Paramedic Curriculum Update

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Paramedic Curriculum Update

• Condell Medical Center EMS System
• Continuing Education
• August 2004
• Site Code 107200E1204

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Purpose of Curriculum Update

• Early EMS training included minimal hours with
  minimal information
• Change in Standard of Care - EMS provider now
  responsible for increased knowledge base - more
  in-depth information needed to understand disease
  process more treatments and interventions being
  performed in the field

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Process to Provide Curriculum Update

• 40 hours of information is to be conveyed to all
  licensed paramedics over the next several years
• This information will be incorporated during
  routine CE programs offered by CMC
• Each paramedic is responsible for completing
  their resource hospital requirements

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• Completing the curriculum update will be the
  responsibility of each individual EMT-P
• CMC EMS office will be keeping records of
  material completion
• All components of the curriculum update are
  mandatory
• CMC will offer additional pertinent information
  during the roll out of the curriculum update
  sessions as dictated by needs of the CMC system

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Curriculum Update Content

• What can you expect?
• Material developed differs in length and depth of
  content
• Most of the material will not be an in-depth
  review of the subject material
• Update material is meant to fill in the blanks
  of material not covered in previous training
  curriculums

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• CMC is starting to roll-out the paramedic
  curriculum update (also previously referred to as
  the bridge course)
• Todays session begins with updates in
  Pathophysiology and Pharmacology
• Activities will be incorporated into CE that will
  enhance learning the updated material
• We want to acknowledge representatives of NIEMSCA
  who have prepared the bulk of the rollout
  material
• So, let us begin...

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General Principles of Pathophysiology
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Pathophysiology

• Understanding disease process is important for
  the EMS provider to better understand,
  anticipate, correct, and provide appropriate care.

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The Cell

• Fundamental unit of living things
• Building blocks
• Carries out bodys basic functions
• Human body composed of 100 trillion cells
• Cells are specialized to perform
  specific functions such as
• Heart cells
• Blood cells
• Muscle cells

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Building BlocksStructural Hierarchy of Body
Cell Tissue Organ Organ System
Human Body
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Homeostasis

• The human body is a dynamic organization where
  cells, tissues, organs, and organ systems perform
  functions essential for preservation of the
  organism
• The body has a natural tendency to keep the
  internal environment and metabolism steady and
  normal

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The Cell

• Each cell consists of specialized cell parts
  called organelles.
• The organelles are
  bathed in a jelly like
  material called
  cytoplasm that gives
• shape to cells

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All cells require various key components and
structures
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Major Functions of Cells

• Movement - skeletal, smooth, cardiac cell
• Conductivity - nerve cell
• Metabolic absorption - take in nutrients
• Secretion - performed by glands
• Excretion - nutrient break down
• Respiration - cells need to take in oxygen
• Reproduction - new tissue growth, healing of
  wounds

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CELLULAR ENERGY

• ATP (Adenosine triphosphate)
• Common energy currency of cells
• ATP essential to all metabolic processes of cell
• Cells spend ATP when they require energy
• Cellular stores of ATP used up faster than they
  can be replaced when
• steps in process of glucose breakdown for energy
  stops
• oxygen levels in the body are low

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CELLULAR ENERGYAerobic Metabolism(in presence
of oxygen)
Glucose Oxygen Water Carbon Dioxide
Energy C6H12O6 6O2 6H2O 6CO2 ATP
(36 units) Primary source of energy for cells
is glucose energy provided after glucose taken
into and broken down in cell. Energy yielded is
higher if produced in the presence of oxygen.
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CELLULAR ENERGYAnaerobic Metabolism(without the
presence of oxygen)

• Glucose Lactate Acid Energy (2 units ATP)
• ? acidic levels of blood reduces
  effectiveness of body functions

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Acid Destroys Cell Membranes
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Anaerobic Metabolism

• Cells will convert from normal processes and
  break down fats and proteins to get energy
• Use of fats proteins contributes to failure of
  cells
• Breakdown of proteins produces ammonia and urea
  (toxic to cells)
• Protein stores in body become depleted leading to
  organ failure

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Cellular and Tissue Death

• In presence of harmful acids (primarily lactic
  acid)
• cell its organelles swell
• cells begin to breakdown
• cell membrane ruptures releasing harmful agents
  into extracellular environment (outside the cell)
  
• cellular injury progresses from reversible to
  irreversible and cell tissue death occurs

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Impaired Use of Oxygen Glucose

• Cellular death
• Tissue death
• Organ failure
• Death of
  the person

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Tissue Types

• Tissue refers to a group
• of cells that perform
• similar functions.
• 4 basic types
• Epithelial
• Connective
• Muscle
• Nervous

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Epithelial Tissue

• Lines internal and external body surfaces
• Protects the body
• Some have specialized functions secretion,
  absorption, diffusion, filtration
• Examples skin, mucous membranes, lining of
  intestinal tract

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Connective Tissue

• Most abundant tissue in body
• Provides support, connection, and insulation
• Examples bones, cartilage, fat

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Muscle Tissue

• Have capability to contract when stimulated
• Three types
• cardiac muscle - unique capability of spontaneous
  contraction without external stimulation
• smooth muscle - found within intestines and
  around blood vessels generally under involuntary
  control of nervous system
• skeletal muscle - most abundant muscle type,
  allows movement mostly voluntary control

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Nervous Tissue

• Specialized to transmit electrical impulses
  throughout body
• Examples brain , spinal cord, and peripheral
  nerves

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Alterations In Cells and Tissues

• Cells try to maintain homeostasis - a constantly
  balanced environment
• Cellular adaptation
• Cells adapt to their environment to avoid and
  protect themselves from injury
• Adaptation may be a common response (ie growth
  of uterus in pregnancy) as well as a part of a
  response to a disease state

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Cellular Adaptation

• Atrophy- a decrease in cell size
• Hypertrophy- an increase in cell size
• Hyperplasia- excessive multiplying of normal
  cells usually a response to ? workload
• Dysplasia- abnormal development of tissue
• Metaplasia- conversion of one kind of tissue into
  a form that is not normal for that tissue (ie
  effects on respiratory tract from smoking)

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Mechanics of Cellular Injury

• Hypoxic injury - oxygen deficiency
• Chemical injury - common esp in kids
• Infectious injury
• Immunologic and inflammatory disease
• Genetic factors - ie sickle cell disease
• Nutritional imbalances
• Physical agents - temp variances, radiation,
  noise, mechanical stresses, illumination (ie UV
  rays)

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Systemic Manifestations Of Cellular Injury

• Fever
• Malaise - sense of feeling ill
• Loss of well-being
• Altered appetite
• Altered heart rate
• Leukocytosis (? white blood cells)
• Pain
• Cellular enzymes may be present in
  extracellular fluid from injured cells or tissue

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Cellular Death/Necrosis

• A cell dies if it has been irreparably damaged
• Shortly after cell death, structural changes
  begin to occur within the nucleus and cytoplasm

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Necrosis

• Death of cells or tissues through injury or
  disease
• Different types of necrosis tend to occur in
  different organs or tissues
• Necrotic changes take several hours to develop
• Necrotic changes are irreversible

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Acid-Base Balance

• A dynamic relationship in the body (always
  changing)
• Reflects the relative concentration of hydrogen
  ions (H) in the body
• Deviation in the H concentration in the body
  adversely affects all biochemical events in the
  body
• Acid/base concentration in body measured by pH
  scale (? pH below 7.35acidosis ?pH above
  7.45alkalosis)

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Acid-Base Regulation

• Bicarbonate buffer system components
• bicarbonate ion (HCO3-)
• carbonic acid (H2CO3)
• H HCO3- H2CO3 H2O
  CO2
• hydrogen bicarbonate carbonic
  water carbon
• ion ion
  acid dioxide

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CARBONIC ACID

• A weak acid that is easily eliminated by an
  enzyme called carbonic anhydrase
• Carbonic anhydrase breaks down carbonic acid
  into water and carbon dioxide
• Carbonic anhydrase can work in the reverse order
  too

ACID
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Acid-Base Problems

• Respiratory acidosis - (pH?) retention of CO2 tx
  aimed at improving ventilation
• Respiratory alkalosis - (pH ?) excessive
  elimination of CO2 from increased ventilation tx
  is to coach patient to reduce respiratory rate
• Metabolic acidosis - (pH?) production of
  metabolic acids or loss of bicarbonate ion
  (diarrhea, vomiting) tx is to increase
  ventilation (eliminate CO2) tx underlying cause
• Metabolic alkalosis - (pH ?) usually caused by
  diuretics, prolonged vomiting tx underlying cause

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ACID-BASE BALANCE
H HCO-3 H2CO3 H2O
CO2 Respiratory system eliminates excess
carbon dioxide (CO2) and water (H2O)
Kidneys eliminates excess hydrogen ion (H),
water (H2O) and Bicarbonate (HCO-3)
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Factors Causing Disease

• May be classified as genetic or environmental
• Environmental factors act differently on
  different people
• Family history of disease may not actually be
  genetic as families share environments and
  life-styles that may contribute to the disease
  more than family history

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Disease Risk

• Familial disease tendency -
• can still modify risk factors
• to prevent, delay, reduce
• impact of the disease
• Aging and age-related
  disorders - witness
• cumulative effects of
• genetics environment

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Environmental Causes of Disease

• Nutrition Obesity
• Physical Inactivity
• Stress
• Alcohol consumption smoking
• Environmental influence - air quality,
  sanitation, disease-carrying insects, sunlight
• Bacterial infection may play a role in some
  diseases

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Common Familial Diseases

• Immunologic disorders
• Allergies - exposure to allergens
• Asthma - variety of triggering factors stimuli
• Rheumatic fever - inflammatory reaction to
  infection
• Cancer
• Breast - greatest risk factor is age (majority
  occur gt60)
• Colorectal - risk factors include age (risk rises
  after 40) and gender (men gt women)
• Lung - causes are overwhelmingly environmental
  (ie smoking)

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Common Familial Diseases

• Endocrine disorders
• Diabetes type I and II - leading cause of
  blindness, heart disease, kidney failure,
  premature death
• Hematologic disorders
• Hemophilia-clotting
• deficiency
• Hematochromatosis- ?
• iron accumulation in body
• Drug induced hemolytic
• anemia-RBCs destroyed

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Common Familial Diseases

• Cardiovascular
• Prolonged QT interval-delay between
  depolarization repolarization of ventricles
  causing unstable dysrhythmias
• Mitral valve prolapse-blood easily regurgitates
  into atrium
• Coronary artery disease
• plaque build up on wall of coronary arteries
• risk factors diet, activity, hypertension,
  stroke, congenital disease
• Hypertension and Stroke-also risk for kidney
  disease
• Cardiomyopathies- disease affecting heart muscle
  usually not genetic

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Common Familial Diseases

• Renal Disorders- Failure primarily from
  hypertension
• Gout-? level uric acid in body
• Kidney stones
• Gastrointestinal disorders
• Lactose intolerance-? lactase
• to break down lactose
• Ulcerative colitis- large
• intestine inflamed,
• ulcers develop
• Crohns disease- chronic
• inflammation of intestine

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Gastrointestinal Disorders Continued

• Peptic ulcers- normal protective structures
  mechanisms break down stomach duodenum become
  inflamed
• Cholecystitis- inflammation of gallbladder
  usually from blockage by gallstones
• Obesity - defined as being more than 20 over
  your ideal body weight

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Common Familial Diseases

• Neuromuscular
• Huntingtons disease - uncontrollable jerking
• Muscular dystrophy- progressive muscle weakness
• Multiple sclerosis - affects nerves (eyes, brain,
  spinal cord)
• Alzheimer disease - progressive mental
  deterioration
• Psychiatric disorders
• Schizophrenia - loses contact with reality
• Manic-depressive - bipolar disorder depression
  mania

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Multiple Organ Dysfunction Syndrome (MODS)

• Progressive failure of two or more organ systems
  after a very severe illness or injury
• Mortality rate 60-90
• Risk factors age gt65, malnutrition, preexisting
  chronic disease
• Clinical presentation is a downward spiral over a
  period of time (ie weeks)

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Multiple Organ Dysfunction Syndrome (MODS)

• Causes
• Trauma
• Burns
• Surgery
• Circulatory shock
• Acute pancreatitis
• Acute renal failure
• Most common causes sepsis septic shock

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Multiple Organ Dysfunction Syndrome (MODS)

• Pathophysiology
• Injury occurs or there is release of an endotoxin
  
• Vascular endothelial damage (lining of blood
  vessels, heart, various body cavities)
• Neuroendocrine response (catecholamine release)
• Release of inflammatory mediators
• Activation of complement, coagulation,
  kallikrein/kinin systems

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Multiple Organ Dysfunction Syndrome (MODS)

• Pathophysiology continued
• Maldistribution of systemic and organ blood flow
• Hypermetabolism
• Oxygen supply/demand imbalance
• Tissue hypoxia
• Organ dysfunction

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MODS Cascade of Responses

• Increased vasodilation
• Vasopermeability
• Cardiovascular instability
• Endothelial damage
• Clotting abnormalites

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Multiple Organ Dysfunction Syndrome (MODS)

• Cellular metabolism impairment
• Anaerobic metabolism
• Increased lactate
• Metabolic acidosis
• Decreased ATP (energy)
• Changes in cellular electrolytes
• Cellular edema
• Release of lysosomal enzymes
• Impaired glucose use

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Multiple Organ Dysfunction Syndrome (MODS)

• Treatment goals
• Decrease O2 demands - decrease stress prevent
  infections promote wound healing treat fever,
  anxiety, shivering and pain
• Increase O2 supply - Adequate ventilation,
  support blood pressure, monitor urine output,
  positive inotropic medications to support
  contractility of heart (ie dopamine)
• Nutrition for energy source
• Medication to support body functions
• Best defense is early recognition and early
  intervention of supportive measures

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Inflammation

• The acute inflammatory response
• Triggered by
• Lethal cellular injury
• Non-lethal cellular injury
• Other microorganisms

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Functions of Inflammation

• Destroy and remove unwanted substances
• Wall off infected and inflamed areas
• Stimulate immune response
• Promote healing

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Mast Cells Activate Inflammation Through 2
Functions

• ? Degranulation - mast cells stimulated to move
  into extracellular environment by
• physical injury
• chemical agents
• immunologic responses direct processes
• Histamine serotonin released - influences blood
  flow to injured site
• Chemotaxis occurs - white cells attracted to site

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2nd Function of Mast Cells For Activation of
Inflammation

• ? Synthesis - 2 substances constructed
• leukotrienes - cause vasoconstriction, vascular
  permeability, chemotaxis (white cells to site)
• prostaglandins - also increases vasoconstriction,
  vascular permeability, chemotaxis. Additionally
  cause pain to site, act to control inflammation
  by suppressing release of histamine from mast
  cells suppressing release of lysosomal
  (digestive) enzymes from white cells

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Systemic Responses of Acute Inflammation

• Fever
• Leukocytosis - ? WBCs for fighting infection
• Increase in circulating plasma proteins or
  acute-phase reactants -
• act to inhibit and
• control inflammatory
• response

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Chronic Inflammatory Responses

• Defined as inflammation gt 2 weeks
• Causes
• Foreign body still in body
• Persistence of infection or antigen
• Characteristics
• Persistence of acute inflammation response
• Neutrophils 1st at injured site degranulate and
  die
• Lymphocyte and fibroblast activation - necessary
  for wound healing
• Pus formation - dead cells, dead tissue, tissue
  fluid
• Tissue repair possible scar formation final
  stage

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Deficiencies in Immunity and Inflammation

• Congenital immune deficiencies - impaired
  development of lymphocytes (type of WBC)
• Acquired deficiencies - developed after birth
  immune function affected by
• Nutritional deficiencies
• Iatrogenic deficiencies - insult caused by
  medical treatment (ie meds, spleenectomy)
• Traumatic injuries destroying normal function
• Emotional stress
• AIDS - acquired immune deficiency disorder

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Stress Response

• During stressful events, there is a complex
  interaction between nervous, endocrine, and
  immune systems
• Physiological stress - events affect body
• Psychological stress - unpleasant emotions
• Variety of hormones released in response
• catecholamines - ACTH
• cortisol - prolactin
• beta-endorphins - testosterone
• growth hormone

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Neuroendocrine Regulation Triggered by Response
to Stress

• Catecholamines (hormones) released when
  sympathetic nervous system activated
• Epinephrine (adrenalin)
• Norepinephrine (noradrenalin)
• Above hormones carried throughout body
• Above hormones act on hormone receptors to
  prepare body to deal with stressful event

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Autonomic Nervous SystemControls involuntary
automatic functions.Two divisions that work
antagonistically

• Sympathetic NS
• Dominates during stress
• Fight or Flight
• Mobilizes the body
• Allows the body
• to function
• under stress

• Parasympathetic NS
• Dominates during rest
• Feed or Breed
• Conservation of body resources
• Restoration of
• body resources

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Sympathetic ReceptorsReceptors located around
body when stimulated cause response in organ or
organs they control. Types of receptors

• Alpha 1 receptors
• Located in vascular smooth muscle
• Causes peripheral vasoconstriction - increases
  B/P
• Mild bronchoconstriction

• Alpha 2 receptors
• Stimulation is inhibitory
• Prevent overrelease of norepinephrine

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Sympathetic Receptors

• Beta 1 receptors
• Located in the heart
• Increases
• Heart Rate
• Conduction
• Contractile force
• Automaticity

• Beta 2 receptors
• Located in the smooth muscle of the bronchi
• Bronchodilation
• Vasodilation

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Physiological Effects of CatecholaminesEffects
noted throughout the body

• Liver
• Skin
• GI/GU tracts
• Lymphoid tissue
• Adipose (fatty) tissue

• Brain
• Cardiovascular system
• Pulmonary system
• Muscle
• Skeleton

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Cortisol (hydrocortisone)

• Hormone produced in response to stress
• Circulates in the plasma
• Mobilizes substances needed for cellular
  metabolism
• Primary metabolic effect is stimulation of
  gluconeogenesis - overall elevation of glucose
• Enhances elevation of blood glucose level and
  inhibits peripheral glucose uptake by cells in
  effort to ? blood glucose
• Also acts as an immunosuppressant
• Decreases migration of macrophages into the
  inflamed area

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Cortisol Response

• Blocks generation of fever
• Inhibits substances critical to inflammatory
  process
• Causes poor wound healing
• Increases susceptibility to wound infection
• Increases gastric secretions (?ulcer formation)
• Suppresses release of sex hormones
• Although not well understood, it is beneficial to
  body in its response during stress in spite of
  all the negative effects

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Coping With Stress

• Coping abilities have direct and indirect effects
  on stress and illness
• Support networks are encouraged to assist persons
  with illness or stressful life situations - both
  which cause stress
• Supporting persons ability to cope with stress
  is just as important as following the medical
  treatment for the illness

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Bibliography

• Bledsoe, B.E., Porter, R.S., Cherry, R.A.
• Paramedic Care Principles Practice.
• Brady. 2000.
• Sanders, M.J. Paramedic Textbook. Mosby.
• 2001.
• PowerPoint prepared by Brian E. Sobeck, EMT-P,
  representative of Northern Illinois EMS
  Coordinators Association (NIEMSCA), with
  additions by Sharon Hopkins, RN, BSN, EMT-P

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Pathophysiology
Questions ??