TRANSITION SERIES Topics for the Advanced EMT CHAPTER Special Challenges 47

Objectives Discuss basic descriptions of the size of the problem regarding special challenge cases. Discuss pathophysiology of unique emergencies that may be seen by EMS.

Objectives (cont’d) Discuss a general assessment approach and treatment strategies for these patients categorized as “special challenges.”

Introduction Due to lifestyle changes and medicine, the life spans of humans are lengthening. Advances in medicine allow technology to go home with the patient.

Introduction (cont’d) Congenital disease patients live longer at home, due to medicine. EMS may not know what the medical technology is, but they must always know what to do.

Epidemiology No specific registry or definition for what “specially challenged” is. Underreporting is also believed to occur, especially with abuse.

Epidemiology (cont’d) Over 3 million pediatric abuse cases and over half a million elder abuse cases. 8 million disabled people are receiving health care from professional providers.

Pathophysiology Abuse –Child abuse  Physical, emotional, sexual –Elder abuse  Physical, emotional, sexual –Passive versus active  Neglect

Physical abuse of an elderly person can have dire consequences because of the patient’s frailty.

Pathophysiology (cont’d) Mental Illness –Mild to severe disabilities –Commonly include the following features:  Cognitive disabilities  Speech impediments  Behavioral disorders  Movement disorders

Causes of Mental Retardation

Pathophysiology (cont’d) Disabilities –A problem of the patient that was caused by a disease, that results in sustained medical care for the person. –Common disabilities seen in EMS include:  Paralysis  Obesity  Traumatized patients

Pathophysiology (cont’d) Disabilities – Paralysis –Loss of function of single or multiple muscles –Damage to nervous system (spinal cord) –Neuromuscular diseases

Pathophysiology (cont’d) Disabilities – Obesity –Over 40% of the U.S. population is obese. –Obesity may be due to lifestyle choices or medical conditions. –Obesity creates a multitude of secondary emergencies. –Obesity also creates a patient handling and movement concern for EMS.

Effects of Excess Weight on Organ Systems

Pathophysiology (cont’d) Disabilities—Traumatized patients – Head and/or brain trauma – Commonly there are residual effects  Mild—speech or gait impairments  Severe—unresponsive, seizures, technology dependent –Most patients fall between these two extremes.

Pathophysiology (cont’d) Technology Assistance/Dependency –Medical equipment designed for patient care  Enhances quality of life  Sustains life –EMS must remain aware of common types of equipment. –Some EMS systems track where patients live who are technology dependent.

Pathophysiology (cont’d) Apnea Monitor –Monitors patient's breathing status –Some monitor heart rate –Common to neonates and infants –Audible alert for when patient stops breathing

Pathophysiology (cont’d) Tracheostomy Tube –Provides an artificial opening into the airway. –Placed through the anterior of the neck. –Bypasses the mouth and nose.

A tracheostomy tube for older children and adults has an outer cannula and an inner cannula.

The AEMT can ventilate a patient with a tracheostomy by attaching the bag- valve device to the tracheostomy tube’s 15/22 mm adapter.

Pathophysiology (cont’d) CPAP and BiPAP –Designed to provide “back pressure” via mask that attaches to face. –Helps to keep small bronchioles open during breathing, and the airway open during sleep. –Commonly found with obese patients and certain chronic lung diseases.

Pathophysiology (cont’d) Home Mechanical Ventilators –Assist or provide total ventilatory needs to a patient who cannot maintain own ventilatory effort. –Include negative and positive pressure units. –Controls include rate, volume, and occasionally oxygen levels.

Pathophysiology (cont’d) Home Mechanical Ventilators –Alarms (may be reason EMS is summoned)  High pressure alarm  Low pressure alarm  Apnea alarm  Low FiO 2 alarm

Vascular access devices include central IV catheters such as a PICC line, central venous lines such as the Broviac catheter, and implants ports such as the MediPort system.

Pathophysiology (cont’d) Vascular Access Devices –Devices implanted into the skin. –Allow for ongoing or multiple medication administrations into the patient's vascular system. Dialysis –Replaces kidney function. –Hemodialysis—done at facility. –Peritoneal dialysis—done at home.

Pathophysiology (cont’d) Feeding Tubes –Provide nutrition to patients who cannot chew. –“Enteral feeding” or “tube feeding” –Types  NG tube—nose to stomach  OG tube—mouth to stomach  G-tube—through skin to stomach  J-tube—through skin to jejunum (middle section of the small intestine)

Pathophysiology (cont’d) Intraventricular Shunts –Medical illnesses or anatomic defects that allow excessive CSF to accumulate. –Increased CSF can cause damaging ICP issues.

Pathophysiology (cont’d) Intraventricular Shunts –Shunt is placed in ventricle of brain and extends to blood vessel in neck, heart, or abdomen. –Occasionally there may be an external reservoir.

Assessment Findings During your assessment, ask about the medical equipment. –Where do I get the best information regarding this equipment? –What does this device do for the patient? –Can I replicate its function should it fail? –Will this equipment change assessment findings?

Assessment Findings (cont’d) During your assessment, ask about the medical equipment –Has this ever occurred before? What fixed it? –Has anyone attempted to remedy the problem? –Do I have movement or handling issues with this equipment?

Emergency Medical Care Manual cervical spine considerations Assess and maintain the airway. Determine breathing adequacy. –High-flow via NRB with adequate breathing. –High-flow via 10-12/min if inadequate. –Maintain saturation >95%.

Emergency Medical Care (cont’d) Assess circulatory components. –Check pulse, skin characteristics.

Emergency Medical Care (cont’d) Initiate transport with Paramedic intercept. Position the patient based on condition and medical equipment. –Consider immobilization needs. Constantly monitor airway, breathing, and circulation. Try to use medical equipment if it is portable and working correctly.

Summary Patients with special needs are those who usually have some medical technology helping them with life. When this equipment malfunctions, typically it is EMS that is called.

Summary (cont’d) The role of the Advanced EMT is to manage the patient's problem(s), incorporating this technology into their assessment and management.