The Challenged Patient

1. The Challenged Patient Ray Taylor Valencia Community College Department of Emergency Medical Services

2. Topics • Physical Challenges • Developmental Disabilities • Pathological Challenges • Other Challenges

3. Challenged Patients Hearing Visual Speech Obesity Paralysis Mental and physical impairments Arthritis Cancer Neuromuscular Introduction

4. Hearing Impairments • Types • Conductive deafness • Sensorineural deafness

5. Conductive Deafness • Blockage of the transmission of sound waves through the external ear canal to the middle or inner ear • Etiologies (Curable) • Infection • Injury • Earwax

6. Sensorineural Deafness • Deafness caused by the inablility of nerve impulses to reach the auditory center of the brain because of nerve damage to either the inner ear or to the brain • Etiologies (Many incurable) • Congenital • Birth injury • Disease • Medication induced • Viral infection • Tumor • Prolonged exposure to loud noise • Aging

7. Recognizing Deafness • Asking questions repeatedly • Misunderstood questions or inappropriate responses • Presence of a hearing aid • Sign language or gestures

8. Hearing aids come in various shapes and sizes. Figure 5-1

9. Accommodations for Deaf Patients • Address patient face to face. • Speak slowly in a normal voice. • Do not shout • 80% of hearing loss is related to the loss of high pitched sounds • Use low pitched sounds directly into ear canal • Reduce background noise as much as possible. • Help find or adjust hearing aids. • Use pen and paper. • Utilize an interpreter. • Use of picture that illustrate basic need/procedures

10. Visual Impairments

11. Causes • Disease • Congenital conditions • Infection • Degeneration of eyeball, optic nerve or nerve pathways

12. Individuals who are visually impaired can maintain active, independent lives. Figure 5-2

13. Accommodations • Retrieve visual aids • Describe everything that you’re going to do • Provide sensory information • If ambulatory, guide by leading, not by pushing • Allow leader dogs to accompany patient • Do not pet or handle dog while in harness

14. Speech Impairments

15. Types of Speech Impairments • Language disorders • Articulation disorders • Voice production disorders • Fluency disorders

16. Etiology of Speech Disorders • Language disorders • Stroke • Head injury • Brain tumor • Delayed development • Hearing loss • Lack of stimulation • Emotional disturbance

17. Etiology of Speech Disorders • Articulation disorders • From damage to nerve pathways passing from brain to muscles in larynx, mouth or lips • Delayed development from hearing problems, slow maturation of nervous system

18. Etiology of Speech Disorders • Voice production disorders • Disorder affecting closure of vocal cords • Hormonal or psychiatric disturbance • Fluency disorders • Not fully understood

19. Recognition • Language disorders • Slowness to understand speech • Slow growth in vocabulary and sentence structure • Articulation disorders • Speech can be slurred, indistinct, slow, or nasal

20. Recognition • Voice production disorders • Hoarseness • Harshness • Inappropriate pitch • Abnormal nasal resonance • Fluency disorders • Stuttering

21. Accommodations for Speech Impairments • Never assume the person lacks intelligence. • Form questions that require short, direct answers. • Never pretend to understand when you don’t. • Let the patient write answers to questions.

22. Obesity • 40% of people in the US are obese. • Excess weight can exacerbate the complaint for which you were called. • Obesity can lead to many serious medical conditions

23. Obesity • Etiologies • When a person has an abnormal amount of body fat • 20-30% heavier than normal weight • Person’s caloric intake is higher than the amount of calories required to meet his energy needs • Genetic factors • Low basal metab

24. Accommodations for Obese Patients • Don’t dismiss signs or symptoms, such as shortness of breath, as being a result of obesity. • Adipose tissue presents an obstruction—EKG electrodes may need to be placed on the arms and legs. • Do not compromise your health or safety—ask for assistance when lifting or moving a patient. • Use appropriately sized diagnostic devices

25. Paralysis • Paraplegia • Weakness or paralysis of both legs • Quadriplegia • Paralysis of all four extremities and trunk

26. Paralysis • The patient may have a home ventilator; be sure to keep the airway clear and patent. • If the patient is in halo traction, be sure to stabilize the traction before transport. • Be aware of other assistive devices— colostomy, canes, wheelchairs, etc.

27. Mental Challenges • Mental illness • Any form of psychiatric disorder • Etiologies • Psychosis • Caused by complex biochemical brain disease • Neuroses • Disease related to personality • Recognition • Behavior may be unaffected • May present with signs and symptoms consistent with illness

28. Accommodations • Obtaining a history • Don’t be afraid to ask about • History of mental illness • Prescribed medications • Compliance with medications • Concomitant ingestion of alcohol, other drugs

29. Assessment and Management • Assessment • Be sure to solicit permission before beginning • Management • Treat as you would any patient that does not have a mental illness, unless call is related specifically to the mental illness • Patients with mental illness also experience myocardial infarctions, hypoglycemic episodes

30. Developmental Disabilities

31. Developmental Disabilities • Description • Impaired/ insufficient development of the brain, causing an inability to learn at the usual rate • Recognition • History • Accommodations • Obtaining a history • Assessment • Management • Transport

32. Developmentally disabled people may have trouble communicating, but can often still understand what you say. Figure 5-3

33. Remember that a person with a developmental disability can recognize body language, tone, and disrespect just like anyone else. Treat them as you would any other patient.

34. Developmental Disabilities • Down Syndrome • A chromosomal abnormality resulting in mild to severe mental retardation, and a characteristic physical appearance • Fetal Alcohol Syndrome (FAS) • Mother with persistent alcoholism during gestation • Shortly after birth infants experience alcohol • Deficient growth and mental capacity

35. Recognition of Down Syndrome • Eyes slope up at outer corners; folds of skin on either side of nose cover the inner corners or eye • Small face and features • Large and protruding tongue • Flattening on back of the head • Hands short and broad

36. Recognition of Fetal Alcohol Syndrome • Small head with multiple facial abnormalities • Small eyes with short slits • Wide, flat nasal bridge • Midface that lacks a groove between the lip and nose • Small jaw

37. Arthritis Cancer Cerebral Palsy Cystic Fibrosis Multiple Sclerosis Muscular Dystrophy Poliomyelitis Previous head injury Spina Bifida Myasthenia Gravis Pathological Challenges

38. Arthritis • Inflammation of a joint; characterized by pain, stiffness, swelling, redness • Accommodations • Decreased range of motion/mobility may limit physical exam • Be sure to solicit current medications before considering the administration of medications • Management • Limited ability to be mobile • Make equipment fit patient, not vice-versa, pad all voids

39. Rheumatoid arthritis causes joints to become painful and deformed.

40. Cancer • Primary site of origin of the cancer cells determines the type of cancer • Carcinoma • Sarcoma • Treatments for the disease do tend to produce telltale signs • Alopecia (hair loss) • Anorexia • Radiation tattoos • Physical changes

41. Cancer • Management • Patient’s risk for infection • Chemotherapy leaves patient neutropenic • Veins may have become scarred • Use of med ports • Requires specialized training

42. Cerebral Palsy • Nonprogressive disorders of movement and posture • Types • Spastic • Abnormal stiffness and contraction of groups of muscles • Athetosis • Involuntary, writhing movements • Ataxia • Loss of coordination and balance

43. Cerebral Palsy • Etiologies • Most occur before birth • Prepartum • Cerebral hypoxia • Maternal infection • Postpartum • Encephalitis • Meningitis • Head Injury

44. Recognition • Spastic: muscles of one or more extremities are permanently contracted • Athetoid: involuntary writhing movement • Quadriplegia • Mental retardation in about 75% of all people with with CP • Many people with athetoid and diplegic CP are highly intelligent

45. Cystic Fibrosis (Mucoviscidosis) • An inherited metabolic disease of the lungs and digestive system, manifesting itself in childhood • A defective, recessive gene • Recognition • History • Patient may be oxygen dependent • Salty taste in mouth • Productive cough • Management • May require respiratory support, suctioning, oxygen

46. Multiple Sclerosis • A progressive autoimmune disease of the CNS, whereby scattered patches of myelin in the brain and spinal cord are destroyed • Unknown etiology • Recognition • Fatigue, vertigo • Clumsiness, muscle weakness • Slurred speech, ataxia • Blurred or double vision • Numbness, weakness or pain in face

47. Multiple Sclerosis • Spinal cord affected • Tingling, numbness, or feeling of constriction in any part of the body • Extremities may feel heavy and become weak • Spasticity may be present

48. Multiple Sclerosis • Accommodations • Recognize characteristic presentation • May be accompanied by • Painful muscle spasms • UTI • Constipation • Skin ulcerations • Changes in mood, from euphoria to depression

49. Muscular Dystrophy • An inherited muscle disorder of unknown cause in which there is slow but progressive degeneration of muscle fibers • Little or no movement of muscle groups • Management: possible respiratory support, patient should not be expected to ambulate

50. Patients with multiple sclerosis and muscular dystrophy may use a cane to aid ambulation. Be sure to take such devices with you on the ambulance. Figure 5-6