Joint Royal Colleges: Enhancing Medical Learning

by Herman Bailey | Jul 22, 2023 | Essays | 0 comments

Committee Members

Dr Charles Deakin (Chair) Royal College of Anaesthetists

Medical Director, South Central Ambulance Service

JRCALC

Dr Tom Clarke Chair, JRCALC

Consultant Anaesthetist

Dr Jerry Nolan Chairman, Resuscitation Council (UK)

Consultant Anaesthetist

Dr David Zideman Chair, British Association for Immediate Care (BASICS)

Consultant Anaesthetist

Dr Carl Gwinnutt Consultant Anaesthetist

Dr Fionna Moore Medical Director, London Ambulance Service

Consultant in Emergency Medicine

JRCALC

Dr Michael Ward Royal College of Anaesthetists

Formerly Medical Director, Oxfordshire Ambulance Service

JRCALC

Mr Carl Keeble Operational Paramedic, East Midlands Ambulance Service Member BPA Governing Council

JRCALC

Dr Wim Blancke Royal College of Anaesthetists

JRCALC

Mr Roland Furber Chief Executive, College of Paramedics

JRCALC

Prof Malcolm Woollard Professor in Pre-hospital & Emergency Care, Coventry University

Contents

1. Executive summary
2. Introduction.
3. Intubation by paramedics. Risk:benefit analysis.
4. Training requirements for tracheal intubation.
5. Supraglottic airway devices.
6. Other issues with tracheal intubation
7. Discussion
8. References

Executive Summary

Paramedic tracheal intubation has been practiced in the UK for more than 20 years and is currently a core skill for paramedics. Growing evidence suggests that tracheal intubation is not the optimal method of airway management by paramedics and may be detrimental to patient outcome. There is also evidence that the current initial training of 25 intubations performed in-hospital is inadequate and that the lack of ongoing intubation practice may compound this further. Supraglottic airway devices (SADs; e.g. laryngeal mask airway), that were not available when extended training and paramedic intubation was first introduced, are now in use in many ambulance services and are a suitable alternative pre-hospital airway device for paramedics.

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SUMMARY AND RECOMMENDATIONS

There is a paucity of evidence to suggest that tracheal intubation without the use of drugs is of patient benefit or improves outcome. The weight of evidence suggests that pre-hospital intubation without the use of drugs can worsen patient outcome.

The group believes that tracheal intubation without the use of drugs has little value in pre-hospital practice.

The current format of paramedic training is inadequate for training pre-hospital intubation. Improving training for all paramedics (and other similar providers) is not considered feasible, both for operational reasons and difficulties in delivering the training. The majority of those managing patients’ airways in the pre-hospital setting should be trained to insert a supraglottic airway device instead of a tracheal tube. Tracheal intubation should be developed as a specialist skill for selected providers and should include the provision of drug-assisted intubation. Very significant improvements in initial and ongoing training and education would be required to develop this as an autonomous specialist skill.

Supraglottic airway devices have been shown to be safe and effective devices in elective and emergency hospital procedures. Their use in airway management in pre-hospital care is increasing and evidence suggests that they are suitable alternatives to tracheal intubation.

Training in the use of supraglottic airway devices is already mandatory for UK paramedic registration. Ambulance trusts should be encouraged to adopt and use these devices as an alternative to tracheal intubation.

Where ventilation proves impossible, particularly when there is a history of possible choking, and other manual techniques have failed, laryngoscopy may be used to attempt to remove any foreign body. This does not require training in laryngoscopy to the same extent as that necessary for tracheal intubation and can be incorporated within the current clinical airway management training.

When pre-hospital tracheal intubation is undertaken, the following should apply:

1. A gum elastic bougie should be available routinely.

2. Correct position of the tracheal tube must be verified using both a stethoscope

and carbon dioxide detector. (Caution should be exercised when measuring and interpreting exhaled CO₂ during low cardiac output states such as cardiac arrest).

Our conclusions are consistent with the recent NCEPOD report (Trauma: Who cares? NCEPOD 2007) that states “Airway management in trauma patients is often challenging. The pre-hospital response for these patients should include someone with the skill to secure the airway (including the use of rapid sequence intubation) and maintain adequate ventilation”.

Introduction

Although some ambulance personnel were practicing tracheal intubation as early as 1968, intubation skills were first widely introduced into paramedic practice in the mid 1980s and are now a core component of the paramedic curriculum. The aim of introducing this skill to the pre-hospital environment was to provide patients with what was thought at the time to be optimal airway management. Subsequently, tracheal intubation has become expounded as a ‘gold standard’ in airway care.

Intubation training has traditionally been undertaken by paramedics on hospital attachments and there was generally no difficulty in obtaining adequate practical experience in the skill. As paramedics matured professionally and evidence-based practice was introduced into ambulance care, the benefits of intubation began to be questioned. . This was reflected in the ‘Joint Recommendation from AETAG/JRCALC Airway Group’, published in November 2004.¹ More recently, the initial training requiring 25 intubations has become more difficult to provide; fewer patients undergoing general anaesthesia require tracheal intubation as the use of supraglottic airway devices (SADs) has become more widespread and concerns over patient consent raised by the Association of Anaesthetists of Great Britain and Ireland (AAGBI)² has resulted in fewer intubation opportunities in most hospitals. For paramedics who are qualified, ongoing competence has also been questioned; most paramedics undertake tracheal intubation relatively rarely, with figures ranging from an average of 2 per paramedic per annum in the former Avon Ambulance Service³ to just 1 per paramedic per annum in South Central Ambulance Service (Hampshire Division).⁴ The benefits of tracheal intubation, particularly in light of recent evidence,^{5 6} the difficulties in training in this procedure and the recent availability of other SADs necessitate a review of this area of practice.

JRCALC is mandated to recommend the most effective, evidence-based treatment for patients requiring emergency and urgent care. JRCALC has recommended that this area of clinical practice is examined in more detail to produce guidance and recommendations for future practice and requested that a group is formed to undertake this review.

This group has therefore been formed from experts in the field of pre-hospital airway management to examine current practice, review evidence of the effectiveness of pre-hospital paramedic tracheal intubation, discuss the adequacy of current training arrangements and report their findings and recommendations to the JRCALC Committee.

Although the initial remit was to review paramedic airway management, it was recognised that ambulance Trusts use the services of other professional groups such as nurses and doctors. It is also recognised that some doctors are able to deliver drug-assisted airway management on scene. Although this document discusses paramedic practice, the conclusions are applicable to other pre-hospital care professionals who are trained to similar or lesser standards as paramedics. The review specifically does not address issues relating to drug-assisted intubation which in the UK is currently undertaken only by doctors and is currently being reviewed by a working party from the Association of Anaesthetists of Great Britain and Ireland (AAGBI).

Intubation by paramedics: risk:benefit analysis

Intubation for cardiopulmonary resuscitation

Tracheal intubation has long been regarded as a fundamental and essential component of cardiopulmonary resuscitation (CPR). It has been assumed that tracheal intubation improves the chances of survival from cardiac arrest. There are no robust scientific data to support this belief and there are several reasons why attempted intubation can be harmful, particularly when undertaken by inexperienced individuals.⁷ The Ontario Pre-hospital Advanced Life Support (OPALS) study documented no improved survival to hospital discharge when the skills of intubation and cardiac drug administration were added to an optimised Basic Life Support-Automated External defibrillator (BLS-AED) system.⁸

The potential benefits of placing a cuffed tube in the trachea during CPR include:

1. Enabling effective ventilation, particularly when lung and/or chest compliance is poor.
2. Minimising gastric inflation and therefore the risk of regurgitation.
3. Protection against pulmonary aspiration of gastric contents.
4. Enabling ventilation while continuing chest compressions uninterrupted. This increases the number of compressions delivered in each minute. ⁹

It is known that the oesophageal sphincter pressure decreases rapidly from 20 to 5 cmH₂0 immediately after cardiac arrest and this predisposes to regurgitation of gastric contents.¹⁰ Regurgitation is documented in about one third of out-of-hospital cardiac arrests and in two thirds of these cases it occurs before arrival of ambulance personnel.¹¹ Pulmonary aspiration after cardiac arrest has been documented in 20% survivors¹² although the impact on outcome is unknown. The chances of successful intubation and the risk of complications are highly dependent on the skill of the individual undertaking the procedure. Several studies indicate that in inexperienced hands the success rate is as low as 50% and complication rates are unacceptably high.^{13 14} This is largely because tracheal intubation does not ‘fail safe’. The risks of attempting tracheal intubation include:

1. Hypoxaemia, especially during prolonged attempts without oxygen supplements, and hypercarbia, when time perception by the rescuer is poor.
2. Harmful, physiological stress to the patient, in particular when performing laryngoscopy.
3. Unrecognised oesophageal intubation: 2.9 – 16.7% in cardiac arrest studies ^14-18
4. Unrecognised main stem bronchial intubation¹⁹
5. Unrecognised dislodgement
6. Interruption of chest compressions during the procedure
7. Trauma to the oro-pharyngeal tissues.

In the apnoeic patient, unrecognised oesophageal intubation is almost certainly fatal. In an emergency medical services (EMS) system with significant rates of unrecognised oesophageal intubation, correctly placed tracheal tubes would have to improve outcome for many other patients in order to offset these disasters. Such a benefit for tracheal intubation in cardiac arrest is very unlikely.⁸

The only prospective randomised trial of pre-hospital tracheal intubation versus management of the airway with a bag-valve-mask (BVM) has been undertaken in children.¹⁹ This showed no overall benefit for tracheal intubation and in a subgroup of children with primary respiratory arrest, the outcome was worse in the tracheal intubation group.

Intubation for trauma

Training in tracheal intubation and skill retention is increasingly problematic. Supraglottic airway devices are now used in up to 80% of anaesthetics in the United Kingdom and this reduces the number of opportunities for paramedics to intubate patients. One study of anaesthesia residents showed that a 90% in-hospital intubation success rate was achieved only after 57 intubation attempts;²⁰ furthermore, intubation is much easier under the conditions of elective anaesthesia than it is in the pre-hospital setting. Among paramedics, intubation success rate has been shown to correlate with the intubation experience of individual paramedics and not with their length of service.²¹ Some studies have documented much higher intubation success rates by paramedics but these have generally been retrospective or via self-reporting.^{22 23} Use of end tidal CO₂ monitoring will reduce the incidence of unrecognised oesophageal intubation,²⁴ but during cardiac arrest, CO₂ may not be detected even if the tracheal tube is placed correctly.²⁵

Data to support paramedic intubation of trauma patients are also scarce. One retrospective study from San Diego concluded that pre-hospital intubation of patients with severe head injury improves survival.²⁶ However, given that these patients were intubated without drugs, the reported survival rate is remarkably high. Furthermore, there was no correction for case mix and there was no mention of how many attempted, but failed, intubations occurred – these would be included in the no intubation group. In contrast, there was just one survivor out of 492 pre-hospital trauma patients who were intubated without drugs by paramedic or doctors working with the London helicopter emergency medical service (HEMS).²⁷ The only other published research showing improved survival after paramedic intubation was a small Finnish study involving head-injured children.²⁸ More recently, a prospective study of rapid sequence induction in 243 severe brain-injured patients by the San Diego group reported that, compared with historical non-intubated matched controls, mortality was significantly higher (33.0% versus 24.2%) in those who were intubated.²⁹ Paramedics intubated after giving midazolam and suxamethonium, and after confirmation of correct tube placement gave rocuronium. Using this technique, intubation still failed in 13% of patients. One third of the study group turned out to have a minor concussion or no head injury. In another study involving a subgroup of 54 patients from the same cohort, 57% became hypoxaemic (SpO₂ < 90%) during the intubation attempt.³⁰ The same investigators have shown that hypoxaemia and hyperventilation (identified by end-tidal CO₂ monitoring) are associated with increased mortality.³¹ A recent review of pre-hospital tracheal intubation concluded that not only was there no evidence of benefit, but that there was increasing evidence of harm.⁵

Alternative airway devices continue to improve and some of the more recently introduced supraglottic airway devices may enable oxygenation and ventilation without the risks associated with tracheal intubation. In particular, insertion is independent of factors used to predict or score difficult tracheal intubation.^{32 33} These issues apply to any professional group that is not experienced in tracheal intubation – not just paramedics.

Training requirements for tracheal intubation

How much training is necessary to become competent in tracheal intubation?

Current IHCD standards require trainee paramedics to achieve 25 intubations during hospital training, of which five must be unassisted. To the best of our knowledge, this figure was chosen because it was considered to be a reasonable number to provide paramedic training, rather than a number based on a scientific assessment of learning curves for intubation.

The attainment of 25 tracheal intubations cannot be taken as assurance of subsequent ability. The use of a logbook to record tracheal intubation has been challenged because it “…gives no clear idea of skill or of progress and merely records ‘exposure’ to a skill or technique.”³⁴ Setting of a numerical standard also does not guarantee competence of any given skill and in a group of individuals, there will always be variation in the rate of skill acquisition with some individuals requiring more training than others.³⁵

Some recent studies have attempted to define the number of attempts needed to perform a given procedure in order to be competent. The learning curve for anaesthetic trainees learning tracheal intubation with two new tracheal tubes has been reported (Fig.1). The estimate of learning half-life (half the total number of procedures necessary to be performed in order to be competent at a given procedure) was 15 intubations, irrespective of the type of tube used³⁶ .Similar results were reported in a study examining first-year anaesthetic residents where it was found that 57 attempts at tracheal intubation were required to achieve a 90% success rate (Figure 2).^{20 36} More recently, an abstract detailing training requirements for tracheal intubation, reported that 32 intubations were necessary for a 75% success rate and 53 for a 90% success rate.³⁷ These figures are similar to those reported in the two earlier studies.^{20 36}

Fig 1: Intubation time vs serial number of the intubation for the 62 cases in which intubation was successful at the first attempt.  = Oxford tube,  = Portex tube.³⁶

Fig 2: Rate of success for tracheal intubation vs number of performed procedures for first-year anaesthetic residents.²⁰

It is clear from these studies that for the majority of those training in tracheal intubation, the 25 attempts at tracheal intubation currently recommended is unlikely to be adequate to attain competence. To reach a 90% success rate with the first intubation attempt, an average laryngoscopist needs at least 57 intubation attempts.²⁰ By applying the results of these three studies^{20 36 37} to current paramedic training, we estimate that under ideal intubation conditions, the average paramedic is likely to achieve an intubation success rate of 70 – 75% at best; with little scope for further improvement in skills performance in practice after initial training.

Skill fade

There are few studies on skill fade in relation to tracheal intubation. Skill fade is faster with more complex tasks. It is therefore likely that skill fade with tracheal intubation occurs at a greater rate than that with more simple airway skills, such as SAD insertion. Skill fade is accelerated by lack of ongoing practical experience. The average paramedic intubates an average of just 1-2 patients per annum.^{3 4} There is a significant correlation between the number of patients intubated each year by a paramedic and intubation success rate (p <.001, R = 0.32).^{38 39} In medical students given practical instruction in tracheal intubation and re-assessed at 6 months, there was a significant decline in performance, as shown by an increase in failure rate, increase in attempts at intubation, increased time to achieve intubation and increased dental trauma.⁴⁰

With incomplete initial training and the subsequently limited opportunity to practice tracheal intubation skills, tracheal intubation performance is likely to be sub-optimal in paramedics trained within the current infrastructure and practice.

Opportunities for Training

Current paramedic training involves the intubation of 25 patients during the trainee’s hospital attachment. It is widely recognised that this is becoming more of a challenge because airway management during general anaesthesia is moving away from tracheal intubation and therefore providing fewer opportunities. Medicolegal considerations and the recent statement from the AAGBI² about consent for paramedics to practice clinical airway management have also contributed to the decline in practical opportunities for tracheal intubation.

Some of the basic intubation skills and knowledge can be acquired using simulation with a manikin. Although simulators are improving all the time, they are not a complete substitute for the training required on real patients. Refresher courses including manikin training may help skill retention.

Supraglottic Airway Devices

The first successful and widely used supraglottic airway device (SAD) was invented in 1981 by Archie Brain, a consultant anaesthetist at the Royal London Hospital. His aim was to produce an airway for use in anaesthesia that was more practical than a face mask but less invasive than a tracheal tube, obtaining a continuous clear airway, closer to the natural anatomical and physiological pathway than via a tracheal tube, with the subsequent added benefit of providing a tracheal intubation aid.⁴¹ The first paper describing its use was published in 1983⁴² and the device became commercially available in 1988. Since its introduction, it is now estimated that there are more than 3000 publications relating to this device and it has been used on more than 200 million occasions worldwide. The device was originally designed as a reusable airway for use in anaesthetised patients breathing spontaneously and although this remains its main application, it has an important role in several other situations, for example resuscitation,⁴³ and is used increasingly by non-medical healthcare professionals.⁴⁴

Since 1988, the LMA has evolved into a number of different forms that are suitable for a variety of circumstances:

• A reinforced version to enable the tube to be flexed without the risk of kinking
• The intubating laryngeal mask (ILM) that once inserted acts as a conduit to enable the insertion of a tracheal tube without the need for direct laryngoscopy
• The ProSeal (PLMA), with an additional posterior cuff to improve the seal around the glottis and facilitate positive pressure ventilation; and an extra oesophageal drain tube which can guide correct positioning of the device.⁴⁵
• Disposable versions of the classic LMA, the PLMA (LMA Supreme) and the ILM to reduce the risk of cross infection.

Once the original patent expired, other manufacturers were quick to produce similar devices. Not all of these have been successful, but there are now several disposable (or single use) devices available, all with slight design variations compared with the original, the latter now referred to as the classic LMA (cLMA). Brain’s device has also stimulated a wide range of interest in the production of alternative devices to provide a secure means of managing the airway without the need for laryngoscopy. All of these devices are now grouped together as SADs, although some are designed to function if placed either above or below the glottis. The following devices are available:

• Glottic aperture seal (GO2)
• Pharyngeal airway xpress (PAX)
• Cobra Perilaryngeal Airway (CobraPLA)
• Laryngeal tube (LT, LT-D,LTS, and LTS-D)
• Airway management device (AMD)
• Elisha Airway Device
• Combitube®
• Easytube
• Streamlined Liner of the Pharynx Airway (SLIPA)
• I-gel

Despite their designation as SADs, these devices vary considerably in their design and function. Consequently, it is increasingly difficult to determine the advantages and disadvantages of the different designs. Furthermore the situation is made more difficult by published trials in which there is no consistency in approach. There are currently:

• Trials in anaesthetised patients
• Insertion by anaesthetists, nurses, medical students, paramedics and fire-fighters
• Trials in manikins
• Trials in different makes of manikins
• Trials of insertion in cadavers
• Use with spontaneous and controlled ventilation
• Trials comparing dissimilar devices
• Varying numbers in trials
• Anecdotal evidence of use of devices

All of this makes comparisons and recommendations about devices, or the circumstances in which different devices may be useful, almost impossible. It must also be remembered that none of these devices have anything like the accumulated experience of usage associated with the LMA.

A summary of the current predicament is expressed succinctly by Cook: “New developments in supraglottic airways may offer benefits over the current preferred devices. Considerable further research in this area is justified. This might include an examination of the appropriateness of training in tracheal intubation to those who rarely use it.”⁴⁴

Other issues with tracheal intubation

Several other issues need to be considered when discussing optimal pre-hospital airway management. This section also discusses the use of devices to aid intubation and to confirm tube placement.

Securing the airway

As highlighted in the previous statement of JRCALC,¹ the primary aim should not be the use of a particular airway device, but to ensure a secure and effective airway, oxygenation and ventilation for the patient.

Several paramedic studies have shown that airway devices not requiring direct visualisation of the vocal cords are more successful in securing the airway. A simulator-based study comparing paramedic insertion of a Combitube^® and tracheal tube (TT) found the time to airway placement was less for the Combitube^® than the TT (median difference 26.5s, p=0.002).⁴⁶ A clinical study comparing paramedic LMA insertion with tracheal intubation found LMA insertion to be more likely to succeed compared with tracheal intubation. Furthermore, LMA insertion was successful in 80% of failed intubations.⁴⁷

Other considerations when choosing an advanced airway management device are the limited number of practitioners present (typically 2-3) at an out-of-hospital cardiac arrest in the UK. In theory, the use of an appropriately secure airway device with an automatic ventilator should release one practitioner to undertake other duties. Airway devices can be difficult to secure reliably: the airway may be dislodged when the patient is moved causing loss of the seal with the larynx or, in the case of a tracheal tube, oesophageal intubation. Hence, meticulous supervision of the airway has to be safeguarded at all times.

Risk of supraglottic airway device cuff leak during chest compressions

The European Resuscitation Guidelines 2005 state that: “Intubation attempts will require interruption of chest compressions, but once an advanced airway is in place chest compression will not require interruption for ventilation.”⁴⁸ The lower sealing pressures of SADs compared with tracheal tubes may result in a leak when attempting ventilation without interrupting chest compressions and this may cause gastric inflation and regurgitation. The frequency and scale of this problem is unknown.

Oropharyngeal leak pressure varies between SADs. Mean +/- SD oropharyngeal leak pressure is significantly higher with the SoftSeal LMA (21+/-6 cmH₂O) compared with the cLMA (17+/-7 cmH₂O) and LMA Unique (16+/-6 cmH₂O).⁴⁹ The laryngeal tube (LT) may provide an even better seal than laryngeal mask devices; LT airway leak pressures of 26.3 +/- 7.3 cm H₂O compared with 19.2 +/- 8.6 cm H₂O (P < 0.001) for the LMA.⁵⁰

Eight studies (858 comparisons) report significantly higher seal pressures

with PLMA than cLMA, with median PLMA and cLMA seal pressures approximately 30 cm H₂O and 20 cm H₂O respectively. In 20% of cases PLMA seal exceeds 40 cmH₂O.

Since its introduction the PLMA has also successfully been used for ventilation of morbidly obese patients (BMI >40, or >35 kg.m^-2 in the presence of obesity-related comorbidity).⁵¹

Airway security

Although the risk of aspiration is considered to be higher with LMAs than TTs, there is no specific evidence to support this assumption. A review of hospital cases published in 2004 identified just 23 published cases.⁵² These were all cases from hospital settings: the relative risk of aspiration in the pre-hospital environment is unknown.

Although other advanced airway management devices may reduce the risk of aspiration, devices with oesophageal cuffs, such as the Combitube^®, are associated with a small but important incidence of oesophageal laceration or rupture.⁵³

The LMA may be dislodged more easily than a tracheal tube, but leak pressure for both the PLMA and the cLMA is increased by cervical flexion and rotation.⁵⁴

The LMA can also cause trauma on insertion, and the risk of this occurring depends on the type of LMA. A study of novice doctors, each undertaking five attempts with three different LMA types in anaesthetised patients reported that a sore throat was experienced by 14% of patients in LMA Unique group, versus 41% and 42% in the LMA Classic and SoftSeal groups respectively. The SoftSeal LMA was most frequently associated with blood on the mask (32%) compared with the LMA Unique (9%) and LMA Classic (6%).⁵¹

Tracheal tube as a route for drug delivery

Tracheal intubation enables the direct introduction of suction catheters into the trachea and bronchial tree. This is unreliable with supraglottic airway devices. Tracheal intubation also enables resuscitation drugs to be injected directly into the trachea when intravenous access is impossible. Absorption of drugs is unreliable when given by this route and this intervention is unlikely to impact on the outcome of cardiac arrest.^55-57

Use of intubation aids: the intubating bougie

The bougie is commonly available in hospital to assist with difficult intubation and its use increases intubation success rates when intubation is difficult.^{58 59} Despite being recommended to support pre-hospital intubation,⁶⁰ few ambulance services train and equip their paramedics with bougies.⁶¹ Intubation in the pre-hospital setting is particularly challenging and it is logical to recommend that a bougie is used routinely.

Availability of devices for confirming tracheal tube placement

Confirmation of correct tracheal tube placement by physical examination alone is unreliable: some studies document unrecognised oesophageal intubation rates of 10%⁶² – 25%.⁶³ Exhaled CO₂ or oesophageal detection devices can be used to identify correct tube position. Confirmation of tracheal tube placement using capnometry is a mandatory minimum monitoring standard in UK anaesthetic and emergency departments. However, this is less reliable if the cardiac output is low or absent such as during cardiac arrest.⁶⁴ The use of the oesophageal detector device (ODD) is an alternative technique but is less reliable and does not provide continuous monitoring as does capnometry.⁶⁵ A survey in 2004 showed that virtually no UK ambulance service used either device routinely.⁶¹

Hospital vs pre-hospital practice

Hospital minimum standards for the practice of intubation⁶⁶ are not currently requirements for the pre-hospital environment where risks are higher. The lack of capnometry increases the risk of unrecognised oesophageal intubation. The lack of availability and training in the use of simple intubation aids such as the intubating bougie increases the number of failed intubations.

The minimum monitoring standards required in hospital should be applied to pre-hospital intubation and simple intubation adjuncts must be used to increase the safety and success of pre-hospital procedures.

Discussion

The group’s aim was to critically evaluate the need for tracheal intubation as a core skill in ambulance practice and to make recommendations about the optimal pre-hospital airway management by UK ambulance services. This was primarily in relation to paramedic practice, but encompassing all those who undertake pre-hospital tracheal intubation without the assistance of anaesthetic drugs. The evidence for the benefit, or not, of pre-hospital intubation without the use of anaesthetic drugs was reviewed and debated in detail, as were the associated topics relating to current training in this procedure and availability of alternative airway devices. A systematic review of pre-hospital airway management was not undertaken as part of this exercise because it was considered that the recent reviews and expertise within the group covered all the main publications in this area and the costs and delay associated with performing a systematic review would have been significant.

The Committee was in general agreement that there is little evidence that pre-hospital intubation without the use of anaesthetic drugs improves outcome in seriously ill or injured patients. Although some studies are of limited quality, the balance of evidence suggests that paramedic intubation may be associated with a worse outcome than basic airway management using the bag- mask device. The reasons for this are not entirely clear, but may be related to difficulties in securing the airway, resulting in significant hypoxaemia during the attempts at intubation.

Intubation is a complex motor skill that requires adequate initial training and sufficient ongoing experience to maintain competency. Current paramedic training was reviewed against the limited evidence for training requirements. Most studies have demonstrated that in order to be competent in the procedure, initial training requires the successful placement of 50-60 tracheal tubes, compared with the 25 that is currently required. There were also concerns expressed that most paramedics do not have sufficient ongoing intubation experience to remain competent in the procedure.

Simple intubation adjuncts (e.g. intubating bougie) are not used by most UK ambulance services and these have been shown to improve tracheal intubation success rates in hospital airway management. Their use in pre-hospital tracheal intubation is recommended. Additionally, pre-hospital capnometry should be mandatory for tracheal intubation in order to minimise the incidence of unrecognised oesophageal intubation. This would bring pre-hospital practice in line with minimum monitoring standards for hospital practice.

Alternatives to tracheal intubation were discussed. Supraglottic airway devices have many advantages over tracheal intubation, particularly in relation to training and maintenance of practical skills. They also do not risk unrecognised oesophageal intubation. Their use in the pre-hospital setting is limited, but growing, and LMAs are now a standard airway device in use by many UK ambulance services.

The Committee concluded that pre-hospital tracheal intubation, as currently practiced by paramedics, could not be endorsed. What evidence there is, suggests that this procedure is more likely to be harmful than beneficial.

The way forward was discussed. It was considered impractical to recommend that all paramedics were trained to an adequate intubation standard and maintain these standards after qualifying. Although these standards have yet to be defined, they are likely to be to a significantly higher standard than that currently practiced and would have parallels with the initial training of doctors entering anaesthesia as a speciality. Training would also necessitate the removal of paramedics from front-line practice for considerable periods, which may not be endorsed by ambulance trusts with significant performance pressures. We agree with the recent NCEPOD report that recommended that the pre-hospital response for trauma patients should include someone with the skill to secure the airway, (including the use of rapid sequence induction and tracheal intubation).⁶⁷ The way in which this is delivered would be the responsibility of each ambulance trust. If ambulance trusts were to permit tracheal intubation as a specialist skill for some providers, these individuals should receive enough training to become competent in the provision of drug-assisted intubation. Very significant improvements in initial and ongoing training and education would be required to develop this as an autonomous specialist skill. This may be best achieved through a physician-based system, although this would require a more long-term approach.

For the majority of paramedics, this Committee recommends that tracheal intubation should be withdrawn and greater emphasis placed on airway management using an appropriate supraglottic airway device (SAD). (The importance of training to a high degree of proficiency in basic airway management skills should not be overlooked during training). Several SADs are in clinical use. It is not the scope of this review to recommend specific SADs and ambulance trusts should discuss the options with their local Clinical Advisory Groups. More pre-hospital research is urgently needed to understand the factors influencing morbidity and mortality in relation to airway management and establish the optimal device(s) with which the airway should be secured.

Where ventilation proves impossible, particularly when there is a history of possible choking, and other manual techniques have failed, laryngoscopy may be used to attempt to remove any foreign body. This does not require training in laryngoscopy to the same level of competence as that necessary for tracheal intubation and can be incorporated with current clinical airway management training.

A small but significant number of patients with partially or completely obstructed airways cannot be managed without the use of drug-assisted techniques. Trauma patients and those with obstructed airways not manageable with basic airway adjuncts or a SAD may need to be treated by a practitioner competent in pre-hospital rapid sequence induction of anaesthesia and intubation, for which there is currently little provision in the UK. The recent NCEPOD review of trauma management ⁶⁷ found that 13.7% of patients with major trauma arriving by ambulance did so with a partially or completely obstructed airway, suggesting that current paramedic training does not equip them with sufficient skills and tools to manage these patients adequately. In 28.6% cases, patients were not intubated when reviewers believed that it should have been attempted. The report concluded that “…if pre-hospital intubation is to be part of pre-hospital trauma management then it needs to be in the context of a physician-based pre-hospital care system.” This may be one option that ambulance Trusts should consider in delivering appropriately trained providers to care for those with difficult airways, “…to ensure that they are seen at the right time, in the right place and by staff with the most appropriate skills.”⁶⁸

The Committee concluded that paramedic tracheal intubation can no longer be recommended as a mandatory component of paramedic practice and should not be continued to be practiced in its current format. If pre-hospital tracheal intubation is to be undertaken, it requires considerably more education and training than that currently provided for paramedics or the use of physicians with appropriate training in advanced airway skills. SADs are suitable alternatives to tracheal intubation. SADs should be introduced into all ambulance services and ambulance trusts should ensure that both paramedics and technicians receive adequate initial and ongoing training in the use of these devices.

The timescale for the introduction of any changes in paramedic practice should be decided at a local level. Changes to training and practice in both tracheal intubation and SAD use will need to be reviewed by individual ambulance services to decide the most appropriate way forward.

References

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Navigating Generational Differences in the Workplace

by Herman Bailey | Jul 13, 2023 | Essays | 0 comments

Introduction

There are several reasons for the transformation that humankind has witnessed in the work environment; however, the most significant cause of change is the advancement in technology, whose fueling by social factors has brought tremendous outcomes as well. A keen analysis of history provides evidence that only two groups constituted the workplace in the recent past. Notably, the two groups were the ‘know-it-all’ and the ‘old-timers’. The old-timers universally referred to the traditionalists and the individuals who were about to retire, not forgetting the people who fixed their thoughts in the old historical schooling. On the other hand, the know-it-all referred to the youngsters believed to be the intruders of big ideas and enthusiastically destined to move higher the hierarchical administration stepladder (Allahyari, 2000). A reflection of the workplace in the contemporary world portrays a completely different and complicated setup with a mixture of a wide range of factors influencing the classification of workers (Asch, 2001). Surprisingly, the categorization of workers drastically and considerably evolved over a short duration to come up with the current five generations that work together for the success of the management in charge. The five generations include the employees born before 1945 (the traditional generation), those born between 1946 and 1964 (the baby boomers), workers born between 1965 and 1980 (the generation X), those born between 1981 and 1995 (the generation Y), and finally a set of employees born in 1995 and beyond (the Linkster Generation). According to (Council of Europe, 1985), there are main historical incidences and events, cultural phenomena, and social trends that influence each of the listed generations. Such forces transform the thought about all things from perceptions and expectations concerning the provisions of the workplace and the behaviors of the workers to the organization’s work ethic and loyalty.

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Generational Distinctiveness

A study by (Allahyari, 2000) on the general factors and characteristics of the five working generations identified unique generational features that influence working styles, communication styles, and team conduct. Assuredly, understanding the distinction or contrast between the groupings of the generational workers can be very fundamental in avoiding conflicts in the work environment (Council of Europe, 1985).

Generational Groups and their Differences

The Traditional Generation

The traditional grouping consists of the sort of internal marketing and the interactive marketing. The service triangle is premised that when organizations attend to their employees born before 1945, and characteristically referred to as the ‘depression babies’. This category of staff members is highly influenced by World War II and the ‘Great Depression’. The workers seem to be having quality traits that distinguish them from other generational categories of employees; for instance, they comparatively respect the authority, they are loyal, stubbornly autonomous, dependable, produce excellent work, and have advanced interpersonal and communication skills (Council of Europe, 1985).

The Baby Boomers

The set of generational employees consists of persons born between 1946 and 1964, and generally known as the ‘Woodstock generation.’ Unique events influence and define the group, which include the postwar social change, the 60’s, and the great Vietnam War. They as well have exceptional and imitable characteristics, for example, outstanding solidarity skills, well educated, query management, and authority, and they thrive superbly on assignments that stimulate adrenaline (Parent, 2013).

The generation X

The workers classified under this category are persons born between 1965 and 1980. People know as the ‘Latchkey Generation’ and jokingly refer to them as the products or creation of separated and divorced parents. Their traits are distinguishable to people who are not part of the workforce for reasons that; they focus on family matters, they are independent, do not tolerate bureaucracy, are socially responsible, are hardworking, as well as critical in all mannerisms about the workplace (Schell, 1994).

The generation Y

The group is composed of workers born between 1981 and 1995. Universally, they are common in the public domain as the ‘entitled generation’; what’s more, evidence suggests that their affectionate and devoted parents, as well as the technology, play a tremendous responsibility in driving and influencing them toward work. Their uniqueness is unquestionable as they are loyal, highly socialized, socially accountable, technologically able, and often need to balance between work and life (Schell, 1994).

The Linkster Generation

This is the last set of employee generational categorization at the workplace and includes all individuals born in the year 1995 and beyond. They are uniquely distinguished from the other groups by the name ‘the Facebook crowd’. The media that has saturated the world presently highly influences them, more specifically the social media. This group is technologically autonomous and has close ties to parents; consequently, it easily tolerates substitute lifestyle, engages in green causes, and heavily link itself to societal activism (Brayne, 2010).

Managing and Working With Diverse Generational Groups

Working or managing divergent generational groups may not be an easy task in a workplace environment, and there are proposed tips offered to resolve conflicts between the different generational groupings if they so happen. Since the groups are dissimilar in their characteristics and interests, it would be tedious and complicated to manage a set of workers composed of the entire mix. Nevertheless, the following tips would guide a manager in developing relevant skills of performing the task without much hassle.

Understanding of Work Styles

Unfortunately, the baby boomers and the traditional generation dislike passionately the idea of being micromanaged. On the contrary, Generation Y and the Linksters yearn for particular, detailed instructions concerning how things should work, and are used to hanging around authorities (the United States, 2009).

Regarding Generational Principles or Values

Ideally, every generation has a distinctive set of principles or values that they dearly protect; nonetheless, if conflicts happen in a working environment mixing the groupings, then it would be a threat to the values put in place. A good example is that of the baby boomers who value working in teams, engaging in cooperation, and buying-in. Another instance involves generation X’s desire to make independent decisions and moving on, if possible, singly.

Sharing of Perceptions

If a conflict erupts between workers of two or more generational groupings, sharing their perceptions can help them learn or gain knowledge a great deal. A person of the traditional generation may be the lacking of manners and formality of the generation Y’s individual as disgusting and unpleasant. At the same time, the generation Y persons may have a feeling of repulsion and revolt if the older workers fail to respect their input and opinions (the United States, 2009).

Finding a Generational Suitable Fix

Douglas (2002) supposes that it is very hard to change or transform the experiences of people’s lives; however, it is possible to function with a sort of expectations and attitudes that arise or result. For example, a boomer with extensive knowledge might see a person of Generation Y face frustrations while performing a task due to lack or deficiency of experience; as such, the boomer can turn into a mentor due to his sense of prerogative.

Finding or seeking Commonality

Persons in the traditional generation and generation Y value stability and security while the traditional group and the boomers are often resistant to change. Nevertheless, both sets of generations value development and training. Generation Y and Generation X workers value very much flexibility at the workplace, as well as the balance between work and life. Linksters and boomers, on the other hand, are often contented with substitute lifestyles and diversity. Lastly, Linksters and the generation Y are proficient in technological matters and show commitment to socially accountable policies.

Learning from One Another

It is indisputable that every generational group has valuable and principled lessons that can transform and teach the subsequent. For example, the boomers and the traditional generation are rich in tricks and full of knowledge regarding their employment that any young employee would desire to have. On the other hand, Generation X workers are famous for their meditation and fairness abilities, while the generation Y employees are wizards on matters of technology. The Linksters, on the contrary, are specialized on issues regarding marketing, business trends, and future workplace (Szporer, 2012).

Converging Trends that have constructed the Five Generational Groups of Workers

A mixture of trends has played an imperative role in creating the current five generations of a workforce. Such patterns include but do not limit to the following (Wilms, 1996):

• Persons having longer lifetimes and living actively, as such they are capable of working for a longer;

• Individuals, for example, the baby boomers, and the traditional generation being in a position not to retire because of their financial positions and capabilities;

• Persons in the groups such as the baby boomers and the traditional generation anticipating and showing a willingness to work up to old age since work has played a significant role in defining them for years;

• The baby boomers providing financial support to their millennial kids already considered adults, who regarding age are in their late twenties and even thirties;

• The duration between generations potentially becoming diminutive or very small as the rate of transformation or change augments in the fields of communication and technology usage;

• All these factors or trends work together to create one workforce of several generations

Challenges Facing a Multigenerational Workforce

Since various workplaces have multiple and different challenges in the contemporary world, it is always important that the multigenerational employees work hand in hand for the vision and strategies of the organization to be attainable. The newcomers comprising of the younger generation, the middle age group already established and holds a better part of the management responsibilities, as well as the generation of senior and older executives aging thirty to forty years in their careers, should all harmonize the working environment to minimize the possibility of conflicts. All these groups with the entirety of their generational distinctions can result in frictional relations amongst bosses and colleagues (International Labor Conference & International Labor Office, 2004). The current workplace is not different from that of the past decades, taking into consideration that all the parties of generation X, generation Y, and baby boomers co-exist in one workplace. However, as a majority of the boomers work beyond retirement age, and the technologically knowledgeable millennial individuals continue grading and joining the workforce, the bleak disparities in the principles and values, work mannerisms, and communication styles of every generation become more pronounced (Szporer, 2012).

Since the postmillennial groups are swiftly coming closer to college-age, other imminent generations might be joining the ranks soon. If so, happens, the five generations workforce will soon become another norm in the workplace. Therefore, leaders and managers should be ready to handle the anticipated challenge of incorporating fresh members of staff while at the same time respecting the experience and seniority of the older employees. As the new generational groups will be joining the workforce, an adaptation period will be necessary on either end (International Labor Conference & International Labor Office, 2004).

Challenges

Style of Communication

There are significant differences in the preference of the communication styles between the younger and the older generations. Generation Y prefers tweeting, texting messages, and sending instant messages as strategies of communicating. On the other hand, generation X and the baby boomers often prefer emails and phone calls. Distinguishably, the sort of younger workers like using abbreviations, colloquialisms, and unofficial language in communication. Older workers, in particular, instances have a habit of communicating to the senior management with much formality as they equate that formality on the communication. However, if not offered the same formality in return, they may as well interpret it as a lack of respect (the United States, 2009).

Negative Stereotypes

Some terms often attach to the thoughts of older employees immediately they think of the millennial generation. Such terms include lazy, technology, entitled, over-enthusiasm, and obsessed. Generation Y workers are not the only victims of these stereotypes since the baby boomers at times get the perception by younger employees as stubbornly set and hard to train in their ways (Douglas, 2002).

Cultural Anticipations or Expectations

As the distinctive place of work changes in keeping up with the transforming work trends and technologies, the health care, cultural factors have a strong influence on patients’ and families” decisions. Some cultural expectancies have subsequently occurred as well. The transition can be particularly harsh for the older generation of workers, who accustom to having functionality or performance deliberated by the length of time spent on taken at their working desk. On the contrary, the majority of the younger managers do not value the time spent in the office as much as they do appreciate the results that the work did produce. Also, generation Y sets higher values and expectations on a healthy balance between work and life (International Labor Conference & International Labor Office, 2004).

Recommendations for Managers

A management team and its leaders that can motivate, understand, communicate, train, as well as, retain four to five dissimilar generations at a similar time are desirable to all the owners of organizations and companies. It is not important whether an individual is in healthcare, retail, finance, or technology since the working together of various generations in harmony is becoming a mission-crucial skill. Most managers may naturally not have the skill-set of cross-generation, although if developed through practice and learning, it can result in the formulation of a comprehensive and significant leadership plan in an organization. For this reason, leaders and managers should learn more concerning generational kinetics, which will make them more competent and aware of the innovation, teamwork, and desire to drive functionality and performance (Douglas, 2002).

Conclusion

Probably, a majority of the younger workers comes from comparatively stable families where both parents are working presently or were working in the past, and, therefore, a greater premium is on a course on the balancing of work and life. The best way leaders and managers can approach the issue of the challenging multigenerational workforce are by allowing individuals to function or work in styles that they prefer and believe suit them well. As well, the entire staff, led by the management team should acknowledge and appreciate every team member, despite the consequences of their working styles. Because everyone in the working environment loves recognition and appreciation for the assignments or tasks, they execute, as well as having access to resources they require and have feedback delivered appropriately, each human in the workplace must receive the honor for the contribution they have made to the group. For significant change and progress to happen in the workforce of multigenerational groups, elements such as openness and flexibility concerning the factors of each age group are crucial. Every age group introduces their own sort of cultural norms and skills; therefore, an efficient staff should be the focal point of diverse personalities, generations, and aptitude, all converging mutually in the direction of a common goal. Assuredly, that is the merely approach an organization will make sure they are introducing new viewpoints too often familiar troubles.

References

Allahyari, R. A. (2000). Visions of charity: Volunteer workers and moral community. Berkeley, CA: University of California Press.

Asch, B. J., United States., & National Defense Research Institute (U.S.). (2001). The pay, promotion, and retention of high-quality civil service workers in the Department of Defense. Santa Monica: Rand.

Brayne, H., & Carr, H. (2010). Law for social workers. Oxford: Oxford University Press.

Council of Europe. (1985). Temporary employment businesses: General problems, specific problems relating to legal or illegal hiring out of workers across borders: report prepared by the Study Group of the 1983/1984 Co-ordinated Research Programme. Strasbourg: Council of Europe.

Douglas, M. (2002). Workers’ compensation 101. Waterford, PA: Douglas Publishers.

International Labor Conference, & International Labor Office. (2004). The situation of workers of the occupied Arab territories: Report of the director-general: appendix. Geneva: International Labour Office.

Parent, C. (2013). Sex work: Rethinking the job, respecting the workers.

Schell, O. (1994). The mandate of heaven: A new generation of entrepreneurs, dissidents, bohemians, and technocrats lays claim to China’s future. New York: Simon & Schuster

Szporer, M. (2012). Solidarity: The great workers strike of 1980. Lanham, Maryland: Lexington Books.

The United States. (2009). Making the connection: Creating pathways to career success for the next generation of workers: field hearing before the Subcommittee on Employment and Workplace Safety of the Committee on Health, Education, Labor, and Pensions, United States Senate, One Hundred Tenth Congress, first session, on examining ways to better educate and train the next generation of workers to create pathways to career success, November 28, 2007. Washington: U.S. G.P.O.

Wilms, W. W. (1996). Restoring prosperity: How workers and managers are forging a new culture of cooperation. New York: Times Business

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

The Roots of Religious Conflict and its Impact

by Herman Bailey | Jul 13, 2023 | Essays | 0 comments

Introduction

Religious warfare refers to violent conflicts with a religious goal, such as protecting sacred places and holy nations. Major religions in the world: under certain conditions, practice violence as a sacred and holy undertaking. Numerous historical instances from various beliefs commend the hypothetical concepts, enlightening that the abolition of the religious battle defies advocates to adopt the highest creeds of their corresponding faiths. Holy war is common in the Islamic religion, which uses terrorism as a form of religious conflict. This essay seeks to understand why major religions support warfare under some appearances such as jihad, crusades, or Dharma despite the diversity in doctrine. This paper aims to take a holistic look at the several causes of religious warfare while recognizing the important role that doctrine plays in religiously endorsed warfare.

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The main question is what increases the vulnerability of the Islamic religion to violence compared to other doctrines. There are several occurrences of conflict motivated by the Muslims, including violence, terrorism, and war, than those of Jewish, Christian, Hindus, and Buddhism. Holy wars are products of doctrine, beliefs, and scriptures (Tor 45). Even though the account and scriptures of the world’s belief articulate stories of harmony, reconciliation, and love, they also speak of violence and war. Some individuals believe in securing holy and sacred places of worship and, therefore, can do whatever it takes to provide protection. Jenkins (45) argues that the holy war is effective in definite situations which are single-sided. Spiritual leaders often condemn this argument and say it contradicts religious teachings and beliefs. They make assumptions that religion can be a means of collecting violent provisions.

Improper interpretation of the scriptures is a major issue in most doctrines. Some believers and even unbelievers come up with inappropriate versions of the Holy Prophet and Quran through written books, articles, journals, and acted movies (Jenkins 52). A good example is a book by David Marshal (1999), which portrayed Islam as a bloody faith with an extracted quote from the Quran. The fact that some Muslim community fails to understand the attitude of the matters of Jihad leads to their dangerous actions (Tor 45). These actions open ground for criticism of the holiness in Islam, which is none other than a replication of the commandments of nature and indicators of the magnificence of the creator.

The ability of Muslims to believe in the Quran’s misinterpretations creates conflict among Mohamed’s followers. The main reason for exposure to religious oppression, violence, extremism, and terrorism is some professors’ wrong interpretation of Jihad (Jenkins 62). According to analysis, the present practices among Muslims, such as a mass attacks, destruction, and killings of civilians, have links to Jihad (Gregg 40). The existence of certain myths that support the need for holy war for self-purification and spiritual peace is a great misguidance to believers. These actions are blasphemy to God’s instructions since they initially start from the destruction of sympathy for humankind. Islamic religion does not require the sustenance of a blade for its promulgation.

Political factors, including leadership and its roles in religion, can cause religious warfare. Both political and religious leaders are significant for the acknowledgment of the holy war. For instance, spiritual front-runners have the gift of translating scripture and preserving religious cultures; these spiritual possessions can be treasured gears for extenuating the application of power and rallying people for war. Political leaders are the managers of public resources, such as the military force, which the country can use to protect from threats (Tor 45). The relationship between the two leading sectors is evitable mostly in spiritually driven violence. Both groups can exploit resources from each side to meet their goals in entanglement cases. The intermixing can be due to religion, political parties, government posts for spiritual leaders, monarchies, and doctrine laws.

Cashman and Leonard (156) argued that religion and politics should be different associations with purely dissimilar objectives. They supported that state leaders need to honor the integrity of God by allowing religious liberties out of federal interference. State leaders cause conflicts through their use of forceful translations of the religion to defy the people in power (Gregg 40). However, separation of state authority from religious leaders can never end the religious war. Some religious authorities use violence to out-smart the state to disturb a revolution. Examples: include the use of jihad by the Islamic organization against their state and the emergence of Christian terrorists in the U.S, whose goal is to overtake the American government and replace it with a Christian theocracy.

The perception of threat is another factor that can motivate an individual to participate in a religious conflict. Gregg (37) explains that leaders plan the religious war in response to perceived and real threats, not as a chance to obtain resources of adherents to trust. Some holy wars do not tend to pose a threat to individuals or nations, but rather, they are for territory expansion, such as the jihad’s fight to enlarge the Dar al-Islam. The frontrunners react to the situation, communities, or territories that oppose the existence of religion. The conflict between Ayodhya and Jerusalem is an instance of spiritual motivation to secure sacred spaces (Jenkins 68). Besides, intimidations that point at terrorizing the social pattern trigger religious responses. They come from occupation, wars, new ideologies, and fresh political systems.

Evolutionary plays an important role in mobilizing a person to participate in religious warfare. The more a religious group possesses numerous properties, the high chances that they can apply force to meet their success. Material, military, and technological resources play a crucial part in initiating conflicts (Tor 58). They include material resources; buildings of institutions, property, and money that can be a major cause of holy war, technological resources; communications technology and transportation, and military equipment; charismatic leaders, social resources, network-educated leaders, and organizations (Gregg 47). The lack of these resources can stimulate the use of soft alternative modes such as hibernating from wars to protect the faith.

There is a significant difference between the war with religion and religious war. General arguments over conditions of spiritual war and conflict with spirits can cause a misunderstanding. The wars of religion come up in situations of separation of societies deemed normal gender roles. Gender is personal, part of everyone’s developing identity and web of relationships, political authority, and religious leaders (Cashman and Leonard 146). It may result in secular conflict with the government. It can also result from intermixing between political and religious goals to achieve both secular and spiritual ends. On the other hand, the holy war is to defend the nation, sacred places, and control over the state through religious rebellions, which allows the groups to implement their translation of faith (Jenkins 53).

Effects of Witnessing Religious Warfare

People who undergo trial for promoting or declining to support a faith or religion are referred to as martyrs (Tor 60). Martyrs gain respect and honor from believers as they consider them heroes. They are significant persons who endured torture, suffering, and even death for their faith in relevant religions. Several people, at one point or the other, witnessed an actual murder attack or watched video footage of a brutal killing. They often respond to the situations differently depending on the degree of the attack or harm and an individual’s exposure to such situations. Some react by screaming, passing out, surrendering, or death (Jenkins 68). Such situations can pose emotional and physical dangers; therefore, such people require frequent visits for spiritual care and group prayers.

Religion War witnesses may end up with mental health complications. The condition affects women and children more than men (Cashman and Leonard 170). Physical torture and psychological manipulation are a great danger to people. The fear of safety, loss of friends and relatives, and witnessing direct slaughtering can greatly impact a person’s sense of control. The result is high depression and unmanageable stress levels caused by frequently distorted memories, disturbed sleep, and nightmares (Jenkins 62). Lack of concentration, poor ability to remember, grief, and high anxiety levels may cause a total mental sickness that may as well take a long recovery period.

The witnesses’ physical abuse results in acute and chronic injuries. Direct beatings or threatening to kill in sequences from inflicting pain to cutting and then slaughtering cause a lot of pain (Tor 45). On most occasions, participants hold civilians in hostages exchange for their demands. They shoot them one after the other as they pose a threat and push for the demanded actions. Another instance is during the mass destruction of an infrastructure or a factory, where civilians get severe injuries as they try to run to their safety. In cases of fire, third-degree burns and death are the main outcomes of the war. According to Gregg (47), these injuries may take time to heal, with some people having a physical disability, apathy, and emptiness.

Religious conflicts such as the Jihad of the Islamic state aim to overtake cities and the government and force people to live according to their twisted Muslim rules (Cashman and Leonard 150). During this war, many people lose their homes and family members, resulting in dislodgment in refugee camps. Immigrants undergo awful situations in camps: sicknesses, death witnesses, lack of medical care, education, and food (Tor 55). Emotional disturbance about the whereabouts of their loved ones is also a major problem. Such undertakings have huge negative impacts on the performance level of daily activities as they cause emotional weakness and mental distortion. The ideal and frustrating conditions in the camps stimulate crime rates among the youths as they live in the belief of violence for personal or group achievement, hence leading to inter-group battles within the camps.

Sexual assault in the refugee camps, especially on children and women, causes fear of strangers and distrust. Most young individuals in these camps lack parental guidance and care since some died during the war, while others are still under trauma and pain (Tor 65). These people are helpless and, therefore, cannot give protection to their children. Sexual abuse results in sexually transmitted infections and unwanted pregnancies among individuals. Young people live with low self-esteem, emotional disturbances, lack of confidence, and suicidal memories (Jenkins 62). Fear of threat from strangers and lack of trust may be a long-lasting impact on the assault.

The civilian captive experience exploitations with forceful recruitment into fighting or terrorist groups. First, the religious leaders accept the existing religious beliefs whether twisted or deal with the consequence of death in denial (Gregg 67). As a result, loses faith in their religion and rejection of their land. Then they use them to make video footage showing live killings to threaten the governments in excellent demanding conditions (Cashman and Leonard 140). Some become the recruits of the fighting crew, where they undergo physical torture during training. The chances that these people survive the attack after training are minimal since they lack experience in endurance techniques. Some captives work as enslaved people for the benefit of the attacking organizations.

The witness of religious war requires psychological and physical assistance to recover from the traumas of conflict. The step is to respond to children, youths, and their families by initiating programs that help provide stable housing and support (Tor 45). For instance, young individuals need coordination and support during recovery. It may include the provision of social amenities such as learning and religious institutions in the refugee camps (Gregg 38). Then finally, assist in dealing with disorders of post-trauma by initiating stress management programs and relaxation techniques to help reduce grief and gain emotional strength.

Conclusion

Religious war must have the element of spiritual achievement, the religious reward for the fighters, and should be under the control of a religious leader to qualify as one. Its main aim is to safeguard sacred spaces, retrieve holy countries, avenge blasphemy (brutal killings and slaughtering of civilians), and spread faith and revolution. This essay portrays the difference between religious wars, wars within religions, and their cause. Even though religion spreads the need for peace and love among nations, it can also initiate conflict within and outside the doctrine. These religious wars greatly impact civilians, including physical and psychological trauma, which may take time for recovery. Therefore, the victim often requires first medical and support attention.

Work cited:

Cashman, Greg, and Leonard C. Robinson. An Introduction to the Causes of War: Patterns of Interstate Conflict from World War I to Iraq. Lanham, Md: Rowman & Littlefield, 2007. 145-180

Gregg, Heather S. The Causes of Religious Wars: Holy Nations, Sacred Spaces, and Religious Revolutions. , 2003. 30-45

Jenkins, Philip. The Great and Holy War: How World War I Changed Religion forever, 2015. 20-75

Tor, D G. Violent Order: Religious Warfare, Chivalry, and the ʻayyār Phenomenon in the Medieval Islamic World. Würzburg [Germany: Ergon, 2007. 40-71

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Insensible Losses: When the Medical Community Forgets the Family

by Herman Bailey | Jul 12, 2023 | Essays | 0 comments

Introduction

The essay will contextualize the personal viewpoint of Pierre Elias ‘experience of health, disease and healthcare in the contemporary American society. The essay will use a personal essay “Insensible Losses: When the Medical Community Forgets the Family” by Pierre Elias from Health Affairs. The essay will discuss and explain how the main issues raised by your Pierre Elias relate to the broader historical context in American current culture, including a comparison to a relevant past historical context. The paper will also have a political, socio-economic, cultural theme that recognizes the social determinants of health. The insensible loss of the patients’ family by the medical community is rampant in many healthcare facilities.

The author

The article “Insensible Losses: When the Medical Community Forgets the Family” was authored by Pierre Elias. The author who is a medical student at Duke University School of Medicine is a scholar who has also served as a TEDMED researcher. Currently, Pierre Elias is a visiting researcher at the University of California, Division of hospitality Medicine, San Francisco (Elias 707-710).

Authors viewpoints and main themes

There are several viewpoints and themes presented by the author in this article. To begin, the author indicates that the family of the patients are always respectful and patient with the doctor when their family members are in the doctor’s care. This patience and respect are also accompanied by trust since the families of the patients believe that the physicians or the health care workers know best on the condition affecting their family member

Under the subtopic, “telling Laura,” many themes and viewpoints come forth. To begin, the theme of neglect of the patient’s family is evident. The author narrates how after the condition of Steve, the patient, had deteriorated; he was rushed to the ICU where new doctors working in the ICU section took over. As the initial doctors assigned to take care of Steve, they had no responsibility over him. However, everybody has returned to their normal duties of attending to other patients and forgetting about Laura, a wife of 40 years to Steve. No healthcare worker considered informing Laura about the developments and the status of her husband for over six hours; she sat apprehensively with her other relatives waiting (Elias 707-710). Pierre states that their clinical team went through their afternoon to-do-list, and they no longer saw Steve as their patient, nor his family as their concern. This is because a new team had assumed the responsibility for his care. Similarly, at the ICU unit, the senior ICU resident on duty only knew the basics about Steve, did not know about the wife of Steve leave alone that she was patiently waiting in the waiting room. Moreover, she had planned to talk to the wife only when she had a new report. This implies that if there will be no new report, then the relatives of Steve would have waited longer to know about the condition of Steve (Elias 707-710).

Another theme evident in the article is a lack of systematic approach to communicating with families to the family members about the condition of their relative who is hospitalized, or when their health deteriorates unexpectedly and requires a change of healthcare providers. The author states that he realized that someone was needed to inform Laura about the condition of her husband, but it was unclear on who to do that. Steve was their patient, but he has been handed over to the neurological unit in other doctor’s care. The unclear protocol is seen on who to inform the family; the previous doctors or the current physicians handling him at the ICU. Lack of proper protocol also saw Pierre, the student physician, taking the responsibility of talking with the family of Steve. A responsibility that should be taken by the doctor in charge of the patient (Elias 707-710).

The theme of lack of emotional care to the families of the patients is also evident. The patient was facing an uncertain and long recovery from stroke and was to go for cancer treatment, and yet the wife with other family members sitting few meters away had no clue about it. Leaving the families of the patients in the dark for longer hours is less a mental torture to the families. Laura was kept for over six hours in darkness about the condition of her husband with no doctor caring to attend to them. Moreover, there was no senior physician to deliver the cancer news to the family, comfort with them, and explain about the condition. That was a blatant lack of emotional care for the families of the patients (Elias 707-710).

Lack of proper policies in place to handle communication with the families or attend to them is also highlighted by the author. Pierre elaborates that most hospitals lack properly instituted handoffs. Handoffs are defined as the care transition that involves transferring responsibility, information and authority amongst clinicians, and it is always risky. Moreover, the author pointed out that even in hospitals with properly instituted handoffs procedures, families are left out (Elias 707-710).

Personal viewpoints

From my personal viewpoints, I believe that the author highlighted some important issues that are evident in many hospitals. Neglect of the families is common in many hospitals especially when the patients have been admitted to hospital units that do not authorize non-staff members. Similarly, lack of systematic communication to the families’ leaves may family members in darkness since they do not understand who to ask about their relative. Furthermore, lack of emotional care to the families is also rampant. Psychologists majorly deal with patients with psychological problems and forgetting that families to the patients also have emotional problems when kept waiting for doctors communication.

Contextualization of the article

Many aspects of the article show that it was written in the present day. For instance, the hospital set up with functional ICU, different departments and working schedules for doctor’s shows that it is of the present day modern hospital.

The article also tells a lot about the current culture in terms of health policy. To begin, the healthcare policies does not focus on implementing policies for preventive checkups and screening to determine some health condition. Also, they do not cover emotional care and how to respond to questions from the families (Goodnough 1).

The article also has highlighted many public health issues, the healthcare system, and healthcare professionals. Many healthcare professionals have not been taught about emotional family care, proper communication, and reporting (para 4). The Pierre pointed out that in a proposed curriculum for the residency program, interns were proposed to be taught about handoffs. Lastly, in the 21st century in America, there are many emergent diseases like cancer, stroke, among others that need proper mechanisms of breaking the bad news to the families (Dower 1).

Comparison this viewpoint with a past period

Comparing the viewpoints in this article to the past time period, I believe there are some improvements in healthcare delivery. Medicine is a changing field with improvements day by day. In the past time period, the proper mechanisms proposed and instituted currently may not have been available in the decade. For instance proper procedure of handoffs. Similarly, an inclusive medication where the family and the healthcare providers are involved in the care and treatment of a patient may not be available in the past, but is being encouraged in the 21st century (Dower 2).

Work cited

Elias, Pierre. ‘Insensible Losses: When The Medical Community Forgets The Family’. Health Affairs 34.4 (2015): 707-710. Web. 18 Oct. 2015.< http://dx.doi.org/10.1377/hlthaff.2014.0536>

Goodnough, Abby. ‘Success Of Kentucky’S Health Plan Comes With New Obstacles’. Nytimes.com. N.p., 2014. Web. 18 Oct. 2015.< http://www.nytimes.com/2014/12/30/us/kentucky-health-plan-is-flooded-with-the-poorest-and-sickest.html?partner=rss&emc=rss&_r=0>

Dower, Catherine, and et al. ”Health Policy Brief: Health Gaps. Among Different Populations Across The United States, Substantial Disparities In Health And Health Care Persist”. N.p., 2013. Web. 18 Oct. 2015. < http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_98.pdf>

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Embracing Challenges in College: Lessons for Success

by Herman Bailey | Jul 12, 2023 | Essays | 0 comments

Challenges or failures are part of life and they do contribute to one’s success. No one embraces failure, but the good thing about it is that there are always lessons to be picked from one challenge to another. A quote by Henry Ford says “Failure is an opportunity to begin again, this time more intelligently”. From this quote we can clearly see how a challenge can be a stepping stone to success. Obstacles in life are for everyone, college students not exempted. I will share my experience of how I encountered challenges, its effect on my life and the lessons I learnt that make me a better person.

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When a person joins college from high school, young and ambitious, there are certain expectations from parents, society and even yourself. Many students expect a relief in terms of studies work load. I remember our academic master in high school telling us to work hard in high school and obtain good grades to join college and that the rest is a walk over. As young people such phrases or advises stick to our heads, little did I know that he was just telling us so that we can work extra harder.

We started our classes on the second week after admission. As an ambitious young person ready to make a mark on this world, I could not wait to start acquiring knowledge, I was so excited. First of all, what caught my attention was the number credit or units that I was supposed to undertake per semester and the reading spiritual and vocational books, praying and mediating early mornings. Upon realization of my true calling, God sent Holy Cross Sister whom I felt attracted to and felt very content to be covered. It was nothing close to what we did in high school. In the back of my mind I convinced myself that all was well and there was nothing to worry about.

Here came the timetable, the classes were so close together, there was very little time to rest between classes. I never missed a class and sacrificed my resting time and even during the weekends to do my studies. I made good use of the college facilities such as the library and the computer laboratory to do my research work. We formed groups that we assisted each other where we had any difficulty. By then I had realized how different it was in terms of content delivery by the lecturers compared to high school. They gave us about 25% of information only and the rest was up to us and on top of that their availability for enquiries was wanting.

After the first month in college, I was starting to lose hope of being one of the top performers in class. I started having difficulty in mastering content in some of the units due to the pressure I had. We undertook our first Continuous Assessment Test and when the results came I was so disappointed, I mostly scored Cs and Ds contrary to my expectation. All was not lost I continued studying hard with the hope of doing better in my final exams. This time I did not even have time for any other activities even sports or social events; my mind was buried in books. After the exams when the exams came I had performed poorly than the previous time. This came as a surprise, I did not expect this, it felt like a big blow on my face.

As days and weeks went by, I started eating less hence looking thinner, could not get enough sleep so I always looked tired, I could sometimes sleep in class in the middle of a lecture. I hardly talked to anyone; I completely withdrew from social life. Avoiding my friends with the excuse that I was studying spending all my evenings and weekends in the library. I could not get myself to understand why I was struggling while others were easily scoring As. I felt worthless and could cry myself to sleep every night.

One of my roommates noticed my change of personality, how unusually quite I became and informed the college counseling service director who approached me. I opened up about my feelings and what I was going through. I went for therapy twice a week until I started feeling better. I was shown a different approach to studies and the strategies I can put across for better performance.

I could not let what I went through define me; I collected myself and faced my challenges head on. I put into use the counseling I got and within no time I was back to my old self. This experience taught me a number of lessons that are contributing to my stability and wellbeing here in school. First of all, there should be a balance when setting goals in life. They should be realistic, attainable and according to our ability. Secondly, we should learn to always take one step at a time and never allow pressure to veer us from the path of success. Lastly, do not let one failure in life lead you to your downfall and give up instead let a challenge be an eye opener for a better tomorrow. I conclude with a quote by Robert F. Kennedy that says “only those who dare to fail greatly can ever achieve greatly”.

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Strategies for Successful Akbar and Sons Business Acquisition: Navigating Transition and Organizational Culture

by Herman Bailey | Jul 12, 2023 | Essays | 0 comments

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Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.