Paramedic And Case Study And Pdf And Weird Patient
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- The turnaround of the London Ambulance Service Computer-Aided Despatch system (LASCAD)
- Digital health at the edge: Three use cases for the healthcare industry
- Clinical Case Studies For Medical Students Pdf
- Clinical Case Studies For Medical Students Pdf
The present study provides theoretical evidence for in-depth analysis of the mechanisms and molecular targets by which Epimedium protects against MCI, AD, and other neurodegenerative diseases and lays the foundation for pragmatic clinical applications and potential new drug development. As the visual media is replacing all the other forms, IBSCDC would endeavor to bolster this activity with a desire to develop movie-based case studies spanning all the functional areas of. Herlihy Course Objective Learning Objectives.
Metrics details. Despite evidence from clinical trials that intravenous IV thrombolysis is a cost-effective treatment for selected acute ischaemic stroke patients, there remain large variations in the rate of IV thrombolysis delivery between stroke services. Study design: Cluster randomised trial with economic analysis and parallel process evaluation. Setting: National Health Service ambulance services, emergency departments and hyper-acute stroke units within three geographical regions of England and Wales.
The turnaround of the London Ambulance Service Computer-Aided Despatch system (LASCAD)
Metrics details. Despite evidence from clinical trials that intravenous IV thrombolysis is a cost-effective treatment for selected acute ischaemic stroke patients, there remain large variations in the rate of IV thrombolysis delivery between stroke services.
Study design: Cluster randomised trial with economic analysis and parallel process evaluation. Setting: National Health Service ambulance services, emergency departments and hyper-acute stroke units within three geographical regions of England and Wales. Randomisation: Ambulance stations within each region are the units of randomisation.
According to station allocation, paramedics based at a station deliver the PASTA pathway intervention or continue with standard stroke care control. Study intervention: The PASTA pathway includes structured pre-hospital information collection, prompted pre-notification, structured handover of information in hospital and assistance with simple tasks during the initial hospital assessment.
Study control: Standard stroke care according to national and local guidelines for the pre-hospital and hospital assessment of suspected stroke. The results from this trial will determine whether an enhanced care pathway delivered by paramedics can increase thrombolysis delivery rates.
Registered on 5 November Peer Review reports. Stroke is responsible for a high global burden of mortality and disability [ 1 ]. The most widely used cost-effective emergency treatment is intravenous IV thrombolysis using recombinant tissue plasminogen activator for selected ischaemic stroke cases within 4. Despite evidence from clinical trials, related guidelines and policy, national audit continues to show large variations in the rate of IV thrombolysis delivery between services and diurnal variations within services [ 4 , 5 ].
Outcomes are highly time dependent [ 3 , 6 ]. Benefits for patients and social care resources would be substantially improved if more eligible patients recieved IV thrombolysis, and if they were treated sooner. Most stroke services have found it challenging to improve IV thrombolysis rates and reduce treatment delays in hospital i.
Brain imaging is a vital component of assessment to exclude haemorrhagic stroke and patients with established ischaemic changes where IV thrombolysis would be futile and potentially harmful.
International clinical guidelines state that brain imaging should be performed immediately when a patient with IV thrombolysis potential arrives [ 7 , 8 ]. An urgent scan is also indicated for other patients presenting with stroke symptoms, including those taking anticoagulation medication and those for whom a haemorrhage is suspected.
Urgent treatments for these patients can include reversal of anticoagulation, intravenous medication to lower high blood pressure and possible neurosurgical intervention [ 8 ]. An improvement in the early identification of patients who meet the criteria for an urgent scan could lead to a cost-effective reduction in dependency, mainly through an increase in the rate and speed of IV thrombolysis treatment, but also by improving access to other treatments and organised stroke care.
Where improvements have been seen, this typically reflects highly resourced, large volume urban centres, but even these may rely upon initial patient assessment by nursing and junior medical staff at nights and on weekends. In some settings, the standard approach is remote stroke specialist assessment by video link or telephone, increasing the reliance upon non-specialist staff for rapid and accurate information collection and communication at the bedside.
However, despite existing operational guidelines within ambulance services to encourange identification of suspected stroke and symptom onset time, pre-notification does not occur systematically in clinical practice, and the significance of other information collected by paramedics for IV thrombolysis decision making may not be realised during patient handover at hospital e.
Although healthcare policy supports ongoing development of the paramedic role [ 12 ], there has been no rigorous examination of how paramedics could best contribute to improving DTNT and DTST. A Swedish randomised trial showed that IV thrombolysis rates and hospital treatment delays significantly improved after paramedics were provided with training and the emergency status of stroke ambulance dispatch was raised [ 13 ].
An observational study in Helsinki collecting data before and after a simple training package for ambulance personnel showed that on-scene time reduced by an average of 2. As the ambulance transfer time from scene to hospital in most of England is already short, this model is unlikely to be adopted [ 18 ]. Feedback from the hospital team to paramedics about individual stroke assessments appears to improve future adherence to pre-hospital protocols including pre-notification [ 19 ], but no process exists to routinely facilitate this.
For unselected emergency admissions, a paramedic-initiated standardised communication approach appears to improve the accuracy and efficiency of handover [ 20 ], and there may be value in a format which is stroke specific.
In acute medical settings there is increasing evidence that checklists are effective for improving patient safety and protocol adherence [ 21 ], and a paramedic protocol could include simple questions to prompt important hospital care processes e. This study will evaluate the clinical and cost effectiveness of a paramedic-initiated ambulance care pathway which seeks to facilitate the hospital assessment of patients presenting with acute stroke symptoms in order to specifically increase IV thrombolysis rates and reduce treatment delays.
Patient and professional views about the care pathway will also be described. The pathway has been developed through systematic review of the literature regarding enhanced roles of paramedics as well as developmental workshops with clinicians and support personnel in order to define professional roles and operational boundaries which are feasible whilst maximizing value for patient care. The aim of the study is to determine the clinical and cost effectiveness of an enhanced PASTA pathway.
Primary outcome: proportion of patients receiving IV thrombolysis. To describe the impact of the PASTA pathway on time intervals from emergency call and hospital admission to first brain imaging, IV thrombolysis treatment if given , HASU admission and formal assessment of swallowing safety.
This study is a cluster randomised controlled trial RCT with embedded economic analysis and process evaluation. Participants receive either the PASTA pathway intervention group or standard stroke care comparison group.
The study is taking place within ambulance services and a selected number of receiving hospital sites. Hospital sites within each region represent a range of service designs and historical efficiencies in the provision of acute stroke care. All hospital sites receive emergency stroke admissions and provide h access to brain imaging and a stroke specialist opinion in order to make an IV thrombolysis decision. Clusters comprise the paramedics based within stations. Prior to the start of the trial within each ambulance service, those ambulance stations which feed into a study hospital were randomised to delivering the PASTA pathway or to continue with standard stroke care.
Stations within each service were stratified according to size categorised as small, medium or large according to the personnel and resources available and distance from the nearest study hospital admitting stroke patients distance categorised as near or far, reflecting the local geography of each ambulance service. The use of these stratifying variables ensured that PASTA care paramedics intervention and standard care paramedics control were approximately equally matched in terms of operational characteristics.
Paramedics based at stations randomised to continuing standard care were informed that there is an ongoing study of pre-hospital assessment for stroke patients but were not given any further information about the intervention. All paramedics could opt out of the study if they wished. It consists of the following stages:.
The paramedic will seek additional information at the scene which is routinely considered during IV thrombolysis treatment decisions but is typically not obtained until after hospital admission. This will include:. The presence of language dysphasia or visual visuospatial problems during a simple clinical examination, which may indicate a level of stroke severity more likely to be considered for IV thrombolysis treatment than FAST symptoms alone.
Prescription of anticoagulant medication, which would require additional urgent measurement of blood clotting indices before a IV thrombolysis decision could be made.
This medication is also an additional indication for urgent brain imaging by itself, as a stroke due to haemorrhage would trigger urgent reversal of its effects.
A recent medical history of surgery or bleeding, which might exclude IV thrombolysis treatment because of an increased risk of uncontrollable haemorrhage. Any previous medical history of transient ischaemic attack TIA or stroke, which could assist interpretation of brain imaging and specialist evaluation of the risk versus benefit of IV thrombolysis treatment. The current level of dependency according to whether the patient requires direct assistance with feeding or walking, in order to judge the value of administering IV thrombolysis treatment relative to the effects of the new stroke.
Within the pathway these information categories will be prompted by the acronym PASTA, which represents Plus dysphasia or visuospatial impairment; Anticoagulant medications; Surgery or other bleeding recently; TIA or stroke previously; Assistance needed daily.
During emergency transfer the paramedic will always be expected to attempt a pre-alert to the destination hospital in accordance with existing local arrangements. Although pre-notification is already a component of standard care, compliance is variable. Existing arrangements differ within regional ambulance services and individual hospitals, e. The individual hospital response can vary according to the timing of the admission e.
In addition, the paramedic will inform the team about the known location of any relatives in order to facilitate information gathering, communication and treatment decisions. If the CT scan is immediately available, the paramedic will assist with patient transfer to the scan room accompanied by at least one member of the hospital team. It will be a local decision whether the patient is first transferred onto a hospital trolley, but any delays should be minimised.
If the CT scan is not immediately available, the hospital team will continue with urgent care of the patient according to the local service protocol, and the patient will be transferred onto a hospital trolley. After completion of the checklist, the paramedic will request feedback from a hospital clinician about the provisional pre-hospital diagnosis of stroke, the estimation of onset time and any other aspect of the assessment process. After seeking the checklist and feedback information, the paramedic will complete and sign the study documentation.
The paramedic will depart as per usual operational procedure. The paramedic will record a reason if study documentation is signed before completion of the PASTA pathway. Anticipated reasons are:. A change in the clinical state of the patient making the PASTA pathway no longer appropriate further details below. A stroke mimic condition is clearly identified during the initial hospital assessment, and the hospital team determine that it would no longer be appropriate to continue with a care pathway for suspected stroke further details below.
A specific request by the regional ambulance control centre that the ambulance crew should become available for another call due to the pressure on resources. The reason for any deviation will be recorded, including the anticipated clinical scenarios of falling conscious level, seizure, hypotension and hypoglycaemia. Thrombolysis treatment is inappropriate for these patients.
If a stroke mimic condition becomes apparent during the initial hospital review, the hospital team will discontinue the IV thrombolysis assessment process as per standard clinical care. Patients with suspected stroke symptoms attended by a control group paramedic receive standard stroke care as per current local ambulance and hospital clinical protocols, which are reinforced by national clinical guidelines and audit. The study does not provide comparison group paramedics with additional training or documentation to support information collection, clinical communication or processes after hospital arrival.
Patients approached about enrolment meet the following criteria:. Patients are identified and recruited and will consent to take part in this study after arrival at hospital and when the IV thrombolysis treatment assessment has been completed.
There is no study enrolment process in the pre-hospital setting. The purpose of the study is to demonstrate that the PASTA pathway can expedite the clinical delivery of a treatment which is already known to be effective in reducing future disability but must be administered rapidly IV thrombolysis.
As the pathway does not involve a new treatment or technology but is attempting to expedite an existing hospital care process using a structured clinical assessment performed by paramedics, the risk of harm to intervention patients is low. Patients will still only receive IV thrombolysis treatment following review by a stroke specialist. Although they do not provide study information to patients, as per usual clinical practice, paramedics explain to patients about possible care processes which may occur in hospital.
In order to identify study-eligible patients, hospital research staff systematically review the ambulance and hospital records of all admitted patients with a confirmed hospital specialist diagnosis of stroke. Patients meeting the enrolment criteria are approached about taking part in the study.
Ideally, patients are approached during their inpatient stay such that a timely discussion about the study can be held. However, as some patients are discharged very early after admission and identification of eligibility may only occur after discharge, postal invitations to take part in the study are also used. The participant eligibility assessment process is shown in Fig. It is still possible that a small number of stroke patients attended by a study paramedic will not be admitted to the local HASU because of:.
In order to reduce the chance of these patients not being located in hospital, where possible, participating ambulance services send a regular site-specific report of all suspected stroke patients admitted by study paramedics to each participating site. Hospital research staff use this report to check the hospital diagnosis assigned. Where the diagnosis is confirmed stroke, other study eligibility criteria are reviewed and patients are approached about the study as appropriate.
Although not contributing towards the study outcomes, the number and nature of stroke mimic conditions and whether or not IV thrombolysis was administered is recorded.
In order to ensure that all eligible patients are provided with an opportunity to participate, several consent options are in use. For eligible patients with capacity to consent to research, hospital research staff approach the patient to discuss the study and provide a patient information sheet.
Digital health at the edge: Three use cases for the healthcare industry
In our overview of the digital health landscape, we wrote about how the healthcare industry needs to transform to meet growing demands globally on medical infrastructure and medical expertise. As populations grow, age, and become wealthier, healthcare systems struggle to provide the increasing level of continuous care that patients need. The rise of the COVID pandemic, a novel Coronavirus strain that has rapidly spread across the world as of 5 th April confirmed cases were 1. Digital health is therefore essential to meet the need for better resource efficiency and collaboration across the healthcare industry. A key driver of digital health will be leveraging capabilities at the edge. Edge computing has been rapidly gaining traction and tangible edge deployments have been increasing significantly.
Because the drug was so expensive, the facility required that it be treated as a controlled substance and pills were counted daily. While doing so, one of them accidentally tipped over the bottle and 12 of the pills fell to the floor. Since the pills came in contact with the floor, the nurses believed they should be discarded. The pills were picked up the from the floor and they disposed of them in the sharps container. The nurses then informed the pharmacist on duty that a refill of the medication would be necessary. Due to the high cost of the pills, the pharmacist immediately contacted their supervisor, who in turn contacted the head physician of the facility responsible for patient care.
and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (DSM-IV-TR) (American promotion and disease prevention interventions—in many cases with increasing autonomy and Paramedics in Shaban's study saw their role as caring for patients, rather than psychiatric history, odd or bizarre behaviour.
Clinical Case Studies For Medical Students Pdf
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The television series Emergency! Six seasons, with a total of episodes, aired, followed by six television films during the following two years. Kelly Brackett Robert Fuller , to support paramedic legislation. Because of his pride, Brackett believes in the field medical response by trained and qualified firefighters is a ridiculous notion. Their colleague, Dr.
Clinical Case Studies For Medical Students Pdf
You are a public health nurse working at a county immunization and tuberculosis TB clinic. She has returned to have you evaluate her reaction. What is TB, and what microorganism causes it?
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Их компьютер через Интерпол засек имя Танкадо в регистратуре полиции Севильи. - От разрыва сердца? - усомнилась Сьюзан. - Ему ведь всего тридцать лет. - Тридцать два, - уточнил Стратмор. - У него был врожденный порок сердца. - Никогда об этом не слышала.
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