Transcript for:
Emergencies with Patients with Special Challenges

chapter 37 emergencies with patience with special challenges before we get started don't forget to like and subscribe for future updates let's start off with the kind of a definition of what patients with special special challenges are and this should go without saying every patient deserves your empathy and respect but those with special challenges take a little bit more concern a little bit uh extra time so you have to be really good at making sure they understand you're there to help them and they're you're going to do everything you can for them make sure we have the right terminology here disability is a condition that interferes with the ability to engage in activities of daily living we no longer use the term handicapped disability access functional needs are the current terms that help describe these people a developmental disability is a chronic impairment beginning at any age up to 22. cerebral palsy down syndrome are two of the common ones we see could be something that's a result of a traumatic injury or a medical condition ms or multiple sclerosis stroke leads leaves a person in the condition that they're going to need have special challenges traumatic brain injury or spinal cord injury all cause additional needs that we're going to have to adjust our care and our way we treat our patients because of all the advances in technology a lot of our patients are living independently they can take care of themselves pretty well with very minimal outside in assistance so you may get a a lot of calls to people that normally would have some type of health care provider there or someone to assist them because of the advances they are by themselves although some of them do have that extra person there with them so just kind of be aware of what's going on and adjust as needed when you're dealing with a patient you may have to adjust your style typically we don't have our patients touching our faces but if the patient is blind that's how they connect with you so get down on their level make sure they understand you're there and where you are and use some some extra care when taking care of these patients we also have patients who are terminally ill that are living in homes uh thanks to hospice they're getting these patients back to a home setting where they're more comfortable and the family can be around them all the time these are typically like your end stage cancer heart failure lou gehrig's disease they'll be at home they may have some hospice care there with them or they may just have family helping them take care of them they may have hospital style equipment ventilators feeding systems iv systems but they're all there to help them have a normal life most of these patients because they are in the terminal illness stages they have advanced directives in place and they will typically have those available for you as soon as they you walk in the door another special challenge we're seeing more of in the ems community we have obesity people that have a body mass index over 30. typically we're seeing patients 300 400 pounds that need some extra assistance we're going to have to use some special technology some special tools to transport them we have bariatric ambulances that have the right size cots and the assistance to get them into the ambulance and has an extra floor space so we have room to transport them comfortably so you want to be when you put them on the cot you want to make sure you're not putting too much pressure on their lungs so they can't be laying supine make sure you keep an eye on the uh airway keep them in the ramp position that's a semi fowler's position and make sure you have plenty of help when you're moving the patients get as much as you need bring in the extra firefighters the other ambulance whatever you need make sure you have the right size equipment homelessness and poverty another challenge we're facing one of the problems with the homeless population is they have a lot of untreated or not well maintained health conditions so they'll end up with pneumonia they typically have a lot of mental health issues malnutrition substance abuse chronic conditions communicable diseases like hiv and aids they don't have access to everything that uh people have on a regular basis so their health care isn't kept up so they may be calling 9-1-1 for those things that you're going to have to provide a little extra care for sometimes we have abuse of the homeless population and there's typically a lot of emotional issues especially if you have kids that are homeless they're they're concerned that they're being judged for being homeless give them the support you can and do what you can help your local communities so some approaches to caring for patients with special needs autism is a developmental disorder that affects the ability to communicate kids with autism do not communicate like other children do so we have a acronym that we use a b c s as opposed this is a different from our abc's for the primary assessment so we have awareness basic needs come and maintain safety so awareness we're talking about making sure uh that they know what's going on around them they do not like change they sometimes have difficulty communicating so you may need to take some extra time and listen to them take your time with all patients but especially with the autism kids if they're having a meltdown or a escalation try to find out what calms them down help them understand that you're there to help them and use the caregivers as much as you can basic keep your instructions very simple and clear ask basic questions uh don't bring in extra noisy stuff like your radios or your cell phones keep the keep it just you and your patient and the caregiver that way there's not any extra stimuli that's going to cause any problems for them keep them calm use one-to-one contact use the caregiver as much as you can keep a nice calm voice talk to them and be willing to listen and take your time if it's not life-threatening you've got time to work with them begin treatment where your patient is found if they are complaining about things they don't like the color of your jacket take your jacket off this is one that you would do just like a pediatric you do the toe to head survey because you as soon as you start irritating them they won't let you finish their assessments so start at the bottom and work your way up if you ask a question be polite and wait for the answer and give them the time to relax between your questions find out what calms them down keeps them from from being agitated a friend of my sons who's a autistic a rubik's cube calms him down you give him a cube and he'll relax and come back to being as calm as you can as he can be so the other thing about uh autistic kids and pretty much any special needs kid don't restrain them that's just going to irritate them and you're going to be surprised at how much strength they have anyway special needs medical challenge you got kids with lung disease heart disease neurological disease they're living at home the parents are the caregivers they may have trach tubes of be on respirators at home there are so many different types of home health care equipment that as an emt you would never be able to keep up with all the different systems out there so you use the caregivers as your source of information to tell you what's available what's the possibilities to fix the problems and then there are your great source of information most of your parents of special needs children or other patients will know more about the disease process than anybody you ever thought so some special considerations when you find these advanced medical devices in the homes don't assume you know everything about them don't try to adjust them unless that's in your protocols but know they're there and use the resources that you have to try to solve the problem call tech support call their 800 number that's on the device and say i'm here with a patient the family members having issues trying to get this reset and they called us and i'm trying to help them out what can we do so use all the resources you have so this is a kind of example of what you might find the patients on the ventilator they've got a feeding bag and they've got an iv bag set up so you've got all kinds of devices there don't start messing with the dials unless you know what you're doing or unless you've conferred with the experts you may be going to private residences where you have these people but you may be called to nursing homes or other group home specialized care rehab facilities just follow the lead of the health care provider there if they're credible sometimes you get there and you find out they don't really know what they're doing so you have to adjust and maybe call a medical direction and find out what else you need to be doing develop a plan of what you're going to do and find out if there's any other resources to help you with this caregivers like we said are very familiar with the equipment so ask the questions have they had this problem happen before and how did they fix it have you been taught how to fix the problem have you tried to fix it and what happened usually they try to fix it on themselves before they call 9-1-1 it's when they got into trouble where something didn't work the way they thought it would that they actually turn around and call 9-1-1 for your help so listen to them they are probably your best resource out there assign one of your team members to work with the family member while you assess the patient your teammate is working with the family to try to figure out what's wrong it could be that because it's taking care of a loved one they're a little stressed on the the problems going on so they may not be able to focus so if you even try to calm them down you might get the answer you need to figure out what to fi how to fix the problem sometimes the patients are the best source they know how to operate the equipment i was working with a probably six or seven year old patient who was on a ventilator and the ventilator was having some issues we were bagging the patient and the patient was telling me how to fix the ventilator so i had a six-year-old telling me how to fix the the problem that was causing us to have to baggy so it's a fascinating world we live in and we use all the resources we can here shows the patient telling the guy what to do they're looking at everything trying to figure out how to help the patient they want to stay at home at all possible if you do have to trace transport a patient like this you're gonna have to bring the equipment with you because they need to see it at the hospital then they can try to fix it every uh state state scope of practice protocols give you guidelines and what you can and can't do with these special needs equipment so make sure you're uh trained in it and you're authorized to do the skills that they're asking you to is it a problem with a medical device and is it life-threatening if it's a ventilator and it's not working that is considered life-threatening but if it's a feeding tube that's not working maybe that's not life-threatening you've got time to wait a little bit do you have the knowledge to fix it just because you stayed at a holiday inn last night doesn't mean you know how to fix medical equipment maybe you have duct tape and some wd-40 but that's not everything you need to fix the problem so know what your protocols are know what your limitations are and know what you can and can't do again to call the help desk number that's on the equipment and they will help you walk through the process of resetting the equipment or figuring out the solution for patients with special needs find out what their baseline is find out what normal for them is maybe they've got parkinson's and having shakes is normal but maybe it's worse than normal so ask the family they're your good resource what's different today and why did you call 9-1-1 they can fill in the details you're not picking up your what happened before you got there why did they uh decide to call 911 because of the the change in the condition they may be able to do things that you can't do like reset equipment so try to figure out what's going on if you have a patient in your area that you've ran on once or twice do a little research ask the family how you can get more information about the disease because you want to be able to help treat them better that shows a lot of care for the patient helps them understand that you're there to help them and actually improve your knowledge base to help treat the patient just because you've got special needs doesn't mean you can get get away from your abc's so make sure you're maintaining the abcs do a good primary assessment do a good secondary assessment looking for your problems that are going to cause the patient compromise so let's talk about some of the specific diseases that we're going to run into we may have some that are congenital so basically at birth their congenital heart disease cleft palate congenital deafness some are acquired or based on some type of medical problem or exposure over their lifetime such as aids copd traumatic spinal cord injury traumatic brain injury things that just develop throughout their lifespan they can be either congenital or acquired depends on what the the background is but we're going to treat the conditions we find as we find them try to find out what the acute problem is that made the chronic problem worse so let's talk about the advanced medical devices we're going to run into here some respiratory devices we've got the non-invasive positive pressure ventilatory devices could be a cpap or a bipap we've talked about cpap that's an emt scale pipe is just biphasic continuous positive airway pressure so it gives you that extra pressure in the lungs during inhalation and exhalation when you're doing an assessment on a patient unless the cpap went the power went out and it stopped and they couldn't get their mask off and they quit breathing there usually isn't a problem with cpap if you do bring them to the hospital bring the machine with you because they're going to want to assess the settings on it and maybe they don't have the exact same device at the hospital and that patient needs that to survive because that's their way to stay breathing at night while they're sleeping this is a typical cpap machine just sits on the nightstand beside them and has a hose and a mass that either goes over the nose or the mouth and nose tracheostomy tubes trachea tracheostomy is that surgical opening in the neck uh it's typically a stoma with some type of connecting tube in it the trach tube is inserted in the opening and that's where you put the bbm if they don't have the trick tube in then you would put your pediatric size mask on your adult bvm and use that as your ventilation device just remember you've lost all the dead space above the opening if it's a complete tracheostomy if it's not a complete tracheostomy as you blow the air in there it's going to go back up out the mouth and nose and into the lung so you have to be aware of what's going on there they typically have these trick tubes for long-term conditions it's because it's easier to keep the ventilator going on the trach tube than it is going through the mouth and the endotracheal tube and they actually eat and function some people have trick tubes that don't have ventilators hooked up to them i knew a guy that had severe sleep apnea and their solution was to give a tracheostomy to it and that gave him a nice complete airway in without worrying about the obstructions from the sleep apnea if they have that tracheostomy if it's complete they will not be able to talk if they is not complete they can still plug it up and create air flow across the vocal cords and have some form of speech pattern one of the problems we run into with the tracheostomy tube is they get mucus in that that tube and it's real simple to suction out with a flexible suction tube the other problem they run into is infection so that that's nothing we can treat pre-hospital but we need to be aware of it and consider the signs and symptoms of sepsis what you're going to do is check the blockage of the tube if it's blocked suck it out if there's any resistance you're going to use the catheter to go in clean the catheter between each use with some sterile water remember this is going right into the lungs so we don't want to be putting things in there that are contaminated or going to be dirty use a bvm and keep the head slightly elevated so lift the head of the cot just a few inches give them a little extra support there and that makes their airway much easier home ventilators these are just like a be a hospital ventilator but very small and used to mainly be used at home they are programmed by the hospital or by the respiratory staff before you take them home so usually they don't have much adjustment to them problems you're going to run into mucous plugs infection or respiratory distress or power mechanical failures most people that have home ventilators have a backup power source for them when that backup power source fails then they're calling 9-1-1 because the only other option is to use a bvm use the dope mechanism when you're doing your assessment displacement of the tube it's not in the right place that causes a problem obstruction a pneumothorax or a pneumonia something's causing the lungs not to function that's as simple as listening to the lung sounds or we have equipment failure if you have a problem make sure the mucus plug is clear bvm and secure the ventilator when you get to the ambulance most ambulances have a power source in there so you can plug them in once you're in and then continue using the ventilator on the way to the hospital we have patients with implanted pacemakers and defibrillators the implanted pacemaker goes in under the skin typically on the upper left uh chest right about the midclavicular line or they can put them in the abdominal cavity they have wires that go to the heart to the various portions where they would need a stimulation stimulus for cardiac output so they will do a low energy pulse 60 to 80 times a minute whatever it's set for and it sends that to the heart it's typically such a low voltage that the patient doesn't feel it it just is uh just like the heart the sa node's kicking it some people have a combination automated implanted or automatic implanted cardiac defibrillator they're under the skin same type of location they're a little bit bigger but they have wires that go directly to the ventricles and if it detects vfab or vtac they will get a shock and they will feel this shock it is uh enough that they will feel the jolt in their chest typically the patient goes uh unresponsive for about us two to three seconds and then they get this shock if you have a patient that is getting shocked you need to break them to the hospital there is a reason they're getting shocked and this is keeping them alive until we correct that problem so call als get them to the hospital make sure they have lots of oxygen if they go into cardiac arrest their implanted pacemaker defibrillator is not working and we treat them identical to any other cardiac arrest patient there's no changes just because they have something implanted they do make a vest that has a defibrillator built into it the patient can put on and wear that and it has pads that attach to the test just like an aed but it uh it it's just a wearable device it's like a wearable a d you can do cpr on this it will actually give you directions on cpr it's like like i said it's just like an aed but it's the best form so they've got it on 24 hours a day or however long they have to wear it we do have ventricular assist devices these typically are pumps that take the blood from the left ventricle out a tube and then comes back into the heart and pushes it through back through through the vascular system so it's a very uh it's kind of like an external heart for lack of better words problems you run into a battery failure that could be a bad thing air leakage infection if you have a ventricular assist device they'll have an external battery pack make sure that's good if it fails and you don't have an ac outlet to plug it into you will use a hand pump they typically have a crank built into them and you crank that 60 to 80 times a minute these are patients that are waiting for a transplant and the the healthcare people that are monitoring them typically meet with the local ems providers and say hey i've got a patient at 1313 muckingbird lane this is what the device is we're going to stop by your station so you can meet them and see the device and make sure everybody's on the same page with what's going on so if they go into cardiac arrest you don't do cpr because the heart is not the pump the pump is outside with the hand crank on this is what it looks like if you see a coach here with uh in cardiac arrest you turn the crank on and you do like the organ grinder and crank the the tune if it plays the theme to a jack-in-the-box you've got the wrong crank other devices we're running into is gastro urinary devices or the the feeding tubes they have uh ng tubes they go through the nose into the stomach those are temporary they provide nutrients down into the stomach a g tube goes through the abdominal wall these are more long-term same type of processes in ng-2 but just direct and a lot more long-term problems you're growing into is it comes out it gets clogged because they didn't flush it after they gave them their food or you get some type of infection at the insertion points when you're dealing with a patient with this you're transporting the hospital you typically do not have to add anything to it if they're in the middle of a feeding just keep the bag above the patient put the cap on it and transport it with them there's nothing special about it you just don't want to pull it out or disturb it here's showing you the kiddo has lunch there they they've just got a syringe they pour the food into it and it flows into the stock urinary catheters typically these are foley catheters that go in through the urethra into the bladder and then they inflate it with saline and there's a balloon on the inside of the bladder that keeps it from coming out it drains out a tube into a bag that's either strapped to the leg or hanging down below the patient again problems you run into or infection blockage discolored urine from some type of infection much easier to see if it's stuck in the bag and it gets pulled out so what you want to do is keep the bag below the patient remember it's draining through gravity so it's going to be below the patient don't step on it or don't drag the cot over it what you want to do is if you have to transport you're going to try to empty it and document what you empty and how much document the color and the any odor you smelled when you did dump the urine here shows the the guy's got his uh catheter bag attached to his walker there that's probably enough you could transport and not worry about it but if it was more you'd probably want to dump it before you get in the ambulance so you don't have any messes ostomy bags a colostomy is a hole directly into the intestine you typically don't see these they're taped to the body and the the fecal matter is coming out through the ostomy into the back problems you run into is the blockage of dislodgement this is not an emt skill you just basically take them to the hospital if you have it you don't want to mess with them dialysis we've talked about we've got the hemodialysis where you've got the patient at a dialysis center where they're using the machine to take the blood out clean it put it back in complications or infection or hypovolemia the peritoneal dialysis we talked about you have the catheter that goes in the abdominal cavity puts the fluid in there through osmosis absorbs the bad waste in the belly and then you pull the fluid out if you have a patient's bleeding you stop the bleeding don't take a blood pressure in the arm of the av shunt and if you have uh you treat for shock we have people that have long term medical care through iv therapy so you're going to have central line care iv ports typically is a port on the subclavian so you'll see the tubes hanging out just on the upper chest if you have any bleeding from that area apply direct pressure same with peripheral they put the tubing in and secure that to the arm they might have two or three tubes these are not authorized for emts to use for ivs so we have to be aware careful of that sometimes they have a implanted port just below the skin if they're like a chemo patient or some type of long term therapy those are not accessible to emtps either for ivs if you have bleeding from it direct pressure the other thing is don't put the ad right over you may have bp shunts these are uh drainage ports coming from the brain or the spine so you get that excess cerebral spinal fluid to drain out so you reduce the intracranial pressure if they get clogged you have an increase in a cranial pressure which means you have an alternative status they also are prone to infections so then you'd have a meningitis infection there so be aware of that and transport your patients appropriately there's not any treatment you can do for these patients you manage what you find make sure they're got good oxygen and you're transporting to the appropriate facility if they have some type of physical impairment hearing sight speech impairment adjust how you're doing your care maybe you have to talk to them directly maybe you have to pull your mask down so they can see your lips because they uh they need to be able to hear you maybe you write your things down use your phone to transpo uh translate a friend of mine has a ipad that she types in what she's wanting to say and it will say it to you so you can actually understand what she's trying to say so there's all kinds of options out there just remember just because they can't communicate doesn't mean they have a uh mental impairment it just means they have a communication impairment maybe they have side issues help them understand what you're doing tell them what you're going to do and what when you're going to touch them so they know because they can't see it coming if they do have a guide dog or a medical assistance dog that dog is part of them and they come to the hospital with it so bring everything you need to sometimes they can't uh speak correctly so like i said they have that tablet to help them say what they need to say maybe they have difficulty walking or standing they've got some type of impairment if they have a wheelchair make sure you bring it to the hospital with them that is their lifeline it's one thing we found out during evacuations for wildfires if we grab the patient put them on an ambulance cot and take them to a shelter without their wheelchair they've lost their functions in life they need that chair to get around they have special special attachments to it that help them live a normal life and you just took that away from them so make sure you bring the wheelchair with you to the hospital if they have any special needs make sure that you're trying to take care of them get a special a baseline make sure you ask them what they need to be comfortable and what they need to maintain their normal lifestyle ask them what normal is for them and if you have any special needs equipment bring it with you that's just common sense you would want to bring everything you need to live a normal life with you to the hospital let's uh talk about something that happens occasionally or actually more often than not more often than it needs to happen the abuse and neglect of our patients that have special needs so abuse and neglect people with special needs are more vulnerable children are more vulnerable to this so we need to be aware of what's going on around our patients get a good scene size up one thing that's really helpful is if your system does this when someone calls 9-1-1 and there's a special needs or a pediatric patient you probably should bring law enforcement with you just for assistance on the scene when a person calls 9-1-1 they're asking for public safety to come in and help take care of their the their problem that way the law enforcement is being invited in and so if they see something they can document that at the time of they don't have to go through the warrant process and get the authorization from a court to get in so you give them an opening to try to help solve these problems at the time what you're looking for are stories that just don't make sense something just tells you this didn't happen the way they said it they could be embarrassed in lying about it but that's not yours to decide you all you have to document is that the story was inconsistent and you're suspicious and then the law enforcement and the health the department of human services will take over and try to figure out injuries that are in multi stages of healing so they've got bruises that are various healing day stages repetit repeated injuries or the stories don't match caregiver tells you one thing and the patient tells you another we are not making accusations we are not accusing anybody we get the patient to the hospital and have them help us figure it out as emts you're required by law to report suspicions that could be as simple as telling the hospital when you get there or like i said if law enforcement comes with you make sure they understand that you have some concerns they need to investigate let's talk about child abuse for psychological or emotional abuse just not being cared for neglect they may have physical abuse or sexual abuse neglect is uh they they just aren't provided food or shelter or safe environment um maybe somebody saw the kids digging out of the dumpster or they're always going to the neighbor asking for food maybe you just got a hungry kid maybe the parents haven't been home for a month both causes for concern so make sure that's passed on physical abuse you have uh the object that's causing the injury doesn't match what the injury looks like uh maybe it looks like a wooden spoon but they said they fell down or maybe it looks like a hand mark burns that don't match up or that match up too well to other things like curling irons or cigarettes be aware of what's going on uh injuries to the genitalia that just don't make sense uh the maturity level that doesn't make sense for a child they use terms that are not typically used by a child that age probably common findings you're gonna have slap marks bruises lacerations broken bones fractures that don't make sense of head injuries that aren't consistent with the source of injury bite marks burn marks increase intracranial pressure on a child shaking baby syndrome always bad repeated visits fortunately because of the location of fire stations they typically have the same crews responding to same geographical areas in larger systems your ambulance may not be in the same area twice so you might not have the ability to piece these things together it may have to rely on the hospital to say hey we've had this patient four times with similar injuries uh indications of past burns or bilateral burns uh different body parts injured unusual behavior or a caregiver that just won't leave the kid alone they're very protective or maybe the kid's showing some signs if he's not comfortable with a caregiver around so observe the adults are they uh concerned are they not uh are they not concerned now if the per the adult caregiver is a ems provider and they don't act like it's as bad as you think it is maybe they've seen this before and it's not as bad as you think it is i know uh i've been accused not not accused for child abuse but by my wife that i didn't show as much concern for injuries that she thought i should have because they weren't really that serious maybe the caregiver doesn't isn't able to control their anger has emotional outbursts something's just not right make sure you pass that on to the uh further care providers into the law enforcement if you have any suspicion of sexual abuse treat that just like any other sexual assault do not undress the child do not let the child go the bathroom or shower pass that on to the hospital let them use their assessing skills to document everything you find and make sure that's taken care of remain professional and control your emotions no matter how much you want to [Music] give some retribution to the uh abuser do not do that uh that'll just get you in trouble and complicate the case so just tell the child you're going to take care of them you're going to get in the hospital it's not their fault but you're going to try to take care of them so that the things get better here if you have any type of injuries you're going to dress them appropriately but document everything you do keep them from going to the bathroom nothing by mouth don't let them wash and transport sometimes we have elderly abuse and neglect these same type of things you're going to run into but we add financial abuse so we have physical psychological financial just neglect think about the geriatric patient now is coming back to live with their adult children they're putting extra stress on them and creating more issues [Music] for their lifestyle and it gets too much and they they have emotional outbursts maybe they uh try this happens a lot family members are not the financial abuse they use the money inappropriately they skim it off the top there's lots of things if something just doesn't seem right make sure you report that and pass that on to the authorities there are all kinds of uh other abuses out there uh also with people that have disabilities they may be taken advantage of because of who they are the fact that they can't say anything and uh we need to we need to stand up for our patients we're our patient advocates if you see the clues document it and pass that on to the appropriate authorities warning signs unexplained absences of caregivers or potential harmful periods of abandonment they haven't seen their caregiver for a week they haven't eaten they haven't been able to get up and use the restroom like they normally would um caregivers just don't act right around them uh they're getting conflicting information on what you're seeing and what the caregiver tells you and what the patient tells you gather your information document the facts don't put opinions in don't say you suspect there's abuse just say hey once i get to the hospital i'm going to tell the doctor what i've got here and let them figure it out in some states in colorado is one of these you have to report any type of abuse so you notify the law enforcement or the hospital know your system some states require you call social services but you you have to report it you have to take care of your patient could be uh intimate partner violence spousal abuse we used to it's what's called uh physical emotional economic sexual abuse if you have any suspicions about abuse or if they tell you about the abuse make sure you document that and pass that on to the next next level of health care or the law enforcement what you want to do with these patients that may be potential abuse patients get them away from everybody and do the interviews where you can in a little privacy what you're looking for are signs of physical abuse the victim is fearful from talking to you you need to make sure they understand you're there to help them and you're you're going to make sure they have what they need they may not be wanting to go to the hospital so you need to try to convince them use some uh good active listening and understanding what's going on and pay attention to how their people around them are reacting their their partner and how they're kind of protecting them from you or isolating them from you so take care of the medical issues first if they refuse care make sure they understand there's lots of options to help them there's a lot of they can always call 9-1-1 again there's substance or abuse hotlines there's shelters they can go to make sure you know what's available in your system when you when you do document it make sure that you're very thorough in your documentation make sure you only do the objective findings you don't do any opinions and that you provide as much information as you can so that the hospital and the law enforcement can figure out what to do another thing we're starting to run into a lot is the human trafficking trafficking is the exploitation of a human a person for compelled labor or commercial sex acts through force we are seeing these victims kept in uh very tight tight quarters being sold out for different uh abuse situations they may you may get these calls for somebody that's not doing well that something's wrong and things just don't add up you have bruises very similar to what you had in any other abuse case but you have scars they typically brand the human trafficking victims they uh they'll have tattoos of a guy's name on them that's their uh their pimp or owner they have uh utis they're pregnant they have stds chronic back pain they're they're not well kept uh physically but they're very well kept uh fashion wise you'll see children that don't probably aren't old enough to have the clothing that they have they have makeup they a friend of mine worked at a women's lingerie store at the mall and she was also uh worked for cspd in dispatch and she was all the time seeing older men bringing in young girls to get various things of lingerie that just didn't seem right and they were always she was getting the information and passing that on and finding out they were actually being human trafficked and they would uh track down those uh those clients that we're coming through other indications that like i said the controlling the person there with them they do all the talking uh they don't let the person talk their ids probably don't match them they're very submissive or fearful they're not dressed appropriate like i said they're wearing things that just don't make sense so treat the medical stuff first uh if you suspect it let law enforcement know immediately uh be careful how you do it because this can be a danger to the uh the victim if they think they're being the the the handler is under any suspicious they'll take it out on the victims they're they have special task force for child trafficking here in colorado and i'm sure they do in every other state so use the resources and with all of this if you suspect something say something pass it on to the health care providers at the hospital pass it on to law enforcement only document the facts what you see and what doesn't make sense say hey this this doesn't make sense i need to have someone look at it further and go with that and as always if you have questions concerns or thoughts on how to make this better reach out let somebody know bring it to class and let's talk about it thanks and have a great day