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Chapter 45: Ready for Review 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. 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. 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.