Manual of First Aid Professional English: Part 2

By Irena Baumruková

The textbook and exercise book is designed for students and medical doctors who will need to speak English in their everyday practice or who wish to read professional journals and books for their work.

It is suitable for intermediate level, good for groups as well as for self-study. English teachers can follow the book for from the beginning to end at high schools and in specialized courses.

Individuals (medical students, paramedics, nurses) can choose different parts according to their needs and interests and can easily use the book as a basis for long-term professional preparation.

• Language: English
• Publisher: Xlibris UK
• Release date: Oct 28, 2016
• ISBN: 9781524594725

Irena Baumruková

The author has been teaching medical English for more than fifteen years. She would like to draw the readers’ attention to other materials published to help physicians, dentists, dental hygienists, medical students, paramedics, and nurses to learn professional English in an interesting and pleasant way.

Book preview

Unit 1

Infectious and Communicable Diseases

Text 1

Emergencies that involve infectious and communicable diseases are common in the prehospital setting. They can pose a significant health risk to emergency medical services (EMS) providers.

Introduction

An infectious disease is any illness caused by a specific biological organism such as bacteria, viruses, protozoa, worms, prions, or fungi. A communicable disease is an infectious disease that can be passed from one person to another.

Infectious diseases may affect entire groups of people as defined by location, age, socio-economic status, and the relationships between the groups. Certain groups are an increased risk of infection (susceptible hosts).

Box 1

Persons at Increased

Risk of Infection

Pathophysiology of

Infectious Disease

Death due to infectious (communicable) disease has been declining since the early twentieth century, but infection still remains a significant cause of death.

The development or manifestations of clinical disease depend on several factors, including the virulence (degree of pathogenicity) of the infectious agent, the number of infectious agents (dose), the resistance (immune status) of the host, and the correct mode of entry. These factors all rely on an intact chain of elements to produce an infectious disease.

The elements of the chain include the following:

• the pathogenic agent

• a reservoir

• a portal of exit from the reservoir

• an environment conductive to transmission of the pathogenic agent

• a portal of entry into the new host

• susceptibility of the new host to the infectious disease.

Even if all these elements are present, exposure does not necessarily mean that a person will become infected.

Pathogenic Agent

Pathogens are organisms that can cause disease in the human host. They are classified according to shape (morphology), chemical composition, growth requirements, and viability.

Some pathogens (e.g. certain bacteria) are metabolically equipped to survive outside a host, whilst others (e.g. certain viruses) can survive only in the human cell.

Some viruses, such as HIV and the hepatitis B virus (HBV), can survive for several hours outside a host, hence why blood products can be infectious.

Most bacteria are susceptible to certain drugs (antibiotics) that either kill the bacteria or inhibit their growth.

Viruses, however, are more difficult to treat because they reside in cells and become intricately enmeshed in the host cell’s deoxyribonucleic acid (DNA).

Factors that affect a pathogen’s ability to cause disease include the following:

• the ability to invade and reproduce in a host and the mode by which it does so

• the speed of reproduction

• the ability to produce a toxin

• the degree of tissue damage that results

• potency

• the ability to induce or evade an immune response in the host.

Reservoir

Pathogens may live and reproduce in humans or other animal hosts. They may also live and reproduce in an arthropod, a plant, soil, water, food, some other organic substance, or a combination of these reservoirs.

When infected, the human host may show signs of clinical illness although the host may be an asymptomatic carrier.

The life cycle of the infectious agent depends on three factors: the demographics of the host, genetic factors, and the efficacy of therapeutic interventions.

Portal of Exit

The method by which a pathogenic agent leaves one host to invade another involves a portal of exit. The portal may be single or multiple, involving the genito-urinary tract, intestinal tract, oral cavity, respiratory tract, an open lesion, or any wound through which blood escapes.

Transmission

The mode of transmission may be direct or indirect. Direct transmission results from physical contact such as oral transmission and transmission by airborne mucus droplets, faecal contamination, and sexual contact. In indirect transmission, the organism survives on animate or inanimate objects (fomites) for a time without a human host. Diseases can be transmitted indirectly by air, food, water, soil, or biological matter.

Portal of Entry

The portal of entry is the means by which the pathogenic agent enters a new host. It may be ingestion, inhalation, percutaneous injection, crossing of a mucous membrane, or crossing of the placenta.

The time it takes for the infectious process to begin in a new host varies with the disease and host susceptibility. Exposure to an infectious agent does not always produce infection.

Translation 1

Infectious and communicable diseases can pose a significant health risk; biological organisms, bacteria, viruses, protozoa, worms, prions, fungi; affect entire groups of people, persons at increased risk of infection, young children, the elderly, immunocompromised patients, high-risk behaviours, shared needles, sexual promiscuity, certain medications, open wounds, intravenous cannulas, skin lesions; infectious disease, cause of death, and manifestations depend on virulence (degree of pathogenicity), resistance of the host, and mode of entry; pathogenic agent, a reservoir, transmission, susceptibility of the new host; pathogens are classified according to shape (morphology), chemical composition, growth requirements, and viability; pathogens survive outside a host; others can survive only in the human cell; antibiotics kill the bacteria or inhibit their growth; ability to cause disease, invade, the speed of reproduction, potency, produce a toxin, the degree of tissue damage, induce an immune response, evade; reservoir, human, an arthropod, a plant, soil, water, food, or some other organic substance; host may show signs of clinical illness or may be an asymptomatic carrier; exit, a pathogenic agent leaves one host to invade another, genito-urinary tract, intestinal tract, oral cavity, respiratory tract, an open lesion, a wound through which blood escapes; direct transmission, oral, airborne mucus droplets, faecal contamination, sexual contact; indirect transmission, the organism survives on fomites for a time; diseases can be transmitted by air, food, water, soil, or biological matter; the portal of entry, ingestion, inhalation, percutaneous injection, crossing of a mucous membrane, crossing of the placenta.

Text 2

Host Susceptibility

Host susceptibility is influenced by a person’s immune response along with several other factors. Some of these factors include the following:

Human Characteristics

• age

• gender

• ethnic group

• heredity

General Health Status

• nutrition

• hormonal balance

• presence of concurrent disease

• history of previous disease

Immune Status

• prior exposure to disease (conferring resistance)

• effective immunization against disease (conferring host immunity)

Geographical and Environmental Conditions Cultural Behaviours

• eating habits

• personal hygiene

• sexual behaviours

Box 2

Methicillin-Resistant

Staphylococcus aureus

Physiology of the Human

Response to Infection

The human body is regularly exposed to pathogens that can cause illness. Even so, most people do not succumb to infectious disease due to the protection corrected by external and internal barriers.

External Barriers

The first line of defence against infection is the surface of the body. This includes the skin and the mucous membranes of the digestive, respiratory, and GU tract. These areas are inhabited by indigenous flora (agents that could produce diseases if allowed access to the interior of the body).

Flora

Microbial flora enhance the effectiveness of the surface barrier. Indigenous flora compete with pathogens for space and nutrients. Some flora also secrete germicidal substances, and some are also thought to stimulate the immune system.

Resident (normal) flora play a key role in the body’s defence; however, some indigenous flora can be pathogenic under certain conditions. For example, when the skin or mucous membranes are interrupted or when the flora are displaced to another area of the body.

Skin

Intact skin defends against infection in two ways. First, it prevents penetration, and second, it maintains an acidic pH level that inhibits the growth of pathogenic bacteria. In addition, microbes are sloughed from the skin’s surface with dead skin cells, and oil and sweat wash microorganisms from the skin’s pores.

Gastrointestinal System

The normal bacteria in the gastrointestinal (GI) system provide competition between colonies of microorganisms for nutrients and space and help prevent the growth of pathogenic organisms. In addition, stomach acid may destroy some microorganisms and deactivate their toxic products. The digestive system eliminates pathogens through faeces.

Upper Respiratory Tract

The sticky membranes of the upper airway protect against pathogens by trapping large particles. These particles may then be swallowed or expelled by coughing or sneezing. Coarse nasal hairs and cilia also trap and filter foreign substances in inspired air, so preventing pathogens from reaching the lower respiratory tract.

In addition, the lymph tissues of the tonsils and adenoids allow a rapid local immunological response to pathogenic organisms that may enter the respiratory tract.

Genito-Urinary Tract

The natural process of urination and urine’s ability to kill bacteria help prevent infections in the GU tract. Antibacterial substances in prostatic fluid and the vagina also help prevent infection in the GU system.

Internal Barriers

Internal barriers include the inflammatory response and the immune response.

Inflammatory Response

Inflammation is a non-specific local reaction to cellular injury that occurs in response to a microbial infection. It works to prevent further invasion by isolating, destroying, or neutralizing the microorganism.

The inflammatory response is usually protective and beneficial; however, it may initiate destruction of the body’s own tissue.

It may be destructive if the response is sustained or directed against the host’s own antigens. The inflammatory response may be divided into three separate stages: first, cellular response to injury; second, vascular response to injury; and third, phagocytosis.

Cellular Response to Injury

Metabolic changes occur with any type of cellular injury. The organelles in the cell begin to swell as sodium ions accumulate. The membranes of the cellular organelles begin to leak. As the cellular contents are dissolved by enzymes, the inflammatory response is stimulated in surrounding tissues.

Vascular Response to Injury

Localized hyperaemia (an increase in blood in the area) develops after cellular injury. This produces oedema. Leukocytes collect inside the vessels, where they release chemotactic factors (chemicals that attract more leukocytes to the area).

Phagocytosis

Though phagocytosis, leukocytes engulf, digest, and destroy the invading pathogens. Circulating macrophages clear the area of dead cells and other debris.

Immune Response

The immune system has four unique characteristics:

• It has ‘self-non-self’ recognition; therefore it usually responds only to foreign antigens.

• It produces antibodies that are antigen specific. That is, new antibodies can be produced in response to new antigens.

• Some of the antibodyproducing lymphocytes become memory cells. These cells allow for a more rapid response to repeat invasions by the same antigen.

• The immune system is selfregulated. It activates only when a pathogen invades, which prevents healthy tissues from being destroyed. When this function goes away, autoimmune disease can occur (e.g. rheumatoid arthritis, active glomerulonephritis, and systemic lupus erythematosus).

The body’s immune response depends partly on the size of the pathogen and partly on the body’s ability to induce production of an antibody.

Often, peripheral phagocytic cells encounter a pathogen first. However, circulating B and T cells are also scouting for pathogens. Complex interactions occur among neutrophils, macrophages, and B and T cells.

Each B cell has a different antibody on its surface, which attaches to a specific antigen that has a complementary shape.

It will bind with the antigen and commence a process that results in the production of large quantities of the specific antibody.

T cells not only process antigen for the B cells, they also include a subpopulation of ‘killer cells’. These cells play a major role in cell-mediated immunity.

Both the humoral and cellmediated types of immunity take time to work. Both require previous exposure to mobilize specialized white cells.

In time, these white cells differentiate between antibodies. They then organize an attack on the foreign material. By comparison, the complement system recognizes and kills invaders on first sight. It does not take time to mobilize specialized responses.

Translation 2

Host susceptibility, age, gender, ethnic group, heredity; general health status, nutrition, hormonal balance, presence of concurrent disease, history of previous disease; immune status, prior exposure to disease, effective immunization; eating habits, personal hygiene, sexual behaviours; Staphylococcus aureus, carried on the skin and in the nose of healthy people, minor infections, pimples, boils, serious infections, surgical wound infections, bone infections, pneumonia, septicaemia; patients elderly, very sick, open wound (bedsore), indwelling urinary catheter, intravenous therapy; spread by direct physical contact, touching of towels, sheets, clothes; avoid contact with open wounds or contaminated dressings; response to infection, protection, external and internal barriers; the surface of the body, skin, mucous membranes, indigenous flora can be pathogenic if allowed access to the interior of the body; skin defends against infection, prevents penetration, maintains an acidic pH level that inhibits the growth of pathogenic bacteria, dead cells are sloughed, oil and sweat wash skin’s pores; gastrointestinal system, stomach acid, eliminate pathogens; upper respiratory tract, trapping large particles, they may be swallowed or expelled by coughing or sneezing, nasal hairs filter foreign substances, the lymph tissues of the tonsils and adenoids, a rapid local immunological response; genito-urinary tract, urine’s ability to kill bacteria, antibacterial substances in prostatic fluid and the vagina; internal barriers, the inflammatory response, immune response; inflammation is a local reaction, isolating, destroying, or neutralizing the microorganisms, usually protective and beneficial; however, it may initiate destruction of the body’s own tissue, three separate stages, cellular response, vascular response, phagocytosis; cellular response to injury, metabolic changes, the inflammatory response is stimulated in surrounding tissues; vascular response to injury, localized hyperaemia, oedema, leukocytes collect inside the vessels; phagocytosis, leukocytes engulf, digest, and destroy the invading pathogens, macrophages clear the area of dead cells; immune response, the immune system responds to foreign antigens, new antibodies can be produced in response to new antigens, memory cells allow for a more rapid response to repeat invasions by the same antigen, it activates only when a pathogen invades, which prevents healthy tissues from being destroyed; autoimmunedisease, rheumatoid arthritis, active glomerulonephritis, systemic lupus erythematosus; previous exposure, mobilizes specialized white cells, these differentiate between antibodies, they then organize an attack on the foreign material.

Text 3

Stages of Infectious Disease

The progression from exposure to an infectious agent to the onset of clinical disease follows specific stages. These stages are the latent period, the incubation period, the communicability period, and the disease period.

Latent Period

The latent period begins when the pathogen invades the body. During this period, an infectious agent cannot be passed to someone else or cause significant symptoms.

In some diseases (e.g. HIV), the latent period is quite stable and can last several years. In others (e.g. influenza), the latent period may last only 24 to 72 hours.

The latent period as a stage of infectious disease is distinct from a latent infection. A latent disease is characterized by periods of inactivity between attacks.

Herpesviruses are examples of pathogens that readily enter a latent stage. During this stage, symptoms disappear but may reappear upon reactivation of the latent infection.

Incubation Period

The incubation period is the interval between exposure to the pathogen and the first onset of symptoms. Like the latent period, the incubation period varies in length.

During the incubation period, the infectious organism reproduces in the host. The body is stimulated to produce antibodies specific for the disease or antigen. In this phase, the antigen is present, but there is no detectable antibody.

Communicability Period

The communicability period follows the latent period. It lasts as long as the agent is present and can spread to other hosts. (Clinically significant symptoms from the infection may manifest during this period.)

The communicability period and the method of transmission can be altered in some diseases (e.g. tuberculosis, syphilis, gonorrhoea).

Disease Period

The disease period follows the incubation period. This stage may be free of symptoms, or it may produce overt symptoms.

During the disease period, the body may be able to rid itself of the disease entirely; however, the organism may become incorporated and lie inactive inside certain cells (a latent disease).

Several viruses (e.g. HIV and hepatitis) can lead to latent infection. The resolution of symptoms does not mean the infectious agent has been destroyed.

Principles of Infection

Prevention and Control

Ambulance staff may be exposed to blood-borne viruses such as hepatitis B (HBV), hepatitis C (HCV), and HIV. The most likely method of transmission is by direct percutaneous inoculation of infected blood.

This may occur as a result of needle-stick injury, splashing of blood on to broken skin, or via mucous membranes and the eyes. In addition to blood, other bodily fluids may also contain pathogenic organisms. Examples include vomit, faeces, urine, and sputum.

Note

It is not always possible to identify patients with infectious disease; therefore, paramedics should take precautions to prevent the spread of infection at all times.

Standard Principles of Infection Control

• handwashing and skin care

• personal protective equipment (PPE)

• safe handling and disposal of sharps

• waste management

• linen management

Handwashing

Hands are the most common vehicle by which microorganisms are transmitted between healthcare workers and patients.

Handwashing should be carried out in accordance with the technique described:

• Remove jewellery (wedding rings excepted).

• Wet hands with water, and then apply liquid soap/cleaning solution.

• Vigorously rub hands for 10–15 seconds; pay particular attention to tips of fingers, thumbs, and between fingers.

• Rinse hands thoroughly and dry properly.

Regular use of hand creams will help to prevent dry skin and cracking, which will help to maintain an effective barrier against infection. The paramedic should use impermeable waterproof dressings to cover any cuts or abrasions whilst on duty and should check these for integrity during the shift.

Personal Protective

Equipment (PPE)

Many of the activities carried out by a paramedic do not involve contact with body fluids and do not require the use of PPE, for example, taking a pulse, connecting ECG electrodes, or taking a blood pressure. The paramedic should make a professional judgement as to the need for PPE and act accordingly.

Disposable Gloves

Disposable gloves should be fitted just prior to patient contact wherever contact with blood/body fluids is anticipated. The practice of driving back from a job with gloves still fitted is unacceptable as it will transfer blood/body fluids to the steering wheel, gearstick, handbrake, door handles, etc.

In cases where the risk of puncture is high (e.g. when dealing with road traffic collisions where glass may be a hazard), the paramedic should consider wearing two pairs of gloves for extra protection.

The size and type of glove is also important. Gloves should be hypoallergenic, well-fitting, seamless, and powder-free. They should fit comfortably—not too tight that they become restrictive but not so loose that they impair the dexterity. The paramedic should also avoid writing patient details on gloves for hygiene reasons.

It is important to note that the wearing of gloves is not a substitute for handwashing; gloves should be changed after each procedure, and hands should be cleaned following their removal.

Aprons

Disposable water-repellent aprons should be used where there is a possibility of clothing contamination from blood/body fluids. These are single-use and should be disposed of as clinical waste after use. The paramedic should always have a spare uniform available in the event of clothing contamination.

Face Masks

Face masks may confer protection against airborne infection and splashing against the face and mouth. Face masks are recommended for use where there is a risk of blood / body fluid splashing into the mouth, if the patient is having recurrent episodes of coughing or sneezing or during intubation of patients with suspected tuberculosis or meningococcal disease.

A recommendation also suggests that a patient with an uncontrolled productive cough should be encouraged to wear a face mask to protect the healthcare worker.

Face masks should fit correctly with no gaps at the sides. The paramedic should avoid touching the mask once in situ and should not lift it up or down between episodes of close patient contact. Masks should be discarded into the clinical waste after each episode of use or if they get wet.

Safe Handling of Sharps

Sharps include any article that can puncture or cut the skin, such as needles, glass ampoules, razors, and scalpels. All sharps should be handled safely to minimize the risk of exposure to blood-borne pathogens.

Clinical sharps should be singleuse items that are stored either in the designated place on the vehicle or within response bags. The paramedic should wear disposable gloves when handling sharps and should dispose of the sharp directly into a properly assembled container immediately after use and at the point of use.

It is important to note that it is the responsibility of the practitioner using the sharp to dispose of it safely and that sharps should not be passed from hand to hand or person to person.

It is important to follow the correct procedure in the event of sharp injury:

• Encourage bleeding from the wound by gently squeezing; do not suck the wound.

• Wash the wound in soap and warm running water or with a disposable wipe if running water is not available.

• Do not scrub when washing.

• Cover wound with a sterile dressing.

• Safely dispose of any relevant sharps involved.

• Report the incident to the appropriate supervisor and complete an incident report form.

• Document details of the patient involved or source of injury (if known).

In the event of splash contamination involving eyes or mouth, irrigate eyes and mouth freely with water or saline.

Waste Management

Healthcare waste can be subdivided into clinical and nonclinical waste. Clinical waste is defined as any waste that consists wholly or partly of:

• human or animal tissue

• blood or bodily fluids

• excretions

• drugs or other pharmaceutical products

• swabs or dressings

• syringes, needles, or other sharp instruments, which unless rendered safe may prove hazardous to any person coming into contact with it

• any other waste arising from medical, nursing, dental, veterinary, pharmaceutical, or similar practice; investigation, treatment, care teaching, or research; or the collection of blood for transfusion, being waste that may cause infection to any person coming into contact with it.

Ambulance staff must make every attempt to dispose of clinical waste in the appropriate manner, but where this has not been possible and waste has been left in a public place, the paramedic should contact the control centre and arrange for collection.

Clinical waste should be

• correctly bagged into yellow bags of suitable thickness

• double-bagged where the exterior of the bag is contaminated, split, or leaking

• kept in a rigid-sided holder with foot-operated lid

• inaccessible to children (as much as practicable)

• filled to a maximum of ¾ full

• sealed and labelled with tags.

Linen Management

The risk of infection from soiled linen is low for a healthy paramedic provided that care is taken.

The risks can be further minimized by

• applying standard principles of infection control and prevention

• wearing disposable gloves and aprons when handling laundry

• removing PPE and washing hands before undertaking further duties.

Disposable linen is preferable for ambulance use. All used items of disposable linen should be placed into a yellow bag and treated as clinical waste.

Non-disposable linen should only be used once and should be replaced after every patient. Linen may be exchanged at the receiving hospital or ambulance station.

All used linen, irrespective of state, should be placed in a white bag, whilst infectious linen (contaminated with blood/body fluids from a known or suspected infectious patient) should be placed in a red soluble bag inside a red nylon bag.

These bags should not be filled in excess of two-thirds capacity and should not be reopened once sealed.

Care of Infected Patients

Paramedics may not know if a patient is infected, so they should apply standard principles for infection control at all times.

Translation 3

Stages of infectious disease, the latent period, the incubation period, the communicability period, and the disease period; the latent period begins when the pathogen invades the body; the pathogen cannot be passed to someone else or cause significant symptoms; latent infection, periods of inactivity between attacks, herpesviruses readily enter a latent stage, symptoms reappear upon reactivation; the incubation period is the interval between exposure to the pathogen and the first onset of symptoms, it varies in length, the infectious organism reproduces, the body is stimulated to produce antibodies; the communicability period follows the latent period, it lasts as long as the agent is present and can spread to other hosts; the disease period follows the incubation period, body may be able to rid itself of the disease entirely; however, the organism may become incorporated and lie inactive inside certain cells, the resolution of symptoms; principles of infection prevention, blood-borne viruses, hepatitis B, hepatitis C, and HIV, percutaneous inoculation of infected blood, needlestick injury, splashing of blood onto broken skin, or via mucous membranes and the eyes, other bodily fluids may also contain pathogenic organisms, vomit, faeces, urine, and sputum principles of infection control, handwashing and skin care, personal protective equipment, safe handling and disposal of sharps, waste management, linen management; handwashing technique, remove jewellery, apply liquid soap, vigorously rub hands, rinse hands thoroughly and dry properly, use impermeable waterproof dressings to cover any cuts or abrasions; personal protective equipment, disposable gloves, hypoallergenic, well-fitting, seamless, and powderfree; fit comfortably, not too tight, restrictive, not so loose that they impair the dexterity; road traffic collision, ambulance, steering wheel, gear stick, handbrake, door handles; apron, water-repellent, single-used, after use, dispose of as clinical waste, spare uniform available; face mask, protection against airborne infection and splashing, wear a face mask, fit correctly, with no gaps at the sides, avoid touching the mask once in situ, not lift it up or down; safe handling of sharps, any article that can puncture or cut the skin, needles, glass ampoules, razors and scalpels, store in the designated place; procedure in the event of sharp injury, encourage bleeding by gently squeezing, wash the wound in soap and warm running water, cover with a sterile dressing; report the incident, complete a form, document details, source of injury; clinical waste, human or animal tissue, blood, bodily fluids, excretions, pharmaceutical products, swabs, dressings, syringes, needles, waste arising from medical, nursing, dental, veterinary, or similar practice; clinical waste should be bagged, suitable thickness, split, leak, holder, lid, seal, label with tag.

Text 4

Classification of Infectious Disease

Infectious diseases are classified into three categories, depending upon the infection control precautions required:

Category 1

This encompasses infections where the risk of person-to-person spread is minimal; standard principles should be maintained.

Category 2

These infections carry a slightly higher risk of personto-person spread, but standard precautions should be effective.

Category 3

These infections are highrisk infections for which special precautions and procedures should be followed.

Box 3

Categories of Infectious Disease

Preparation for Transfer

Once a request for transportation has been received, ambulance control will designate a crew to undertake the case and an officer to escort the crew to the patient and then on to the receiving hospital. A crew of three may be required in cases where the patient has reduced mobility.

The crew should be directed to an appropriate point to pick up and don their PPE for the case; this will normally include:

• theatre greens/blues (remove all underwear and socks, otherwise they will be incinerated on completion)

• white boiler suit

• infectious disease suit with hood (worn over the boiler suit)

• double gloving (second glove should overlap the cuff of the boiler suit and be taped)

• white gumboots (boiler suit should be tucked inside the boots, infectious disease suit should be rolled down over the boots ready for taping)

• filter mask

• full-face anti-splash visor (placed over the hood and the filter mask).

Jewellery should be removed. Contact lenses should also be removed unless they are essential; if they are worn during the transfer, they will be decontaminated on completion, although it may be advisable to have a spare pair of lenses or glasses available.

Note

The appearance of a crew dressed in full protection suits may be disconcerting for the patient, so the paramedic should be prepared to offer reassurance and support to both the patient and relatives.

The Vehicle

The vehicle should be checked for roadworthiness, fuel levels, etc., and all equipment not deemed to be essential should be removed from the vehicle and left on station for later collection.

Box 4

Essential Equipment for Category

3 Infectious Disease Transfer

Box 5

Additional Items for

Storage in the Cab

Collecting the Patient and Transportation

The crew should ensure that all protective clothing is correctly fitted prior to entering the patient’s home or location.

The patient should be asked to wear a face mask with respiratory filter and safety eyewear in order to minimize the risk to the crew.

In a crew of three, the driver should maintain a distance from the patient and should endeavour to keep bystanders or onlookers away from the scene.

During the journey, the crew should provide appropriate medical and emotional support for the patient but should avoid any unnecessary procedures or handling.

It is essential that the crew who have been in contact with the patient do not leave the vehicle except for an emergency evacuation procedure.

In the event of a breakdown, contact should be made with the escorting officer and control room; they will make arrangements to either repair the fault or tow the vehicle to its destination.

At the Hospital

The hospital staff or escorting officer will direct the crew to the appropriate entrance where the patient can be handed over.

The crew will then take the vehicle to a decontamination area, where it will be cleaned using hot water and detergent followed by agents specified for such use. All removable objects should be retaken off to facilitate cleaning of both the vehicle and the removed objects; all disposable equipment should be placed into a clinical waste bag. Clinical waste bags should be sealed and labelled with the patient’s diagnosis clearly written on the label. Hospital staff will receive the clinical waste bags and make arrangements for their disposal.

The crew should then enter the hospital through the patient admission door and proceed to the ‘dirty’ changing room. There they should undress and place all items into a yellow clinical waste bag labeled as above. Items such as spectacles should be placed in a clear plastic bag for processing by hospital staff.

Once undressed, the crew should proceed to shower and ensure that they wash thoroughly. It is the responsibility of each crew member to clean the shower and throw towels and paper foot mats back into the ‘dirty’ area before moving to the ‘clean’ changing area. In the clean area, the crew should retrieve their clean uniform and get dressed before leaving the unit via the designated exit.

Translation 4

Classification of infectious disease, category 1, the risk of personto-person spread is minimal, standard principles should be maintained, category 2, standard precautions are effective, category 3, highrisk infections for which special precautions and procedures should be followed; category 1 (glandular fever, influenza, malaria, scabies, tetanus, whooping cough); category 2 (anthrax, chickenpox, cholera, diphtheria, dysentery, encephalitis, food poisoning, gastroenteritis, hepatitis B, HIV/AIDS, infestations, measles, meningitis and septicaemia, mumps, poliomyelitis, German measles, tuberculosis, typhus); category 3 (Ebola, plague, smallpox, yellow fever); preparation for transfer, request for transportation, designate a crew, to undertake the case, don the PPE, theatre greens/blues, remove all underwear and socks, white boiler suit, suit with hood, double gloving, overlap the cuff, tape, white gumboots, tuck inside, roll down, filter mask, visor, remove contact lenses, have a spare pair; the vehicle, check for fuel level, essential equipment, transfer of a patient, trolley stretcher, carrying chair, blankets, vomit bowls, clinical waste bags, for incineration, gloves, plastic aprons, tissue, drinking water flask, cups, bedpans and urine bottles; items for storage in the cab, cardiac monitor/defibrillator, bagvalve-mask and oxygen reservoir bag, mechanical resuscitator, suction unit (charged), torch, spare batteries for portable devices; collecting the patient, minimize the risk to the crew, maintain a distance from the patient, endeavour to keep bystanders and onlookers away from the scene, provide emotional support, avoid any unnecessary procedures, in the event of a breakdown, escorting officer, repair the fault, tow the vehicle; at the hospital, direct the crew to the appropriate entrance, hand the patient over, clean the vehicle with hot water and detergent, the patient admission door, changing room, undress, proceed to shower, throw towels and paper foot mats away, retrieve clean uniform, and get dressed.

Text 5

Specific Diseases

Human Immunodeficiency Virus

HIV is present in the blood and serum-derived body fluids (semen, vaginal, or cervical secretions) of people infected with the virus.

The disease is directly transmitted from person to person through anal or vaginal intercourse, across the placenta, or by contact between infected blood or body fluids and mucous membranes or open wounds.

It can also be transmitted indirectly through transfusion with contaminated blood or blood products, transplantation of tissues and organs, and the use of contaminated needles or syringes.

The incidence of HIV is highest in people with the following risk factors:

• high-risk sexual behaviour

• intravenous drug abuse

• transfusion recipient between 1978 and 1983

• haemophilia or other coagulation disorders requiring blood products

• infant born to an HIVpositive mother.

Other factors that may affect susceptibility to HIV include concurrent sexually transmitted diseases (STDs), especially those that cause skin ulcerations.

Pathophysiology

Even though the body develops antigen-specific antibodies to HIV, these antibodies do not protect against HIV.

Secondary complications are generally caused by opportunistic infections that develop as the immune system deteriorates.

These infections include the following:

• pulmonary tuberculosis

• recurrent pneumonia

• wasting syndrome

• HIV dementia

• sensory neuropathy

• toxoplasmosis of the central nervous system.

Personal Protection

Strict compliance with universal precautions is the only preventive measure healthcare workers can take against HIV.

The risk to healthcare workers increases under the following circumstances:

• The exposure involves a large amount of blood. This can occur when a piece of equipment is visibly contaminated with blood, when care of the patient involves placing a needle in a vein or an artery, and when the patient has deep injuries.

• The exposure involves a patient with a terminal illness, possibly reflecting a higher dose of HIV in the late course of acquired immune deficiency syndrome (AIDS).

Post-Exposure Prophylaxis

If exposure is confirmed or suspected, the paramedic should immediately notify the duty officer. This allows elective post-exposure prophylaxis (PEP) to begin.

Information on primary HIV indicates that systemic infection does not occur immediately; this leaves a narrow window of opportunity in which postexposure antiretroviral intervention may modify viral replication.

Note

There are three types of exposure in healthcare settings associated with significant potential to transmit HIV. These are:

• percutaneous injury (from needles, instruments, bone fragments, significant bites that break the skin, etc.)

• exposure of broken skin (abrasions, cuts, eczema, etc.)

• exposure of mucous membranes, including the eye.

The paramedic should weigh up the balance of risks in their particular circumstances and should receive counselling regarding evaluation and treatment after an exposure.

Psychological Reactions to HIV

HIV is almost always a progressive disease with morbid late consequences. Throughout the course of the infection, patients are likely to feel and express anger about many aspects of their illness. These include pain, dying prematurely and without dignity, and the social rejection and prejudice that the person may experience.

Patient care should include helping these patients feel that they can obtain acceptance and compassion from healthcare workers. Despite current limitations, the progression of the illness can be delayed with drug therapy and other strategies.

Translation 5

Human immunodeficiency virus, present in the blood, body fluids (semen, vaginal, or cervical secretions), disease is transmitted through anal or vaginal intercourse, across the placenta, mucous membranes, open wounds, through transfusion, transplantation of tissues and organs, the use of contaminated needles or syringes; the incidence of HIV, risk factors, sexual behaviour, intravenous drug abuse, coagulation disorders, infant born to an HIV-positive mother, concurrent sexually transmitted diseases, secondary complications, opportunistic infections, immune system deteriorates, pulmonary tuberculosis, recurrent pneumonia, wasting syndrome, HIV dementia, sensory neuropathy, toxoplasmosis of the central nervous system; strict compliance with precautions, the risk to healthcare workers, a large amount of blood, equipment visibly contaminated with blood, placing a needle in a vein or an artery, deep injuries, patient with a terminal illness; post-exposure prophylaxis, if exposure is confirmed or suspected, intervention may modify viral replication; potential to transmit HIV, break the skin, instruments, bone fragments, bites, abrasions, cuts, eczema; psychological reactions to HIV, progressive disease, feel and express anger, dying prematurely, social rejection and prejudice, patient care, acceptance and compassion.

Text 6

Hepatitis

Hepatitis is a viral disease that produces pathological changes in the liver. The hepatitis viruses are divided into three main classes: hepatitis A (viral hepatitis), hepatitis B (serum hepatitis), and hepatitis C (non-A/non-B hepatitis).

Hepatitis A Virus

Hepatitis A is a disease acquired by ingesting HAV-contaminated food or drink or via the faecal/oral route.

The virus localizes in the liver, reproduces, enters the bile, and is carried to the intestinal tract. From there it is shed in the faeces. Antibodies (anti-HAV) develop during acute disease and also late in convalescence.

Once infected, the person is immune to HAV for life. HAV is the only hepatitis virus that does not lead to chronic liver disease or a chronic carrier state. Many HAV infections are subclinical and often manifest with influenza-like symptoms.

Hepatitis B Virus

Infectious HBV particles are found in blood and secretions containing serum (e.g. oozing, cutaneous lesions). They also are found in secretions derived from serum (e.g. saliva, semen, vaginal secretions).

HBV affects the liver and causes the signs and symptoms described previously. The virus may produce chronic infection, which can lead to cirrhosis and other complications. Although HBV usually lasts less than six months, the carrier state may persist for years.

The effects of HBV vary from low-grade fever and malaise to extensive liver necrosis that can lead to death. Other complications include coagulation defects, impaired protein production, impaired bilirubin elimination, pancreatitis, and hepatic cancer.

HBV is stable on environmental surfaces and can remain infective in visible blood for longer than seven days.

Pre-Exposure Prophylaxis

HBV is a serious concern to all healthcare workers. Blood is the most important potential source of HBV in the workplace. Effective vaccinations are available.

The HBV vaccination schedule generally requires three doses over six months, although adults requiring rapid protection can have the vaccination at 0, 7, and 21 days. For the best protection against HBV, the series should be completed before an exposure occurs.

Post-Exposure Prophylaxis

Post-exposure prophylaxis may be indicated if an unvaccinated person is exposed to HBV. Before treatment, a blood test is performed to determine immunity to HBV. People who are not immune generally receive the HBV vaccine and hepatitis B immunoglobulin. (This is an antibody used in post-exposure treatment to provide passive immunity to HBV.)

Hepatitis C Virus

Hepatitis C virus (HCV) is a blood-borne virus that causes a disease similar to HBV. Hepatitis C is the infection that most often results from needle-stick and sharps injury. Of healthcare workers who become infected, 85% become chronic carriers.

Signs and symptoms of the disease, when they occur, are similar to those of other types of hepatitis.

Signs and Symptoms

Infection with any of the causative viruses may be symptomless. On the other hand, it may cause a typical hepatitis with an abrupt onset of flulike illness that is followed by jaundice or dark urine or both.

A patient is most infectious during the first week of symptoms. Within two to three months of infection, the patient usually develops non-specific symptoms. These may include anorexia, nausea and vomiting, fever, joint pain, and generalized rashes.

Patient Management and

Protective Measures

The management of patients out of the hospital is mainly supportive. The goal is to maintain circulatory status and prevent shock. All healthcare workers involved in the patient’s care must follow careful personal protective measures, including effective handwashing.

It also involves proper care in the use of diagnostic and therapeutic equipment (e.g. high-level disinfection of laryngoscope blades) and appropriate disposal of sharps.

Translation 6

Hepatitis, a viral disease, pathological changes in the liver; hepatitis A virus, contaminated food, drink, via the faecal/oral route, the virus localizes in the liver, reproduces, enters the bile, is carried to the intestinal tract, is shed in the faeces, influenza-like symptoms, the person is immune for life; hepatitis B virus, blood, saliva, semen, vaginal secretions, chronic infection, cirrhosis, the carrier state may persist for years, fever, malaise, liver necrosis that can lead to death, coagulation defects, impaired protein production, impaired bilirubin elimination, pancreatitis, hepatic cancer; potential source of HBV in the workplace, effective vaccinations, three doses over 6 months, perform blood test, determine immunity; hepatitis C virus, needlestick and sharps injury, healthcare workers can become chronic carriers; hepatitis, an abrupt onset of flu-like illness, jaundice, dark urine, anorexia, nausea, vomiting, fever, joint pain, generalized rashes.

Text 7

Tuberculosis

Each year, eight million new cases of tuberculosis (TB) occur worldwide, and three million people die of the disease. TB is also more prevalent where HIV/AIDS are epidemic; people with HIV and TB are 30 to 50 times more likely to become sick with TB than someone infected with TB who is HIV-negative.

Other factors include:

• immigration of people from areas with a high prevalence of TB

• transmission of TB in highrisk environments, such as prisons, homeless shelters, hospitals, and nursing homes

• deterioration of the TB public healthcare infrastructure.

Pathophysiology

TB is a chronic pulmonary disease that is acquired through inhalation of a dried-droplet nucleus containing tubercle bacilli.

TB is passed mainly by infected persons coughing or sneezing the bacteria into the air. It can also be passed through contact with the sputum of an infected person. People who share the same air space as those with infection TB are at highest risk for infection.

The pathology of TB is related to the production of inflammatory lesions throughout the body and to the ability of the TB bacillus to break through the body’s natural defences.

This leads to the formation of caseating granulomas (necrotic inflammatory cells). These may cause chronic and debilitating lung disease.

Susceptibility to mycobacterial infection is generally highest in children younger than 3 years of age, in adults older than 65, and in chronically ill, malnourished, and immunosuppressed or immunocompromised individuals.

The infection may remain dormant or it may lead to active, contagious disease. Signs and symptoms of TB include cough, fever, night sweats, weight loss, fatigue, and haemoptysis.

The organ systems affected and the associated complications include the following:

• cardiovascular system (pericardial effusions)

• lymphadenopathy (cervical lymph nodes are usually involved)

• skeletal system (intervertebral disc deterioration, chronic arthritis of one joint)

• central nervous system (subacute meningitis, brain granulomas)

• systemic miliary TB (extensive dissemination by the bloodstream of tubercle bacilli).

Paramedics should maintain a high degree of suspicion for TB in individuals with undiagnosed lung disease, especially patients who are HIV-positive.

Patient Care and Protective Measures

Paramedics should be aware of areas with a high incidence of active TB in their service region.

As with any other infectious disease, universal precautions should be taken during patient care. This includes respiratory barriers for the patient and the paramedic.

Surgical masks are insufficient. However, they do reduce the number of droplet nuclei escaping from the patient. Therefore, they should be placed on the patient during transport.

Healthcare workers use particulate filter respirators (N-type respirators). Ambulance ventilation system that include high-efficiency particulate air (HEPA) filtration and a non-recirculating ventilation cycle are another measure for preventing exposure to TB during patient transport.

After each call, disinfection of all patient care equipment should be performed.

Treatment

If effective treatment is begun without delay, TB is usually curable. Sputum and cultures usually become negative three to eight weeks after the start of therapy.

Translation 7

Tuberculosis, immigration of people from areas with a high prevalence, prisons, homeless shelters, hospitals, nursing homes, deterioration of public healthcare infrastructure; chronic pulmonary disease, coughing or sneezing the bacteria into the air, contact with the sputum, inflammatory lesions throughout the body, break through the body’s natural defences, formation of necrotic inflammatory cells, debilitating lung disease, susceptibility in chronically ill, malnourished, and immunosuppressed individuals; the infection dormant, active, disease contagious, curable, cough, fever, night sweats, weight loss, fatigue, haemoptysis; the affected organ systems, the associated complications, cardiovascular system, pericardial effusions, lymphadenopathy, cervical lymph nodes, skeletal system, intervertebral disc deterioration, chronic arthritis of one joint, central nervous system, subacute meningitis, brain granulomas, systemic military TB, extensive dissemination by the bloodstream of tubercle bacilli; precautions, surgical masks are insufficient, filter respirators, ambulance ventilation system.

Text 8

Meningococcal Meningitis

Meningococcal meningitis is also known as spinal meningitis. It is inflammation of the membranes that surround the spinal cord and brain. Meningococcal meningitis can be caused by a variety of different bacteria, viruses, and other microorganisms.

The usual mode of transmission is prolonged, direct contact with upper respiratory secretions (discharge from the nose and throat) from an infected person or carrier.

Once inhaled, the bacteria invade the respiratory passages and travel by way of the blood to the brain and spinal cord.

As the infecting agent spreads to more organs, it causes toxic effects in the involved organ system.

The throat’s epithelial lining generally prevents the germ from invading the meninges and the cerebrospinal fluid. The total number of cases of meningococcal disease has been falling, following the introduction of vaccination into routine infant immunization.

The general trend in other strains of the disease is also encouragingly downwards, but there is still a need for vigilance by the paramedic.

Other Infectious Agents

Known to Cause Meningitis

Other common pathogens that cause meningitis include Streptococcus pneumoniae and Haemophilus influenzae type b (Hib) and some viruses.

Streptococcus pneumoniae is the second most common cause of bacterial meningitis in adults, the most common cause of pneumonia in adults, and the most common cause of otitis media (middle ear infection) in children.

This bacterium is spread by droplets, prolonged personal contact, or extended contact with linen soiled with respiratory discharges.

Haemophilus influenzae has the same mode of transmission. Vaccines for children were introduced in the 1980s. (These bacteria are also responsible for conditions such as paediatric epiglottitis, septic arthritis, and generalized sepsis.)

This type of meningitis can be treated with antibiotics. However, 50% of infected children have lasting damage to the nervous system.

Viral meningitis is a syndrome generally associated with an existing systemic viral disease (e.g. enteroviral infection, herpesvirus infection, mumps, and less commonly, influenza).

In most cases, viral meningitis is self-limited, and the patient recovers fully. The patient may experience muscle weakness and malaise during prolonged convalescence. Viral meningitis is not believed to be communicable.

Signs and Symptoms

The signs and symptoms of meningitis depend on the patient’s age and general health. In infants, for example, signs of meningeal irritation may be absent. On the other hand, they may include irritability, poor feeding or vomiting, a high-pitched cry, and fullness of the fontanelle. (Maternal antibodies generally protect neonates to six months of age.)

In older infants and children, signs of meningitis may include malaise, low-grade fever, projectile vomiting, petechial rash, headache, and stiff neck from meningeal irritation (nuchal rigidity).

Diagnostic signs of meningitis in older children include involuntary flexion of the arm, hip, and knee when the neck is passively flexed and loss of the ability in a seated or supine patient to completely extend the leg when the thigh is flexed on the abdomen; the patient usually can extend the leg completely when the thigh is not flexed on the abdomen.

Infection should be suspected in any patient with fever, headache, stiff neck, altered mental status, or underlying health problems (e.g. recent neurosurgery, trauma, or immunocompromise).

If extensive meningeal involvement develops in a toxic or debilitated patient, the illness may be accompanied by acute adrenal insufficiency, convulsions, coma, and disseminated intravascular coagulation. In this case, death can occur in six to eight hours.

Other conditions and longterm complications associated with severe meningitis include blindness and deafness (from cranial nerve damage), arthritis, myocarditis, and pericarditis. Death can follow overwhelming infection.

Immunization and Control Measures

Vaccines are available for Hib, some strains of Neisseria meningitidis, and many types of Streptococcus pneumoniae. The vaccines against Hib are very safe and highly effective.

By 6 months of age, infants should have received at least three doses of Hib vaccine; a fourth dose (booster) is recommended between 12 and 18 months of age.

Patient Management and Protective Measures

Patient management focuses on ensuring an adequate airway and ventilatory and circulatory support. The paramedic must take protective measures when caring for patients who have signs and symptoms of meningitis.

Early diagnosis and treatment of bacterial meningitis are essential. The diagnosis is usually confirmed by finding the bacteria in a sample of the patient’s spinal fluid, which is obtained through a spinal tap (lumbar puncture).

The disease is then treated using several antibiotics. Drugs to prevent the disease are available for those who may have intimate contact with the patient (e.g. family members).

Note

Meningitis is a true medical emergency. A chief goal of emergency care is administration of benzylpenicillin, which should be administered in the presence of a non-blanching rash and signs/symptoms indicative of meningococcal septicaemia.

Translation 8

Meningococcal meningitis, spinal meningitis, inflammation of the membranes that surround the spinal cord and brain, mode of transmission, contact with upper respiratory secretions, discharge from the nose and throat, the bacteria invade the respiratory passages and travel by way of the blood to the brain and spinal cord, they spread to more organs, toxic effects, the total number of cases has been falling, introduction of vaccination; bacterial meningitis, pneumonia, otitis media, epiglottitis, septic arthritis, generalized sepsis; viral meningitis, associated with an