• 
  Hufsa Ali
  

The concept of death is one that has been shrouded with mystery and wonder for as long as humans have lived and died. The understanding and implications of death have varied greatly across eras and cultures. Historically, there has been little consistency in the understanding of the concept of the event of death, the moment at which one is dead. The Oxford English Dictionary defines death as “the end of life; the permanent cessation of the vital functions of a person […] or


organism

[2]
.” This definition, while precisely written, leaves considerable ambiguity about the diction of the definition itself. It is uncertain what is meant by “life” and “vital functions” of a person or organism. Further, one may question whether the vital functions of humans as persons differ from those of humans as organisms. Is death a process rather than an event? If so, when does it begin and end, and when is it appropriate to declare death? Is it possible that a human may experience two deaths, death of the person and death of the organism? If so, which death is relevant to medicine? In this paper, I will review the evolution of the definition of death in the Western world in the context of advancing medicine, and explore the implications in relation to organ donation.

The philosophical examination of human death has concentrated two underlying questions:


what is human death, and how can we determine that death has occurred?

[3]
The first question addresses the concept or definition of death, while the second concerns developing the corresponding standards: criteria and clinical protocol to be used to declare death. Examples of the answer to the first question include

death as the functions of an organism

or

human death as the irreversible loss of personhood

(Stanford Encyclopedia of Philosophy,


2011

[4]
). Examples of answers to the second questions include the cardiopulmonary standard, the whole-brain standard, and the cerebral standard. It was not until the last century that seeking answers to these questions became the source of a painstakingly complex on-going debate about death, personhood and medicine.

Prior to the advent of the stethoscope in the 19th century, cessation of breathing marked the occurrence of death


(Daroff)

[5]
. Then, the loss of pulse became the characterizing event (Jennett, 2001). The Fourth Edition of Black’s Law Dictionary was published in 1951, reidentifying the occurrence of death as the “cessation of life, defined by physicians as a total stoppage of heart of the circulation of the blo


od…”

[6]

[7]
in the United States. The definition of death (particularly the distinction between death of the body and death of the person) was not relevant because the death of the brain and the rest of the body tissues occurred concurrently. Cardiopulmonary failure inevitably led to irreversible loss of all brain functions, and the irreversible loss of all brain functions quickly led to cardiopulmonary arrest.

The issue of distinguishing between cardiopulmonary failure and brain function failure was not clinically relevant until the invention and widespread use of mechanical resuscitation and ventilation


devices

[8]
. A stopped heart could now be restarted and blood could be oxygenated without functioning intercostal and pleural muscles, after the tissues of the brain had began ischemic necrosis


^[1]

. Although they were still occurring, the functions of circulation and respiration were being performed by mechanical respirators and defibrillators. While this did not meet the criteria for death as defined in 1951, it is important to note that such patients would have met the criteria for death as soon as the use of life-support machines was discontinued. Essentially, this meant that either death could be reversed, or that death could be delayed well beyond the failure of vital organs. This also meant that a body with irreversible loss of brain functions could be indefinitely kept “alive.” This highlighted the distinction between neurological failure, and circulatory and respiratory failure.

During the 1950’s, several physicians around the world began to recognize the futility of continuing treatment for patients who had lost all neurological functions. In 1954, a neurologist practicing in Massachusetts, Dr. Robert Schwab, noted this while examining a comatose brain hemorrhage patient who was on a respirator. “The question was, ‘Is this patient alive or dead?’ Without reflexes, without breathing and with total absence of evidence of an electroencephalogram, we considered the patient was dead in spite of the presence of an active heart maintaining circulation. The respirator was therefore turned off and the patient pronounced dead.” In 1959, four French neurologists came to the same conclusion. However, they some of them preferred the term

coma dépassé

, meaning “beyond coma”


(Mollaret, 1959)

[9]
. This was the prognosis of certain death, they argued, but not did not meet the criteria for death itself. Schwab disagreed, stating that death of the the death of the nervous system would be death of the patient. In 1963, he proposed criteria to consider certain patients dead in spite of continuing cardiac function: loss of reflexes, a flat EEG, and


apnea

[10]


^[2]

. Over the next five years, he reported having treated 90 such patients. None of them survived and autopsies showed that every one of them had pervasive tissue necrosis in their brains. His findings went on to greatly influence the legal and medical redefining of death.

Meanwhile, there were developing concerns about the futility of extensive, expensive medical care for patients whose deaths were imminent and inevitable. In 1957, Pope Pius XII proclaimed that physicians were not obliged to give “extraordinary” treatment in such


cases

[11]
. In 1962, psychiatrist Frank Ayd published a paper in which he contended that there was a moral obligation to withdraw care when death was inevitable.


In 1965, THe American Medical Association held it’s First National Congress on Medical Ethics and Professionalism to detail guidelines for end-of-life-care.

[12]

As the initiation of the transition from heart to brain criteria for death, the field of organ transplantation was developing. The first successful kidney transplant was performed between live twins in 1954 by Dr. Joseph Murray. Eight years later, Dr. Murray performed a kidney transplant from a cadaver donor. In the years following, liver, lung and heart transplants were performed, using organs from cadavers. Most of the recipients died soon after the surgery. There was the idea that “live donors” would improve the chances of survival, but physicians were weary about using vital organs from patients that were “alive” by cardiopulmonary criteria, even if they had lost total brain function. The ethical standard regarding organ retrieval is the Dead Donor Rule (DDR), which prohibits organ vital procurement from donors that have not yet been declared death. This limits possible sources of organs to cadavers that still have salvageable tissues and organs. As medical technology prevented more and more “deaths” through advancements in life-support technology, it also accelerated the demand for organs of dead donors, as the capacity to perform successful transplants increased. This growing concern for organ transplantation sources, coupled with the futility of having “hopeless” patients on artificial ventilation and resuscitation created a climate that facilitated the major change that occurred at the end of the 1960s.

In 1968, an Ad Hoc committee was formed at Harvard University to address the “ethical problems created by the hopelessly unconscious


patient

[13]
.” The committee developed criteria similar to the concept of “coma dépassé.” Patients who met the criteria


^[3]

would be considered essentially dead, but not actually dead. The final report was titled “A Definition of Irreversible Coma: Definition of Brain Death.” While this report didn’t explicitly realign the definition of death to brain-based criteria, it outlined appropriate standard of care for comatose patients whose deaths were inevitable and imminent. It was never said outright, but they implied that the death of the brain is the death of the patient, and hinted that the cardiopulmonary criteria for death were


obsolete

[14]
.

On the same day as the publication of the Harvard report, the 22nd World Medical Association (WMA) met and announced the Declaration of Sydney. The declaration distinguished the gradual process of the death of cells and tissues from the death of the patient. “Clinical interest lies not in the state of preservation of isolated cells but in the fate of a person […] the point of death of the different cells and organs is not so important as the certainty that the process has become irreversible.” While it has been overshadowed in the United States by the Harvard report, the WMA’s declaration was the first major committee distinguishment between the death of the body and the death of the person.

Throughout the 1970’s, widespread acceptance of the implied Harvard definition grew among the medical community. State legislatures and courts began legally recognizing some form of death based on brain-criterion, although there was little consistency among the criteria across jurisdictions. In 1971, Mohandas and Chou (neurologist and psychiatrist, respectively) published their “Minnesota Criteria,” based on autopsy discoveries that identified the destruction of the brain stem as the cause of brain death. Thus, the requirement for the EEG was eliminated


^[4]

. Because both respiratory control and consciousness


originated

[15]
in the brain stem, the loss of brainstem function equaled death of both persons and organisms. In the UK, the criteria for brain death was tweaked to exclude the EEG requirement, which meant a patient with detectable cortical activity would be dead in the UK and alive in most of the US.

The President’s Commision for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research was formulated in 1979 to clarify brain death and other biomedical ethics issues. The committee published a report in 1981 that provided a clearer and more practical definition of death than the previous, conceptually ambiguous ones that had been used before. The commission reasoned that death occurred when the “body’s physiological system ceases to constitute an integrated


whole

[16]
.” Because the brain functions as the “great integrator and regulator,” the death of the organism occurs when the total brain functions are lost, and the organism disintegrates to a collection of it’s parts. As a result, the Uniform Determination of Death Act (UDDA) gave both brain-based and circulatory-respiratory-based criteria a “separate but equal” status in the eyes of law and clinical care. In the United States, death could now be determined by the “irreversible cessation of circulatory and respiratory functions” or “irreversible cessation of all functions of the entire brain.” While the UDDA recognized the whole brain standard as a means to determine death, it did not specify the neurological test criteria to be used. It also did not specify the amount of elapsed time required before stopped circulation can be considered irreversible. Different hospitals, providers, and associations used varying sets of tests to determine death.

In 1995, the American Academy of Neurology (AAN) attempted to standardize the clinical protocol used to determine death using brain criteria. Tests to be performed were similar to the Harvard report criteria, without the EEG requirement and the 24-hour repeat was left unaddressed. While the UDDA and AAN’s guidelines have brought consistency to the clinical process of determining death, there has been widespread disagreement about the criteria of death itself.

The traditional criteria for determining death, the cessation of heartbeat and breathing, have been updated by the UDDA. The circulatory-respiratory standard holds death as the

irreversible

cessation of circulatory-respiratory function. Leaving aside the implications of word “irreversible,” this definition may still not be entirely accurate nor practical. Rather than changing the reality of the nature of death, life-support devices and other technologies of modern medicine have shined a light on an aspect of the process of death that was not visible before. Before the possibility of mechanically and artificially continuing respiration and circulation, the failure of these processes were associated with the occurrence of death. However, after such “death” could be reversed and put off indefinitely, it became apparent that the onset of cardiopulmonary failure was not the moment of death, but simply indicative of death. As Bernat, Culver and Gert argue, heartbeat and regular breathing usually indicate life, but they do not constitute life


(Bernat, Culver, and Gert 1981)

[17]
. “Life involves the integrated functioning of the whole organism.” Brain-based criteria better suited this understanding of life because the brain is responsible for much regulation of the entire organism. Thus, including brain-based criteria to declare death is seen as an “update” to the previous understanding of death, not a complete overhaul of it.

The transition to brain-based criteria is nowhere near free of criticism. For some, one of the most obvious flaws in the logic behind the brain-based criteria for death was its basis on the idea that the brain is the sole organ responsible for integration of the organism as a whole. If death is defined as the irreversible loss of functioning of the organism as a whole, then only after the complete cessation of all whole-body integrating functions may a patient be considered dead. While the brain plays the biggest role in integrating interdependent functions of the body, somatic integration is a holistic phenomenon that involves organs and tissue systems throughout the body. Immune responses, regulation of blood glucose levels, and hematopoiesis are regulatory functions that can continue to occur without the entire brain


(Shewomn, 2001)

[18]
. Therefore, if the definition of death is understood to be the end of the existence of the organism as an integrative whole, then the death of the whole brain does not necessarily mean the biological organism has died.

Brain-based criteria may have been a step in the right direction, but perhaps for the wrong reasons. The significance and necessity of the brain may lie in another aspect of it’s function; one that cannot be attributed to any other part of the body: personhood. The brain is the origin of human thought, reasoning, consciousness, emotion, and self-awareness. If the entire brain is dead, than the human person is dead, even if the human organism continues to live.

Another problem with the development of brain-based criteria is again unrelated to the concept itself, but how it came about as standard of care. The ethically dangerous notion that the climate of evolving medical innovation, particularly organ transplantation, had influenced and driven the acceptance of whole-brain death is a very concerning one. When the Harvard committee met to discuss brain death in 1968, they seemed to be concerned about two things: the futility of spending resources on patients with no chance of recovery, and the idea of wasting the organs of these patient’s bodies. Their main focus of concern seemed to not be the well-being of the patients at hand, but protecting the physicians who would withdraw care from patients that would previously have been considered alive. Without the redefinition of death, doctors would have been morally responsible for the death of such patients.

Officially, the reason the Harvard committee cited for their efforts was to free up resources spent in vain on untreatable patients. Murray, who was on the committee specified that the primary concern was the dying patient, and that organ transplantation was “distinct and unrelated,


” ()

[19]
However, many have been skeptical of this separation, arguing that the motive for changing the definition of death had everything to do with organ transplantation. Neurosurgeon Richard Nilges, calls attention to the fact that respiratory and other life-support technologies had been in use for nearly two decades before the hasty formulation of the Harvard committee, and no one had so loudly expressed the urge to end such care. Instead, he points out, that the Harvard committee met less than a year after the first successful heart transplant surgery.


^[5]

Based on the heart-lung criteria of death at the time, the act of removing the heart from a “live” patient on life support would have been the cause of death of that patient. Nilges suggests that a second, underlying reason for changing the criterion of death was the underlying motivation behind the Harvard report: providing organs for transplantation. This situation was an ideal one for organ transplant advocates, because it was an “opportunity to tailor the definition of death to fit the moral acceptability of transplanting living hearts. Taking a beating heart from a body is not equivalent to taking innocent human life if ‘brain dead’ individuals are ‘defined’ as already dead.” Interestingly, Nilges is not against the idea of using brain-based criteria for death in organ donors. Rather, he disagrees with the way this criteria is practiced. His experience working with such patients and organ transplant teams has left him with disdain towards the practice of organ transplantation. In his paper titled “Organ Transplantation, Brain Death, and the Slipper Slope: A Neurosurgeon’s Perspective,” Nigles proposes a causal relationship between the changes in the understanding and practice of death declaration to the desires of the insatiable transplant advocates. He recalls trying protect his dying patients from transplant teams, who he compares to hungry vultures eyeing a small, dying animal. He criticizes the unofficial leeway allowed when diagnosing whole brain death, pointing out that over 20% of patients declared dead on brain-based criteria actually had brain activity detectable by an EEG.

Save for the finale: [HANS JONAS: uncertainty about border b/w life,


death

[20]
]

^[1]

Necrosis, death of tissue, can be caused by ischemia, insufficient blood supply to those tissues. Brain tissue is among the body’s most sensitive to ischemic hypoxia, and is the earliest to die. It is possible for the rest of the body to regain function after a period of time without oxygen, but the brain to have lost it permanently.

^[2]

Schwab’s criteria were: loss of reflexes (dilated and fixed pupils, no elicitable reflexes, and no independent movements), a flat EEG (electroencephalogram detecting no electrical activity in the brain), and apnea (inability to spontaneously breath).

^[3]

Harvard report criteria included the following: (1)

deep coma

, no withdrawal from painful stimuli, (2) cranial and spinal

arreflexia

, (3)

apnea

, persistent after disconnected from ventilator for 3 minutes, (4)

flat EEG

, no detectable electrical brain activity, (5)

exclusion of hypothermia or drugs

, which may sometimes cause false-negatives in the above tests, and (6) evaluation

repeated

twice, 24-hours apart.

^[4]

The brainstem is the pathway through which the brain (cerebrum and cerebellum) sends and receives signals to and from the rest of the body. If the brain stem is dead and all brainstem functions are lost, then the communication between the brain and spinal cord is severed. A body of a patient with a dead brain stem is functionally equivalent to that of a patient with whole brain death. Thus, any electrical activity in the cerebrum is not going to affect the outcome of tests of the rest of Harvard criteria.

^[5]

The first successful heart transplantation was performed in December of 1967. The committee developed their criteria in August of 1968, a mere eight months after the heart transplant.

[1]
Write later

[2]
Cite oxford english dictionary

[3]
either cite Stanford Encyclopedia of Philosophy. Definition of Death

[4]
Written 2007, revised 2011. Review?

[5]
Fix citation

[6]
Cite this

[7]
Black Law’s Dictionary, 1951. 4e

[8]
cite source: either de goergia, stanford, or daroff

[9]
#8, De Geogia

[10]
cite swchab, from de georgia, pg 674

[11]
Citation needed

[12]
another someone talks about this conference, but says something more relevant.

[13]
cite: beecher. (From De Georgia, 674. bottom left.

[14]
cite this

[15]
use a different word. Plagiarism

[16]
cite this: de georgia, #48, 49. pg 676

[17]
cite. (stanford encyclopedia, 1. mainstream view)

[18]

http://www.ncbi.nlm.nih.gov/pubmed/11588655

[19]
Murray, letter to Beecher, calling for committee formulation/meeting. De Georgia # 26, pg 675

[20]
#40 De goergia, pg 676

Sepsis is defined by the clinical signs and symptoms of a systemic immune response to infection. (1-2) Currently, sepsis on a worldwide level creates a significant level of mortality; and results in approximately one third of all Intensive Care admissions. (3-5) In Victoria alone there are approximately 8500 admissions to Emergency Departments with patients suffering from sepsis (3) and this number is increasing.

Sepsis treatment can be initiated with a broad spectrum antibiotic, and then transferred onto a specific antibiotic regimen. Currently the level of pre hospital data available on the management of sepsis is very limited and the most advanced model has been initiated in the United Kingdom; including a pre hospital screening tool and then the hospital management known as the ‘Sepsis six’. (6) Pre hospital management can be utilised to the full potential of paramedics training and knowledge with the administration of pre hospital antibiotics; however this is not without risk.

Perhaps the resistance to hand over the authority to paramedics in the United States is the notion of creating a super bug; similar to Methicillin-resistant Staphylococcus aures. This paper proposes that the administration of antibiotics in the pre hospital field does carry some risk, but the research suggest that the benefits clearly outweigh these risks. A new pre hospital guideline must be created due to the sheer number of Emergency Department admissions. The potential to make a significant difference to a patient’s outcome is imperative.

Epidemiology

It has been highly researched and reported across the world that sepsis is a major cause of morbidity, mortality and places an enormous financial burden on the respective health system. (21, 5, 7) Statistics from Australia, United States and the United Kingdom are similar in nature and provide a wealth of information regarding the epidemiology of sepsis. Sepsis in the United States has been recognised as a public health issue, (8) with studies reporting that there are 300 reported cases per 100,000 with approximately 40% mortality. (5, 7-9) Severe sepsis in the United kingdom accounts for 27% of Intensive Care Unit admissions (4) and this is comparable with 23.8% of Intensive Care admissions in Victoria, Australia. (3) However it may be noted that this data is not very recent and that in the time of study the incidence was increasing by approximately 9% per year; whilst also reporting a decrease in the number of deaths associated with sepsis from approximately 45% to 37.7%. (5, 7, 9) Whilst many studies report the number of admissions, few report the age distribution of patients presenting with sepsis. Sundararajan et. al. highlight that the age distribution within their study was bimodal which identified that the age brackets at the extremes of the spectrum were overrepresented; with children less than 1 and adults in the 70-79 age bracket. (3) Upon further investigation into the types of causative pathology causing sepsis in these patients; gram-positive organisms account for 28%, gram-negative for 20%, fungal infections 2%, and other organisms for 49%. (3) These figures are comparable with a study conducted by MacArthur et. al. of approximately 2634 patients with approximately 30% identified as gram-positive and 26% gram-negative bacteria. (10)

Pathophysiology and clinical features

What is Sepsis?

Sepsis is an infection induced syndrome and the clinical appearance in nature is the consequences of cellular interactions between the host and invading pathogen. (21, 11-12) Sepsis may be initialised by prolonged local inflammation to eliminate and clear the invading pathogen. The second line of defence against invading pathogens involves the production and activation of leukocytes at the local site of infection. (13-14) Throughout this phase, immune cells identify the pathogen through pattern recognition protein receptors on the cells. (15) An example of one of these receptors are toll like receptors and these are among the recognition receptors which have the ability to activate immune cells, inducing the production of pro-inflammatory cytokines and chemokines by the stimulation with bacteria and viral proteins (depending on the infection). (15-16) The invading pathogen may initiate the complement pathway of the immune system, allowing leukocytes to phagocytose [digest] the pathogen. If the host fails to limit the invading pathogen to a local area, the pathogen may invade the bloodstream. (16) If phagocytosis continues in the blood stream, toxic substances released by the pathogen may leak directly into the bloodstream; these include endotoxins released by gram negative bacteria (17) and lipoteichoic acid and peptidoglycan released by gram positive bacteria. (18) These by-products of phagocytosis and death of the cell may trigger a systemic activation of the complement system and stimulate the production of inflammatory cytokines. (19) Subsequently leading to an increased excessive and prolonged inflammatory response. (20) The result of this prolonged response leads to Systemic Inflammatory Response Syndrome (SIRS) which is the result of either direct or indirectly through the production and activation of nitrous oxide, oxidants and proteolytic enzymes which is known to have the potential to lead to inflammation induced organ injury. An example of this would be Acute Respiratory Distress Syndrome. (16, 20) SIRS is characterised by two or more of the following: body temperature >38°C or <36°C, heart rate >90 beats per minute, respiratory rate >20 per minute or arterial CO2 >32mmhg or a need for artificial ventilation, and white blood count greater than 12,000/mm3 or <4000mm3 or >10% immature forms. (21) SIRS can be also initiated not only by infection, it may also develop as a result of trauma, ischemic injury or sterile inflammation. (22)

What is severe sepsis?

If SIRS is left untreated, this response then cascades into what is known as severe sepsis. Severe sepsis is defined as ‘sepsis associated with organ dysfunction, hypoperfusion or hypotension responsive to fluid resuscitation’. (23) This can progress to septic shock, which involves ‘persistent hypotension unresponsive to fluid administration’. (23) An example of severe sepsis is called Multiple Organ Dysfunction Syndrome (MODS). This occurs when the infection of the bloodstream leads to progressive failure of two or more organ systems which result from a prolonged and uncontrolled inflammatory response. This organ dysfunction can lead to potential organ failure and death. (19)

Analyse evidence relating to the prehospital management of sepsis to identify risks and benefits of paramedic-initiated antibiotic therapy;

Sibley and Sibley (23) suggest that if Emergency Medical Services (EMS) or Paramedics have a patient suffering from suspected sepsis, that they must be managed with oxygen therapy, well documented vital signs and IV access to initiate fluid resuscitation. (24) The goal for EMS is to maintain systolic blood pressure just above 90mm Hg, with a Mean arterial pressure of 65mm Hg as any higher has the potential to worsen cardiac output, with adverse reactions. (24-26) Other studies support the notion of maintaining Mean arterial pressure at 65mm Hg as there is no clinical benefit to increasing this value higher. (27-28) Sibley and Sibley (23) contradict many other studies which suggest that early empiric antibiotic treatment of patients suspected of having sepsis is a standard practice; and the earlier treatment is initiated, the more positive the outcome. (21, 6, 8, 10, 16, 25, 29-30)

Empirical antibiotic treatment is the use of a broad spectrum antibiotic whilst therapeutic treatment with antibiotics is the initiation of antibiotic treatment after blood cultures are taken and the specific pathogen is identified. (31) Whilst empirical antibiotic treatment in the management of sepsis may be the initial drug of choice, it is in the patient’s best interest that appropriate antibiotic therapy is continued within the hospital. Appropriate antibiotic therapy is defined as “the use of an antimicrobial agent that is correct on the basis of all available clinical, pharmacological and microbiological evidence.” (32) With respect to the pre-hospital administration of antibiotic therapy, a recent study concluded that, if a patient is suffering septic shock, with each hour of delay in antibiotic administration after the onset of hypotension was associated with an average decrease in survival of approximately 8%. (33) However, a potential problem with empirical antibiotic treatment is that because sepsis is not the result of a single pathogen, the use of empirical antibiotics may not cover the pathogen causing the disease or illness.

Broad spectrum antibiotics may ‘bide time’ until blood cultures and appropriate testing can be done within a hospital setting. The current research suggests that the antibiotic selection used to treat conditions such as sepsis has a profound impact on patient outcomes (34) and this is also the case with inadequate antibiotic therapy, where the invading pathogen is not being effectively treated. (31) With regard to the empirical treatment, there are many different forms of pathogens that can cause sepsis, including Staphylococcus aures, Streptococcus pneumoniae, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. (10) With this in mind, the aforementioned figures that roughly 28% of septic patients are caused by a gram stain positive, and 20% of patients are gram stain negative, and the rest being approximately 52% (3, 10), the notion is that broad spectrum antibiotics may not cover these specific pathogens, therefore rendering treatment useless. Potentially this could lead to a negative or adverse outcome.

An International Initiative, the ‘Surviving Sepsis Campaign’ (30, 35) and the Critical Care Community in the United Kingdom (6) initially concentrated on educating emergency department staff to promote the introduction of management of sepsis known as ‘Early Goal Directed Therapy’. Upon review, poor implementation of this initiative and resuscitation lead the education staff involved to a move to target the staff working in areas outside of the emergency department, including the implementation of an operationalised resuscitation management plan referred to as the ‘Sepsis Six’. The ‘Sepsis Six’ involves the administration of high flow oxygen, blood cultures, IV antibiotics, fluid resuscitation, measure serum lactate and haemoglobin and the insertion of a urinary catheter to measure urine output. The ‘Sepsis Six’ can be implemented by hospital staff with different skill sets in the first hour following the diagnosis of sepsis and can make a significant contribution to decreasing mortality. (6)

With respect to the rationale of the ‘Sepsis Six’ Robson et. al. proposes that components of this treatment can be initiated pre hospital, and interestingly, the authors also highlight that pre hospital sepsis care is unusual, but pre hospital cardiac care is common. The question remains as to why that is. Given that all the literature available suggests that there is a significant decrease in morbidity and mortality associated with early antibiotic treatment.

Within Ambulance Victoria, the current management for the treatment of severe sepsis has not been established. Only a guideline is specifically written for meningococcal septicaemia which allows paramedics to administer Ceftriaxone in the pre hospital field in the suspected case of meningococcal septicaemia. (36) Walker (37) proposes that in the year 2003, meningococcal disease affected approximately 500 Australians with approximately 100 of these cases presenting in Victoria. It would seem logical that an appropriate guideline is established for sepsis and severe sepsis based on the available data from Sundararajan et. al. (3) which suggest within a 4 year time frame, approximately 34,000 admissions to hospital were identified as suffering from sepsis. However, it must be recognised that this only accounts for 1.1% of the total number of admissions to Victorian emergency departments. (3) This is considerably more hospital admissions when compared with meningococcal septicaemia, with similar, if not more deadly consequences.

Perhaps the thought of utilising empirical antibiotic therapy causing a ‘super bug’ with sepsis is debateable. Whilst many studies report that Methicillin-resistant Staphylococcus aures is developed within the hospital system (38) rather than the community based setting; this attitude is changing with larger numbers of community acquired Methicillin-resistant Staphylococcus aures being reported, (39) with an estimated 50% of the population being a carrier of the bacteria. (40) The concern of doctors and other health professionals to the thought of initiating treatment with an empirical antibiotic may be a result of previous dealings with Methicillin-resistant Staphylococcus aures. Methicillin-resistant Staphylococcus aures has evolved and mutated to be come ‘resistant’ over generations with different strains of antibiotic that were initially effective at eliminating the bacterial pathogen. (41) The thought that exposing such a broad spectrum antibiotic; for example ceftriaxone, (a cephalosporin antibiotic) is that the exposure of a drug like this may potentially initiate a genetic mutation in potentially a wide spread of different strains of pathogens.

Many studies have investigated the use of empirical antibiotics and also the possibility of not only one pathogen causing disease, therefore developing an appropriate antibiotic regime. This makes logical sense however, with consideration to the potential to cause a genetic mutation, exposing a pathogen to several antibiotics may have the potential to produce a resistant strain to not only one antibiotic, but several. The surprising news is that these studies have proven to have little or no extra effect in reducing mortality. (42-43)

Walker (37) proposes that the administration of pre hospital antibiotics by paramedics does have the potential for complications, including adverse reactions such as anaphylaxis and vasomotor collapse. However, the risk of antibiotic administration is no different to the administration of any other drug, with potential side effects and adverse reactions specific to individual patients.

Synthesise recommendations for paramedic management of sepsis based on available evidence.

Pre hospital data available on the treatment and management of septic patients are scarce. It is evident that more research needs to be undertaken in order to correctly identify septic patients and initiate early treatment. However the question remains as to whether data will ever be available due to the potential adverse reactions and the ethical dilemmas surrounding the prospective withholding of treatment to patients. The data that is available suggest that paramedics can make a difference in the potential outcomes of these patients. A mortality rate of close to 40% is unacceptable. It is proposed that paramedics undertake a similar model to the ‘Sepsis Six’ with an available pre hospital screening tool; similar to what the United Kingdom propose. This involves the identification of systemic involvement of the immune system by utilising the classification for SIRS; whilst using this in conjunction with history of a new infection. Taking both of these into consideration, persistent hypotension, low oxygen saturation and lack of urine output classifies pre hospital patients as suffering from severe sepsis. (6)

Paramedics are an integral part of the health care team and within the United States they are being overlooked and potential skills are being disregarded and this is still not understood when the literature suggest that early treatment does make a difference in outcomes. With regard to the early administration of antibiotics, not all patients will call at the onset of symptoms. Many will wait until the condition is unbearable or they feel like they are deteriorating, therefore it is important that empirical antibiotic therapy is undertaken at the earliest opportunity.

From the available literature; the United Kingdom’s model is the gold standard in terms of pre hospital screening and management of sepsis. Paramedics are highly trained health professionals and are able to manage septic patients accordingly, and as previously mentioned, the sepsis six involves high flow oxygen, blood cultures, IV antibiotics, fluid resuscitation, measured serum lactate and haemoglobin and urinary catheter and measure urine output. This paper does not propose that paramedics undertake all of the treatment outlined, but instead have the ability to initiate oxygen therapy, deliver intravenous fluid and antibiotics; and potentially have the ability to take blood cultures to hand over to the hospital. However, it must be emphasised that extra on scene time to complete these assessments and treatment must be taken into consideration as well as how long till the nearest hospital. Also important to note that paramedics must notify a receiving hospital so that the hospital can appropriately triage (44) and utilise the pre hospital taking of blood in the commencement of faster treatment and provide the ability to initiate an appropriate antibiotic regime.

Perhaps a review of the current guideline in Victoria is needed to extend the scope of paramedic practice to screen for potential septic patients, as the literature suggest that this current proportion of patients are exponentionally increasing. However; it may be easy to speculate changes that need to be made to the system, and this will take time and money. Walker (37) proposes from a management perspective there are significant costs associated with the antibiotics, training and assessment and ongoing replacement of antibiotics on all vehicles. Therefore it is imperative to continue research and therefore implement a new guideline into ambulance practice; which will benefit the health of all invested parties.

The early recognition and management of sepsis has implications on potential patient outcome. Sepsis has an extremely high mortality associated with it and as mentioned previously the sooner antibiotics can be administered; the rapid decrease in patient morbidity and mortality. With respect to the high numbers of presentations to Victorian emergency departments and intensive care admissions; this is mirrored throughout the world. One of the important points to understand that the admissions to intensive care can be avoided if sepsis is recognised earlier and paramedics may have a significant impact on the recognition and administration of antibiotics, as septic patients have the potential to be very unwell. The financial burden on the health system is enormous with one study speculating that the United States approximate spend on sepsis alone to be sixteen billion dollars. (21, 7) Data is unavailable from Victoria and Australia; however the costs associated with providing antibiotics for the management of sepsis will cost less than treating in an Intensive Care Unit.

Conclusion

One of the main recurring themes throughout this paper is that sepsis and severe sepsis have a high association with morbidity and mortality, even though the number of presentations have increased. The point needs to be emphasised that current management is not good enough. The research within hospitals is evident, that early antibiotic treatment of patients suffering from sepsis has profound effects on survival and recovery. Paramedics are potentially the first line of health care workers exposed to patients suffering severe sepsis and have the ability to act with broad spectrum antibiotics. Within Victoria, ambulances already carry Ceftriaxone; an example of a broad spectrum antibiotic. A guideline specific to sepsis needs to be developed and implemented in the pre hospital field, potentially on the basis of the United Kingdom’s model of recognising severe sepsis. The cost benefit analysis of implementing a new guideline, with the possible administration of antibiotics to more patients would severely outweigh the costs associated with an admission to an intensive care facility. The notion of taking pre hospital blood and notifying a receiving hospital of the potential septic patient may initiate appropriate treatment faster. Paramedics have the ability to make a difference with this time critical patient.

Abstract

Ways in which young woman, and now even young girls, view their bodies has been a topic of interest for many decades. Social media and the possible repercussions of subscribing to social media is what will be examined in this study. How do those who suffer from Anorexia Nervosa or AN, utilize social media to coincide with their illness? Does having a regular presence on social media influence the individual’s level of self-esteem and reliance on symptom usage when experiencing distress? 20 female participants who have been diagnosed with AN by a psychologist and are between the ages of 14-18 were obtained for this study. A clinical interview is mandatory for all participants. The clinical interview is necessary to collect crucial information regarding the participants upbringing, family medical history, and individual medical history that led up to having AN. Regular users of the popular social media app Instagram is operationally defined as logging at least 10 hours per week. The participants were divided into two groups of ten. The control group was instructed to continue their normal use of the app Instagram while the experimental group was instructed to not use the app for one year. At the beginning of the first month and every month thereafter, each participant was given an Eating Disorder Questionnaire that asks specific questions regarding body image, self-esteem, and overall satisfaction with oneself to determine the severity of symptoms experienced throughout the duration of the study. At the end of the study, the results from the questionnaire are then quantified to see if there is any correlation between social media use and severity of the eating disorder symptoms.

Introduction

According to

The Oxford Handbook of Eating Disorders,

AN holds the highest mortality rate of any other psychiatric disorder (Hoek, 2006). This reason alone is why AN can strongly be considered a public health concern. Research conducted by Verma and Avgoulas (2015) on the matter of eating disorders found that the perception the individual holds of themselves physically has become distorted in terms of their weight and body shape. Those struggling have a difficult time seeing their bodies for how they look. Body dysmorphia is extremely prevalent and can hinder someone struggling with AN to connect with reality, thinking one is fat when they are, in fact, dangerously thin (2015).

A considerable amount of research has uncovered many interesting secrets of eating disorders. Social media and prevalence of anorexia type symptoms in individuals who have been pre-diagnosed with the disorder is the aim of this study. What Verma and Avgoulas (2015) uncovered in their research are the attitudes that the individuals have towards themselves is a huge indicator of the type of content being consumed via social media. To take it a step further, Instagram, as a major social media platform for young women all over the world, will be incorporated into an experiment where participants will be assigned to one of two groups. Group A, participants will be instructed to log into their Instagram accounts as they normally would and in group B, participants will refrain from using Instagram. This will continue over the duration of one year. At the beginning of each month, the participants will be given an Eating Disorder Examination Questionnaire in order to measure if there is any adjustment in attitudes towards themselves throughout the experiment.

Literature Review

Anorexia Nervosa is an eating disorder characterized by weight loss, difficulty maintaining an appropriate weight for age, height and stature according to the National Eating Disorder Association (NEDA, 2018). Distortion of body image, calorie restriction, and purging (over exercising, laxatives, diuretics or vomiting) are typically found in those diagnosed with AN.  According to NEDA (2018), AN can affect people of any age, race, religion and sexual orientation. Although AN typically occurs in adolescence, many children and adults have also been diagnosed with the mental disorder. A common misconception is that one needs to be emaciated in order to have the disorder. On the contrary, cannot be diagnosed by looking at the individual solely. Unfortunately, those who are deemed normal or even overweight often get misdiagnosed because of cultural stigma around the disorder (2018).

A study by Verma (2015), looked to access how young women conceptualize eating disorders in comparison to how the media discusses and portrays eating disorders (Verma, 2015). This qualitative research used in-depth interviews and social media to create a detailed understanding to how eating disorders are perceived among young woman and those who are in recovery from or currently live with an eating disorder (2015). Similarly, this study aims to look at young who have a current diagnosis of Anorexia Nervosa and see how the presence of regular social media use influences severity of AN symptoms.

Furthermore, a larger overview of

Social Media and Body Image Concerns

published by Williams and Ricciardelli (2014) discussed the prevalence of social media and similar technologies in the lives of youths and how it influences and shapes the perceptions, attitudes, and self-esteem of its users (Williams, 2014). This fact stresses the importance of studies performed to investigate how forms of social media are impacting the youth. Williams (2014) reports that as demonstrated in other studies; social media has penetrated the lives of many Westerners that past forms of mass media simply could not amount to.

Methods

Anorexia Nervosa is an eating disorder characterized by extreme weight loss and inability to maintain an ideal body weight in conjunction with height, age, and body type. Typically, individuals with AN have limited social spontaneity highly restrictive food intake and rigid exercise regimens in desperate attempts to maintain an unrealistic low body weight (NEDA, 2019). Social media is form of electronic communication in which its users can create online communities to share ideas, messages, information, and personal content (Webster, 2019).

Participants

The participants for this study are females ranging in age from 14-18. All the participants have had a confirmed diagnosis of Anorexia Nervosa. The participants were recruited through a partnership with a therapeutic clinic specializing in eating disorders (TBD). Participants and legal guardian are asked if they would like to participate in the study after a formal diagnosis was made for the client. If so, a consent form is given. After consent has been granted, by either legal guardian or client if the client is legally able to do so, the participants are assigned into one of two groups at random.

Materials

Social media platform, Instagram, is being utilized as the independent variable in the experimental group. The Eating Disorder Examination Questionnaire will be used as the constant, or dependent, variable among both the experimental and control group throughout the study to measure the severity of AN Symptoms of the participants in both groups. The EDEQ will be administered at the beginning of each month in the presence of a therapist in the facility where the participants had their initial diagnosis to evaluate any changes in symptom severity amongst participants throughout the duration of the study. The questionnaire consists of 28 questions pertaining to eating disordered symptoms and severity. Severity of symptoms are rated on a scale from 0-6, 0 being “Not at all” and 6 being “Markedly”. In addition, the participants current weight, height, and menstrual cycle pattern is recorded.

Social media platform, Instagram, will be acting as the independent variable in the experimental group. All participants have been undergone a clinical interview that included questioning regarding how many hours per week, on average, each participant spends on Instagram. It was decided by the experimenter that a base rate of 10 hours per week is operationally defined as “excessive” use of the platform. To assure an accurate log of use for the experimental group, participants were given an iPhone that logs data usage for the Instagram app.

Procedure

Once the screening process is complete and the participants have been briefed about the study, each participant will be randomly assigned to either group 1 or group 2. Group 1 is instructed to utilize their personal Instagram accounts as they normally would on a day to day basis. Group 2 is instructed to refrain from using their Instagram account. This will go on over the duration of 12 months. The EDEQ is given at the beginning of each month as a baseline for symptom severity of each participant. The goal is to see if the severity of symptoms differs in the individual who does not look on Instagram compared to someone who does, given they both have Anorexia.

Results

The results of this study will not be discussed. Please see ‘Discussion’.

Discussion

This study will be looking at the relationship between social media use, specifically Instagram, and AN symptom severity. The goal of this study is to measure the difference between participants, who all share the same diagnosis of AN, while comparing their AN symptom severity by limiting the availability for half the participants in their social media use. Considering that eating disorders are a mental health issue and that the mind frame of individuals could be negatively impacted through seeking corresponding negative content (Verma, 2015), it is suspected that by limiting the use of Instagram, participants will experience alleviation of AN symptom severity.

The strength of this study’s design allows the researcher to examine the types of AN symptoms that are negatively correlated with social media influence. Using the EDEQ, a rating scale questionnaire, the researcher was able to quantify the results and calculate an average. Through Pearson’s ‘r’ Correlation Coefficient, there is a visible representation between the relationship of Instagram and ED symptom severity among participants who did not look at Instagram versus those who did. The results of this data prove that 10 or more hours of Instagram shows a linear correlation whereas no Instagram shows a negative correlation. This means that the less Instagram used, the lower rate of symptom severity in patients over time. These results will give clinicians an insight into the impact social media can have on their client’s rate of recovery. Those suffering from AN will also be allotted more knowledge on the impact they have on their own recovery.

Limitations of this study are that it will not be applicable in countries where social media is not prevalent. In addition, cultures where vanity is not of value, and other AN symptom are stemmed from other life factors were not be calculated into the data of this study. Participations truthfulness on the answers of the EDEQ are also recognized as potential confounding variables. In order to limit falsified information, participants names will not be revealed on the questionnaire, rather a serial number will be assigned to each participant.

The replication of this study using other types of social media will show which types of social media can have a negative impact on those suffering from AN. Looking at other forms of social media where vanity is not the main focus will give a broader understanding to what drives individuals to seek various forms of social media. This way, medical professionals can make improved recommendations to their patients as to how much social media input could be a hindrance to their recovery and well-being.

Related content

• 
  Anorexia and Bulimia Risk Factors
  

• 
  Literature Review on Anorexia Nervosa
  

• 
  Impact of the Media on Eating Disorders
  

References

• Williams, R. J., & Ricciardelli, L. A. (2014). Social media and body image concerns: Further considerations and broader perspectives.
  
  
  
  Sex Roles,
  
  
  
  
  71
  
  (11-12), 389-392. doi:http://dx.doi.org.libproxy.temple.edu/10.1007/s11199-014-0429-x
• Verma, A. & Avgoulas, M. (2015). Eating Disorders: Perceptions of Young Wozmen and Social Media Portrayal.
  
  The International Journal of Health, Wellness, and Society, Vol. 5
  
  (4), 97-105. file:///C:/Users/Piper/Downloads/Psychological%20Research/article%20one.pdf
• Dohnt, H. K., & Tiggemann, M. (2006). Body image concerns in young girls: The role of peers and media prior to adolescence.
  
  
  
  Journal of Youth and Adolescence,
  
  
  
  
  35
  
  (2), 135-145. doi:http://dx.doi.org.libproxy.temple.edu/10.1007/s10964-005-9020-7
• 
  http://cedd.org.au/wordpress/wp-content/uploads/2014/09/Eating-Disorder-Examination-
  
  Questionnaire-EDE-Q.pdf
• Hoek, H. “Incidence, Prevalence and Mortality of Anorexia Nervosa and Other Eating Disorders.” Current Opinion in Psychiatry, 2006: 389-394.
• Anorexia Nervosa. (2018, February 28). Retrieved March 14, 2019, from
  
  https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia
  
• Social Media. (n.d.). Retrieved March 26, 2019, from
  
  https://www.merriam-
  
  webster.com/dictionary/social media
• Regressions and Correlations: Pearson’s r. (n.d.). Retrieved April 11, 2019, from
• https://erc.barnard.edu/spss/pearsons_r