Today, over 150 million people in the world suffer from bronchial asthma, and there is a tendency to further increase their number. Bronchial asthma is a chronic disease that is an allergic inflammation of the airways.
During asthma attacks, it is important for the emergency team to respond quickly and competently in order to normalize the patient’s condition. Correctly issued call cards for bronchial asthma allow you to assess as accurately as possible how timely and correct assistance was provided.
What is an ambulance card and what is it for
An ambulance call card is an expert assessment document, indicating the correct and timely determination of the diagnosis, as well as the provision of medical assistance to the patient by the emergency workers. Refers to primary medical documentation.
Filled in according to the 110 / y form, approved by the order of the Ministry of Social Development of the Russian Federation in 2009.
The information in it has three purposes:
- medical – data on the patient’s condition;
- legal – indicates the person responsible for the implementation or non-implementation of certain actions for emergency assistance;
- financial – certifies the costs of diagnostics and treatment.
All of this information is clearly displayed and logically linked to each other. The actions of the health care provider must fully comply with the treatment protocol for a specific diagnosis. For example, with bronchial asthma, first of all, measures are taken to quickly stop an attack of suffocation.
All records in the document are detailed, distinct, legible, without corrections, with mandatory signatures. The information in the card is set out so that the diagnosis can be established not only by the medical worker who arrived at the call, but also by other doctors.
Only a correctly filled out call card with high-quality emergency care provides a doctor, as well as a medical institution, guaranteed financial and legal protection. When initiating legal proceedings, inaccuracies in the ambulance call chart can negatively affect the protection of the health worker.
When to call an ambulance for asthma
The main reason for calling emergency help is an acute asthmatic attack. If it occurs for the first time, you should immediately call the ambulance team.
In the event of an asthma attack, a drug is used to expand the bronchi of rapid action, which patients with bronchial asthma should always have with them. Asphyxiation requires urgent help.
An ambulance is called if:
- bronchodilator aerosol does not help;
- there is a strong lack of air;
- severe attacks were observed before;
- the attack develops rapidly;
- the patient’s skin turns blue in the area of the nasolabial triangle.
All observed symptoms must be recorded in the ambulance call card. It also displays further manipulations by the medical team.
Actions of ambulance doctors when calling to a patient with asthma
It is important to eliminate the asthma attack with bronchodilator drugs as soon as possible . As clearly as possible, the ambulance team should receive answers to the following questions:
- duration of an attack of suffocation;
- its possible causes: severe stress, crying, laughter, a sharp change in the weather, smells of paints, household chemicals, perfumes, cigarette smoke and other factors;
- harder to breathe in or out;
- is there wheezing, what is the nature of the cough;
- what drugs the patient usually uses (specifying the dose and method of administration);
- first or second seizure;
- time of the last attack and how it was stopped;
- whether bronchial asthma was diagnosed.
It is important to conduct an examination, evaluate the work of the main body systems and record the data in the call card:
- visual assessment;
- check of NPV;
- heart rate check;
- blood pressure measurement;
- listening to the lungs: characteristics of breathing and wheezing.
When a person’s life is at stake, it is necessary to have reliable information about his illness. It is possible to set and mark all the necessary parameters in an arbitrary form, but there is a risk of missing an important symptom or decisive factor in bronchial asthma.
Correctly completed documentation will provide complete information for further treatment. For this, an integrated approach is used, including the use of anti-inflammatory drugs, immunotherapy, and other means of controlling the course of the disease.
When determining the diagnosis, the stage of exacerbation should be indicated in order to begin immediate treatment. The goal of emergency treatment for a severe attack is to stop the asthma attack. To do this, exclude the patient’s contact with any allergens and use inhalation therapy.
Bronchodilators are used if the heart rate does not exceed 130 per minute.
After emergency procedures, patients are subject to immediate hospitalization if:
- an attack of bronchial asthma does not go away;
- complications are observed;
- there is no result after bronchodilatory therapy;
- glucocorticoids have been used for a long time.
High-quality and urgent therapy will prevent the deterioration of the patient’s condition, reduce the frequency and duration of expensive hospital treatment, avoid adverse drug reactions, and improve the life of the patient and his loved ones. The main thing for the team is to strictly follow the sequence of actions during an asthma attack, taking into account the condition and basic treatment of the patient. This is the only way to effectively cope with the exacerbation of bronchial asthma.
Rules for filling out a call card to a patient with bronchial asthma
In its form, almost all the information that is in the medical history is recorded: personal data of the patient, complaints, examination results, the established diagnosis and methods of emergency therapy. The number of the ambulance team that left, the time of receiving the call and arrival at the address is certainly recorded.
Characterizing the anamnesis, specify the signs and the order of the onset of symptoms. Lists the medications that the patient used prior to the emergency. Cases of allergy to medicines and some food must be indicated.
The patient’s condition is objectively assessed and entered into the call card, body temperature, blood pressure are measured, the lungs and heart are listened to, the patient’s consciousness and skin condition are assessed.
Based on the results of the anamnesis, the diagnosis is determined. Its correctness is a very important factor, the health and even the life of the patient depends on it. When establishing a diagnosis, the main and concomitant ailments are taken into account. After completing the required fields, describe the actions taken by the specialists on site.
The emergency team is always waiting for the result of the actions taken. All information is displayed in the last points of the call card. The obligatory column “Consent to medical intervention” is filled in by the patient himself or his relatives.
If a patient with bronchial asthma is hospitalized, the name of the clinic where he was taken is certainly entered, and the doctor on duty marks the admission.
Mandatory points of the card:
- Complaints. All the symptoms of the patient during an attack fit in: choking, cough, breathing pattern.
- Anamnesis. The reason, initial signs and duration of the attack are indicated. Bronchodilators previously taken, the presence of concomitant diseases are listed .
- Objective data. They indicate the severity of the patient’s condition, body position, numbers of NPV and heart rate.
- Taken measures. The list of drugs is indicated, the effect obtained from therapy, the further condition of the patient after it.
- Hospitalization. When transporting a patient with asthmatic status to the hospital, the vehicle is indicated. The call card must indicate the time of arrival at the clinic and the name of the doctor who received the patient. If the patient refuses the help of doctors or hospitalization, the refusal should be correctly issued.
Finally
When filling out an ambulance call card, the diagnosis must be complete, correct, reasonable, logically structured, the actions of the team must be timely and effective, the documentation must be correctly drawn up. After getting acquainted with it, the doctor should clearly understand the patient’s condition.
Observing the rules for filling out the call card, the emergency medical doctor prepares a medical and legal document that meets all the requirements of modern medicine. Such documentation not only provides maximum information on the patient’s condition, but also reflects the professionalism of the doctor who came to the call.