1 Patients With Special ChallengesChapter 36 Patients With Special Challenges Chapter 36: Patients with Special Challenges

2 National EMS Education Standard Competencies (1 of 5)Special Patient Populations Applies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs. National EMS Education Standard Competencies Special Patient Populations Applies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs.

3 National EMS Education Standard Competencies (2 of 5)Patients With Special Challenges Health care implications of Homelessness Poverty Bariatrics Technology dependent National EMS Education Standard Competencies Patients With Special Challenges Recognizing and reporting abuse and neglect. Health care implications of • Abuse • Neglect • Homelessness • Poverty • Bariatrics • Technology dependence

4 National EMS Education Standard Competencies (3 of 5)Patients With Special Challenges (cont’d) Health care implications of (cont’d) Hospice/terminally ill Tracheostomy care/dysfunction Home care Sensory deficit/loss Developmental disability National EMS Education Standard Competencies Health care implications of • Hospice/terminally ill • Tracheostomy care/dysfunction • Home care • Sensory deficit/loss • Developmental disability

5 National EMS Education Standard Competencies (4 of 5)Trauma Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. National EMS Education Standard Competencies Trauma Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

6 National EMS Education Standard Competencies (5 of 5)Special Considerations in Trauma Pathophysiology, assessment, and management of trauma in the Cognitively impaired patient National EMS Education Standard Competencies Special Considerations in Trauma Recognition and management of trauma in the • Pregnant patient • Pediatric patient • Geriatric patient Pathophysiology, assessment, and management of trauma in the • Cognitively impaired patient

7 Introduction (1 of 2) Today, more people with chronic diseases live at home. Shorter hospitalization Improvements in medicine and technology Patients with special challenges: Patients with diseases resulting in altered body function Patients with sensory deficits Geriatric patients with chronic diseases Lecture Outline I. Introduction A. Today, more people with chronic diseases live at home or outside of a hospital setting. 1. Focus on decreasing the length of hospitalization 2. Improvements in medicine and medical technology B. Examples of patients with special challenges: 1. Children who were born prematurely and have associated respiratory problems 2. Infants or small children with congenital heart disease 3. Patients with neurologic disease 4. Patients with congenital or acquired diseases resulting in altered body function that requires medical assistance for breathing, eating, urination, or bowel function 5. Patients with sensory deficits such as hearing or visual impairments 6. Geriatric patients with chronic diseases requiring visitation from a home health care service

8 Introduction (2 of 2) Some patients depend on mechanical ventilation, intravenous pumps, and other devices. Do not be distracted by the equipment! Focus on the patient. Lecture Outline C. Some people living at home depend upon: 1. Mechanical ventilation 2. Intravenous pumps 3. Other devices D. Do not allow yourself to be distracted by the noise and mechanics of the medical equipment—your focus needs to remain on the patient. 1. Focus on the ABCs. 2. If the emergency is the result of mechanical failure, use equipment on the ambulance or the family’s “go bag.”

9 Intellectual Disability (1 of 4)Developmental disability Refers to insufficient development of the brain, resulting in some level of dysfunction or impairment Can include intellectual, hearing, or vision impairments Intellectual disability Results in the inability to learn and socially adapt at a normal developmental rate Lecture Outline II. Intellectual Disability A. Developmental disability 1. Refers to insufficient development of the brain, resulting in some level of dysfunction or impairment 2. Can include intellectual, hearing, or vision impairments that surface during infanthood or childhood a. Intellectual disability results in the inability to learn and socially adapt at a normal developmental rate.

10 Intellectual Disability (2 of 4)Possible causes Genetic factors Congenital infections Malnutrition Environmental factors Fetal alcohol syndrome Traumatic brain injury Poisoning Lecture Outline b. Possible causes i. Genetic factors ii. Congenital infections iii. Complications at birth iv. Malnutrition v. Environmental factors vi. Prenatal drug or alcohol use vii. Traumatic brain injury viii. Poisoning (eg, with lead or other toxins)

11 Intellectual Disability (3 of 4)Slight impairment: Slow to understand or limited vocabulary Behave immaturely compared to peers If severe, may have inability to care for themselves, communicate, understand, or respond Lecture Outline 3. Characteristics of a patient with slight intellectual impairment: a. May appear slow to understand or have a limited vocabulary b. May behave immaturely compared to their peers c. If severely disabled, may not have the ability to care for themselves, communicate, understand, or respond to surroundings

12 Intellectual Disability (4 of 4)Rely on patients and family members for information. Patient may have difficulty adjusting to change or a break in routine. Patients with intellectual disabilities are susceptible to the same diseases as other patients. Lecture Outline 4. Rely on patients and family members for information to: a. Understand how well the patient can understand you b. Understand how the patient will interact with you c. Gain additional medical information regarding the patient 5. Patient anxiety a. Patient may have difficulty adjusting to change or a break in routine. b. Patient may become more difficult to interact with as anxiety increases. c. Make every effort to respect the patient’s wishes and concerns. d. Take as much time as necessary to explain in a calming, understandable way the treatment the patient is about to receive. 6. Patients with intellectual disabilities are susceptible to the same diseases as other patients.

13 Autism Spectrum Disorder (1 of 3)Pervasive developmental disorder characterized by impairment of social interaction Severe behavioral problems Repetitive motor activities Impairment in verbal and nonverbal skills May be hyper- or hyposensitive to sensory stimuli Lecture Outline B. Autism Spectrum Disorder 1. General term used to describe a group of complex disorders of brain development that vary greatly in signs and symptoms 2. Pervasive developmental disorder characterized by impairment of social interaction 3. Other characteristics a. Severe behavioral problems b. Repetitive motor activities c. Impairment in verbal and nonverbal skills d. May be hyper- or hyposensitive to sensory stimuli e. May show their pain in unusual ways, such as humming, singing, and removing clothing

14 Autism Spectrum Disorder (2 of 3)Wide spectrum of disability Patients have difficulty using or understanding nonverbal communication. Do best with simple, one-step directions Affects males four times more than females Typically diagnosed by age 3 Lecture Outline 4. Wide spectrum of disability—some patients are independent; others are unable to care for themselves 5. Patients have difficulty using or understanding nonverbal means of communicating a. Frequently have difficulty making eye-to-eye contact b. Do best with simple, one-step directions c. Tend to have trouble answering open-ended questions d. May talk in robotic or monotone speech patterns e. May repeat phrases over and over again f. May confuse pronouns (eg, say “you” when they really mean “I”) g. May not speak at all 6. Approximately 1 in every 68 American children is diagnosed. 7. It affects males five times more than females. 8. Typically diagnosed by 3 years of age 9. Children with autism receive special instruction and care in school-based settings.

15 Autism Spectrum Disorder (3 of 3)Older adults may not be diagnosed. Patients have medical needs similar to their peers without autism. Move slowly, stay calm, and perform physical examinations from distal to proximal. Lecture Outline 10. It is likely that some older adults with autism have never been diagnosed nor received any assistance. 11. Patients with autism generally do not have other medical disorders and will have medical needs similar to their peers without autism. 12. Rely on parents or caregivers for information, and keep them involved in the patient’s treatment. 13. Explain what you are going to do before you do it. 14. Move slowly, stay calm, and perform physical examinations from distal to proximal. 15. Demonstrate the examination on a parent or caregiver first to show the patient what he or she can expect.

16 Down Syndrome (1 of 4) A genetic chromosomal defect that can occur during fetal development Results in mild to severe intellectual impairment Increased maternal age and family history are known risk factors Lecture Outline C. Down syndrome 1. Characterized by a genetic chromosomal defect that can occur during fetal development, resulting in mild to severe intellectual impairment 2. Increased maternal age and a family history are known risk factors for this condition.

18 Down Syndrome (3 of 4) Increased risk for medical complications40% may have heart conditions and hearing and vision problems Intubation may be difficult due to large tongues and small oral and nasal cavities. Mask ventilation can be challenging Jaw-thrust maneuver or a nasopharyngeal airway may be necessary Lecture Outline 4. Increased risk for medical complications a. As many as 40% may have heart conditions and hearing and vision problems. 5. Intubation may be difficult due to large tongues and small oral and nasal cavities. 6. Mask ventilation can be challenging—jaw-thrust maneuver or a nasopharyngeal airway may be necessary.

19 Down Syndrome (4 of 4) Management of seizures is the same for any other patent The atlantoaxial joint is unstable in approximately 15% of patients with Down syndrome. Increased risk of complications when they experience trauma Lecture Outline 7. Management of seizures is the same as for any other patient with seizures, as discussed in Chapter 17, “Neurologic Emergencies.” 8. In approximately 15% of people with Down syndrome, the atlantoaxial joint, where the first two vertebrae meet, is unstable. a. Atlantoaxial instability (AAI) b. Most patients do not show symptoms. c. Increased risk of complications when they experience trauma

20 Patient Interaction (1 of 2)It is normal to feel uncomfortable. Treat the patient as you would any other patient. Approach in a calm, friendly manner. Establish rapport. Lecture Outline D. Patient interaction 1. It is normal to feel somewhat uncomfortable when initiating contact with a developmentally disabled patient. 2. Treat the patient as you would any other patient. 3. Approach the patient in a calm, friendly manner, watching for signs of increased anxiety or fear. 4. Have the members of your team hold back slightly until you can establish a rapport with the patient.

21 Patient Interaction (2 of 2)Introduce team members. Explain what you are going to do. Move slowly but deliberately. Watch carefully for signs of fear. Make sure you are at eye level. Soothe the patient’s anxiety. Establish trust and communication. Lecture Outline 5. Introduce the team members and explain what they are going to do. 6. Move slowly but deliberately, explaining beforehand what you are going to do, just like you would with any other patient. 7. Watch carefully for signs of fear or reluctance from the patient. 8. Make sure you are at eye level with the patient. 9. Do your best to soothe the patient’s anxiety and discomfort as you work through your assessment and provide treatment. 10. By initially establishing trust and communication, you will have a much better chance for a successful outcome.

22 Brain Injury Patients with a prior brain injury may be difficult to treat. Talk with patient and family. Establish what is considered normal for the patient. Explain procedures and reassure patient. Lecture Outline E. Brain injury 1. Patients with a prior brain injury may be difficult to assess and treat. 2. Take the time to speak with the patient and family to establish what is considered normal for the patient. 3. Talk in a calm, soothing tone, and watch the patient closely for signs of anxiety or aggression. 4. Do not expect the patient to walk to the ambulance or stretcher. 5. Treat the patient with respect, use his or her name, explain procedures, and reassure the patient throughout the process.

23 Visual Impairment (1 of 4)Possible causes Congenital defect Disease Injury Degeneration of the eyeball optic nerve or nerve pathway Lecture Outline III. Sensory Disabilities A. Visual Impairment 1. Possible causes a. Congenital defect b. Disease c. Injury d. Degeneration of the eyeball optic nerve or nerve pathway

24 Visual Impairment (2 of 4)Range in degree of visual impairment Some patients lose peripheral or central vision Some can distinguish light from dark or shapes Visual impairments may be difficult to recognize. Lecture Outline 2. Degree of visual impairment may range from partial to total. a. Some patients lose peripheral or central vision. b. Some can distinguish light from dark or discern general shapes. 3. Visual impairments may be difficult to recognize. a. Look for signs that the patient is visually impaired (glasses, cane, service animal).

25 Visual Impairment (3 of 4)Patient interaction Make yourself known when you enter. Introduce yourself and your team. Retrieve any visual aids and give them to your patient. Patient may feel vulnerable and disoriented. Describe the situation and surroundings to the patient. Lecture Outline 4. Patient interaction a. Make yourself known when you enter the room. b. Introduce yourself and your team or have them introduce themselves so that the patient can identify their voices and locations. c. Retrieve any visual aids and give them to your patient to make the interaction more comfortable. d. A visually impaired patient may feel vulnerable, especially during the chaos of a crash scene. e. The patient may have learned to use other senses such as hearing, touch, and smell to compensate for the loss of sight, and the sounds and smells of the scene may be disorienting. f. Tell the patient what is happening, identify noises, and describe the situation and surroundings, especially if you must move the patient.

26 Visual Impairment (4 of 4)Transport considerations Take cane or walker, if used. Make arrangements for care or accompaniment of service animal. Patients should be gently guided, never pulled or pushed. Communicate obstacles in advance. Lecture Outline 5. Transport considerations a. Patient may use a cane or walker (be sure to take it with you). b. A service animal can remain with the patient and will provide reassurance for the patient and prevent delays in transport; however, in some cases you may need to make arrangements for the care or accompaniment of the animal. c. An ambulatory patient may be led by a light touch on the arm or elbow or the patient may rest his or her hand on your shoulder. i. You may ask patients which method they prefer to use. ii. Patients should be gently guided but never pulled or pushed. iii. Obstacles need to be communicated in advance.

27 Hearing Impairment (1 of 2)Problems range from slight hearing loss to total deafness. Patients may speak Many older people have some hearing loss. Sensorineural deafness is caused by nerve damage Conductive hearing loss is caused by faulty transmission of sound waves Lecture Outline B. Hearing Impairment 1. Impairment can range from a slight hearing loss to total deafness. a. Patients may have difficulty with pitch, volume, and speaking distinctly. b. Patients may learn to speak even though they have never heard sounds. c. Patients may have since sustained partial or total hearing loss, leading them to speak too loudly. d. Many older people will have some degree of hearing loss. 2. Most common forms of hearing loss a. Sensorineural deafness i. Nerve damage ii. Results from a lesion or damage to the inner ear b. Conductive hearing loss i. Caused by a faulty transmission of sound waves ii. Can be caused by an accumulation of wax within the ear canal or a perforated eardrum

28 Hearing Impairment (2 of 2)Clues that a person could be hearing impaired Presence of hearing aids Poor pronunciation of words Failure to respond to your presence or questions Lecture Outline c. Clues that a person could be hearing impaired i. Presence of hearing aids ii. Poor pronunciation of words iii. Failure to respond to your presence or questions

29 Communication With Hearing Impaired Patient (1 of 4)Assist the patient with finding and inserting any hearing aids. Face the patient while you communicate. Do not exaggerate your lip movements or look away. Position yourself approximately 18″ directly in front of the patient. Lecture Outline d. Communication i. Assist the patient with finding and inserting any hearing aids. ii. Face the patient while you communicate. iii. Do not exaggerate your lip movements or look away. iv. Position yourself approximately 18″ directly in front of the patient.

30 Communication With Hearing Impaired Patient (2 of 4)Most people who are hearing impaired have learned to use body language (hand gestures and lip reading). Do not speak louder; try lowering the pitch of your voice. Ask the patient, “How would you like to communicate with me?” American Sign Language may be useful. Lecture Outline v. Do not speak louder, and try lowering the pitch of your voice. vi. Most people who are hearing impaired have learned to use body language (eg, hand gestures and lip reading). vii. Ask the patient, “How would you like to communicate with me?” viii. American sign language (a) May use an interpreter, family member, or friend (b) If an interpreter is not readily available, call your receiving facility early on to request one.

31 Communication With Hearing Impaired Patient (3 of 4)Hints for communication Speak slowly and distinctly into a less-impaired ear Change to a speak with a low-pitched voice Provide paper and a pencil Use the “reverse stethoscope” technique Lecture Outline ix. Helpful hints for communication (a) Speak slowly and distinctly into a less-impaired ear, or position yourself on that side. (b) Change speakers to someone with a low-pitched voice. (c) Provide paper and a pencil so that you may write your questions and the patient may write responses. (d) Only one person should ask interview questions, to avoid confusing the patient. (e) Try the “reverse stethoscope” technique: put the earpieces of your stethoscope in the patient’s ear and speak softly into the diaphragm of the stethoscope.

32 Communication With Hearing Impaired Patient (4 of 4)The figure on this slide shows terms in American Sign Language related to illness and injury: sick (A), hurt (B), and help (C). © Jones & Bartlett Learning. Photographed by Glen E. Ellman. © Jones & Bartlett Learning. Photographed by Glen E. Ellman. © Jones & Bartlett Learning. Photographed by Glen E. Ellman.

33 Hearing Aids (1 of 2) Hearing aids make sound louder.May be external or internal Several types are available. Behind-the-ear, conventional body, in-the-canal, in-the-ear Device should fit snugly. If whistling occurs, it may not be in far enough. Lecture Outline C. Hearing aids 1. Device that makes sound louder 2. May be either external or internal 3. Several types are available. a. Behind-the-ear type i. Contained in plastic case that rests behind the ear b. Conventional body type i. Older style used for profound hearing loss c. In-the-canal and completely in-the-canal type i. Contained in plastic case that fits partly or completely inside of ear canal d. In-the-ear type i. Contained in shell that fits in outer part of ear e. Implantable options are also available. 4. The device should fit snugly. 5. If you hear whistling, the hearing aid may not be in far enough. 6. If the hearing aid is not working, troubleshoot the problem.

34 Hearing Aids (2 of 2) © Piotr Marcinski/Shutterstock. © Stine Lise Nielsen/Shutterstock. © Steve Hamblin/Alamy The figure on this slide shows different types of hearing aids: behind-the-ear (A), conventional body (B), in-the-canal (C), in-the-ear (D), and completely in-the-canal (E). © Jiri Hera/Shutterstock. © Terry Smith Images/Alamy.

35 Cerebral Palsy (1 of 4) Group of disorders characterized by poorly controlled body movement Possible causes Damage to the developing brain in utero Oxygen deprivation at birth Traumatic brain injury Infection such as meningitis during early childhood Lecture Outline IV. Physical Disabilities A. Cerebral palsy 1. Group of disorders characterized by poorly controlled body movement 2. Possible causes a. Result of damage to the developing fetal brain while in utero b. Oxygen deprivation at birth c. Traumatic brain injury at birth d. Infection such as meningitis during early childhood

37 Cerebral Palsy (3 of 4) ConsiderationsObserve airway closely and suction as needed. Do not assume intellectual disability. Underdeveloped limbs are prone to injury. Ataxic or unsteady gait makes patients prone to falls. Patient may have special pillow or chair. Lecture Outline 4. Observe airway closely a. Patient may have increased secretion production and difficulty swallowing (dysphagia). b. May require aggressive suctioning to clear the airway 5. Important considerations a. Do not assume that patients have an intellectual disability. b. Limbs are often underdeveloped and are prone to injury. c. Patients who have the ability to walk may have an ataxic or unsteady gait and are prone to falls. d. If the patient has a specially made pillow or chair, the patient may prefer to use it during transport.

38 Cerebral Palsy (4 of 4) Considerations (cont’d)Pad the patient to ensure comfort. Never force extremities into position. Whenever possible, take walkers or wheelchairs along during transport. Be prepared for a seizure and keep suctioning available. Lecture Outline e. Pad the patient to ensure his or her comfort. f. Never force a patient’s extremities into any position. g. Whenever possible, take walkers or wheelchairs along during transport. h. Be prepared for a seizure and keep suctioning available.

40 Spina Bifida (2 of 2) Associated conditionsHydrocephalus (requires shunt) Partial or full paralysis of the lower extremities Loss of bowel and bladder control Extreme latex allergy Lecture Outline 4. Associated conditions a. Hydrocephalus i. Requires the placement of a shunt to drain excessive amounts of cerebrospinal fluid from the brain b. Partial or full paralysis of the lower extremities c. Loss of bowel and bladder control d. Extreme latex allergy 5. Ask patients or caregivers how to best move them before you transport them.

41 Paralysis (1 of 3) Inability to voluntarily move body partsCauses: stroke, trauma, birth defects May have normal sensation or hyperesthesia May cause communication challenges Diaphragm may not function correctly (requires ventilator). Lecture Outline C. Paralysis 1. Inability to voluntarily move one or more body parts 2. Possible causes a. Stroke b. Trauma c. Birth defects 3. Patient may have normal sensation or hyperesthesia (increased sensitivity). 4. Facial paralysis may also cause communication challenges 5. Diaphragm may not function correctly, requiring the use of a ventilator.

42 Paralysis (2 of 3) Specialized equipmentUrinary catheters Tracheotomy tubes Colostomy bags Feeding tubes Difficulty swallowing may require suctioning Lecture Outline 6. Patients may have specialized equipment a. Urinary catheters b. Tracheotomy tubes c. Colostomy bags d. Feeding tubes 7. Patients may have difficulty swallowing, creating the need for suctioning.

43 Paralysis (3 of 3) Each type of spinal cord paralysis requires its own equipment and may have its own complications. Always take great care when lifting or moving a paralyzed patient. Ask patients how it is best to move them before you transport them. Lecture Outline 8. Each type of spinal cord paralysis requires its own equipment and may have its own complications. 9. Always take great care when lifting or moving a paralyzed patient. 10. Ask patients or caregivers how to best move them before you transport them.

44 Bariatric Patients (1 of 2)Obesity: person has excessive body fat Obese: 30% over ideal body weight Severe obesity: 2–3x over the ideal weight Imbalance between calories consumed and calories used May be attributed to low metabolic rate or genetic predisposition Lecture Outline V. Bariatric Patients A. Obesity is a condition in which a person has an excessive amount of body fat. 1. The result of an imbalance between calories consumed and calories used 2. Causes of obesity are not fully understood. 3. May be attributed to a low metabolic rate or genetic predisposition 4. Term obese used when someone is 30% or more over his or her ideal body weight 5. Severe obesity is when a person is 2–3 times over the ideal weight.

45 Bariatric Patients (2 of 2)Quality of life is negatively affected Associated health problems Mobility difficulties Diabetes Hypertension Heart disease Stroke Lecture Outline 6. Quality of life may be negatively affected. 7. Associated health problems a. Mobility difficulties b. Diabetes c. Hypertension d. Heart disease e. Stroke

46 Interaction with Patients with Obesity (1 of 4)Patient may be embarrassed. Plan early for extra help or equipment. Find easiest and safest exit. Do not risk dropping the patient or injuring a team member. Lecture Outline B. Interaction with patients with obesity 1. Patients may be embarrassed by their condition or be fearful of scorn as a result of past experiences. 2. If transport is necessary, plan early for extra help and/or specialized equipment. a. Send a member of your team to find the easiest and safest exit. b. Do not risk dropping the patient or injuring a team member by trying to lift too much weight.

47 Interaction with Patients with Obesity (2 of 4)Treat the patient with dignity and respect. Ask your patient how it is best to move him or her before attempting to do so. Avoid trying to lift the patient by one limb, which would risk injury to overtaxed joints. Coordinate and communicate all moves to all team members prior to starting to lift. Lecture Outline C. Interaction with patients with morbid obesity 1. Treat the patient with dignity and respect. 2. Ask your patient how it is best to move him or her before attempting to do so. 3. Avoid lifting the patient by only one limb, which would risk injury to overtaxed joints. 4. Coordinate and communicate all moves to all team members prior to starting to lift.

48 Interaction with Patients with Obesity (3 of 4)If the move becomes uncontrolled at any point, stop, reposition, and resume. Look for pinch or pressure points from equipment (deep venous thrombosis). Large patients may have difficulty breathing if you lay them in a supine position. Lecture Outline 5. If the move becomes uncontrolled at any point, stop, reposition, and resume. 6. Look for pinch or pressure points from equipment because this could cause significant soft tissue injury or deep venous thrombosis. 7. Large patients may have difficulty breathing if you lay them in a supine position.

49 Interaction with Patients with Obesity (4 of 4)Specialized equipment is available. Become familiar with the resources available in your area. Plan egress routes. Notify the receiving facility early. Lecture Outline 8. There are many types of specialized equipment for morbidly obese patients, and some areas have specially equipped bariatric ambulances for such patients. 9. Become familiar with the resources available in your area. 10. Plan egress routes to accommodate large patients, equipment, and the lifting crew members. 11. Notify the receiving facility early.

50 Tracheostomy Tubes (1 of 5)Tracheal stoma provides a path between the neck and the trachea Kept open by plastic tracheostomy tube Tubes bypass nose and mouth Temporary or permanent For patients who depend on home automatic ventilators and have chronic pulmonary illness Lecture Outline VI. Patients With Medical Technology Assistance A. Tracheostomy tubes 1. Tracheal stoma provides a path between the surface of the neck and the trachea 2. Stoma is kept open by a plastic tracheostomy tube 3. Can be temporary or permanent 4. Passes from the neck directly into the major airways 5. For patients who: a. Depend on home automatic ventilators b. Have chronic pulmonary medical conditions 6. Tubes bypass the nose and mouth.

51 Tracheostomy Tubes (2 of 5)Tubes are prone to obstruction by mucus or foreign bodies Emergency event Portex® Blue Line® Ultra Tracheostomy courtesy of Smiths Medical Lecture Outline 7. Tubes are prone to becoming obstructed by mucous plugs or foreign bodies. a. Obstructions of the tracheostomy tube are emergency events.

52 Tracheostomy Tubes (3 of 5)DOPE mnemonic helps recognize causes of obstruction Displacement, dislodged, or damaged tube Obstruction of the tube Pneumothorax Equipment failure Lecture Outline b. DOPE mnemonic helps to recognize cause of obstruction i. Displacement, dislodged, or damaged tube ii. Obstruction of the tube (secretions, blood, mucus, vomitus) iii. Pneumothorax iv. Equipment failure (kinked tubing, ventilator malfunction, empty oxygen supply)

53 Tracheostomy Tubes (4 of 5)Common problems May be bleeding or air leaking around the tube Tube can become loose or dislodged. Opening around the tube may become infected. Lecture Outline 8. Common problems a. May be bleeding or air leaking around the tube b. Tube can become loose or dislodged c. Opening around the tube may become infected

54 Tracheostomy Tubes (5 of 5)Management Maintain an open airway. Suction tube if necessary to clear a mucous plug. Maintain the patient in a position of comfort. Administer supplemental oxygen. Provide transport to the hospital. Lecture Outline 9. Management a. Maintain an open airway. b. Suction tube if necessary to clear a mucous plug. c. Maintain the patient in a position of comfort. d. Administer supplemental oxygen. e. Provide transport to the hospital.

55 Mechanical Ventilators (1 of 3)Used when patients cannot breathe without assistance Possible causes Congenital defect Chronic lung disease Traumatic brain injury Muscular dystrophy Lecture Outline B. Mechanical ventilators 1. Used when patients cannot breathe without assistance 2. Possible causes a. Congenital defect b. Chronic lung disease c. Traumatic brain injury d. Muscular dystrophy e. Disease process that weakens the ability to breathe and requires a permanent tracheostomy and mechanical ventilator

56 Mechanical Ventilators (2 of 3)If ventilator malfunctions: Remove patient from ventilator. Apply a tracheostomy collar Designed to cover the tracheostomy hole May not be available in prehospital setting. Can improvise by placing a face mask over the stoma. Lecture Outline 3. If the ventilator malfunctions: a. Remove the patient from the ventilator. b. Apply a tracheostomy collar. i. Designed to cover the tracheostomy hole and has a strap that goes around the neck. ii. May not be available in a prehospital setting iii. Can improvise by placing a face mask over the stoma c. Patients require assisted ventilation throughout transport.

57 Mechanical Ventilators (3 of 3)Caregivers will know how the equipment works. © ResMed Used with permission. Lecture Outline 4. The patient’s caregivers will know how the mechanical ventilator works. a. Caregivers can help you attach the bag and valve from a BVM to the tracheostomy tube.

58 Apnea Monitors (1 of 2) Used for infants who:Are premature and have severe gastroesophageal reflux Have family history of SIDS Experienced a life-threatening event Lecture Outline C. Apnea monitors 1. Used for infants who: a. Are premature and have severe gastroesophageal reflux that causes choking episodes b. Have a family history of sudden infant death syndrome c. Have experienced an apparent life-threatening event

59 Apnea Monitors (2 of 2) Used 2 weeks to 2 months after birth to monitor the respiratory system Sounds an alarm if the infant experiences bradycardia or apnea Attached with electrodes or belt around the infant’s chest or stomach Will provide a pulse oximetry reading Lecture Outline 2. Used for 2 weeks to 2 months after birth to monitor the respiratory system 3. Monitor sounds an alarm if the infant experiences bradycardia or apnea. 4. Attached with electrodes or belt around the infant’s chest or stomach 5. Will provide a pulse oximetry reading that will assist you in assessing the patient’s respiratory status 6. If possible, bring the apnea monitor to the receiving hospital with the patient.

60 Internal Cardiac PacemakersImplanted under skin to regulate heart rate On nondominant side of the patient’s chest May include automated implanted defibrillator Never place defibrillator paddles or pacing patches directly over the implanted device. Gather information about the type of cardiac pacemaker when obtaining history. Lecture Outline D. Internal cardiac pacemakers 1. Device implanted under the patient’s skin to regulate the heart rate 2. Typically placed on the nondominant side of the patient’s chest (or, for small or extremely thin patients, in the abdomen) 3. Pacemaker may also include an automated implanted cardioverter defibrillator to monitor heart rhythm. 4. Never place defibrillator paddles or pacing patches directly over the implanted device. 5. Gather information about the cardiac pacemaker while you obtain the patient’s history. a. Some patients will have a pacemaker identification card in their wallets containing information about the device.

61 Left Ventricular Assist DevicesTakes over the function of either one or both heart ventricles Typically used as a bridge to heart transplantation May be difficult to palpate a pulse. Provide support measures and basic care. Use the caregiver as a resource. Be prepared to provide CPR. Lecture Outline E. Left ventricular assist devices 1. Special piece of medical equipment that takes over the function of one or both heart ventricles 2. Typically used as a bridge to heart transplantation while a donor heart is being located 3. May be a permanent solution for patients who do not qualify for a transplant. 4. Multiple devices available for adult patients 5. One device approved for use in patients aged 5–16 years 6. May be difficult to palpate a pulse in patients who use an LVAD. a. Assess perfusion by noting: i. Level of consciousness ii. Skin color, temperature, and moisture iii. Blood pressure 7. Care a. Provide support measures and basic care. d. Use the caregiver as a resource during the transport. c. The patient should have a “go bag” that must be transported with him or her. d. Be prepared to provide CPR. e. Contact medical control or follow local protocols. f. Notify ALS personnel as soon as possible so that other supportive measures may be initiated.

62 External Defibrillator VestVest with built-in monitoring electrodes and defibrillation pads Worn by the patient under his or her clothing Attached to a monitor that provides alerts and delivers a shock If patient is in cardiac arrest, vest should remain in place while you perform CPR Lecture Outline F. External defibrillator vest 1. A vest with built-in monitoring electrodes and defibrillation pads, which is worn by the patient under his or her clothing 2. Attached to a monitor that provides alerts and voice prompts when it recognizes a dangerous rhythm and before it delivers a shock 3. Uses high-energy shocks similar to an AED. a. Avoid contact with the patient if the device warns it is about to deliver a shock. 4. If the patient is in cardiac arrest, the vest should remain in place while you perform CPR unless it interferes with compressions. 5. Any patient who is wearing a device that has already delivered a shock should be transported to the hospital for further evaluation.

63 Central Venous Catheter (1 of 3)Catheter with its tip placed in vena cava to provide venous access Used for many types of home care patients Common locations Chest Upper arm Subclavicular area Lecture Outline G. Central venous catheter 1. A catheter that has its tip placed in the vena cava to provide venous access 2. Used for many types of home care patients receiving: a. Chemotherapy b. Long-term antibiotic drug therapy or pain management c. Total parenteral nutrition (TPN) d. Hemodialysis 3. Common locations a. Chest b. Upper arm c. Subclavicular area

65 Central Venous Catheter (3 of 3)Common problems Broken lines Infections around the lines Clotted lines Bleeding around the line or from the tubing attached to the line Lecture Outline 4. Common problems a. Broken lines b. Infections around the lines c. Clotted lines d. Bleeding around the line or from the tubing attached to the line

66 Gastrostomy Tubes (1 of 4)Placed into the stomach for patients who cannot ingest fluids, food, or medication by mouth May be inserted through the nose or mouth into the stomach May be placed surgically directly into the stomach through the abdominal wall Lecture Outline H. Gastrostomy tubes 1. Sometimes referred to as gastric tubes or G-tubes 2. Placed into the stomach for patients who cannot ingest fluids, food, or medication by mouth a. May be inserted through the nose or mouth into the stomach (using a nasogastric or orogastric tube) b. May be placed surgically directly into the stomach through the abdominal wall

68 Gastrostomy Tubes (3 of 4)May become dislodged Immediately stop the flow of any fluids. Assess for signs or symptoms of bleeding into the stomach. Vague abdominal discomfort Nausea Vomiting (especially “coffee ground” emesis) Blood in emesis Lecture Outline 3. May become dislodged during the patient’s normal daily activity a. Immediately stop the flow of any fluids. b. Assess for signs or symptoms of bleeding into the stomach. i. Vague abdominal discomfort ii. Nausea iii. Vomiting (especially “coffee ground” emesis) iv. Blood in emesis

69 Gastrostomy Tubes (4 of 4)Increased risk of aspiration Always have suction readily available. Patients with difficulty breathing should be transported while sitting or lying on their right side with head elevated 30°. Continue tube feeding unless the tube is dysfunctional, dislodged, or partially dislodged. Lecture Outline 4. Patients may be at increased risk of aspiration. a. Always have suction readily available. b. Patients with difficulty breathing should be transported while sitting or lying on their right side with the head elevated 30°. 5. Diabetic patients who receive insulin and gastric tube feedings may become hypoglycemic quickly. a. Unless the tube is dysfunctional, dislodged, or partially dislodged, continue the tube feeding and transport the pump with you.

70 Shunts (1 of 4) For patients with chronic neurologic conditionsTubes that drain excess cerebrospinal fluid Fluid reservoir Device beneath skin on side of head, behind the ear Should alert you to the presence of a shunt Lecture Outline I. Shunts 1. For patients with chronic neurologic conditions 2. Tubes that drain excess cerebrospinal fluid 3. During assessment, you will likely feel a device beneath the skin on the side of the head, behind the ear. a. Fluid reservoir b. Should alert you to the possibility that the patient has an underlying shunt

71 Shunts (2 of 4) Types Ventricular peritoneum shunt Ventricular atrium shunt Blocked/infected shunt may cause changes in mental status and respiratory arrest Infection may occur within 2 months of insertion Lecture Outline 4. Types a. Ventricular peritoneum shunt—drains excess fluid from the ventricles of the brain into the peritoneum of the abdomen b. Ventricular atrium shunt—drains excess fluid from the ventricles of the brain into the right atrium of the heart 5. Blocked or infected shunt a. Changes in mental status and respiratory arrest may occur. b. Infections may occur within the first 2 months after insertion.

72 Shunts (3 of 4) Signs of distressHigh-pitched cry or bulging fontanelles Headache Projectile vomiting Altered mental status Irritability Fever Nausea Lecture Outline 6. Signs of distress a. High-pitched cry or bulging fontanelles (in infants) b. Headache c. Projectile vomiting d. Altered mental status e. Irritability f. Fever g. Nausea

73 Shunts (4 of 4) Signs of distress (cont’d)Difficulty with coordination (walking) Blurred vision Seizures Redness along shunt track Bradycardia Heart dysrhythmias Lecture Outline h. Difficulty with coordination (walking) i. Blurred vision j. Seizures k. Redness along the shunt track l. Bradycardia m. Heart dysrhythmias

74 Vagus Nerve Stimulators (1 of 2)Treatment for seizures not controlled with medication Surgically implanted Stimulate the vagus nerve to prevent seizure activity Lecture Outline J. Vagus nerve stimulators 1. Treatment used for seizures that are not controlled with medication 2. Stimulate the vagus nerve at predetermined intervals to prevent seizure activity

75 Vagus Nerve Stimulators (2 of 2)Used in children older than 12 years Located under the patient’s skin About the size of a silver dollar If you encounter a patient with this device, contact medical control or follow your local protocols. Lecture Outline 3. Used in children older than 12 years 4. Located under the patient’s skin 5. About the size of a silver dollar 6. If you encounter a patient with this device, contact medical control or follow your local protocols.

76 Colostomies, Ileostomies, and Urostomies (1 of 3)Colostomy or ileostomy Procedure that creates opening between the small or large intestine and the surface of the body Allows for elimination of waste products into a clear, external bag or pouch Emptied or changed frequently Lecture Outline K. Colostomies, ileostomies, and urostomies 1. Colostomy or ileostomy is a surgical procedure that creates an opening between the small or large intestine and the surface of the body. a. Allows for elimination of waste products into a clear, external bag or pouch, which is emptied or changed frequently

77 Colostomies, Ileostomies, and Urostomies (2 of 3)Assess for dehydration if the patient has been complaining of diarrhea or vomiting. Area around the stoma is prone to infection. Signs of infection: Redness Warm skin around the stoma Tenderness over the colostomy or ileostomy site Lecture Outline b. Assess for signs and symptoms of dehydration if the patient has been complaining of diarrhea or vomiting. c. Area around the stoma is prone to infection. d. Signs of infection: i. Redness ii. Warm skin around the stoma iii. Tenderness with palpation over the colostomy or ileostomy site

78 Colostomies, Ileostomies, and Urostomies (3 of 3)Urostomy Surgical procedure that connects the urinary system to the surface of the skin Allows urine to drain through a stoma in the abdominal wall Contact medical control or follow local protocols for care of a patient with a colostomy, ileostomy, or urostomy bag. Lecture Outline 2. Urostomy is a surgical procedure that connects the urinary system to the surface of the skin. a. Allows urine to drain through a stoma in the abdominal wall instead of through the urethra. 3. Contact medical control or follow local protocols for care of a patient with a colostomy, ileostomy, or urostomy bag.

79 Patient Assessment GuidelinesInteraction with caregiver is an important part of patient assessment process. They are experts on caring for these patients. Determine patient’s normal baseline status before assessment. Ask, “What is different today?” Lecture Outline VII. Patient Assessment Guidelines A. Interaction with the caregiver of an adult or child with special needs is an important part of the patient assessment process. 1. They have become experts on caring for the patient. B. Determine the patient’s normal baseline status before assessment. 1. Ask, “What is different today?”

80 Home Care (1 of 2) Occurs within home environmentRepresents a spectrum of populations Infants, older adults, chronic illness, developmental disabilities Services: delivering meals, cleaning, laundry, maintenance, physical therapy, personal care Lecture Outline VIII. Home Care A. Home care occurs within a patient’s home environment. B. Represents a spectrum of special health care populations 1. Infants 2. Older adults 3. Patients with chronic illnesses 4. Patients with developmental disabilities 5. Services a. Delivering meals b. House cleaning c. Laundry d. Yard maintenance e. Physical therapy f. Personal care (eg, bathing and wound care)

81 Home Care (2 of 2) EMS may be called to residence by home care provider. Obtain baseline health status and history from home care provider. Lecture Outline C. EMS may be called to a residence by the home care provider. D. Obtain baseline health status and history from the home care provider.

82 Hospice Care and Terminally Ill Patients (1 of 3)Terminally ill may receive hospice care at a hospice facility or at home. Most have DNR order May have medical orders for scope of treatment Lecture Outline IX. Hospice Care and Terminally Ill Patients A. Terminally ill patients may receive hospice care at a hospice facility or at home with diseases such as: 1. Cancer 2. Heart and lung failure 3. End-stage Alzheimer’s disease 4. AIDS B. Most patients have completed a do not resuscitate (DNR) order. 1. May have medical orders for scope of treatment

83 Hospice Care and Terminally Ill Patients (2 of 3)Comfort care Palliative care (pain medications) Improves quality of life before patient dies Follow local protocol, patient’s wishes, legal documents Bring documentation to the hospital. Show compassion, understanding, and sensitivity. Lecture Outline C. Comfort care 1. Palliative care (pain medications) 2. Improves the patient’s quality of life before the patient dies and allows the patient to be with family and friends D. Follow your local protocols, the patient’s wishes, or legal documents such as a DNR order. 1. All necessary documentation must be brought to the hospital if the patient is to be transported. E. If the patient is at home, the care you give will have a lasting impact on family; show compassion, understanding, and sensitivity.

84 Hospice Care and Terminally Ill Patients (3 of 3)Ascertain the family’s wishes regarding transport. Allow family member to accompany the patient. Follow local protocols for handling the death of a patient. Lecture Outline F. Ascertain the family’s wishes about having the patient remain in the home or having the patient transported to the hospital. 1. If a family member requests to accompany the patient, he or she should be allowed to do so. G. Follow local protocols for handling the death of a patient.

85 Poverty and Homelessness (1 of 2)Unable to provide for basic needs Disease prevention strategies are absent Leads to increased probability of disease Homeless population includes: Patients with mental illness or prior brain trauma Domestic violence victims Addicts Impoverished families Lecture Outline X. Poverty and Homelessness A. People who live in poverty are unable to provide for all of their basic needs: 1. Housing 2. Food 3. Child care 4. Health insurance 5. Medication B. Disease prevention strategies (dental care, nutrition, and exercise) are likely absent, which leads to increased probability of disease. C. Homeless population includes: 1. People with mental illness or prior brain trauma 2. Victims of domestic violence 3. Persons with addiction disorders 4. Impoverished families

86 Poverty and Homelessness (2 of 2)Advocate for all patients. All health care facilities must provide assessment and treatment regardless of the patient’s ability to pay. Become familiar with social services resources within your community. Lecture Outline D. You are an advocate for all patients. E. Your job is to provide emergency care and transport to the appropriate facility. F. All health care facilities must provide assessment and treatment regardless of the patient’s ability to pay. G. You can be an advocate by becoming familiar with the social services resources within your community.

87 Review Which of the following is a developmental disorder characterized by impairment of social interaction? Down syndrome Autism Cerebral palsy Spina bifida

88 Review Answer: B Rationale: Autism is a developmental disability characterized by impairment of social interaction. Cerebral palsy and spina bifida are physical disabilities. Down syndrome is characterized by a genetic chromosomal defect.

89 Review (1 of 2) Which of the following is a development disorder characterized by impairment of social interaction? Down syndrome Rationale: Down syndrome is characterized by a genetic chromosomal defect. Autism Rationale: Correct answer

90 Review (2 of 2) Which of the following is a development disorder characterized by impairment of social interaction? Cerebral palsy Rationale: Cerebral palsy is a physical disability. Spina bifida Rationale: Spina bifida is a physical disability.

91 Review Known risk factors for Down syndrome include: smoking.traumatic brain injury at birth. increased maternal age. lack of vitamin B.

92 Review Answer: C Rationale: Increased maternal age, along with a family history of Down syndrome, are risk factors of Down syndrome.

93 Review (1 of 2) Known risk factors for Down syndrome include:smoking. Rationale: Smoking is a risk factor for many conditions. traumatic brain injury at birth. Rationale: TBI is a risk factor of cerebral palsy.

94 Review (2 of 2) Known risk factors for Down syndrome include:increased maternal age Rationale: Correct answer lack of vitamin B Rationale: This is a risk factor for spina bifida.

95 Review Which of the following may be difficult to perform on a patient with Down syndrome? CPR Pulse oximetry Splinting Intubation

96 Review Answer: D Rationale: Intubation may be difficult because patients with Down syndrome often have large tongues and small oral and nasal cavities.

97 Review Which of the following may be difficult to perform on a patient with Down syndrome? CPR Rationale: This should not be difficult. Pulse oximetry Rationale: This should not be difficult. Splinting Rationale: This should not be difficult. Intubation Rationale: Correct answer

98 Review Most patients with this disease also have hydrocephalus.Paralysis Down syndrome Spina bifida Cerebral palsy

99 Review Answer: C Rationale: Most patients with spina bifida also have hydrocephalus, which requires the placement of a shunt.

100 Review Most patients with this disease also have hydrocephalus.Paralysis Rationale: This is not the correct answer. Down syndrome Rationale: This is not the correct answer. Spina bifida Rationale: Correct answer Cerebral palsy Rationale: This is not the correct answer.

101 Review What does the DOPE mnemonic help you to recognize?Causes of airway obstruction Risk factors for patients using technology assistance Questions to ask patients with pacemakers A vagal nerve stimulator

102 Review Answer: A Rationale: The DOPE mnemonic helps you to recognize causes of airway obstruction in patients using technology assistance.

103 Review What does the DOPE mnemonic help you to recognize?Causes of airway obstruction Rationale: Correct answer Risk factors for patients using technology assistance Rationale: This is not the correct answer. Questions to ask patients with pacemakers Rationale: This is not the correct answer. A vagal nerve stimulator Rationale: This is not the correct answer.

104 Review What device is placed directly into the stomach to feed patients? Colostomy Ileostomy Gastrostomy tube Central venous catheter

105 Review Answer: C Rationale: A gastrostomy tube is used to feed patients who cannot ingest fluids, food, or medication by mouth.

106 Review (1 of 2) What device is placed directly into the stomach to feed patients? Colostomy Rationale: This allows for elimination of waste. Ileostomy Rationale: This allows for elimination of waste.

107 Review (2 of 2) What device is placed directly into the stomach to feed patients? Gastrostomy tube Rationale: Correct answer Central venous catheter Rationale: This is a venous access device.

108 Review What do vagal nerve stimulators do?Keep seizures from occurring Keep the airway clear from secretions Act as an alternative treatment to medicine Both A and C

109 Review Answer: D Rationale: Vagal nerve stimulators are an alternative treatment to medication for patients with seizures and keep seizures from occurring.

110 Review What do vagal nerve stimulators do?Keep seizures from occurring Rationale: This is one of the two correct answers. Keep the airway clear from secretion Rationale: This is not the correct answer. Act as an alternative treatment to medication Rationale: This is one of the two correct answers. Both A and C Rationale: Correct answer

111 Review An important part of the assessment process for a patient with special needs is to: interact with the caregiver. interact with the patient. talk to the manufacturer of the equipment being used. transport immediately.

112 Review Answer: A Rationale: Interaction with the caregiver of a child or adult with special needs will be extremely import. They are trained to use and troubleshoot problems with medical equipment.

113 Review (1 of 2) An important part of the assessment process for a patient with special needs is to: interact with the caregiver. Rationale: Correct answer interact with the patient. Rationale: Although this is important, it is more important to talk to the caregiver.

114 Review (2 of 2) An important part of the assessment process for a patient with special needs is to: talk to the manufacturer of the equipment being used. Rationale: The caregiver will be able to help you with the equipment. transport immediately. Rationale: It is more important to talk to the caregiver.

115 Review What improves a patient’s quality of life shortly before death?Home care Hospice care Comfort care Health care

116 Review Answer: C Rationale: Comfort care is also called palliative care. Pain medications are provided during a patient’s last days so he or she can enjoy time with family and friends.

117 Review (1 of 2) What improves a patient’s quality of life shortly before death? Home care Rationale: Home care may improve the patient’s quality of life. Hospice care Rationale: Hospice care may improve the patient’s quality of life.

118 Review (2 of 2) What improves a patient’s quality of life shortly before death? Comfort care Rationale: Correct answer Health care Rationale: This is not the correct answer.

119 Review The EMTALA act states that:patients should only be treated if they can pay for care. all patients must be treated regardless of their ability to pay for care. only those with serious injuries can be treated without payment for care. only certain facilities can treat patients who cannot pay for care.

120 Review Answer: B Rationale: The Emergency Medical Treatment and Active Labor Act (EMTALA) requires all facilities to assess and treat patients regardless of their ability to pay for care.

121 Review (1 of 2) The EMTALA act states that:patients should only be treated if they can pay for care. Rationale: This is not the correct answer. all patients must be treated regardless of their ability to pay for care. Rationale: Correct answer

122 Review (2 of 2) The EMTALA act states that:only those with serious injuries can be treated without payment for care. Rationale: This is not the correct answer. only certain facilities can treat patients who cannot pay for care. Rationale: This is not the correct answer.