hello and welcome to chapter 37 patients with special challenges this is of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the special needs of patients with developmental sensory and physical disabilities you will understand the unique anatomy and physiology and the assessment and treatment needed for these patients the special care considerations for patients who relay on medical technology assistance are also discussed as are considerations for the management of obese patients today more people with chronic diseases live at home or outside the hospital setting children who are born prematurely and have associated respiratory problems there's also infants or small children with congenital heart disease in patients with neurologic disease or patients with congenital or acquired diseases resulting in altered body function that requires medical assistance for breathing eating urination or bowel function there's also patients with sensory defects such as hearing or visual impairments or geriatric patients with chronic diseases requiring visitation from home health care service people who live at home depend upon mechanical ventilation intravenous pumps or other devices do not allow yourself to be distracted by the noise and mechanics of the medical equipment focus your needs to remain on the patient and follow the abcs if the emergency is the result of mechanical failure use equipment on the ambulance or the families to go back okay so let's first talk about intellectual disability developmental disability and this refers to a group of conditions that may impair development in the areas of physical ability learning language development skills or behavioral coping skills intellectual disability is a subset of developmental disability where patients have significant limitations in both intellectual functioning and skills needed for daily living diagnosis is made before age 18 and it ranges from mild to profound level of care and support varies possible causes are genetic factors congenital factors there could have been some complication at birth or malnutrition perhaps environmental factors prenatal drug or alcohol use or traumatic brain injury for possible poisoning rely on patients and family members for information patients with intellectual disabilities are susceptible to the same diseases as any patients so let's talk about autism in the autism spectrum disorder intellectual disability characterized by deficience in social communication and interactions along with restrictive repetitive patterns of behaviors interests and activities often they have abnormal sensory responses so may not feel heat or cold or pain as others do and they may respond to pain by laughing or humming singing or removing clothes they may also have an increased sensitivity to noise or physical stimulation so keep the environment calm and minimize stimulation three to four times more common in males than females and in those who have an older sibling with the same condition demonstration of examination techniques on a trusted individual may comfort that patient use short direct and simple phrases when communicating and allow extra time for the patient to process the communication if possible next we're going to talk about down syndrome this is characterized by a genetic chromosomal defect defect that can occur during fetal development resulting in mild to severe intellectual impairment known risk factors are increased maternal age and a family history are known risk factors for this condition physical abnormalities they're going to have a round head with a flak ops occipit and large protruding tongue slanted wide eyes and folded skin on either side of their nose covering the inner corners of their eyes short wide hands and small face and features they're at an increased risk for medical complications such as leukemia congenital heart defects sensory endocrine muscular skeletal dental gastrointestinal and neurological complications an innovation may be difficult due to the large tongues and small oral and nasal cavities mass ventilations can also be challenging and the jaw thrust maneuver or nasopharyngeal airway may be necessary judgment of seizures is the same as for any other patient with seizures and approximately 15 percent of patients with down syndrome so a large amount the first two areas where the vertebrae meet is unstable this places them at an increased risk of complications when they have trauma so patient interaction action approach the patient calm friendly watching for signs of increased anxiety or fear fear have the member of your team hold back slightly until you establish rapport with the patient introduce the team members explain what they're going to do and move slowly but deliberately explaining beforehand what you are going to do and make sure you are at the eye level with the patient do your best to sue the patient's discomfort as you work through your assessment and provide treatment brain injury so patients with a prior brain injury may be difficult to assess and treat take the time to speak with the patient and the family to establish what is considered normal for the patient treat the patient with respect use his or her name explain the procedures and reassure the patient throughout the process and then there's sensory disabilities first we'll start with visual impairment so possible causes are congenital disease injury or degeneration of the optic nerve or nerve pathways the degree of visual impairment may range from partial to total some patients lose their peripheral or central vision and some can distinguish between light from dark um or shapes visual impairments may too be difficult to recognize so look for signs that the patient is visually impaired such as a cane or service animal patient interaction so make yourself known when you enter the room introduce yourself and your team retrieve any visual aids and give them to your patient to make the interaction more comfortable a visually impaired patient may feel vulnerable especially during the chaos of a crash scene so tell the patient um the patient may have learned to use other senses such as hearing touch and smell to compensate for the loss of sight tell the patient what is happening identify noises and describe the situation and surroundings especially if you must move the patient transport consideration so a patient may use a cane or walker and you should make sure that we take that with us a service animal can remain with the patient and will provide reassurance for the patient and prevent delays and transport however in some cases you may need to arrange for care or accompaniment of the animal an ambulatory patient may be led by a light touch on the arm or an elbow or the patient may rest his hand on his or her shoulder ask the patient which method they prefer to use patients should be gently guided but never pulled or pushed and obstacles need to be communicated in advance and then there's the hearing impaired so hearing impairment may range from slight hearing to total deafness most common forms of hearing loss are sensor neuro deafness which is nerve damage and then there's conductive hearing loss which is a faulty tremendous transmission of the sound waves clues that a person could be hearing a peer paired would be presence of hearing aids or poor pronunciation of words or failure to respond to your presence or questions communication you're going to assist the patient with finding and inserting hearing aids if needed or face the patient when you communicate because they can lip read okay do not exaggerate your lip movements though and do not look away position yourself approximately 18 inches directly in front of the patient do not speak louder and try lowering the pitch of your voice you could learn american sign language or provide a paper and a pencil only one person should be asking questions to avoid confusing the patient the figure on this slide shows terms in sign language related to illness injury hurt and help okay so um the first one is sick the second one you're gonna see is hurt and then help all right so hearing aids they're devices that make sound louder you could have a behind the ear type a conventional type and in the canal or completely in the canal type and in the ear type or an implantable option are also available the device should fit snugly if whistling occurs the hearing aid might may not be um in far enough so this this slide just shows the different types of hearing aids physical disabilities so the first one we're going to talk about is cerebral palsy this is a group of disorders characterized by poorly controlled body movement result of damage to the developing fetal brain while in utero and oxygen deprivation to the brain or perhaps a traumatic brain injury at birth or infections such as meningitis during early childhood they range mild to severe so poor posture controlled movements of the limbs visual or hearing impairments difficulty communicating epilepsy intellectual disabilities or unsteady gait which may necessitate wheelchair or walker important consideration so observe the airway closely do not assume that the patient have an intellectual disability limbs are often underdeveloped or are prone to injury and patients who have the ability to walk may have a gait an unsteady gait and are prone to falls had the patient to ensure his or her comfort never force a patient's extremities into any positions however possible take walkers and wheelchairs along during transport and be prepared for seizure and keep suctioning available next we're going to talk about spina bifida and this is a birth defect caused by incomplete closure of the spinal column during embryonic or fetal development the spinal cord is exposed and an opening can be closed surgically but often leaves spinal and neurologic damage associated congenital conditions are hydrocephalus partial or for pleurolysis of the lower extremities loss of bowel or bladder control or extremity latex allergies ask the patient or caregivers how to best move them before you transport them and then you could also have patients who have paralysis so that's an inability to voluntarily move one or more body parts it could possibly be from a stroke trauma or birth defect patients may have normal sensation or hyper an increased sensitivity facial paralysis may also cause communication challenges and diaphragm may not function correctly requiring the use of a ventilator patients may have specialized equipment such as urinary catheters or tracheotomy tubes colostomy bags or feeding tubes patients may have difficulty swallowing creating the need for suctioning ask the parents or caregivers the best way to move them before you transport these patients as well and then you have bariatric patients and this is an obesity and it's a condition in which the person has an excessive amount of body fat the result of an imbalance between calories consumed and calories used its causes of obesity are not fully understood and it may be attributed to a low metabolic metabolic rate or genetic predisposition severe or morbid obesity so the terms obese is used when someone with 30 or more of his or her ideal body weight so that's 30 or more severe obesity is when a person is two to three times over the ideal body weight quality of life may be negatively affected and associated health problems include mobility difficulties diabetes high blood pressure heart disease or stroke interaction with patients with this with obesity so patients may be embarrassed of their condition if transport is necessary plan early for extra help or specialized equipment send a member of your team to find the easiest and safest exit and also the risk of dropping the patient or injuring a team member by trying to lift too much weight is a possibility the patient with dignity and respect at all times and ask your patient how is the best way to move them avoid lifting the patient with only one limb which would risk injury or over-tax joints coordination and communication are big issues so all moves um by all team members should be talked about and communicated prior to lifting to prevent significant soft tissue injury or deep vein thrombosis look for pinch and pressure points from equipment become familiar with types of specialized equipment and resources which will be available large patients may have difficulty breathing if placed in a supine position so plan egress routes to accommodate large patients equipment and lifting crew members notify the receiving hospital early patients with medical technology assistance okay so the first one we're going to talk about is the tracheostomy tube so a tracheal stoma provides a pathway between the surface of the neck and the trachea it can be temporary or permanent for patients who depend on home ventilators require frequent suctioning and have chronic pulmonary medical conditions because it is foreign to the respiratory tract the body reacts by building up secretions on or around the tube tubes are prone to becoming obstructed by mucus plugs or foreign bodies use the dope mnemonic so the dope mnemonic helps to recognize causes of his obstruction d stands for displacement dislodged or damaged tube o stands for obstruction of the tube such as with blood or secretions or mucus or vomit the p is the pneumothorax and e is equipment failure such as some type of kinking or ventilator malfunction or and maybe empty oxygen supply common problems are bleeding or air leaking around the tube the tube can become loose or dislodged or the infection around the opening of the tube you could have an infection so what are we going to do for these patients suction the patient in the position of comfort insert the suction catheter no more than one to two inches do not suction for more than 10 minutes do not force the suction catheter into the cannula oxygenate before and after the procedure and call for advanced life support so people who are on home oxygen two types of oxygen delivery devices so there's oxygen from a gas cylinder or um an oxygen tank or there's oxygen from an oxygen concentrator so compressed oxygen cylinders do not require electricity the leader flow is limited only by the regulator and the amount of gas in the cylinder they're heavy and bulky and can be difficult to transport and it will eventually run out and patients need to coordinate pickup and delivery of new cylinders home oxygen concentrator however it takes ambient air and scrubs out the nitrogen from the atmospheric air and leaves behind almost 100 oxygen it can provide an unlimited supply of oxygen as long as it's functioning from a reliable source of electricity usually able to supply one to three liters and the patient must have a backup of compressed gas cylinders in case there is a power failure ask the patient on home oxygen why they're on it and how long they have been on it and what is their baseline home oxygen requirement so what is the patient's baseline oxygen saturation meaning if they're normally on two liters or three liters and then medical mechanical ventilators so these are used when patients cannot breathe without assistance and possible causes are congenital defects chronic lung disease traumatic brain injuries or muscular dystrophy or a disease process that weakens the ability to breathe and requires permanent trach and mechanical ventilator if the ventilator malfunctions remove the patient from the ventilator apply a tracheostomy collar or you could use a face mask over the stoma if you do not have a trach collar patients requiring assisted ventilation throughout transport um so the patient's caregivers will know how the ventilator works that's a picture of the ventilator and then you have apnea monitors and these are used for children for infants who are premature or have some type of gastro gastro reflex disease or have a family member of a sudden infant death syndrome who who have already had sids or have experienced an apparent life-threatening event they're usually used for two weeks to two months after birth to monitor the respiratory system the monitor sounds an alarm if the infant experiences some type of low heart rate or low respiratory rate it's attached with electrodes to a belt around the infant's chest and stomach and it provides a pulse ox reading that will assist you in assessing the patient's respiratory status if possible bring that apnea monitor to the receiving facility with the patient and then you have internal cardiac pacemakers so it's a device implanted under the skin to regulate the heart a pacemaker may also include an aed to monitor the rhythm never place d-fib pads or pacing pads over the implanted device gather information about the cardiac pacemaker when you obtain the patient's history some patients will have a pacemaker identification card in their wallets containing information about the device and then there are left ventricular assist devices and this is a mechanical device that takes over the function of one or both heart ventricles typically used to bridge between heart transplant while the donor of the heart is being located or maybe a permanent solution for patients who do not qualify for a heart transplant a left ventricular assist device or lvad is most common and all vads are more common in adults okay so may be difficult to palpate a pulse in patients who use an lvad assess perfusion by noting the level of consciousness skin color temperature moisture and blood pressure there are risks to these and its excessive bleeding can follow spike could follow surgery also infection or blood clots a cure or acute heart failure if you encounter a patient with a vad call the number for the patient support team contact medical control and follow protocols if the device is alarm is sounding check the connections and be sure the batteries are fully charged and notify advanced life support an external defib vice so this is a vest with a built-in monitoring with electrodes and defeb pads which is worn by patient under his or her clothing it's attached to a monitor that provides alerts and prompts voice prompts when it recognizes a dangerous rhythm and before it delivers a shock so if the patient's in cardiac arrest the vest should remain in place while you're performing cpr unless it interferes with compressions any patients who's wearing a device that has already delivered a shock should be transported to the hospital for further evaluation and then there's central venous catheters so this is a cath that has a tip placed in the vena cava to provide venous access used for many types of home care patients and including cardi chemotherapy or long-term antibiotic drug therapy total nutrition so tpn or hemodianolysis were often located in the chest upper arm or subcliffic area and so the figure on the slide shows the central venous catheter common problems with this is you could have broken lines or an infection clotted lines or bleeding around the line from the tubing attached to the line then you could have a gastro gastrotomy tube and this is sometimes referred to as a gastric tube or a g-tube it's placed into the stomach for patients who cannot ingest foods fluids or medication by mouth may be inserted through the nose or mouth into the stomach or it may be placed surgically directly into the stomach through the abdominal wall and so this figure on the slide shows a gastronomy tube and a child okay so it may become dislodged during a patient's normal daily activity immediately stop the flow of any fluids okay so assess the signs and symptoms of bleeding in the stomach and so if there's any abnormal abdomen discomfort or nausea vomiting especially coffee ground emesis or blood in the emesis patients may be at an increased risk of aspiration so always have suctioning readily available and patients with difficulty breathing should be transported while sitting or laying on the right side with the hell head elevated 30 percent diabetic patients who receive insulin and gastric tube feedings may become hypoglycemic quickly unless the tube is dysfunctional dislodge or partially dislodged continue the feeding tube and transport the pump with you and then there's shunts for patients with chronic neurologic conditions and these are tubes that drain excessive cerebral fluid from the ventricles of the brain to keep pressure from building up during assessment you will likely feel a device beneath the skin on the side of the head behind the ear and it's a fluid reservoir it should alert you to the possibility that the patient have an underlying shunt there are types there's a ventricular peritoneum shine and this drains excess fluid from the ventricles of the brain into the abdomen and then there's a ventricle atrium shunt and this drains excess fluid from the ventricles of the brain into the right atrium of the heart it can become blocked or infected and chances changes of mental status and respiratory arrest may occur infections may occur within the first two months after the insertion you might hear a high pitch crying or bulging fontanelles in infants perhaps a headache projectile vomiting altered mental status irritability or fever and nausea difficulty with coordination or walking blurred vision seizures redness along the shunt track or bradycardia or heart dysrhythmias and then you could see patients with vagal nerve stimula stimulators and these are for treatment used for seizures that are not controlled with medication so what it does is it stimulates the vagal nerve at predetermined intervals to prevent seizure activity they're used in conjunction with medications to reduce the frequency of seizures and they're located under the patient's skin and is about the size of a silver dollar and then you can have colostomies ileostomies or urostomies and so what of these are our surgical procedure that creates an opening between small and large intestines at the surface of the body it allows for elimination of waste products into clear external bags or pouches which is then emptied or changed frequently you want to assess for signs and symptoms of dehydration if the patient has been complaining of diarrhea and vomiting area around the stoma is prone to infection so signs of infection include warmness or redness around the stoma or tenderness on palpation over the colostomy site okay urostomy is a surgical procedure that connects the urinary system to the surface of the skin that allows urine to drain from a stoma in the abdomen wall so contact medical control or follow local protocols to care for patients with a colostomy ileostomy or urostomy bag okay so patient assessment are guidelines so interaction with the caregiver of an adult or child with special needs is important part of the patient assessment process they become experts on caring for the patient determine the patient's baseline mental status before assessment so ask what is different today when it comes to home care home care occurs within the patient's home environment so this represents a spectrum of special care uh healthcare op um population so you could have infants older adults or patients with chronic chronic illnesses or patients with developmental disabilities also services such as delivering meals or house cleaning laundry yard maintenance and physical therapy and also personal care such as bathing in wound care ems may be called to residents by the home health care provider so what you want to do is obtain health care status and history from the home care provider then you could also have calls with hospice care and terminally ill patients okay so terminally ill patients may require hospice at a hospice facility or at a home with diseases such as cancer heart and lung failure and stage alzheimer's or aids most patients have completed do not resuscitated orders when they're on hospice okay so they may have medical orders for that scope of treatment basically it's comfort care and this means it's palliative care and that is only pain medicines and it improves the patient's quality of life before the patient dies and allows for the patient to be home with family and friends follow your local protocols the patients with wishes and legal documents such as the dnr order if the patient is at home the care you give will have a lasting impact on the family so show compassion understanding and sensitivity ascertain the family's wishes about having the patients remain in the home or having the patient transmitted to the hospital transported to the hospital and follow local protocols for handling the death of the patient you will also special situations you'll run into is poverty and homelessness so people who live in poverty are unable to provide all of their basic needs such as housing food health care child care health insurance and medication disease prevention strategies such as dental care nutrition and exercise are likely absent which leads to increased probability of disease when it comes to the homeless population people with mental illness and prior brain trauma victims of domestic abuse or persons with addiction behaviors or impoverished families your job is to provide emergency care and transport to the appropriate facility all healthcare facilities must provide assessment and treat treatment regardless of the patient's ability to pay you can be an advocate and become familiar with the social services resources within your community okay so that concludes chapter 37 of the patients with special challenges lecture next we're going to see what we've learned so which of the following is a development disorder characterized by impaired meant of social interaction okay and we know that this is autism so autism is a developmentally disability characterized by impairment of social interaction known risk factors for down syndrome include so smoking traumatic brain injury increased maternal age or lack of vitamin b and we know it's increased maternal age which of the following may be difficult to perform on a patient with down syndrome and we know it's innovation because of their abnormal their large tongues and the small oral and nasal cavities most patients with a disease also have hydrocephalus and so we know that patients usually with a shunt and that's spina bifida what does the dope mnemonic help you recognize so we know that this is some type of airway obstruction when talking about patients who have some type of event or stoma what device is placed directly into the stomach to feed patients that's a g tube a gastronomy tube okay what do vagal nerve stimulators do and they do help seizures from occurring keep them and they're also an alternative treatment to medicine bagel nerve syndrome stimulators an important part of the assessment process for a patient with special needs what should you do we know we're going to interact with the caregiver and also the patient but what is important um so we're interacting with the caregiver what improves a patient's quality of life shortly before death and that's hospice care it's palliative care the emergency medical treatment and active labor act states and we didn't really discuss this so let's see it's b and so we we know all patients must be treeless oh retreat treated regardless of the ability to pay and so that's the emergency medical treatment and active labor act okay thank you for joining us this evening with patience uh for the chapter 37 patients with special challenges lecture if you enjoyed this lecture go ahead and subscribe to the channel we're going to put out the remaining chapters of the 12th edition