Alexander ch46 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 46
Patients with
Special Challenges

• The Advanced EMT applies a fundamental
knowledge of growth, development, and aging and
assessment findings to provide basic and selected
advanced emergency care and transportation for
a patient with special needs.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Explain the importance of understanding the care of
patients with special challenges.
3. Demonstrate empathy and respect when caring for
patients who have special challenges.
4. Advocate for the empathetic treatment of patients who
have a variety of special challenges.
5. Give examples of special challenges.
Objectives (1 of 2)

6. Describe the special physiologic, medical, and
psychosocial concerns, and accommodations and
modifications to patient assessment and management
that are required when caring for patients with special
challenges.
7. Describe common types of home medical equipment,
including apnea monitors, CPAP and BiPAP, feeding
tubes, intraventricular shunts, mechanical ventilators,
medical oxygen, ostomy bags, tracheostomy tubes,
urinary catheters, and vascular access devices.
8. Describe the philosophy of hospice care.
Objectives (2 of 2)

Introduction (1 of 2)
• Special challenges
– Obesity
– Sensory impairments
– Paralysis
– Reliance on medical equipment
– Social conditions
• Patients with special challenges are encountered
in variety of settings.

Introduction (2 of 2)
• Be empathetic to patient’s condition, not
judgmental.
• Care for patient regardless of history, mental state,
physical state, and living conditions.
• Patient/caregivers are the most reliable sources of
information about condition or disability.

Think About It
• What are the first actions that Robert and Al
should take?
• What are some potential causes of the patient’s
condition?
• What additional information would assist Robert
and Al in determining the cause of the patient’s
condition?

• Hearing impaired
– Hearing impairment (deafness)
– Partial loss can involve one ear or both ears.
– Result of congenital condition, brain injury, or illness
 Rely on hearing aids or cochlear implants
– May be necessary to speak in louder voice (tone);
shouting distorts sound of words
 Many deaf patients rely on lip reading or sign language.
Sensory and Speech Impairments
(1 of 3)

• Vision impaired
– Vision impairment (blindness)
– Vision loss in only one eye, in specific visual fields, or
total loss involving both eyes
– Can be congenital or result of illness, infection, injury,
or degenerative conditions involving eye or optic nerve.
– Make sure you are in constant verbal contact with the
patient.
(2 of 3)

• Speech impairment
– Language disorders: inability to understand spoken or
written communication
– Articulation disorders (dysarthria): inability to speak
clearly
– Voice production disorders: impairment of normal
voice; hoarseness or unusual pitch results
– Fluency disorders: stuttering speech
(3 of 3)

Figure 46-1
Developmentally impaired patients are often difficult to communicate with, so you should
enlist the assistance of caregivers whenever possible.

Cognitive Impairment (1 of 3)
• Result of developmental disorders, past traumatic
brain injury or stroke, dementia, mental illness
• With some types, judgment and inhibition are
affected; be alert for potential violent or
inappropriate behaviors.

• Developmental impairments
– Difficulty learning or limited ability to learn
– Mild impairment: can generally answer questions
– Severe impairment: cannot communicate effectively
– If possible, allow caregiver to accompany patient in
ambulance.

• Brain-injured patients
– Impairments in cognition, emotions, or behavior
– Result of brain trauma, encephalitis, or meningitis.
– Often require use of medical devices (ventilators,
catheters, pumps)
 Individuals responsible for care of patient are well versed in
proper use of devices.

Paralyzed Patients
• Paralysis: result of trauma (spine injury) or
medical causes (stroke or neuromuscular disease)
– Paralysis in only one extremity.
– Paraplegic: paralysis from waist down
– Quadriplegic (tetraplegic): paralysis of all four
extremities
• Susceptible to pressure sores, pneumonia, urinary
tract infections

Figure 46-2
Many EMS agencies use specialized bariatric ambulances to transport obese patients.

Bariatric Patients (1 of 2)
• Bariatrics
– Medical care that specializes in care of obese patients
– Obese patients: limited mobility; risk for coronary artery
disease, diabetes, congestive heart failure, stroke,
chronic obstructive pulmonary disease, hypertension
– Many EMS agencies have specialized bariatric
ambulances.

Bariatric Patients (2 of 2)
• Bariatrics (continued)
– Obesity occurs when caloric intake exceeds amount of
calories required to meet body’s needs.
– Result of overeating, inadequate physical activity, or
underlying problem.
– Prior to lifting obese patient, ensure you have adequate
assistance to do so safely.

Figure 46-3
Homeless people are often seen in public with little to no personal belongings.
(© Michal Heron)

Homeless and Impoverished Patients
(1 of 3)
• Chronic homelessness
– Unaccompanied individual with disabling condition
continuously homeless for year or more
– Experienced four or more episodes of homelessness
over past three years
• What are the factors that contribute to an
individual being homeless?

(2 of 3)
• Homeless are at risk for:
– Illness and disease
– Violence
– Abuse
– Discrimination
• Sleep on ground or benches in public places
– Find shelter wherever they can
• Cannot afford to pay for necessities

(3 of 3)
• When caring for individuals who are homeless or
impoverished, care for them as you would anyone
else.
– Do not be judgmental or prejudiced.
• Be aware of special health care needs of the
homeless and impoverished, such as lack of
access to routine medical care or prescription
medications.

Abused Patients (1 of 9)
• Physical abuse: physical force that results in
bodily injury
• Psychological abuse: willful infliction of mental or
emotional anguish through threat, humiliation,
verbal or nonverbal means
• Sexual abuse: contact of any kind, nonconsensual
for competent adults and any kind for children

• Financial abuse: illegal or improper use of
individual’s money, property, resources; often
involves elderly
• Domestic abuse: violence used to intimidate a
partner to gain power or control
• Neglect: failure of caregiver to provide proper care
to individual for whom he or she is responsible

• Report your suspicions to proper authorities
according to your state’s guidelines.
• Goal is to remove patient from environment, care
for him or her, report suspicions.
• Document with as much detail as possible; be
objective and factual without drawing conclusions.

Figure 46-6
Bruising resulting from physical abuse.
(© Biophoto Associates/Science Source)

• Child abuse
– Affects children up to 18 years of age
– Abuser is most often someone child knows and trusts,
including child’s own parents.
– All races and socioeconomic groups
– Abusers tend to be male more than female

• Traits typical of abuser
– Drug and/or alcohol abuse
– Obvious lack of concern for child
– Lack of concern for child’s injuries or condition
– Blaming child for child’s injuries or condition
– Open criticism of child

• Behaviors that should alert you to abuse
– Avoiding or pulling away from parent or caregiver
– Wary or fearful of physical contact
– Lack of normal crying or emotion consistent with injury
or situation
– Parent or caregiver evasive; provides contradictory
information

Figure 46-8
Signs of elder abuse should be reported to the appropriate authorities so that they may
intervene as appropriate.
(© Dr. P. Marazzi/Science Source)

• Elder abuse
– Occurs in patient’s home, nursing homes, medical care
facilities
– Caregiver under additional stress
– Adult male children caring for elderly parent most likely
to commit elder abuse

• Signs of elder abuse
– Changes in personality or behavior
– Tension/arguing between patient and caregiver
– Unexplained injuries
– Evidence of restraints
– Caregiver’s refusal to let you be alone with patient
– Unexplained vaginal or anal bleeding
– Malnourished appearance

• You may find it difficult to maintain your
composure when you suspect abuse of children or
the elderly.
• Maintain emotional control so that you can remove
the patient from the environment.
• After the patient is safe, report your suspicions to
the proper authorities.

Technology-Dependent Patients
(1 of 15)
• Medical equipment allows patient to maintain
independence.
• Do not let presence of equipment distract you
from performing assessment of patient.
• Equipment categorized as: airway and respiratory,
vascular access, gastrointestinal and
genitourinary

(2 of 15)
• Medical oxygen
– Transport oxygen wherever they go.
– Nasal cannula connected to humidifier and oxygen
cylinder
– Oxygen concentrator: captures and concentrates
oxygen from ambient air, delivers to patient
– Liquid oxygen: cooled and compressed into cylinder
– If patient is not able to receive oxygen, condition can
deteriorate and require intervention.

(3 of 15)
• Apnea monitors
– Constantly monitors patient’s breathing; alarms when
patient ceases to breathe
– Determine how long alarm has been sounding prior to
arrival; will tell you how long patient has been apneic.

(4 of 15)
• Tracheostomy tubes
– Tracheostomy: surgical hole through the tissues of the
neck into the trachea; alternate airway for the patient
 Performed as temporary or permanent airway; stoma if
permanent
– Chronic upper airway problems; on mechanical
ventilator long term

(5 of 15)
• Tracheostomy tubes (continued)
– Single-lumen tracheostomy tube used for infants
because of small diameter
– Inner and outer cannula used for larger children and
adults
 Outer cannula ensures stoma remains open; inflated bulb
holds tube in place and seals between cannula and trachea.

Figure 46-9
Tracheostomy tubes. Top: A single-lumen tube used for infants. Bottom: A tracheostomy
tube and inner cannula used for larger children and adults.

(6 of 15)
• Tracheostomy tubes (continued)
– Complications with tracheostomy tube
 Obstruction
 Air leakage around cuff
 Tube dislodgement
 Infection

(7 of 15)
• CPAP and BiPAP
– Continuous positive airway pressure (CPAP)
– Bilevel positive airway pressure (BiPAP)
– Positive airway pressure for spontaneously breathing
patients through tubing attached to mask that covers
patient’s mouth and/or nose
– Benefit greatly from CPAP, with or without medications;
in many cases, patients avoid endotracheal intubation

(8 of 15)
• Mechanical ventilators
– Patients who require breathing assistance
– Mechanical ventilator alarms:
 High-pressure alarm; ventilation pressure
 Low-pressure alarm; decrease in tidal volume
 Apnea alarm; no spontaneous ventilation
 Low FiO2 alarm; decreased FiO2

Figure 46-10
Vascular access devices (VADs) include central IV catheters such as a PICC line, central
venous lines such as a Broviac catheter, and implanted ports such as a MediPort.

(9 of 15)
• Vascular access devices
– Readily available vascular access when patients
require ongoing intravenous medication administration
– Hemodialysis, chemotherapy, total parenteral nutrition
(TPN), long-term intravenous antibiotic administration
– Central intravenous catheters (central lines): placed
into large subclavian vein below clavicle
– Implanted venous access ports: disk-shaped devices
surgically implanted just beneath skin of upper chest

(10 of 15)
• Dialysis shunts
– Patients who require hemodialysis; loss of kidney
function; surgically implanted arteriovenous (AV) shunt,
AV fistula, AV graft
– Control any bleeding by applying constant direct
pressure, providing high-flow oxygen, and treating for
shock if indicated.

(11 of 15)
• Gastrointestinal and genitourinary devices
– Loss of gastrointestinal or genitourinary function; may
rely on medical devices to receive nutrition or eliminate
waste
– Devices: feeding tubes, ostomy bags, urinary tract
devices
– Feeding tubes: provide nutrition directly into stomach
or small intestine in patients who cannot chew or
swallow

Figure 46-11
Surgically inserted feeding tubes are used for long-term nutritional support.

(12 of 15)
– Nasogastric (NG) tube: inserted through nose
– Orogastric (OG) tube: inserted through mouth
– Gastric (G) tube: surgically implanted tube inserted into
stomach
– Jejunal (J) tube: feeding tube placed through gastric
wall and into jejunum

(13 of 15)
(continued)
– Ostomy bags: devices connected to opening in
abdominal wall
– Collect feces directly from patient’s colon
– Result of medical conditions (diverticulitis, colon
cancer, Crohn’s disease)
– Urinary catheter: empty urine from urinary bladder
through tube and into collecting bag
– Condom catheters: placed on penis just as
prophylactic condom would be

Figure 46-12
An external, or condom, catheter.

(14 of 15)
(continued)
– Foley catheter: threaded into urinary bladder through
urethra
– Urinary tract infection (UTI)
 Can be severe enough to cause life-threatening sepsis

Figure 46-13
An internal catheter system.

(15 of 15)
• Ventriculostomy shunts
– Surgically placed in one of the ventricles in brain,
allowing pressure to be relieved
– Drain into abdomen, heart, pleural space, blood vessel
in neck
– Complications: infection, subdural bleeding, occlusion
 May be necessary to transport the patient where neurosurgical
services are available

Figure 46-14
Intraventricular shunts originate within a ventricle in the brain and drain into the abdomen,
heart, pleural space, or a blood vessel in the neck to relieve ICP.

Hospice Care
• Comfort care of terminally ill patients
• Pain management
• Provide patient and family with support.
• Terminal illness: leads to deterioration of patient,
results in death
• Hospice evaluates patient on a regular basis and
makes recommendations to physician regarding
patient’s care.

Chapter Summary (1 of 2)
• You will encounter patients with special
challenges that range from hearing disability to
homelessness to utilization of life-sustaining
medical technology.
• Understand their needs and how their challenges
relate to reason you were called.
• Always remain a patient advocate.
• Avoid temptation to give in to your feelings under
stress of difficult situation.

Chapter Summary (2 of 2)
• Do not allow presence of equipment to distract
you from performing systematic assessment and
treating patient.
• Caregivers can provide wealth of knowledge
about patient’s medical equipment, medical
history, and needs.

Alexander ch46 lecture

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