An important part of the activity of paramedics is providing medical care sick at home. The procedure for treating patients at home is determined by doctors at the local hospital or central district hospital (CRH), and only in some cases by the paramedic himself. Patients left at home must be constantly monitored until they recover. This especially applies to children. It is advisable to hospitalize patients from settlements remote from the FAP; when leaving the patient at home, the paramedic notifies the doctor of the rural medical district about this and monitors the patient.
When providing outpatient services to patients with tuberculosis, the paramedic, being the direct executor of medical prescriptions, carries out immunochemoprophylaxis, clinical examination, anti-epidemic measures in foci of tuberculosis infection, work on hygienic education, etc.
A paramedic working at a first aid station must master the simplest techniques of resuscitation at the prehospital stage, especially in case of sudden cardiac or respiratory arrest, the causes of which may be severe injuries, blood loss, acute myocardial infarction, poisoning, drowning, or electrical trauma. Paramedics and midwives, working independently, are also responsible for providing emergency medical care in acute diseases and accidents. In case of an urgent call, the paramedic must have with him a suitcase containing medical instruments and medications according to the packing list.
A major role belongs to paramedics in the medical examination of the rural population. Its main goal is to implement a set of measures aimed at forming, preserving and strengthening the health of the population, preventing the development of diseases, reducing morbidity, and increasing active creative longevity.
To carry out general medical examination, personal registration of the entire population living in the service area of the clinic, outpatient clinic and first-aid post is carried out, in accordance with the “Instructions on the procedure for recording the annual medical examination of the entire population.” IN rural areas lists of residents are compiled by paramedical workers of the FAP.
For personal registration of each resident, nursing staff fill out the “Medical examination record card” (training form No. 131/u - 86) and number it in accordance with the outpatient medical record number (registration form No. 025/u). After clarifying the composition of the population, all “Medical Medical Examination Cards” are transferred to the card index.
A paramedic or midwife ensures that patients who need seasonal (autumn, spring) anti-relapse treatment receive it in a timely manner in a hospital or outpatient setting. Proper organization of the examination of temporary disability at the FAP is important for reducing morbidity.
In accordance with the “Regulations on the head of a paramedic-midwife station,” the head of a private individual paramedic may have the right to issue sick leave certificates, certificates and other medical documents in the manner established by the Ministry of Health Russian Federation.
Grounds for granting extradition sick leave The paramedic receives a petition from the chief physician of the district, which must indicate:
The distance of the FAP from the hospital (outpatient clinic) to which it is assigned;
The number of settlements served by the state farm and the number of workers in them;
Condition of communications;
The paramedic's work experience and level of qualifications;
Knowledge and observance by the paramedic of the basics of temporary disability examinations and the “Instructions on the procedure for issuing sick leave certificates.” The paramedic keeps records of issued sick leave in the “Sick Leave Registration Book” (Form No. 036/u) with the obligatory completion of all its columns.
Treatment and preventive care for women and children. At each individual entrepreneur, the paramedic (midwife) keeps a personal register of women starting from the age of 18, where they enter passport data, previous diseases, information about all pregnancies (years, how each pregnancy ended, complications). At the first visit, the paramedic (midwife) begins the examination of each pregnant woman with a general examination, measures body length and weight, blood pressure in the general arms, within the limits of her competence, determines the condition of the heart, lungs and other organs, examines urine for protein. When monitoring pregnant women, the paramedic (midwife) of the FAP is obliged to show each of them to the doctor; in cases where a woman exhibits the slightest deviation from the normal development of pregnancy, she should be immediately referred to a doctor.
One of the important sections of the activities of FAP paramedics is to carry out primary anti-epidemic measures when outbreaks of infectious diseases occur, the timeliness and quality of which determines the effectiveness of preventing the spread of infection beyond the boundaries of the outbreak. In this regard, the organization of activities of individual entrepreneurs aimed at identifying infectious diseases among the population is of great importance.
When diagnosing an infectious disease (or suspecting it), the nursing staff of the FAP must:
Carry out primary anti-epidemic measures in the outbreak;
Isolate the patient at home and organize ongoing disinfection before hospitalization of the patient;
Identify all persons who had contact with the patient, register them and establish medical supervision over them;
Carry out (together with a doctor) quarantine measures in relation to persons in contact with sick people visiting children's preschool institutions, schools or working at epidemically important facilities;
Report to the place of work, study, preschool institutions, place of residence about the sick person and persons in contact with him;
As directed by a pediatrician or epidemiologist, administer gammaglobulin prophylaxis to those in contact with a patient with viral hepatitis A.
An infectious patient is hospitalized during the first day of illness on special transport. In its absence, the patient can be transported on any transport with subsequent disinfection. Subsequently, the FAP medical worker follows the instructions of the epidemiologist (assistant epidemiologist) and carries out:
Collecting material from persons in contact with patients for laboratory testing to identify bacteria carriers;
Vaccinations according to epidemiological indications and chemoprophylaxis;
Dynamic monitoring of persons in contact with patients during the incubation period of this infectious disease.
Paramedics and midwives of FAPs play a major role in carrying out health promotion activities, hygienic education of the rural population and propaganda healthy image life. In order to correctly assess the level of well-being of a subject, paramedics are trained in simple laboratory tests, express methods, and are provided with on-site express laboratories. Using such a laboratory, it is possible to determine residual amounts of chlorine in disinfectant solutions, on objects and surfaces (iodine-starch method), residual amounts detergents on tableware (test with phenolphthalein).
The FAP paramedic often has to take part in the analysis industrial injuries and the development of measures to reduce it, so he must be well acquainted with the main causes of injuries: technical, organizational and sanitary-hygienic. More than half of all victims go to the first aid station, so nursing staff are required to constantly improve their knowledge, in particular, in providing first aid for injuries. In addition to providing first aid to the victim, FAP paramedics register and record injuries; identify, study and analyze their causes depending on various factors; Together with doctors, they develop specific measures to eliminate the identified causes; monitor compliance with safety regulations; train employees Agriculture first aid techniques.
When working as part of a medical team, the paramedic is completely subordinate to the doctor during the call. His task is to carry out all assignments clearly and quickly. Responsibility for decisions made lies with the doctor. The paramedic must master the technique of subcutaneous, intramuscular and intravenous injections and ECG recording, be able to quickly install a system for drip fluid administration, measure blood pressure, count the pulse and number of respiratory movements, insert an airway, perform cardiopulmonary resuscitation, etc. He must also be able to apply a splint and a bandage, stop bleeding, know the rules for transporting patients.
In the case of independent work, the ambulance paramedic is fully responsible for everything, so he must be fully proficient in diagnostic methods at the prehospital stage. He needs knowledge of emergency therapy, surgery, traumatology, gynecology, and pediatrics. He must know the basics of toxicology, be able to independently deliver a child, assess the neurological and mental state of the patient, and not only register, but also roughly evaluate an ECG.
Appendix No. 10 to the order of the Ministry of Health of the Russian Federation No. 100 dated March 26, 1999
“Regulations on the paramedic of the mobile emergency medical team”
I. General provisions
1.1. A specialist with secondary medical education in the specialty “General Medicine”, having a diploma and an appropriate certificate.
1.2. When performing duties to provide emergency medical care as part of a paramedic team, the paramedic is the responsible performer of all work, and as part of a medical team he acts under the direction of a doctor.
1.3. The paramedic of the mobile ambulance team is guided in his work by the legislation of the Russian Federation, regulatory and methodological documents of the Ministry of Health of the Russian Federation, the Charter of the Emergency Medical Care station, orders and instructions of the administration of the station (substation, department), and these Regulations.
1.4. A paramedic of the mobile ambulance team is appointed to a position and dismissed in accordance with the procedure established by law.
II. Responsibilities
The paramedic of the mobile ambulance team is obliged to:
2.1. Ensure the immediate departure of the brigade after receiving a call and its arrival at the scene of the incident within the established time standard for the given territory.
2.2. Provide emergency medical care to sick and injured people at the scene of an accident and during transportation to hospitals.
2.3. Administer medications to sick and injured patients for medical reasons, stop bleeding, and carry out resuscitation measures in accordance with approved industry norms, rules and standards for paramedic personnel in providing emergency medical care.
2.4. Be able to use available medical equipment, master the technique of applying transport splints, bandages and methods of performing basic cardiopulmonary resuscitation.
2.5. Master the technique of taking electrocardiograms.
2.6. Know the location of medical institutions and station service areas.
2.7. Ensure that the patient is carried on a stretcher and, if necessary, take part in it (in the working conditions of the team, carrying a patient on a stretcher is regarded as a type of medical care). When transporting a patient, be next to him, providing the necessary medical care.
2.8. If it is necessary to transport a patient in an unconscious state or in a state of alcoholic intoxication, inspect for documents, valuables, money indicated in the “Call Card”, hand them over to emergency department hospital with a mark in the direction for signature by the staff on duty.
2.9. When providing medical care in emergency situations, in cases of violent injuries, act in accordance with the procedure established by law (report to the internal affairs authorities).
2.10. Ensure infection safety (comply with the rules of sanitary and hygienic and anti-epidemic regime). If a quarantine infection is detected in a patient, provide him with the necessary medical care, observing precautions, and inform the senior shift doctor about the clinical, epidemiological and passport data of the patient.
2.11. Ensure proper storage, accounting and write-off of medications.
2.12. At the end of duty, check the condition of medical equipment, transport tires, replenish medications, oxygen, and nitrous oxide used during work.
2.13. Inform the administration of the Emergency Medical Service station about all emergencies that occurred during the call.
2.14. At the request of internal affairs officers, stop to provide emergency medical care, regardless of the location of the patient (injured).
2.15. Maintain approved accounting and reporting documentation.
2.16. In the prescribed manner, increase your professional level and improve practical skills.
III. Rights
A paramedic of an emergency medical care team has the right to:
3.1. If necessary, call the emergency medical team for help.
3.2. Make proposals to improve the organization and provision of emergency medical care, improve working conditions for medical personnel.
3.3. Improve your qualifications in your specialty at least once every five years. Pass certification and recertification in accordance with the established procedure.
3.4. Take part in medical conferences, meetings, seminars held by the administration of the institution.
IV. Responsibility
The paramedic of the mobile ambulance team is responsible in the manner prescribed by law:
4.1. For the carried out professional activity in accordance with approved industry norms, rules and standards for ambulance personnel.
4.2. For illegal actions or inaction that resulted in damage to the patient’s health or death.
In accordance with the order of the Ministry of Health of the Russian Federation No. 100, visiting teams are divided into paramedic and medical teams. The paramedic team consists of two paramedics, an orderly and a driver. The medical team includes a doctor, two paramedics (or a paramedic and a nurse anesthesiologist), an orderly and a driver.
Tactics of behavior of an ambulance paramedic during a call. Ambulance personnel, including paramedics, work in very difficult conditions. While on call, a paramedic may encounter any, even the most unexpected, pathology. He needs to have a broad outlook, have knowledge from a variety of fields of medicine, be able to quickly navigate a difficult situation, maintain composure, and make the right decision in a short time. For this, special training alone is not enough; certain moral qualities, good health and life experience are also required.
One of the main difficulties is that at the moment of leaving for a call you never know exactly what lies ahead. A “heart attack” can turn into anything from hysteria to pill poisoning, and when leaving for a hand injury, you may find yourself on the spot with a gunshot wound, massive blood loss and shock. Therefore, the paramedic must be constantly prepared for any situation. But you should not maintain yourself in a state of nervous tension for a long time - you need to be able to quickly navigate and mobilize once you arrive at the place.
Already approaching the place of the call, you need to start observing and drawing conclusions. Whether they greet you or not; what the people who meet you look like - worried, tearful, alarmed, or indifferently leisurely; whether they are in a state of alcoholic intoxication, or whether they look strange for the given circumstances. There are no general laws, but, as a rule, when something really serious happens, the ambulance is met on the street. Unusual behavior may suggest that the caller is insincere. If you are leaving for a clearly criminal reason (fights, riots, etc.), you must request police escort.
The person meeting you should be let ahead and let him show the way. On the way, you should start asking questions to find out what happened.
Having arrived to the patient, you need to quickly assess the situation. Taking anamnesis in an emergency setting has its own characteristics. It should be done purposefully. At the very beginning, you should not allow lengthy stories about your life history, marriage and many chronic illnesses. You should find out what happened right now, everything else - later and if necessary. This often baffles chronic patients who abuse Ambulance without sufficient grounds. At the same time, a truly seriously ill person may become confused, frightened, and not be able to immediately find words. This one needs help. You should not only follow the patient’s lead, but also suppress him, adjust his complaints to your (possibly incorrect) idea of the nature of the disease. You should definitely ask what the patient himself associates his condition with, but evaluate his answer critically.
After clarifying the picture of what happened, you need to find out whether this condition arose for the first time or a similar one has already happened, what helped then, what diagnosis was made, what other diseases the patient suffers from, whether there are any medical documents (outpatient records, hospital extracts, examination results) .
Simultaneously with the collection of anamnesis, it is necessary to begin an examination (count the pulse, measure blood pressure, palpate the abdomen, etc.).
If Small child sleeps, it is better to first carefully palpate the abdomen, and only then wake him up and carry out further examination. The pharynx of restless children should be examined last, as this unpleasant procedure can make contact with the child difficult for a long time.
In case of injuries, you should first examine the site of injury, while simultaneously assessing the general condition of the patient, and then proceed to an examination of organs and systems.
5-10 minutes are allotted for collecting anamnesis and examination in an ambulance. But sometimes they are not there either! After this, it is necessary to draw conclusions, make a preliminary diagnosis and make a decision regarding the provision of assistance.
At the patient's bedside one should behave kindly, correctly, but in a businesslike and firm manner. You should not allow familiarity or condescension towards yourself on the part of relatives or the patient, much less rudeness. All actions must be clear, confident, and you must instill calm in the patient with your entire appearance.
Before giving injections or giving pills, it is necessary to find out whether the patient is allergic to these drugs.
Calls to the street or other places are especially difficult morally. public place regarding car accidents, falls from heights or sudden serious illnesses, when a heated crowd gathers around, usually negative or even aggressive towards the ambulance staff. People in such a situation do not adequately assess what is happening. Other emergency personnel may also be at the scene. You should listen to their advice and accept help. During transportation to the hospital, you should not take more than one accompanying person into the car. If you have to hospitalize a drunk or aggressive patient, he should be placed or seated so that he cannot suddenly and quickly reach the paramedic. If the ambulance was stopped on the way to a call to assist another patient and he really needs it, you should inform the dispatcher so that the first call can be transferred to another team for execution.
After medical care has already been provided, you should explain to the patient what happened to him, how to behave in a similar case next time, and give general recommendations for the treatment and prevention of this disease. If necessary, you should transfer an active call to the local doctor (when the patient is not hospitalized for any reason, but requires dynamic monitoring) or to the medical team (when the patient is in serious condition and requires specialized care or the picture of the disease is not completely clear and you are not sure of the diagnosis ).
The principle of work of a paramedic (and an ambulance doctor) is overdiagnosis. It is better to overestimate the severity of the patient's condition than to underestimate it.
Methods and means of sanitary educational work of a paramedic
In organizing his sanitary and educational work, the paramedic, along with traditional methods training the population on health issues (such as interviews, group discussions, lectures, theme evenings, question and answer evenings, round table, oral magazines, health schools, press publications, conferences) also widely uses methods of visual propaganda: wall newspapers; health bulletins; exhibitions and health corners; book exhibitions.
A health bulletin is an illustrated health education newspaper devoted to only one topic. The topic should be relevant and selected taking into account the challenges facing modern healthcare, as well as the seasonality and epidemiological situation in the region. The title is highlighted in large font. The title should be interesting, intriguing, and it is advisable not to mention the words “disease” and “prevention”.
The health bulletin consists of two parts - text and illustrated. The text is placed on a standard sheet of Whatman paper in the form of columns, 13-15 cm wide, and printed on a typewriter or computer. It is allowed to write the text in calligraphic handwriting using black or purple paste. It is necessary to highlight the editorial or introduction, the rest of the text should be divided into subsections (headings) with subheadings that outline the essence of the issues and give practical advice. The presentation of material in the form of questions and answers is noteworthy. The text should be written in a language that is understandable to the general public, without medical terminology, with the obligatory use of local material, examples of correct hygienic behavior in relation to one’s health, and cases from medical practice. Decoration: drawings, photographs, applications should illustrate the material, but not duplicate it. There can be one or more drawings, but one of them - the main one - should carry the main meaning and attract attention. Text and artwork should not be bulky. The health bulletin ends with a slogan or appeal.
It is necessary to ensure that a sanitary bulletin is issued at least 1-2 times a quarter.
Health corner. The organization of a corner must be preceded by a certain preparatory work: coordination with the management of this institution; determination of the list of works and necessary building materials(stands, strips, buttons, glue, fabric, etc.); choosing a place - one where there are a lot of people constantly or often; a selection of relevant illustrated material (posters, photo and literary exhibitions, transparencies, photographs, memos, leaflets, newspaper and magazine clippings, drawings).
The leading theme of the health corner is various aspects of a healthy lifestyle. In the event of any infection or its threat in a given area, appropriate prevention material should be placed in the corner. This could be a sanitary bulletin, a leaflet prepared by the local sanitary and epidemiological surveillance authority, a short memo, a clipping from a medical newspaper, etc. The health corner should have a question and answer board. Answers to questions should always be timely, prompt and useful.
Oral journals. In addition to medical workers, traffic police officers, juvenile affairs inspectors, and lawyers should participate in oral journals. In their messages, they address issues not only of a medical nature, but also those affecting legal, social and moral issues. Therefore, oral journals can address multiple topics at once.
Disputes and conferences. Dispute is a method of polemical discussion of any topical, moral or educational problem, a method of collective search, discussion and resolution of issues of concern to the population. A debate is possible when it is well prepared, when it involves not only specialists, but also (for example, at school) students and teachers. Clashes and struggles of opinions are associated with differences in people’s views, life experiences, needs, tastes, knowledge, and the ability to approach the analysis of phenomena. The purpose of the debate is to support the progressive opinion and convince everyone that it is right.
A form of propaganda close to a debate is a conference with a pre-developed program and fixed speeches by both specialists and the population itself.
Oral forms of health education also include theme evenings, round table discussions, and question and answer evenings. Theatrical and entertainment events, mass sporting events. Contents of work during various forms and methods of hygienic education of the population and promotion of a healthy lifestyle at the FAP should be aimed at highlighting the basics of personal and public hygiene, hygiene of villages, towns, housing, landscaping and landscaping, maintenance of personal plots; to combat environmental pollution; prevention of diseases caused by exposure to unfavorable meteorological conditions on the body (high air humidity, high and low temperatures, etc.); for implementation physical culture into the life of every person. The topics of this activity also include labor and professional orientation: creating healthy household and production conditions, formation of a healthy lifestyle. Much attention must be paid to the prevention of infectious diseases, improvement of water supply and water use. One of the important tasks is to promote occupational hygiene measures during agricultural work, prevent agricultural injuries and poisoning by pesticides, and explain hygienic requirements for the delivery, purification and storage of water in the field. Anti-alcohol propaganda and explanation of the dangers of smoking should occupy a significant place. Smoking is one of the most common types of drug addiction. The work of a paramedic on anti-alcohol propaganda should be based on a certain system, including legal, medical-biological and moral aspects.
Depending on gender and age, you can select topics for better perception by listeners.
Sample lecture plans
1. For men: the effect of alcohol on all organs and systems of the body; alcohol and trauma; alcohol and sexually transmitted diseases; alcohol and mortality; alcohol and work ability; alcohol and family; alcohol and heredity; economic damage caused to the state by alcohol abusers.
2. For women: the effect of alcohol on a woman’s body; the effect of alcohol on pregnancy; alcohol and children; the role of women in strengthening the family and overcoming the drunkenness of men.
3. For teenagers: anatomical and physiological characteristics of the teenager’s body; the effect of alcohol on a teenager’s body; the influence of alcohol on a teenager’s abilities; the effect of alcohol on offspring; alcohol and law enforcement; how to maintain mental health.
Large section preventive work on promoting a healthy lifestyle should be highlighted in pediatrics. Hygienic training and education begins in early childhood, with antenatal protection of future offspring.
It is advisable to promote a healthy lifestyle and prevent various diseases with pregnant women during prenatal care and group classes in the form of individual conversations (for example, at the “School for Pregnant Women”). It is advisable to conduct conversations about the hygiene of a pregnant woman and the peculiarities of the newborn period not only among the women themselves, but also among their family members, especially husbands, at the School of Young Fathers.
The need to carry out broad preventive measures in relation to the child population and youth, including, first of all, educational and sanitary-educational measures, increases due to the fact that at this age the basic behavioral attitudes, attitudes, skills, habits, etc. are formed, i.e. ... everything that subsequently determines a person’s lifestyle. During this period, it is possible to prevent the occurrence bad habits, emotional incontinence, an attitude towards passive rest and poor nutrition, which in the future can become a risk factor for many diseases. It is relatively easy for children to develop the habit of physical activity, physical education and sports, a varied and moderate diet, and a rational regimen.
Sanitary and educational work at the FAP should be carried out according to a pre-drawn plan. Drawing up a plan for sanitary and educational work is carried out for the entire current year and for the month. The annual plan includes the main tasks for protecting health and promoting a healthy lifestyle, and for each month they draw up a specific plan with the names of topics and methods of covering them. At the end of the month and at the end of the reporting year, the medical worker is required to report on the sanitary educational work done.
Hygienic education of the population and promotion of a healthy lifestyle should contribute to early seeking medical care, improving obstetric care rates, reducing infant mortality, morbidity with temporary disability and injuries, timely hospitalization of patients, attracting the population for preventive examinations, increasing the level of sanitary culture of the population, improving conditions their work and life, activation of people’s creative activity in matters of preserving and strengthening health, increasing efficiency and creative longevity.
We bring to your attention typical example job description for a paramedic, sample 2019. should include the following sections: general position, job responsibilities of a paramedic, rights of a paramedic, responsibility of a paramedic.
Job description paramedic belongs to the section " Qualification characteristics health care worker positions".
The job description of a paramedic should reflect the following points:
Job responsibilities of a paramedic
1) Job responsibilities. Provides therapeutic and preventive and sanitary care, first emergency medical care for acute diseases and accidents. Diagnoses typical cases of the most common diseases and prescribes treatment using modern methods therapy and prevention of diseases, writes prescriptions. Provides first aid, assists the doctor during operations and complex procedures, and assists in normal childbirth. Carries out ongoing sanitary supervision, organizes and carries out anti-epidemic measures. Organizes and conducts dispensary observation of various groups population (children; adolescents; pregnant women; war veterans and disabled people; patients who have suffered acute diseases; patients suffering from chronic diseases). Organizes and conducts preventive vaccinations for children and adults. Carries out examination of temporary disability. Ensures storage, accounting and write-off of medications, compliance with the rules for taking medications by patients. Maintains medical records and reports. Conducts health education work among patients and their relatives to promote health and prevent diseases, promote a healthy lifestyle.
The paramedic should know
2) When performing his duties, a paramedic must know: laws and other regulations legal acts Russian Federation in the field of healthcare; structure, main aspects of activity medical organizations; statistics on the health status of the population served; rules for operating medical instruments and equipment; medical ethics; psychology of professional communication; basics of medical examination; basics of disaster medicine; basics labor legislation; internal labor regulations; labor protection and fire safety rules.
Paramedic qualification requirements
3) Qualification requirements. Average professional education in the specialty "General Medicine" and a specialist certificate in the specialty "General Medicine" without presenting requirements for work experience.
Job description for a paramedic - sample 2019. Job responsibilities of a paramedic, rights of a paramedic, responsibility of a paramedic.
Fundamentals of the organization and structure of paramedic work. To provide high-quality medical care, it is necessary to ensure continuity of the diagnostic and treatment process at all stages of treatment. Here, a clear division of functions at each stage of medical care becomes important. The paramedic is the direct executor of medical prescriptions, must master the simplest resuscitation techniques at the prehospital stage, and provide emergency medical care in acute diseases and accidents. Paramedics work in the ambulance service, in clinical diagnostic laboratories and in the paramedic-obstetric station (FAP), where they provide medical care to the rural population.
Ambulance Service
The ambulance service is one of the most important links in providing medical care to the population in our country. The life, health and good attitude of the population towards the ambulance service depend on the quality of medical care. Paramedics undergo advanced training and specialization at the regional basic school for advanced training of healthcare workers. Practicing emergency physicians give lectures during these cycles.Paramedics can work both inside and outside the affected areas. In some cities, under the leadership of the Center for Disaster Medicine, tactical training of personnel on medical care and interaction with other medical and non-medical units is conducted. Paramedics must be able to work with the equipment equipped at the ambulance station (electrocardiographs, pneumatic systems).
Paramedic and midwife stationA paramedic-midwife station (FAP) is a primary pre-hospital medical institution that provides health care to the rural population. The medical staff of the FAP carries out a complex of treatment, preventive and sanitary and anti-epidemic measures on the territory assigned to them, and provides first aid to the patient at outpatient appointments and at home. Medical care is provided to patients within the competence and rights of a paramedic and midwife under the guidance of a local doctor.
Basic functional responsibilities paramedics An important part of the work of paramedics is providing medical care to patients at home. The procedure for treating patients at home is determined by doctors at the local hospital or central district hospital (CRH), and only in some cases by the paramedic himself. Patients left at home must be constantly monitored until they recover. This especially applies to children. It is advisable to hospitalize sick people in settlements remote from the FAP; when leaving the patient at home, the paramedic notifies the doctor of the rural medical district about this and monitors the patient.
When providing outpatient services to patients with tuberculosis, the paramedic, being the direct executor of medical prescriptions, carries out immunochemoprophylaxis, clinical examination, anti-epidemic measures in foci of tuberculosis infection, and work on hygienic education. A paramedic working at a first aid station must master the simplest techniques of resuscitation at the prehospital stage, especially in case of sudden cardiac or respiratory arrest, the causes of which may be severe injuries, blood loss, acute myocardial infarction, poisoning, drowning, or electrical trauma. Loss of time or inept actions of a paramedic can lead to dire consequences.
Paramedics and midwives, working independently, are also responsible for providing emergency medical care in acute diseases and accidents. In case of an urgent call, the paramedic must have with him a suitcase equipped with medical equipment and medicines according to the stowage list. A major role belongs to paramedics in the medical examination of the rural population. Its main goal is to implement a set of measures aimed at forming, preserving and strengthening the health of the population, preventing the development of diseases, reducing morbidity, and increasing active creative longevity.
To carry out general medical examination, personal registration of the entire population living in the service area of the clinic, outpatient clinic and first-aid post is carried out, in accordance with the “Instructions on the procedure for recording the annual medical examination of the entire population.” In rural areas, police lists of residents are compiled by paramedics at FAPs. For personal registration of each resident, nursing staff fill out the “Medical examination record card” (training form No. 131/u-86) and number it in accordance with the outpatient medical record number (registration form No. 025/u). After clarifying the composition of the population, all “Medical examination cards” are transferred to the card index.
If persons under dispensary observation do not see a doctor, then a paramedic or midwife visits them at home or at work and explains the need for a medical examination. A paramedic or midwife ensures that patients who need seasonal (autumn, spring) anti-relapse treatment receive it in a timely manner in a hospital or outpatient setting. The quality of the work of paramedics and midwives in clinical examination is determined by the timeliness of the appearance of those undergoing medical examination and the implementation of therapeutic and recreational measures prescribed by the doctor, as well as the correctness of filling out the control card of dispensary observation (form No. 030/u) and maintaining a file of those undergoing medical examination.
Proper organization of the examination of temporary disability at the FAP is important for reducing morbidity. In accordance with the “Regulations on the head of a paramedic-midwife station,” the head of a medical obstetric center - a paramedic may have the right to issue sick leave certificates, certificates and other medical documents in the manner established by the USSR Ministry of Health. The basis for granting the right to issue sick leave to a paramedic is a petition from the chief physician of the district, which must indicate:
the distance of the FAP from the hospital (outpatient clinic) to which it is assigned;
the number of settlements served by the state farm and the number of workers in them;
state of communications;
the paramedic's work experience and level of qualifications;
knowledge and observance by the paramedic of the basics of temporary disability examinations and the “Instructions on the procedure for issuing sick leave certificates.”
The paramedic keeps records of issued sick leave in the “Sick Leave Registration Book” (form No. 036/u) with the obligatory completion of all its columns. When the doctor closes the sick leave, the patient appears at the FAP. The paramedic must fill out the remaining columns of the book; final diagnosis, name of the doctor who closed the sick leave, on what date the patient was released from work, total number calendar days release from work. Special attention paramedics need to pay correct design, storage and recording of sick leaves, which should be stored in the FAP safe, and in its absence, deposited at the end of the working day in the state farm safe.
Treatment and preventive care for women and children. At each FAP, the midwife, as paramedics, maintains a police file of the woman, starting from the age of 18, where they enter passport data, previous diseases, information about all pregnancies (years, how each pregnancy ended, complications). At the first visit, the paramedic (midwife) begins the examination of each pregnant woman with a general examination, measures body length and weight, blood pressure in the general arms, within the limits of her competence, determines the condition of the heart, lungs and other organs, examines urine for protein. When monitoring pregnant women, the paramedic (midwife) of the FAP is obliged to show each of them to the doctor; in cases where a woman exhibits the slightest deviation from the normal development of pregnancy, she should be immediately referred to a doctor.
An important part of a paramedic’s activity is protecting the health of children. Patronage plays a significant role in this work. According to the current situation, a paramedic (midwife) visits a newborn in the first 3 days after discharge from the maternity hospital; if the first child is born in the family, then he is visited on the first day after discharge, and then every 2-3 days during the first week and weekly during the first month of life. During the examination, attention is paid to the general condition of the child, as well as to the condition of various organs and systems, especially the nervous system, skin, umbilical ring, and the presence of developmental anomalies.
From sensitive and qualified supervision of a child under 1 month of age. The prevention of septic diseases, the successful treatment of congenital diseases, and, consequently, the health of the child in the future largely depend. A paramedic (midwife) must see a child during the first year of life 12 times during preventive appointments and 20 times during home visiting. During the second year of the child’s life, the paramedic gives a detailed report on his state of health and evaluates his physical and neuropsychic development. This conclusion must be brought to the attention of parents, with an emphasis on the shortcomings, and recommendations for the further upbringing and improvement of the child must be given.
Paramedics and midwives when serving schoolchildren (where there is no school nurse) are required to:
take part in medical examinations of schoolchildren conducted by a pediatrician, prepare medical records and fill them out common part; record anamnesis, complaints, information about previous diseases, vaccinations; carry out anthropometric measurements, determine visual and hearing acuity; refer, as directed by a doctor, to medical institutions for additional laboratory tests and consultations with medical specialists;
bring to the attention of school teachers the results of medical examinations with recommendations from medical specialists;
control the organization of a rational daily routine and nutrition, hygienic education of students, organization of labor education;
exercise control over compliance with the sanitary and anti-epidemic regime, compliance with sanitary requirements for food preparation technology, washing dishes, as well as compliance with deadlines for the sale of products and prepared food;
carry out work to prevent childhood injuries (including sports), record and analyze (together with a doctor) all cases of injuries;
carry out preventive vaccinations for students after examination by a doctor and under his supervision, notifying parents about this in advance, keep records of them and isolate sick schoolchildren; examinations, thermometry and other measures in relation to children who have been in contact with infectious patients, inform the doctor of the rural medical district, the director of the school in the SES about each case of an infectious disease;
examine students for helminths and, under the guidance of a pediatrician and epidemiologist, carry out deworming.
One of the important sections of the activities of FAP paramedics is the implementation of primary anti-epidemic measures in the event of outbreaks of infectious diseases, the timeliness and quality of which determines the effectiveness of preventing the spread of infection beyond the boundaries of the emerging outbreak. In this regard, the organization of activities of FAP workers aimed at identifying infectious diseases among the population is of great importance. When a diagnosis of an infectious disease is made (or suspected), the nursing staff of the FAP must carry out primary anti-epidemic measures in the outbreak:
isolate the patient at home and organize ongoing disinfection before hospitalization of the patient;
identify all persons who had contact with the patient, register them and establish medical supervision over them;
carry out (together with a doctor) quarantine measures in relation to persons in contact with sick people who attend pre-school institutions, schools or work at epidemically important facilities;
inform the place of work, study, preschool institutions, place of residence about the sick person and persons in contact with him;
as directed by a pediatrician or epidemiologist, carry out gammaglobulin prophylaxis for those in contact with a patient with viral hepatitis A.
An infectious patient is hospitalized during the first day of illness on special transport. In its absence, the patient can be transported on any transport with subsequent disinfection. Subsequently, the FAP medical worker follows the instructions of the epidemiologist (assistant epidemiologist) and carries out:
collection of material from persons in contact with patients for laboratory testing to identify bacteria carriers;
vaccinations according to epidemiological indications and chemoprophylaxis.
dynamic monitoring of persons in contact with patients during the incubation period of this infectious disease.
FAP paramedics and midwives play a major role in carrying out health-improving activities, hygienic education of the rural population and promoting a healthy lifestyle. Every year, the district SES draws up a work plan to involve nursing staff in ongoing sanitary supervision, which is approved by the chief physician of the FAP and brought to the attention of all FAPs. In order to correctly assess the level of well-being of a subject, paramedics are trained in simple laboratory tests, express methods, and are provided with on-site express laboratories. For a field express laboratory, equipped chemical reagents, indicator paper, cotton wool, tweezers, instructions, you can adapt an ordinary automobile first aid kit. Using such a laboratory, it is possible to determine residual amounts of chlorine in disinfectant solutions, on objects and surfaces (iodine-starch method), and residual amounts of detergents on tableware (phenolphthalein test).
The involvement of FAP paramedics in ongoing sugar supervision has a positive effect on the quality of sanitary and health measures and helps improve the sanitary condition of facilities. The next important section of the work of FAP paramedics is the organization and implementation of anthelmintic measures, the task of which is to identify and timely treat patients, as well as to implement a set of measures aimed at improving the focus (settlement) and microfocus of helminthiasis (households, estates, children's institutions). To carry out this work, it is necessary to know the species composition of helminths in a specific area.
Microfoci of helminthiases (ascariasis and trichuriasis) can be detected by examining the soil by taking samples from the most fecal-contaminated areas on personal plots. This work should be carried out jointly with the SES, but the paramedic will organize the collection of material for laboratory testing. During mass deworming of the population, the medical staff of the FAP involves public sanitary activists in their work.
All identified patients with helminth infections in the shortest possible time undergo sanitization and report them to the rural medical station. Patients who have undergone treatment are monitored until complete healing and elimination of the microfoci. A FAP paramedic often has to take part in the analysis of occupational injuries and the development of measures to reduce them. Therefore, he must be well acquainted with the main causes of injuries: technical, organizational and sanitary-hygienic.
More than half of all victims go to the first aid station, so nursing staff are required to constantly improve their knowledge, in particular in providing first aid for injuries. Such training of paramedics should be carried out in the surgical room or trauma center of the Central District Hospital. The chief physician of the local hospital (outpatient clinic) and the district surgeon supervise and direct the work of paramedics in providing first aid for injuries.
In addition to providing first aid to the victim, FAP paramedics register and record injuries; identify, study and analyze their causes depending on various factors; Together with doctors, they develop specific measures to eliminate the identified causes; monitor compliance with safety regulations; train agricultural workers, reception and provision of self- and mutual assistance. In improving the qualifications of medical staff of FAPs, an important role is played by organizational, methodological, treatment and advisory assistance provided by their specialist doctors from the Central District Hospital and rural medical districts during scheduled visits. After an in-depth study of the activities of the FAP, specialists conduct classes with paramedics, during which they analyze in detail the shortcomings in treatment and preventive work and outline measures to improve it.
One of effective methods advanced training for secondary medical workers is an exchange of experience, providing for a detailed study of the work of an advanced first aid station on site for 3–5 days. Certification is of great importance for the correct placement of paramedical workers and the improvement of their qualifications. It is an important incentive to improve performance indicators, retain personnel in rural areas and a necessary condition to determine the suitability of paramedical workers for their positions, assess the prospects for their use, as well as to develop new criteria for training and creative initiative.
Laboratory service
Responsibilities of a medical laboratory assistant. A specialist with a secondary medical education in the specialty “Laboratory Diagnostics”, qualification “Medical Laboratory Technician” (paramedic laboratory assistant) and a specialist certificate is appointed to the position of medical laboratory technician. The medical laboratory technician reports to the head of the clinical diagnostic laboratory (CDL), as well as the clinical laboratory diagnostics doctor. In his work, a medical laboratory technician is guided by current regulatory documents, job descriptions, and these regulations.Laboratory Technician:
Performs laboratory tests in accordance with established standards load and qualification requirements.
Prepares reagents, chemical glassware, equipment, and disinfectant solutions for work.
Registers biological material entering the laboratory for research, including using a personal computer, processes the material and prepares it for research.
Takes blood from a finger.
Sterilizes laboratory equipment in accordance with current instructions.
Leads necessary documentation(registration, entries in journals, forms of analysis results).
Carry out instructions from the head of the laboratory for logistics and technical support of the laboratory.
Takes part in classes for employees with secondary medical education.
Complies with safety regulations and industrial sanitation, in accordance with the requirements of the sanitary and epidemiological regime.
Improves professional qualifications in the prescribed manner.
A medical laboratory technician has the right to:
Make proposals to senior officials on issues of improving organization and working conditions.
Periodically, in accordance with the established procedure, undergo certification for assignment of a qualification category.
The medical laboratory technician is responsible for failure to fulfill his duties as provided for in these regulations and internal labor regulations.
Equipment. In accordance with the requirements of Order of the Ministry of Health of the Russian Federation No. 100 dated March 26, 1999.
Basic medical storage box.
Additional medical box for placing a birth package, resuscitation kit, infusion solutions.
Portable single-channel electrocardiograph.
Portable defibrillator with electrocardioscope.
Ventilator device type “Pnevmokomp” or (and) KI-5.
AN-9 inhalation anesthesia device.
Manual portable ventilator type ADR-1200.
Portable glucometer or glucose tests.
Tonometer and phonendoscope.
A set of pneumatic and (or) vacuum immobilization tires.
Set of immobilization head holders such as Shants collars.
Vacuum mattress.
The stretcher is foldable.
A stretcher-panel of the “dragging” type.
The wheelchair is foldable.
Reception device with stretcher.
Infusion stand.
Oxygen cylinder with reducer 10 l.
Aspirator portable mechanical or electric.
Furniture for placing medical equipment and supplies.
Directional lamp in the cabin.
Communication means (radio station or radiotelephone).
Medicines:
Adrenergic agonists: dopamine, mesaton.
Adrenergic agents: isoprenaline (isadrin).
Adsorbing agents: activated carbon in table. 0.5 each No. 50.
Analeptics: niketamide (cordiamin), 2 ml No. 2.
Antianginal agents: nitroglycerin tab. 0.0005 No. 40, isosorbide dinitrate (isoket, nisopercutene), aerosol - 1 bottle.
Antiarrhythmic drugs: novocainamide, finoptin.
Antibiotics: chloramphenicol, streptomycin.
Antihistamines: diphenhydramine, calcium chloride 10%, tavegil, pipolfen, suprastin.
Antiseptics: iodine 5% alcohol solution, potassium permanganate, hydrogen peroxide 3% - 30 ml, brilliant green solution - 10 ml.
Anticholinergic drugs: atropine 0.1% - 1 ml No. 10.
Bronchodilators: Berotec (aerosol), 1 fl.
Vitamins: ascorbic acid 5% - 1 ml No. 10, pyridoxine, thiamine chloride, cyanocobalamin.
Ganglion blockers: pentamine 5% - 1 ml No. 4.
Antihypertensive: clonidine (clonidine, hemiton) 0.01% - 1 ml No. 2.
Hormonal agents: hydrocortisone, 0.025 (0.05) with solvent - 1 amp., insulin 400 units. - 10 ml., norepinephrine, oxytocin, prednisolone - 30 mg No. 10, adrenaline 0.1% - 1 ml No. 10.
Infusion agents: sodium chloride 0.9% - 500 ml No. 2, glucose 5% - 500 ml No. 2, polyglucin - 500 ml, rheopolyglucin 500 ml, hemodez - 400 ml, gelatinol, disol, etc.
Local anesthetics: novocaine, trimecaine, lidocaine, chloroethyl.
Muscle relaxants: myorelaxin (listenon) 2% - 5 ml No. 1.
Diuretics: furosemide (Lasix) 1% - 2 ml No. 2.
Narcotic analgesics: morphine - 2 amps, omnopon - 2 amps, promedol - 2 amps, fentanyl - 2 amps.
Non-narcotic analgesics: analgin - 4 amps., Tramal - 2 amps.
Neuroleptics: aminazine - 3 amp., droperidol 0.25% - 10 ml - 1 amp No. 1.
Antidotes: unithiol - 1 amp., naloxone - 1 amp.
Antimalarials: chloroquine (delagil, hingamine).
Sedatives: tincture of valerian or valocordin.
Cardiac glycosides: strophanthin-K - 4 amps, korglykon - 4 amps, digoxin - 2 amps.
Antispasmodics: aminophylline 2.4% - 10 ml - 2 amps, dibazol - 5 amps, no-spa - 3 amps, magnesium sulfate 25% - 5 amps, baralgin - 2 amps, papaverine hydrochloride (or platifillin) - 5 amp.
Alcohols: ammonia 10 ml, ethyl alcohol 96% 30 ml, ethyl alcohol 70% 30 ml.
Agents affecting blood clotting: aminocaproic acid - 100 ml, vikasol, heparin - 5000 units in 1 ml, dicinone.
Anesthesia: nitrous oxide 5 l, ketamine (calypsol, ketalar) 10 ml, sodium hydroxybutyrate 20% - 10 ml.
Central nervous system stimulants: caffeine 20% - 1 ml No. 2.
Tranquilizers: diazepam (Relanium, Seduxen, Sibazon), 3 amp.
Thrombolytic agents: streptokinase 250,000 units.
Anticholinergics: scopolamine 0.05% - 1 ml 2 amp.
Anti-burn aerosol “Panthenol” or analogues - 1 fl.
Vaseline oil, 30.0.
Dressings: sterile bandages of various sizes - 6 pcs., adhesive plaster, sterile napkins of various sizes - 20 pcs., hemostatic napkins (or sponges) - 2 pcs.
Instruments and patient care items: scissors, tweezers - 2 pcs., hemostatic clamps - 2 pcs., mouth dilator, tongue holder, scalpel - 2 pcs., set of air ducts and endotracheal tubes, rechargeable laryngoscope with removable blades, gastric lavage probe with funnel (adult and child), rubber urinary catheters.
Mechanical hemostatic tourniquet with dosed compression.
Venous tourniquet for intravenous injections.
Pipette, plastic beaker, thermometer in a case, disposable spatulas - 10 pcs., disposable sterile syringes with needles of various capacities - 10 pcs., device for opening ampoules.
Systems for transfusion of blood substitutes, disposable, sterile - 2 pcs.
Disposable sterile rubber gloves - 2 pairs, disposable sterile catheters for peripheral veins - 2 pcs., disposable apron.
A container with a disinfectant solution for used needles, a bag for used syringes.
Epidemiological structure (formed in accordance with the action plan when identifying a patient with AIO, see above - diagram No. 2 in the section “Basic orders regulating work.”
Sterile birth package: Kocher clamp - 2 pcs., scissors - 1 pc., umbilical cords - 5 pcs., napkins - 5 pcs., ligature - 1 pc., diaper - 1 pc., rubber bulb - 1 pc.
Resuscitation unit (box): sets of intubation tubes and air ducts, a device for closed cardiac massage of the “Cardiopamp” type, a device for mechanical ventilation of the “Ambu” bag type (adults and children), a set for catheterization of blood vessels, a set for conicotomy, disposable syringes of various capacities - 5 pcs., systems for transfusion of blood substitutes - 2 pcs., infusion solutions of 500 ml - 3 pcs., portable aspirator, mouth dilator, tongue holder.
Inventory: pillow, blanket, set of linen (preferably disposable), towel, soap.
Note: these medicines can be replaced with analogues or supplemented with new ones medicines, registered and approved for use in the Russian Federation.
Chapter 1 The basic structure of a paramedic’s work at a FAP
Organization of work at the paramedic-midwife station (FAP)
Characteristics of the paramedic-midwife station
The paramedic and midwife station is an outpatient clinic in rural areas. The management of the medical and sanitary activities of the FAP is carried out by health authorities. The FAP carries out treatment and preventive, sanitary and epidemiological work and sanitary and hygienic education of the population; has its own estimate, round seal and stamp indicating its name; draws up plans and reports explanatory note morbidity analysis; maintains accounting and reporting documentation. A paramedic (paramedic-midwife) with completed secondary medical education is appointed to the position of head of a paramedic-midwife station. At the paramedic-midwife station located in the village (where there is no pharmacy), it is organized Pharmacy(or kiosk) selling ready-made medicines and patient care items to the public.
Job responsibilities of the head of the FAP
Job responsibilities of the head of the FAP (paramedic). The head of the FAP (paramedic) leads the work on organizing and planning medical and preventive care at the site; is responsible for providing timely medical (pre-hospital) care for various acute diseases and accidents.
The paramedic is obliged:
1) know the features of organizing emergency care in case of mass accidents, poisoning with chemicals and drugs;
2) know the basics of pre-hospital resuscitation; perform closed cardiac massage and artificial ventilation;
3) provide outpatient care and care for patients at home;
4) promptly refer patients for consultation to the nearest medical and preventive institution (central district hospital);
5) if necessary, accompany the patient personally.
The paramedic organizes the appointment of patients by local doctors and other specialists at the FAP according to a schedule approved by the chief physician. By the day of the appointment, the paramedic prepares patients and primary documentation. The doctor sees patients together with the paramedic. The personal participation of a paramedic in the consultation of patients contributes to the timely treatment of patients, their employment and the improvement of the paramedic’s qualifications.
The paramedic takes an active part in the medical examination of the population of his area, draws up cards for patients who are subject to clinical observation. The paramedic, under the guidance of a doctor, periodically organizes medical examinations population with unfavorable working conditions. Patients with tuberculosis, hypertension, coronary heart disease, peptic ulcer of the stomach and duodenum, diabetes, glaucoma, thrombophlebitis, obliterating endarteritis, etc. are subject to dispensary observation. Disabled people and veterans of the Great Patriotic War are subject to dispensary registration and observation. Patriotic War, liquidators of the consequences of the accident at the Chernobyl nuclear power plant. To properly organize the work of the FAP, a plan of treatment and preventive measures for the current year is drawn up. The plan specifically indicates the planned activities, deadlines, and responsible person. The pre-developed plan is approved by the chief physician. All planned activities are carried out on time.
The paramedic carries out medical control over the development and health of children in nurseries, kindergartens, orphanages, schools located in the territory of the FAP operation and which do not have appropriate paramedical workers on their staff; carries out sanitary-anti-epidemic and sanitary-educational work according to the approved plan.
Organization of emergency care
To provide emergency care and pre-hospital resuscitation, the FAP must have the necessary set of instruments, dressings and medications according to the approved report card. The emergency room contains a bed with a board or a flat hard couch, a stretcher, immobilization equipment, a cabinet for storing medicines, a table, a sterilizer, syringes (2, 5, 10, 20 ml), rubber tourniquets, a tonometer, a thermometer, probes of various types. sizes and a funnel for gastric lavage, a stethoscope, beakers, a bucket, a basin, a set of rubber catheters, dressings, breathing and oxygen equipment, an incubation kit, an oxygen cylinder.
Organization of medical care for the rural population
Obstetric and gynecological care for the rural population
Features of the living and working conditions of the rural population, expressed in the dispersion of settlements, different forms of organization of agricultural production, a variety of types of agricultural work (farming, livestock farming, poultry farming, etc.), a large scope of these works, their seasonality, determine the features of the organization of all medical care in rural area, including obstetrics and gynecology.
Obstetric and gynecological care is provided to the rural population by a complex of medical and preventive institutions. Depending on the degree of proximity to the rural population, on the specialization and qualifications of medical care, the level of material and technical equipment in the system of providing obstetric and gynecological care, it is customary to distinguish three stages.
Stages of obstetric and gynecological care
The first stage is the implementation of pre-medical and first medical aid. This stage is a rural medical site. It includes a rural district hospital with an outpatient clinic and a hospital, paramedic and obstetric stations (FAP), and maternity hospitals. The location of the first stage is the periphery of the region.
The second stage is the provision of qualified medical care. It includes district (registered) and central district hospitals, which include obstetrics and gynecology departments and antenatal clinics. The location of the second stage is the regional center.
The third stage is to provide the rural population with highly qualified (specialized) obstetric and gynecological care. It includes a regional (territorial, republican) hospital, which includes obstetrics and gynecology departments and a antenatal clinic or an independent maternity hospital with a antenatal clinic. The location of the third stage is the regional (territorial, republican) center.
Medical obstetric and gynecological care
Medical obstetric and gynecological care at a rural medical site is carried out by a general practitioner - the chief physician of the rural district hospital (if there are two doctors in the local hospital - one of them). Under his direct supervision, a midwife works at the local hospital, who helps the doctor both in the hospital (takes part in the management of childbirth) and in the outpatient clinic (takes part in monitoring pregnant women, postpartum women and treating gynecological patients). The number of maternity beds in a rural district hospital usually does not exceed 3–5. To bring qualified medical care closer to rural residents, there is a gradual reduction in the number of maternity beds in rural district hospitals and an expansion of the number of beds in regional and central district hospitals. However, in a number of areas where, due to local conditions, it is not possible to provide the population with obstetric and gynecological care in district and central hospitals, rural district hospitals are being consolidated, and in accordance with this, the number of maternity beds is being expanded to eight, and the position of an obstetrician-gynecologist is provided.
Pregnant women and women in labor with a pathological course of pregnancy and childbirth and a burdened obstetric history should not be admitted to a local hospital (if there is no obstetrician-gynecologist on staff).
Despite the presence of a medical hospital on the periphery of the region - a rural district hospital, the bulk of obstetric and gynecological care in a rural medical district relates to pre-medical care, and is carried out by midwives from a medical and obstetric station and a collective farm (inter-collective farm) maternity hospital. The work of these institutions is carried out under the direct supervision of the chief physician of the rural district hospital. If there is an obstetrician-gynecologist on staff at the local hospital, the latter provides all medical and advisory assistance at the medical assistant station and in the collective farm maternity hospital.
FAP: work structure
Paramedic and midwifery stations (FAP) are provided for by the nomenclature medical institutions. A FAP is organized in a village with a population of 300 to 800 residents in cases where there is no rural local hospital or outpatient clinic within a radius of 4–5 km.
All work of the FAP is provided by a paramedic, midwife, and nurse. The number of service personnel is determined by the capacity of the FAP and the size of the population it serves.
The FAP provides the following positions:
1) paramedic – 1 position for a population of 900 to 1300 people; 1 position for a population of 1300 to 1800 people; 1.5 positions for a population of 1800 to 2400 people and 2 positions for a population of 2400 to 3000 people;
2) nurse – 0.5 positions for a population of up to 900 people and 1 position for a population of over 900 people.
Depending on local conditions, the FAP may provide only outpatient care or have maternity beds. In the latter case, the FAP, along with outpatient care, also provides inpatient care.
Due to the fact that the FAP provides medical care to the entire rural population, and not just women, the room in which it is located should consist of two halves: a paramedic and an obstetrician.
Obstetric part of the FAP
The obstetric part of the FAP should have the following set of premises: an entrance hall, a waiting room and a midwife's office. FAPs with maternity beds, in addition to these premises, must have an examination room, labor and delivery rooms and postpartum wards. The FAP midwife carries out all the work on organizing and providing obstetric and gynecological care to rural residents within the service radius of the point.
Responsibilities of a FAP midwife
The responsibilities of a FAP midwife include:
1) identifying all pregnant women in the service area as early as possible, ensuring dispensary observation of them, including carrying out the necessary treatment and preventive measures, patronage of pregnant women, postpartum women and children under the age of 1 year;
2) carrying out health education work among women;
3) provision of medical care during normal childbirth;
4) identifying gynecological patients, referring them to a doctor and providing them with medical care as prescribed by the doctor.
Household rounds of the population
Significant assistance in the early detection of pregnant women is provided by door-to-door visits conducted by the FAP midwife. When monitoring pregnant women, the midwife performs the bulk of the necessary research. So, at the first visit of a pregnant woman, the midwife collects a detailed history, general (heredity, previous diseases, etc.) and special obstetric (menstrual, sexual, generative, lactation functions, gynecological diseases, etc.).
From the medical history, the midwife finds out the peculiarities of the course of previous pregnancies, the presence of extragenital diseases and other abnormalities in the woman’s health that can affect the course of pregnancy and childbirth.
Examination of pregnant women
The midwife begins the examination of each pregnant woman with a study internal organs: cardiac activity, measuring blood pressure (on both arms), examining pulse, urine for protein (by boiling). The midwife currently studies the health status of pregnant women based on measuring height, body weight (over time), the presence of edema, pigmentation, the condition of the mammary glands and nipples, and the condition of the abdominals.
Carrying out a special obstetric examination, the midwife measures the external dimensions of the pelvis and, through a vaginal examination, determines the gestational age and internal dimensions of the pelvis. In the second half of pregnancy, measures the height of the uterine fundus above the womb, determines the position and presentation of the fetus, and listens to its heartbeat.
On general analysis blood, group affiliation, determination of the Rh factor, antibody titer, Wasserman reaction, general urine test, the pregnant woman is sent to the nearest laboratory. Here, a bacteriological study of the vaginal flora is carried out to determine the degree of purity, the discharge of the urethra, cervix and vagina for gonococcus, and the reaction of vaginal secretions. X-ray examinations in pregnant women (x-ray of organs chest, fetus, pelviography, etc.) are performed only if there are strict indications.
A thorough examination of pregnant women makes it possible to identify various pathological conditions, on the basis of which these pregnant women are identified as high-risk groups and require the closest attention to them during pregnancy; During childbirth and the postpartum period, high-risk groups are distinguished for cardiac pathology, bleeding in the postpartum and early afterbirth periods, inflammatory and septic complications after childbirth, endocrinopathies: diabetes mellitus, obesity, adrenal insufficiency and other types of obstetric and somatic pathologies.
All individual cards Pregnant women at risk are usually marked with appropriate color markings, indicating in a certain color the risk of a particular pathology (red for bleeding, blue for toxicosis, green for sepsis, etc.).
Scope of research on gynecological patients
The scope of research in gynecological patients also includes the collection of general and special gynecological history. The study of women's health is currently carried out on the basis of a general clinical examination, similar to the examination of pregnant women. A special gynecological examination includes two-manual and instrumental (examination in mirrors) examination. A bacterioscopic examination of the discharge of the urethra, cervix and vagina for gonococcus is carried out using provocation methods, according to indications - the Bordet-Giangu reaction; examination of a vaginal smear for cell atypia; research on functional diagnostic tests.
If a woman needs a biochemical blood test for cholesterol, bilirubin, sugar, residual nitrogen and a urine test for acetone, urobilin, bile pigments, she is sent to the nearest multidisciplinary laboratory. Women and couples who have a history of hereditary diseases or children with deformities of the central nervous system, Down's disease, or defects of the cardiovascular system are sent for examination, including to determine sex chromatin, to specialized medical genetic centers. When monitoring pregnant women, the FAP midwife is obliged to show each of them to the doctor. If a woman’s pregnancy is progressing normally, then she will meet with a doctor at her first scheduled visit to the FAP. All pregnant women who exhibit the slightest deviation from the normal development of pregnancy should be immediately referred to a doctor.
At each subsequent visit to the FAP, the pregnant woman undergoes the necessary repeated examinations. In the second half of pregnancy, you need to especially carefully monitor the possible development of late toxicosis, for which you need to pay attention to the presence of edema, blood pressure dynamics and the presence of protein in the urine. It is very important to monitor the dynamics of a pregnant woman’s weight.
Organization of patronage work
A mandatory part of a midwife’s work in monitoring pregnant women should be conducting classes on psychoprophylactic preparation for childbirth.
In organizing monitoring of pregnant women in rural areas, as well as in the city, patronage work is very responsible. Patronage of pregnant and gynecological patients is an element of the active dispensary method. The goals of patronage are very diverse, so each patronage visit to a woman has a specific goal. First of all, this is an acquaintance with the living conditions of women. Knowing the peculiarities of the life of each family (housing conditions, family composition, level of material security, degree of culture, including health literacy, etc.), it is easier for the midwife to monitor the health status of the population. The purpose of patronage is the need to find out the health status of a pregnant woman who did not show up for an appointment at the appointed time. In this case, the midwife, in a conversation with the pregnant woman, finds out the general condition of the woman, performs a thorough examination, pays attention to the presence of edema, and measures blood pressure. During long periods of pregnancy, she measures the circumference of the abdomen and the height of the uterine fundus, and determines the position of the fetus. Having made sure that there are no deviations from the normal development of pregnancy, the midwife sets a date for the woman to appear for the next examination. If there is the slightest sign of pregnancy complications, the midwife invites the pregnant woman to see a doctor or informs the doctor about this, who decides whether the pregnant woman can be treated at home or whether she needs to be hospitalized. In the latter case, the midwife monitors the timeliness of the woman’s admission to the hospital and continues active monitoring after she is discharged home. The reason for patronage may be the desire to make sure that the woman is following the doctor’s orders correctly, or the need to conduct additional tests (laboratory tests, measure blood pressure, etc.).
The FAP midwife is obliged to provide patronage to children, especially the first 3 years of life. In this case, it is necessary to observe the frequency of observations of children of the 1st year of life by the midwife (paramedic) of the FAP: 1st month of life - observation only at home - 5 times; 2nd month of life – observation at home – 3 times; 3-5 months of life – observation at home – 2 times a month; 6-12th months of life - observation at home - 1 time per month. In addition, a child under 1 year of age must be examined by a pediatrician at the FAP at least once a month.
Thus, the midwife sees the child during the 1st year of life 12 times during preventive examinations by a doctor and 20 times during home visiting.
The midwife's patronage work is strictly planned. The plan provides for days of visiting villages and hamlets. A special notebook keeps records of patronage work and records all visits to women and children. The midwife enters all advice and recommendations into the home visiting nurse’s work notebook (patronage sheet) for subsequent verification of their implementation.
Mobile teams from the Central District Hospital
The majority of women from rural areas give birth in the obstetric departments of the Central District Hospital. If necessary, inpatient qualified medical care is provided to rural women in large republican, regional, and regional maternity hospitals.
To bring medical outpatient care closer to residents of rural areas, visiting teams from the Central District Hospital are created, which arrive at medical and obstetric centers according to the approved schedule.
The visiting team includes an obstetrician-gynecologist, a pediatrician, a therapist, a dentist, a laboratory assistant, a midwife, and a children's nurse. The composition of the visiting team of doctors and paramedical workers is brought to the attention of the heads of medical and obstetric centers.
Carrying out preventive periodic examinations
The paramedic and midwife are required to have in their area a list of women subject to preventive and periodic examinations.
Practically healthy women with a good obstetric history and a normal course of pregnancy during the period between team visits are observed by a midwife at a FAP or local hospital, and are sent to the nearest local or regional hospital for childbirth.
With a group of women for whom pregnancy is contraindicated, the obstetrician-gynecologist and midwife talk about the dangers of pregnancy to their health, possible complications of pregnancy and childbirth, teach them how to use contraceptives, and recommend intrauterine contraceptives. When visiting the team again, the obstetrician-gynecologist checks the obstetrician-gynecologist's compliance with the prescriptions and recommendations. Significant assistance in the early detection of pregnant women is provided by door-to-door visits conducted by a midwife. All identified pregnant women, starting from the earliest stages of pregnancy (up to 12 weeks), and postpartum women are subject to medical examination.
In the normal course of pregnancy, a healthy woman is recommended to attend a consultation with all tests and doctor’s opinions 7-10 days after the first visit, and then visit the doctor in the first half of pregnancy once a month, after 20 weeks of pregnancy - 2 times a month, after 32 weeks – 3–4 times a month. During pregnancy, a woman should attend a consultation approximately 14–15 times. If a woman is ill or has a pathological course of pregnancy that does not require hospitalization, the frequency of examinations is determined by the doctor on an individual basis. It is important that pregnant women carefully attend consultations during antenatal leave.
Hospitalization of pregnant women in medical hospitals
Very important in the work of a FAP midwife is the timely hospitalization of pregnant women in medical hospitals when initial signs of deviation from the normal course of pregnancy appear, as well as women with a burdened obstetric history. Pregnant women with a narrow pelvis (with an external conjugate of less than 19 cm), abnormal fetal position and breech presentation, immunological incompatibility of the blood of mother and fetus (including a history), extragenital diseases, and the appearance of bloody discharge from the genital tract are subject to prenatal hospitalization in medical hospitals. , edema, the presence of protein in the urine, increased blood pressure, excessive weight gain, when a multiple pregnancy is established, as well as other diseases and complications that threaten the health of a woman or child.
When sending a pregnant woman to an obstetric hospital, it is very important to choose the right method of transportation (ambulance transport, air ambulance, passing transport), as well as to correctly decide the issue of the institution where this pregnant woman should be hospitalized. A correct assessment of the health status of a pregnant woman will allow you to avoid multi-stage hospitalization, and immediately assign the patient to the obstetric hospital where there are all the conditions for providing her with full medical care.
Conducting childbirth at a FAP At the paramedic-midwife station, only normal (uncomplicated) births are provided. In cases where one or another complication occurs during childbirth (which cannot always be foreseen), the FAP midwife should immediately call a doctor or (if possible) take the woman in labor to a medical hospital. In this case, it is very important to resolve the issue of means of transportation. It must be remembered that women with unseparated placenta, preeclampsia and eclampsia, as well as with threatening uterine rupture cannot be transported. If a woman with an unseparated placenta needs to be transported due to certain complications of pregnancy, the FAP midwife is obliged first of all to manually separate the placenta and transport the woman with a contracted uterus. If it is impossible to provide the woman with the necessary assistance to such an extent that she is in a state of transportability, a doctor should be called to her and a plan of further action should be outlined with him. When providing emergency pre-medical care to a pregnant and laboring woman, a FAP midwife has the right to perform the following obstetric operations and aids: turning the fetus onto its leg when the uterine pharynx is fully open and the waters are intact or have just broken, removing the fetus by the pelvic end, manual separation of the placenta, manual examination of the uterine cavity , restoration of the integrity of the perineum (after a rupture of the perineum or perineotomy). If there is bleeding in the early postpartum period, the midwife must exclude rupture of the birth canal tissue. Complications that arise during childbirth require the midwife, in addition to urgently calling a doctor, to take clear organizational actions, on which the outcome of the birth largely depends. The midwife must be fully proficient in the primary methods of resuscitation of newborns born with asphyxia.
Maintaining documentation for the FAP
It is very important in the work of a FAP midwife to carefully maintain documentation. For each pregnant woman who contacts the FAP, an “Individual Pregnant Woman Card” is filled out. If obstetric complications or extragenital diseases are detected, a duplicate of this card is filled out and sent to the district obstetrician-gynecologist.
There are many options for storing individual cards. One of the most convenient options for work, which can be recommended, is as follows: a box for storing individual cards (the width and height of the box must correspond to the size of the card) is divided by transverse partitions into 33 cells. Each partition is marked with a number from 1 to 31. These numbers correspond to the dates of the month. When scheduling a pregnant woman's next appointment, the midwife places her card in a box marked with the corresponding date of the month, i.e., the day on which she needs to attend. Before starting work, the midwife takes out all the individual cards from the box corresponding to the day of the appointment and prepares them for the appointment: they will check the accuracy of the records, the presence of the latest tests, etc. When finishing the appointment with the pregnant woman, she assigns her a day of subsequent appearance and places the card of this pregnant woman in the box with a mark, corresponding to the day of the month for which she is scheduled to appear. At the end of the appointment, it is easy to judge by the number of remaining cards about pregnant women who did not show up for the appointment on the day assigned to them. The midwife places these cards in the 32nd cell of the box marked “Patronage”. Then the midwife visits at home (patronizes) all women who do not show up for appointments. All cards of those who have given birth and are subject to dispensary observation until the end of the postpartum period are placed in the 33rd cell marked “Postpartum women”.
In addition to these documents, the FAP keeps a diary-notebook for recording pregnant women (f-075/u) and a diary (f-039-1/u). When a pregnant woman (after 28 weeks of pregnancy) or a postpartum woman is sent to an obstetric hospital, she is given an “Exchange Card”. If a pregnant woman is hospitalized before 28 weeks, she is given an extract from the medical history. When leaving the hospital, she receives an extract from the medical history using the same form, which is given to her by the midwife of the FAP.
Organization and conduct of preventive examinations of rural women
An important section in the work of a midwife at a medical and obstetric station is the organization and conduct of preventive examinations of women. It is advisable to carry out preventive examinations of rural residents in the autumn-winter period in order to complete the recovery of identified patients before the start of spring field work.
All work on organizing preventive examinations is led by the district obstetrician-gynecologist and the chief midwife of the district. An inspection plan is drawn up in advance, which indicates the place where the inspection will be carried out and the calendar dates for inspections for each locality. Preventive examinations are carried out by FAP midwives who have undergone special training and instruction. To successfully conduct a preventive examination, the midwife must first make a door-to-door visit, the task of which is to explain to women the purpose of the examination, the method of conducting it, the place of examination, etc.
The purpose of preventive examinations is the early detection of pre-tumor, tumor, inflammatory and so-called functional diseases of the genital organs in women and the prescription of appropriate treatment if necessary. Preventive examinations also make it possible to identify among the organized part of the female population occupational hazards that affect the genital organs, and to develop measures to eliminate them.
Direct examination of women consists of two sequential procedures:
1) examination of the external genitalia, vagina and vaginal part of the cervix (using mirrors);
2) two-handed studies to determine the condition of the internal genital organs.
During preventive examinations, objective diagnostic methods are used: cytological examination of vaginal discharge, “prints” from the cervix, colposcopic examination.
To carry out laboratory research, material is taken from various parts of the woman’s genitourinary system:
1) smears from the urethra and cervical canal for bacteriological examination of Neisser gonococci and flora. The material obtained from the urethra is applied to a glass slide in the form of a circle, and from the cervical canal - in the form of a streak in the longitudinal direction;
2) a smear from the posterior vaginal fornix to determine the degree of purity of the vaginal contents is taken after insertion of the speculum;
3) a smear from the side wall of the vagina for hormonal cytodiagnosis is also taken after insertion of the speculum.
At the slightest suspicion of the presence of a disease, which arises from a midwife performing a preventive examination, the woman should be immediately referred to a doctor.
In carrying out preventive examinations, it is very important to carefully register and record all women examined, for which a list of persons subject to a targeted medical examination is compiled. To register and account for women subject to active dispensary observation, dispensary observation control cards are created for them.
Another institution providing pre-hospital obstetric and gynecological care in rural areas is the collective farm maternity hospital. The following premises must be provided in a collective farm maternity hospital: a vestibule, a reception room, a labor room (10–12 m2), a postpartum ward (6 m2 for 1 mother and child bed), a kitchen, and a toilet. Each collective farm maternity hospital has from 2 to 5 beds (at the rate of 1 bed per 1000 population).
The collective farm maternity hospital is located at a distance of 6–8 km from the rural medical site to which it is attached. Under good transport conditions, this distance can be increased to 10–15 km. Collective farm maternity hospitals are served by a midwife, whose responsibilities are similar to those of a midwife at a FAP. If in one village near the FAP there is a collective farm maternity hospital and due to the volume of its work there is no need for an independent staff, the service of the latter is entrusted to the midwife of the FAP.
Issues of labor protection in the work of obstetrics and gynecology services In the work of obstetric and gynecological services in rural areas at all stages, a lot of space is occupied by the issues of labor protection of female agricultural workers. Agricultural work has its own characteristics, the main ones being seasonality, performing various production operations in a short time under any weather conditions, etc. This requires significant effort and stress from a person, which inevitably leads to violations of the work and rest regime. Female workers in agricultural production experience additional adverse effects of such production factors as noise, vibration, dust, contact with pesticides (pesticides) and mineral fertilizers. The main work on implementing measures aimed at protecting the labor of rural residents is carried out by hygienists. But the obstetrics and gynecology service should also take part in this work, since unfavorable production factors also have a negative impact on the specific functions of the female body.
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From the author's bookCharacteristics of the paramedic-midwife station
The paramedic and midwife station is an outpatient clinic in rural areas. The management of the medical and sanitary activities of the FAP is carried out by health authorities.
The FAP carries out treatment and preventive, sanitary and epidemiological work and sanitary and hygienic education of the population; has its own estimate, round seal and stamp indicating its name; draws up plans, a report with an explanatory note for morbidity analysis; maintains accounting and reporting documentation. A paramedic (paramedic-midwife) with completed secondary medical education is appointed to the position of head of a paramedic-midwife station. At a paramedic-midwife station located in a village (where there is no pharmacy), a pharmacy point (or kiosk) is organized to sell ready-made medicines and patient care items to the population.
Job responsibilities of the head of the FAP
Job responsibilities of the head of the FAP (paramedic). The head of the FAP (paramedic) leads the work on organizing and planning medical and preventive care at the site; is responsible for providing timely medical (pre-hospital) care for various acute diseases and accidents.
The paramedic is obliged:
1) know the features of organizing emergency care in case of mass accidents, poisoning with chemicals and drugs;
2) know the basics of pre-hospital resuscitation; perform closed cardiac massage and artificial ventilation;
3) provide outpatient care and care for patients at home;
4) promptly refer patients for consultation to the nearest medical institution (central district hospital);
5) if necessary, accompany the patient personally.
The paramedic organizes the appointment of patients by local doctors and other specialists at the FAP according to a schedule approved by the chief physician. By the day of the appointment, the paramedic prepares patients and primary documentation. The doctor sees patients together with the paramedic. The personal participation of a paramedic in the consultation of patients contributes to the timely treatment of patients, their employment and the improvement of the paramedic’s qualifications.
The paramedic takes an active part in the medical examination of the population of his area, draws up cards for patients who are subject to clinical observation. A paramedic, under the guidance of a doctor, periodically organizes medical examinations of the population with unfavorable working conditions. Patients with tuberculosis, hypertension, coronary heart disease, peptic ulcer of the stomach and duodenum, diabetes, glaucoma, thrombophlebitis, obliterating endarteritis, etc. are subject to dispensary observation and observation. Disabled people and veterans of the Great Patriotic War, liquidators of the consequences of the accident are subject to dispensary registration and observation. Chernobyl nuclear power plant. To properly organize the work of the FAP, a plan of treatment and preventive measures for the current year is drawn up. The plan specifically indicates the planned activities, deadlines, and responsible person. The pre-developed plan is approved by the chief physician. All planned activities are carried out on time.
The paramedic carries out medical control over the development and health of children in nurseries, kindergartens, orphanages, schools located in the territory of the FAP operation and which do not have appropriate paramedical workers on their staff; carries out sanitary-anti-epidemic and sanitary-educational work according to the approved plan.
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