Download Chapter 45: Patients With Special Challenges

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 Paramedics will encounter patients with a variety of economic, psychological, and
medical challenges.
 Patients with special challenges and their caregivers have likely become experts on a
particular condition or impairment.
 Poverty and patients’ lack of health insurance have a direct impact on EMS services
nationwide. These patients may not receive preventive health services or may not
purchase needed medications, thereby increasing the incidence and severity of disease,
and making an emergency more likely.
 Homeless and low-income patients are prone to numerous chronic medical conditions.
 Federal laws require emergency departments to stabilize patients experiencing an
emergency or active labor, regardless of the patient’s ability to pay. Paramedics should
become familiar with health care resources for low-income and homeless people.
 Abuse, neglect, and assault occur at all levels of society. Because maltreatment and
assault are common reasons for calls to EMS, you must recognize the signs and
symptoms of these problems.
 Child abuse includes any improper or excessive action that injures or otherwise harms a
child or infant, including physical abuse, sexual abuse, neglect, and emotional abuse.
 Some benign physical findings may mimic child abuse. Toddlers are more prone to
bruising and minor injuries as they develop psychomotor skills. Older children are prone
to injuries from sports and recreational activities such as bicycling. Infants of Asian or
African origin may have Mongolian spots on the buttocks or back. Other practices that
may visually look like child abuse include coining and cupping.
 Your own safety is the number one priority when you are encountering an abusive
situation. These situations can evoke powerful emotions; it is imperative that you remain
calm and neutral while providing optimal clinical care. As always, treating life threats
takes priority over collecting history.
 Careful, objective documentation of potential abuse or neglect is essential. Reporting of
child abuse or neglect is mandatory in most states. Failure to report may lead to a variety
of civil, criminal, or regulatory penalties.
 Terminal illnesses are those that cannot be cured. As health care providers, you and your
team will sometimes be called on to assist a patient who is facing imminent death. With
such a patient, always ask if there is an advance directive or DNR order.
 Obese (bariatric) patients may present significant clinical and logistical hurdles for EMS
providers. For example, airway procedures and intravenous access are physically more
difficult to perform. These patients may be too heavy for traditional EMS crews to
package and transport safely and effectively. Careful planning and proper body
mechanics are essential to avoid injury to emergency responders or the patient, and
special equipment may be needed.
 Patients with communicable diseases deserve treatment with the same respect and dignity
as any other patient.
 Many patients require physical support and care of chronic illnesses. This care that may
take place in the home setting. Paramedics may need to troubleshoot these devices when
they malfunction or incorporate this technology into traditional prehospital patient care.
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Like caregivers of patients with special challenges, family members who care for
chronically ill patients are often the paramedic’s best source of information and care
guidelines.
Medical technology likely to be encountered by EMS providers includes tracheostomy
tubes, long-term ventilators, apnea monitors, long-term vascular devices, medical
infusion pumps, insulin pumps, nasogastric or orogastric feeding tubes, colostomy,
urostomy, dialysis, surgical drains/devices, and cerebrospinal fluid shunts.
Patients with tracheostomy tubes may experience emergencies related to occlusion or
accidental removal. In some patients, loss of a tracheostomy tube may become an
immediate threat to life. Follow the DOPE acronym for troubleshooting tracheostomy
tube problems (Dislodged/displaced/ disconnected, Obstruction, Pneumothorax,
Equipment).
Patients may be on long-term ventilators at home for a variety of reasons, including
spinal cord injury, neuromuscular disease, and lung injury. If you are called to an
emergency for a patient who is on a long-term ventilator, ensure that the longterm
ventilator is working effectively. It is possible to severely injure a patient by improperly
adjusting his or her ventilator. If the ventilator appears to be adequate for the particular
patient, it is typically best to leave the ventilator connected to the patient and unchanged.
Long-term vascular access devices require guidance from medical control before
removal, replacement, or flushing.
Use extreme caution when you are treating patients who receive dialysis; IV fluid
administration requires careful monitoring.
Do not manipulate orthotic devices, prosthetic limbs, or braces; such equipment should
always accompany the patient to the hospital.
When you are assisting with interfacility transport, you may encounter any of the
following: hemodynamic monitoring, intra-aortic balloon pumps, or intracranial pressure
monitors.
Use extreme caution when you are transporting a patient with an arterial sheath because
any associated bleeding may be life threatening.
Special challenges may include cognitive, sensory, or communication impairment in your
patients.
Developmental delay covers a spectrum of cognitive impairment. Early intervention may
allow these children to recover previously missed developmental milestones. With these
patients, it may be useful to use the same approaches used for working with young
children.
Autism is a developmental delay in which the patient displays verbal or nonverbal
symptoms related to communication and the ability to purposefully shift attention.
Autistic patients require a mindful approach to communication and physical contact.
Limit external stimuli. These patients may have minimal reaction to pain or an
exaggerated painful reaction to minor physical contact.
Learning cursory sign language can help facilitate communication with hearing-impaired
patients.
Patients who are visually impaired may benefit from more detailed explanation of any
physical contact or intervention before it occurs.
Speech impairment can occur for a number of reasons and may be unrelated to cognitive
impairment.
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Paramedics may encounter patients with spastic paralysis, paraplegia, or quadriplegia.
Paralysis of respiratory muscles can make the patient dependent on a ventilator. The
paralyzed patient is also prone to pressure ulcers. Paralyzed patients will likely require
total lifting assistance.
When caring for cognitively impaired patients who have experienced trauma, remember
that these patients will not necessarily be able to give you a reliable medical history. You
may need to locate a valid surrogate decision-maker. Interventions may require additional
time, explanation, and holding assistance.
Chronic conditions that EMS providers may encounter include arthritis, cancer, cerebral
palsy, cystic fibrosis, multiple sclerosis, muscular dystrophy, myasthenia gravis,
poliomyelitis, spina bifida, systemic lupus erythematosus, and traumatic brain injury.
Become familiar with these conditions so that you can recognize them and manage
emergencies in patients with these conditions.