The Approaches Required Of A Paramedic To Effective Care Delivery For A Paediatric Patient

Introduction

This essay will analyse interventions or therapies a paramedic could utilise whilst treating a paediatric patient with a lower limb fracture, in the pre-hospital setting. It will briefly cover the assessment skills required of a Paramedic for a paediatric patient, however, it will focus primarily on pharmacological pain management relevant to age.

Main Body

As a paramedic pre-hospitally, it is sometimes difficult to earn the trust of a paediatric patient, due to the fact the majority of children have limited or no experience of severe injury/illness that requires intervention from an ambulance crew, in contrast to adults who are more likely to have. To a paediatric patient, the experience is new, alien and the unknown and usually can result in the experience being intense for a child experiencing pain. As a result of this, a paramedics approach to a paediatric has to be altered to that of an adult, in order to gain the trust of the child. Using a developmental approach is the important first step, if a child trusts you, as a paramedic, it will enable a more thorough assessment to be carried out and as a result, a higher level of treatment given. Paediatric patients will likely, feel uncomfortable with a stranger asking them questions, therefore it is important for Paramedics to remain calm, quietly spoken and most importantly build up a good rapport, where possible alongside the parents to help convince the child that they are there to help. Once trust has been earned, and consent gained the Paramedics role is now to establish the extent of the injury. The Royal Children’s Hospital Melbourne, reported that although the severity of fractures in paediatrics is usually less than that of an adult, it needs to be remembered that due to the ‘elastic’ nature of a child’s bones it allows a greater level of energy absorption prior to the fracture, therefore the degree of soft tissue trauma in the local area should not be underestimated.

Once the extent of the injury has been established the Paramedic now needs to commence with treatment options, including pain management. A journal published by Roberts (2005) reported that there are some serious failings in the provision of care and skills in relation to Paediatric treatment from ambulance services in the UK. Further research by Shaw, Fothergill and Virdi (2015) showed that historically paediatric pain management was a considerable area of concern for ambulance services. The Wong-Baker Faces scale card was introduced to enable clinicians to gain a pain score from a child, which differs from the 1-10 pain score used for adults. Prior to the card being introduced, the Shaw, Fothergill and Virdi study goes on to show that pre-hospitally, ambulances services were failing to manage pain in paediatric patients, there often wasn’t a pain assessment carried out, furthermore, the percentage where there was an assessment, results showed a further lower percentage of patients receiving analgesia – ‘A pain assessment was undertaken for 64% of patients. When a pain assessment was undertaken, and the child reported they were in pain, only 23% of patients received pharmacological pain relief’. The Wong-Baker card had an impact, and percentages increased – ‘The introduction of the card resulted in great improvements. A pain assessment was documented for 96% of patients, representing an improvement of 32%. When analgesia was indicated, it was administered to 66% of patients, an improvement of 43%’. However, there were still patients not receiving analgesia pre-hospitally – ‘Despite this improvement, pain was still not managed effectively for 34% of patient’s’. As such, the level of pain should first be established- a pain score/level needs to be gained to enable the Paramedic to ensure the correct analgesia is administered, is the pain – mild, moderate or severe and then treat accordingly. Once the severity has been determined, it is now a question as to what analgesia the Paramedic has available to them working within their trust guidelines. Bpac.org.nz, (2019) states that for ‘mild pain’ in under 12’s, Paracetamol and Ibuprofen should be considered as first-line treatments- a stepwise approach. Likewise, it is suggested that all patients complaining of pain should be considered candidates for analgesia. Opioid medications, such as Morphine should be considered for patients expressing ‘moderate-severe pain’. Pain is an individual’s feeling – pain is what the patient says it is. One person’s feeling of pain is different from another’s. It is important, as a paramedic to treat the patient’s pain based on how they are feeling it. Pain is subjective; therefore, a patient's self-report provides the gold-standard measurement of the pain. This can sometimes place Paramedics in a tricky situation, should they be expected to administer Morphine to a patient who is laughing and joking, and displaying no obvious signs of pain, yet is stating a pain score of 10?

A study carried out by Walsh, Brooks & C Cone (2012) detailed the 5 main reasons Paramedics were reluctant to administer opioid analgesia pre-hospitally. Furthermore, a journal by Iqbal, Spaight and Siriwardena (2012) went on to detail results from a study of 55 participants (17 patients, 25 ambulance clinicians and 13 ED clinicians) in relation to paediatric patients being transported to the ED with a painful condition over a 6-month period. Patients and staff expected pain to be relieved in the ambulance; however, refusal of or inadequate analgesia was common. Key themes to come from the study included: (1) consider beliefs of patients and staff in pain management; (2) widen pain assessment strategies; (3) optimise non-drug treatment; (4) increase drug treatment options; and (5) enhance communication and coordination along the pre-hospital pain management pathway. Drug therapies and dosages should be tailored to the individual, based on age and where appropriate weight and Paramedics are able to check these dosages using the ‘age per page’ provided by JRCALC.

Conclusion

Ultimately, research has suggested that everybody who is in pain has the right to pain relief. For a paramedic, it is suggested that anybody who presents in pain, should be offered pain relief. The articles suggested that there has been a positive impact from tools that have been released, and as such better-quality care has been given, but there is still room for improvement. The findings of this essay suggest further research is required in the field of suitable paediatric analgesia pre-hospitally. Paediatric patients who are not receiving pain relief are suffering because there is a lack of analgesia available, but also down to a lack of confidence from the Paramedics attending due to the infrequency of paediatrics needing analgesia. Fortunately, Paramedics deal with paediatric emergencies infrequently, as such it could be suggested that this results in de-skilling or a lack of confidence in dealing with children in pain. It is suggested that most Paramedics have little interaction with paediatric patients whilst in training, and this trend continues post qualification. As such this can result in a lower comfort/confidence level when treating paediatrics as a whole, and pain management is likely to be overlooked for younger children due to a lack of experience when treating pain in paediatric patients.