. Human coronaviruses: what do they cause? 10. Parrino J, Graham BS. Smallpox vaccines: past, present, and Antivir Ther. 2007;12(4 Pt B):651–658. future. J Allergy Clin Immunol. 2006;118(6):1320–1326. 4. Cheng VC, Lau SK, Woo PC, Yuen KY. Severe acute respiratory 11. Fleming ST. Complications, adverse events, and iatrogenesis: syndrome coronavirus as an agent of emerging and reemerging classifi cations and quality of care measurement issues. Clin infection. Clin Microbiol Rev. 2007;20(4):660–694. Perform Qual Health Care. 1996;4(3):137–147. 5. Gu J, Korteweg C. Pathology and pathogenesis of severe acute respiratory syndrome. Am J Pathol. 2007;170(4):1136–1147. 12. Jefferson T, Foxlee R, Del Mar C, Dooley L, Ferroni E, 6. Kohl BA, Deutschman CS. The infl ammatory response to Hewak B, et al. Physical interventions to interrupt or reduce surgery and trauma. Curr Opin Crit Care. 2006;12(4):325–332. the spread of respiratory viruses: systematic review. Bmj. 7. Pallister I. Current concepts of the infl ammatory response after 2008;336(7635):77–80. major trauma: an update. Injury. 2005;36(1):227–229; author 13. Hart S. Using an aseptic technique to reduce the risk of reply 229–230. infection. Nurs Stand. 2007;21(47):43–48. Principles of Pathophysiology 197 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 14. Larson EL, Quiros D, Lin SX. Dissemination of the CDC’s Hand 36. Haljamae H. The pathophysiology of shock. Acta Anaesthesiol Hygiene Guideline and impact on infection rates. Am J Infect Scand Suppl. 1993;98:3–6. Control. 2007;35(10):666–675. 37. Bongard F, Sue D. CURRENT Critical Care Diagnosis & 15. Cardona PJ. New insights on the nature of latent tuberculosis Treatment. New York: McGraw-Hill Medical; 2002. infection and its treatment. Infl amm Allergy Drug Targets. 38. Little RA, Jones RO, Eltraifi AE. Cardiovascular refl ex function 2007;6(1):27–39. after injury. Prog Clin Biol Res. 1988;264:191–200. 16. http://www.cdc.gov/mmwr 39. Shepherd JT, Vanhoutte PM. Role of the venous system in 17. Yellon DM, Hausenloy DJ. Myocardial reperfusion injury. N Engl circulatory control. Mayo Clin Proc. 1978;53(4):247–255. J Med. 2007;357(11):1121–1135. 40. Sanz G, Nadal-Ginard B, Malpartida F, Froufe J. Hemodynamics 18. Hamilton KL. Antioxidants and cardioprotection. Med Sci Sports of myocardial infarct (critical analysis of experimental studies). Exerc. 2007;39(9):1544–1553. Rev Esp Cardiol. 1971;24(6):575–584. 19. Tang W. Drug metabolite profi ling and elucidation of drug- 41. Seeto RK, Fenn B, Rockey DC. Ischemic hepatitis: clinical induced hepatotoxicity. Expert Opin Drug Metab Toxicol. presentation and pathogenesis. Am J Med. 2000;109(2):109–113. 2007;3(3):407–420. 42. Henrion J. Hypoxic hepatitis: the point of view of the clinician. 20. Park BK, Kitteringham NR, Maggs JL, Pirmohamed M, Acta Gastroenterol Belg. 2007;70(2):214–216. Williams DP. The role of metabolic activation in drug-induced 43. O’Brien JM, Jr., Ali NA, Aberegg SK, Abraham E. Sepsis. Am hepatotoxicity. Annu Rev Pharmacol Toxicol. 2005;45:177–202. J Med. 2007;120(12):1012–1022. 21. Prescott LF. Reactive metabolites as a cause of hepatotoxicity. Int 44. Hollenberg SM. Vasopressor support in septic shock. Chest. J Clin Pharmacol Res. 1983;3(6):437–441. 2007;132(5):1678–1687. 22. Way JL, Leung P, Cannon E, Morgan R, Tamulinas C, Leong- 45. Lever A, Mackenzie I. Sepsis: defi nition, epidemiology, and Way J, et al. The mechanism of cyanide intoxication and its diagnosis. Bmj. 2007;335(7625):879–883. antagonism. Ciba Found Symp. 1988;140:232–243. 46. Gentili A, Iannella E, Giuntoli,L, Baroncini S. System for 23. Eastridge BJ. Things that go boom: injuries from explosives. predicting outcome and for clinical evaluation in sepsis and J Trauma. 2007;62(6 Suppl):S38. septic shock: could scores and biochemical markers be of greater 24. Garner MJ, Brett SJ. Mechanisms of injury by explosive devices. help in the future? Med Sci Monit. 2006;12(6):LE11–12. Anesthesiol Clin. 2007;25(1):147–160, x. 47. Hardaway RM. A brief overview of acute respiratory distress 25. Bridges EJ. Blast injuries: from triage to critical care. Crit Care syndrome. World J Surg. 2006;30(10):1829–1834; discussion Nurs Clin North Am. 2006;18(3):333–348. 1835. 26. Roubertoux PL, Kerdelhue B. Trisomy 21: from chromosomes to 48. Lasky M, Puyo C. Acute respiratory distress syndrome update. mental retardation. Behav Genet. 2006;36(3):346–354. Mo Med. 2005;102(5):469–474. 27. Gardiner K, Davisson M. The sequence of human chromosome 49. Gowda RM, Fox JT, Khan IA. Cardiogenic shock: basics and 21 and implications for research into Down syndrome. Genome clinical considerations. Int J Cardiol. 2008;123(3):221–228. Biol. 2000;1(2):REVIEWS0002. 50. Aymong ED, Ramanathan K, Buller CE. Pathophysiology of 28. Munford RS. Severe sepsis and septic shock: the role of gram- cardiogenic shock complicating acute myocardial infarction. Med negative bacteremia. Annu

heart, “my,” meaning muscle, and “patho,” meaning disease. root and changes the meaning of the term (Tables 12-6 to The letter “O” separates the roots “cardia,” “my,” and “path.” 12-9). Using the term “myocarditis,” for example, and read- “Cardiomyopathy,” reading from right to left, means disease ing from right to left, the term “-itis” means infection, the of the muscle of the heart. term “cardi-” means heart, and the prefi x “myo-” means mus- cle. The term “myocarditis” means an infection of the cardiac Combining Forms muscle. Sometimes two root terms are used and a combining vowel must be used to make the two root terms distinguishable but connected (Table 12-10). Typically the letter “o” is used. For Table 12-6 Partial List of Common Suffi xes example, “cardi-: “o” “-logy” is the study of the heart. for Diagnosis However, if the root word ends with a vowel, then it is Suffi x Meaning Used Meaning unnecessary to use a combining vowel. For example, combin- -algia Pain Neuralgia Nerve pain ing “cyst-” with “-itis” would be “cystitis,” not “cystoitis.” -cele Swelling Hydrocele Water cyst Plural Forms -emia Blood Anemia Without blood To establish a plural meaning from a singular word, the -ectasis Expansion Bronchiectasis Enlarged bronchi Paramedic only needs to apply a few rules (Table 12-11). For -dynia Pain Angiodynia Pain with IV example, if the singular word ends with “ax” then remove the -edema Swelling Laryngoedema Swollen throat “ax” and replace it with “aces” to make the meaning of the -gen Begin Carcinogen Cancer causing word plural. -iasis Formation Cholelithiasis Gall stone -itis Infl ammation Pharyngitis Sore throat Table 12-8 Diagnostic Suffi xes -megaly Enlargement Cardiomegaly Enlarged heart for Medical Instruments -oma Tumor Carcinoma Cancer Suffi x Meaning Used -pathy Disease Myopathy Disease of muscle -gram Record Electrocardiogram -phasia Speech Aphasia Speechless -graph Recording tool Electrocardiograph -plegia Paralysis Hemiplegia Help paralysis -meter Measurement tool Capnometer -phobia Fear Agoraphobia Fear of places -scope Instrument Laryngoscope -rrhagia Flow Dysmenorrhagia Excessive menstrual fl ow -rrhage Burst Hemorrhage Bleeding Table 12-9 Medical Suffi xes -rrhea Discharge Otorrhea Discharge from ear Suffi x Meaning Used -scopy Examine Bronchoscopy Examine the bronchi -iac Affl icted Hemophiliac -spasm Contraction Bronchospasm Contraction of -ia Unhealthy Anesthesia bronchi -ism Condition Alcoholism -ist Expert Cardiologist Table 12-7 Surgical Suffi xes Suffi x Meaning Used Table 12-10 Examples of Combining Terms -clasis Breakdown Osteoclasis Root Suffi x Use -ectomy Removal Appendectomy Cardiology -ist Cardiologist -centesis Tap or drain Pericardial centesis Enter -lysis Enterolysis -lysis Loosen/divide Fibrinolysis Bronchi -scopy Bronchoscopy -plasty Formation Rhinoplasty Lith -tripsy Lithotripsy -stomy Opening Tracheostomy Ortho -pnea Orthopnea -tripsy Crush Lithotripsy Trachea -tomy Tracheotomy -tomy Cut Tracheotomy Trachea -stomy Tracheostomy 204 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 12-11 Making Plural Forms of Terms Spelling Singular Form Plural Form Many medical terms have a similar sounding constituent but -a add -e are spelled differently. Spelling them correctly can be diffi cult, -ax drop –ax, add -aces especially if the Paramedic hears the word spoken and then must -en drop –en, add -ina spell it. For example, the “si” sound can be spelled with “psy,” as -is drop –is, add -es in “psychiatry,” “sy” as in “symptom,” or “cy” as in “cystitis.” To avoid errors and confusion the term should be spelled -ix drop –ix, add -ices correctly. When in doubt, the Paramedic should consult a -sis drop –sis, add -ses medical dictionary for the correct spelling. -um drop –um, add -a -us drop –us, add -i -x drop –x, add -es Professional Paramedic -y drop –y, add -ies While speaking medicalese is an expectation among Reading Medical Terminology medical professionals, it may be inappropriate to use medical terminology with a patient.3, 4 Use When both a suffi x and a prefi x are used in a word, then the suffi x is read fi rst, then the prefi x, and then the root (read last, appropriate common language to interview or explain fi rst, and middle). For example, the term “hypoglycemia” has interventions to the patient. “gly” as its root and “gly” refers to glucose. To read this term correctly, fi rst read the suffi x, “-emia,” referring to blood, then “hypo-,” meaning low, and then “gly.” Together the term Abbreviations means blood with low sugar. The basis for abbreviations is brevity, meaning short and con- All medical terms are interpreted with the suffi x read cise. Paramedics strive to be short and concise in their medi- fi rst, prefi x next, and root last (last, fi rst, and middle). This cal writing. Correct use of abbreviations can help with that concept is diffi cult for those Paramedics who have been edu- process, provided that the meaning of the communication is cated to read from left to right. It takes practice to become not lost in the process. For example, the abbreviation “Ca” profi cient at deciphering medical terminology. With a little can mean both “calcium” and “cancer.” practice, the Paramedic rapidly becomes profi cient at learn- Emergency physicians, allied healthcare professionals, ing the meaning of these terms and can incorporate them into EMS managers, educators, and attorneys are just a few of the the documentation. people who may read a PCR. Without a common translation, abbreviations can become meaningless to the reader, and the Pronunciation PCR loses its potency as a vehicle for communication. Proper pronunciation of medical terms is key to understanding. As a result of common medical errors, some abbrevia- While verbalizing these terms may seem diffi cult, dissection tions are no longer accepted.5 For example, the abbreviation of the term to its constituent parts (prefi x, root, and suffi x) and for morphine sulfate is MSO . Unfortunately, during tran- 4 careful articulation will likely produce satisfactory results. scription, the MSO may be confused with MgSO , which 4 4 Often other medical professionals will help to correct is magnesium sulfate. For this reason clinicians, including errors in infl ection or in pronunciation. By repeating the cor- Paramedics, should spell out MSO as morphine in order to 4 decrease confusion and prevent errors.6-9 rected pronunciation, the Paramedic helps to commit the term to memory. To help resolve the problem, many EMS agencies have a list of accepted abbreviations (Table 12-12). This list is usu- ally gleaned from a similar list of abbreviations used by the Cultural / Regional differences healthcare professionals at the local hospital(s). Paramedics should obtain and utilize their agency’s abbreviation list. As with all languages, there are some regional dialects that make the same word sound different depending Street Smart on the region. Whenever there is a question, the term should be spelled out. This is particularly important in Whenever there is a possibility that an abbreviation radio communications where two words with a similar might be unclear to another healthcare provider, then pronunciation can have very different meanings (for the word should be spelled out. The maxim is “when example, “hypo” and “hyper”). in doubt, spell it out.” Medical Terminology 205 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 12-12 List of Common Abbreviations /a Before DOE Dyspnea on exertion AAA Abdominal aortic aneurysm DPT Diphtheria, pertussis, tetanus AAL Anterior axillary line DTs Delirium tremens AB Abortion Dr. Doctor ABCs Airway, breathing, circulation Dx Diagnosis Abd Abdominal ECG/EKG Electrocardiogram AC Antecubital fossa EEG Electroencephalogram ACLS Advanced cardiac life support EENT Ears, eyes, nose, throat ADL Activities of daily living EID Esophageal intubation detector AED Automatic external defi brillator EJV External jugular vein A fi b Atrial fi brillation EMD Emergency medical dispatch AIDS Acquired immune defi ciency syndrome EMS Emergency medical service ALS Advanced life support EMT Emergency medical technician AMA Against medical advice EPI Epinephrine AMI Acute myocardial infarction Eq Equivalents AMS Altered mental status ET Endotracheal tube A/O Alert and oriented ETA Estimated time of arrival A/P Anterior–posterior EtOH Ethyl alcohol ASA Aspirin °F Fahrenheit ASHD Arteriosclerotic heart disease FU Follow up ARDS Adult respiratory distress syndrome FUO Fever of unknown origin ATV Automatic transport ventilator Fx Fracture AV Atrioventricular GCS Glasgow coma scale BAC Blood alcohol content GI Gastrointestinal BBB Bundle branch block GSW Gun shot wound BG Blood glucose gtt Drops Bid Twice per day GU Genitourinary BLS Basic life support GYN Gynecologic BM Bowel movement H Hour BP Blood pressure HBO Hyperbaric oxygen Bpm Beats per minute HBV Hepatitis B virus BSA Body surface area HIV Human immunodefi ciency virus BVM Bag valve mask h/o History of Bx Biopsy HPI History of the present illness /c With HTN Hypertension C Celcius/Centigrade Hx History Ca Cancer I&D Incision and drainage CABG Coronary artery bypass graft ICP Intracranial pressure CAD Coronary artery disease ICU Intensive care unit C/C Chief complaint or concern IDDM Insulin dependent diabetes mellitus cc Cubic centimeters IM Intramuscular CCU Critical care unit IO Intraosseous CHF Congestive heart failure IPPB Intermittent positive pressure breathing CNS Central nervous system IUD Intrauterine device c/o Complained of IV Intravenous CO Carbon monoxide IVP IV push (medication) CO2 Carbon dioxide JVD Jugular venous distention COBS Chronic organic brain syndrome KED Kendrick extrication device COPD Chronic obstructive pulmonary disease kg Kilogram CP Chest pain KVO Keep vein open CPR Cardiopulmonary resuscitation L Liter CSF Cerebrospinal fl uid Lac Laceration CSM Circulatory/sensory/motor function LLQ Left lower quadrant CT Computerized tomography LMP Last menstrual period CVA Cerebral vascular accident LPN Licensed practical nurse D5W 5% Dextrose LOC Loss of consciousness or level of consciousness d/c Discontinue LR Lactated ringers solution DKA Diabetic ketoacidosis LUQ Left upper quadrant DM Diabetes mellitus mcg Microgram DOA Dead on arrival MCI Multiple casualty incident DOB Date of birth MCL Modifi ed chest lead 206 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 12-12 (continued) MD Physician RMA Refused medical assistance mEq Milliequivalents RN Registered nurse mg Milligram ROM Range of motion MI Myocardial infarction RUQ Right upper quadrant mL Milliliter r/o Rule out mm Millimeter ROM Range of motion mmHg Millimeter Mercury RR Respiratory rate MRI Magnetic resonance imaging Rx Prescription or treatment MVA Motor vehicle accident /s Without MVC Motor vehicle collision SSS Sick sinus syndrome MVP Mitral valve prolapsed S1 First heart sound N/A Not applicable S2 Second heart sound NAD No apparent distress S3 Third heart sound NC Nasogastric S4 Fourth heart sound NKA No known allergies SA Sinoatrial NPA Nasal pharyngeal airway SIDS Sudden infant death syndrome NPO Nothing by mouth SE Sublingual NRB Nonrebreather face mask SOB Shortness of breath NS Normal saline SQ/SC Subcutaneous NSR Normal sinus rhythm SSCP Substernal chest pain NTG Nitroglycerine STD Sexually transmitted disease N/V Nausea and vomiting STAT Immediately O2 Oxygen SVT Supraventricular tachycardia OB/GYN Obstetrics/gynecology TB Tuberculosis OD Overdose TIA Transient ischemic attack OPA Oral pharyngeal airway Tid Three times a day OR Operating room TKO To keep open OTC Over-the-counter TOT Turned over to oz. Ounce Tx Treatment or traction P Pulse URI Upper respiratory infection /p After UTI Urinary tract infection PA Physician assistant VD Venereal disease PAC Premature atrial contraction VS Vital signs PAT Paroxysmal atrial tachycardia VF/VFib Ventricular fi brillation PCN Penicillin VT/VTach Ventricular tachycardia PE Physical exam w/ With PEA Pulseless electical activity WNL Within normal limits PEARL Pupils equal and

reactive to light w/o Without PIAA Personal injury auto accident WPW Wolff-Parkinson White Syndrome PID Pelvic infl ammatory disease y/o Year old PJC Premature junctional contraction xport Transport PMH Past medical history PND Paroxysmal nocturnal dyspnea Approved Symbols PO By mouth ♂ Male Pm As needed ♀ Female PSVT Paroxysmal supraventricular tachycardia  Equal Pt Patient  Positive PVC Premature ventricular contraction  Negative Q Every > Increase Qd Every day < Decrease Qh Every hour Change Qid Four times a day R Right Qod Every other day L Left RLQ Right lower quadrant  Times or multiply Medical Terminology 207 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Topographic Anatomy divides the body into upper and lower. With these reference points in place, the Paramedic can more accurately describe a Medical terminology includes a number of positional and specifi c location on the body using topographic anatomy. directional terms (Tables 12-13 to 12-16). These terms direct a In every case, the assumption is that the patient is stand- Paramedic to an area of the body or the organs involved. To serve ing in the standard anatomical position; that is to say, the as a reference, the body is divided into three planes. The frontal patient is standing upright, eyes forward, hands to the side plane divides the body in half front from back. The sagittal plane with the palms of the hand forward and feet together. divides the body from left to right, whereas the transverse plane Table 12-13 Directional Terms Table 12-15 Terms Describing Patient Positions Term Plane Relation Description Term Description Caudal Transverse Inferior Toward the feet Prone Lying on belly Cephalic Transverse Superior Toward the head Supine Lying on back Dorsal Frontal Inferior Toward the back Left lateral Lying on left side Ventral Frontal Anterior Toward the front Fowlers Sitting up right Trendelenburg Supine with legs elevated Sims Side lying knee to chest Table 12-14 Relational Terms Table 12-16 Terms Describing Movement Term Description Term Description Apex Top of the pyramid Abduction Away from midline Base Bottom of the pyramid Adduction Toward the midline Distal Away from the structure Circumduction Circular motion Lateral To the side of the structure Dorsifl exion Backwards Medial Toward the structure Eversion Turn outward Deep Away from the surface Extension Straightening Superfi cial Toward the surface Flexion Bending Inversion Turn inward Pronation Turn downward Supination Turn upward 208 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Abbreviations and medical terminology, when used inappropriately, only serve to confuse the message. With practice and attention to detail, the Paramedic can learn medicalese and become conversant with fellow healthcare professionals. Key Points: • Medicalese has its roots in Greek and Latin words. • Terms should be spelled correctly. Use a medical • dictionary for the correct spelling. Medical terms may consist of four parts: the root word, a prefi x and/or a suffi x, and a combining form. • Paramedics should use appropriate and accepted • abbreviations. A prefi x complements a root; it is placed at the beginning of the root. • The body can be divided up into three planes: • frontal, sagittal, and transverse planes. A suffi x complements a root; it is placed behind the root. • The standard anatomical position is when a patient • is standing upright, eyes forward, hands to the Sometimes when two root terms are used a side with the palms of the hand forward, and feet combining vowel must be used to make the two root together. terms distinguishable but connected. • • Using the three planes and standard anatomical All medical terms are interpreted with the suffi x position, the Paramedic can use topographic being read fi rst, then the prefi x, and then the root anatomy to describe a specifi c location. (last, fi rst, and middle). Review Questions: 1. What are the origins of medical terminology? 4. List several examples of commonly accepted 2. Explain how a prefi x complements a root medical abbreviations. word’s meaning. 5. What is standard anatomical position? 3. Explain how a suffi x complements a root word’s meaning. Case Study Questions: Please refer to the Case Study at the beginning of the contained misspelled words, as chapter and answer the questions below. well as inappropriately used words or 1. Why would the correct use and spelling of abbreviations? medical terms be of concern to the quality 3. Using topographical anatomy, describe a bruise improvement committee? located on the left arm between the elbow and 2. How would you perceive the care given by a wrist on the same side of the arm as the palm of Paramedic if the only documentation available the hand. Medical Terminology 209 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. References: 1. Waife SO. Medicalese. Miss Valley Med J. 1958;80(1):10–11. 6. JCAHO says: watch your p’s and q’s. Nursing. 2004; 34(3): 55. 2. Dzuganova B. Word analysis—a useful tool in learning 7. Brunetti, L., J. P. Santell, et al. The impact of abbreviations on the language of medicine in English. Bratisl Lek Listy. patient safety. Jt Comm J Qual Patient Saf. 2007; 33(9): 576-83. 1998;99(10):551–553. 8. Scalise, D. Clinical communication and patient safety. Hosp 3. Williams N, Ogden J. The impact of matching the patient’s Health Netw. 2006; 80(8): 49-54, 2. JCAHO says communication vocabulary: a randomized control trial. Fam Pract. problems were the leading root cause of sentinel events in 2005. 2004;21(6):630–635. The reasons are manifold: a harried environment, a hierarchical 4. Zeng Q, Kogan S, Ash N, Greenes RA. Patient and clinician staffi ng system and illegible handwriting, to name a few. This vocabulary: how different are they? Medinfo. 2001;10(Pt 1): gatefold examines the scope of the problem, including data and 399–403. risk factors, and offers some strategies for improvement. 5. Nagel KR. Prohibited abbreviations. Am J Health Syst Pharm. 9. National Patient Safety Goal on abbreviations clarifi ed, 2005;62(15):1559. implementation revised. Jt Comm Perspect. 2003; 23(12): 14-5. 210 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. C ommunication with and assessment of the patient is essential to every encounter. Through this process, the Paramedic gains the information needed to form a differential diagnosis and develop an appropriate treatment plan for the patient. These seven chapters provide the Paramedic with the base skills to obtain an effective history and perform a thorough physical examination. • Chapter 13: Scene Size Up and Primary Assessment • Chapter 14: Therapeutic Communications • Chapter 15: History Taking • Chapter 16: Physical Examination and Secondary Assessment • Chapter 17: Clinical Decision Making and Teamwork • Chapter 18: Communications • Chapter 19: Documentation 211 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • Thorough scene size-up • An algorithmic approach to carry out the primary assessment • Determining level of consciousness, airway, breathing, and circulation status plus treatment of life-threatening conditions • The value of vital signs Case Study: Two Paramedic crews were called to the scene of a motor vehicle versus bicycle collision. When the fi rst crew arrived, they notifi ed dispatch that there was a teenager, down on the ground, apparently unresponsive; the driver of the pickup truck was complaining of shortness of breath; and an elderly gentleman was leaning against a tree complaining of chest pain. A witness stated that the bicycle darted out from between two parked cars. She did not see an airbag deploy in the truck and didn’t believe that the truck was moving very fast as it had been stopped for a traffi c signal just before the incident. As soon as the bike was struck, she said the elderly gentleman yelled that he was his grandson and immediately slumped down against a tree. 212 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Scene Size-Up and Primary Assessment 213 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW An experienced care provider at any level may take only minutes to complete a primary assessment. However, in those moments he or she may acquire pertinent information that will dictate further care. This chapter outlines the methods used to carry out this valuable assessment. Paramedic safety and patient safety are paramount when arriving on-scene and treating the patient. Knowing how to size-up a scene reduces the risk for injury or exposure and offers an organized way to assess environmental conditions, type and number of patients, and need for additional resources. Each component is vital in determining any life-threatening conditions that require immediate interventions. Patient Assessment patients, and need for specialized resources to assist in scene management. Some of this information may be obtained, and Patient assessment is required as part of every patient con- some at least anticipated, before the Paramedic arrives at the tact. During a medical emergency, time is of the essence— scene. What was the dispatch information? Did the dispatch environmental conditions may be less than ideal, sometimes give any hints of possible scene hazards, such as fi re or haz- even dangerous, and the sights and sounds stressful. In these ardous materials? What is the area like that the Paramedic situations the Paramedic must quickly and thoroughly form is responding to? Is it possible that there may be multiple an impression of the patient’s medical condition and assess patients or the need for specialized rescue services? All of the need for any additional resources, all while continuously these issues should be considered while on the way to the assessing the safety of the scene. This requires both the sci- scene. ence of medicine and the art of crisis and resource manage- ment. Regardless of skill level,

an algorithmic approach to Scene Safety these situations will assist the Paramedic to provide assess- ment in the safest, most effi cient, most effective, and most The fi rst step in any patient assessment is to assure that the consistent manner. scene is safe to enter. Scene safety assures the Paramedic’s Initially, the Paramedic must assess the scene to evaluate well-being. An injured Paramedic is not helpful to anyone. its safety and determine the need for other resources. Next, Likewise, unsafe scenes must never be entered. The Para- she must determine the general problem, and then perform a medic must continually ask if the conditions remain safe primary assessment of the patient (Figure 13-1). enough for continued work on the scene. It must be remem- The goal of the primary assessment is to fi nd and man- bered that even dangerous scenes may initially appear safe age any life-threatening injuries or conditions the patient and that conditions may deteriorate quickly. might have by assessing for, and correcting, if possible, any When assessing scene safety, the fi rst priority should threats to airway, breathing, and circulation. Once life threats always be that of personal protection.4–7 Many of the scenes have been assessed for and managed within the skills of the where EMS is called have the potential for danger. Vehicular Paramedic, he/she identifi es patients in need of immediate crashes, industrial accidents, and rescue scenes all expose the transport.1–3 Paramedic to potential injury from moving vehicles, sharp High priority patients are generally transported surfaces, pinching or crushing hazards, and electric shock or immediately, with further assessment being performed en exposure to fi re. route. The assessment of low priority patients is typically Certain situations involve hazardous materials, toxic conducted in a more focused manner while remaining on the gasses, or an environment without adequate oxygen. These scene. If time and personnel allows for it, a full set of vital can lead to injury or death. Crime scenes and calls for assis- signs can be obtained at any point during the primary assess- tance to emotionally disturbed persons always carry the risk ment. This process should, however, never interfere with the for violence. performance of the primary assessment. Often Paramedics are injured at scenes by far less obvi- ous hazards. Falls from slips on unstable surfaces, ice, pud- Scene Size-Up dles, and unseen trip hazards are quite common. Domestic animals, often agitated by the unusual and chaotic activities Every scene that the Paramedic responds to requires an assess- at emergency scenes, have also been known to injure emer- ment of safety, environmental conditions, type and number of gency personnel. 214 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Scene size-up Initial assessment Focused history Focused history and and physical exam physical exam TRAUMA MEDICAL Mechanism Mental of injury status Significant Not Responsive Unresponsive significant Rapid trauma Focused trauma HPI Rapid assessment assessment SAMPLE physical exam Vital Vital Focused Vital signs signs physical exam signs Vital HPI SAMPLE SAMPLE signs SAMPLE Transport Transport Transport Transport Detailed physical exam Ongoing assessment Figure 13-1 Algorithm of scene size-up and primary assessment. Body Substance Isolation infection.15,16 For an in-depth review of infection control tech- niques and exposure management, please refer to Chapter 3. Along with the visible safety hazards at an emergency scene, one should always remember the unseen potential for expo- sure to blood- and airborne pathogens. The Paramedic should apply body substance isolation (BSI) precautions to all patient Street Smart encounters regardless of the suspected diagnosis. BSI cre- ates a barrier between the Paramedic and possibly infectious For hands that are not visibly soiled, waterless hand materials through the use of gloves, masks, gowns, and eye protection (Figure 13-2).8–11 Gloves should always be worn cleaner is a good option. The Paramedic should wash when the Paramedic is interacting with body fl uids, non- with soap and water as soon as time and location intact skin, and moist body surfaces.12–14 permit. The use of a mask and eye protection or a face shield to protect the eyes, nose, and mouth is imperative whenever performing procedures or patient care activities that might generate splashes or sprays of blood or body secretions. A gown should also be worn to protect skin and prevent soil- Mechanism of Injury ing of clothing whenever the possibility of splashes of blood or Nature of Illness or body secretions exists. After assuring the safety of the scene, the next step is to Proper hand washing is one of the most important assess the patient’s mechanism of injury (MOI) or the things that the Paramedic can do to prevent the spread of patient’s nature of illness. For patients who have experienced Scene Size-Up and Primary Assessment 215 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 13-2 Personal protective equipment for body substance isolation includes gloves, gown, goggles, and a mask. traumatic events, the Paramedic must determine the MOI by The Primary Assessment obtaining information from the patient, family, or bystand- ers, as well as from an inspection of the scene. The MOI is After assuring the scene is safe to enter and making a scene the instrument or event which resulted in harm to the patient. size-up, the Paramedic can begin the primary assessment. Often, the MOI is obvious, such as a motor vehicle collision The primary assessment—the fi rst evaluation performed on (MVC) or a fall. Sometimes, however, it is not so clear. every patient—is the beginning of “hands on” patient assess- When in doubt, it is safest to assume that the condition ment and is performed to address life-threatening problems. is related to trauma and take appropriate precautions to avoid The primary assessment involves forming a general worsening possible injuries which might not be immediately impression of the patient, assessing the patient’s mental obvious (Figure 13-3). status, airway, breathing, and circulation and determining When assessing the MOI, remember to note the environ- which patients require immediate transport. Any immedi- mental surroundings so as to make a report of these fi ndings ate life threats found in the primary assessment must be to hospital staff who are unable to determine these conditions addressed as they are discovered and then reassessed on a for themselves. The nature of illness is essentially the history regular basis. of present illness. Number of Patients General Impression Every scene must be investigated to determine the actual num- The fi rst step of the primary assessment is to integrate the ber of patients.17 Although this probably seems intuitive, it is not observations obtained in the scene survey into a general unusual to have “tunnel vision” and focus efforts immediately impression of the patient’s condition. The Paramedic should on caring for the fi rst patient found rather than determining if concentrate on the patient and ask himself if this patient there are more patients. It is essential to make a determination appears very ill or severely injured. Experienced providers of how many patients will need care on the scene. often can identify critically ill patients within a few seconds If there are more patients than the responding units can of entering the room (Figure 13-4). This initial impression effectively care for, then a mass casualty plan should be ini- has been called “the look test” or “gut impression” by some tiated. Any additional resources required should be called experienced clinicians attesting to the speed at which these for. In these situations, it is important for the fi rst respond- providers can determine through observation if a patient is ing unit to establish command and begin triage. A Paramedic critically ill or not. Some demographic information can also is less likely to organize an adequate response of additional be obtained by observation, and the Paramedic should note resources if directly involved in patient care activities. the patient’s approximate age, sex, and race. 216 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 13-3 Questionable mechanism of injury: The Paramedic must assume a traumatic cause until proven otherwise. Mental Status Completely normal mental status is considered to be a good indication of adequate perfusion, and therefore an important parameter to evaluate in the primary assessment.18 Upon approaching a patient, it is often fairly easy to determine a patient’s general state of consciousness. Most of the time patients will be awake and aware of the Paramedic’s approach. Of course, some patients will not be awake upon the Paramedic’s arrival, and it is important to try to determine how impaired their mentation may be. Even when a patient appears alert, it is also important to try and quantify how oriented he is to his surroundings. The abbreviation AVPU is often used to report the patient’s general level of consciousness. A stands for alert, V stands for responsive to voice, P stands for responsive to pain, and U stands for unresponsive.19 Alert If the patient’s eyes are open and he appears aware of the Paramedic, then he is referred to as alert. Any patient deter- mined to be alert should have the level of consciousness fur- ther qualifi ed by eliciting how well the patient is oriented. To determine orientation, the Paramedic commonly asks three questions relating to person, place, and time. After introductions to the patient, ask him what his name is, where he is, and what the date is. If he can correctly answer all three questions, then he is determined to be alert and oriented to person, place, and time or “alert and oriented times three.” The statement “alert and oriented times three” is often abbreviated as A&O. If the patient cannot correctly answer all three questions, then he is determined to be disoriented. It is useful for the purpose of reassessment to report which Figure 13-4 Forming a general impression. questions the patient cannot answer upon primary evaluation. Scene Size-Up and Primary Assessment 217 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. For example, the patient who is oriented to person, but unsure used for medical patients or a jaw thrust for trauma patients may of place or time, would be reported as “alert and oriented to relieve the obstruction and open the airway (Figure 13-6). Once person only.” open, the airway must be reassessed to make sure it is clear. Listen for noises such as gurgling, which may indicate fl uid in Voice the airway, or snoring or high pitch whistling, which may indi- If the patient does not seem to be awake upon approach, cate continued obstruction of the airway. If there is fl uid in the the Paramedic should attempt to awaken the patient before airway, suction should be used to evacuate it. making physical contact with him. Before closing in on the If the airway remains obstructed after positioning and patient’s personal space, the Paramedic should say in a loud suctioning,

then an attempt at repositioning the airway is clear voice, “Sir, can you hear me?” If the patient opens his warranted. If repositioning does not resolve the obstruction, eyes to the Paramedic’s voice, but shuts them again, he is then the Paramedic should consider the possibility that there determined to be responsive to voice. may be a foreign body in the airway. This obstruction must be relieved before continuing with the assessment. Pain If repositioning the airway only temporarily relieves If the patient does not awaken or respond to the Paramedic’s the obstruction, or there continues to be a partial obstruc- voice, the Paramedic should attempt to awaken him with tion, consider the use of an airway adjunct. As a general physical stimuli. The Paramedic should fi rst fi rmly tap him rule, it makes sense to start with less invasive devices such on the shoulder while asking in a loud clear voice, “Can you as oropharyngeal or nasopharyngeal airways. However, if a hear me?” If this does not arouse the patient, a more noxious less invasive device does not maintain the patency of the air- physical stimuli must be used. way, the Paramedic must consider a more defi nitive method Several techniques can be used to elicit a painful stimulus. to control the airway. One common technique is the sternal rub. The sternal rub is The Paramedic may need to consider immediate endotra- performed by applying the knuckles of one hand on the patient’s cheal intubation, a blindly placed supraglottic airway device, sternum and moving it in a fi rm, circular motion (Figure 13-5a). or a surgical airway. Remember that the patient’s survival depends on achieving and maintaining a patent airway.21 Other methods include squeezing the trapezius muscle on either side of the base of the neck (Figure 13-5b), applying pressure above the eyes (supraorbital pressure—Figure 13-5c), or pres- Breathing sure with one fi nger to the soft area just behind the angle of the Once the airway has been determined to be patent, assess- mandible (Figure 13-5d). The Paramedic assesses for purpose- ment should continue to evaluate the adequacy of the patient’s ful movement by the patient to stop the painful stimulus.20 breathing. The Paramedic should also check for any possible threats to adequate breathing. To remember what to assess, Unresponsive think “Look, listen, and feel.” If the patient does not respond in any way to verbal or painful Look stimuli, then he is considered unresponsive. The unresponsive patient is considered to be very ill until proven otherwise. The chest should be exposed enough to inspect for wounds and for the work of breathing. Any open wounds on the chest Airway wall should be immediately covered to prevent the potential After determining the patient’s level of consciousness, the Paramedic must next assess the status of the patient’s airway. If the patient is conscious and alert, then the airway is most Cultural / Regional differences likely being maintained without diffi culty. The Paramedic should confi rm this assumption by observing the patient’s The chest must be exposed to allow a visual exam effort to breathe and listening to the patient’s speech. If the patient has normal speech and noiseless, effortless for wounds and effort of breathing. Additionally, the breathing, then the airway is patent and unlikely to need any stethoscope should be placed directly on the skin. immediate interventions. If the patient is not awake or has Efforts should be made, whenever possible, to protect noisy or diffi cult breathing, then the airway must be further the patient’s modesty. A sheet or towel can be loosely evaluated for possible obstruction. The number one cause of airway obstruction is simply the patient’s tongue. placed over the patient’s chest or a bystander can The protective refl ex and muscle control of the upper air- be employed to hold a sheet up as a visual barrier. way decreases as the level of consciousness decreases. This loss Depending upon local custom, it may be prudent to of control leads to relaxation of the soft tissues of the pharynx and occlusion of the upper airway. The ability to swallow is have a Paramedic of the same gender, if available, affected and this condition leads to a buildup of airway secre- examine the patient. tions. Simple positioning maneuvers such as a head-tilt chin-lift 218 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (a) (b) Figure 13-5 Methods used to assess response to painful stimulus: (a) Sternal rub (b) Trapezius squeeze. for sucking chest wounds. Bruising should be noted as it may painful, can cause decreased ventilation, and should be stabi- be a sign of signifi cant underlying injury. lized as soon as possible. The Paramedic should also observe If two or more ribs are broken in two or more places, the the chest to determine the respiratory rate.22,23 segment may move out when the chest wall moves in with Ventilatory rates which are either too fast or too slow exhalation and in when the chest wall moves out with inspira- will not allow for adequate gas exchange in the lungs. If tion. The paradoxical movement of this fl ail segment is quite the patient’s ventilatory rate is less than 10 or greater than Scene Size-Up and Primary Assessment 219 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. (c) (d) Figure 13-5 Methods used to assess response to painful stimulus: (c) Supraorbital pressure (d) Mandibular pressure. 30 breaths per minute, then the Paramedic should consider the possible need for ventilatory support. Listen A quick way to ascertain that the patient’s respiratory After inspecting the chest, the Paramedic should listen to the rate is between 10 and 30 is to observe the chest and start chest with a stethoscope to determine the effectiveness of counting the seconds between the fi rst breath and the second. air movement. At this point in the assessment it is important If the time between the fi rst and second breath is 6 seconds to determine that air is entering each lung and that the air or greater, then the respiratory rate is 10 breaths per min- entry is equal on both sides. The best place to listen during ute or less. If the time between the fi rst and second breath is the primary assessment is just below the axilla on each side 2 seconds or less, then the respiratory rate is 30 breaths per (Figure 13-7). One inhalation/exhalation cycle is generally minute or more. enough to assess the depth and equality of breath sounds. 220 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Paramedic should make note of any unusual or abnormal breath sounds heard, but a full assessment of breath sounds can be made later after life threats are ruled out. If air exchange is inadequate, all measures should be taken to correct the defi cit. The patient may require positive pressure ventilation, thoracic decompression, or medication adminis- tration to correct problems. Feel After listening to the chest to assure adequate and equal air entry, the Paramedic should palpate the chest to assess for potential life threats. Place a hand on each side of the chest and feel full inspiration and expiration. If the patient is conscious, ask her to take a deep breath and ask about pain. While palpating the chest, evaluate for tenderness, crepitus, or subcutaneous air. Any of these conditions may indicate a signifi cant underlying chest injury. Also feel for equal expan- sion of the chest wall. Circulation After securing the patient’s airway and breathing, the next step in the primary assessment is to evaluate the effectiveness of circulation. As with the airway and breathing steps, any life threats discovered must be corrected whenever possible during the primary assessment. Pulse The Paramedic should evaluate the presence of a radial pulse. If a radial pulse is present, it is reasonable to assume that the Figure 13-6 Assessing the airway can be patient’s blood pressure is adequate to supply perfusion to simplifi ed to the mantra “Look, listen, and feel.” that peripheral site.24,25 If there is no radial pulse, immediately Figure 13-7 Auscultation of lung sounds at the axilla during the primary assessment. Scene Size-Up and Primary Assessment 221 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. assess the carotid pulse. If the carotid pulse is present, but assessment. However, a complete and accurate set of vital the radial pulse is not, the patient’s blood pressure should be signs can be a useful triage tool to estimate the severity of the assumed to be quite low. patient’s condition. Some life-threatening conditions can be identifi ed by the Bleeding vital sign abnormalities they cause. Taking vital signs at this After assessing for the presence and quality of pulses, the time establishes a set of baseline vital signs to which all sub- next step is to check for external bleeding. Any active bleed- sequent vital signs are compared. ing should be further evaluated and any life-threatening hem- All other sets of vital signs taken are considered to be orrhage must be corrected immediately whenever possible. serial vital signs and are useful to illustrate trends in vital With gloved hands, the Paramedic should sweep under sign changes. For example, a low normal blood pressure dis- all non-visible parts of the patient’s body and expose the covered when the fi rst set of vital signs is taken is not as sig- patient enough to assure that any external bleeding site can nifi cant as a blood pressure which gets slightly lower with be adequately assessed (Figures 13-8). each measurement. After assessing for the presence of external bleeding, the A set of vital signs should include, at a minimum, an patient’s skin should be evaluated for signs of internal bleed- assessment of pulse, respirations, and blood pressure.26 ing. Pale, cool, and clammy skin may be signs of signifi cant hypoperfusion. Sick or Not Sick: Vital Signs Priority Decision Making As time, available personnel, and patient condition allows, Once the primary assessment has been completed, the Para- a full set of vital signs should be taken during the primary medic must make a determination of the patient’s priority. assessment. In no way should obtaining vitals take prece- This determination is made by integrating all of the fi nd- dence over—or interfere with—the completion of the primary ings gathered in the primary assessment to make a decision Figure 13-8 A Paramedic performing a sweep for blood during the primary assessment. 222 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves

the right to remove additional content at any time if subsequent rights restrictions require it. whether or not the patient has any life-threatening complaints Those patients who are not determined to have poten- which would require immediate, rapid transport to the hospi- tial life threats may be considered low priority and should tal (Table 13-1). These patients are considered high priority have full assessment and any necessary treatments performed patients and require that only life-saving interventions and on the scene prior to being packaged for transport. Although appropriate packaging take place before they are expedi- scene time should never unnecessarily be delayed to com- tiously moved to the hospital. plete these tasks, it is appropriate to spend time on-scene All other assessments and interventions performed on with these patients managing their condition as local medical high priority patients should take place en route to the hospi- authority allows. tal. This type of patient generally receives a minimal amount of interventions while on scene. Focused History Table 13-1 Clues to Life-Threatening Conditions and Physical Exam • Poor general impression Once the primary assessment has been performed and a pri- • Unresponsiveness ority determined, the appropriate focused history and physi- • Decreased level of consciousness cal exam may be performed. For medical patients who are responsive, the Paramedic should conduct a focused history • Diffi culty breathing and physical exam. For unresponsive patients, the Paramedic • Shock (Hypoperfusion) should use a rapid physical exam. • Complicated childbirth For trauma patients with signifi cant mechanism of injury, • Chest pain the Paramedic should carry out a rapid trauma assessment • Uncontrolled bleeding with a detailed physical exam being performed en route to the • Severe pain anywhere hospital. For trauma patients without signifi cant mechanism • Multiple injuries of injury, the Paramedic should conduct a focused trauma assessment. Scene Size-Up and Primary Assessment 223 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. As described in this chapter, the Paramedic’s assessment starts the moment she pulls onto the scene. Observation skills are key to rapidly identifying hazards, determining if additional resources are needed, and determining when to move quickly into a rapid transport mode with a critically ill patient. Key Points: • Patient assessment is necessary for each patient • A patient alert to voice will respond to verbal stimuli. contact and offers an algorithmic approach to quickly and thoroughly form an impression of the • A patient who is not responsive to voice but patient’s condition; determine the need for any responds to a painful stimulus is said to be alert to additional resources, and continuously assess the pain. safety of the scene. • A patient that does not respond in any way to • The primary assessment is the fi rst “hands on” verbal or painful stimuli is considered unresponsive. assessment of the patient and is performed to • A patient with normal speech and noiseless, address life-threatening problems. effortless breathing has a patent airway. • Responding to an emergency requires an • The patients’ airway may be obstructed by the tongue, assessment of safety, environmental conditions, foreign body object, or buildup of airway secretions. type and number of patients, and need for specialized resources. • In opening the airway, consider simple positioning • fi rst. Use suction as needed. Scene safety is the fi rst priority before initial patient contact. • Evaluate the need for airway adjuncts such as oro- or • nasopharyngeal devices or more invasive devices such The Paramedic should use body substance isolation as an endotracheal tube or alternative airway device. (BSI) precautions in all patient encounters regardless of the suspected diagnosis. • After an airway is established, assess depth, rate, • and effort of breathing. Proper hand washing is one of the most important things that the Paramedic can do to prevent the • After auscultation of the chest, the Paramedic spread of infection. should inspect the chest for wounds such as • bruising or fl ail segments as well as tenderness, The Paramedic must determine the mechanism of crepitus, or subcutaneous air. injury (MOI) for patients who have experienced traumatic events. • If the patients’ respiratory rate is less than 10 or greater than 30 breaths per minute, ventilatory • The Paramedic must determine the number support may be needed to treat inadequate gas of patients in order to determine if adequate exchange in the lungs. resources are available. • The presence of a radial pulse represents a blood • Regardless of whether the patient appears alert, pressure that is adequate to supply perfusion to the Paramedic should quantify orientation to that peripheral site. surroundings. • Circulation also includes evaluating for any active • Alert refers to responding appropriately to bleeding or life-threatening hemorrhage that must questioning relative to person, place, and time. be corrected immediately whenever possible. 224 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. In addition, skin color, temperature, and condition must make a determination of the patient’s should be noted. priority. • Vital signs are assessed to establish a baseline to • After an primary assessment is performed and a which all subsequent vitals are compared. priority is determined, the Paramedic may perform • appropriate further exams. After integrating all of the fi ndings from the primary assessment, the Paramedic Review Questions: 1. What is the primary goal of the primary 6. Name four different painful stimuli that assessment? can be used to determine a patient’s level of 2. When the Paramedic arrives on-scene, what consciousness. should be assessed? 7. After performing a head-tilt chin-lift on the 3. Who is the Paramedic responsible for while nontraumatic patient, ventilations on the on-scene? unconscious patient do not go in. What 4. Name the pieces of personal protective should be done? equipment the Paramedic can use for body 8. What does a weak and thready radial pulse say substance isolation. about a patient’s perfusion? 5. Describe what the Paramedic is looking for 9. What is included in a complete set of vital signs? when conducting the “look test.” 10. What information is used to assign a priority to the patient’s transport? Case study Questions: Please refer to the Case Study at the beginning of 2. Describe the primary assessment of the three the chapter and answer the questions below. different patients. 1. Describe the scene size-up needed for this 3. Name the further exams that will be conducted incident. for each of the three patients. References: 1. Koenig KL. Quo vadis: “scoop and run,” “stay and treat,” or 5. Corbett SW, Grange JT, Thomas TL. Exposure of prehospital “treat and street”? Acad Emerg Med. 1995;2(6):477–479. care providers to violence. Prehosp Emerg Care. 1998;2(2): 2. Seamon MJ, Fisher CA, Gaughan J, Lloyd M, Bradley KM, 127–131. Santora TA, et al. Prehospital procedures before emergency 6. Grange JT, Corbett SW. Violence against emergency department thoracotomy: “scoop and run” saves lives. J Trauma. medical services personnel. Prehosp Emerg Care. 2007;63(1):113–120. 2002;6(2):186–190. 3. Cone DC, Wydro GC. Can basic life support personnel safely 7. Neely KA. Scene control in prehospital care. Top Emerg Med. determine that advanced life support is not needed? Prehosp 1987;9(1):79–86. Emerg Care. 2001;5(4):360–365. 8. Carrillo L, Fleming LE, Lee DJ. Bloodborne pathogens risk and 4. Eckstein M, Cowen AR. Scene safety in the face of automatic precautions among urban fi re-rescue workers. J Occup Environ weapons fi re: a new dilemma for EMS? Prehosp Emerg Care. Med. 1996;38(9):920–924. 1998;2(2):117–122. Scene Size-Up and Primary Assessment 225 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 9. Marcus R, Srivastava PU, Bell DM, McKibben PS, Culver 18. Limmer D, Monosky K. Assessment of the altered mental status DH, Mendelson MH, et al. Occupational blood contact among patient. Emerg Med Serv. 2002;31(3):54–58, 81. prehospital providers. Ann Emerg Med. 1995;25(6):776–779. 19. Gill M, Martens K, Lynch EL, Salih A, Green SM. Interrater 10. Eustis TC, Wright SW, Wrenn KD, Fowlie EJ, Slovis CM. reliability of 3 simplifi ed neurologic scales applied to adults Compliance with recommendations for universal precautions presenting to the emergency department with altered levels of among prehospital providers. Ann Emerg Med. 1995;25(4): consciousness. Ann Emerg Med. 2007;49(4):403–407, 512–515. 407, e401. 11. Hellinger WJ, Gonsoulin SM. Risking everything. EMTs, 20. Mistovich JJ, Krost W, Limmer DD. Beyond the basics: patient universal precautions, and AIDS. Jems. 1998;23(7):56–59. assessment. Emerg Med Serv. 2006;35(7):72–77; quiz 78–79. 12. Lund S, Jackson J, Leggett J, Hales L, Dworkin R, Gilbert D. 21. Krost WS, Mistovich JJ, Limmer D. Beyond the basics: airway Reality of glove use and handwashing in a community hospital. assessment. Emerg Med Serv. 2006;35(1):85–89; quiz 90–91. Am J Infect Control. 1994;22(6):352–357. 22. Pettiford BL, Luketich JD, Landreneau RJ. The management of 13. Kaczmarek RG, Moore RM, Jr., McCrohan J, Arrowsmith-Lowe fl ail chest. Thorac Surg Clin. 2007;17(1):25–33. JT, Caquelin C, Reynolds C, et al. Glove use by health care 23. Davignon K, Kwo J, Bigatello LM. Pathophysiology workers: results of a tristate investigation. Am J Infect Control. and management of the fl ail chest. Minerva Anestesiol. 1991;19(5):228–232. 2004;70(4):193–199. 14. Wolfe FD. Wearing gloves: is it protection or punishment? Rdh. 24. McManus J, Yershov AL, Ludwig D, Holcomb JB, Salinas 1998;18(9):22–24, 26, 30 passim. J, Dubick MA, et al. Radial pulse character relationships to 15. Larson EL, Quiros D, Lin SX. Dissemination of the CDC’s Hand systolic blood pressure and trauma outcomes. Prehosp Emerg Hygiene Guideline and impact on infection rates. Am J Infect Care. 2005;9(4):423–428. Control. 2007;35(10):666–675. 25. Benson M, Koenig KL, Schultz CH. Disaster triage: START, 16. Bubacz MR. Community-acquired methicillin-resistant then SAVE—a new method of dynamic triage for victims Staphylococcus aureus: an ever-emerging epidemic. Aaohn J. of a catastrophic earthquake. Prehosp Disaster Med. 2007;55(5):193–194. 1996;11(2):117–124. 17. Zoraster RM, Chidester C, Koenig W. Field triage and patient 26. Mistovich JJ, Krost WS, Limmer DD. Beyond the basics: maldistribution in a mass-casualty incident. Prehosp Disaster interpreting vital signs. Emerg Med Serv. 2006;35(12):194–199; Med. 2007;22(3):224–229. quiz 200–201. 226 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is expected that the reader will understand these following concepts: • The process of effective communication • Cultural competence when serving others • Defi nitions of space • Common strategies for establishing patient rapport • Interview techniques for the Paramedic Case Study: Paramedics were called to the home of Susan Garratt for her 22-month-old daughter, who had fallen from the swings and injured her

leg. When they arrived, the toddler was crying and wouldn’t let her mother touch her right leg. The new Paramedic spoke to Mrs. Garratt but she didn’t turn toward him. He yelled her name, which caused the toddler to cry even harder. His partner quickly wrote a short note which asked, “Are you deaf? If so, do you sign or read lips?” Mrs. Garratt appeared relieved and her answer to the questions was, “Yes I am deaf and I do both.” The Paramedic then introduced himself by name and function using both sign language and voice, which was normal toned and well articulated. The interview proceeded smoothly and the child was transported for evaluation of an injured ankle. Later, the new Paramedic inquired as to where his partner had learned sign language. His reply was, “The community college.” 228 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Therapeutic Communications 229 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Communication goes beyond articulate speech and good handwriting. The Paramedic’s actions, as well as those of the patient, can speak louder than words. This chapter examines how the Paramedic can be compassionate and understanding while still effectively performing his duties. The Paramedic must also be able to recognize nonverbal behaviors and establish patient rapport. To make the most of patient communication, several interview techniques are discussed. Therapeutic Communications the communication and improves the chance that the message conveyed and the message received are the same. Carefully chosen words and a gentle hand on a patient’s shoulder—actions which bring comfort to a patient—help Encoding defi ne Paramedics as compassionate caregivers. Caregivers are aware of the limitations of medicine to cure disease and Before conveying the message, the Paramedic needs to reduce suffering as well as the power of interpersonal com- assemble the message carefully. Ill chosen words can send munication as a therapeutic tool. As healthcare providers, an incorrect message to the patient and can also elicit an Paramedics bring both high touch as well as high technology unwanted response. to the patient’s bedside. Take the word “pain,” for example. All patients have some pain history. When the word “pain” is used it can sub- Human Communications consciously bring back memories of prior painful events. As a result, the patient’s sympathetic nervous system responds to People communicate with one another directly through the stimulus (i.e., fear engendered by the word “pain,”) and speech (verbal) or indirectly, through a medium such as the causes the patient’s heart rate and blood pressure to rise. The written word, in order to convey a message. For the commu- word “discomfort,” on the other hand, does not necessarily nication to be successful, the message must fi rst be encoded, conjure the same memories. Therefore, the word may be less transmitted by the sender, then received and decoded by the infl ammatory than pain and allows the patient to avoid the receiver (Figure 14-1). This process, which occurs similarly physiological response that the word “pain” elicits. in radio communications, can experience transmitter failure, Dr. Gnatt, of Johns Hopkins Medical School, has studied interference, and poor reception. Identifying those problems the human physiological response to words and has advanced and resolving them before they occur improves the quality of the theory of schizokinesis.1,2 A student of Ivan Pavlov, Dr. Gnatt’s theory suggests that past painful experiences, unconsciously recalled by trigger words, can elicit an auto- Sender Encodes nomic nervous system response. In some cases, this response message could be harmful to the patient. Street Smart Examples of words that trigger a negative response Message Speaking include the statement “he’s walking with a time bomb Feedback Listening in his chest,” or “those are tombstone ST changes on Gesturing Writing the ECG.” Whether intended for the patient’s ears or not, the effect is the same. The patient is left to feel fearful. Transmission Receiver The process of conveying a message, its transmission, can Decodes message be either a true and accurate representation of the sender’s Figure 14-1 The process of communications. thoughts (i.e., the message expressed is the message meant 230 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to be conveyed) or may be conveyed in such a way that the patient to have an altered mental status can interfere with the meaning is misconstrued by the receiver. Factors that affect patient’s ability to decode the message. whether a message’s transmission is true include the choice of words as well as the sender’s body language. Body language Feedback is the transmission of a message by nonverbal visual cues. Feedback is the mechanism by which the Paramedic can Experts suggest that 70% of any spoken message is conveyed ensure that the message sent was the message received and by body language. Body language is important and discussed decoded; that is, the message heard was the message sent. in more detail shortly. Feedback is obtained by asking the patient some simple questions. Reception To use feedback effectively, the Paramedic must practice Factors that infl uence the receiver’s reception of the message, active listening. It has been estimated that the average person what the patient understands the message to be, include both can hear 500 words per minute yet can only speak about 125 physical and cultural infl uences. An example of a physical to 150 words per minute. Therefore, in an average conversa- infl uence that would have an impact on the message’s recep- tion the listener is only listening, receiving, and decoding the tion is the presence of pain. The patient in pain tends to be spoken word about one-third of the time. The remainder of the self-absorbed and shuts out the outside world. Therefore, pain time the listener is left to think. The active listener uses that can be a powerful distracter that interferes with the patient’s time to note nonverbal cues such as body language, as well as reception of the message. To get the patient’s attention it may cognitive gestures, such as facial expressions and fi dgeting, be necessary to speak loudly or to fi rst provide some form of to add depth of comprehension to the feedback. analgesia to remove the pain. To practice active listening skills, the Paramedic should Cultural infl uences, in the form of customs, and language stop talking. Interruptions are disruptive to the communica- barriers can also affect the reception of the message. For tion process. The Paramedic should also take a non-defensive example, a person of Japanese descent may nod in agree- posture, with arms open, and a genuine look of interest on the ment. However, the nod may be a consequence of respecting Paramedic’s face. The Paramedic should proceed to ask clari- authority rather than of understanding. In such a case, the nod fying questions which add detail to the patient’s responses. may not mean that the patient understands the message sent The use of encouraging words, such as “I understand,” and by the Paramedic. hand gestures will encourage the patient to be forthright with answers. Decoding An intangible in the process of communication is the receiv- er’s ability to understand, or decode, the message. That ability to decode a message is based upon intelligence, the person’s Street Smart basic knowledge of language, life experience (which varies from person to person), and maturity, among many other Patients expect Paramedics to take notes.6 It would be variables. unreasonable for a Paramedic to remember everything The statement “I know what you heard, but that’s not that was said. However, when the Paramedic appears what I said,” illustrates how two people can take two different meanings from the same statement. Many humorous stories to be “treating the clipboard” (taking more interest in have been told of children who hear an allegorical message completing a form than what the patient has to say), and take it literally. the patient tends to ignore the Paramedic. An obstacle to decoding the message is the use of medi- calese. Paramedics who choose to use medical terminology when speaking to patients are at risk of being misunder- stood or not understood at all. During a Paramedic–patient c onversation, the Paramedic should attempt “double–speak,” Hermeneutics offering lay terms to explain medical terminology to the The overarching goal of communications is to obtain clini- patient. Then it will be easier for the patient to understand cally relevant information about the patient so that a diagno- what is being said. sis can be made and treatment offered. Key to decoding the message is the patient’s mental Key to a successful interview is for the Paramedic to put capacity. Medical conditions, such as stroke, can impair the himself in the patient’s situation, with all of the accompany- patient’s ability to decode the message, a condition called ing physical and cultural infl uences, in order to understand receptive aphasia. the patient better. This approach is called hermeneutics. Other conditions that can impair the patient’s ability to By taking a “fi rst person” perspective, the Paramedic understand include hypoxia, hypoglycemia, hypoperfusion, gains understanding, as well as empathy, for the patient’s and poisoning.3-5 In fact, any condition which causes the plight. Therapeutic Communications 231 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Improving Communications Paramedics who view their own cultural practices and customs as superior, a form of ethnocentrism, may have dif- Improving communications starts with an awareness of fi culty communicating with people from other cultures. p ersonal factors which have an impact on communications. A person’s education also can have a great deal of infl u- Everyone is shaped and changed by personal life experience; ence over one’s ability to communicate. It is estimated that these infl uences and experiences, in turn, color our p erception 50% of the U.S. population communicate at or below the of ourselves and other people. By being self-aware, hav- eighth-grade literacy level.8 ing a conscious understanding of one’s life infl uences and To be culturally aware, the Paramedic must fi rst be aware prejudices, the Paramedic can factor those infl uences into the of all of his or her own biases and attempt to eliminate their process, suppress negative infl uences, and augment positive impact upon the Paramedic–patient interaction. Bias can infl uences. not only prevent effective communication but it can cause A key feature of self-awareness is the person’s physical the patient to mistrust the Paramedic and thus harm the being, which is a manifestation of one’s genetics. A person’s Paramedic–patient relationship. genetic make-up—those physical characteristics that make up a person, including appearance, disposition, and so on— Interview Techniques can have a tremendous impact on one’s outward appearance. For example, a man who has a large stature and stands over The goal of every patient communication is to be complete, six feet tall may appear to be very intimidating to a short clear,

concise, courteous, and cohesive. A number of tech- elderly woman. The self-aware Paramedic compensates for niques can help improve the probability of success. this by kneeling on one knee, bringing himself to the patient’s When approaching a patient, the Paramedic should make eye level. an estimate of the degree of distress that the patient is pres- Culture, that culmination of life experiences in a local- ently experiencing in order to modify his or her approach ity or region that affects the way a person thinks and behaves, to the patient. For example, the patient “in extremis” is not also has an impact on how the Paramedic acts toward, and likely to want long-winded conversations about past medical is perceived by, the patient. The self-aware Paramedic is not history. On occasion, it is better to reassure the patient that only aware of how culture affects behavior but also is aware relief is coming and that conversation, for the moment, is not of how the patient’s culture infl uences the patient’s interaction needed. with the Paramedic. However, in most cases the patient is not in extreme Culture relates in part to countries and areas within coun- distress and the Paramedic needs to engage the patient in a tries. There are tremendous variations among people from a meaningful conversation to ascertain a symptom pattern for particular region. For example, among the fi rst Americans, diagnostic determination. the native American population, there are over 700 different cultures. People of Asian descent originally came from over a dozen countries. One cannot identify a person as being of a particular culture based simply on one characteristic. Cultural / Regional differences It is estimated that over 14% of the United States popu- lation, or 31.8 million Americans, do not speak English as their primary language.7 In New York and California, it is The Paramedic must take care in judging a degree of estimated that 30% of the population speak Spanish. This distress. Many persons express their culture’s stoicism cultural diversity makes communications a formidable chal- in the face of discomfort while others are more vocal lenge to the Paramedic. or effusive. Cultural / Regional differences Proxemics While language is an important component of culture, The physical distance between a Paramedic and a patient dur- ing the history gathering can have either a positive impact or simply speaking the same language does not mean a chilling effect on the dialogue. The idea that interpersonal persons are of the same culture. People from South distance affects communication was advanced in a theory by and Central America may speak Spanish as the primary Edward T. Hall in 1959. Dr. Hall studied the effect of inter- language but their cultures are very different from personal space upon communications and advanced the the- ory of proxemics.9 that of Spain. In many cases their cultures are quite The theory of proxemics is based on the concept of four different from each other. spaces that surround a person. The fi rst space, the intimate 232 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. space, about the size of a beach blanket or one-half to one and Kinesics one-half feet, is that space where patients feel most vulner- Dr. Ray Birdwhistell suggested that body language may consti- able. Entry into that space is only permitted to those people tute 70% of a person’s interpersonal communication.10,11 This whom the patient trusts. All Paramedics must work toward statement makes it clear that effective communication is more being permitted into that intimate space in order to perform than just the spoken word (Figure 14-3). A Paramedic should invasive treatments and routine patient care. be aware of the messages, intended and unintended, which the The second space is the personal space, that area where body language is sending to the patient. A knowledge of kine- a patient would engage in a one-on-one conversation. The sics, the study of nonverbal behavior for communications, can personal space, about one and one-half feet to four feet, is help the Paramedic improve communication skills the distance within which most Paramedics initially interview The simplest example of kinesics might be nodding one’s patients for a history. head yes or shaking one’s head no. However, kinesics includes The third space is the social space, an area of relative all the movements of the body including facial expression, pos- safety where strangers can enter, with certain expectations of ture, stance, and gestures. Understanding the concepts of kine- conduct. A dining room in a restaurant is an example of the sics, a Paramedic knows that standing above a seated patient use of social space, where everyone is expected to eat politely and speaking down to the patient is conveying a message of and maintain a conversational tone. superiority or strength. This position may be counterproduc- The fourth space, greater than 12 feet, is called the pub- tive to the task at hand (e.g., gathering a patient history). lic space. It is that area one would occupy with a stranger Similarly, when a Paramedic, unwittingly or purposefully, without fear but with an ability to fl ee if danger should arise blades a patient (stands in front of but at a tangent to the patient) (Figure 14-2). to limit exposure and in preparation for a fi ght or fl ight, the When walking in a public space (e.g., in a shopping Paramedic is telegraphing the patient a message of distrust. mall), people become immediately aware of an unknown per- Gestures and mannerisms can also have unintended son who is closing the public space and entering the social meanings. For example, most patients will perceive fi nger- space. The expectation is that the person will step aside and pointing as an aggressive act and that fi nger-tapping is a sign allow the other person to pass unhindered. of impatience. The O.K. sign made with the thumb and fore- Dr. Hall’s theory of proxemics is based upon American fi nger means alright in New England. However, the O.K. sign cultural practices and traditions. A Paramedic must also be in Japan means money and in France means zero. Perhaps aware of other cultures which may have larger spaces. An more alarming, the O.K. sign is an insult in Brazil and Turkey. area that a Paramedic might consider a social space may be Lacking knowledge of the patient’s background and heritage, perceived by the patient as within the personal space. it is best not to use hand gestures and other mannerisms dur- Similarly, when a person (e.g., a mental health patient) ing patient care. feels threatened, the distances tend to grow larger. Intimate space, normally defi ned as one to one and one-half feet, might be four feet for a patient with schizophrenia. Invading Compassionate Touch that intimate space may result in violence. Nurses have known about the power of the human touch to bring comfort and solace to patients for years. Whether in the form of handholding, stroking a forearm, or rubbing a back, the compassionate touch is very human and therapeu- Intimate Personal Social tic. Studies performed in critical care units have shown that (1.5 ft) (4 ft) (9 ft) intracranial pressure, heart rate, and blood pressure can lower toward normal with compassionate touch. Dr. Dolores Krieger, RN, has researched and spoken about the power of touch to heal, or therapeutic touch.12,13 Dr. Krieger states that therapeutic touch is fi rst established in the human experience when a mother strokes the soft cheek of a distressed infant. It is developed throughout life dur- ing interactions with others. Therapeutic touch is intentional touching that mimics these earlier experiences and telegraphs reassurance, understanding, and caring to the patient. Paramedics should consider using therapeutic touch, such as hand-holding, to help calm patients and as a means to transmit a message of compassion to the patient. The key to success with therapeutic touch is to recognize the opportu- nity and to intervene at that time. However, some caution is advised. Misapplied, therapeutic touch can be perceived as an Figure 14-2 Proxemics illustrated. unwanted intrusion into the patient’s privacy. Therapeutic Communications 233 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 14-3 Body language often speaks louder than words. Hearing Impaired subconsciously fi lter out ambient background noise, the hearing aids of the hearing impaired amplify all noise. The Conveying a message to the patient who is either hearing resulting mass of noise is diffi cult for the patient to decipher impaired or hard of hearing (HOH) requires the Paramedic into an intelligent message. to take deliberate action. While communicating with the Having identifi ed that there may be a potential impediment hearing impaired can be diffi cult, demanding patience and to communication (i.e., that the patient is hearing impaired), persistence from the Paramedic, the end result (improved the Paramedic should be especially conscious of the mes- communication) ultimately results in better patient care. sages being sent to the patient by body language. Patients The fi rst step in communicating with this patient popu- with a hearing impairment often utilize facial expressions, lation is recognizing that the patient is hearing impaired. In hand gestures, and the person’s general posture to assist in some cases the patient may be forthright and tell the Para- ascertaining the meaning of a message. medic that he is hearing impaired. In other cases subtle clues, Next, the Paramedic should attempt to gain the patient’s such as inattention to the Paramedic during a conversation or attention before speaking. Sitting directly in front of the inappropriate answers to questions, may lead the Paramedic patient is often all that is needed to get the patient’s attention. to suspect that the patient is hearing impaired. The Paramedic should be cautious about tapping the patient If the patient is hearing impaired, the Paramedic should inquire if the patient can read lips, uses sign language, or would prefer to write down his or her responses. If the patient is a lip reader then the Paramedic should Street Smart position himself in front of the patient, so that his lips can be clearly seen, and enunciate words carefully. Some EMS services have special language boards available to improve Some patients with a hearing impairment have communication with the hearing impaired patient. working dogs. These working dogs listen for and Whenever possible, the Paramedic should consider protect their masters; they are the ears of their moving the patient to a quiet area or attempt to elimi- nate background noises, such as squawking radios or idle masters. It is inappropriate to touch or pet a working conversation. While hearing people automatically and dog without the master’s permission. 234 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. on the shoulder or waving his hands in front of the patient’s communications, some EMS services have special language face. These actions could be misconstrued as aggressive. If boards available for use by the Paramedic. These language needed, a simple touch of the hand or forearm will get the boards provide visual cues that permit the Paramedic and the patient’s attention. patient to communicate quickly. When speaking to the patient, the Paramedic should speak slower than normal, carefully enunciating words, and

avoid putting her hands in front of her face. The Paramedic should avoid the use of “yeah” or “nah” as these two words are diffi cult to distinguish. Instead, the Paramedic should Street Smart clearly say “no” or “yes,” taking time to enunciate (hiss) the letter s. When possible, the Paramedic should move the The Paramedic should avoid the temptation to shout. patient with a hearing aid indoors or to the back Shouting not only makes the Paramedic appear impatient but of the ambulance. The blowing wind generates a also strains the vocals cords, thereby distorting sounds and making comprehension more diffi cult. whistling sound in the ear of the patient, making it The Paramedic may want to inquire if the patient can read almost impossible for the patient to hear what is said. lips. If the patient is a lip reader then the Paramedic should position herself in front of the patient, so that the lips can be clearly seen. It is important that the Paramedic’s face be well- lighted so that the patient can clearly see the Paramedic’s Introductions lips. A common error made which can reduce the visual cues It is not only a common courtesy to introduce oneself to a available is standing in front of a window or a light source. patient, but it is a professional responsibility for the Para- The result is that the Paramedic is silhouetted and the Para- medic to advise the patient who he is and what qualifi cations medic’s face cannot be seen clearly. he possesses to care for the patient. Some states even mandate After the message has been conveyed to the patient, the that all healthcare providers identify themselves to the patient Paramedic should ask the patient to repeat the message back. by name and title. Frequently this can be accomplished by use This “echo” technique helps to ensure that the intended mes- of identifi cation tags or name badges. sage was transmitted and the patient understands. But for the professional Paramedic, it is more than com- In some cases a hearing interpreter may accompany pliance with the law. The tradition of introducing oneself the patient. If the patient has an interpreter, the Paramedic helps to set the groundwork for future dialogue between the should introduce herself to the interpreter and briefl y dis- patient and the Paramedic. Some Paramedics prefer to shake cuss the intent of the conversation. Even though the inter- the patient’s hand, a generally accepted activity that is seen as preter is present, the Paramedic should still speak directly nonthreatening. Besides conveying a message of goodwill, to the patient. The interpreter will then use American sign the Paramedic has the fi rst opportunity to assess the patient’s language or signed English to convey the message to the physiologic state. Cold and sweaty palms may indicate shock patient after the Paramedic is done speaking. The Para- while a weak grasp may indicate exhaustion. When the cour- medic should speak in short sentences and then allow time tesy is returned and the patient gives the Paramedic his name, for translation. After receiving the message, the patient will the Paramedic can further assess the patient’s speech and use sign language to speak to the interpreter and then turn to mental status. face the Paramedic as the interpreter translates the message to the Paramedic. If the patient has diffi culty understanding the message, the Paramedic should repeat the question or restate the mes- Street Smart sage in other words. A large number of hearing aids are available for the hear- The Paramedic should inquire as to the patient’s ing impaired patient including those that are worn behind the ear (BTE) and in the ear (ITE). If the patient has a hearing preferred manner of address. If the patient states that aid, then the Paramedic should talk to the side of the patient his name is Joe Smith, the Paramedic can immediately in which the hearing is best; the patient often indicates this ask if he prefers Joe or Mr. Smith. by turning that side of the head toward the Paramedic. It is appropriate to ask the patient if he or she has a good side and then to direct conversation to that side. In some cases, the easiest method of communication is to The saying goes that a “picture is worth a thousand write down the message. While time-consuming, this method words.” The image of the patient seated in a chair, obtained can help reduce errors. The Paramedic should write plainly during the introduction, helps the Paramedic immediately and avoid the use of cursive handwriting. To facilitate visual gauge the severity of the illness or injury (Figure 14-4). Therapeutic Communications 235 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Figure 14-4 A Paramedic’s fi rst opportunity for assessment. Selecting the Correct Questions Using Proper Tone The Paramedic should carefully select questions that The tone of voice is thought to transmit some 23% of the spo- maximize patient information and provide for a free fl ow of ken message (the remaining 77% is left to the actual words dialogue. The Paramedic may elect to use either open-ended spoken). When talking to a patient, the Paramedic should be questions or closed-ended questions to obtain the patient’s aware that the infl ection of the voice can transmit a meaning history during the interview. Each type of question has altogether different than the one intended. its merits. Open-ended questions allow the patient to express himself without restriction and the answers can be used as a Encouraging Behaviors springboard to other questions. Open-ended questions usu- By practicing certain behaviors, a Paramedic can help facili- ally begin with words like “how,” “what,” or “could” and tate the dialogue. For example, acknowledging the patient’s ask for an explanation. Patients with limited patience may response, either verbally or nonverbally, can encourage the fi nd these questions frustrating, but generally speaking open- patient to volunteer more information. ended questions provide the greatest yield of information. In certain instances, when the patient is making what Closed-ended questions require the person to answer appears to be a painful disclosure, it may be appropriate for a question with a limited number of options. Closed-ended the Paramedic to remain silent. Silence, in this instance, is questions are used when specifi c information is needed comforting to the patient and shows that the Paramedic quickly. A closed-ended question generally starts with words respects the patient’s privacy. like “do,” “is,” or “are” and result in automatic answers— Sharing one’s observations with the patient can also help single word responses such as “yes” or “no”—that add small focus the patient’s thoughts as well as direct the dialogue. amounts of information. For example, the statement “You seem upset” may bring During an emergency Paramedics often prefer to use the patient’s behavior to the patient’s attention and allow the closed-ended questions in order to obtain succinct answers. patient to correct the impression or explain the behavior. However, the use of closed-ended questions can lead to a lim- Conveying empathy, the message that “I am with you” ited history from the patient. can be as simple as acknowledging the patient’s feelings or Some Paramedics prefer to use an indirect statement to asking for clarifi cation. Both approaches show the patient obtain needed patient information. An indirect statement is a that the Paramedic is interested and cares. question that asks for an explanation that is not constrained Clarifi cation is an excellent tool when the Paramedic is by the question. An example of an indirect statement would sensing a mixed or confusing message. Clarifi cation asks the be, “Please tell me about your pain.” patient to restate the message in other words. By asking the 236 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. question (e.g., “What do you mean when you say . . . ?”) the patient from the behavior, and accept the patient but reject Paramedic is bringing the previous statement to the patient’s the behavior. The Paramedic should understand that the attention and asking for further explanation. patient is expressing genuine feelings (care) in an inappro- At the end of a patient interview, the technique of sum- priate manner. The Paramedic needs to express his feelings marization can be helpful to ensure the Paramedic’s under- (e.g., “I am uncomfortable with what you just said.”) and standing of the information in the interview. Summarization then proceed to establish boundaries. In most cases, the involves taking the patient’s own words, then paraphrasing the patient needs the help that EMS can provide and will dem- patient’s words to ensure that the message sent was received onstrate correct behavior. correctly. Summarization allows the Paramedic to focus on specifi cs of a patient history. Summarization also reassures Provider Errors in Interviewing the patient that the Paramedic was attentive during the patient interview. Sometimes the Paramedic is his or her own worst enemy when it comes to facilitating a dialogue. The following are a few behaviors that are counterproductive to the task of Behaviors Detrimental to Dialogue gathering a patient history and maintaining a therapeutic A Paramedic should keep in mind that certain behaviors can communication. be detrimental to the Paramedic–patient dialogue. For exam- Some Paramedics take pride in their ability to use medi- ple, inappropriate slang words, curse words, and laughter cal terms and professional jargon. However, when speak- can have a devastating effect upon the conversation between ing to a patient such medicalese is confusing and erodes the patient and Paramedic. While patients do sometimes get patient’s confi dence that the Paramedic can relate to the situ- themselves into genuinely humorous situations, the laughter ation or problem. is best left for after the call. During the call, all providers Another common pitfall is frequent interruptions. When should be professional and polite. a patient is frequently interrupted by the Paramedic, the patient gets the sense that the Paramedic does not really care Patient Conduct about the patient. Patients may exhibit self-protective behaviors, called block- Paramedics should also avoid giving false assurances. ing behaviors, which inhibit free dialogue with the Para- While reassuring clichés, such as “everything will be alright,” medic. Many of these blocking behaviors are manifestations can come glibly off the tongue, these words are altogether of psychological defense mechanisms. For example, when a meaningless to the patient and undermine the trust that the patient slams a door he may be displacing his anger from a patient has in the Paramedic. threatening object (e.g., the Paramedic) to a nonthreatening Similarly, Paramedics should avoid giving advice. Such object (e.g., the door). statements usually begin with “If I were you,” or “You should Similarly, the patient may deny the feelings. Denial, a do this.” Such advice is generally not based upon a suffi cient strong defense mechanism, is commonly used and is an knowledge base and assumes authority. Even physicians gen- unconscious refusal to acknowledge feelings or situations. erally couch their words of advice with statements like, “It is An example of denial is the patient who appears to be hav- my recommendation that,” or “You might want to consider ing an acute coronary event but keeps telling the Paramedic this,” leaving the decision to the patient. that it is just indigestion. The patient fears the truth and all of As a rule, Paramedics should also avoid “why” questions. the consequences that would accompany an acute coronary Questions prefaced with the word “why” imply judgment. event, including a loss of independence. When a patient senses judgment, a sense of futility prevails

Fear is a powerful feeling. Patients overwhelmed with and the patient tends to become uncooperative. Moralizing fear may experience debilitating panic attacks or exhibit also falls along the same lines as giving advice and asking outright hostility toward the Paramedic. When confronted “why” questions. with a hostile patient, the Paramedic is under no obliga- tion to remain in danger. However, if the Paramedic can recognize the source of the fear or anger and help the patient recognize that fear or anger, the Paramedic could potentially Street Smart defuse the situation and continue providing patient care. To deescalate an angry or frightened patient, the Para- medic should permit the patient some control of the situa- The Paramedic should listen carefully to the words of tion and then, using a problem-solving approach, analyze and the patient’s spouse. Generally speaking, the spouse neutralize the cause of the fear.14 of a patient is genuinely concerned and can often add On rare occasions, a Paramedic may be confronted with inappropriate sexual behavior, often in the form of sexual important information about the situation which the innuendo. It is important that the Paramedic separate the patient may not know or may be withholding. Therapeutic Communications 237 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Statements by Friends and Family In some cultures, the practice of folk medicine is the Friends and family can offer a rich source of information prevalent medical care. Special practitioners may use concoc- about a patient, but such information should always be looked tions of herbs and special rituals to cure illness. The Mexican at with a skeptical eye. The Paramedic cannot be sure of the folk healer, for example, is called a “Curandero.” In one study motives of friends and families and such hearsay information of 405 Hispanics in Denver, Colorado, 29% indicated that can be inaccurate. they had visited a Curandero in the past.19 All Paramedics should strive for cultural competence, an Special Communication Situations ability to function effectively within the populations that they serve. Cultural competence requires an awareness and knowl- There are many situations which require the Paramedic to use edge of common medical practices in the communities. specifi c techniques or actions to handle communications with the patient. Death and Dying Drugs and Alcohol No situation puts the Paramedic’s therapeutic communication Paramedics commonly encounter drug- or alcohol- intoxicated skills to the test more than a patient’s death. A caring Paramedic patients. These patients, despite distasteful mannerisms or can support the patient’s family during this stressful moment behaviors, are deserving of care and may not be aware of the in a person’s life through therapeutic communications. danger to their health.15–17 The Paramedic should fi rst listen. Listening, nonjudg- When confronted with an intoxicated patient, the Para- mentally, to the patient’s spouse or loved one allows the medic should not moralize about the patient’s conduct, but p rocess of grieving to begin. If the patient’s family is in denial, rather recognize that the patient may have unresolved prob- the Paramedic should gently reestablish reality by refocusing lems. This recognition paves the way for the Paramedic to the person to the reality of the situation (i.e., that the patient separate patient from behaviors and provides the start of a has died). therapeutic relationship with the patient. Any displays of anger or criticism from the family should not be taken personally. The professional Paramedic can sep- Alternative Medicine arate the behavior from the person and understands that the Paramedics may also encounter patients who lack faith in behaviors are part of the mourning over the patient’s death. western medicine. These patients may have already used alternative medicine or complementary medicine before calling EMS. Unsure of the Paramedic’s reaction, the patient may withhold such vital information from the Paramedic. Paramedics should recognize that alternative medicine is becoming increasingly popular and is more commonplace Professional Paramedic in some cultures. A study in the New England Journal of Medicine indicated that some 34% of Americans have tried Some allied health programs including paramedicine alternative medicine.18 The domain of alternative medicine includes mega-vitamins, therapeutic massages, chiropractic offer courses in thanatology, the social and medicine, and acupuncture, to name just a few. psychological study of death and dying. 238 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. While Paramedics are in many respects taught to “romance the technology,” EMS is—above all else—a caring profession. Therapeutic communication helps to establish Paramedics as professionals in the minds of their patients, other healthcare team members, and the general public. Key Points: • The overarching goal of communications is to obtain • Knowledge of kinesics, the study of nonverbal clinically relevant information about the patient behavior for communications, can help the so that a diagnosis can be made and treatment Paramedic improve communication skills. offered. Communication should be complete, clear, concise, courteous, and cohesive. • Applied correctly, therapeutic touch, such as hand- holding, can help calm patients and transmit a • Successful communication depends on correctly message of compassion to the patient. sending and receiving the message. The reception of the message can be affected by physical, cultural, • Conveying a message to the patient who is either and educational differences between the message’s hearing impaired or hard of hearing (HOH) requires sender and receiver. the Paramedic to take deliberate action. • A common obstacle to successful communication • The Paramedic should carefully select questions is the use of diffi cult to understand medical that maximize patient information and provide for a terminology. It is good practice to offer lay terms free fl ow of dialogue. to explain medical terminology to ensure that the • Open-ended questions allow a patient to give more patient understands. thorough answers, while closed-ended questions • Any medical condition causing the patient to have result in fast responses and limited information. an altered mental status can interfere with the • Clarifi cation and summarizing are both excellent patient’s ability to understand the message. ways to ensure that the message sent was received • The Paramedic should check for patient correctly. understanding by looking for feedback in the form • Patients may exhibit self-protective behaviors, of body language, facial expressions, and questions called blocking behaviors, which inhibit free and answers. dialogue with the Paramedic. • Active listening skills include taking a nondefensive • The Paramedic should not give false assurances or posture, keeping arms open, having a genuine look advice. of interest, asking clarifying questions, and not interrupting the patient responses. • In interviewing, avoid “why” questions, as they • imply judgment. Paramedics should put themselves in the patient’s situation in order to understand the patient better • Paramedics should strive for cultural competence, (hermeneutics). an ability to function effectively within the • populations that they serve. The theory of proxemics illustrates the importance of keeping the appropriate physical distance • Therapeutic communication is crucial when dealing between Paramedic and patient. Different with a patient’s death. people require differing amounts of space to feel comfortable. Therapeutic Communications 239 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Review Questions: 1. What theory explains how words can trigger 6. In an interview with an elderly woman who has unpleasant memories and subsequent physical mild dementia and is slow to respond, what reaction? techniques can the Paramedic use to promote 2. Describe how the process of radio effective communication? communications is similar to communication 7. Explain how cultural competence allows between two people. Paramedics to function effectively within the 3. Defi ne the study of kinesics and explain why populations that they serve. it makes up a majority of person-to-person 8. How should the Paramedic conduct him- or communication. herself when dealing with the spouse of a 4. Describe the four types of space that the theory patient who just died? of proxemics outlines. 5. What are some blocking behaviors the patients or family members might display? Case Study Questions: Please refer to the Case Study at the beginning of the 3. How should the speaker position himself for the chapter and answer the questions below. lip reader? 1. Explain why speaking louder may increase the 4. In addition to Mrs. Garratt’s hearing impairment, anxiety of persons present on a scene. what other factors are likely to interfere with 2. How does “yelling” affect lip reading? communication? References: 1. Gantt WH. Principles of nervous breakdown-schizokinesis and 7. National Institute For Literacy. Available at: http://www.nifl .gov/ autokinesis. Ann N Y Acad Sci. 1953;56(2):143–163. nifl /facts/facts.html Accessed May 16, 2009. 2. Gantt WH. Pain, conditioning and schizokinesis. Cond Refl ex. 8. Kaestle C, Damon-Moore H. Literacy in the United States. New 1973;8(2):63–66. Haven: Yale University Press; 1991. 3. Barratt K, von Briesen JD. The continued vitality of a patient’s 9. Meade DM. Mixed messages: interpreting body language. informed consent, or, when the patient says “no.” Wmj. Emerg Med Serv. 1999;28(9):59–62, 73. 1999;98(2):60–61. 10. Birdwhistell RL. Introduction to Kinesics: An Annotation System 4. Sturman ED. The capacity to consent to treatment and research: for Analysis of Body Motion and Gesture. Louisville: University a review of standardized assessment tools. Clin Psychol Rev. of Louisville; 1952. 2005;25(7):954–974. 11. Birdwhistell RL. Kinesics and Context: Essays on Body-Motion 5. Tunzi M. Can the patient decide? Evaluating patient capacity in Communications. London: Lane Press; 1970. practice. Am Fam Physician. 2001;64(2):299–306. 12. Krieger D. Alternative medicine: Therapeutic touch. Nurs Times. 6. Johnson A. Note to self: tips on internal & external 1976;72(15):572–574. communication. Jems. 2007;32(6):26–27. 240 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 13. Krieger D. Therapeutic touch: two decades of research, teaching 17. Remy JD. Prehospital care of the intoxicated individual. Emerg and clinical practice. Imprint. 1990;37(3):83, 86–88. Med Serv. 2004;33(12):88–89, 91. 14. Hills LS. Working with anxious or fearful patients: a training 18. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional tool for the medical practice staff. J Med Pract Manage. medicine in the United States. Prevalence, costs, and pattern of 2007;23(1):50–53. use. N Engl J of Med. 1993;328(4):246–252. 15. Dick T. Stinky people. Respecting your limitations & other 19. Padilla R, Gomez V, Biggerstaff SL, Mehler PS. Use of people’s predicaments. Emerg Med Serv. 2005;34(11):26. curanderismo in a public health care system. Archives of Internal 16. Nordberg M. Mixed emotions. EMTs and Paramedics are often Medicine. 2001;161(10):1336–13340. ambivalent about treating the homeless. Emerg Med Serv. 1992;21(5):39–45, 48–39, 75. Therapeutic Communications 241 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. KEY CONCEPTS: Upon completion of this chapter, it is

expected that the reader will understand these following concepts: • The need for an accurate medical history to provide competent patient care • Using a comprehensive medical history to discover as much information about a patient’s complaints, interpersonal relationships, and medical history as possible • Using a focused health history to generate the historical fi ndings necessary to manage an emergent medical condition • The benefi ts of asking open-ended questions so patients are allowed to answer in their own words and generate a less-biased history Case Study: The Paramedics approached Mrs. Jones, an elderly woman who called EMS frequently. One Paramedic said quietly, “Let’s just get her into the bus and get going. She always has the same complaint and her history doesn’t change.” His partner said, “No, we’ll use a history gathering mnemonic to work this through. There’s something different here but I’m not sure what it is.” Mrs. Jones always complained of shortness of breath. However, this time the onset was slower and it was accompanied by extreme fatigue. Her physical exam was essentially the same as always but the pair worked her up for a possible myocardial infarction, which was later confi rmed at the hospital. 242 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. History Taking 243 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. OVERVIEW Obtaining an accurate medical history is an essential provision of quality patient care. This chapter discusses the art and science behind history taking. A patient’s medical history is best obtained by asking the right questions and developing a rapport that allows for a free exchange of information. Asking questions in an open-ended manner allows patients to answer in their own words and generates a history that is less biased by the Paramedic’s own interpretation. Once the dialogue has been opened, the Paramedic should guide the patient through the interview using the techniques of facilitation, refl ection, clarifi cation, interpretation, and direct questioning to gather the history without diverting the patients from their own account. Using the information generated from a focused health history, the Paramedic is able to expose historical fi ndings necessary to manage a patient’s emergent medical condition. History Taking Setting the Stage History taking is the most important skill for a Paramedic Any medical records available should be briefl y reviewed; for to master. History taking is defi ned as the medical ques- example, a Vial of Life® (Figure 15-1). Important data such as tioning of a patient to determine the disorder, syndrome, previous illnesses and treatments can often be easily obtained or condition affecting the patient that resulted in the call from such records. If the patient is in the care of another pro- for assistance. With most patients, the medical condition vider upon arrival, then a brief report should also be obtained related to their chief concern can be correctly identifi ed from that person. The Paramedic should also consider the envi- by history taking alone.1 Often physical exam fi ndings and ronment in which the interview takes place, as a proper atmo- other tests assist in confi rming the paramedical diagnosis. sphere can greatly enhance effective communication. If a Paramedic listens to the patient, she will tell the Para- The Paramedic should try to make the patient as comfort- medic what is wrong, and if the Paramedic really listens, the able as possible and be respectful of personal space. Gener- patient will tell the Paramedic how to fi x it!2 If history tak- ally, there should not be any obstacles, but a distance of a few ing is improperly performed, however, the Paramedic can be feet should lie between the Paramedic and the patient. During led to a completely different conclusion about the patient’s the interview, the Paramedic should be alert to the patient’s illness. Therefore, the history must be conscientiously gath- comfort level.6,7 The Paramedic should watch for any signs of ered on a patient-by-patient, case-by-case basis. The history and chief concern must also be confi rmed with the patient and not be taken for granted from dispatch information or other EMS providers. The Art and Science of History Taking The science in history taking is asking the right questions of the patient and interpreting the answers to those questions. The art in history taking is developing a relationship with the patient that allows the Paramedic to ask the right questions and also allows the Paramedic to trust that the patient will provide open and honest answers to those questions. Emergency medicine is a fi eld of medical practice which often requires a great deal of data to be gathered in a very limited amount of time.3–5 To achieve this goal, the Paramedic must combine art and science to a great degree. Patient care experience is the best teacher in the art of history taking. Figure 15-1 The Vial of Life® can provide However, some basic tenets apply. important patient information. 244 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. uneasiness and, if necessary, ask the patient directly about his The Paramedic should pay close attention to the way the feelings. Standing over a supine or sitting patient implies a patient responds. People who introduce themselves with titles position of power and can be detrimental to good communica- or their full name usually expect the Paramedic to address tion. Remember that just as the Paramedic watches the patient them that way. Avoid using demeaning terms like “Honey” for nonverbal clues, so is the patient watching the Paramedic. “Sweetheart” or “Bud.” Paramedics must always be aware of the messages transmit- ted by both words and actions. Paramedics must be sensitive Starting the Interview to those messages and control them as well as possible. After introductions are made, the Paramedic should ask the patient open-ended questions in an effort to help determine the problem.6 An open-ended question is one which cannot be answered simply with yes or no. This type of question allows Street Smart the patient to answer in his or her own words and generates a history which is less biased by the Paramedic’s own interpre- A good provider appears like the duck: smooth, calm, tation. A good example of an open-ended question would be: “What’s seems to be the trouble today?” or “Why did you call and well ordered on the surface, but underneath for EMS today?” Once a dialogue has been opened, the Para- paddling like crazy. An unfl appable demeanor in the medic should follow the patient’s lead and guide him through face of crisis is a great tonic not only to the patient, the interview without diverting the patient from his own but to the Paramedic’s fellow crewmembers. account. Some follow-up questions might be: “Can you tell me any more about that?”, and “Anything else you can think of?” Some techniques which might assist the Paramedic in this pro- cess include facilitation, refl ection, clarifi cation, interpreta- The Paramedic only has one chance to make a good tion, and direct questioning about feelings (Table 15-1). fi rst impression. A clean, neat, and professional appearance implies to a patient that the Paramedic will be a profi cient Table 15-1 Interviewing Techniques medical provider. A slovenly appearance, in contrast, leaves Facilitation the patient wondering if the Paramedic will take better care of Actions such as the Paramedic nodding his head in acknowledgement him than the patient can give himself. Due to the volume of and saying “Go on,” as well as trying to make eye contact, may information contained in the patient’s history, it may be nec- encourage the patient to continue talking about a subject. essary for the Paramedic to take notes during the interview. Refl ection Most patients are just fi ne with note taking, but it should never divert the Paramedic’s attention from the patient. If Repeating the patient’s words may encourage additional responses. An example would be: Paramedic: “You said it was a crushing pain?” note taking is necessary, the Paramedic should try to make Patient: “It felt like a vise around my chest.” Refl ection is helpful “shorthand” notes which she can then later transcribe onto because it typically doesn’t interrupt the patient’s train of thought. the fi nal report. Clarifi cation When the Paramedic meets the patient for the fi rst time, he should formally introduce himself and explain his job Make sure to clarify statements which are unclear or vague. function. For example, a Paramedic might say, “Good morn- Empathetic Response ing sir, I’m Marvin, a Paramedic with the ambulance.” If the Try to show the patient acceptance and understanding of how patient does not identify himself, then the Paramedic should he or she feels. ask for her name. The Paramedic might ask, “What would Confrontation you like us to call you?” When the patient’s story has been inconsistent, directly presenting the patient with the inconsistencies about the words or actions can sometimes be helpful. An example might be when a patient tells the Paramedic that the topic they are discussing is not disturbing to him, but then begins to cry. The Paramedic could then directly question the Cultural / Regional differences patient about this inconsistency. Interpretation In some regions, the fi rst name is used with Miss A step beyond confrontation in which the Paramedic, as the history or Mr., regardless of marital status. This denotes taker, actually makes an interpretation of the patient’s words or actions and presents it to the patient. For example, as in the previous case in respect. Using madam or sir when unsure of the interpretation the Paramedic might state why the Paramedic thinks the name is generally considered respectful. However, story is inconsistent. the Paramedic is advised to obtain the exact way the This results in direct questioning about feelings. patient wishes to be addressed. Madam may have Unless asked, patients may not offer how their chief concern makes them feel. negative connotations in some locales. History Taking 245 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Structure and Content of the Patient History Street Smart The patient history consists of several individual elements, each of which serves a specifi c purpose. Together these parts A patient’s vulgar language might at times be provide the structure of the history. A comprehensive medical appropriate to document as a refl ection of the mental history (Table 15-2) is taken to discover as much information status or state of behavior. Whenever a Paramedic about a patient’s concerns, interpersonal relationships, and medical history as possible. chooses to directly quote a patient’s words, she should make sure to use quotation marks around the The Focused History words and the phrase “patient states” before or after The comprehensive history, due to the extensive amount the quote. of data it collects, is often not used in emergent situations.

When time is of the essence, a focused history concentrating on the chief concern (CC), history of present illness (HPI), signifi cant past medical history (PMH), and pertinent cur- Table 15-3 SAMPLED History rent health status information is obtained. S Signs and symptoms (chief concern plus OPQRST AS/PN) The mnemonic SAMPLED can be used to help remem- A Allergies ber the different historical components that are important to M Medications obtain (Table 15-3). P Past medical history L List whatever is important based on chief concern: meal, MD visit, Chief Concern menses, and so on E Events leading up to chief concern The chief concern is the main reason for which the patient is D Does the patient have any advance directives (e.g., healthcare seeking medical care. It is best discovered by asking an open- proxy, POLST)? ended question. Whenever feasible, it should be expressed Table 15-2 Elements of a Comprehensive History Date and time • Psychiatric illnesses Identifying data • Accidents and injuries • Age • Operations • Sex • Hospitalizations • Race Current health status focuses on present state of health • Birthplace • Current medications • Occupation • Allergies Source of referral • Tobacco use • Who called the ambulance? • Alcohol, drugs, and related substances Source of history • Diet • Patient • Screening test • Family • Immunizations • Friends • Sleep patterns • Police • Exercise and leisure activities • Others • Environmental hazards • Reliability • Use of safety measures • Variable reliability Family history • Memory, trust, and motivation Psychosocial history • Assessed at the end of the interview • Home situation and signifi cant other Chief concern • Daily life History of present illness • Important experiences Past history • Religious beliefs • General state of health • Patient’s outlook • Childhood illnesses Review of body systems • Adult illnesses 246 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. and documented in the patient’s own words. Occasionally a Table 15-4 OPQRST AS/PN Mnemonic to Help patient’s own words will be too vulgar or ambiguous to use Obtain a History about Painful Concerns directly. In these cases, it is often best to paraphrase the com- Onset When did the pain start? ments in more precise medical language. Provoke What caused the pain? What makes it worse? History of Present Illness Quality Describe the pain. Region Where is the pain? Where did it start? Once the Paramedic has determined the main symptom that is causing the patient’s distress, it is important to gather as many Radiation Does the pain radiate or migrate? attributes of that symptom as possible. The responses given by Relief Is there anything that improves or relieves the pain? the patient allow the Paramedic to think about associated body Recurrence Is there anything that makes the pain return? systems and develop an idea of the nature of the illness. Sev- Severity How severe is the pain? eral mnemonics can be used to help the Paramedic recall the Timing When did it start? essential elements of the history based on the chief concern. Associated What other symptoms does the patient have along with The mnemonic OPQRST AS/PN (Table 15-4) can be used Symptoms the chief concern? for any concern of pain. The severity of pain can be measured Pertinent Associated symptoms important to the chief concern using a simple “mild, moderate, severe” scale or using a 0 to Negatives that are not present; for example, chest pain without 10 or Faces scale (Figure 15-2). Other mnemonics can also be shortness of breath. useful for specifi c chief concerns (Table 15-5). To gather further information, the Paramedic often needs to directly ask the patient questions about the symptoms. Past Medical History When asking a direct question of the patient, the Paramedic and Current Health Status should be careful not to ask a leading question. Certain information about the patient’s past medical history A leading question is one which may direct the patient and current heath status should be obtained with every patient toward an answer that might not necessarily have been given contact. However, there are many aspects of one’s medical his- if asked in another manner. For example, instead of asking tory, most of which are not necessary to obtain during a medi- “Was the pain crushing?” the Paramedic should ask, “Tell me cal emergency. The key is to focus on signifi cant historical what the pain in your chest was like.” The Paramedic should information or those aspects necessary to determine the nature also be careful to ask only one question at a time to avoid and potential severity of the patient’s illness or injury. All confusing the patient. The Paramedic should remember to patients should be questioned about chronic illnesses, medica- use language that is appropriate to the patient’s education and tions taken, allergies, and tobacco, alcohol, or other drug use. knowledge level. When in doubt, it is always best to use plain Some medical conditions are specifi c to related body sys- language instead of medical jargon. An example might be, tems (Table 15-6). Most patients should be specifi cally asked “Do you ever feel like your heart is racing?” as opposed to about heart problems, hypertension, breathing problems, and “Do you have palpitations?” diabetes. Universal Pain Assessment Tool This pain assessment tool is intended to help patient care providers assess pain according to individual patient needs. Explain and use 0–10 Scale for patient self-assessment. Use the faces or behavioral observations to interpret expressed pain when patient cannot communicate his/her pain intensity. 0 1 2 3 4 5 6 7 8 9 10 Verbal descriptor No Mild Moderate Moderate Severe Worst pain scale pain pain pain pain pain possible Wong-Baker facial grimace scale Alert No humor Furrowed brow Wrinkled nose Slow blink Eyes closed Smiling Serious Pursed lips Raised upper lips Open mouth Moaning Flat Breath holding Rapid breathing Crying Activity tolerance No Can be Interferes Interferes Interferes Bedrest scale pain ignored with tasks with concentration with basic needs required Figure 15-2 Example of several different pain assessment scales in one reference. (Photo courtesy of UCLA Department of Anesthesiology, David Geffen School of Medicine at UCLA) History Taking 247 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 15-5 Other Useful Mnemonics Table 15-6 Past Medical Conditions Related for Obtaining the History of Present Illness to Specifi c Body Systems System Elements System Past Medical History Any concern of pain OPQRST AS/PN as described Neurological Stroke, seizure, head injury previously Cardiovascular Acute myocardial infarction, angina, coronary Altered mental status AEIOU-TIPS artery bypass graft (CABG), angioplasty/cardiac A – alcohol catheterization E – epilepsy/seizure Respiratory Asthma, emphysema, smoking, hospitalization, I – insulin (hyper- and intubation hypoglycemia) O – overdose Gastrointestinal Surgery, abdominal aortic aneurysm, appendicitis, U – uremia/metabolic small bowel obstruction T – trauma Genitourinary STD, pregnancy, abortions, kidney stones I – infection Musculoskeletal Fractures, surgery, multiple sclerosis, sports injuries P – psychiatric S – stroke Psychiatric Depression, suicide attempts, admission, medications, drug and alcohol use Shortness of breath HAPI-SOCS H – history of pulmonary disease Endocrine Diabetes, thyroid disorder, surgery A – activity at onset Hematologic Leukemia, infection, travel, transfusion P – pain on inspiration Allergic Known allergies, allergy testing, anaphylaxis I – infection symptoms (chills, history night sweats, fever) S – smoker (# packs per day x number of years  # pack years O – orthopnea C – cough? productive? Allergies S – sputum (and color)? The Paramedic should determine if the patient has any aller- Psychiatric/Depression IN SAD CAGES gies to medications. If an allergy is reported by the patient, IN – interest (apathy, withdrawn, the Paramedic should inquire what type of reaction the patient disinterested) had to the medication. In some cases, a reported allergy is S – sleep disorder (insomnia, night actually a common side effect or a familial “allergy” in which walking) A – appetite the patient’s relative is allergic, so the patient avoids a certain D – depression/mood swings medicine. If related to the chief concern, such as a bee sting, C – concentration the Paramedic should inquire about environmental allergies. A – activity G – guilt Medications E – energy The Paramedic should ask the patient about any medication S – suicidal ideation use and inquire about prescription, over the counter, and homeopathic or nutritional substances. The Paramedic should also determine if the patient is compliant with medication use and how long the patient has been taking each medicine. It is important to ask about recent changes in medications, such Street Smart as dosage. Occasionally when Paramedics ask a patient if he has Tobacco, Alcohol, and Drug Use any medical problems, some patients will tell the The use of tobacco, alcohol, or other recreational drugs is Paramedic that there are not any, even though there a signifi cant risk factor for many diseases.8–22 Knowledge of their use may raise the Paramedic’s index of suspicion for is a history of a chronic disease. People sometimes certain illnesses such as heart or vascular disease, COPD, and feel that, since they are under care for an illness, it cirrhosis. is no longer “a problem.” The best approach is to ask Clinical Reasoning if the patient has any medical problems and then ask Based on the patient’s chief concern, history of present ill- if the patient has ever been under a health provider’s ness, and answers to direct questioning, the Paramedic can care for any reason. develop a general sense of the body systems that may be involved in the patient’s problem. Forming this impression 248 Foundations of Paramedic Care Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. will allow the Paramedic to decide which other questions she Regardless of the situation, the Paramedic should not should ask and which physical exams she should perform to let impatience show. If necessary, he should explain to the confi rm the Paramedic’s conclusion. Clinical decision mak- patient that time is short and that the current discussion will ing is discussed further in Chapter 17. be continued later. Special Challenges Patients with Multiple Symptoms Some patients seem to have every possible symptom. to History Taking Although it’s possible that this patient might have multiple The Paramedic can face diffi culty in obtaining an accurate organic illnesses, it’s more likely that other confounding fac- medical history in some situations. Application of several tors are present. The Paramedic should refocus the patient on simple techniques can assist the Paramedic in obtaining a his- one concern by asking the patient about the most important tory in these situations. concern, for example, “You told me many concerns. Which is the most important concern, or the reason you called us to Sensitive Topics help you today?” It is often imperative to question the patient about topics that Anxious Patients may be embarrassing or socially sensitive in order to learn more about factors which may have contributed to the illness. It is natural for a patient to be anxious during a medical These topics might include such issues as drug and alcohol emergency. For some patients, anxiety has signifi cant impli- use, physical abuse, and sexual history. Much of the diffi - cations in their