Primary services that a FES organization should focus on
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Primary services that a FES organization should focus on
Instructions:
Based on the background information, you will use your skills as a fire and emergency services (FES) administrator to develop a cooperative relationship with those attending the town hall meeting. You will need to emphasize the primary services that a FES organization should focus on when planning customer service efforts.
In addition, you will discuss the importance of criteria-based dispatching while, at the same time, demonstrating the importance of a good working relationship with public officials and the community by being attentive to their concerns of responding to noncritical, non-emergency medical incidents.
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Fire and emergency services (FES) administrator
Scenario: You are the fire and emergency services (FES) administrator, and one of your firefighters came to you stating she was having thoughts and images related to witnessing the injuries and deaths of those at a recent mass shooting. She stated that she began spending more time at work and would trade time and shifts with other firefighters to keep her mind busy.
However, whenever she had free time, she would have unwanted and intrusive thoughts about the devastation of the shooting. Additionally, she was having increasingly distressing nightmares of the shooting with some of the patients who she worked on coming after her. She has been exposed to shooting incidents and carnage for several years because she was assigned to the fire station known as the knife and gun club.
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How do you believe you should handle the conversation without causing her to relive that terrible event? What actions or assistance can you provide for her? Discuss your plan of action.
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Exposure to the WMD agents
You are asked to perform a briefing to the mayor and her staff on the following situation below
At approximately 9:15 pm, on the 11th of September in Orange Beach, Alabama (Temp 71oF, cloudy with calm winds), there is a 9-1-1 report that the movie theater in town that is packed to capacity to see the new adventure movie has had three explosions. The first explosion involved an explosion with a flash and loud bang resulting in a fine mist being released on the movie goers. As the movie goers were frantically leaving through the exits, two more explosions went off at each exit with another flash and loud bang but no physical shrapnel or other reports of physical damage to the theater.
Several days ago, it was reported by the news that the mayor’s office received a threat of a terrorist organization planning on releasing a biological agent in the town. According to reports at the movie theater, four used canisters marked Yersinia pestis were found in the location of the secondary bombs.
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As you are traveling to the scene you hear reports of patrons convulsing in the parking lot of the theater; they are unable to control their muscles and other bodily functions and are twitching uncontrollably.
Based on the cryptic details, what category of WMD weapon(s) was released on the crowd?
What is the potential outcome of being exposed to these WMD agents?
In what capacity will your organization of first responders be able to help (e.g. decontamination, weapon identification, first aid, etc.)?
What risk-based response procedures need to be taken to stabilize the scene and prevent further exposure to the WMD agents?
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Heat-related emergencies
Heat-related emergencies lasting an extended time can cause extreme issues for special-needs populations as well as test emergency services.
How would you prepare for a heat-related emergency? What do you think would be the most important step in your preparations? Why?
Heat emergencies are health crises caused by exposure to hot weather and sun. Heat emergencies have three stages: heat cramps, heat exhaustion, and heatstroke. If your body is overheating, and you have a high temperature, bumps on your skin, muscle spasms, headache, dizziness, nausea or a number of other symptoms, you may have one of the most common heat-related illnesses: heat rash, heat cramps, heat exhaustion or heat stroke. Heat illnesses range from mild to severe, and heat stroke can be deadly.
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A first responder
Order Instructions:
You are a first responder who is responding to an incident that is a mass casualty event where a school bus carrying middle school children collided with two trucks. One track is carrying benzene, and the other truck is carrying ammonium nitrate. Both trucks have released their cargo via spill, and now the school students are in danger of breathing in the vapors.
Complete an outline of how you will write the paper. In your outline, make sure you have components that meet the following requirements:
Distinguish between organic and inorganic chemicals.
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Apply chemical reaction basic precautions at the accident scene.
Describe potential reactions that may be present with the chemicals.
Describe the families of hydrocarbons in terms of hazard.
Explain the chemical characteristics of each chemical family.
Outline the potential chemical reactions of hydrocarbons.
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In this paper, the main emergency management theories which act as the backbone for the proposed research proposal are described comprehensively. The paper also provides an analysis of how the research topic actually expands the selected theories and a justification is provided of why the selected theories were selected for the research topic of this proposal.
Lastly this paper provides an assessment of why the identified emergency management theory are suitable for the selected methodology of this research.
Emergency management theory
For this research proposal, the main emergency management theories which serve as the backbone of the research proposal include the Emergency Response Theory and the Disaster Preparedness Theory. Environmental emergencies refer to events or incidents which threaten public welfare, health, and safety, and they include such things as acts of terrorism, industrial plant explosions, hurricanes, chemical spills, wild fires, and even floods.
Emergency Response Theory pertains to organizing available resources, coordinating and directing them so as to respond effectively and properly to an incident and bring the emergency situation under control (Medlin, 2011). In essence, this coordinated response is aimed at protecting the health of members of the public by reducing the impact of the incident on the environment and the community.
The Disaster Preparedness Theory gives emphasis to educating people about hazards which might impact their area and the importance of training people in essential disaster skills for instance disaster medical operations, light search and rescue, fire safety as well as team organization (Mitzel, 2014).
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How research topic expands theory
In this project, the research topic is Community Emergency Response Teams (CERT) in the Northeast Region of the United States. This research topic clearly expands theory by incorporating something new regarding processes of disaster management and preparedness and emergency response. Community Emergency Response Teams are voluntary programmes that entail doing the most good for the most number of people in the community through people assisting people as well as through preparedness.
This is a constructive approach and the members could help other people within their place of work or community after an incident when professional responders are not instantly available to assist (Bobko & Kamin, 2015). On the whole, the topic expands theory by highlighting that community emergency response teams are about encouraging individuals to take active roles in alleviating the effects of a disaster event by having preparedness projects within their communities.
Empowering communities through safer practices serves to encourage a culture of safety in the area as communities would be better prepared in a situation of emergency to do the most good for the most people.
In essence, the CERT program assists in training individuals in the community to be prepared well to respond to situations of emergency within their communities. Whenever emergency situations take place, members of Community Emergency Response Team could provide crucial support to first responders, give immediate help to the affected victims, and arrange spontaneous volunteers at the location of the disaster or emergency (Medlin, 2011). In addition, members of the CERT team could assist with non-emergency projects which help in improving the community’s safety.
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Justification for the selected theory for the chosen research topic
The selected theories – Emergency Response Theory and Disaster Preparedness Theory – are appropriate for the project’s research topic considering that Community Emergency Response Teams are usually involved in educating individuals as regards disaster preparedness for the hazards which might impact their area. In addition, CERTs provide training to people in basic response skills like disaster medical operations and fire safety, which is emphasized by the Emergency Response Theory.
It is notable that CERT volunteers use training which they learned during exercises and in the classroom to help other people within their community after a disaster has occurred when professional responders are not immediately available to provide assistance: this is something that is underscored by the selected emergency management theories. Moreover, Community Emergency Response Team volunteers are encouraged to support emergency response organizations by assuming active roles in disaster preparedness projects (Fithen & Fraser, 2012).
Why the chosen emergency management theories are appropriate for the methodology
The chosen emergency management theories are suitable for the selected methodology considering that these two theories behind community emergency response team are rooted in a simple observation: in major emergency situations, professional emergency services are often overloaded. All parts of the globe have tornadoes and/or earthquakes, and severe storms and floods are the most common disasters.
The common mass disasters include earthquake, floods, tsunami and hurricanes. All these could create mass emergencies hence community emergency response teams have a mission everywhere. The main aim of the CERT program is disaster preparedness. In general, the belief according to the selected emergency management theories is that civilians who receive community emergency response team training are more likely to prepare beforehand for a major emergency situation and are aware of the proper steps to be taken following an emergency.
This helps to reduce the probability that they would require help from emergency responders hence eases pressures on limited resources for instance rescuers and their equipment (Fithen & Fraser, 2012). The other objective of the community emergency response team program as per the selected theories is providing an auxiliary force of trained emergency personnel who are able to respond to events which are really not life-threatening and includes things like light search and rescue operations, shelter management, dispatch and paperwork.
These time-consuming or non-urgent tasks would otherwise belong to emergency professionals, which divert them from rescue operations. As such, the theories are suitable for the methodology.
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Conclusion
In conclusion, the main emergency management theories which act as the backbone of the proposed research study are the Emergency Response Theory and the Disaster Preparedness Theory. The research topic expands theory by incorporating something new regarding processes of disaster management and preparedness as well as emergency response.
The selected theories are appropriate for the research topic because Community Emergency Response Teams are often involved in educating individuals on the subject of disaster preparedness for the hazards which could impact their area, and this is something underscored by the two theories.
References
Bobko, J. P., & Kamin, R. (2015). Changing the paradigm of emergency response: The need for first-care providers. Journal Of Business Continuity & Emergency Planning, 9(1), 18-24.
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The Department of Emergency
Question 24
The Department of Emergency has the role of providing emergency services that are comprehensive to all patients 24 hours in 7 days of a week throughout the year. In particular, it offers patient care services including:
Accepting every patient who comes with acute illness and provide treatment for them.
Accepting 5-level triage patients as stipulated in the Canadian Triage Acuity Scale System (CTAS); and ensure assessment and sorting of patients is done according to acuity.
Performing emergent resuscitation and medical intervention.
Planning for the assessing, diagnosis, treatment as well as referrals for specialized medical treatment for all patients when necessary.
Providing advanced Trauma Care for patients with trauma.
Liaising with all other departments in the hospital for admission of patients and follow-up.
Providing care when a disaster occurs within the community by operating an Urgent Care Centre in a manner that is almost continuous to ensure needs of patients’ presentations that are less acute are met as well as receiving and assessing the stability of direct admissions, which includes Medivac patients on their way to critical or specialized care units within the hospital.
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Emergency and admission procedures for both new and existing patients have been laid down for any medical, psychiatric and surgical emergency, for the initiation of life-saving care procedures in a timely manner. In particular, for all emergency situations the basic procedures for both new and existing patients begins with diagnosis, initiation of treatment, discharge in case of recovery, admission for treatment continuation or monitoring, appropriate referral for specialized care in case of complications, and then follow up services.
The department of emergency medicine uses an electronic information system for the purpose of recording patients’ details when available or await for them afterwards, and transfers them to the relevant intensive care units for surgical and acute medical emergencies since they these services are only offered for a short time in the department prior to the transfer of the patients to appropriate in-patient units.
The system’s main users are the emergency department personnel, and its easy access and security is guaranteed due to its location in the King Khalid University Hospital (KKUH) Building’s ground floor, near the building’s main entrance.
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Part 1: Code Blue educational video from the Regina Qu’Appelle Health Region.
Time sequence
Issue noted
code
comments
0-22 seconds
Breach of Australian Resuscitation Council Guidelines:
BARCG- Guideline 2 priorities in an emergency
Finds Mr. Smith unresponsive. Fails to follow the Guide 2 BLS algorithm because she failed to assess danger, but she assessed the airway, as she is seen checking for the escape of air from the patients mouth or nose as recommended by guide 5. Implications: Delay in resuscitation processes increases the risk of reduced cardiac output to the brain due to poor compressions.
Time 3.26
Poor technical skills
PTS – BARCG Guide 6 & 8
Chest compressions inadequate as recommended by Guide 6. The recommended chest compressions are 30 chest compressions followed by two breaths. The chest compressions are slow than required by Guide 8. “A good CPR should deliver chest compressions over the lower half of the sternum at a depth of 5 cm” (ARC guide 8). Long pauses in CPR before shock delivery. Guide 6 discourages long pauses and distractions during a CPR Implications: Long pauses, distractions, slow and inadequate chest compressions lower the chance of patient’s survival
Poor Non-Technical skillsPNTS
Time 0.30
Situation awareness
PNTS- SA
The nurse did not press the emergency push button system to call for help immediately and instead used the overturn Implications: Delayed response by the code blue team
Time 0.30 secsTime 2.26 minutes
Decision making
PNTS- DM
Delay in full code response. The team arrived 2 minutes later after the call alert Implications: This led to delay important activities such as defibrillation. However, the rest of the decisions such as medication, hyperventilation and defibrillation activities went on well once the code blue captain arrived.
Time 3.36
Task management
PNTS-TM
Compressors for more than five cycles. One compressor was working for almost 5 minutes which is too long for a compressor. According to Guide 5, “the compressor roles approximately after 2 minutes or after five cycles of compressions and ventilations at a ratio of 30:2 so as to maintain the quality of compressions” (ARC guide 5). However, other task management processes such as airway positioning, nasopharyngeal airway placement, bag-valve mask ventilation were correctly performed.
Time 5.28Time 12.55
Communication
PNTS- comm
Occasionally fails to use the closed up communication which leads to miscommunications. For instance, at minute 12.55, the recorder had missed recording the endotracheal tube particulars due to poor communication strategy. The team used the SBAR technique to report the patient’s medical history to the code blue team leader. All the information was recorded including all the medication administered and other CPR outcomes such as cardiac rhythm before a shock was delivered. This is vital for future references.
Teamwork
PNTS-Team
No introduction was done by the team members, but they delegated the resuscitation duties appropriately. The team consisted of a coordinator, compressor nurse, airway manager, nurse in charge of defibrillator, captain/leader and crash cart manager.
Leadership
PNTS- Leadership
The leader failed to evaluate the BLS on arrival. However, Mr. Sellinger (the code captain) performed his tasks effectively including identification of cardiac rhythm, initiation of ACLS protocol, and evaluation of the protocol reviewed the code blue documentation form and signed the code blue form after completing the code blue.
PART 2: Analysis of the issues covered
Code blue should be contacted immediately for all unresponsive patients. Calling for help and initiation for help should be done simultaneously. One of the issues identified in this case study is delayed in the response of code blue code due to poor call out systems. The code team member should call out loudly for help through the facility-wide response system. In this technology, the nurse should have pressed the Blue code push button to ensure that the code blue team were notified accordingly (Bayramoglu et al., 2013).
As the nurse in charge waits for code blue team, he or she should initiate CPR (Clarke, Apesoa-Varano, & Barton, 2016). The code team are expected to introduce themselves as they arrive as well as and their roles statements such as “Am Mr. J. and will take document” or “I’ll take the airway” which helps in ensuring there is clear role differentiation. The service user physician should be contacted immediately.
According to Price, Applegarth & Price (2012), the healthcare provider should first assess the patient dangers and risks before they start the air management. This was not done in the case study and violated the ARC guide four which states that the patient’s mouth should be opened and head slightly turned downwards to remove the airways (Australian Resuscitation Council, 2008).
An ineffective cough indicates a severe obstruction. In this case, if the patient is responsive, the healthcare provider should give about five back blows, and if still, it is ineffective, they should give at least five chest thrusts (McInnes et al., 2012). This article states that for all unresponsive patients, the healthcare should send for help and start CPR immediately. Similarly, guideline 5 recommends that all patients who are breathing abnormally or are unresponsive require being resuscitated.
The first thing when assessing breathing, the rescuers should check for movement around the chest (lower part) and abdomen (upper part). They should check for the exhalation through the patient’s oral cavity or nose, and feel the movement of air in the patient’s mouth or nose. The guide recommends a ratio of compressions to rescue breaths as 30:2 (Australian Resuscitation Council, 2008).
According to this article, the first nurse to respond should start saving the patient’s life by performing chest compressions immediately (100 compressions per minute). Although important, the nurse should not wait for backboard , they should start chest compressions as it can be put in place later when the code team arrives. The switching the compressor roles in the case study is present but it took quite a long time than that recommended by ARC guide 6 which is approximately after 2 minutes.
To maintain the quality, the ventilations ratio should be maintained at 30:2 (Castelao et al., 2013). This is supported by Guide 6 which recommends that interruptions to chest compressions should be minimized. The best location to perform the compressions is the sternum- the lower half part of it. The healthcare provider’s heel is placed at the central part of the chest and put the other hand on top it. The recommended rates of compressions are 100 to 120 compressions per minute which are about two compressions per second.
The guide also outlines on the quality of compressions ( which is identified as poor in the case study) where it suggests that depth of compressions should be “at least 2 inches (5cm) with complete chest recoil after every compression” this helps the heart to re-fill completely by the next round of compressions. The number of interruptions should be minimized to ensure maintain the quantity and quality of compressions (Eroglu et al., 2014).
According to the article, the patient should be given 2 ventilations for every 30 seconds of oxygen-bag-mask device assisted ventilation. The oxygen level should be set to the flow meter 15 L/min, and where applicable, the reservoir should be fully open ensure that the patient gets 100% oxygen for each breath. One strength observed in the study is the fact that bag-mask device is best done by two blue code team members where one open the airway to fasten the mask on whereas the second one squeezes the oxygen bag.
Also, the article states that defibrillation is very critical and that the use of placement hands-free defibrillation pads is a safer option than hands held defibrillation paddles (Girotra et al., 2012; Prince et al., 2014). The article states that the deployment of automated external defibrillators (AED) should be used as soon as possible as it reduces mortality and morbidity associated with cardiac arrest caused by either ventricular fibrillation or ventricular tachycardia (Australian Resuscitation Council, 2008).
The compressions should resume immediately after delivering shock even with a normal heart rhythm as it will not provide enough cardiac output that will ensure adequate perfusion. It is recommended that 2 minutes the cardiac rhythm should be assessed after 5 cycles of a CPR (Merchant et al., 2014). The use of vasopressors in cardiac arrest is recommended only when there are no high-quality CPR. It is important to be extra cautious when administering a drug. This is because miscommunication is a common issue which often leads in the administration of incorrect drug doses or medications.
This can be prevented by using “closed loop” method of communication (Segon et al., 2014; William et al., 2016). For instance, when a nurse receives an order to inject some medicine, they should repeat the information of drug prescribed out loud, inject it and then announce it again after administration (Price et al., 2012). This method was used in some instances, but in the instance that it was absent, the recorder was prone to miss out some key aspects; for example, in this code blue simulation, the recorder had missed recording the endotracheal tube measurements.
The article suggests that an effective code blue team should have leader who controls the all the procedures and efforts of resuscitation. They communicate with the staff involved and evaluate the cardiac rhythm of a patient. Mr. Sellinger is the team captain of the case study and was standing in a position such that he could effectively see all of the resuscitation procedures and efforts. If the organization allows, the family member can be allowed into the room. It is also important to ensure that the information is well recorded.
In the case study, the recorder is shown documenting all the resuscitation process. However, it is important to understand that documentation process is done according the healthcare facility’s policy (McEvoy et al., 2014; Sahin et al., 2016). The recorder should remind the code team when time for a specific task has elapsed and must record all the activities taking place including the medicines prescribed. The article also suggests that all clinical areas should grant quick access to equipment such as blood glucose, blood pressure, and equipment of pulse oximetry and other equipment so as to effectively manage a deteriorating patient (Clarke, Carolina Apesoa-Varano, & Barton, 2016).
Through this case study, it is evident code training programs using simulation is beneficial and has been recommended by various healthcare institution organizations since 1999. This training will help the learners to improve cardiac resuscitation outcomes as it offers an opportunity for regular hands-on practice within the hospitals. This also helps the team to understand the various roles and responsibilities expected during a full code. Along with continuing education and mock codes, the team members become confident in their responsibilities (Gutwirth, Williams, Boyle, & Allen, 2012).
Bayramoglu, A., Cakir, Z. G., Akoz, A., Ozogul, B., Aslan, S., & Saritemur, M. (2013). Patient-Staff Safety Applications: The Evaluation of Blue Code Reports. The Eurasian Journal of Medicine, 45(3), 163–166. http://doi.org/10.5152/eajm.2013.34
Castelao, E. F., Russo, S. G., Riethmüller, M., & Boos, M. (2013). Effects of team coordination during cardiopulmonary resuscitation: A systematic review of the literature. Journal of critical care, 28(4), 504-521.
Clarke, S., Apesoa-Varano, E. C., & Barton, J. (2016). Code Blue: Methodology for a qualitative study of teamwork during simulated cardiac arrest. BMJ open, 6(1), e009259.
Girotra, S., Nallamothu, B. K., Spertus, J. A., Li, Y., Krumholz, H. M., & Chan, P. S. (2012). Trends in Survival after In-Hospital Cardiac Arrest. The New England Journal of Medicine, 367(20), 1912–1920. http://doi.org/10.1056/NEJMoa1109148
Gutwirth, H., Williams, B., Boyle, M., & Allen, T. (2012). CPR compression depth and rate about physical exertion in paramedic students. Journal of Paramedic Practice, 4(2).
McEvoy, M. D., Field, L. C., Moore, H. E., Smalley, J. C., Nietert, P. J., & Scarbrough, S. (2014). The Effect of Adherence to ACLS Protocols on Survival of Event in the Setting of In-Hospital Cardiac Arrest. Resuscitation, 85(1), 10.1016/j.resuscitation.2013.09.019. http://doi.org/10.1016/j.resuscitation.2013.09.019
Merchant, R. M., Berg, R. A., Yang, L., Becker, L. B., Groeneveld, P. W., & Chan, P. S. (2014). Hospital Variation in Survival After In‐hospital Cardiac Arrest. Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, 3(1), e000400. http://doi.org/10.1161/JAHA.113.000400
McInnes, A. D., Sutton, R. M., Nishisaki, A., Niles, D., Leffelman, J., Boyle, L., … Nadkarni, V. M. (2012). The ability of code leaders to recall CPR quality errors during the resuscitation of older children and adolescents. Resuscitation, 83(12), 1462–1466. http://doi.org/10.1016/j.resuscitation.2012.05.010
Price, J. W., Applegarth, O., Vu, M., & Price, J. R. (2012). Code Blue Emergencies: A Team Task Analysis and Educational Initiative. Canadian Medical Education Journal, 3(1), e4–e20.
Prince, C. R., Hines, E. J., Chyou, P.-H., & Heegeman, D. J. (2014). Finding the Key to a Better Code: Code Team Restructure to Improve Performance and Outcomes. Clinical Medicine & Research, 12(1-2), 47–57. http://doi.org/10.3121/cmr.2014.1201
Segon, A., Ahmad, S., Segon, Y., Kumar, V., Friedman, H., & Ali, M. (2014). Effect of a Rapid Response Team on Patient Outcomes in a Community-Based Teaching Hospital. Journal of Graduate Medical Education, 6(1), 61–64. http://doi.org/10.4300/JGME-D-13-00165.1
Sahin, K. E., Ozdinc, O. Z., Yoldas, S., Goktay, A., & Dorak, S. (2016). Code Blue evaluation in children’s hospital. World Journal of Emergency Medicine, 7(3), 208–212. http://doi.org/10.5847/wjem.j.1920-8642.2016.03.008
Williams, K.-L., Rideout, J., Pritchett-Kelly, S., McDonald, M., Mullins-Richards, P., & Dubrowski, A. (2016). Mock Code: A Code Blue Scenario Requested by and Developed for Registered Nurses. Cureus, 8(12), e938. http://doi.org/10.7759/cureus.938
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Neonatal Resuscitation
Introduction
Is there a thing that is as defenseless and precious as a baby who is newly born? I agree with the fact that thousands of babies in the United States are premature before their small bodies can sustain life. The normal time needed for a fetus to be fully developed in to a normal baby is usually thirty six to forty weeks. Premature infants therefore, are those born before the thirty sixth week.
Infants born before the twenty sixth gestation week have anatomically underdeveloped lungs and, they cannot physiologically support ventilation. I appreciate that there has been giant leaps forward within the last decades which has enabled us all but the most premature and smallest infants.
Currently, analyzing the Millennium Development Goals on Neonatal resuscitation in the developing world indicates that there is an impressive progress in child health. However, there is barely any notable achievement as far as neonatal health is concerned. Neonatal deaths’ proportion (death within the initial twenty eight days) is anticipated to increase as a result of the reduction in postneonatal deaths burden.
The World Health Statistics shows that the health-related MDGs indicate that approximately thirty seven percent of the under-five mortality is usually within the neonatal period. Most deaths occur during the first week (early neonatal period). More than one million neonates lose their life within the first twenty four hours as a result of poor quality care, globally and annually.
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Continuum of Care
The key principle in developing strategies aimed at addressing (NHC) Neonatal Health Care revolves within the continuum of care. Throughout the lifecycle, including childhood, childbirth, pregnancy and adolescence, the care need to be offered as a seamless continuum spanning the health center, community and home, globally and locally (Atkins and Murphy, 1994, 50). Therefore, decreasing child mortality depends entirely on managing neonatal mortality or otherwise, tackling Neonatal Health Care.
Personal Experience
I am a RRT (Registered Respiratory Therapist) and have worked in NICU (Neonatal Intensive Care Unit). Additionally, I have visited many other units as part of the duties as a Respiratory Care nurse. I have experienced the procedures and tests, the angst and waiting as well as the sensitive roller coaster of emotions that both parents and child endure. In case the infant is developed adequately and is strong enough for survival, there is anxiety concerning the quality of life for the child and the family that has to cater for the child’s specific needs.
Is the cost measurable in terms of real dollars and emotionally? Mezirow (1990) argues the mortality and morbidity rates in particularly low birth weight children is remarkably high; it is in fact, so high that the sole ethical choice is to leave them die a painless and natural death. Infants that are born before the twenty fourth gestation week need not be resuscitated for financial, medical and ethical reasons.
Medical ethic principles are justice, beneficence, non-maleficence and respect for autonomy. These principles act as the guideline for health care professionals when dealing with all their patients. There is no exception. Respect for autonomy recognizes “the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act” (Lim et al, 2000, 492).
In the case of neonates, the biological parents have the responsibility of making the child’s health care decisions, as far as ethics in medicine is concerned. The non-maleficence principle implies that healthcare professionals should not create needless injury or harm intentionally to the patient, either with omission or commission acts. All procedures ad tests should have their benefits weighed. Beneficence can be defined as “the duty of health care providers to be of a benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient”.
In respect to the justice principle, each patient should be given what is rightfully theirs. Equal persons should be given equal treatment (Speck, 1985, 93). Moreover, patients need to be treated with honesty and dignity, and together with their families, the healthcare community’s total disclosure is necessary so that they are able to make informed decisions. Even if, a health care professional does not agree with the decision made, it is necessary to treat the patient with dignity; the choice should be respected.
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My Critical Experience
From my many years of practice as a nurse, I choose this critical experience since it was tremendously emotional and had a profound impact on me until today. Douglas was delivered at twenty five weeks of gestation with a weight of five hundred and fifty grams. He was born spontaneously preterm in vertex presentation. His primigravida single mother, Annette, had pre-eclampsia which led to the preterm birth.
Annette was given a dose of steroids thereby delivering Douglas within the next hour. Using antenatal steroids is considered as critical intervention in anticipation of prematurity which improves preterm babies outcome (Teasdale, 2000, 581).
At birth, Douglas’ condition was critical and therefore, the need for resuscitation. As mentioned earlier, surfactant treatment is administered to preterm infants having respiratory distress since they lack a protein referred to as surfactant which prevents the lung’s small air sacs from collapsing. Douglas was therefore given surfactant treatment together with a breathing mechanical ventilator aid so that his lungs could remain expanded.
The boy’s condition improved, and he was successfully transferred to CPAP (Continuous Positive Airway Pressure). This was aimed at delivering pressurized air to his lings via small tubes in the nose to help in breathing. Douglas developed bleeding in the brain (intracranial bleed) of grade III on the second day. Intracranial bleed is prevalent during the first 3 days of life and an ultrasound examination diagnoses it. Mild intracranial bleeds resolve themselves and no of few lasting problems (Miles, 1989, 71).
More severe bleeds cause the brain ventricles to expand rapidly, causing brain pressure which brings about permanent brain damage. The results are neuro developmental delay or cerebral palsy. Douglas also had PDA (Patent Ductus Arteriosus), a common heart problem in premature babies. This however did not need treatment as it was small.
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Irrespective of the boy’s critical condition during the first week in life, there was an improvement in his general condition. Naso-gastric tube feeds started being used, and intravenous fluids stopped (Shields-Poe and Pinelli, 1997, 32). While still an inpatient at the hospital, Annette visited Douglas for 2 days during which she was updated of his critical condition. Annette did not bond with her son comfortably, although the nurses encouraged her to.
She gave excuses so that she could not express milk and therefore Douglas was fed with donor breast milk. On the 3rd day, she was discharged, and she visited only once every week. However, she called nurses most of the times to enquire about his progress. Annette’s behavior was brought to the attention of a social worker, and it was reviewed. When I was delegated to look after Douglas, I met the mother once during which I spoke with her and encouraged her to hold and touch the baby which she did.
On the 22nd day after birth, the CPAP was working for Douglas; he could tolerate the feeds and was adding weight. For the six days I took care of him, his general condition was satisfactory. Annette called at nights to check on Douglas’ condition. I informed her he was stable with a 30 grams weight gain. She was enthralled and promised to come the following day.
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On my seventh night duty, on the twenty eight days after birth, I was surprised to meet Douglas re-intubated and on Nitric oxide high frequency mode ventilator. Douglas has developed PPHN (Persistent Pulmonary Hypertension), stopped breathing and was cyanotic. According to Wood (2009), preterm PPHN is linked to high risk adverse neurodevelopmental and health outcomes. To date, it is among the most complicated conditions experienced in NICU.
His critical condition made him be supported using various intravenous infusions, among them morphine to manage pain. Annette had visited at day time and cuddled her baby. She also has a social talk with the in-charge nurse and she was to come during the evening and stay overnight with her son. Unfortunately, Douglas succumbed to cyanotic attack after she left. She was updated of this on her way back to the hospital. On arrival, Annette and the friend she had come with were confused to see the extreme technical situation surrounding the boy.
I offered a drink and a chair to Annette. The serving consultant counseled her and recommended the life support to be withdrawn since Douglas IVH was at grade IV. Annette was unable to decide on the care withdrawal. She begged to leave and come back with her mother the following morning to discuss the situation further and come up with a decision. She immediately left.
At NICU, 4 nurses are delegated with the responsibility of receiving admissions from the theatre and labor ward and taking care of sick babies. We were 3 three nurses that night as a result of staff shortage. An emergency came from the clinical nurse manager from the labor room. One of the nurses rushed to the labor room and brought back twenty eight weeks preterm Mark who was intubated. He required medications and infusions and since his condition was grave, attention was focused to him.
After Mark settled, I was beside Douglas when I realized that his heart rate had gone down to 120 per minute from the usual 160 per minute. The consultant agreed with me that nothing more could be done. The morphine infusion had to be increased to manage pain (Reid, 1993, 307). I called Annette as they were driving home with the friend to inform her of the development. She confirmed that she would come back the following with her mother as earlier agreed.
I touched Douglas’s hand soothingly and wished Annette was there to console and hold him. Suddenly, the nurse attending to Mark called out for drugs as Mark had developed cardiac arrest. We worked to resuscitate Mark but I could see that Douglas was also going in to an arrest since there was continuous drop in the heart rate. Mark was the priority at the moment but I wished I could go over to Douglas and console him.
His monitor stopped indicating vital signs. Mark died shortly after Douglas. We did all we could have done to save the two lives but as with hundreds of other babies, we were unsuccessful. The social worker had to follow Annette to provide further care.
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The Care of Premature Newborns
“Good ethics begin with compelling facts” is a guiding principle when dealing with ethical care for premature newborns. So as to make a profound decision, the first thing is the qualified obstetrician to assess and gather all the necessary information utilizing all the available resources. Consequently, the parents need to be informed in a way that they can understand (respect for autonomy).
“It should be emphasized that there is some uncertainty with any predictive process, because every infant is unique. The prognosis for the fetus may change after birth, when a more accurate assessment of the gestational age and actual condition can be made” (Daly et al, 2004, 2).After the fetal weight and gestational age are determined; the parents should be presented with the facts and counseled on the child’s possible outcomes.
It is imperative that the health care team and physician address the process of decision making as a team, together with the parents. Moreover, the parent’s belief system and desires as well as the child’s needs should be kept at the forefront. The Journal Pediatrics have categorized the treatment decisions and summarized them on prognosis basis as:
1. In case there is a high likelihood of early death and survival would encompass high risk of morbidity that is unacceptably severe: intensive care not indicated.
2. In case there is a likelihood of survival and the risk of inadmissibly severe morbidity is small: indicate intensive care.
3. In cases that fall within the mentioned categories and there is uncertain prognosis and likely extraordinarily poor, and survival encompasses diminished child’s quality of life, parental desires determine the approach for treatment. (Carkhuff, 1996, 211).
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During the last few decades, there has been an improvement in the prognosis for tremendously premature infants. However, many of the exceptionally small and extremely premature infants die or possess a morbidity rate that is unacceptably high. In this population, the medical complications are usually profound and complicated. Some complications result from the birth event and others are congenital defects. Majority of the morbidities are linked to immature lung development.
Fetuses produce surfactant, an essential proper lung function protein, at the age of thirty two weeks. Surfactant deficiency is treated by medical science by refining and producing porcine and bovine surfactant. However, this is usually not as effective compared to native surfactant. There is the instantaneous complication of reduced delivery of oxygen to the brain, organs and blood. Besides this, the long term complication is anoxia, brain injury as a result of inadequate oxygen supply to the brain. High morbidity rates attract the greatest categories of complications.
Majority of the morbidities bring about profound and severe disabilities, and cause early demise (Murphy et al, 2003, 227). The mortality rate of neonates in this group is relatively high, and the severe to moderate morbidity rate is more than fifty percent. It is worth noting that the statistics for very small and very premature neonates indicate a one hundred percent mortality rate. These children possess physical limitations and abnormalities that they have to bear with for their entire lives and which their families need to provide care. The outstanding care is extremely expensive and emotionally exhausting.
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Reflect on the cost of offering care to late preterm vs a term infant. Late preterm have far much less complications as well as complicated medical needs as opposed to Extremely Low Birth Weight (ELBW) neonates, and yet the cost of caring for them during their 1st year of life is astoundingly vast. The cost for taking care of a premature infant who is late term is three times more the cost for term infants.
Extremely Low Birth Weight neonates’ cost is six times a term infant’s cost, if the infant survives. At a national level, the cost for ELBW’s care is staggering. United States spends 5.8 billion dollars annually (Raeside, 2000, 98). This represents forty seven percent of all infant hospitalization costs and twenty seven of all pediatric stays. 65, 600 dollars is the average cost, where the least viable consume most of the resources.
The figures refer to the initial hospital stay costs. This is the first care as far as caring for children with profound or severe disabilities are concerned. Is this burden fair to the society? These are some of the prevailing questions in the light of the discussion on medicine socialization and healthcare coverage. What is the belief of the society on the value of life? Can a baby’s existence be replaced with the dollar value?
Considering that resources are infinite, should they be used on the few neonates and leave the majority to share the smaller percentage? (Schmieding, 1999, 636). What if it is my child is among those that require disproportionate resources and care to survive? What if my child is among those being given a normal care level since there are few providers as majority of the providers are focused on ELBW who need the highest care level? The answer to these questions will vary depending on the role of a person; a parent, health care consumer or a provider.
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Figure 1: Grave Neonatal Morbidities in < 750 g Birth Weight Infants in the National Institute of Child Health and Human Development Neonatal Centers, 1995-1996
Condition
Frequency of Morbidities (%)
Range
Respiratory Distress Syndrome
78
54-97
Oxygen required at twenty eight days after birth
81
64-92
Chronic Lung Disease
52
8-86
Necrotizing Enterocolitis
14
9-38
Septicemia
48
30-64
Grade 3 intraventricular hemorrhage
13
6-29
Grade 4 intraventricular hemorrhage
13
3-26
Periventricular Leukomalacia
7
2-30
Growth failure
100
92-100
This data is for infants who are alive at twenty days (Cotton, 2001, 515).
Conclusion
Preterm neonates require extensive care to ensure their survival. Major challenges that make this goal ineffective include inadequate nurses and medication. More than often, care has to shift to neonates who require immediate attention. It is sue to these reasons that neonate mortality is still high although there has been an improvement in child care as per the MDGs. It takes a lot of courage to work as a nurse and especially when emphatic with the mother to the neonate infant.
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