Patients with Special Challenges

There are numerous examples of patients with special challenges EMTs may encounter during a medical emergency. Some examples are as follows. Children who were born prematurely and who have associated respiratory problems. Infants or small children with congenital heart disease. Patients with neurologic disease (occasionally caused by hypoxemia at the time of birth, as with cerebral palsy). Patients with congenital or acquired diseases resulting in altered body function that requires medical assistance for breathing, eating, urination, or bowel function. Patients with sensory deficits such as hearing or visual impairments. Geriatric patients with chronic diseases requiring visitation from a home health care service. These populations may depend on mechanical ventilators, intravenous pumps, or other devices to maintain their lives.

There are special considerations that are required when providing emergency medical care to patients with intellectual disabilities. Some examples of those intellectual disorders are patients with autism spectrum disorder (ASD), Down syndrome, or prior brain injuries. Developmental disability refers to a group of conditions that may impair development in areas of physical ability, learning, language development, or behavioral coping skills. Intellectual disability is a subset where patients have significant limitations in both intellectual functioning and skills needed for daily living. It may be caused by genetic factors, congenital infections, complications at birth, malnutrition, or environmental factors. Prenatal exposure to drugs or alcohol use may also cause intellectual disability. Other causes that may occur after birth include traumatic brain injury and poisoning. Take as much time as necessary to calmly and clearly explain the treatment the patient is about to receive. Ask family how to communicate.

Autism Spectrum Disorder is an intellectual disability characterized by deficits in social communication and interaction along with restricted, repetitive patterns of behavior, interest, and activities. 1 in 40 and 3 to 4 times more common in males than it is in females. (New research on this every day.) May not feel cold, heat, or pain as others do; respond to pain by laughing, humming, singing, or removing clothing. Applying bandages or tape can cause anxiety or aggression. Start from feet up and explain everything; even when the patient cannot speak, they often understand speech. Patients with autism may have increased sensitivity to noise or physical stimulation. Keep the transport environment calm and minimize stimulation to help with these issues. Use short, direct, and simple phrases when communicating. May have a particular routine to be carried out.

Down Syndrome is a genetic chromosomal defect resulting in mild to severe intellectual impairment. A normal human somatic cell contains 23 pairs of chromosomes. Trisomy 21 occurs when two chromosome 21s fail to separate so that the ovum or sperm contains 24 chromosomes. Down syndrome is characterized by a round head with a flat occiput, an enlarged protruding tongue, slanted, wide-set eyes, folded skin on either side of the nose covering the inner corner of the eye, short wide hands, a small face and features, congenital heart defects, thyroid problems, and hearing and vision problems. Increased risk for medical complications, including leukemia and conditions that affect the cardiovascular, sensory, endocrine, musculoskeletal, dental, and gastrointestinal systems as well as neurologic development. Due to the fact that individuals with Down syndrome often have large tongues and small oral and nasal cavities, airway management may be difficult. The atlantoaxial joint, where the first two cervical vertebrae meet, is unstable in approximately 15%. If the joint becomes dislocated, the patient may experience difficulty walking, neck pain, decreased neck mobility, and sensory deficits.

Different types of visual impairments and the special patient care considerations required when providing emergency medical care for visually impaired patients depend on the level of their disability. Remember to tell the patient what is going on and to communicate. Grab all the patient’s belongings and provide the service dog to avoid separation. May occur because of a congenital defect, disease, injury, degeneration of the eyeball, optic nerve, or nerve pathway. May range from partial to total. Some patients have a loss of peripheral or central vision; others can distinguish light from dark or identify general shapes.

There are also various types of hearing impairments and special patient care considerations required when providing emergency medical care for hard-of-hearing patients. Patients who are hard of hearing may have difficulty with pitch, volume, and speaking distinctly. Some patients learn to speak even though they have never heard sounds. Other patients may have heard speech and learned to speak but have since sustained partial or total hearing loss, leading them to speak too loudly. The two most common forms of hearing loss are sensorineural deafness and conductive hearing loss. Sensorineural deafness, or nerve damage, results from a lesion or damage to the inner ear. Conductive hearing loss is caused by a faulty transmission of sound waves, which can occur when a person has an accumulation of wax inside the ear canal or a perforated eardrum. Look for the presence of hearing aids, poor pronunciation of words, or failure to respond to your presence or questions. Never shout; instead, write or use sign language. There are several types of hearing aids: behind-the-ear hearing aids, where the working parts are contained in a plastic case that rests behind the ear; conventional body aids, where the older style is generally used by people with profound hearing loss; in-the-canal and completely-in-the-canal hearing aids, which are contained in a tiny case that fits partly or completely into the ear canal; and in-the-ear aids, where all parts are contained in a shell that fits in the outer part of the ear. If you hear a whistling sound, the hearing aid may not be in far enough to create a seal, or the volume may be too loud. Try repositioning the hearing aid or remove it and turn down the volume. If you cannot insert the hearing aid after two tries, put it into a box and take it with you. Never try to clean it or get it wet. To troubleshoot, make sure the aid is turned on, try a fresh battery, and check to make sure it is not twisted or bent. Ensure that the switch is set on M (microphone) and not T (telephone). Some patients who are hard of hearing are sensitive to loud noises close to their ears.

Cerebral palsy is a term for a group of disorders characterized by poorly controlled body movement. This disorder is a result of damage to the developing fetal brain while in utero, oxygen deprivation at birth, a traumatic brain injury at birth, or infection such as meningitis during early childhood. It is associated with other conditions such as visual and hearing impairments, difficulty communicating, epilepsy (seizures), and intellectual disabilities. May possess some degree of intellectual impairment. May have an unsteady gait (ataxia) and may require the assistance of a wheelchair or walker. XABC is important when treating a patient with cerebral palsy because these patients may have increased secretion production and difficulty swallowing (dysphagia), requiring aggressive suctioning to clear the airway. Whenever possible, transport walkers or wheelchairs with the patient. Approximately 25% of patients with cerebral palsy have a seizure disorder. Be prepared to address a seizure if one occurs. 75% have an intellectual disability, but many people have a normal IQ.

Spina bifida is a birth defect caused by the incomplete closure of the spinal column during embryonic or fetal development, resulting in an exposed portion of the spinal cord. The opening can be closed surgically, but the child is often left with spinal and neurologic damage. B9 (folic acid) reduces the risk of spina bifida. Some patients with spina bifida also have hydrocephalus, which requires the placement of a shunt to drain excessive amounts of cerebrospinal fluid from the brain. Be aware that some patients with spina bifida have partial or full paralysis of the lower extremities, loss of bowel and bladder control, and an extreme allergy to latex products.

Paralysis is the inability to voluntarily move one or more body parts. It may be caused by stroke, trauma, or birth defects. Paralysis does not always involve a loss of sensation; there may even be hyperesthesia, which may cause the patient to experience touch as pain in the affected area. May need ventilators, urinary catheters, tracheostomy tubes, colostomy bags, or feeding tubes, which are discussed later in this chapter. There may be difficulty swallowing, creating the need for suctioning.

A tracheostomy is a surgical procedure that creates a stoma through a patient’s anterior neck, providing a pathway directly into the trachea where a tracheostomy tube may be placed to allow for a patent airway. The standard tracheostomy tube has three components. There is an outer cannula with a flange that helps support and stabilize the device as it passes through the neck. The outer cannula may have a cuff that seals the trachea off from the upper airway. This cuff is inflated through a pilot balloon and valve on the outside of the device. Within the outer cannula is a slightly smaller inner cannula through which the patient is ventilated. The inner cannula has a 15 mm adapter that allows for a bag-mask device or ventilator circuit to be attached. Most inner cannulas are capable of being removed for cleaning or in case a plug has developed. The final component of a tracheostomy tube setup is a rigid obturator. This blunt-tipped device is curved and long enough to reach the distal end of the outer cannula. It is used when reinserting the flexible inner cannula. Some patients use a valve attached to the end of the tracheostomy to help them speak. An obstruction of the tracheostomy tube is an emergency that requires you to intervene immediately. A useful mnemonic is DOPE. Failure to clear an obstructed tracheostomy tube could lead to cardiopulmonary arrest. D – Displaced, dislodged, or damaged tube; O – obstructed tube (secretion, blood, mucus, vomitus); P – pneumothorax; E – equipment failure (kinked tubing, ventilator malfunction, empty oxygen supply). If suctioning of the tracheostomy tube is necessary, first attempt to use the patient’s suction device. It is probably already sized correctly and readily available. If the size of the suction catheter is unknown, estimate the size by doubling the inner diameter of the tracheostomy tube. If the length of the patient’s tracheostomy tube cannot be determined, insert the suction device no more than 1 to 2 inches (3 to 6 cm) deep. The suction unit should be set to 100 mm Hg. You may need to instill 2 to 3 mL of saline before suctioning thick tracheal secretions. Do not suction for more than 10 seconds and do not force the suction catheter into the cannula. Oxygenate before and after the procedure. Call for ALS backup.

Home oxygen is useful for certain patients with chronic obstructive pulmonary disease. There are two types of oxygen delivery systems which are used for these patients. The first option is the use of oxygen from compressed gas cylinders or machines that concentrate oxygen from the ambient air and then compress it for delivery to the patient. These devices require electricity, meaning that they need to have gas cylinders as backup during emergencies. The compression that home oxygen concentrators are able to achieve varies by machine but is generally limited to 10 L/min. Portable oxygen concentrators can provide patients with increased mobility but are only able to provide 1 to 3 L/min.

Apnea monitors are used when there is a family history of sudden infant death syndrome or when an infant is born prematurely, has severe gastroesophageal reflux that causes choking episodes, or has experienced an apparent life-threatening event and in high-risk infants from 2 weeks to 2 months after birth. A typical apnea may last for approximately 15 to 20 seconds during periods of sleep. It is designed to sound an alarm if the infant experiences bradycardia or an episode of apnea occurs.

When there is an internal cardiac pacemaker, never place automated implanted cardioverter defibrillator pads over the device. An implanted cardioverter defibrillator monitors the patient’s heart rhythm and is able to slow accelerated heart rates. A useful question to ask is at what heart rate will the defibrillator fire and how many times has the defibrillator delivered a shock. Ventricular assist devices take over the function of one or both heart ventricles and are a bridge until there is a heart donor. Left ventricular assist device is the most common. It may be difficult to palpate a pulse in patients who use a VAD. In such cases, assess perfusion by noting level of consciousness, skin color, temperature, moisture, and blood pressure. The patient should have a go bag that must always be transported with them. Risk factors include excessive bleeding following surgery, infection, blood clots leading to stroke, and acute heart failure. Be prepared to provide CPR. Assess the patient’s level of consciousness, skin color, and capillary refill. If the device’s alarm is sounding, check all connections and be sure the batteries are fully charged. Notify ALS personnel as soon as possible.

External defibrillator vest is a vest with built-in monitoring electrodes and defibrillation pads, which is worn by the patient under his or her clothing. The vest is attached to a monitor that provides alerts and voice prompts when it recognizes a dangerous rhythm and before it delivers a shock. Avoid touching the patient if the device warns of shock. In situations of cardiac arrest, the vest should remain in place while you perform CPR unless it interferes with compressions.

A central venous catheter is a central line placed in the vena cava to provide venous access. It is used for those receiving chemotherapy, long-term antibiotic therapy, pain management, total parenteral nutrition, and hemodialysis. Problems associated with central venous catheters include broken lines, infections around the lines, clotted lines, and bleeding around the line or from the tubing attached to the line. If bleeding occurs, apply direct pressure to the tubing and provide prompt transport.

Gastrostomy tubes are placed into the stomach of patients who cannot adequately ingest fluids, food, or medication by mouth. These tubes may be inserted through the nose or mouth into the stomach or inserted surgically directly into the stomach through the abdominal wall. Gastric tubes may become dislodged during the patient’s normal daily activities. If such a situation arises, immediately stop the flow of any fluids being infused through the tube, assess the patient for signs or symptoms of bleeding into the stomach, such as abdominal discomfort, nausea, and vomiting, especially emesis with a coffee-ground appearance or with bright red blood. There is increased risk of aspiration—vomitus or other foreign material in the lungs. Patients with gastric tubes who have difficulty breathing should be transported while sitting or lying on the right side with the head elevated 30 degrees to prevent the contents of the stomach from passing into the lungs. Patients with diabetes who receive insulin may become hypoglycemic quickly if the gastric tube feedings are discontinued for any reason.

Patients with chronic neurologic conditions may have shunts in place. Hydrocephalus will have shunts (spina bifida). Shunts are tubes that drain excess cerebrospinal fluid from the ventricles of the brain to keep pressure from building up in the brain. During the assessment, you will feel a device beneath the skin on the side of the head behind the ear. The device is a fluid reservoir, which should alert you to shunts. There are different types of shunts; a ventriculoperitoneal (VP) drains excess fluid from the ventricles of the brain into the peritoneum of the abdomen. A ventriculoatrial (VA) drains excess fluid from the ventricles of the brain into the right atrium of the heart. A shunt may become blocked or infected. A blockage is a medical emergency due to increased intracranial pressure, which may affect the patient’s mental status. The signs include a high-pitched cry or bulging fontanelles (in infants), headache, projectile vomiting, altered mental status, irritability, fever, nausea, difficulty with coordination or walking, blurred vision, seizures, redness along the shunt tract, bradycardia, and heart dysrhythmias.

Vagus nerve stimulators help to prevent seizure activity. A colostomy or ileostomy is a surgical procedure that creates an opening from the small or large intestine to the surface of the body that allows for elimination of waste products. Feces are expelled and collected into a clear external bag or pouch. When you encounter this, assess for signs and symptoms of dehydration (skin turgor is one way to do this). Signs of infection include redness, warm skin around the stoma, and tenderness with palpation over the colostomy or ileostomy site. A urostomy is a surgically created connection between the urinary system and the surface of the skin that allows urine to drain through a stoma in the abdominal wall instead of through the urethra.

Services offered by home care agencies include meal delivery, house cleaning, laundry, yard maintenance, physical therapy, and personal care, including bathing and wound care. Home care staff is useful when obtaining SAMPLE and other medical history. For hospice care and terminally ill patients, there may be a do not resuscitate order or given medical orders for the scope of treatment, outlining the care agreed upon by the patient. Hospice care provides comfort care or palliative care, which is treatment for pain, nausea, and difficulty breathing during a person’s last days. Comfort care improves the patient’s quality of life before death and allows the patient to be with family and friends. You may be called to the home because of a delay in the arrival of the regular care provider or for transport so that a physician can address an immediate need such as increasing pain. If there is a DNR order, ask to review it and consult medical control.