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State autonomous professional educational institution of the Saratov region

“Engels Medical College of St. Luke (Voino-Yasenetsky).

QUALIFYING WORK

Diagnostic activity of a paramedic in bronchial asthma

Engels 2016

INTRODUCTION

This thesis is devoted to the issues of modern diagnostics and prevention of bronchial asthma.

The topic of the thesis is relevant, since bronchial asthma "is the most frequent chronic disease" and about 4 million people (5% of the population) suffer from it in our country.

Over the past 15 years, the incidence of bronchial asthma in the Russian Federation has almost tripled. In 2007, the national average was 902.8 per 100,000 population. At the same time, in the Chechen Republic, the incidence rate was minimal (98.7 per 100,000 population), and in the Yaroslavl region - the maximum (1,444.5 per 100,000 population), which is associated with differences in climatic and geographical, as well as socio-economic factors of external Wednesday. The consequence of this is ineffective and inadequate treatment, including outdated and ineffective drugs that have lost their clinical significance. In addition, the lack of a unified approach to the management of patients at the prehospital stage reduces the quality of medical care and creates conditions for the further growth of this disease.

The topic of the thesis has practical significance, because the results of the work can be applied in the individual prophylaxis of patients. bronchial asthma first aid

Purpose of work: is to study theoretical and practical issues related to the action of an emergency medical assistant. To consider and show the importance of a competent, step-by-step algorithm for the action of a paramedic in setting and providing first aid to a patient diagnosed with bronchial asthma.

And also the use of new opportunities that can study knowledge and practical actions at the pre-medical stage, in a patient with bronchial asthma. According to this, the following tasks must be solved:

1) study the theoretical foundations of this disease.

2) Collection of statistical data on the formulation and correct diagnosis of "Bronchial asthma" in patients admitted by the ambulance to the admission department of the City Hospital No. 1 in Engels.

3) Conduct an assessment and analysis of the data of the statistics.

4) Conduct a questionnaire survey among the paramedics of the SSMP in order to identify a unified and correct algorithm for actions at the pre-medical stage with a given diagnosis.

5) Conduct an assessment and analysis of the psychological climate at the ambulance station

6) Identification of additional opportunities applicable at the pre-medical stage, according to the analysis of the actions of the paramedic, which will allow him to competently and correctly guide a patient with a diagnosis of bronchial asthma.

Subject of the study: a patient with bronchial asthma, employees of the SSMP in Engels.

Subject of research: the activity of a paramedic in providing assistance to a patient with bronchial asthma.

Research methods: logical (analysis of call cards, synthesis and generalization), comparison and methods of mathematical statistics.

1.1 Definition and etiology of bronchial asthma

"Bronchial asthma" is a chronic inflammatory disease of the airways, in which many cells and cellular elements are involved. The disease manifests itself as symptoms of widespread, but not permanent, airway obstruction, occurring spontaneously or under the influence of therapy, and is accompanied by an increase in the sensitivity of the airways to various external stimuli. Risk factors for the development of bronchial asthma include heredity, occupational and environmental hazards, some drugs and microorganisms, food, household chemicals. One of the causes of bronchial asthma is an atopic reaction to the secretions of ticks, pollen of plants, fungal spores, feathers of birds, wool and desquamated scales of the stratum corneum of the epidermis of animals. Such exogenous bronchial asthma is characterized by a genetic predisposition.

According to the statement, "from 5% to 10% of asthma cases develop under the influence of occupational hazards." Bakers, dyers and varnishers, welders, health workers, farmers, radio installers and representatives of some other professions have high risks of morbidity due to unfavorable factors of professional activity. Their work is accompanied by the inhalation of pollutants, for example, grain dust, fine droplets of paints and varnishes, the smoke of melting electrodes, the smallest splashes of cephalosporin and tetracycline antibiotics, casein, rosin vapors and solder fluxes containing ammonium and zinc chlorides. The isolation of these organisms is due to the fact that the products of their vital activity have a high ability to initiate bronchial asthma, some of them are classified as occupational hazards, and they are common both in nature and in living quarters. There are also factors that cause exacerbation: causal (allergens) and aggravating factors, exercise, cold air, weather changes, emotional stress, respiratory viral infection.

1.2 Pathogenesis of bronchial asthma

The progression of bronchial asthma and the appearance of episodes of asphyxiation occur in the case of altered body reactivity. The hereditary-constitutional factor is important, which causes pathological reactivity due to sensitization of the body. Sensitization of the body in bronchial asthma often occurs under the influence of protein allergens, however, other substances and influences are resolving factors. Weather conditions have a significant effect on the reactivity of the organism: it has been noticed that the frequent occurrence of attacks of bronchial asthma in spring and autumn in damp and cold weather is characteristic. A decisive place in the appearance of attacks of bronchial asthma is attributed to the pathological reaction to irritation of the interoreceptors and exteroreceptors of the parasympathetic nervous system. Dysfunction of its center is the result of a violation of the interaction of cortical processes of excitation and inhibition, which regulate the work of subcortical centers. Excitation of the nervus vagus causes a spasm of the small bronchi and the filling of their lumen with thick viscous mucus. The afferent receptors of the bronchial walls 8 of the sensitized organism acquire hypersensitivity to local stimuli and form an altered response to stimulation. This occurs during acute and chronic inflammatory processes in the bronchi. In some patients with severe bronchial asthma, irreversible bronchial obstruction occurs due to structural changes in the airways. Deposition of collagen and proteoglycan fibers under the basement membrane initiates subepithelial fibrosis. It is typical for all patients with bronchial asthma. The thickness of the bronchial walls increases due to hypertrophy and hyperplasia of the smooth muscles of the bronchial walls. Under the influence of the growth factor of the endothelium of blood vessels, the vessels of the bronchial walls proliferate, causing their thickening. An increase in the number of goblet cells in the epithelium of the respiratory tract and hypertrophy of the submucous glands promote mucus hypersecretion. The endocrine pathology of the adrenal glands contributes to the emergence and progression of bronchial asthma. Narrowing the lumen of the bronchi increases airway resistance and the body uses the accessory muscles. By the time the expiration is completed, both the alveoli and the peripheral airways overwhelm significant volumes of non-evacuated air, therefore, there is a functional ventilation stenosis and perfusion-ventilation imbalance. Due to a decrease in the saturation of arterial blood with oxygen, hypoxia develops.

1.3 Classification of bronchial asthma

According to the Fifth National Congress on Respiratory Diseases, held in Moscow in 1995, bronchial asthma is classified according to the form and clinical severity of the process.

I) Forms of bronchial asthma:

1) atopic (allergic or exogenous); nine

2) non-atopic (non-allergic or endogenous):

2.1) aspirin asthma;

2.2) exercise asthma;

2.3) infectious-dependent;

3) mixed.

The classification is based on the severity and nature of the airway obstruction, and is of great clinical importance, since it allows you to determine the tactics of patient management.

There are four degrees of severity:

1) mild intermittent or episodic course (symptoms occur less than once a week; short exacerbations; nocturnal symptoms less than twice a month;

2) mild persistent course (symptoms are observed less than once a day, but more often than once every seven days; exacerbations can disrupt both sleep and physical activity; night symptoms - more than twice a month;

3) moderate asthma (symptoms are daily; exacerbations interfere with performance, sleep, physical activity; night symptoms - more than once a week;

4) severe asthma (symptoms are constant during the day; both exacerbations and nocturnal symptoms are frequent; physical activity is significantly reduced, limited. The severity is determined by the worst clinical sign and only before the start of treatment.

There are several definitions of the term "asthma control". “Controlling a disease is preventing or even curing a disease. However, today these goals are unattainable in treatment, therefore, in this case, this term means control over the manifestations of the disease. " The goal of bronchial asthma treatment is to achieve and maintain control over a long period of time, taking into account the safety of therapy, potential adverse reactions and the cost of treatment. Therefore, when assessing control over bronchial asthma, one should focus not only on control over clinical manifestations (symptoms, nocturnal awakenings, use of short-acting drugs, activity limitation, respiratory function), but also on control over future risks (exacerbations, rapid deterioration of lung function, side effects of medications.

The severity of the exacerbation of bronchial asthma is classified: mild - more than 95%,

medium - from 91% to 95%,

severe - less than 90%,

asthmatic status - less than 88%.

According to A. D. Ado, P. K. Bulatov, G. B. Fedoseev, according to the stages of the development of the disease, biological defects in practically healthy people, a state of pre-asthma and clinically expressed bronchial asthma are distinguished. According to the patient's condition, bronchial asthma is isolated in the stages of exacerbation, unstable remission, remission and stable remission (lasting more than two years).

1.4 Clinical picture

Exacerbation of bronchial asthma - the reappearance of shortness of breath and suffocation, which can occur in the form of an acute attack associated with brnchospasm or exacerbation of the disease due to the gradual development of bronchial obstruction. The latter is characterized by prolonged (days, weeks, months), shortness of breath with clinically pronounced bronchial obstruction syndrome, against which acute attacks of bronchial asthma of varying severity may recur.

Exacerbations are assessed based on clinical signs and functional breathing tests. Exacerbation in severity can be mild, moderate-severe, severe with the threat of respiratory arrest.

The severity of asthma and the severity of exacerbation are different concepts, although they have much in common. The course of mild intermittent asthma can be accompanied by severe attacks, and in severe asthma, exacerbations of mild severity can develop.

BA exacerbation criteria:

The mild degree is characterized by:

Shortness of breath (suffocation), with physical exertion, NPV 20-25 per minute.

On auscultation, a moderate amount of dry wheezing, usually at the end of expiration. Moderate tachycardia (less than 100 per minute).

Physical activity is maintained or moderately limited. The patient is excited, talking in sentences. Peak expiratory flow rate less than 80% of normal or better. Measured by "Peakflowmeter".

A moderate degree is characterized by:

Shortness of breath (suffocation) when talking, NPV 25-30 per minute, the participation of auxiliary muscles in the act of breathing. On auscultation of the lungs, dry wheezing, severe tachycardia (100-120 per minute). Physical activity is limited, the patient is agitated, sometimes aggressive, speaks in separate phrases. The peak expiratory flow rate is 60-80% of the individual norm or the best indicator.

A severe degree is characterized by:

Shortness of breath (suffocation) at rest, NPV more than 30 per minute, pronounced participation of auxiliary muscles in the act of breathing, retraction of the jugular fossa. On auscultation of the lungs - widespread dry wheezing, severe tachycardia (more than 120 per minute), often a paradoxical pulse. Physical activity is sharply limited, the position is orthopnea, agitation, fright, "respiratory panic", utters individual words. Burst speed less than 60% of individual rate or better.

The threat of respiratory arrest is characterized by:

Consciousness is confused, the patient is lethargic, inhibited, there is no physical activity, the patient does not speak. Auscultatory picture of a silent lung. Cyanosis, bradycardia. It is impossible to estimate the PSV.

ASTHMATIC STATUS - a non-arresting attack of bronchial asthma, characterized by acute obstructive respiratory failure during the day. The main distinguishing features of astamatic status: lack of effect from conventional bronchodilatory therapy (an attack that does not stop within 24 hours should be considered an astamatic status); unproductive, debilitating cough.

According to the literature, mortality in status asthmaticus reaches 1.5%.

The immediate causes leading to status asthmaticus are most often the following:

1) errors in the drug treatment of patients - the termination or self-reduction of the dose of hormonal drugs taken, the abuse of sympathomimetic drugs, the excessive use of sedatives (tranquilizers, neuroleptics, barbiturates);

2) bacterial and viral infection in the acute stage;

3) neuropsychic stress;

improperly conducted desensitizing therapy;

repeated contact with the allergen

progressive chronic heart failure.

Pathogenetic mechanisms of development of status asthmaticus:

As a result of the blockade of b-adrenoreceptors of the bronchi, hyper and discrimination are noted (increased production of a thick, viscous tracheo-bronchial secretion, which can be allergic, stagnant, inflammatory. Expiratory collapse of small and medium bronchi develops, hypoxia, hypercapnia, tissue dehydration, polycythemia, acute cor pulmonale.

The clinical picture of acute respiratory failure status asthmaticus is characterized by three syndromes:

Respiratory syndrome: tachypnea up to 30 per minute, shortness of breath, participation in breathing of the auxiliary muscles of the chest, limitation of diaphragm excursions, difficult and delayed exhalation, severe cyanosis, weakening of respiratory noises, unproductive cough, sputum is absent. Profuse perspiration on face and neck. The patient takes a forced position, the chest in the position of maximum inhalation.

As the decompensation grows, the severity of symptoms increases, a difference appears in the auscultatory picture ("mosaic" breathing, "mute" lung) and the sonority of hanging rales heard at a distance. The extreme severity of acute respiratory failure contrasts with poor physical and radiological data.

Circulatory syndrome: characterized by manifestations of cor pulmonale. Tachycardia grows, blood pressure can be high at first, then gradually falls. There is a significant difference in systolic pressure on the brachial artery during inhalation and exhalation, it can reach 50 mm Hg. Signs of right ventricular overload: swelling of the cervical veins, high CVP, acute swelling of the liver, edema of the lower extremities with prolonged right ventricular failure.

Neuropsychic syndrome: Inadequate excitement, then lethargy, which can progress to a coma, trembling in the limbs. The culmination of an asthmatic state is a hypoxic-hypercapnic coma.

Forms of astamatic status:

1) anaphylactic form - immunological or pseudo-allergic reactions prevail with the release of a large amount of biologically active substances, allergy mediators;

2) metabolic form - in which the leading role belongs not to mediators, but to the functional blockade of bronchial adrenergic receptors. The mechanism of this form is an increase in the blockade of bronchial adrenoreceptors with excessive intake of inhalers containing b2-sympathomimetics.

According to the severity of the course, status asthmaticus is divided into compensation, subcompensation, decompensation.

Stage of compensation: Patients note pain in the muscles of the shoulder girdle, chest, and abdominal area. The most alarming symptom is the absence of phlegm. With continued hyperventilation, a large excretion of moisture through the exhaled air, the sputum dries up and its viscosity increases. Viscous casts obturate the lumen of the bronchi. The onset of atelectasis is especially characteristic of childhood. Hyperventilation, hypocapnia persist, ventilation-perfusion separation increases, blood flow shunting from right to left, hypoxemia, hypercapnia. The ECG shows signs of an overload of the right heart.

Stage of subcompensation: The stage of "silent" lung is always striking a discrepancy between the severity of distant wheezing and their absence on auscultation. This is an extremely serious condition, when it is difficult for the patient to speak, each movement is accompanied by a sharp deterioration in the condition. The chest is emphysematous swollen, its excursion is almost invisible, a pulmonary sound with a box shade, breathing is sharply weakened, wheezing is heard only in the upper parts. The development of this picture is preceded by precursors, breathing begins to acquire a "mosaic" character. In the posterior-lower sections, zones of the "mute" lung appear, which quickly spread to the lateral and anterior sections and above to the level of the shoulder blades. Changes in the cardiovascular system indicate the extreme severity of hemodynamic disorders in the pulmonary circulation. A paradoxical pulse often appears, the number of heartbeats exceeding 120 per minute. On the ECG, there are signs of an overload of the right heart, arrhythmias are possible. Blood pressure tends to rise. Pain in the right hypochondrium increases due to stretching of the fibrous capsule of the liver. The acid-base state changes. In the blood, pCO2 increases, respiratory, and then mixed acidosis is formed, under which the pharmacological activity of drugs changes. So, in conditions of hypoxemia and hypercapnia, arrhythmogenic properties of sympathomimetics, adrenaline appear.

Stage of decompensation: Stage of hypoxic-hypercapnic encephalopathy. If the resolution of the "silent" lung syndrome does not occur, then signs of cerebral hypoxia appear - hypoxic agitation, inappropriate behavior. Rapid exhaustion of the patient develops, the degree of shortness of breath increases, cyanosis is pronounced. Before loss of consciousness, there may be epileptiform seizures. With the loss of consciousness, tachypnea turns into bradypnea, the auscultatory picture of the "silent" lung remains, blood pressure drops, and a paradoxical pulse persists. Respiratory muscle fatigue occurs when the muscles involved in inhalation, primarily the diaphragm, are unable to create the vacuum required for adequate ventilation. Early signs of respiratory muscle fatigue foreshadow a significant decrease in alveolar ventilation and an increase in pCO2. The appearance of rapid shallow breathing and uncoordinated contractions of the respiratory muscles, with alternating chest and abdominal breathing, and paradoxical retraction of the abdominal wall during inspiration is a harbinger of threatening respiratory acidosis and respiratory arrest.

All patients with status asthmaticus are subject to hospitalization, if necessary, against the background of intensive care. Only in the stage of compensation is hospitalization in the therapeutic department, in other cases in the intensive care unit. Transportation should be carried out on a stretcher with a raised head end.

Measures to remove the patient from status asthmaticus:

compulsory hospitalization

complete physical rest

distracting procedures (hot foot baths), copious alkaline, warm drinks.

directions of drug therapy:

reduction of pressure in the pulmonary circulation and improvement of pulmonary microcirculation.

reducing the reactivity of the tracheo-bronchial tree and overcoming resistance to sympathomimetics (sedation);

prevention of thromboembolic complications (heparin);

improvement of mucociliary clearance and drainage of the bronchial tree (mucolytics);

sanitation of the tracheo-bronchial tree;

correction of the acid-base state (mechanical ventilation, О2);

Complications of bronchial asthma

Pulmonary:

Pneumonia

Atelectasis

Pneumotorox

Extrapulmonary:

Acute pulmonary heart

Acute heart failure

Cardiac arrhythmia.

1.5 Features of the diagnosis of bronchial asthma at the pre-medical stage

Differential diagnosis is carried out with other diseases accompanied by severe shortness of breath, especially in elderly patients or in the absence of a positive effect of treatment.

BA attack - wheezing with reduced PSV. A history of similar seizures that were controlled by bronchodilators. Seasonal changes in symptoms during the day. Attacks are triggered by contact with an allergen or nonspecific irritating environmental factors. Sleep disturbance due to shortness of breath and wheezing.

Acute heart failure (pulmonary edema) - heart disease, ECG changes, bilateral wet wheezing in the lungs.

Pneumonia - fever, productive cough, pleural chest pain.

Exacerbation of COPD - an increase in the viscosity and amount of sputum discharge or the appearance of pus in the sputum. History of chronic bronchitis.

PE - chest pains, hemoptysis, the presence of risk factors for venous thromboembolism.

Pneumothorax is a sudden onset of shortness of breath in apparently healthy young people. Shortness of breath occurs immediately after invasive procedures (for example, catheterization of the subclavian vein). Pleural chest pains.

Laryngeal obstruction - history of inhalation of smoke or corrosive substances. Swelling of the palate or tongue. Acute allergy symptoms.

Caller advice:

Before the arrival of the ambulance, take the following measures:

1.Help the patient to breathe freely, unbutton the tight collar.

2. Position - with a raised head end, if possible, sitting with a palm rest (to connect additional respiratory muscles).

3. Try to calm the patient down. Prevent hypothermia.

4. Give the patient inhaled bronchodilators (specify the drug or dose) if he does not use them too often and the heart rate is less than 130 per minute. Find the drugs the patient is taking and show them to the emergency room staff.

6. Do not give food or drink

7. Do not leave the patient unattended.

1.6 Treatment

Treatment of bronchial asthma should not be limited to taking only bronchodilator drugs that eliminate the symptoms of the disease; in this case, an integrated approach is of great importance, which will include anti-inflammatory drugs, drugs to control the course of the disease, immunotherapy and other supportive measures.

1.Glucocorticosteroids in tablets and inhalations, which have an anti-inflammatory effect. In this case, inhalations are considered the main remedy for the treatment of bronchial asthma, as they promptly eliminate inflammation in the bronchi.

2.Beta-agonists of adrenergic receptors (adrenomimetics) and short-acting M-anticholinergics. They are used for the operative relief of an asthmatic attack due to their ability to expand the bronchi and eliminate its edema during smooth muscle spasm.

3.Long-acting beta-ogonists. They are used to control the course of the disease, they are able to keep the bronchi in an expanded state for a long time.

4. Antibodies to immunoglobulin E. They are prescribed in case of development of allergic bronchial asthma and if there is no result from hormone treatment.

5. Hormones. Suppress inflammation in the bronchi, are used, as a rule, for mild and moderate asthma;

6. Immunostimulants. It should be remembered that as a result of the use of adrenomimetics alone (relieving asthma attacks), addiction of the receptors of the bronchial system to the action of these drugs can develop, as a result of which the effect weakens over time, and eventually disappears completely.

Therefore, basic therapy with anti-inflammatory drugs is mandatory in the case of bronchial asthma.

One of the most effective means in the treatment of bronchial asthma today is the use of a nebulizer.

The effectiveness of this device is due to the fact that it breaks down drug molecules into microparticles that penetrate into every part of the bronchial tree.

The diagnosis of bronchial asthma involves timely treatment, control over the course of the disease and systematic interaction with the attending physician, who prescribes an individual therapy plan, taking into account the characteristics of the organism of a particular patient.

Depending on the severity of the disease, the plan may change. To achieve positive dynamics, stepwise treatment is of particular importance.

This approach involves moving to a higher level when symptoms intensify and changing the concept of treatment.

The weakening of the symptoms and the preservation of this state for three months allows the patient to be transferred to the lower stage and, as a result, completely cancel the drug treatment.

The main goal of such a therapeutic method is a prolonged state of remission, which is accompanied by a reduction in the number of attacks or their complete absence.

Relief of an asthmatic attack:

· Remove allergens that could trigger an asthma attack;

· Provide the patient with peace and fresh (but not cold) air;

· Free the neck and chest from clothing;

Inhale 1-2 portions of a bronchodilator with an inhaler or nebulizer;

· If relief does not come, make another inhalation in 10-15 minutes;

· If the asthma attack persists, call an ambulance immediately.

1.7 Prevention

Distinguish between primary, secondary and tertiary prophylaxis of bronchial asthma.

Primary prevention of bronchial asthma is a complex of medical and non-medical measures aimed at preventing the onset of the disease, combining the following:

1) reducing the impact of allergens, viruses, certain drugs, household chemicals, cosmetics, perfumes on a person who has a history of atopy;

3) normalization of body weight for persons with BMI> 30 kg / m2, because, “in most cases, obesity precedes the development of bronchial asthma

4) maintaining normal immunity: hardening, a rational regime of work and rest, sufficient daily intake of ascorbic acid (90 mg for adults) and the trace element zinc (10-15 mg for adults);

5) a ban on travel to places where flowering plants are currently emitting pollen (for example, acacia, ragweed, birch, quinoa, alder, hazel, wormwood, poplar) and arthropod bites are not uncommon;

6) normalization of the structure and quality of food (content of onions and garlic in the diet, rejection of allergenic foods and food additives);

7) identification and minimization of other factors that can provoke the occurrence of bronchial asthma, including of a behavioral nature.

Secondary prevention of bronchial asthma is a set of measures to prevent attacks of bronchial obstruction both in patients who are currently ill and in remission. It combines a set of the following measures:

1) conducting dispensary examinations to identify the dynamics of health status and assess changes in the severity of bronchial asthma;

2) individual and group counseling of patients and their family members, training in the necessary manipulation techniques;

3) elimination of professional factors (we suggest changing jobs);

4) elimination of allergens from living quarters (replacing feather pillows with synthetic winterizers, stopping contact with food for aquarium fish, refusing to have pets with hair, for example, cats, rabbits, dogs) and regular wet cleaning;

5) prevention of stress, warning about the inadmissibility of intense emotional stress (anger, crying, laughter);

6) a doctor's warning that the patient is sick and the prescription of certain medications (salicylates and other NSAIDs in the case of the asthmatic triad, ampicillin, paracetamol, penicillin) may cause complications;

7) improving the quality of inhaled atmospheric air (moving to an area with a favorable environmental situation, without photochemical smog);

8) complete elimination of the use of alcohol and drugs (self-control and treatment by a narcologist);

9) carrying out medical and psychological adaptation of the patient to the disease of bronchial asthma, creating an adequate attitude to the capabilities and needs of the body, and more.

Tertiary prophylaxis of bronchial asthma - rehabilitation - includes health schools, stay of patients in sanatoriums-dispensaries in resorts with a maritime climate or in the highlands.

The paramedic is obliged to form the patient's adherence to a healthy lifestyle, to inform and promote knowledge about the influence of risk factors for the onset, progression, and relapse of the disease.

CHAPTER 2. PRACTICAL ACTIVITIES OF THE FELDSHER IN THE SPHERE OF DIAGNOSTICS AND PREVENTION OF BRONCHIAL ASTHMA

2.1. Unified tactics of an ambulance paramedic in relation to a patient with bronchial asthma

Paramedic actions on call:

Mandatory questions:

How long does the asthma attack last?

What provoked him?

Is it more difficult for the patient to inhale or exhale?

Is there wheezing, paroxysmal cough?

Did the patient take any drugs (if the patient used bronchodilators, then clarify the route of administration: dose, frequency, and time of the last drug intake)? Their effectiveness?

Have you had similar attacks before?

When was the previous attack? How did you stop it?

Has a history of bronchial asthma been diagnosed?

Does the patient receive glucocorticoids (inhalation, systemic), in what doses?

Physical examination and physical examination

Assessment of the general condition and vital functions: consciousness, respiration, blood circulation.

1) Assessment of the patient's position: orthopnea is characteristic.

2) Visual assessment of availability:

Barrel chest;

Participation in the act of breathing of the auxiliary muscles of the chest;

Long expiration;

Cyanosis;

Swelling of the neck veins;

Hyperhidrosis;

3) Calculation of NPV (tachypnea).

4) Research of pulse (may be paradoxical), calculation of heart rate, (tachycardia, in severe cases there may be bradycardia).

5) Measurement of blood pressure (arterial hypertension, in severe cases there may be arterial hypotension).

6) Percussion of the lungs: there may be a boxed sound.

7) Auscultation of the lungs: hard breathing, multi-tone dry wheezing, mainly on exhalation; variegated wet wheezing may be heard. In status asthmaticus, a sharp weakening of breathing is noted mainly in the lower parts of the lungs, and in more severe cases, a complete absence of bronchial conduction and wheezing ("silent lung").

Instrumental research:

Study of PSV using a peak flow meter.

Treatment tactics are determined by the severity of BA exacerbation, therefore, when formulating the diagnosis, it is necessary to indicate the severity of the exacerbation.

The goal of emergency therapy is to relieve an attack of suffocation.

1) If possible, exclude contact with causal allergens and triggers.

2) It is preferable to use inhalation therapy through a nebulizer and infusion forms of drugs.

3) Bronchodilators are used - selective b2adrenoagonists of short action, if the heart rate is less than 130 per minute.

Salbutamol - inhalation of 2.5-5.0 mg through nebulization for 10-15 minutes. Onset of action in 5 minutes, maximum effect within 30-90 minutes, duration 3-6 hours. If necessary, repeat inhalation every 20 minutes or up to a total dose of 10-15mg / h. Frequent side effects are possible: tremors, tachycardia, palpitations, nervousness, restlessness, nausea. Muscle spasms and twitching are possible, rarely arrhythmias.

Contraindications: hypersensitivity; with caution in case of ischemic heart disease, tachyarrhythmias, thyrotoxicosis

4) In case of a severe attack of suffocation or asthmatic status, anticholinergics are added:

Ipratropium bromide - inhalation of 0.4-2.0 ml through nebulization for 10-15 minutes. Onset of action after 5-20 minutes, maximum effect after 90 minutes, duration 3-4 hours. Possible side effects: cough, dry mouth, unpleasant taste.

Contraindications: hypersensitivity, pregnancy (1 trimester)

5) It is advisable to use combined preparations of short-acting selective b2-agonists with anticholinergics (for an attack of any severity).

Fenoterol + ipratropium bromide - inhalation of 1-2 ml (20-40 drops) through a nebulizer for 10-15 minutes. The onset of action in 15 minutes, the maximum effect is achieved in 1-2 hours, duration up to 6 hours.

Glucocorticoids - their use depends on the severity of the asthma attack.

With a moderate course of an attack, the application is indicated:

Prednisolone - i.v. 60-90mg, pre-dilute in 0.9% sodium chloride solution to 10-20ml, inject in a stream, slowly. The clinical effect of glucocorticoids develops within 1 hour after administration.

Side effects with intravenous injection: anaphylaxis, redness of the face and cheeks, convulsions. Contraindications: hypersensitivity, gastric ulcer and duodenal ulcer, severe hypertension, renal failure.

With a severe attack and status asthmaticus -

Prednisalone IV 90-150mg (up to 300mg). There are no contraindications for health reasons.

If the condition worsens and there is a threat of respiratory arrest,

Epinephrine 0.1% -0.3-0.5 ml intramuscularly or subcutaneously, if necessary, repeat up to three times after 20 minutes.

In status asthmaticus, oxygen therapy is indicated (be careful with cyanosis) at a rate of 2-4 l / min.

Monitoring of NPV, heart rate, blood pressure, and in a severe attack and status asthmaticus ECG due to possible complications from the heart. Readiness for mechanical ventilation and resuscitation.

Criteria for the effectiveness of treatment:

A) After stopping the attack, repeat the definition of PSV.

A good response to the therapy: stable condition, dyspnea and dry wheezing in the lungs decreased, PSV increased by 60 l / min.

B) Incomplete response to the therapy: the state is unstable, the symptoms are expressed in the same degree, there is no increase in PSV.

C) Poor response to therapy: symptoms are expressed in the same degree or increase, PSV decreases.

Indications for hospitalization:

After the provision of emergency treatment, urgent hospitalization is required for patients with:

Severe asthma attack, or status asthmaticus.

Suspected complications;

Lack of rapid response to bronchodilatory therapy;

Further deterioration of the patient's condition against the background of the started treatment;

Long-term use or recently converted intake of systemic glucocorticoids.

Patients should also be referred to the hospital:

Hospitalized several times in the intensive care unit during the last year;

Not maintaining a BA treatment plan;

Those suffering from mental illness;

When a mild / moderate asthma attack is relieved, patients are stable, and there are no complications, patients can be left at home.

Eliminate (or limit as much as possible) the influence of nonspecific irritants: smoking, occupational hazards, pollutants, pungent odors and others. If necessary, limit the physical and psycho-emotional stress.

Prohibit the use of p-blockers.

Outpatient consultation with the attending physician (pulmonologist, allergist-immunologist) to determine further tactics (examination, treatment of exacerbation of bronchial asthma, selection of basic therapy).

Education in asthma school

Common mistakes

The use of psychotropic drugs, narcotic analgesics, first generation antihistamines.

Massive hydration.

The use of acetylsalicylic acid.

Routine use of intravenous aminophylline (aminophylline *) in an attack of bronchial asthma in addition to P2-agonist therapy is not indicated.

This does not lead to an additional bronchodilatory effect, but is accompanied by an increase in the frequency of side effects (tremor, headache, tachycardia, nausea and / or vomiting, increased urine output, gastroesophageal reflux, dermatitis; due to the low therapeutic latitude, overdose and the risk of sudden death from arrhythmia are possible or seizures). In adults, it is permissible to prescribe aminophylline as part of the complex therapy of status asthmaticus (a small additional effect), if the patient has not previously taken theophylline orally: 2.4% aminophylline IV - 10-20 ml, previously diluted in 0.9% solution sodium chloride - 10-20 ml and inject over 10-20 minutes.

In children with a severe attack of bronchial asthma and status asthmaticus, the need for intravenous aminophylline (6-10 mg / kg) should be considered as an adjunct to systemic glucocorticoids, β2-agonists and anticholinergics. This provides a small additional bronchodilatory effect, but it comes at the cost of a fourfold increased risk of vomiting.

2.2 Research, analysis and assessment of the diagnosis of a paramedic, according to the correspondence of the diagnosis "bronchial asthma" between paramedics of emergency medical care and doctors of the admission department 2gor. Hospitals

For the study, the statistical data, admissions of patients to the hospital, and the number of hospitalized with bronchial asthma, for 2015, 2p were considered. hospitals in Engels.

From the analysis carried out, both in% and in numerical terms, it is noted that a greater number of patients with bronchial asthma, the onset period falls on the age of 40 to 50 years (11 and 45 patients), (15% and 64%), this corresponds to general statistics. And also bronchial asthma makes up one third of all emergency diseases of the pulmonary system, which require an emergency ambulance. Considering the data of the analysis of hospitalized patients, it should be noted that the number of patients (70) with bronchial asthma is the final clinical diagnosis, because all patients were subsequently hospitalized. Therefore, using the data of the admission ward regarding the admission of patients with a preliminary feldsher's diagnosis of "Bronchial asthma" in 2015, I found that the number of those admitted with this diagnosis was 80. Consequently, the number of discrepancies in the diagnosis was 10.

A study was carried out about the discrepancy in the diagnosis between the admission ward and the diagnoses made by the paramedic when the patient was delivered to the hospital.

Analyzing the data, it is especially important to note that a serious condition of one patient was underestimated and a correspondingly incorrect diagnosis was made. The problem is caused by subjective reasons for the discrepancy in diagnoses:

1) insufficient examination of the patient

2) underestimation of anamnestic data,

3) underestimation of clinical data

4) incorrect construction or execution of the final pre-medical diagnosis.

Three patients with a diagnosis of COPD. In this case, a diagnostic, but not a tactical error is allowed. There is no danger for the patient when such a diagnosis is made, the main condition of the paramedic is not to worsen the patient's condition.

This includes six patients with overdiagnosis; there is also a discrepancy in diagnoses, because in these patients, according to the admission ward, the main clinical diagnosis was "an attack of bronchial asthma", but in this case, the patient management tactics were correct.

Evaluating the analysis carried out, we can say that, despite the discrepancy in the diagnosis, regarding an attack of bronchial asthma, and the correct tactics of the paramedic, in relation to these patients, diagnostic errors are present, and the problem of accurate diagnosis in this case remains, which is very important knowing about the consequences of this complication - that when the wrong diagnosis is made and, accordingly, the wrong tactics of patient management, and subsequently the failure to provide timely assistance, the patient is fatal due to the development in this case - complications of the "silent lung". In this regard, it is possible to apply additional measures to eliminate the subjective reasons for the discrepancy between the diagnosis of "bronchial asthma attack" - paramedic and clinical, both on the basis of EMS and FAPAH.

2.3 Statement of possible measures to eliminate the subjective reasons for the discrepancy between the diagnosis "Bronchial asthma onset period" - medical assistant and clinical

Currently, there are generally accepted measures - this is the conduct of advanced training courses for paramedics on the basis of specialized departments of medical universities, which allows them to fully prepare them for independent work and, ultimately, maintain a sufficient amount of medical care during life with dangerous conditions at the prehospital stage, regardless of the composition mobile teams.

It is especially important to note that in recent years, much attention has been paid to the development by paramedics - rational diagnostic schemes (in the form of action algorithms, protocols or standards) for the management of patients with critical conditions and the development of practical life skills of saving manipulations, which allow them to independently carry out full-fledged therapeutic and diagnostic measures with direct a threat to the life of patients, which is important for patients with bronchial asthma.

It is also desirable to equip paramedic teams with modern medical and diagnostic equipment, adapted for nursing staff, that is, simple to operate, but allowing for life-saving medical care in full.

To increase the level of professionalism, it is possible to create a training center for paramedics, where to actively apply the methodology of business games with modeling emergency situations as close as possible to real conditions, in particular, in a situation in patients with an attack of bronchial asthma. It is advisable to hold these games on a competitive basis, with subsequent evaluation points, the withdrawal of prizes, as well as an analysis of the mistakes made.

It is also possible to introduce computer testing, for the theoretical analysis of the errors made by the paramedic, in urgent situations, in particular if there is no coincidence in the diagnosis of bronchial asthma, the onset period, pre-medical and medical, with the subsequent analysis of errors and the development of action protocols for the paramedic in this situation.

2.4 Features of individual preventive conversations with patients suffering from bronchial asthma

Taking into account the experience of preventive conversations with patients who apply to the Ambulance Station in Engels, I concluded that communication with a patient should take the form of a dialogue, not a monologue. The paramedic should listen carefully to the patient, even if he wants to speak out, unobtrusively directing the conversation according to the established plan. In addition, the author, I am sure that a paramedic, especially in contact with patients with bronchial asthma, should not use perfumery, and he should not exude intense odors that can cause bronchospasm.

From prevention conversations, according to GINA 2012, “all patients should receive key information, skills and abilities, but most of the training should be individualized and carried out in stages”.

The main components of a conversation:

1. emphasis on cooperation between the paramedic and the patient, which is necessary for the formation of compliance - scrupulous adherence to the recommendations of the healthcare professional;

2. recognition of the need not to interrupt the process of collaboration between health care provider and patient;

3. thorough exchange of information;

4. discussion of the expected results of diagnosis, prevention and treatment, as well as the patient's fears and concerns;

5. informing the patient about the differences in the means of emergency and supportive therapy, about the possible side effects of drugs;

6. teaching the patient the correct use of inhalation devices and self-diagnosis of bronchial asthma;

7. informing about the signs of a threat of bronchial obstruction and the actions that the patient should take in this case;

8. providing the patient with a diary of control over bronchial asthma.

CONCLUSION

Based on the above, we can say that it is completely impossible to solve this problem, but it is possible to reduce the% of mortality from complications. On the example of the practical part, the solution to the problem can be seen at the first stages of the development of the disease - pre-medical, and it is the correct tactics of managing a patient with an attack of bronchial asthma by a paramedic at the pre-hospital stage that allows solving the problem of complications that may appear. This includes (based on the practical part) the algorithmic action of the paramedic at each stage of the course, as well as the provision of correct first aid at each stage of the disease (bronchial asthma). The totality of the paramedic's knowledge both in practical and theoretical activity, namely knowledge of the signs of each degree of the disease, knowledge of differential diagnosis (in relation to other acute diseases of the pulmonary system), and, which is especially important, to prevent the development of status asthmaticus. medical assistance, as well as delivery of the patient is reflected in the positive treatment.

Improving theoretical knowledge and practicing practical skills in this case is possible, in addition to the generally accepted ones, is the creation of a training center for paramedics, where you can actively apply the methodology of business games with simulation of emergency situations, as close as possible to real conditions, which is also acceptable for the diagnosis "Bronchial asthma onset period ".

To increase theoretical knowledge, this is also the introduction of computer testing, for the theoretical analysis of errors made by a paramedic in urgent situations, in particular, if there is no coincidence in the diagnosis of bronchial asthma, pre-medical and medical, with the subsequent analysis of errors and the development of action protocols for the paramedic in this situation. The combination of all these possibilities, for a paramedic, will allow to suspend and reduce mortality in this disease.

LIST OF USED LITERATURE

1.Shatikhin A.I. Direct examination of the patient in the clinic of internal diseases. Tutorial. Part I. Respiratory system. - M .: Triada-X, 2012 .-- 448 p.

2. Baur K. Bronchial asthma and chronic obstructive pulmonary disease / Baur K., Preisser A .; per. with him. ed. I. V. Leshchenko. - M .: GEOTAR-Media, 2012 .-- 192 p.

3. Internal diseases: textbook / MV Malishevsky [and others]; ed. M.V. Malishevsky. - 4th ed., Revised and enlarged. - Rostov n / a: Phoenix, 2012 .-- 984 p.

4. Gitun TV Treatment of bronchial asthma: the latest medical techniques. - Ripol Classic, 2010 .-- 64 p.

5. Global strategy for the treatment and prevention of bronchial asthma (revision 2011) / Ed. A. S. Belevsky. - M .: Russian Respiratory Society, 2012 .-- 108 p.

6. Kosarev, V. V. Professional bronchial asthma / V. V. Kosarev, S. A. Babanov // Handbook of a general practitioner. - 2010. - No. 3. - p. 29 - 34.

7. Kosarev, V. V. Diagnostics, treatment and prevention of occupational bronchial asthma / V. V. Kosarev, S. A. Babanov // Handbook of a paramedic and midwife. - 2012. - No. 2. - p. 12 - 18.

8. Nenasheva NM Bronchial asthma. Pocket Guide for Practitioners. - Atmosphere, 2011 .-- 96 p.

9. Otvagina T. V. Therapy: a tutorial / T. V. Otvagina. - Ed. 6th. -Rostov n / a: Phoenix, 2014 .-- 367 p.

10. Handbook of a paramedic of general practice / E. V. Smolev [and others]. - Ed. 4th. - Rostov n / a: Phoenix, 2015 .-- 537 p.

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Introduction

Thermal injuries (injuries) represent a serious medical, social and economic problem and occupy the third place in the structure of peacetime injuries.

This problem has especially increased in connection with man-made accidents, increased production, the development of vehicles, increased urbanization of the population and an increase in natural disasters.

More than 600 thousand cases of burn injuries are registered in Russia annually. At the same time, about 70% of patients receive limited area and shallow burns. Assistance is provided to them mainly on an outpatient basis.

According to Russian authors, mortality from burns in Russia as a whole ranges from 2.3% to 3.6%. Of the 180-200 thousand victims hospitalized in all medical institutions in Russia, 8-10 thousand people die annually. At the same time, 85-90% are people of working age and children. And out of the number of survivors, 12-15 thousand people need long-term rehabilitation.

Of the burned, hospitalized in hospitals, 60-80% of patients also have superficial and borderline II - IIIA degree burns that do not require surgical treatment. However, such burns largely determine the severity of the injury and its prognosis.

Electric burns in frequency among burns from other causes account for only 2 - 3%, but often cause disability and, in some cases, death.

Rehabilitation is the restoration of health, functional state and working capacity, impaired by diseases, injuries or physical, chemical and social factors. The goal of rehabilitation is the effective and early return of sick and disabled people to everyday and work processes, into society, and the restoration of a person's personal properties. The World Health Organization (WHO) gives a very close definition of rehabilitation: "Rehabilitation is a set of measures designed to provide people with disabilities as a result of diseases, injuries, birth defects, adaptation to the new conditions of life in the society in which they live."

According to WHO, rehabilitation is a process aimed at comprehensive assistance to sick and disabled people in order to achieve the maximum possible physical, mental, professional, social and economic usefulness in this disease.

Improving the efficiency of the paramedic's work based on the model of organizing medical care for patients with thermal injuries allows realizing these directions and achieving an increase in the quality of life after injury. The aim of this course work is to analyze the role of a paramedic in carrying out rehabilitation measures for patients with thermal injuries to improve their quality of life.

To achieve the goal set in the course work, the following tasks were identified:

Consider the anatomy of tissues exposed to thermal factors.

List the most common causes of thermal damage.

Classify thermal damage.

Describe the methods of treatment and rehabilitation for thermal injuries.

Determine the activities of the paramedic during the

Analyze the effectiveness of the rehabilitation performed.

The object of research is thermal damage.

The coursework consists of two chapters. The first chapter examines the anatomy, clinical manifestations, methods of treatment and rehabilitation for thermal injuries.

The second chapter, which is a practical part, provides a statistical analysis of the cases of patients' appeals to the FAP paramedic associated with thermal injuries, as well as paramedic activities during rehabilitation measures.

1.Treatment and rehabilitation for thermal injuries

.1 Anatomy: human skin, eyes, oral cavity

The skin is formed by three layers of tissues: the outer layer is the epidermis, the dermis is located under it, the deep layer is the subcutaneous tissue. The epidermis is a type of epithelial tissue. The outer layer of the epidermis is dead keratinized cells. They constantly peel off: every minute you lose about 50 thousand of these horny scales. However, the thickness of the epidermis does not decrease.

The upper layer of the epidermis is constantly renewed by the cells of the lower layer, which are cubic in shape and are constantly dividing. Some cells remain in the lower layer, while others form the upper layer. These cells lose their ability to divide, flatten, accumulate the protein keratin, and, as a result, they become keratinized, dead and exfoliated. In the lower layer of the epidermis, new cells are constantly being produced. So in 10-30 days it is completely renewed. Typically, the epidermis is 0.03-1.5 mm thick. But in areas of the body experiencing strong friction (palms, feet), it is several times thicker.

1.2 Derma

The intercellular substance of the connective tissue, which forms the dermis, contains collagen and elastic fibers. Thanks to them, the skin is elastic and easily stretched: pull it back on the back of your hand and release it - it will immediately return to its original state.

The thickness of the dermis is 0.5-5 mm, it is thick on the back, shoulders, hips. The dermis protrudes into the epidermis with many papillae, which raise the epidermis to form ridges and ridges. Their drawing is different for each person. The dermis contains blood and lymphatic capillaries, muscle and nerve fibers, nerve endings, pigment cells, sweat and sebaceous glands, hair follicles. Skin glands are endocrine glands that secrete secretions onto the surface of the skin. The sweat gland looks like a tube with a diameter of 0.3-0.4 mm, twisted into a glomerulus. One end of it is connected to the time in the epidermis. In humans, unlike other mammals, sweat glands are located on the entire surface of the body, but most of them are on the palms, feet, and armpits. The secret of the sweat glands is sweat, which is formed from the intercellular fluid. It consists of 98% water, the rest is salts, urea and other metabolic products dissolved in it.

Unlike sweat glands, the sebaceous glands are branched, and their ducts open into the hair follicle. Most of the sebaceous glands are located on the head, face, and upper back. their secret contains fatty substances. They reach the hair and skin surface and soften it. The waterproof layer formed by these substances protects the skin from dust and microorganisms, and also prevents it from drying out. The sebaceous glands secrete about 20 g of secretion per day.

Subcutaneous tissue is the lower layer of the skin formed by adipose tissue with a thickness of 3-10 mm. The subcutaneous tissue works as a shock absorber, dampening mechanical stress on the body surface. It is not for nothing that a thick layer of this tissue is contained on the buttocks and soles - they are constantly under great pressure. Adipose tissue is a good heat insulator, so thin ones usually freeze more than fat ones.

Derivatives of the epidermis perform an additional protective function, are hair and nails. Hair covers almost the entire surface of the skin, with the exception of the palms, soles, lateral surfaces of the fingers. On average, about 100 thousand hairs grow on a person's head, and although a person loses 75-100 of them daily, their number is normally restored.

In the hair, a rod protruding above the skin and a root located in the dermis are distinguished. The root is located in the hair follicle and ends with a thickening - the hair follicle. The base of the follicle is connected to the smooth muscle, when the contraction of which the hair rises. The hair follicle is made up of epithelial cells that divide to grow hair. Moving to the surface of the skin, these cells are filled with keratin and keratinized. In a month, the hair grows by about 1 cm. The cells of the hair follicle are capable of dividing for 2-4 years, then the hair growth stops and it falls out. After a while, the hair follicle can restore its activity.

Hair color is determined by the amount of melanin pigment contained in its outer layer. With age, melanin synthesis decreases and the hair turns gray.

The nail is a dense stratum corneum that lies on the nail bed. The bed is bounded from the sides by skin folds - nail ridges. The nail grows due to the division of the cells of the root of the nail in the same way as hair grows.

1.3 Function of the skin

The skin is one of the largest organs in the human body, its mass in an adult reaches 5 kg, and its area is 1.5-2 m2. And this is not surprising, because it is a shell that separates almost the entire human body from the external environment. The skin protects the internal organs from mechanical damage, from the penetration of various substances and microorganisms, from the harmful effects of ultraviolet radiation.

With the secretion of the sweat glands of the skin, water and certain metabolic products are released.

The skin also works as a sense organ. The sensation of touch, pressure, vibration, pain occurs due to the stimulation of the corresponding neurons, the nerve endings of which are contained in the skin. Thanks to the thermoreceptor neurons of the skin, you perceive changes in the ambient temperature. The skin plays an important role in thermoregulation: almost 82% of the body's total heat transfer occurs through it.

Skin is a blood depot and storage of reserve substances. The branched network of its vessels can hold up to 1 liter of blood, and fat accumulates in the subcutaneous adipose tissue. The role of the skin in metabolism is unique: vitamin D is synthesized only in its cells under the influence of ultraviolet radiation.

1.4 Organ of vision

Our eye is a complex optical system whose main task is to transmit images to the optic nerve. The initially visible image passes through the cornea. There, the primary refraction of light occurs. From there, through a round hole in the iris, called the pupil, it enters the lens. Since the lens is a biconvex lens, after passing through the vitreous, the visible image is reversed when it hits the retina. It is the signal of the inverted image that comes from the retina along the optic nerve to the brain. And the brain is for that and the brain is to turn the image back.

1.5 External structure

1.6 Eyelids

The eyelids (upper and lower) are covered on the outside by skin, from the inside by a mucous membrane (conjunctiva). In the thickness of the eyelids, there are cartilage, muscles (the circular muscle of the eye and the muscle that lifts the upper eyelid) and glands. The eyelid glands produce components of the eye tear, which normally wets the surface of the eye.

On the free edge of the eyelids, eyelashes grow, which perform a protective function, and the ducts of the glands open. The palpebral fissure is located between the edges of the eyelids. In the inner corner of the eye, on the upper and lower eyelids, there are lacrimal points - holes through which a tear flows through the nasolacrimal canal into the nasal cavity.

1.7 Shells of the eyeball

The human eyeball has 3 shells: outer, middle and inner.

The sclera occupies 4/5 of the fibrous membrane and consists of connective tissue, it is dense enough and the eye muscles are attached to it. The main function is protective, it provides a certain shape and tone of the eyeball. From the posterior pole of the eye in the sclera there is a place of exit of the optic nerve - the ethmoid plate. The cornea is 1/5 of the outer shell, it has a number of characteristics: transparency (absence of blood vessels), luster, sphericity and sensitivity. All these signs are characteristic of a healthy cornea. With diseases of the cornea, these signs change (opacity, loss of sensitivity, etc.). The cornea belongs to the optical system of the eye, it conducts and refracts light (its thickness in different sections ranges from 0.2 to 0.4 mm, and the refractive power of the cornea is approximately 40 diopters).

The middle (choroid) of the eye consists of the iris, the ciliary body and the choroid itself (choroid), which are located directly under the sclera. The middle membrane of the eye provides nutrition to the eyeball, participates in metabolic processes and the removal of metabolic products of the eye tissue. The iris is the anterior part of the vascular tract of the eye, it is located behind the transparent cornea, in the center there is an adjustable round opening - the pupil. Thus, the iris in the structure of the human eye plays the role of a diaphragm, painted in a certain color. Human eye color is determined by the amount of melanin pigment in the iris (light blue to brown). This pigment protects the eyes from excess sunlight. The pupil diameter varies from 2 to 8 mm, depending on the illumination, nervous regulation or the action of medications. Normally, the pupil constricts in bright light and dilates in low light.

1.8 Most common causes of thermal damage

Burns result from exposure to high temperatures (thermal burns), as well as from ultraviolet and other types of radiation (radiation burns). In peacetime, the main place is occupied by thermal burns as a result of negligence in everyday life (scalding with boiling water), fires, rarely due to industrial injuries due to non-observance of safety measures. The most common radiation burns are sunburn. Burns as a combat injury can be caused by the use of incendiary mixtures, as well as nuclear weapons, the light radiation of which causes skin burns and damage to the organs of vision.

The most common are flame burns, which were detected in 84.3% of more than 1000 patients who were in the hospital. In the second place were burns with liquids (7.2%), in the third place - electric burns and burns by an electric arc flame (6.4%). Burns caused by other factors were observed in 2.1% of patients.

In modern conditions of intensive industrialization, the ever-increasing use of sources of thermal energy in production and in everyday life, there is a tendency to an increase in the frequency of burns. According to the World Health Organization, burns rank third among other types of injuries, and in Japan - second, second only to traffic injuries, in peacetime burns account for 5-12% of all types of injuries. Analysis of literature data suggests that burns occur everywhere in 1 person per 1000 population. The incidence of burns can depend on a number of conditions: the level of development of the national economy, the nature of production, transport, living conditions, etc. It increases sharply in conditions of war, the use of nuclear weapons and incendiary mixtures. Burns are often fatal, and among those who have recovered, many remain disabled.

2.Classification of thermal damage

2.1 Thermal skin burns

Coagulation of skin proteins occurs from exposure to high temperatures. Skin cells die and undergo necrosis. The higher the temperature of the traumatic agent and the longer its effect, the deeper the damage to the skin. There are four degrees of burns: I degree - persistent hyperemia, II degree - peeling of the epidermis and blistering. III degree - burnout of the skin itself (dermis). Burns of III degree are divided into superficial - III a degree and deep - III b degree; IV degree - burnout of the skin, subcutaneous tissue and deeper structures.

2.2 Frostbite

Local exposure to low temperatures causes a pathological process in the tissues - frostbite. The latter can also occur at a positive ambient temperature in conditions of other unfavorable factors - high humidity, wet clothes, strong wind, tight wet shoes, starvation, blood loss.

There are four degrees of frostbite: Superficial frostbite (I - II degree) heal on its own - epithelialization without scarring. With frostbite II degree, the growth layer of the skin is preserved. Blisters on the skin with transparent contents are characteristic. Epithelialization occurs after 1.5-2 weeks. The degree of frostbite is characterized by skin necrosis throughout its entire depth. After rejection of the scab, healing is possible only with the formation of scars. Grade IV frostbite is characterized by necrosis not only of the skin, but also of deep tissues, including bones. The formation of thick-walled blisters with dark hemorrhagic contents is possible. Demarcation and rejection of necrosis occurs for a very long time, amputation is often indicated.

2.3 General cooling (freezing)

light (adynamic) - with a decrease in body temperature to 34-32 degrees;

moderate (stuporous) - at a body temperature of 31-29 degrees;

severe (comatose) - at a body temperature of 28-26 degrees.

A drop in body temperature below 25-23 degrees leads to the clinical death of the victim.

2.4 Clinical signs of thermal injury

I-II degree burns are superficial and heal without scarring. Third degree burns are deep, accompanied by scarring. To heal them, it is often necessary to resort to free skin plastic surgery. With IV degree burns, necrosis of the limb may occur, requiring amputation.

Burns of the 1st degree are characterized by persistent hyperemia of the burned skin, severe pain; with burns of the II degree against the background of hyperemic skin, bubbles of various sizes are distinguished, filling with transparent contents; with third-degree burns against the background of areas of hyperemia, open blisters, areas of white ("pig") skin with scraps of epidermis are visible; IV degree burn - skin charring. Extensive burns (superficial - more than 30% of the skin area, deep - more than 10%) are complicated by Burn shock, characterized by a prolonged erectile phase with psychomotor agitation, moderately elevated blood pressure. The victims rush about in pain, strive to escape, they are poorly oriented in the place and situation. Excitation is replaced by prostration with a fall in blood pressure. Burn shock is characterized by blood thickening due to large plasma loss. There is little urine, it is sharply concentrated, and in severe burns of a dark color due to the admixture of hemolyzed blood.

2.5 Frostbite

Unlike burns, in case of frostbite, exposure to low temperatures does not directly lead to tissue necrosis. It occurs a second time, in the reactive period, due to vasospasm, blood stasis in them and thrombus formation with subsequent changes in the vascular wall itself. The endothelium swells and infiltrates, followed by connective tissue degeneration and the development of vascular obliteration.

During frostbite, two periods are distinguished: latent (pre-reactive), in which the affected areas are pale, devoid of sensitivity, but it is impossible to determine the depth and area of ​​frostbite during this period. The latent period lasts for several hours (up to a day). After warming the limb and restoring blood circulation in it, the second period begins - the reactive one. In the first 12 hours from the beginning of rewarming - the early reactive period, characterized by microcirculation disorders and thrombus formation. The subsequent late reactive period is characterized by the development of subsequent tissue necrosis, infectious complications, increasing intoxication, anemia.

In the reactive period, it becomes possible to determine the depth of the lesion. There are 4 degrees of frostbite.

Superficial frostbite (I - II degree) heal on its own - epithelialization without scarring. With frostbite II degree, the growth layer of the skin is preserved. Blisters on the skin with transparent contents are characteristic. Epithelialization occurs after 1.5-2 weeks. The degree of frostbite is characterized by skin necrosis throughout its entire depth. After rejection of the scab, healing is possible only with the formation of scars. Grade IV frostbite is characterized by necrosis not only of the skin, but also of deep tissues, including bones. The formation of thick-walled blisters with dark hemorrhagic contents is possible. Demarcation and rejection of necrosis occurs for a very long time, amputation is often indicated.

Long-term repeated cooling of the legs in a humid environment, even at above-zero temperatures, leads to the development of a kind of cold injury, which is called "trench foot". The defeat is manifested by aching pains in the feet, a feeling of "stiffness", burning. Feet are cold, swollen. Blisters with hemorrhagic contents appear. The body temperature rises, weakness, tachycardia increase, infectious complications join.

2.6 Freezing

The adynamic stage of general cooling is characterized by increasing weakness, drowsiness, chanting speech, decreased heart rate (60 in 1 minute), thirst, chills. The skin takes on a marbled appearance - alternating pale areas (spots) with cyanotic ones. In the stuporous stage, further suppression of functions occurs: consciousness is depressed, movements are difficult, limited, breathing is rare (10 in 1 minute), bradycardia increases (up to 40 in 1 minute), the pulse is weak, the skin is cold, bluish-pale. Blood pressure decreases. In the comatose stage, consciousness is absent, the reaction of the pupils to light is sharply reduced. Tonic cramps of the limbs with rigidity (stiffness) are observed. Breathing is shallow, rare (5 in 1 minute), the pulse is reduced by about 30 in 1 minute, blood pressure is sharply reduced. In a state of clinical death, pulse, blood pressure, heart sounds are not detected, breathing is absent, areflexia is noted, and the corneal reflex is absent.

2.7 Eye burns

Accurate diagnosis of the severity of eye damage in burns is very difficult, since in the first hours and days after the injury, it may look light, and after 2-5 days, severe irreversible changes in tissues, especially the cornea, may appear, up to its perforation and eye death. In this regard, all patients with eye burns, after providing emergency first aid or non-specialized medical care at the site of the lesion, must be urgently delivered to the nearest trauma center operating around the clock on the basis of the inpatient ophthalmological department.

Photophobia, pain in the eye, spasm of the eyelids, redness, swelling of the skin of the eyelids and conjunctiva, decreased vision with all degrees of burn. Burns of the 1st degree (light) are characterized by superficial lesions of the epithelium of the eye tissues in the form of redness and slight edema of the skin of the eyelids and conjunctiva, slight edema of the corneal epithelium, less often erosion of the epithelium.

Second-degree burns (moderate) are characterized by damage not only to the epithelium, but also to the surface layers of the eyelid skin itself, subconjunctival tissue and corneal stroma, which is manifested by the formation of blisters on the skin, surface films and erosions on the conjunctiva and cornea. Burns of the III degree (severe) occur with damage and necrosis of the deeper layers of the eye tissues and occupy half or less of the surface of the eyelid, conjunctiva, sclera and cornea in area. Tissue necrosis looks like a white, gray or yellow scab, the conjunctiva is pale, ischemic, edematous, episclera is affected, the cornea looks like frosted glass. Burns of the IV degree (especially severe) are characterized by even deeper necrosis of the eye tissues, occupying the entire thickness of the skin, conjunctiva, muscles, eyelid cartilage, sclera and cornea, and in the area of ​​the lesion - more than half of the tissue surface. The necrosis scab looks gray-yellow or brown, the cornea has a white porcelain appearance.

Agents in peacetime: hot steam, water, oils, flames, molten metal, chemical mixtures (contact burns). Burns by steam, liquids are more often combined with damage to the skin of the face, body, limbs, however, the eyeball itself is affected less often and less severely due to the reflex of the quick closing of the palpebral fissure and at a low temperature of the damaging agent (up to 1000 ° C). Contact burns are distinguished by a significant depth with a small area of ​​\ u200b \ u200bthe lesion. In wartime, with the use of combustible mixtures and thermonuclear weapons, the proportion of thermal burns increases. For example, napalm, the ignition of which gives a temperature of 600-800 ° C, causes extensive severe burns, more often III and IV degrees. Thermal and thermochemical eye burns, as a rule, occur against the background of general burn disease as a result of burns of the face and other parts of the body.

2.8 Burn disease

Limited superficial burns are usually relatively easy and heal within 1 to 3 weeks, without affecting the general condition of the victim. Deep burns are more difficult. Damage to tissues on an area of ​​up to 10%, and in young children and seniors up to 5% of the body surface is accompanied by severe disorders of the activity of all body systems as a result of strong thermal exposure. An intense flow of nerve-pain impulses from a large area of ​​the burn leads to a disruption in the relationship between the processes of excitation and inhibition, and then to overstrain, exhaustion and a sharp disruption of the regulatory function of the central nervous system.

Disturbances in the central and peripheral nervous system arising under the influence of burn injury lead to pathological reactions and morphological changes in the cardiovascular, respiratory, endocrine, immune systems, blood, kidneys, liver, and ventricular tract. The victims develop disorders of all types of metabolism and oxidation-reduction processes, burn disease develops with a variety of clinical manifestations, which are based on neurodystrophic processes.

In the pathogenesis of burn disease, disorders of systemic hemodynamics and microcirculation, pronounced metabolic changes, characterized by a catabolic orientation and increased proteolysis, are of great importance. During a burn disease, it is customary to distinguish between periods of shock, acute toxemia, septicotoxemia and recovery, or convalescence.

Burn shock is the body's response to a super-strong pain stimulus. It is based on thermal trauma, leading to severe disorders of central, regional and peripheral hemodynamics with a predominant violation of microcirculation and metabolic processes in the body of the burned person; there is a centralization of blood circulation.

Prolonged painful irritation leads to dysfunction of the central nervous system, endocrine glands and the activity of all body systems.

Hemodynamic disorders are characterized by hemoconcentration, a decrease in MOC and BCC due to plasma loss, and inadequate blood supply to tissues. The victims develop tissue hypoxia and acidosis, diuresis decreases, there are pronounced violations of the water-electrolyte balance, protein, carbohydrate, fat and other types of metabolism, the basal metabolism increases sharply, progressive hypo and dysproteinemia develop, deficiency of vitamins C, group B, nicotinic acid. The development of hypoproteinemia is facilitated by the increased breakdown of tissue proteins, their loss through the wound due to an increase in the permeability of the capillary walls. The volume of circulating erythrocytes decreases due to their destruction in damaged tissues at the time of injury, and to a greater extent - as a result of pathological deposition in the capillary network due to microcirculation disorders.

Despite hemodynamic disorders, blood pressure in the first hours after injury can remain relatively high, which is explained by an increase in the total peripheral resistance to blood flow, which occurs due to vasospasm caused by an increase in the activity of the sympathoadrenal system, as well as an increase in blood viscosity due to hemoconcentration and deterioration of its rheological properties.

Burn shock is observed with burns, the area of ​​which is not less than 10-15% of the body surface. In children and persons over 60 years of age, manifestations of burn shock can be observed with a smaller area of ​​the lesion.

According to the severity and duration of the course, light, severe and extremely severe burn shock are distinguished.

The duration of the burn shock is 24-72 hours. The criteria for recovering from the state of shock and the transition to the second period of the burn disease are stabilization of hemodynamic parameters, restoration of BCC, IOC, absence of hemoconcentration, reduction of tachycardia, normalization of blood pressure and urine output, increase in body temperature.

Diagnosis of shock is based on determining the total area of ​​burns and the so-called Frank index (IF), identifying hemodynamic and renal excretory disorders. The total area of ​​the burn includes superficial and deep lesions. IF - the total value of superficial and deep burns, expressed in units. The Frank index suggests that a deep burn affects a person 3 times stronger than a superficial one. In this regard, 1% of superficial burn is 1 unit. IF, and 1% deep - 3 units. IF. Concomitant respiratory tract damage is equivalent to 15-30 units. IF.

3. Methods of treatment and rehabilitation for thermal injuries

medical thermal injury paramedic

Outpatient treatment is possible with extensive I degree burns, II and IIa degree burns of no more than 5% of the body surface, mainly in functionally inactive areas.

Victims with limited deep thermal and chemical burns are operated on and treated in a trauma center. It is possible to perform necrosectomy and free skin grafting only in a surgical hospital, where the operated person must stay at least until the first dressing, that is, at least 5-7 days.

Patients discharged from hospitals must also complete treatment in polyclinic medical institutions. The main task of the outpatient treatment of such patients is the earliest possible restoration of their ability to work, that is, rehabilitation.

First aid to a burned person who applies to a polyclinic medical institution immediately or early after an injury should be provided in compliance with the basic rules set forth earlier. Limited first-degree burns, even in outpatient settings, have to be observed extremely rarely only because such victims almost always self-medicate (cooling the burn areas with water, treatment with alcohol, cologne, etc.) and do not seek medical help.

In such cases, it is advisable to use a cooling cream (lanolin, peach oil, distilled water in equal parts), slightly disinfecting (2% boric petroleum jelly) ointments containing corticosteroid hormones (prednisolone ointment, oxycort), indifferent shaken mixtures (zinc oxide, talcum powder, 30 g, distilled water 100 ml). There is no need to apply a bandage. Hyperemia and edema are eliminated within 3 - 5 days, pain disappears much earlier.

If the victim handles a bandage already applied at the scene of the incident, after its removal, the area and depth of the lesion are determined. After making sure that the patient can be treated on an outpatient basis, you should immediately make a primary toilet for II-III degree burns. Since this manipulation, if it is performed skillfully and carefully, with limited burns is not traumatic, the preliminary administration of narcotic analgesics is not required.

The skin in the circumference of the burn, as well as its surface, if the integrity of the exfoliated epidermis is not broken, is cleaned with alcohol or washed with a 0.25% solution of ammonia. Large bubbles are cut, the exfoliated epidermis is cut off. Small bubbles can be left unopened. Overly careful removal of the epidermis, increasing the duration and trauma of the primary burn toilet, does not significantly affect the subsequent healing of burn wounds.

After the toilet, the surface of the burn is closed with an emulsion-ointment dressing (Vishnevsky ointment, 5 and 10% synthomycin emulsion, 0.5% furacilin ointment and other similar agents). If these ointments are not available, antiseptic solutions or other means to treat burns can be used. It is perfectly acceptable to limit yourself to the imposition of a dry aseptic dressing. An anti-tetanus serum with toxoid is introduced.

In case of second-degree burns, the first dressing on the 7-8th day after the injury, in principle, may be the last. By this time, epithelialization of the burned surface occurs and the bandage is no longer needed. If unhealed areas of a third-degree burn remain, dressings are made in 1-2 days until their complete epithelialization.

An indication for earlier removal of the bandage is a suspicion of the development of acute purulent inflammation, manifested by increased pain in the burn wound, sometimes acquiring a pulsating character, blotting the bandage with pus, regional lymphadenitis, edema in the circumference of the burn, sometimes a significant increase in body temperature, chills.

Examination of the burn wound, assessment of the state of regional lymph nodes and other symptoms allow us to establish the nature of the complication.

With burns of the II degree, suppuration of the wound surface and fluid of unopened burn blisters does not affect the timing and outcomes of healing. At the same time, in case of burns with necrosis of the dermis (partially or to the entire depth), demarcation and rejection of dead tissues are necessarily accompanied by the development at the end of the first - beginning of the second week in varying degrees of pronounced purulent-demarcation inflammation. In such cases, it is an indispensable component of the wound process. Therefore, with suppuration of a burn wound, the depth of the lesion should be carefully evaluated again and, if areas of deep burn are identified, the patient should be hospitalized.

If you decide to continue the treatment on an outpatient basis, you should repeat the toilet of the burn wound, completely removing the exfoliated epidermis and pus-filled blisters that have not been opened earlier. The wound surface is thoroughly washed with a solution of hydrogen peroxide or an antiseptic, after which a bandage is applied with an antiseptic solution. With a deterioration in health, chills, high fever, it is advisable to prescribe broad-spectrum antibiotics. Antibiotic therapy should be corrected depending on the clinical effectiveness of its use and laboratory data on the sensitivity of the microflora of burn brine to antibiotics. The same should be the tactics for the occasionally observed erysipelas, lymphadenitis and lymphangitis. As a rule, acute inflammation in superficial burns quickly subside and does not significantly increase the duration of treatment.

Studies carried out in the clinic of thermal injuries have shown that 3.3% of patients with limited superficial burns develop various dermatoses in the early stages after trauma. Of these, the most common are peri-wound pyoderma.

They flow for a long time, and after the healing of the burns they often recur. It should be borne in mind the possibility of dermatitis arising from intolerance to the medications used (antibiotics, sulfa drugs, amprovizole, fastin), or the irritating effect of disinfectants. Sometimes dermatitis develops from the use of ointments made on the basis of petroleum jelly. One of the causes of dermatitis can be a rare change of dressings on festering burn wounds. To combat pyoderma, careful disinfection of the skin surrounding the burn is necessary, the use of aqueous or alcoholic solutions of aniline paints, 1% hex-chlorafenic or 5% boron-naphthalene ointments on the affected areas. In case of allergic dermatitis, the medication used should be changed.

In case of burns of functionally active areas, 3 days after the injury, it is necessary to start physical therapy in order to accelerate the recovery of function. Initially, active movements are used with minimal muscle load and limited amplitude, which do not cause painful sensations. The movements in the joints of the affected area should be combined with exercises of the symmetrical unaffected limb. A prerequisite for the effectiveness of physiotherapy exercises is their regularity and a gradual increase in the load.

It is especially important to use this method for burns of the hands. Slow painless movements in the joints of the hand and fingers at the maximum possible amplitude (flexion, extension, opposition) should be supplemented with exercises to strengthen the muscles (squeezing a soft sponge in a bath after soaking the dressing). The most important exercises are those that restore grip functions as well as coordination of movements. For this, folding of matches, cubes, mosaics, weaving of braids from a ribbon, possibly an earlier restoration of household skills are used.

In case of II degree burns, these measures allow restoring the function of the hand in 1.5-2 weeks, and in case of III degree burns, 4-6 weeks after injury.

In case of burns of the legs and feet, considerable attention should be paid to restoring the support ability of the lower extremities. Pain in the areas of burns, aggravated when standing up, forces the victims to lie down for at least 6-7 days after the injury. Even after the epithelialization of the burns, several days pass before the burned person is able to walk in ordinary shoes. Full recovery of the limb support ability occurs at the end of the third - at the beginning of the fourth week with burns of the II degree, and with burns of the IIIa degree, this period increases by 1.5 - 2 times.

To speed up the restoration of the support ability of the lower extremities, physical exercises are necessary from the first days after the injury - frequent changes in the position of the limbs, dorsal and plantar flexion in the ankle joint, abduction, adduction and circular movements of the foot. After the start of walking, you need to monitor the correctness of the movements - to achieve the natural extension of the leg, the placement of the foot, its roll. If these requirements are not followed, gait may turn out to be pathological even after the complete restoration of joint mobility.

A special, still very little studied and very important problem is the rehabilitation of burned, discharged from the hospital. Usually, outpatient treatment of such patients is reduced mainly to conservative treatment by bandaging small wounds left after superficial burns and around the engrafted grafts in those operated on for deep burns. This is not enough in patients who have undergone severe burn disease, as well as with various post-burn deformities, late dermatoses.

4. Features of rehabilitation after discharge from the hospital

It is advisable to distinguish the following groups of pathological conditions:

) dysfunction and cosmetic defects after conservative treatment of superficial, including extensive burns;

) dysfunction and cosmetic defects remaining after surgical treatment of IIb degree burns;

) the consequences of IV degree burns, as well as mutilation interventions: amputations, exarticulations, resections of the joints, performed for the death of a limb segment due to a deep burn;

) late dermatoses;

) various functional disorders and diseases of internal organs, which are the result of burn disease or its complications.

Rehabilitation of survivors of superficial burns is mainly reduced to physical therapy, as applied to outpatient treatment of limited superficial burns. It is necessary to bear in mind the possibility of developing keloid scars after III degree burns, especially in patients predisposed to their formation. If such scars are a significant cosmetic defect, treatment with pyrogenal or the introduction of lidase with corticosteroid hormones into the scar tissue should be performed. Sometimes satisfactory results are achieved after using electrophoresis with ronidase, ultrasound with hydrocortisone emulsion, 70% dimethyl sulfoxide solution. If conservative treatment is unsuccessful, there is a need for surgical correction of scars, which should be undertaken in a specialized department for the treatment of burns and their consequences.

The same methods should be used in the rehabilitation of patients who underwent surgical restoration of the skin in the areas of IIIb degree burns. The main task is to stretch the scars, accelerate their maturation, as well as prevent irreversible graft reactions.

This is achieved mainly by passive movements in the joints, performed with the help of an exercise therapy methodologist. To combat contractures, it is important to strengthen the antagonist muscles, which is achieved by active strength exercises and relaxation of the muscles that are in a state of contraction, for which small amplitude movements are carried out with unloading. The set of exercises used is determined by the exercise therapy methodologist, depending on the period that has passed since the moment of injury, developed local changes and localization of the burn.

The effectiveness of physiotherapy exercises increases if it is used with massage and physiotherapy procedures. In the early stages after epithelialization of wounds, warm (35-40 ° C) baths, sollux should be used. As scars form and the strength of the epithelium covering them increases, paraffin applications should be done before physical therapy. The massage should be done carefully so as not to injure the young epidermis. This procedure significantly accelerates the normalization of blood circulation and lymph circulation, contributes not only to deretraction of scars and operatively restored skin, but also to an increase in the elasticity of deeper anatomical structures that are also involved in the development of contracture. In addition, the massage stretches the surrounding intact skin, which increases the range of motion. Sometimes the range of motion achieved during exercise therapy decreases after a few hours. To prevent this undesirable phenomenon, it is advisable to immobilize the joint in the position that was achieved at the end of the session.

It is especially important not to waste time for the production of those interventions, the delay with which threatens the development of severe consequences (keratitis with ulceration of the cornea and loss of vision with cicatricial eversion of the eyelids, impaired bone growth due to cicatricial deformities in children). Such patients should be promptly referred to restorative surgery facilities.

The most difficult rehabilitation after burns of the IV degree, leading to severe dysfunctions due to the destruction of deep anatomical structures (tendons, joints, bones) or disfigurement with the loss of part or all of the organ (nose, ears, fingers and toes). Such patients should be referred to surgical hospitals for reconstructive or maxillofacial surgery. The question of rehabilitation of those who have suffered deep burns of the cranial vault, especially in the presence of bone defects, should be resolved with the participation of a neuropathologist and neurosurgeon. With ankylosis and deforming arthrosis that have developed after postponed purulent arthritis, it is necessary to consult an orthopedic traumatologist to assess the indications for reconstructive interventions (arthroplasty, tendoplasty, arthrodesis in a functionally advantageous position). To partially restore the function of the hand after the loss of fingers, especially fingers I, in a number of patients, it is advisable to apply phalangization of the first metacarpal bone, transplantation of any of the remaining fingers on the vascular pedicle to the place of the first finger, or its formation with Filatov's stem.

For those who have undergone amputations of large segments of the limbs, the leading link in rehabilitation is prosthetics. It can be carried out on an outpatient basis only after typical amputations, mainly of one of the upper limbs. After multiple amputations, as well as in cases where limb truncation is made distal to the level of deep skin burn, and the skin on the stump is restored promptly, prosthetics is usually difficult. It is especially complicated by the diseases and defects of the stumps that often develop in such cases. Their elimination requires long-term treatment in a specialized hospital, where prosthetics and training in the use of a prosthesis should also be carried out.

Thermal injury classification is based on indicators such as the area and depth of the affected tissue.

Clinical manifestations depend on the damaging factor and the volume of destroyed tissues.

Rehabilitation methods for thermal injuries are aimed at restoring the physical, mental, professional, social and economic usefulness of such patients.

5. Investigation of the peculiarities of paramedic activity during various rehabilitation methods in order to improve the quality of life of patients with thermal injuries

Table 1. Generalized statistical indicators.

Country Russia Total burns 0.5 million people are treated on an outpatient basis 390-400 thousand 80% Hospitalized 100-110 thousand 20%

5.1 Quantitative analysis of patients with thermal injuries at the FAP site

The research work was carried out on the basis of BUZ VO "Rossoshanskaya RB". To determine the role of the paramedic in the provision of first aid for thermal injuries, treatment and prevention, it was decided to analyze the records in the outpatient cards of the FAP of a rural settlement for 2015, in which cases of treatment of persons living in the territory of this settlement were recorded regarding thermal injuries, as well as described the actions of a paramedic during rehabilitation measures.

As a result of the study, the following data were obtained:

the total number of complaints in connection with thermal injuries was 72 people.

table 2

Degree of burn Number of calls Cause I38 Hot water, steam II20 Flame III8 Flame IIIa6 Flame IV0 Flame TOTAL 72

The result of the analysis of records in outpatient cards by age criteria.

The percentage is as follows:

Age 18-30 25%;

45 years 37%;

60 years old 23%;

years and older 15%.

5.2 Methods of rehabilitation of patients with the participation of a paramedic in a FAP

Tactics at the prehospital stage: - cessation of the effect of the damaging factor; - removal of the victim from the thermal effect zone; - the imposition of a protective aseptic bandage; - the introduction of anesthetics, drugs to prevent shock; - the use of transport immobilization for extensive and deep burns; - the introduction of cardiovascular funds and antibiotics according to indications; emergency hospitalization in the surgical department of the hospital.

In accordance with the content of records in the outpatient cards of the FAP:

38 patients (I degree), the area of ​​thermal damage was treated with a 33% alcohol solution, recommendations were given for the care and toilet of the damaged surfaces;

20 patients (II degree), the area of ​​thermal injury (5 foot surface, 15 hand) was treated with a 33% alcohol solution, a sterile dressing with 0.2% furacilin ointment was applied, recommendations were given for the care and toilet of the damaged surfaces;

For 14 patients (III degree), the area of ​​thermal injury was treated with a 33% alcohol solution, before hospitalization, bandages with 0.2% furacilin ointment, 5% streptocidal ointment were applied to the burn surfaces; by the paramedic and FAP staff, hospitalization was organized in the surgical department of the Central District Hospital.

Feldsher activity in the rehabilitation of patients with the consequences of thermal injuries of II, III and IIIa degrees.

It is advisable to divide the rehabilitation of post-burn convalescents into 3 stages. The first stage is early, starting immediately after the patient is discharged from the hospital with healed burn wounds, when conservative rehabilitation is required. The second stage is surgical rehabilitation. And the third stage is the final, when conservative follow-up care, expansion and stabilization of the restored functions are carried out.

At the beginning of the first stage of the post-burn rehabilitation period, four groups of post-burn reconvalescents are distinguished:

) who do not need special follow-up treatment;

) in need of physiotherapy and restorative treatment;

) subject to relatively urgent surgical interventions;

) requiring systematic complex conservative treatment.

Physiotherapy and restorative treatment for patients of group 2 is carried out outside working hours with the appropriate equipment.

Reconvalescents of 3 groups requiring relatively urgent operations (sharp contractures of the joints, neck, perineum, eversion of the eyelids) are sent to rehabilitation centers, burn centers or burn departments of regional hospitals.

The fourth group of convalescents, who are under dispensary supervision and need complex conservative treatment at the 1st stage of rehabilitation, is the main one both in terms of the volume of treatment measures carried out and in terms of consequences, which will largely be determined by the thoroughness of the implementation of the rehabilitation program.

Patients with the consequences of grade II, III, and IIIa thermal injuries presented identical complaints of pain and muscle tension.

During the examination, motor and sensory disorders were determined.

For anesthesia, dynamic currents were applied to the zone of hyperalgesia in a push-pull current mode (for 2 min) and a current modulated with long periods. The electrode connected to the cathode was located in the zone of hyperalgesia at the nerve exit point. The analgesic effect was manifested during the procedure. The effectiveness of anesthesia increased when the pads were wetted with a solution of 2% solution of lidocaine. With the open method of treatment, local electric light baths were used for 2-3 hours / day. Aeronization was carried out with negatively contaminated ions. For burns of fingers, feet, or joints, a paraffin-oil bandage (1 / part of fortified fish oil and 3 / part of paraffin) was used.

For thermal burns in the acute period, segmental reflex massage was used to eliminate the pain factor and inflammatory edema. For this purpose, the intercostal spaces, sternum, costal arches and ridges of the iliac bones were rubbed. Compression, stretching and concussion of the chest was used. When the burn was localized on the lower extremities, the paravertebral zones of the lumbar and lower thoracic spinal segments were massaged.

Massage of the burn surface is started at the stage of scarring. After exposure to thermal paraffin-oil applications, the following were used: stroking, rubbing with fingertips, hatching, sawing, spanking, longitudinal and transverse kneading, stretching, shifting, with persistent contractures - redressing movements. The duration of the procedure was 5-20 minutes daily or every other day.

Exercise therapy technique for burns

Exercise therapy is indicated for all patients, regardless of the degree of the burn, its localization and the area of ​​the lesion. Contraindications for exercise therapy are:

burn shock; severe general condition;

severe complications: hepatitis, myocardial infarction, nephritis, pulmonary edema; - the risk of bleeding (if burns are localized in the area of ​​the great vessels);

suspicion of latent bleeding.

Exercise therapy tasks:

) normalization of the activity of the central nervous system, cardiovascular system and the respiratory system;

) prevention of complications (pneumonia, thrombosis, intestinal atony);

) improvement of trophic processes in damaged tissues;

) preservation of mobility in the joints of damaged body segments;

) prevention of dysfunction in unaffected limbs (prevention of contractures, muscle atrophy, tightening scars).

To solve the above tasks, the following complex was used.

Physical therapy consisted of 3 stages: introductory, main and final. At the introductory stage, general tonic and breathing exercises with a small load were carried out; on the main - special exercises, corresponding to the location and nature of the lesion. At the final stage, the load gradually decreased, the pace of the exercises slowed down with an emphasis on breathing movements. The duration of each stage depended on the patient's condition and the program planned for him. Physiotherapy exercises in some patients were individual, group and independent, under the direct supervision of a specialist or on his recommendations.

I. p. - sitting on a chair; legs slightly apart, palms on knees, back straight. Raise straight arms forward, upward - inhale (look at the hands). Return to and. n. - exhale. Repeat 5-0 times.

I. p. - sitting on a chair; hands on the belt - inhale, tilt to the side - exhale. Repeat 4-5 times in each direction.

I. p. - the same; raise your arms to the sides - inhale. Raise the bent leg slightly, placing both palms on the knee - exhale. Repeat 4-6 times with each leg. To increase the load, hug the knee with your hands and, while exhaling, raise it higher.

I. p. - sitting on a chair; turning the body to the left; take your straight left hand back to the side, look at the palm, return to and. n. exhale. Repeat 3-5 times in each direction.

I. p. - the same; lower your arms and take your shoulders back, bending in the chest - inhale. Having made a slight forward bend, put your hands (fingers inward) on your knees - exhale. Repeat 5-0 times. To increase the load, spread your legs wider and make a tilt alternately to each knee - exhale, putting your palms on the knee and spreading your elbows wider.

I. p. - the same; get up, raise your hands up - to the sides - inhale, return to and. n. - exhale. Repeat 4-6 times. To increase the load, the exercise is performed with dumbbells.

I. p. - standing behind the back of the chair; feet together, palms resting on the back of the chair. Raise a straight leg to the side - inhale, lower it into and. n. - exhale. Repeat 4-5 times with each shoulder strap.

Rise on your toes - inhale. Roll down onto your heels - exhale (lift your socks up). Repeat 6-10 times.

I. p. - standing, holding the back of the chair; sit down - exhale, return to and. p. - inhale. To increase the load, do 2 spring squats.

I. p. - the same, when turning the body to the right; take the right straight hand back as far as possible (clench the hand into a fist) - inhale, return to and. n. - exhale. Repeat 5-6 times in each direction. To increase the load, take your hands away with springy jerks (2-3 jerks in a row).

I. p. - raise one hand up, put the opposite leg back on the toe - inhale, return to and. n. - exhale. Repeat 3-5 times with each leg and arm.

Walk for 1 - 2 minutes, breathing deeply (2 - 3 steps - inhale, 4 - 8 steps - exhale). Walking can be replaced by walking on the spot.

I. p. - sitting on a chair, arms forward. Squeeze and unclench your fingers, breathing is free. Repeat 10-15 times. Clench your fingers into fists and make 5-10 circles in the wrist joints alternately in both directions, then shake loosely with your brushes.

Repeat exercise. 1 5 - 6 times.

6. Medical assessment of the effectiveness of rehabilitation measures

with the participation of a paramedic in patients with thermal injuries

In the process of physiotherapy and massage, complaints of pain, general weakness, and fatigue decreased. Sleep improved. Physiotherapy exercises were carried out regardless of the degree of the burn, its localization and the area of ​​the lesion. Physical exercises increased the general tone of the autonomic nervous system, ensured an increase in the speed of blood flow, improved microcirculation, positively influenced the function of respiration, increased emotional mood, gave confidence in their abilities,

The rehabilitation measures carried out proved to be an effective method of restorative treatment of patients with thermal injuries, improving their quality of life.

Conclusion

With regard to patients with thermal injuries, it seems appropriate to define rehabilitation as a system of measures carried out after complete or almost complete healing of burn wounds resulting from conservative or surgical treatment and elimination of acute manifestations of burn disease. For some patients, rehabilitation can be carried out from start to finish in general polyclinics. In a number of patients who have suffered burns, there is a need for repeated hospitalizations to deal with the consequences, the correct assessment of which and the timely referral of victims to a specialized medical institution, after consultations, if necessary, with appropriate specialists, is an important task of the polyclinic staff.

The rehabilitation technique, its duration and expected results are determined by a number of factors, the main of which are: the area of ​​burns, especially deep ones, their localization, the presence or absence of primary or secondary lesions of deep anatomical structures, the method of treatment of burns, their complications, and the peculiarities of the course of burn disease. Naturally, this determines the variety of necessary rehabilitation measures, in which the paramedic is assigned a significant role.

The aim of this course work was to analyze the role of a paramedic in carrying out rehabilitation measures for patients with thermal injuries to improve their quality of life.

To achieve the goal set in the course work, the following tasks were solved:

The anatomy of tissues exposed to thermal factors is considered.

The most common causes of thermal damage are noted.

Thermal damage classified.

Methods of treatment and rehabilitation for thermal injuries are described.

The paramedic activity in carrying out rehabilitation measures has been determined.

The effectiveness of the performed rehabilitation has been analyzed.

The object of the study was thermal damage.

The subject of the analysis is the role of a paramedic in carrying out rehabilitation measures for patients with thermal injuries in order to improve the quality of life.

During the course work, the literature on anatomy, combustiology, methods of rehabilitation for thermal injuries, and organization of paramedic activities were used.

To carry out the practical part, the data from the records in the outpatient cards of the FAP of a rural settlement were used.

The coursework consists of two chapters. The first chapter discusses

anatomy, clinical manifestations, methods of treatment and rehabilitation for thermal injuries.

The second chapter, which is a practical part, provides a statistical analysis of the cases of patients' appeals to the FAP paramedic associated with thermal injuries, as well as paramedic activities during rehabilitation measures.

Based on the results of the work carried out, it seems possible to draw the following conclusions:

Today, the problem of thermal injuries retains its importance in practical surgery.

Physiotherapy, massage and exercise therapy are used for physical rehabilitation of patients with thermal injuries. These techniques allow in a relatively short time to restore the functionality of patients and, as a result, improve their quality of life.

The direct participation of a paramedic in rehabilitation activities increases their overall effectiveness.

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Chapter 1 The main structure of the work of a paramedic at a FAP

Organization of work at the feldsher-obstetric station (FAP)

Characteristics of the feldsher-obstetric station

The feldsher-obstetric center is an outpatient clinic in a rural area. The management of the medical and sanitary activities of the FAP is carried out by the health authorities. FAP conducts medical and preventive, sanitary and epidemiological work and sanitary and hygienic education of the population; has its own estimate, round seal and stamp indicating its name; draws up plans, a report with an explanatory note of the morbidity analysis; keeps accounting and reporting documentation. A paramedic (paramedic-midwife) with a completed secondary medical education is appointed to the position of the head of the feldsher-obstetric station. At the feldsher-obstetric center located in the village (where there is no pharmacy), a pharmacy (or kiosk) is organized to sell finished medicines and patient care items to the population.

Responsibilities of the head of the FAP

Responsibilities of the head of the FAP (paramedic). The head of the FAP (paramedic) is in charge of organizing and planning medical and preventive care at the site; bears responsibility for the provision of timely medical (first-aid) care for various acute diseases and accidents.

The paramedic is obliged:

1) know the features of the organization of emergency care in case of mass accidents, poisoning with chemicals and drugs;

2) know the basics of pre-medical resuscitation; to produce closed heart massage and artificial ventilation of the lungs;

3) carry out outpatient reception and service of patients at home;

4) promptly send patients for consultation to the nearest medical and prophylactic institution (central district hospital);

5) if necessary, accompany the patient personally.

The paramedic organizes the reception of patients by district doctors and other specialists at the FAP according to the schedule approved by the chief physician. By the day of admission, the paramedic prepares patients and primary documentation. The doctor receives patients together with a paramedic. The personal participation of a paramedic in consultation with patients contributes to the timely treatment of patients, their employment and advanced training of a paramedic.

The paramedic takes an active part in the clinical examination of the population of his area, draws up maps for patients subject to dispensary observation. The paramedic, under the guidance of a doctor, periodically organizes medical examinations of the population with unfavorable working conditions. Patients with tuberculosis, hypertension, ischemic heart disease, gastric ulcer and duodenal ulcer, diabetes, glaucoma, thrombophlebitis, obliterating endarteritis, etc. are subject to dispensary observation. Chernobyl nuclear power plant. For the correct organization of the work of the FAP, a plan of medical and preventive measures for the current year is drawn up. The plan specifically indicates the planned activities, the deadline for implementation, the responsible executor. A pre-developed plan is approved by the chief physician. All planned activities are carried out on time.

The paramedic carries out medical control over the development and health of children in nurseries, kindergartens, orphanages, schools located in the territory of FAP activities and do not have appropriate secondary medical workers in their states; according to the approved plan, conducts sanitary-anti-epidemic and sanitary-educational work.

Organization of emergency care

For the provision of emergency care, first-aid resuscitation at the FAP, according to the approved report card, there must be a necessary set of instruments, dressings and medicines. In the emergency room there is a bed with a shield or a flat rigid couch, a stretcher, means of immobilization, a cabinet for storing medicines, a table, a sterilizer, syringes (2, 5, 10, 20 ml), rubber bands, a tonometer, a thermometer, probes of various sizes and funnel for gastric lavage, stethoscope, beakers, bucket, basin, set of rubber catheters, dressings, breathing and oxygen equipment, incubation set, oxygen cylinder.

Organization of medical care for the rural population

Obstetric and gynecological care for the rural population

The peculiarities of the living and working conditions of the rural population, expressed in the dispersion of settlements, the difference in the forms of organization of agricultural production, the variety of types of agricultural work (agriculture, animal husbandry, poultry farming, etc.), the large front of these works, their seasonality, determine the features of the organization of all medical care in rural area, including obstetric and gynecological.

Obstetric and gynecological assistance to the rural population is provided by a complex of medical and preventive institutions. Depending on the degree of approach to the rural population, on the specialization and qualifications of medical care, the level of material and technical equipment in the system of providing obstetric and gynecological care, it is customary to distinguish three stages.

Stages of providing obstetric and gynecological care

The first stage is the implementation of pre-medical and first medical aid. This stage is the rural medical area. It includes a rural district hospital with an outpatient clinic and a hospital, feldsher-obstetric points (FAP), and maternity hospitals. The location of the first stage is the periphery of the district.

The second stage is the implementation of qualified medical care. It includes district (numbered) and central district hospitals, which include obstetric and gynecological departments and antenatal clinics. The location of the second stage is the regional center.

The third stage is providing the rural population with highly qualified (specialized) obstetric and gynecological care. It includes a regional (regional, republican) hospital, which includes obstetric and gynecological departments and an antenatal clinic or an independent maternity hospital with an antenatal clinic. The location of the third stage is the regional (regional, republican) center.

Medical obstetric and gynecological care

Medical obstetric and gynecological care in a rural medical area is carried out by a general practitioner - the chief physician of a rural district hospital (if there are two doctors in a district hospital, one of them). Under his direct supervision, the midwife of the local hospital works, who helps the doctor both in the hospital (takes part in the management of childbirth) and in the outpatient clinic (takes part in the observation of pregnant women, postpartum women and the treatment of gynecological patients). The number of maternity beds in a rural district hospital usually does not exceed 3-5. To bring qualified medical care closer to rural residents, a gradual reduction in the number of maternity beds in rural district hospitals and an increase in the number of beds in district and central district hospitals are being carried out. However, in a number of districts, where, due to local conditions, it is not possible to provide the population with obstetric and gynecological care in district and central hospitals, rural district hospitals are being consolidated, and in accordance with this, the number of maternity beds has been expanded to eight, the post of an obstetrician-gynecologist is provided.

Pregnant women and women in labor with a pathological course of pregnancy and childbirth and a burdened obstetric history should not be hospitalized in a local hospital (in the absence of a specialist obstetrician-gynecologist on the staff).

Despite the presence on the periphery of the district of a medical hospital - a rural district hospital, the bulk of obstetric and gynecological care in a rural medical area refers to first aid, and it is carried out by midwives of the feldsher-obstetric station and the collective-farm (inter-collective farm) maternity hospital. The work of these institutions is carried out under the direct supervision of the chief physician of the rural district hospital. If there is an obstetrician-gynecologist on the staff of the district hospital, the latter provides all medical and consultative assistance at the feldsher-obstetric station and in the collective farm maternity hospital.

FAP: structure of work

Feldsher-obstetric points (FAP) are provided for by the nomenclature of medical institutions. FAP is organized in a village with a population of 300 to 800 inhabitants in cases where there is no rural district hospital or outpatient clinic within a radius of 4–5 km.

All the work of the FAP is provided by a paramedic, a midwife, a nurse. The number of service personnel is determined by the capacity of the FAP and the size of the population served by it.

The FAP provides the following positions:

1) paramedic - 1 position with a population of 900 to 1300 people; 1 position with a population of 1300 to 1800 people; 1.5 positions with a population of 1800 to 2400 people and 2 positions with a population of 2400 to 3000 people;

2) nurse - 0.5 positions with a population of up to 900 people and 1 position with a population of over 900 people.

Depending on local conditions, the FAP may only conduct outpatient appointments or have maternity beds. In the latter case, along with outpatient care, inpatient care is also provided to the FAP.

Due to the fact that the FAP provides medical assistance to the entire rural population, and not only to women, the premises in which it is located should consist of two halves: paramedic and obstetric.

Obstetric unit of FAP

The obstetric part of the FAP should have the following set of premises: an entrance hall, a waiting room and a midwife's office. FAPs with maternity beds, in addition to these rooms, must have an examination room, delivery and postnatal wards. The FAP midwife carries out all the work on the organization and provision of obstetric and gynecological care to rural women within the radius of the service point.

Responsibilities of a FAP midwife

The responsibilities of a FAP midwife include:

1) identification of all pregnant women in the service area as early as possible, provision of dispensary observation of them, including the implementation of the necessary therapeutic and preventive measures, patronage of pregnant women, postpartum women and children under the age of 1 year;

2) carrying out sanitary and educational work among women;

3) provision of medical care for normal childbirth;

4) identifying gynecological patients, referring them to a doctor and providing them with medical assistance as prescribed by a doctor.

Population bypasses

Significant assistance in the early detection of pregnant women is provided by household rounds of the population, carried out by a FAP midwife. In the observation of pregnant women, the midwife performs all the bulk of the necessary research. So, at the first visit of a pregnant woman, the midwife collects a detailed history, general (heredity, past diseases, etc.) and special obstetric (menstrual, sexual, generative, lactation functions, gynecological diseases, etc.).

From the anamnesis, the midwife finds out the features of the course of previous pregnancies, the presence of extragenital diseases and other abnormalities in the woman's health that can affect the course of pregnancy and childbirth.

Examination of pregnant women

The midwife begins the examination of each pregnant woman with a study of internal organs: cardiac activity, blood pressure measurement (on both hands), pulse analysis, urine for protein (by boiling). The midwife is currently studying the state of health of pregnant women on the basis of measuring height, body weight (in dynamics), the presence of edema, pigmentation, the state of the mammary glands and nipples, and the state of the abdominal press.

Conducting a special obstetric examination, the midwife measures the external dimensions of the pelvis, by means of a vaginal examination, sets the gestational age and the internal dimensions of the pelvis. In the second half of pregnancy, measures the height of the fundus of the uterus above the bosom, determines the position and presentation of the fetus, listens to its heartbeat.

For a general blood test, group affiliation, determination of the Rh factor, antibody titer, Wasserman reaction, general urine analysis, the pregnant woman is sent to the nearest laboratory. Here, a bacteriological study of the vaginal flora is carried out for the degree of purity, the discharge of the urethra, cervix and vagina for gonococcus, the reaction of vaginal secretions. X-ray examinations in pregnant women (fluoroscopy of the chest, fetus, pelviography, etc.) are performed only if there are strict indications.

A thorough examination of pregnant women makes it possible to identify various pathological conditions, on the basis of which these pregnant women are allocated to high-risk groups and require the most close attention to them during pregnancy; in childbirth and the postpartum period, groups of increased risk are distinguished for cardiac pathology, bleeding in the postpartum and early successive periods, inflammatory and septic complications after childbirth, endocrinopathies: diabetes mellitus, obesity, adrenal insufficiency and other types of obstetric and somatic pathology.

All individual cards of pregnant women belonging to the risk group are usually marked with the appropriate color marking, indicating in a certain color the risk of a particular pathology (red - bleeding, blue - toxicosis, green - sepsis, etc.).

The volume of studies of gynecological patients

The scope of studies of gynecological patients also includes the collection of general and special gynecological anamnesis. The study of the state of health of women is currently carried out on the basis of a general clinical examination, similar to the examination of pregnant women. Special gynecological examination includes two-handed and instrumental (examination in mirrors) examination. A bacterioscopic examination of the discharge of the urethra, cervix and vagina for gonococcus is carried out using methods of provocation, according to indications - the Borde-Zhangu reaction; examination of a vaginal smear for cell atypia; research on tests of functional diagnostics.

If a woman needs a biochemical blood test for cholesterol, bilirubin, sugar, residual nitrogen and urine tests for acetone, urobilin, bile pigments, she is sent to the nearest multidisciplinary laboratory. Women and married couples with a history of hereditary diseases or children with deformities of the central nervous system, Down's disease, and cardiovascular defects are sent for examination, including for the determination of sex chromatin, to specialized medical genetic centers. While monitoring pregnant women, the FAP midwife is obliged to show each of them to the doctor. If a woman's pregnancy is proceeding normally, then her meeting with a doctor is carried out at her first scheduled visit to the FAP. All pregnant women who show the slightest deviation from the normal development of pregnancy should be immediately referred to a doctor.

At each subsequent visit to the FAP, the pregnant woman undergoes the necessary re-examinations. In the second half of pregnancy, it is especially necessary to carefully monitor the possible development of late toxicosis, for which it is necessary to pay attention to the presence of edema, the dynamics of blood pressure and the presence of protein in the urine. It is very important to monitor the dynamics of the weight of the pregnant woman.

Organization of patronage work

An obligatory section of the midwife's work in monitoring pregnant women should be conducting classes on psycho-preventive preparation for childbirth.

In organizing monitoring of pregnant women in the countryside, as well as in the city, patronage work is very responsible. Patronage of pregnant women and gynecological patients is an element of the active dispensary method. The goals of patronage are very diverse, so each patronage visit to a woman sets a specific goal. First of all, this is an acquaintance with the living conditions of a woman. Knowing the peculiarities of the life of each family (living conditions, family composition, level of material security, degree of culture, including health literacy, etc.), it is easier for a midwife to monitor the health of the population. The purpose of patronage is the need to find out the state of health of a pregnant woman who does not appear for an appointment at the appointed time. In this case, the midwife, in a conversation with the pregnant woman, finds out the general condition of the woman, performs a thorough examination, draws attention to the presence of edema, and measures blood pressure. With long periods of pregnancy, it measures the circumference of the abdomen and the height of the uterine fundus, determines the position of the fetus. After making sure that there are no deviations from the normal development of pregnancy, the midwife appoints the woman a deadline for the next examination. In the presence of the slightest signs of complications of pregnancy, the midwife invites the pregnant woman to see a doctor or informs the doctor about it, who decides whether to treat the pregnant woman at home or whether she needs to be hospitalized. In the latter case, the midwife monitors the timeliness of the woman's admission to the hospital and continues active monitoring after she is discharged home. The reason for the patronage may be the desire to make sure that the woman fulfills the doctor's prescriptions correctly, the need to conduct additional research (laboratory tests, measure blood pressure, etc.).

The FAP midwife is obliged to carry out patronage of children, especially the first 3 years of life. At the same time, it is necessary to observe the frequency of observations of children of the 1st year of life by the midwife (paramedic) of the FAP: 1st month of life - observation only at home - 5 times; 2nd month of life - observation at home - 3 times; 3-5th months of life - observation at home - 2 times a month; 6-12 months of life - observation at home - once a month. In addition, a child under 1 year old should be examined by a pediatrician at the FAP at least 1 time per month.

Thus, the midwife sees the child during the first year of life 12 times during preventive examinations by a doctor and 20 times during home patronage.

The midwife's patronage work is strictly planned. The plan provides for the days of visiting villages and villages. In a special notebook, a record of patronage work is kept, all visits by women and children are recorded. The midwife enters all the advice and recommendations in the home visiting nurse's notebook of work at home (patronage sheet) for subsequent verification of their implementation.

Mobile teams from the Central District Hospital

The bulk of women from rural areas give birth in medical obstetric departments of the Central District Hospital. If necessary, inpatient qualified medical care is provided to rural women in large republican, regional, regional maternity hospitals.

To bring ambulatory and polyclinic medical care closer to rural women, mobile teams from the Central Regional Hospital are created, which come to the feldsher-obstetric stations according to the approved schedule.

The mobile team includes an obstetrician-gynecologist, pediatrician, therapist, dentist, laboratory assistant, midwife, children's nurse. The composition of the mobile team of doctors and paramedical workers is brought to the attention of the heads of the feldsher-obstetric centers.

Conducting preventive periodic examinations

The paramedic and midwife are required to have a list of women in their area who are subject to preventive and periodic examinations.

Practically healthy women with a successful obstetric history, a normal course of pregnancy in the period between team visits are observed by a FAP midwife or a local hospital, and are sent to the nearest local or district hospital for childbirth.

With a group of women who are contraindicated to carry a pregnancy, an obstetrician-gynecologist and a midwife hold conversations about the harm to their health of pregnancy, possible complications of pregnancy and childbirth, teach them to use contraceptives, and recommend intrauterine contraceptives. The obstetrician-gynecologist of the mobile team checks the obstetrician-gynecologist's fulfillment of appointments and recommendations during the next visit. Household visits by a midwife provide significant assistance in the early detection of pregnant women. All identified pregnant women, starting from the earliest stages of pregnancy (up to 12 weeks), and postpartum women are subject to medical examination.

In the normal course of pregnancy, a healthy woman is recommended to visit a consultation with all analyzes and conclusions of doctors 7-10 days after the first visit, and then visit a doctor in the first half of pregnancy once a month, after 20 weeks of pregnancy - 2 times a month, after 32 weeks - 3-4 times a month. During pregnancy, a woman should visit the consultation about 14-15 times. In case of a woman's illness or a pathological course of pregnancy that does not require hospitalization, the frequency of examinations is determined by the doctor on an individual basis. It is important that pregnant women attend the consultation carefully during antenatal leave.

Hospitalization of pregnant women in medical hospitals

Timely hospitalization of pregnant women in medical hospitals when initial signs of deviation from the normal course of pregnancy appear, as well as women with a burdened obstetric history, is very important in the work of a FAP midwife. Pregnant women with a narrow pelvis (with external conjugate less than 19 cm), abnormal position of the fetus and breech presentation, immunological incompatibility of the blood of the mother and the fetus (including a history), extragenital diseases, with the appearance of bloody discharge from the genital tract are subject to prenatal hospitalization in medical hospitals , edema, the presence of protein in the urine, increased blood pressure, excess weight gain, when multiple pregnancies are established, as well as other diseases and complications that threaten the health of a woman or child.

When sending a pregnant woman to an obstetric hospital, it is very important to choose the right way of transporting her (ambulance, air ambulance, passing transport), as well as to correctly resolve the issue of the institution in which this pregnant woman should be hospitalized. A correct assessment of the state of health of a pregnant woman will avoid multi-stage hospitalization, and immediately identify the patient to that obstetric hospital where there are all conditions for providing her with full medical care.

Delivery at FAP At the feldsher-obstetric station, only normal (uncomplicated) childbirth is provided. In cases where a complication occurs during childbirth (which cannot always be foreseen), the FAP midwife should immediately call a doctor or (if possible) take the woman in labor to a hospital. In this case, it is very important to resolve the issue of means of transportation. It must be remembered that women with an unseparated placenta, preeclampsia and eclampsia, as well as with a threatening rupture of the uterus, cannot be transported. If a woman with an unseparated placenta needs transportation due to certain complications of pregnancy, the FAP midwife must first of all perform manual separation of the placenta and, with a contracted uterus, transport the woman. If it is impossible to provide a woman with the necessary assistance to such an extent that she is in a state of transportability, a doctor should be called to her and a plan for further action should be drawn up with him. Providing emergency first aid to a pregnant and giving birth woman, the FAP midwife has the right to perform the following obstetric operations and benefits: turning the fetus on the leg with full opening of the uterine pharynx and whole or just departed waters, removing the fetus by the pelvic end, manual separation of the placenta, manual examination of the uterine cavity , restoration of the integrity of the perineum (after rupture of the perineum or perineotomy). With bleeding in the early postpartum period, the midwife must exclude rupture of the tissues of the birth canal. Complications arising during childbirth require from the midwife, in addition to urgently calling a doctor, clear organizational actions, on which the outcome of childbirth largely depends. The midwife should be fully proficient in the primary methods of resuscitation of newborns born with asphyxiation.

FAP documentation

It is very important in the work of a FAP midwife to maintain thorough documentation. For each pregnant woman who applies to the FAP, an “Individual card of a pregnant woman” is filled out. When obstetric complications or extragenital diseases are detected, a duplicate of this card is filled in, which is transferred to the district obstetrician-gynecologist.

There are many options for storing individual cards. One of the most convenient options for work, which can be recommended, is as follows: a box for storing individual cards (the width and height of the box must match the size of the card) is divided by transverse partitions into 33 cells. Each partition is marked with a number from 1 to 31. These numbers correspond to the dates of the month. When appointing the next visit to the pregnant woman, the midwife places her card in the box with the corresponding day of the month, that is, the day when she needs to come to the appointment. Before starting work, the midwife takes out all individual cards from the cell corresponding to the day of reception and prepares them for admission: they will check the correctness of the entries, the presence of the latest tests, etc. corresponding to the day of the month for which she is scheduled to attend. At the end of the appointment, by the number of cards remaining, it is easy to judge about pregnant women who did not show up for an appointment on the day they had been assigned. The midwife places these cards in the 32nd cell of the box marked "Patronage". The midwife then visits (patronizes) all women who do not show up. All cards of those who have given birth and are subject to dispensary observation until the end of the postpartum period are placed in the 33rd cell with the mark "Postpartum women".

In addition to these documents, the FAP maintains a diary-notebook of records of pregnant women (f-075 / y) and a diary (f-039-1 / y). When a pregnant woman (after 28 weeks of pregnancy) or a postpartum woman is sent to a medical obstetric hospital, an "Exchange card" is issued to her. If a pregnant woman is hospitalized before 28 weeks, an extract from the medical history is issued to her. When she is discharged from the hospital, she receives an extract from the medical history in the same form, which is given to her by the FAP midwife.

Organization and conduct of preventive examinations of rural women

An important section in the work of a midwife of a feldsher-obstetric station is the organization and conduct of preventive examinations of women. It is advisable to carry out preventive examinations of rural women in the autumn-winter period in order to complete the rehabilitation of the identified patients before the start of spring field work.

All work on the organization of preventive examinations is supervised by the district obstetrician-gynecologist and the chief midwife of the district. A preliminary plan for conducting inspections is drawn up, which indicates the place where the inspection will be carried out, the calendar dates of inspections for each locality. Preventive examinations are carried out by FAP midwives who have undergone special training and instruction. For a successful preventive examination, the midwife must first make a home visit, the tasks of which are to explain to women the purpose of the examination, the way it is carried out, the place of examination, etc.

The purpose of preventive examinations is the early detection of precancerous, neoplastic, inflammatory and so-called functional diseases of the genital organs in women and the appointment, if necessary, of appropriate treatment. Preventive examinations also provide an opportunity to identify occupational hazards among the organized part of the female population that affect the organs of the genital area, and to develop measures to eliminate them.

Direct examination of women consists of two sequential procedures:

1) examination of the external genital organs, the vagina and the vaginal part of the cervix (using mirrors);

2) two-handed studies in order to clarify the state of the internal genital organs.

During preventive examinations, objective diagnostic methods are used: cytological examination of the vaginal discharge, "prints" from the cervix, colposcopic examination.

For laboratory research, material is taken from various departments of the woman's urogenital apparatus:

1) smears from the urethra and cervical canal for bacteriological examination for Neisser's gonococci and flora. The material obtained from the urethra is applied to the glass slide in the form of a circle, and from the cervical canal - in the form of a stroke in the longitudinal direction;

2) a smear from the posterior fornix of the vagina to determine the degree of purity of the vaginal contents is taken after the introduction of the mirrors;

3) a smear from the lateral wall of the vagina for hormonal cytodiagnostics is also taken after the introduction of the speculum.

At the slightest suspicion of a disease that has arisen in a midwife performing a routine examination, a woman should be immediately referred to a doctor.

In conducting preventive examinations, it is very important to carefully register and record all examined women, for which a list of persons subject to targeted medical examination for identification is drawn up. For registration and registration of women subject to active dispensary observation, dispensary observation control cards are entered on them.

Another institution that provides pre-medical obstetric and gynecological care in rural areas is the collective farm maternity hospital. In a collective farm maternity hospital, the following premises must be provided: vestibule, reception, delivery room (10-12 m2), postnatal ward (6 m2 for 1 mother's and children's bed), kitchen, toilet. In each collective farm maternity hospital, from 2 to 5 beds are deployed (at the rate of 1 bed per 1000 population).

The collective farm maternity hospital is located at a distance of 6-8 km from the rural medical area to which it is attached. With good transport conditions, this distance can be increased to 10-15 km. Collective farm maternity hospitals are served by a midwife, whose duties are similar to those of a FAP midwife. If in one village near the FAP there is a collective farm maternity hospital and there is no need for an independent staff in terms of the volume of its work, the service of the latter is assigned to the FAP midwife.

Occupational safety issues in the work of the obstetric and gynecological service In the work of the obstetric and gynecological service in the countryside, at all its stages, a lot of space is occupied by the issues of labor protection of agricultural workers. Agricultural work has its own characteristics, the main of which are seasonality, the performance of various production operations in a short time in any weather conditions, etc. This requires considerable effort and stress from a person, which inevitably leads to violations of the work and rest regime. Agricultural workers experience additional adverse effects of such production factors as noise, vibration, dust, contact with pesticides (pesticides) and mineral fertilizers. The main work on the implementation of measures aimed at the labor protection of rural residents is carried out by hygienists. But the obstetric and gynecological service should also take part in this work, since unfavorable production factors have a negative impact on the specific functions of the female body.

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Paramedic

Man has the right to be bad an artist or a carpenter,

but does not havethe right to be a bad doctor.

V. Ya. Danilevsky

Profession "paramedic " first appeared in Germany; the term "feldscher" itself is translated from German as "field barber", as in the Middle Ages they called a person who provided medical care directly on the battlefield during wars. Today, a paramedic is an assistant or assistant to a doctor in city and district medical institutions, and in rural medical posts he performs the functions of both a doctor and a manager. The profession of a medical assistant is very responsible and important, as it combines considerable medical knowledge with unique practical skills.

In this profession, the following specializations are distinguished:

Medical assistant-laboratory assistant;

Ambulance paramedic;

Feldsher-obstetrician;

Sanitary paramedic;

Military paramedic.

With all the variety of specialties of this profession in educational organizations, you can get a general medical assistant education with the qualification of a "medical assistant", however, the content of a specialist's professional activity will be determined by the specifics of the place of work.

Professionally important qualities:

good operational and long-term memory;

organizational skills;

the ability to concentrate and distribute attention;

good hand-eye coordination;

the ability to act effectively in a crisis situation;

logical and analytical thinking;

communication skills;

benevolence;

self-control;

a responsibility;

tact;

accuracy;

stress tolerance;

physical endurance;

neuropsychic stability.

Medical restrictions:

Reduced level of vision and hearing;

cardiovascular diseases;

neuropsychiatric diseases;

allergy to drugs;

disorders of the musculoskeletal system;

chronic infectious diseases.

Paramedic is a specialist with a secondary medical education. Provides first pre-medical, urgent and emergency medical care to the sick and injured. Working in the ambulance team, he is a doctor's assistant and works under his supervision. Provides inpatient, outpatient and home care independently, performing the functions of a doctor in rural health centers; carries out measures for the prevention and reduction of morbidity, for the early detection of diseases; assists in childbirth; conducts various analyzes; develops treatment-and-prophylactic and sanitary-hygienic measures and participates in their implementation; performs medical appointments; supervises the actions of junior medical personnel. The range of responsibilities depends largely on the place of work.

Educational organizations of Omsk and Omsk region:

Medical College of the Omsk Region;

Omsk Medical School of Railway Transport (OmGUPS);

Omsk State Medical Academy of the Ministry of Health of the Russian Federation.

Professional activity

Most of the college graduates go to the Emergency Medical Service. Only doctors and paramedics are allowed to work here. There are no nurses in the ambulance, and the paramedic works in the same team with the doctor or in a special paramedic team. In both cases, the paramedic must have a fairly broad medical knowledge, be able to make decisions correctly and quickly. It can work in health centers, hospitals, clinics, dispensaries, sanatoriums, maternity hospitals and other medical institutions.

Career

Paramedics are constantly in demand in the labor market. In the future, a paramedic can become the head of a health center, a senior paramedic. Higher medical education provides an opportunity for career growth.

An important section of the activity of paramedics is the provision of medical care to patients at home. The procedure for treating patients at home is determined by the doctors of the local hospital or the central district hospital (CRH) and only in some cases the paramedic himself. Patients left at home should be monitored continuously until they recover. This is especially true for children. It is advisable to hospitalize patients from remote from FAP settlements; when the patient is left at home, the paramedic notifies the doctor of the rural medical department and monitors the patient.

In the outpatient care of tuberculosis patients, the paramedic, being the direct executor of medical appointments, conducts immunochemical prophylaxis, clinical examination, anti-epidemic measures in the foci of tuberculosis infection, work on hygienic education, etc.

A paramedic working at a FAP should be familiar with the simplest resuscitation techniques at the prehospital stage, especially in case of sudden cardiac or respiratory arrest, which can be caused by severe trauma, blood loss, acute myocardial infarction, poisoning, drowning, and electrical injury. Feldshers and obstetricians working independently are also entrusted with the provision of emergency medical care in case of acute illnesses and accidents. In case of an urgent call, the paramedic must have a suitcase complete with medical instruments and medicines according to the packing list.

A large role belongs to paramedics in the clinical examination of the rural population. Its main goal is the implementation of a set of measures aimed at the formation, preservation and strengthening of the health of the population, the prevention of the development of diseases, the reduction of morbidity, and an increase in active creative longevity.

To conduct a general medical examination, a personal registration of the entire population living in the service area of ​​the polyclinic, outpatient clinic and FAP is carried out in accordance with the "Instruction on the procedure for accounting for the annual medical examination of the entire population." In rural areas, the lists of residents are compiled by FAP nurses.

For personal accounting of each resident, paramedical workers fill out the "Dispensary registration card" (educational form No. 131 / y - 86) and numbered it in accordance with the number of the outpatient's medical card (registration form No. 025 / y). After clarifying the composition of the population, all "Dispensary registration cards" are transferred to the card index.

A paramedic or midwife makes sure that patients who need seasonal (autumn, spring) anti-relapse treatment receive it in a timely manner in a hospital or on an outpatient basis. Proper organization of examination of temporary disability at the FAP is of great importance for reducing the incidence of morbidity.

In accordance with the "Regulations on the head of the feldsher-obstetric station", the head of the private entrepreneur, the paramedic may have the right to issue sick leave certificates, certificates and other medical documents in the manner established by the Ministry of Health of the Russian Federation.

The basis for granting the right to issue sick leave certificates to a paramedic is a petition by the head physician of the district, which must indicate:

The distance of the FAP from the hospital (outpatient clinic) to which it is assigned;

The number of serviced settlements of the state farm and the number of workers in them;

The state of the means of communication;

Work experience of a paramedic and the level of his qualifications;

Knowledge and observance by a paramedic of the basics of examinations of temporary disability and "Instructions on the procedure for issuing sick leave". The paramedic keeps records of the issued sick leave certificates in the "Book of registration of sick leave certificates" (form No. 036 / y) with the obligatory completion of all its columns.

Medical and preventive care for women and children. At each private entrepreneur, a paramedic (midwife) maintains a personal register of women from the age of 18, where they enter passport data, past illnesses, information about all pregnancies (years before each pregnancy ended, complications). At the first visit, a paramedic (midwife) begins the examination of each pregnant woman with a general examination, measures the length and weight of the body, blood pressure in common arms, within the limits of his competence determines the state of the heart, lungs and other organs, examines urine for protein. Observing pregnant women, the paramedic (midwife) of the FAP is obliged to show each of them to the doctor; in cases where a woman has the slightest deviation from the normal development of pregnancy, she should be immediately referred to a doctor.

One of the important sections of the activity of FAP paramedics is to carry out, in the event of foci of infectious diseases, primary anti-epidemic measures, on the timeliness and quality of which the effectiveness of preventing the spread of infection outside the emerging focus depends. In this regard, it is of great importance to organize the activities of FLP workers aimed at identifying infectious diseases among the population.

When establishing a diagnosis of an infectious disease (or suspicion of it), FAP nurses should:

Carry out primary anti-epidemic measures in the outbreak;

Isolate the patient at home and organize ongoing disinfection before hospitalization of the patient;

Identify all persons in contact with the patient, register them and establish medical supervision over them;

Carry out (together with a doctor) quarantine measures in relation to persons in contact with sick persons attending preschool institutions, schools or working at epidemically important facilities;

Inform at the place of work, study, in preschool institutions, at the place of residence about the sick person and the persons in contact with him;

As directed by a pediatrician or epidemiologist, to carry out gamma globulin prophylaxis in contact with the patient with viral hepatitis A.

An infectious patient is hospitalized during the first day of the disease on a special vehicle. In his absence, the patient can be transported on any transport with subsequent disinfection. In the future, the FAP medical worker fulfills the instructions of the epidemiologist (assistant epidemiologist) and carries out:

Collection of material from persons in contact with patients for laboratory research in order to identify bacteria carriers;

Vaccinations for epidemiological indications and chemoprophylaxis;

Dynamic observation of persons in contact with patients during the incubation period of this infectious disease.

FAP paramedics and midwives play an important role in carrying out recreational activities, hygienic education of the rural population and promoting a healthy lifestyle. In order to correctly assess the level of the object's well-being, paramedics are trained in the simplest laboratory tests, express methods and are equipped with marching express laboratories. With the help of such a laboratory, it is possible to determine the residual amounts of chlorine in disinfecting solutions, on objects and surfaces (iodine-starch method), residual amounts of detergents on tableware (test with phenolphthalein).

Feldsher FAP often have to take part in the analysis of industrial injuries and the development of measures to reduce it, so he must be well acquainted with the main causes of injuries: technical, organizational and sanitary and hygienic. More than half of all victims go to FAP, therefore, nurses are required to constantly improve their knowledge, in particular, on the provision of first aid for injuries. In addition to providing first aid to the victim, FAP paramedics register and record injuries; identify, study and analyze their causes, depending on various factors; together with doctors, they develop specific measures to eliminate the identified causes; monitor compliance with safety regulations; train agricultural workers in first aid techniques.

When working as part of a medical team, the paramedic is completely subordinate to the doctor during the call. His task is to clearly and quickly fulfill all appointments. Responsibility for the decisions made lies with the physician. A paramedic must be proficient in the technique of subcutaneous, intramuscular and intravenous injections and ECG recording, be able to quickly install a system for drip infusion, measure blood pressure, count the pulse and the number of respiratory movements, introduce an air duct, perform cardiopulmonary resuscitation, etc. He must also be able to apply a splint and a bandage, stop bleeding, know the rules for transporting patients.

In the case of independent work, an ambulance paramedic is fully responsible for everything, so he must fully master the diagnostic methods at the prehospital stage. He needs knowledge of emergency therapy, surgery, traumatology, gynecology, pediatrics. He must know the basics of toxicology, be able to independently deliver childbirth, assess the neurological and mental state of the patient, not only register, but also roughly evaluate the ECG.

Appendix No. 10 to the order of the Ministry of Health of the Russian Federation No. 100 dated 26.03.99

"Regulations on the paramedic of the ambulance brigade"

I. General Provisions

1.1. A specialist with secondary medical education in the specialty "General Medicine", who has a diploma and a corresponding certificate, is appointed to the position of a paramedic of the ambulance brigade.

1.2. When performing the duties of providing emergency medical care as part of a paramedic brigade, a paramedic is the responsible executor of all work, and as part of a medical team he acts under the guidance of a doctor.

1.3. The paramedic of the ambulance brigade is guided in his work by the legislation of the Russian Federation, regulatory and methodological documents of the Ministry of Health of the Russian Federation, the Charter of the ambulance station, orders and orders of the station (substation, department) administration, this Regulation.

1.4. The paramedic of the ambulance brigade is appointed and dismissed in accordance with the procedure established by law.

II. Responsibilities

The paramedic of the ambulance brigade is obliged to:

2.1. Ensure the immediate departure of the brigade after receiving the call and its arrival at the scene within the established time standard in the area.

2.2. Provide emergency medical care to the sick and injured at the scene of the accident and during transportation to hospitals.

2.3. To administer medications to the sick and injured according to medical indications, to stop bleeding, to carry out resuscitation measures in accordance with the approved industry norms, rules and standards for paramedic personnel to provide emergency medical care.

2.4. To be able to use the available medical equipment, to master the technique of applying transport splints, bandages and methods of conducting basic cardiopulmonary resuscitation.

2.5. Possess the technique of taking electrocardiograms.

2.6. Know the location of medical institutions and service areas of the station.

2.7. To ensure the carrying of the patient on a stretcher, if necessary, take part in it (in the working conditions of the team, carrying the patient on a stretcher is regarded as a type of medical care). When transporting a patient, be near him, providing the necessary medical care.

2.8. If it is necessary to transport a patient in an unconscious state or intoxicated, make an examination for the detection of documents, valuables, money with an indication in the "Call card", hand them over to the admission department of the hospital with a mark in the direction against the signature of the personnel on duty.

2.9. When providing medical assistance in emergency situations, in cases of violent injuries, act in accordance with the procedure established by law (inform the internal affairs bodies).

2.10. Ensure infectious safety (observe the rules of sanitary and hygienic and anti-epidemic regime). If a quarantine infection is detected in a patient, provide him with the necessary medical assistance, observing precautions, and inform the senior doctor of the shift about the clinical, epidemiological and passport data of the patient.

2.11. Ensure the correct storage, accounting and disposal of medicinal products.

2.12. At the end of the watch, check the condition of the medical equipment, transport tires, replenish the medicines, oxygen, nitrous oxide consumed during operation.

2.13. Inform the administration of the ambulance station about all emergencies that occurred during the call.

2.14. At the request of the internal affairs officers, stop to provide emergency medical care, regardless of the location of the patient (victim).

2.15. Maintain approved accounting and reporting documentation.

2.16. In accordance with the established procedure, improve their professional level, improve their practical skills.

III. Rights

The paramedic of the ambulance brigade has the right to:

3.1. If necessary, call the ambulance medical team for help.

3.2. Make proposals for improving the organization and provision of emergency medical care, improving the working conditions of medical personnel.

3.3. Improve your qualifications in your specialty at least once every five years. Pass certification and recertification in the prescribed manner.

3.4. Take part in the work of medical conferences, meetings, seminars held by the administration of the institution.

IV. A responsibility

The paramedic of the ambulance brigade is responsible in the manner prescribed by law:

4.1. For the professional activity carried out in accordance with the approved industry norms, rules and standards for the paramedic personnel of the "Ambulance".

4.2. For unlawful acts or omissions that resulted in damage to the patient's health or his death.

In accordance with the order of the Ministry of Health of the Russian Federation No. 100, mobile teams are divided into paramedics and medical teams. The paramedic brigade includes two paramedics, an orderly and a driver. The medical team includes a doctor, two paramedics (or a paramedic and an anesthesiologist nurse), an orderly and a driver.

Tactics of behavior of an ambulance paramedic during a call. Ambulance personnel, including paramedics, work in very difficult conditions. While making a call, a paramedic may encounter any, the most unexpected pathology. He needs to have a broad outlook, possess knowledge of various fields of medicine, be able to quickly navigate in a difficult situation, maintain composure, and make the right decision in a short time. For this, special training alone is not enough; certain moral qualities, good health and life experience are also required.

One of the main difficulties is that at the moment of going to a call it is never absolutely known exactly what lies ahead. A "heart attack" can turn into anything - from hysterics to poisoning with pills, and when leaving for a hand injury, a patient with a gunshot wound, massive blood loss and shock may appear on the spot. Therefore, the paramedic must be constantly prepared for any situation. But one should not maintain oneself in a state of nervous tension for a long time - one must be able to quickly navigate and mobilize upon arriving at the place.

Already approaching the place of call, it is necessary to begin to observe and draw conclusions. Whether they meet you or not; what those who meet them look like - worried, crying, anxious or indifferent and unhurried; whether they are in a state of alcoholic intoxication, whether they look strange for the given circumstances. There are no general laws, but, as a rule, when something really serious happens, the ambulance is met on the street. Unusual behavior can lead to the idea of ​​insincerity of the caller. In case of departure for a deliberately criminal reason (fights, riots, etc.), police escort must be requested.

The greeter should be passed ahead, let him show the way. On the way, you should start asking questions to clarify what happened.

Arriving at the patient, you need to quickly assess the situation. Collecting anamnesis in an ambulance has its own characteristics. It should be done purposefully. At the very beginning, you should not allow lengthy stories about the history of life, marriage and many chronic ailments. You should find out what happened right now, everything else - later and if necessary. Often, chronic patients who abuse "Ambulance" without sufficient reason, this is perplexing. At the same time, a really seriously ill person can get confused, frightened, and not be able to find the right words right away. This needs help. One should not not only follow the lead of the patient, but also suppress him, adjust his complaints to his (possibly wrong) idea of ​​the nature of the disease. It is imperative to ask what the patient himself associates his condition with, but evaluate his answer critically.

After clarifying the picture of what happened, you need to find out whether this condition arose for the first time or something like that has already happened, what helped then, what was the diagnosis, what other diseases the patient suffers from, are there any medical documents (outpatient card, hospital discharge, examination results) ...

Simultaneously with the collection of anamnesis, it is necessary to begin an examination (count the pulse, measure blood pressure, palpate the abdomen, etc.).

If a small child is sleeping, it is better to first gently palpate the abdomen, and only then wake him up and conduct further examination. Examining the pharynx in restless children should be the last thing, as this unpleasant procedure can make contact with the child difficult for a long time.

In case of injuries, you should first examine the site of injury, while assessing the general condition of the patient, and then proceed to the examination of organs and systems.

On the collection of anamnesis and examination in an ambulance, 5-10 minutes are given. But sometimes they are not there either! After that, it is necessary to draw conclusions, make a preliminary diagnosis and make a decision regarding the provision of assistance.

At the patient's bedside, one should behave kindly, correctly, but efficiently and firmly. You should not tolerate familiarity or condescending attitude towards yourself from relatives or a patient, especially rudeness. All actions in this case should be clear, confident, it is necessary to instill calmness in the patient with all his appearance.

Before giving injections or giving pills, it is necessary to find out if the patient is allergic to these drugs.

Calls to the street or to another public place about car accidents, falls from a height or sudden serious illnesses are especially difficult morally, when a heated crowd gathers around, as a rule, negatively or even aggressively disposed towards the ambulance staff. People in such a situation do not adequately assess what is happening. Other employees of the ambulance may also be at the scene. You should listen to their advice, accept help. During transportation to the hospital, you should not take more than one accompanying person into the car. If a drunk or aggressive patient has to be hospitalized, he should be put or seated so that he could not suddenly and quickly reach the paramedic. If an ambulance car was stopped on the way to a call to provide assistance to another patient and he really needs it, the dispatcher should be informed so that the first call is transferred to another team for execution.

After medical assistance has already been provided, it is necessary to explain to the patient what happened to him, how to behave in such a case next time, to give general recommendations for the treatment and prevention of this disease. If necessary, you should transfer an active call to the district doctor (when the patient is not hospitalized for any reason, but requires dynamic observation) or the medical team (when a patient in serious condition requires specialized care or the picture of the disease is not completely clear, and you are not sure of the diagnosis ).

The principle of operation of a paramedic (and even a doctor) of an ambulance is overdiagnosis. The severity of the patient's condition is better overestimated than underestimated.

Methods and means of sanitary and educational work of a paramedic

In organizing his health education work, the paramedic, along with traditional methods of educating the population on health issues (such as interviews, group discussions, lectures, thematic evenings, question and answer evenings, round tables, oral journals, health schools, publications in press, conferences) widely uses methods of visual agitation: wall newspapers; sanitary bulletins; health exhibitions and corners; book exhibitions.

The Health Bulletin is an illustrated health education newspaper dedicated to only one topic. The topic should be relevant and selected taking into account the challenges facing modern healthcare, as well as the seasonality and epidemiological situation in the region. The heading is highlighted in large print. The name should be interesting, intriguing, it is advisable not to mention the word "disease" and "prevention".

The sanitary bulletin consists of two parts - text and illustrated. The text is placed on a standard sheet of Whatman paper in the form of columns, 13-15 cm wide, typed on a typewriter or computer. It is allowed to write the text in calligraphic handwriting with black or purple paste. It is necessary to highlight the editorial or introduction, the rest of the text should be divided into subsections (headings) with subheadings, which set out the essence of the issues and give practical advice. The presentation of the material in the form of questions and answers is noteworthy. The text should be written in a language that is understandable to the general public without medical terminology, with the obligatory use of local material, examples of correct hygienic behavior in relation to one's health, cases from medical practice. Artistic design: drawings, photographs, applications should illustrate the material, but not duplicate it. The drawing can be one or several, but one of them - the main one - should carry the main semantic load and attract attention. Text and art shouldn't be cumbersome. The health bulletin ends with a slogan or appeal.

It is necessary to ensure that the health bulletin is issued at least 1-2 times a quarter.

Health corner. The organization of the corner should be preceded by a certain preparatory work: coordination with the leadership of this institution; determination of the list of works and the necessary building materials (stands, planks, buttons, glue, fabric, etc.); choosing a place - one where a lot of people are constantly or often; selection of relevant illustrated material (posters, photo and literary exhibitions, transparencies, photographs, memos, leaflets, clippings from newspapers and magazines, drawings).

The leading topic of the health corner is various aspects of a healthy lifestyle. If any infection or threat appears in a given area, appropriate prevention material should be placed in the corner. This can be a health bulletin, a leaflet prepared by a local sanitary and epidemiological agency, a brief memo, a clipping from a medical newspaper, etc. The health corner should have a question and answer board. Answers to questions should always be timely, prompt and helpful.

Oral journals. In addition to medical workers, oral journals should include traffic police officers, juvenile inspectors, lawyers. In their messages, they speak out on issues not only of a medical nature, but also affecting legal, social and moral problems. Therefore, in oral journals, several topics can be considered at once.

Disputes and conferences. Dispute is a method of polemical discussion of any urgent, moral or educational problem, a way of collective search, discussion and resolution of issues of concern to the population. A dispute is possible when it is well prepared, when not only specialists participate in it, but also (for example, at school) students and teachers. Clashes, the struggle of opinions are associated with differences in the views of people, life experience, in requests, tastes, knowledge, in the ability to approach the analysis of phenomena. The purpose of the debate is to maintain the leading edge and convince everyone that they are right.

A form of propaganda, close to a dispute, is a conference with a pre-developed program and fixed speeches of both specialists and the population itself.

Oral forms of sanitary and educational propaganda also include thematic evenings, round table discussions, evenings of questions and answers. Theatrical and entertainment events, mass sports events can play an important role in promoting a healthy lifestyle. The content of work in carrying out various forms and methods of hygienic education of the population and promoting a healthy lifestyle at FAPs should be aimed at highlighting the basics of personal and public hygiene, hygiene of the village, settlement, dwelling, landscaping and gardening, maintenance of household plots; to combat environmental pollution; prevention of diseases caused by exposure to unfavorable meteorological conditions (high air humidity, high and low temperatures, and others); on the introduction of physical education into the everyday life of each person. The range of topics of this activity also includes work and vocational guidance: the creation of healthy living and working conditions, the formation of a healthy lifestyle. Much attention must be paid to the prevention of infectious diseases, improvement of water supply and water use. One of the important tasks is the promotion of occupational hygiene measures during agricultural work, the prevention of agricultural injuries and poisoning with pesticides, the clarification of the hygienic requirements for the delivery, purification and storage of water in the field. Anti-alcohol propaganda and explanation of the dangers of smoking should take a significant place. Smoking is one of the most common types of drug addiction. The work of a paramedic on anti-alcohol propaganda should be built according to a certain system, including legal, medico-biological and moral aspects.

Depending on gender and age, you can select topics for better perception by the audience.

Sample lecture plans

1. For men: the influence of alcohol on all organs and systems of the body; alcohol and trauma; alcohol and sexually transmitted diseases; alcohol and mortality; alcohol and working capacity; alcohol and family; alcohol and heredity; economic damage caused to the state by alcohol abusers.

2. For women: the effect of alcohol on a woman's body; the effect of alcohol on pregnancy; alcohol and children; the role of women in strengthening the family and overcoming the drunkenness of men.

3. For adolescents: anatomical and physiological characteristics of the adolescent's body; the effect of alcohol on the teenager's body; the effect of alcohol on the abilities of a teenager; the effect of alcohol on offspring; alcohol and law enforcement; how to maintain mental health.

A large section of preventive work to educate a healthy lifestyle should be highlighted in pediatrics. Hygienic education and upbringing begins from early childhood, with antenatal protection of future offspring.

It is advisable to educate a healthy lifestyle and prevent various diseases with pregnant women at antenatal care and group sessions in the form of individual conversations (for example, at the School for Pregnant Women). It is advisable to hold talks about the hygiene of a pregnant woman and the peculiarities of the neonatal period ™ not only among women themselves, but also among members of their families, especially husbands at the School of Young Fathers.

The need for broad preventive measures in relation to the child population and adolescents, including, first of all, measures of an educational and sanitary and educational nature, is also increasing due to the fact that at this age basic behavioral attitudes, attitudes, skills, habits, etc., are formed, i.e. all that further determines the way of life of a person. During this period, it is possible to prevent the emergence of bad habits, emotional incontinence, attitudes to passive rest and inappropriate nutrition, which in the future can become a risk factor for many diseases. It is relatively easy for children to develop the habit of physical activity, physical education and sports, varied and moderate nutrition, and a rational regimen.

Sanitary and educational work at the FAP should be carried out according to a pre-drawn up plan. Drawing up a plan for sanitary and educational work is carried out for the entire current year and for a month. In the annual plan, they provide for the main tasks for health protection and education for a healthy lifestyle, and for each month they draw up a specific plan with the names of the topics and the methods of their coverage. At the end of the month and at the end of the reporting year, the medical worker is obliged to report on the performed sanitary and educational work.

Hygienic education of the population and promotion of a healthy lifestyle should promote early access to medical care, improve obstetrics rates, reduce infant mortality, morbidity with temporary disability and injuries, timely hospitalization of patients, involve the population for preventive examinations, increase the level of sanitary culture of the population, improve conditions their work and life, activation of the creative initiative of people in matters of preserving and strengthening health, increasing efficiency and creative longevity.

Atherosclerosis is the leading cause of death in many industrialized countries. This disease is characterized by narrowing of the arteries that feed the tissues of various organs.

This is the main form of application of physiotherapy exercises, including special physical exercises used for therapeutic purposes and corresponding to all basic principles.