Special Challenges in EMS: Assessment and Treatment Strategies

1. 47 Special Challenges

2. 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.

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

4. 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.

5. 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.

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

7. 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.

8. Pathophysiology • Abuse • Child abuse • Physical, emotional, sexual • Elder abuse • Physical, emotional, sexual • Passive versus active • Neglect

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

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

11. Causes of Mental Retardation

12. Causes of Mental Retardation

13. 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

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

15. 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.

16. Effects of Excess Weight on Organ Systems

17. 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.

18. 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.

19. 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

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

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

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

23. 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.

24. 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.

25. Pathophysiology (cont’d) • Home Mechanical Ventilators • Alarms (may be reason EMS is summoned) • High pressure alarm • Low pressure alarm • Apnea alarm • Low FiO2 alarm

26. 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.

27. 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.

28. 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)

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

30. 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.

31. 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?

32. 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?

33. 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 PPV @ 10-12/min if inadequate. • Maintain saturation >95%.

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

35. 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.

36. 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.

37. 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.