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Chapter 45 Patients With Special Challenges National EMS Education Standard Competencies Special Patient Populations Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. National EMS Education Standard Competencies Patients With Special Challenges • Recognizing and reporting abuse and neglect • Health care implications of: − Abuse − Neglect − Homelessness − Poverty − Bariatrics National EMS Education Standard Competencies Patients With Special Challenges • Health care implications of (cont’d): − Technology dependent − Hospice/terminally ill − Tracheostomy care/dysfunction − Home care − Sensory deficit/loss − Developmental disability National EMS Education Standard Competencies Special Considerations in Trauma • Pathophysiology, assessment, and management of trauma in the − − − − Pregnant patient Pediatric patient Geriatric patient Cognitively impaired patient Introduction • Patients may have a wide variety of special challenges. − May be necessary to modify: • Communications • Assessments • Treatment • Transport Introduction • Many lifesustaining therapies are handled by families and patients. − Mechanical ventilation − IV medication General Strategies for Patients With Special Challenges • Patients and caregivers are often experts in their condition or impairment. − Have an open mind and willingness to listen. − Demonstrate confidence in enlisting patient expertise. General Strategies for Patients With Special Challenges • Invaluable resources include: − Online medical control − Electronic medical reference materials − Coworkers’ experience EMS, Health Care, and Poverty • EMS providers and EDs often deal with economic and health care crises. − Nearly 50 million people did not have health insurance in the United States in 2010. − Nearly 46.2 million people were in poverty in the United States in 2010. EMS, Health Care, and Poverty • Poverty and lack of health insurance affect health habits: − Stop seeking or receiving preventative services. − Incidence and severity of disease increases. − Health care is delayed until an emergency. EMS, Health Care, and Poverty • Homeless people are prone to: − Numerous chronic medical conditions − Mental illness − Substance abuse • Medical care is difficult because of: − Environmental exposure − Crime/violence − Malnutrition − Lack of hygiene EMS, Health Care, and Poverty • EMS and ED assistance may be sought if: − Chronic medical condition becomes severe − No other healthcare options • In some cases patients may not need transport. − Never refuse to transport if requested. EMS, Health Care, and Poverty • Health care services are provided through a variety of community-based facilities. • Hospitals are frequently able to provide: − − − − Financial assistance Payment plans Low-cost health care services Help enrolling in insurance programs Care of Patients With Suspected Abuse and Neglect • Care for victims of abuse and neglect is often difficult. • Groups particularly susceptible include: − Children − Dependent elderly − Impaired adults Epidemiology • Infants and young children are more likely to be victims of abuse or neglect. • Occurs with varied frequency across race and socioeconomic status • Determination can be difficult. Definitions • Physical abuse − Intentional act that results in physical impairment or injury. • Throwing • Striking • Hitting and kicking • Burning • Biting Definitions • Neglect − Caregivers fail to provide protection so that health and well-being are affected − Signs are often subtle and require awareness on part of EMS personnel. Definitions • Sexual abuse and sexual exploitation − Includes: • Sexual contact • Forced prostitution • Inappropriate undressing • Suggestive photography • Forcing victim to watch sexual acts or pornography Definitions • Emotional abuse − Causes substantial change in victim’s: • Behavior • Emotional response • Cognitive function − May be verbal or nonverbal Definitions • Caregiver substance abuse − Includes: • Fetus harmed by pregnant woman • Providing alcohol or drugs to a child • Manufacturing or selling drugs in presence of child • Becoming impaired while caring for a child • Driving while intoxicated with a child in the car • Allowing a child to become a designated driver Definitions • Abandonment − Child or vulnerable adult suffers harm because the caregiver fails to maintain adequate contact • Leaving a young child home alone • Allowing a child to wander unsupervised Recognizing Abuse or Neglect • Variety of behavioral cues and findings should prompt suspicion. − Caregiver is intoxicated. − Caregiver tries to interfere with physical examination of child or vulnerable adult. Recognizing Abuse or Neglect • Do not confront suspected perpetrator. − Report to hotline and ED physician. • Caregiver’s story may not match patient’s: − Age − Capability − Medical condition Recognizing Abuse or Neglect • Suspicious behavior signs from patient: − Does not become agitated when caregiver leaves the room − Cries excessively or not at all − Is wary of physical contact − Appears apprehensive Recognizing Abuse or Neglect • Physical signs: − Bruises − Closed head injury − Burns and ligature marks − Bruise patterns − Seizure activity without prior history in an afebrile child Courtesy of Ronald Dieckmann, M.D. Courtesy of Ronald Dieckmann, M.D. Benign Physical Findings • Some physical findings mimic signs of physical abuse. − Bruises as psychomotor skills develop − Scald burns from grabbing a pot − Bites or scratches from playmates Benign Physical Findings • Mongolian spots − Lesions resembling bruises, present at birth on many Asian and African American infants © Dr. P. Marazzi/Photo Researchers, Inc. Benign Physical Findings • Some Eastern healing techniques may cause marks that look like abuse: − Coining − Cupping Used with permission of the American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, © American Academy of Pediatrics, 2000. © Cora Reed/ShutterStock, Inc. Benign Physical Findings • Physical findings suggestive of sexual abuse may actually be caused by: − Poor hygiene − Skin irritation from cleaning products − Poorly fitting undergarments − Various infections Management of Suspected Abuse or Neglect • Emotions may undermine patient care and worsen the situation for the patient. • Assessment process − First priority: Safety of emergency responders − Second priority: Provide optimal clinical care. Management of Suspected Abuse or Neglect • Documentation − Patient care reports/other documentation will be reviewed by: • Law enforcement officers • Social service agencies • Court officials Management of Suspected Abuse or Neglect • Document: − Physical findings − Whether assessment of particular body areas was accomplished or deferred − Timing or time frame of injury or event Management of Suspected Abuse or Neglect • Mandatory reporting and legal involvement − Health professionals are obligated to report suspected child abuse and neglect. − Reports are made to state or government social services agency of a particular jurisdiction. Management of Suspected Abuse or Neglect • Law enforcement frequently becomes involved. − Intervene when there is an immediate threat to the health or safety of child or vulnerable adult. − Conduct investigation into associated criminal activity. Care of Patients With Terminal Illness • Many terminally ill may forgo invasive and marginally effective medical treatment. • Terminal illness: Disease process expected to cause death within 6 months Care of Patients With Terminal Illness • Be prepared to alter or forego lifesaving interventions. • Patients may transition from curative care to palliative care. − Focus changes to improving quality of time left Care of Patients With Terminal Illness • Patient and caregiver often know the best way to manage sudden discomfort. − Assess for pain using techniques based on: • Patient’s age • Ability to communicate • Cognitive function Care of Patients With Terminal Illness • Assessment should include: − Level of consciousness − Vital signs − Past medical history − Pain medication history • Follow standing protocols for medications. Care of Patients With Terminal Illness • May enter hospice programs near end of life − Provide social and emotional support. − Treat discomfort. − Help patient/family cope with impending death. Advance Directives • Signed by patient or surrogate decision maker • Instruct health care providers on medical decisions for when patient is incapacitated • Can be revoked if patient has decisionmaking capacity Advance Directives • Do-not-resuscitate (DNR) orders − Physician orders to withhold resuscitation efforts in case of respiratory or cardiovascular collapse − May be generic or specifically discuss what methods are indicated or withheld Care of Bariatric Patients • More than 1/3 of American adults are obese. − Obese—BMI greater than 30 kg/m2 − Morbidly obese—BMI between 40 and 49.9 kg/m2 − Extreme obesity—BMI above 50 kg/m2 Care of Bariatric Patients • Causes of obesity: − Lifestyle − Genetics − Metabolism − Environment • Prone to: − Physical injury − Musculoskeletal problems Clinical Concerns for the Bariatric Patient • Airway procedures are more difficult. • Bag-mask ventilation may be ineffective with patients in supine position. • Diminished respiratory reserve decreases the window to perform airway procedures. Clinical Concerns for the Bariatric Patient • Peripheral IV access is often problematic. − Large neck mass may obscure landmarks. − Conventional IM needles may not be able to reach IM space. − Absorption and distribution may be altered. Operational Concerns for the Bariatric Patient • Patients are often too heavy for two-person EMS crews to transport. − Additional lifting assistance may be necessary. − Small rooms and narrow staircases may limit using additional lifting personnel. − Weight may exceed equipment’s carrying capacity. Care of Patients With Communicable Diseases • Safety precautions should be followed. • Respect and privacy is essential. • Assumptions based on stereotypes may undermine care. © Mark C. Ide Medical Technology in the Prehospital Setting • Many invasive, unusual, or life-sustaining therapies are used in homes and long-term care facilities. • Family members may be a paramedic’s best source for information and care guidelines. Tracheostomy Tubes • May be fenestrated − Used for: • Patients being evaluated for tube removal • Patients requiring intermittent ventilator support Tracheostomy Tubes • Follow DOPE acronym for troubleshooting: − Dislodged/displaced/disconnected − Obstruction − Pneumothorax − Equipment Long-Term Ventilators • Primary assessment includes determining if the ventilator is working effectively. − If it does not appear to be working effectively: • Work to adjust ventilator settings. • Disconnect the ventilator completely. Ventricular Assist Devices • Provide life-saving bridge for patients with severe heart failure • Used by patients who: − Are awaiting heart transplant − Need long-term treatment when not candidates for heart transplantation Long-Term Vascular Access Devices • Placed for a number of reasons • Many are maintained with heparin. − Contaminated catheters can cause serious infections. Long-Term Vascular Access Devices • Common devices include: − Peripherally inserted central catheter (PICC) − Midline catheter − Double or triple lumen central catheter − Hickman, Broviac, and Groshong catheters − Implanted ports − Dialysis catheter Medication Infusion Pumps • Many IV medications are administered with infusion pumps. © BELMONTE/age fotostock Insulin Pumps • Electronic devices allowing diabetic patients to titrate exogenous insulin needs • Potential to complicate EMS treatment of patients with insulin-dependent diabetes who develop hypoglycemia Tube Feeding • EMS personnel do not often need to troubleshoot or manipulate feeding tubes. − May need to monitor during interfacility transport − If complications develop: • Stop feeding. • Flush catheter with tap water. Colostomy • Surgery directing large intestine through a stoma − Colostomy bag collects stool and intestinal liquid for disposal. Courtesy of ConvaTec. © / ™ indicated a registered trademark of E.R. Squibb & Sons, LLC. Urostomy/Urinary Diversion • Urinary diversion is required for certain medical conditions, such as: − Bladder cancer − Congenital anomalies − Massive urinary tract obstructions © 2012 C. R. Bard, Inc. Used with permission. Urinary Catheterization • Used when patients cannot urinate on their own − May remain in placed (indwelling catheters) − May be used intermittently (straight catheters) Dialysis • Replacement for failed or failing kidneys − As kidney function declines, substances accumulate in the body. − If untreated, these substances may cause death. Dialysis • Complications of dialysis include: − Massive fluid and electrolyte abnormalities − Hypovolemia and fluid overload − Infection • Complications of fistulas includes: − Life-threatening hemorrhage − Thrombosis − Stenosis Surgical Drains and Devices • A variety of drains and devices are used after surgery. − Prevent fluid from collecting at surgical site. © CHASSENET/age fotostock Surgical Drains and Devices • Outside of scope of practice to manipulate most of these devices and drains − Can cause significant complications, including: • Hemorrhage • Infection • Need for more surgery Cerebrospinal Fluid Shunts • Hydrocephalus: Excess volume of cerebrospinal fluid (CFS) around brain • Leads to: − − − − − − Headaches Visual disturbances Unsteady gait Nausea, vomiting Seizures Altered mental status Developmental Disability • Diverse group of severe chronic conditions due to mental and/or physical impairments • Adversely impacts: − Communication − Movement − Learning − Behavior − Ability to care for oneself − Employment prospects Developmental Delay • Failure to reach a developmental milestone − Gross/fine motor skills − Cognitive skills − Social skills − Language milestones Developmental Delay • Problem may be in one or multiple areas. • Early intervention may allow children recovery of previously missed milestones. • Cues from patient and caregiver help determine the best way to interact. Hearing Impairment • Can be congential or acquired − Congenital • Genetic factors • Maternal infection • Rh incompatability • Hypoxia • Maternal diabetes • Pregnancy-induced hyptertension − Acquired • Excessive exposure to loud noise • Various infections • Tumors • Ototoxicity • Diseases • Aging Hearing Impairment • Hearing aids (cont’d) − To insert: • Follow the natural shape of the ear. − If there is a whistling sound: • Reposition the hearing aid. • Remove it, and turn the volume down. Hearing Impairment • Hearing aids (cont’d) − If not working, troubleshoot the problem. • Make sure it is turned on. • Try a fresh battery; check that tubing is not bent. • Check to make sure it is set on M. • If a body aid, try a spare cord. • Check that it is not plugged with wax. Visual Impairment • Congenital causes: − Fetal exposure to cytomegalovirus − Hypoxia in delivery − Albinisms − Hydrocephalus − Retinopathy of prematurity • Acquired causes: − − − − − − − Trauma Degeneration Glaucoma Cataracts Hypertension Diabetic retinopathy Vitamin A deficiency Visual Impairment • Explain before physically contacting patients with profound visual impairments. − Warn patients before palpating a body region or performing a procedure. − Discuss with the patient any needed movement or transport before doing so. Speech Impairment • Impaired speech may be associated with: − Neurologic injury − Toxicologic exposure − Anatomic abnormalities of the face or neck − Numerous other conditions Paralysis, Paraplegia, and Quadriplegia • Paralysis: Inability to move • Caused by many medical conditions: − Head trauma − Cerebrovascular accident (CVA, stroke) − Spinal cord injury − Malignancy − Other neuromuscular diseases Trauma in Cognitively Impaired Patients • Isolated sensory or communication impairments can cause: − Additional anxiety − Confusion − Delays − Disruption of patient care or transport Trauma in Cognitively Impaired Patients • Effective communication may be almost impossible. − If caregiver is not available, rely on physical or behavioral cues of the patient. Trauma in Cognitively Impaired Patients • Medical treatment consent may be uncertain. − May need to: • Locate valid surrogate decision maker. • Initiate treatment under the doctrine of implied consent. Trauma in Cognitively Impaired Patients • Interventions may require additional time, explanation, and assistance. • Management is generally the same. • Check for signs of abuse and neglect. Arthritis • Inflammation of joints, causing: − Pain − Stiffness − Swelling − Redness − Discomfort • May be caused by: − Excessive use of joint or limb − Infection − Autoimmune process − Previous fracture Arthritis • During response: − Administer analgesia medication. − Maintain limb or joint in comfortable position. − Assess current long-term medications. Trauma and Pregnancy • Trauma is a complicating factor in pregnancy. • Leading cause of maternal death in United States Pathophysiology and Assessment Considerations • Anatomic changes are important in trauma. − Abdominal contents compress into upper abdomen. − Diaphragm elevates by about 1.5 inches. − Peritoneum maximally stretches. Pathophysiology and Assessment Considerations • Pregnant patients will have different signs or responses to trauma. − May be more difficult to interpret tachycardia − Signs of hypovolemia may be hidden. − Higher chance of bleeding to death in case of pelvic fractures − Respiratory rate less than 20 breaths/min is not adequate. Considerations for the Fetus and Trauma • Fetal injury can occur from: − Rapid deceleration − Impaired fetal circulation • If a pregnant woman has massive bleeding, maternal circulation will reroute blood from the fetus. Considerations for the Fetus and Trauma • Fetal heart rate is the best indication of fetal status after trauma. − Normal fetal heart rate is between 120 and 160 beats/min. − Rate slower than 120 beats/min means fetal distress and a dire emergency. Management of the Pregnant Trauma Patient • Can only treat the woman directly − Determine gestational age of fetus if possible. • Transport a pregnant woman on left side if no spinal injury is suspected. Management of the Pregnant Trauma Patient • Ensure adequate airway. • Administer oxygen. • Assist ventilations when needed and provide a higher-than-usual minute volume. • Control external bleeding and splint fractures. Management of the Pregnant Trauma Patient • Start one or two IV lines of normal saline. • Inform the receiving facility of the patient’s status and estimated time of arrival. • Transport the patient in the lateral recumbent position. Postpartum Complications • Maternal cardiac arrest − Provide CPR and ALS like any other trauma patient. − CPR and ventilator support may keep the fetus viable, even if the mother is already dead.