1. Condell Medical Center EMS System
Curriculum Update: Patients With Special Challenges and Interventions for Patients with Chronic Care Needs
Condell Medical Center EMS System
August 2006
Site Code # E1206
Revised by:
Sharon Hopkins, RN, BSN
EMS Educator

2. Patients With Hearing Impairments
Deafness – partial or complete inability to hear
Conductive problem due to:
infection
injury
earwax
Sensorineural deafness due to:
congenital problem, birth injury
disease, tumor, viral infection
medication-induced
aging
prolonged exposure to loud noise
Faulty transportation of sound from outer to the inner ear.
Curable disease process. Infections like otitis media and
Injury like barotrauma may cause this problem.

3. Patients With Special Challenges - Hearing Impairments
Recognizing patients with hearing loss
Hearing aids
Poor diction
Inability to respond to verbal communication in the absence of direct eye contact
Speaks with different syntax (speech pattern)
Use of sign language

4. Patients With Special Challenges - Hearing Impairment
Assessment/management accommodations
Provide pen/paper
Do not shout or exaggerate lip movement
Speak softly into their ear canal
Use pictures or demonstrate procedures
Notify hospital so interpreter is available
80% of hearing loss is related to the loss of
High-pitched sounds. Use low-pitched sounds is more
Effective. Specialized assistive devices that may be used by the hearing impaired patient include amplified or typed message
Telephones, low frequency or flashing doorbells, closed-caption
TV decoders, flashing alarm clocks and fire alarms

5. Patients With Special Challenges - Visual Impairment
Etiologies
Injury
Disease
Degeneration of eyeball, optic nerve or nerve pathways
Congenital
Infection (C.M.V.)
Visual impairment is any condition that obstructs the passage of
Light from the retina. May be present at birth or congenital.
Congenital etiologies are: cataracts, diabetes, hypertension.
Vitamin A deficiency in children in developing countries.

6. Patients with Special Challenges - Visual Impairment
Central vs peripheral loss
Patients with central loss of vision are usually aware of the condition
Patients with peripheral loss are more difficult to identify until it is well advanced
Central loss
Peripheral loss

7. Patients With Special Challenges - Visual Impairment
Assessment/management accommodations
Retrieve visual aids/glasses
Explain/demonstrate all procedures
Allow guide dog to accompany patient
Notify hospital of patient’s special needs
Carefully lead patient when ambulatory
patient holds your arm
call out obstructions, steps and turns ahead of time

8. Etiologies of Speech Impairment
Language disorders
Stroke •Hearing loss
Head injury •Lack of stimulation
Brain tumor •Emotional disturbance
Delayed development
Articulation disorder
Damage to nerve pathways passing from brain to muscles in larynx, mouth, or lips
Delayed development from hearing problems; slow maturation of nervous system
Speech can be slurred, indistinct, slow, nasal
Patients frequently demonstrate aphasia with slowness to
Understand speech and problems with vocabulary and
Sentence structure. Delayed development of language
May result from hearing loss, lack of stimulation, or emotional
Disturbance.

9. Etiologies of Speech Impairment
Voice production disorders
Disorder affecting closure of vocal cords
Hormonal or psychiatric disturbances
Severe hearing loss
Hoarseness, harshness, inappropriate pitch, abnormal nasal resonance
Fluency Disorders
Not well understood
Marked by repetition of single sounds or whole words
Stuttering
Characterized by hoarseness, harshness, inappropriate
Pitch, abnormal nasal resonance.

10. Recognizing Patients With Speech Impairment
Reluctance to verbally communicate
Inaudible or nondiscernable speech pattern
Language disorders (aphasia)
Limitations in speaking, listening, reading & writing
Slowness to understand speech
Slow growth in vocabulary/sentence structure
Common causes: blows to head, GSW, other traumatic brain injury, tumors

11. Utilizing Translation Line

12. Patients With Special Challenges -Obesity
Definition
body weight 20% over the average weight of people same size, gender, age
>58 million Americans are obese
2nd leading cause of preventable death
Etiologies
Caloric intake exceeds calories burned
Low basal metabolic rate
Genetic predisposition

13. Obesity Risk Factors Hypertension Stroke Heart disease Diabetes
Some cancers
Kidney failure

14. Assessment/management Accommodations- Obesity
Appropriate sized equipment
May have extensive medical history
Additional assistance for lifting/moving
Recognize your own biases
Assessment techniques may need to be altered

15. Breathing Considerations in Obesity
Lungs 35% less compliant
Increased weight of the chest
Increased work of breathing
Hypoxemia common
O2 sats not reliable on finger tips (poor circulation)
Diaphragm higher

16. Airway Considerations in Obesity
Control of airway challenging!!!
Short neck
Large powerful tongue
Distorted landmarks
Cricoid pressure helpful in stabilizing anatomy during intubation attempts
Positioning is critical
towels, blankets, pillows

17. Circulation Considerations in Obesity
Hypertension common
Alternate blood pressure cuff size
may need to use thigh cuff around upper arm
if difficulty fitting cuff around upper arm, place around forearm, stethoscope over radial artery
Prone to pulmonary emboli due to immobility

18. Transport Considerations in Obesity
Can be dangerous
Ensure ample personnel
Patient must fit through doorway
Patient may not tolerate supine position
May need to remove cot from ambulance for patient to fit
Know weight limitations of stretcher

19. Patients With Special Challenges - Spinal Cord Injuries
Conditions result from nerve damage in the brain and spinal cord
MVC, sports injury, fall, GSW, medical illness
Paraplegia
Weakness/paralysis of both legs
Quadriplegia
Paralysis of all four extremities and possibly the trunk

20. Assessment/Management Accommodations - Spinal Cord Injuries
Assistive devices may need to be transported with the patient
May have ostomies (trachea, bladder,colon)
May be ventilator dependent
May need to transport wheel chairs
Priapism in male patients - may be presenting as a medical emergency

21. Patients With Special Challenges - Mental Illness
Any form of psychiatric disorder
Psychoses – mental disorders where there is loss of contact with reality; patient may not be aware they have a disorder
schizophrenia, bipolar, organic brain disorder
Neuroses-related to upbringing and personality where person remains “in-touch” with reality; patients are aware of their illness
depression, phobias, obsessive/compulsive disorder
Psychoses- may be related to biochemical disease that alters brain function. Such as
Schizophrenia, bipolar disorder (manic-depressive disorder), organic brain disease.
Neuroses- don’t limit social or work responsibilities. Fluctuate with intensity and stress
Level. Such as depression, phobias, obsessive-compulsive disorders

22. Assessment/Management Accommodations - Mental Illness
Solicit permission before beginning care
Gain rapport/trust but your safety is first
Don’t make promises you can’t keep
Don’t be afraid to ask about medications, mental illness history, ingestion of alcohol or non-prescription drugs
Evaluate for underlying medical illnesses
If presents as danger to self or others; use proper restraints; document use and distal circulation
If handcuffs, police in rig to ride with patient

23. Patients With Special Challenges - Down’s Syndrome
Chromosomal abnormality that causes mild to severe mental retardation
IQ varies from 30-80
Eyes slope upward and at the outer corners
Folds of skin at side of nose that covers inner corners of the eyes
Small face and facial features
Large and protruding tongue
Flattening on back of the head
Hands that are short and broad

24. Assessment/Management Accommodations - Down’s Syndrome
Congenital heart, intestinal, hearing defects
Limited learning capability
Generally affectionate and friendly
Utilize patience with assessment
Explain procedures before beginning task

25. Patients With Special Challenge - Emotional Impairment
Impaired intellectual functioning that results in inability to cope with normal responsibilities of life
Neurasthenia - irritability, lack of concentration, worry, hypochondria
Anxiety neurosis - mild deviation of mind with unpleasant distressing emotion to imagined fear
Compulsion neurosis - recurrent & intrusive thought, feeling, idea, or sensation
Hysteria

26. Emotional or Mental Impairment
IQ • Mild impairment 55-70
• Moderate impairment 40-54
• Severe impairment 25-39
• Profound impairment < 25
Extensive history taking needed to differentiate emotional issue vs medical issue
Utilize patience and extra time in history taking and while providing care
Remain supportive & calm

27. Etiologies Emotional/Mental Impairment
During pregnancy
Use of alcohol, drugs or tobacco
Illness/infection (toxoplasmosis, rubella, syphilis, HIV)
Genetic
Phenlketonuria (PKU)-single gene disorder caused by a defective enzyme
Chromosomal disorder (down syndrome)
Fragile X syndrome - single gene disorder on Y chromosome. Leading cause of mental retardation

28. Etiologies Emotionally/Mentally Impaired cont’d
Poverty/cultural deprivation
Malnutrition
Disease-producing conditions (lack of cleanliness)
Inadequate medical care
Environmental health hazards
Lack of stimulation

29. Patients With Special Challenges - Emotionally or Mentally Impaired
Assessment/management accommodations
Chronological age may not be consistent with developmental age
May have numerous underlying medical problems
May show no psychological symptoms apart from slowness in mental tasks
Moderate to severe may have limited or absent speech, neurological impairments
Allow extra time for evaluation and patient responses

30. Patients With Special Challenges Due to Disease
Physical injury or disease may result in pathological conditions that require special assessment and management skills
arthritis muscular dystrophy
cancer myasthenia gravis
cerebral palsy poliomyelitis
cystic fibrosis spina bifida
head injury
multiple sclerosis

31. Patients With Special Challenges - Arthritis -
Inflammation of a joint, characterized by pain, stiffness, swelling and redness
Has many forms and varies in its effects
Osteoarthritis - results from cartilage loss and wear of joints (elderly)
Rheumatoid arthritis - autoimmune disorder that damages joints/surrounding tissue
Ask patient least painful method to assist in moving & touching them

32. Patients With Special Challenges - Cancer
Signs and symptoms
Pale, ashen skin
Loss of hair due to chemotherapy
VAD (venous access device)
Weakness
Transdermal skin patches for pain medication
Determine if under hospice care and DNR status
DNR must be valid State form to be honored by EMS in field
questions - contact medical control

33. Patients With Special Challenges - Cerebral Palsy
Non-progressive disorder of movement and posture due to a damaged area of brain that controls muscle tone
Most occur before birth
cerebral hypoxia, maternal infection
Damage to fetal brain in later stages of pregnancy, during birth, newborn or early childhood

34. Patients With Special Challenges
Types of Cerebral Palsy
Spastic – abnormal stiffness and difficulty with movement
Athetoid – involuntary & uncontrolled movements
Ataxic – disturbed sense of balance & depth perception
Mixed - some combination of the above in one person

35. Patients With Special Challenges - Cerebral Palsy
Signs and Symptoms
Unusual muscle tone noted during holding and feeding
60% have mental retardation/
developmental delay
Many have high intelligence
Weakness or paralysis of extremities
Each case is unique to the degree of limitations
Prepartum cerebral palsy results from cerebral hypoxia and maternal infection. Postpartum results from encephalitis, meningitis and head
Injury. Although no cure, many are of high intelligence and have
Relative independence and normal life expectancy.

36. Patients With Special Challenges - Cystic Fibrosis
Inherited metabolic disease of the lung and digestive system
Childhood onset
Defective, recessive gene inherited from each parent (become carrier if gene inherited from only 1 parent)
Gland in lining of lung produces excessive amounts of thick mucous
Pancreas fails to produce enzymes required to break down fats and their absorption from the intestines

37. Patients with Special Challenges - Cystic Fibrosis
Signs and Symptoms
Patient predisposed to chronic lung infections
Pale, greasy looking, foul smelling stools
Persistent cough/breathlessness
Stunted growth
Sweat glands produce salty sweat
May be oxygen dependent, need of suctioning
May be a heart/lung transplant recipient

38. Patients With Special Challenges - Previous Head Injuries
Traumatic brain injury affects cognitive, physical and psychological skills
Physical appearance may be
uncharacteristic
or may be
obvious

39. Patients With Special Challenges - Previous Head Injury
Signs and Symptoms
Speech and mobility may be affected
Short term memory loss
Cognitive deficit of language and communication
Physical deficit in balance, coordination, fine motor skills
Patients may use protective or helpful appliances (ie: helmet, braces)

40. Patients With Special Challenges - Multiple Sclerosis
Progressive/incurable autoimmune disease
Brain and spine myelin destroyed
May be inherited or viral component
Begins in early adulthood
Physical/emotional stress exacerbates severity

41. Patients With Special Challenges - Multiple Sclerosis
Signs and Symptoms
Fatigue, mood swings
Vertigo
Muscle weakness; extremities that feel heavy and weak
Spasticity; difficulty ambulating
Slurred speech
Blurred vision
Numbness, weakness, or pain in face
Midlife incontinence; frequent UTI’s

42. Patients With Special Challenges - Muscular Dystrophy
Inherited, incurable muscle disorder that results in a slow but progressive degeneration of muscle fibers
Life span generally not beyond teen years
Duchenne muscular dystrophy
Most common sex-linked cause
Recessive gene that only affects males
Diagnosed after age 3

43. Patients With Special Challenges - Muscular Dystrophy
Signs and Symptoms
Child that is slow to sit and walk
Unusual gait
Patient eventually unable to ambulate
Curvature of the spine
Muscles become bulky and replaced with fat
Immobility causes chronic lung diseases
Management & care includes respiratory support

44. Patient With Special Challenges - Myasthenia Gravis
Chronic autoimmune disorder of CNS
Weakness to skeletal (voluntary) muscles
Caused by defect in transmission of nerve impulses to muscles
Eye & eyelid •Throat
Face • Extremities
Chewing, talking, swallowing
Symptoms vary by type & severity
Dependent on precise timing of daily medication
Can live normal or near normal life

45. Myasthenia Gravis Signs and symptoms Women ages 20-30; men ages 70-80
Drooping eyelid, double vision
Difficulty speaking, chewing & swallowing
Weakened respiratory muscles
Exacerbated by infection, medications and menstruation
Controlled with drug therapy to enhance transmission of nerve impulses

46. Patients With Special Challenges - Poliomyelitis (polio)
Infectious disease caused by poliovirus hominis
Virus is spread through direct and indirect contact with infected feces and by airborne transmission
Salk & Sabin vaccines in have reduced incidences
In USA polio virus now injected and not oral form (virus shed thru GI system when given orally)

47. Patients With Special Challenges - Poliomyelitis
Signs and Symptoms
Paralysis of lower extremities
Unable to ambulate
Chronic respiratory diseases
Management & care
Needs support for ambulation
May need careful handling of extremities to avoid further injury
Assessment may take longer due to body disfigurement

48. Patients With Special Challenges - Spina Bifida
Congenital defect where part of vertebra fails to develop, leaving part of the spinal cord exposed
Ranges from minimal severity to severely disabled
Loss of sensation in all areas below defect
Associated abnormalities
Hydrocephalus with brain damage
Cerebral palsy
Mental retardation

49. Patients With Special Challenges
Financial Challenges
A patient’s ability to pay should never be a factor in obtaining emergency care
Federal laws mandate that quality, emergency health care be provided, regardless of the ability to pay

50. Patients With Financial Challenges
Issues patient deals with
Homelessness
Chronic illness with frequent hospitalizations
Lack of funds for purchase of routine medications
Poor personal hygiene
Poor nutritional status
Emaciation

51. Patients With Financial Challenges
Resources
Payment programs may be available
Government services are available to assist
What does your township office offer?
Free (or near-free) health care services available through local, state and federally-funded organizations

52. Interventions for the Specially Challenged and Chronic Care Patient

53. Home Healthcare Providers
Home health providers know the equipment in the home
They know the patient and the normal state of holistic health
Can make a quick response to acute changes in status
Often highly trained providers
They can be a great resource

54. EMS vs. Home Healthcare
Both have to compliment each other to provide high level of care to the patient
By being integral parts to the overall care delivery system, the patient gets ultimate care
If either decides their job is more important, the delivery of care diminishes

55. Healthcare Delivery Training or education possibilities
Registered nurse (hospice oriented)
Registered respiratory therapist
Certified nurses aid (CNA)
Registered occupational therapist
Registered speech pathologist
Licensed paramedic (EMT)
Certified nursing assistant (CNA)

56. Delivery of Home Healthcare
Benefits of home health care
Early disposition of acute health problems
Socialization of home-bound client
Family members can be more involved
Patient gets to stay at home while recovering from illness or injury
Less stress to the patient

57. Delivery of Home Healthcare
Deficiencies in care
Cost
Variety of levels and competencies of healthcare providers
Low pay to the provider
Incompetence of provider
Family members not in agreement with care
Complications
Inadequate recognition of acute illness
Theft to the patient

58. In-hospital vs. Homecare
Mortality and quality
Higher incidence of infection as an in-patient
Quality of care depends on competence of the provider in each situation
Can be very supportive and actually diminish the instance for hospitalization if the home care provider is aggressive
Less stress on the patient to be cared for at home

59. Home Care
Equipment
Nearly any piece of equipment found in a hospital can be used at home
Complications and pathologies to summon EMS support
Inadequate respiratory support
Acute cardiac events
Acute sepsis
GI/GU crisis
Home dialysis emergencies
Displaced catheters or G/J-tubes

60. Home Care Airway Adjuncts
Oxygen delivery devices
CPAP machine (mask and nasal)
BiPAP machine
Tracheotomies
Home ventilators
Peak flow machine

61. Vascular Access Devices
Central venous access devices
Hickman, Groshon
Directly into central circulation
Often surgically implanted
Dialysis shunts - usually forearm, may be abdominal placement
PICC access device
Peripheral line
Generally in antecubital
Peripheral venous IV

62. Nutrition (Delivery/Removal)
Gastric emptying or feeding
NG tubes
Feeding tubes
PEG tubes (J-tubes)
Colostomy
Urinary tract
Internal/external catheters
Suprapubic catheters
Urostomy - collection bag worn
PEG tubes

63. Urinary Catheter Insertion
Indications
Ability to monitor output
Incontinence
Decreased level of consciousness
Frequency
Contraindications
Inability to care for insertion site
Increases risks of infections that could lead to sepsis

64. Assessing Complications of the Airway
Evaluate
Respiratory effort
Tidal volume
Peak flow
Oxygen saturation
Breath sounds
Compare values based on the patient’s “normal” or baseline levels

65. Assessing Complications of Vascular Access Devices
Infection/sepsis
Inadvertent removal
Hemodynamic compromise
Hemorrhage
Embolus
Stable vs. unstable angina
Improper fluid administration
Inability of home caregiver to flush device
PICC line

66. Assessing Complications of GI/GU Devices
Abdominal pain
Inability of caregiver to flush device
Distention
Lack of bowel sounds
Palpation of bladder indicating fullness
Change in color/character/amount of urine
Redness/discharge at insertion sites

67. Ventilatory Devices Recognizing device or patient failure
Inadequate oxygenation
Anxiety
Hypoventilation
Management
Reposition airway
Remove secretions - suction
Support ventilations with BVM
May need to transport patient to hospital with their ventilator - will it fit in rig?
Consider using home caregiver to continue assisting in providing care

68. Rights of the Terminally Ill
Right to refuse care
Right to comfort
Right to advanced healthcare
They need family support as well as integrated healthcare team
Hospice care
Comfort care

69. Hospice care Definition
The ability to provide care for a patient in a comfort type of environment as the disease process is in an advanced stage
Patient usually terminal within 6 months
Care is patient and family centered
Palliative & comfort care is necessary

70. Hospice Care Employs team of caregivers
Advanced directives followed to honor the patients wishes
Family is very involved in process of care
Disease process not limited to cancer care only
Family may call 911 for acute problem (dyspnea, chest pain) that needs to be attended to with full care provided prior to arresting
Involves great deal of emotional support

71. DNR/DNAR Do not attempt resuscitation
Does not mean do not treat medical conditions
The DNR form must be the State form including the patient name, patient signature, date, doctor’s signature and the words “do not resuscitate”
CPR must be started in the absence of a valid, signed DNR form except for decapitation, rigor mortis without hypothermia, dependent lividity, body decompensation, incineration

72. Patients with Special Challenges and Chronic Care Needs
Questions ??