Download Chapter 45: Patients With Special Challenges

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.