ECRN Packet 2006:

SOP UpdatesDisaster Communication

Patients With Special Challenges and

Interventions for Patients with Chronic Care Needs

Condell Medical Center EMS System

Revised by: Sharon Hopkins, RN, BSNEMS Educator

ObjectivesUpon successful completion of this module, the ECRN

should be able to:

• identify key changes in the Region IX & X SOP’s

• state the components of disaster communication

• discuss the uniqueness when caring for patients with special challenges

• identify the differences between hospitalization and homecare

• review acute interventions necessary at home for the chronic care patient

• identify components of a valid DNR form

Region X SOP UpdateHighlights

Effective March 1, 2007

SOP Update

• Many updates are in keeping with revised AHA guidelines

• Synopsis in notebook by EMS radio

• All ECRN’s to read the document and sign off in the notebook

• EMS providers were updated during February in-station CE

What’s New With The SOP’s?• AHA changes

– CPR 1 and 2 person adult 30:2– CPR 1 person infant and child 30:2– CPR 2 person infant and child 15:2– Switch compressors every 2 minutes , you’ll be tired– Once intubated, breaths are 1 every 6-8 seconds for all

persons, compressor does not pause– Immediately after a shock, resume CPR

• check rhythm only after 2 minutes of CPR• check pulse after 2 minutes of CPR only if you see

a rhythm that should have a pulse

SOP’s and Antidysrhythmics

• Any SOP that had listed Lidocaine now also includes Amiodarone in adult and pediatric SOP’s

– It is EMS choice for which antidysrhythmic to use

– ED should continue with same drug choice

• heart more irritable when mixing antidysrhythmic drugs

Revised SOP’s• Table of Contents

– organized into sections and each section alphabetized• Pediatric patient

– Per EMSC guidelines, a pediatric patient is someone under the age of 16 (15 or less)

– medications are calculated on weight– pediatric medication dose is maximized at the adult dosage

(ie: cap off the dose at the adult dosage even if the child’s weight indicates more to be given)

Revised SOP’s• Conscious sedation

– initial dose of Versed 5 mg, repeated every 1 minute at 2mg until sedation achieved

– may continue Versed 1 mg every 5 minutes after intubation to keep patient sedated

• Asystole - no longer recommend TCP attempt• Bradycardia

– all Atropine dosages at 0.5 mg (“when they’re alive give them 0.5”) with a maximum still of 3mg

Revised SOP’s• Acute Coronary Syndrome

– if patient reliable and took ASA in last 24 hours EMS will hold the dose and document

– if pain unchanged after 2 doses of NTG will advance to Morphine (NTG continues only on Medical Control order)

• Ventricular Fibrillation/Pulseless VT– shocks are delivered singularly & at highest watt setting– EMS choice of antidysrhythmic - (use only 1)

• Amiodarone 300mg; in 5 minutes 150 mg• Lidocaine 1.5 mg/kg; in 5 minutes 0.75 mg/kg

Revised SOP’s• Ventricular Tachycardia with Pulse

– EMS choice for Amiodarone or Lidocaine– Amiodarone to be diluted in 100 ml D5W and run IVPB over 10 minutes

for adult

• Acute Abdominal/Flank Pain– Pain control must be ordered by Medical Control– Be an advocate for the patient for pain control

• Severe Respiratory Febrile Illness– New; heightens awareness of infection control– If patient needs a mask, use surgical mask– N95 (orange duck bill) only for medical team use

Revised SOP’s• Adult and Pediatric Heat Emergencies

– Clarifies that heat stroke (the worst) can present hot & dry or hot & moist

– Moist skin if exerting self before the collapse • marathoner• construction worker

• Pediatric Bradycardia– Epinephrine is first drug of choice– EMS must contact Medical Control for Atropine order

• appropriate for AV block or increased vagal tone

Revised SOP’s• Pediatric Allergic Reaction/Anaphylaxis

– Benadryl 1 mg/kg added to the SOP’s

• 25 mg maximum for stable allergic reactions with hives, itching and rash

• 50 mg maximum for stable patient with airway involvement

• 50 mg maximum for patient with anaphylaxis

• Suspected Elder Abuse– effective 1-1-07 added self-neglect to behaviors that can be

reported to the hot line

ECRN Responsibilities• Answer radio promptly

• Identify that appropriate interventions/SOP’s are being followed based on report received

• ECRN cannot order what is not already stated in protocol

– to give an additional order, the ECRN must obtain the order from the ED MD

• Document clearly and fully on the EMS radio log - it is a legal document

Highlights of Changes to Region 9 NWC EMSS SOP’s

Member Fire Departments transporting to Condell:

Buffalo GroveLincolnshire/Riverwoods

Long GroveLake Zurich

NWC EMSS SOP’s

• Full SOP in notebook above radio marked “NWC SOP”

• ECRN & ED MD responsible to know the NWC SOP for those respective transporting departments

• Each ECRN & ED MD responsible to:– review changes

– review 55 question self-assessment tool– sign off that information was reviewed

Pediatric Ages

Region X - CMC

• <16 years old

(15 and younger)

Region 9 - NWC

<13 years old

(12 and younger)

Advanced Airway ToolsRegion X - CMC

• ETT

• Combitube

Region 9 - NWCETTKing LTS-D airway

Reinforcement of AHA Changes• Ventilations

– With BVM: 1 breath every 5-6 seconds (10-12 breaths/minute)

– With BVM to ETT: 1 breath every 6-8 seconds (8-10 breaths/minute)

• Obstructed airway, unconscious person– Reposition head once & reattempt ventilation– If unsuccessful, begin CPR

• look in mouth when opening airway to ventilate

• Compressions– Minimize interruptions to <10 seconds– Switch compressors at end of every 2 minute cycle

• Defibrillation– 360 joules if monophasic device; if biphasic

device joules are manufacturer dependent

• IV access– IO route via EZ IO drill for adult and pediatric

patients if unable to establish a peripheral IV

Conscious Sedation vs Drug Assisted Intubation

Region X - CMC• Lidocaine if head injury• Benzocaine to eliminate

gag reflex• Morphine for pain• Versed for sedation• Versed for post-sedation

continued sedation

Region 9 NWC EMSS Lidocaine if head injuryBenzocaine to eliminate

gag reflexMorphine for painVersed & Etomidate for

sedationVersed for post-sedation

continued sedation

Allergic Rx/AnaphylaxisRegion X - CMC• Stable - Benadryl• Stable with airway

involvement– Epi 1:1000

– Benadryl

– Albuterol if wheezing

• Anaphylaxis– Epinephrine 1:1000

– Benadryl

– Albuterol if wheezing

Region 9 NWC EMSSMild - BenadrylModerate

Epinephrine 1:1000BenadrylAlbuterol & Atrovent if wheezing

SevereEpinephrine 1:10,000Dopamine if B/P <90Glucagon possiblyBenadrylAlbuterol & Atrovent if wheezing

Asthma/COPD

Region X - CMC

• Albuterol nebulizer

• Call Medical Control to consider use of CPAP for COPD

Region 9 NWC EMSSAlbuterol & AtroventSevere distress:

Epinephrine 1;1000Albuterol &

AtroventMagnesium if

distress persists

Acute Coronary SyndromeRegion X - CMC• 12 lead faxed to

receiving hospital• Aspirin• NTG 2 doses• Morphine if pain persists• NTG taken with Viagra,

Levitra, or Cialis can lead to untreatable hypotension

Region 9 NWC EMSS12 lead faxed to receiving

hospitalAspirinNTG 3 dosesMorphine if pain persistsNTG taken with Viagra,

Levitra, or Cialis can lead to untreatable hypotension

BradycardiaRegion X - CMC

• Narrow QRS

– Atropine

• Wide QRS

– TCP

– Atropine if TCP ineffective

• Valium for comfort during TCP use

Region 9 NWC EMSSTCP if clinical

deteriorationVersed and Morphine for

comfort during TCP useIf TCP ineffective or

delayed, give AtropineGlucagon if beta or

calcium blockers (stimulates release of catecholamines)

Ventricular Fibrillation & Pulseless Ventricular Tachycardia

Region X - CMC

• Vasopressor used:

• Epinephrine 1:10,000 every 3-5 minutes

Region 9 NWC EMSSVasopressor used:

Epinephrine 1:10,000 every 3-5 minutes or

Vasopressin one time in place of 1st or 2nd dose Epinephrine

Asystole/PEA

Region X - CMC

• Vasopressor used:

• Epinephrine 1:10,000 every 3-5 minutes

Region 9 NWC EMSSVasopressor used:

Epinephrine 1:10,000 every 3-5 minutes or

Vasopressin one time in place of 1st or 2nd dose Epinephrine

Heart Failure/Pulmonary Edema

Region X - CMC

• NTG - 3 doses max

• Consider CPAP

• Lasix

• Morphine

• If wheezing, Albuterol

Region 9 NWC EMSSCPAPAspirinNTG - no dose limitMorphine

Hypertension

Region X - CMC

• Lasix

• NTG only on Medical Control order

• Valium if seizures

Region 9 NWC EMSSMorphineNTGVersed if seizures

SeizuresRegion X - CMC

• Valium IVP, IM, or rectally

Region 9 NWC EMSSVersed IVP or

intranasally (IN) via MAD device (“mucosal atomization device”). Dose different - not in ED or EMS pyxis for patient safety reasons!

Pre-eclampsia

Region X - CMC

To control seizure activity:

•Valium

Region 9 NWC EMSS

To control seizure activity:Magnesium

For persistent seizures:Versed

Disaster Communication

Steps

Disaster Communication• Everyone’s responsibility to know their duties

– Internal plan

– Local plan

– State wide plan

– Federal plan

• Resource manuals

– Which ones are in your ED?

– Where they are kept?

– What do they contain?

– How do you use them?

Types of Disaster Plans

• Multiple Victim & Mass Casualty Plan– local plan with local resources

• Emergency Medical Disaster Plan– State response plan with POD hospital

• National Disaster Medical System NDMS– large scale national response utilized

Multiple Victim & Mass Casualty Plan

• When the local event occurs, the Resource Hospital (CMC) for that department acts as the communication link to Receiving Hospitals

Condell departments included are:Countryside LibertyvilleGrayslake Round LakeMundelein WaucondaLake Forest FireLake Bluff, KnollwoodMurphy Ambulance

Multiple Victim & Mass Casualty Plan

• Patients are being transported now

• Transport from the scene may have already started with the most critical patients before official notification has even taken place

• Resource hospital (CMC) will also be a receiving hospital

• Need good coordination from the scene to the Resource Hospital (CMC) to best distribute the patient load to appropriate receiving hospitals

Emergency Medical Disaster Plan - State Plan

• Statewide disaster plan for when a local area has exhausted their resources (ie: tornado)

• Local POD hospital (ie: Highland Park Hospital for Region X) is the lead hospital in that Region (communication & coordination)

PODCMCAssociate Hosp (LFH)

• Resource Hospital (CMC) contacts their Associate Hospital (LFH) and conveys information back to the POD

State Plan - Phase I • Purpose

– to determine resource availability within the region

• No personnel or equipment is mobilized yet, this is a “heads-up” alert phase

• Resource Hospital (CMC) to contact Associate Hospital (LFH) to obtain Phase I information (ie: resources)

• Phase I form completed by CMC with CMC and LFH information combined and faxed to POD (HPH) within 1 hour

State Plan - Phase II

• When notified by the POD (HPH), Resource Hospital (CMC) contacts Associate Hospital (LFH) for Phase II information

• Phase II form completed by CMC with CMC and LFH information combined and faxed to POD (HPH) within 1 hour

• The POD (HPH) passes on regional resource information to the State

Phase I & Phase II Paperwork• Forms in small red notebook by EMS radio

marked “Disaster Worksheets - State Plan”

• Instructions printed on the forms

• State Disaster Plan could go on for days

• Typically, early days are fact finding and gathering of information on availability of local resources

• Typically may not see patient activity for days

National Disaster Medical System NDMS

• Federal response for a major disaster (ie: Katrina)

• FEMA coordinating activities

• Utilize POD system for hospital communications

• Most likely will not see patient activity for days

• Early days spent gathering information regarding local resources

Special Challenges and

Chronic Care

Patients With Hearing Impairment• Deafness – partial or complete inability to hear

– Conductive problem due to:infectioninjuryearwax

– Sensorineural deafness due to:congenital problem, birth injurydisease, tumor, viral infectionmedication-inducedagingprolonged exposure to loud noise

Patients With Hearing Impairment

• Recognizing patients with hearing loss– Hearing aids– Poor diction– Inability to respond to verbal

communication in the absence of direct eye contact

– Speaks with different syntax (speech pattern)

– Use of sign language

Patients With Hearing Impairment

• Assessment/management accommodations– Provide pen/paper– Do not shout or exaggerate lip

movement– Speak softly into their ear canal– Use pictures or demonstrate procedures– Consider use of interpreter services as needed

(ie: discussion medical issues, consents)

Patients With Visual Impairment

• Etiologies– Injury– Disease– Degeneration of eyeball, optic nerve

or nerve pathways– Congenital– Infection (C.M.V.)

Patients with Visual Impairment• Central vs peripheral loss

– Patients with central loss of vision are usually aware of the condition

– Patients with peripheral loss are more difficult to identify until it is well advanced

Central loss

Peripheral loss

Patients With Visual Impairment

• Assessment/management accommodations– Retrieve visual aids/glasses– Explain/demonstrate all procedures– Allow guide dog to accompany patient– EMS to notify hospital of patient’s special needs– Carefully lead patient when ambulatory

• patient holds your arm• call out obstructions, steps and turns

ahead of time

Etiologies of Speech ImpairmentLanguage disorders

• Stroke •Hearing loss• Head injury •Lack of stimulation• Brain tumor •Emotional disturbance• Delayed development

Articulation disorder– Damage to nerve pathways passing from brain to

muscles in larynx, mouth, or lips– Delayed development from hearing problems; slow

maturation of nervous system

– Speech can be slurred, indistinct, slow, nasal

Etiologies of Speech ImpairmentVoice production disorders

– Disorder affecting closure of vocal cords– Hormonal or psychiatric disturbances– Severe hearing loss– Hoarseness, harshness, inappropriate pitch, abnormal nasal

resonanceFluency Disorders

– Not well understood– Marked by repetition of single sounds or whole words

– Stuttering

Recognizing Patients With Speech ImpairmentReluctance to verbally communicate Inaudible or nondiscernable speech patternLanguage disorders (aphasia)

– Limitations in speaking, listening, reading & writing

– Slowness to understand speech– Slow growth in vocabulary/sentence structure– Common causes: blows to head, GSW, other

traumatic brain injury, tumors

Patients With Special Challenges -Obesity

• Definition– body weight 20% over the average weight of

people same size, gender, age• >58 million Americans are obese• 2nd leading cause of preventable death• Etiologies

– Caloric intake exceeds calories burned– Low basal metabolic rate– Genetic predisposition

Obesity Risk Factors

• Hypertension• Stroke• Heart disease• Diabetes• Some cancers• Kidney failure

Assessment/management

Accommodations- Obesity • Appropriate sized

equipment

• May have extensive medical history

• Additional assistance for lifting/moving

• Recognize your own biases

• Assessment techniques may need to be altered

Breathing Considerations in Obesity

• Lungs 35% less compliant• Increased weight of the chest• Increased work of breathing• Hypoxemia common

• O2 sats not reliable on finger tips (poor circulation)

• Diaphragm higher

Airway Considerations in Obesity

Control of airway challenging!!!

• Short neck

• Large powerful tongue

• Distorted landmarks

• Cricoid pressure helpful in stabilizing anatomy during intubation attempts

• Positioning is critical– towels, blankets, pillows

Circulation Considerations in Obesity• Hypertension common

• Alternate blood pressure cuff size– may need to use thigh cuff around upper arm

– if difficulty fitting cuff around upper arm, place cuff around forearm and place stethoscope over radial artery

• Prone to pulmonary emboli due to immobility

Patients With Special Challenges - Spinal Cord Injuries

• Conditions result from nerve damage in the brain and spinal cord

– MVC, sports injury, fall, GSW, medical illness

• Paraplegia

– Weakness/paralysis of both legs

• Quadriplegia

– Paralysis of all four extremities and possibly the trunk

Assessment/Management Accommodations - Spinal Cord Injuries

• Assistive devices may need to be transported with the patient

• May have ostomies (trachea, bladder,colon)

• May be ventilator dependent• Priapism in male patients -

may be presenting as a medical emergency

Patients With Special Challenges - Mental Illness• Any form of psychiatric disorder• Psychoses – mental disorders where there is

loss of contact with reality; patient may not be aware they have a disorder– schizophrenia, bipolar, organic brain

disorder• Neuroses-related to upbringing and personality

where person remains “in-touch” with reality; patients are aware of their illness– depression, phobias, obsessive/compulsive

disorder

Patients With Special Challenges - Down’s Syndrome

• Chromosomal abnormality that causes mild to severe mental retardation

• IQ varies from 30-80• Eyes slope upward and at the outer corners• Folds of skin at side of nose that covers

inner corners of the eyes• Small face and facial features• Large and protruding tongue• Flattening on back of the head• Hands that are short and broad

Assessment/Management Accommodations - Down’s

Syndrome • Congenital heart, intestinal, hearing defects• Limited learning capability• Generally affectionate and friendly• Utilize patience with assessment• Explain procedures before beginning

task

Emotional or Mental Impairment

• IQ • Mild impairment 55-70

• Moderate impairment 40-54

• Severe impairment 25-39

• Profound impairment < 25• Extensive history taking needed to differentiate

emotional issue vs medical issue• Utilize patience and extra time in history taking

and while providing care• Remain supportive & calm

Etiologies Emotional/Mental Impairment

During pregnancy• Use of alcohol, drugs or tobacco• Illness/infection (toxoplasmosis, rubella, syphilis,

HIV)GeneticPhenlketonuria (PKU)-single gene disorder caused by a

defective enzymeChromosomal disorder (down syndrome)Fragile X syndrome - single gene disorder on Y

chromosome. Leading cause of mental retardation

Etiologies Emotionally/Mentally Impaired cont’d

Poverty/cultural deprivation– Malnutrition– Disease-producing conditions (lack of

cleanliness)– Inadequate medical care– Environmental health hazards– Lack of stimulation

Patients With Special Challenges - Emotionally or Mentally Impaired

• Assessment/management accommodations

– Chronological age may not be consistent with developmental age

– May have numerous underlying medical problems– May show no psychological symptoms apart from

slowness in mental tasks– Moderate to severe may have limited or absent

speech, neurological impairments– Allow extra time for evaluation and patient

responses

Involuntary Commitment Papers

• EMS can be asked to complete the narrative to describe statements made or behavior noted for involuntary commitments when EMS is a witness

• EMS cannot document hearsay– if family or significant other were the witness, they

must fill out the papers– if police were the witness, police must fill out the

papers

• Completing these papers is often a group effort

Narrative must be filled out by the witness to the statements or the behavior.The rest of the form can be a group effort

Signatures importantPhone & address may be work

Patients With Special Challenges Due to Disease

• Physical injury or disease may result in pathological conditions that require special assessment and management skills– arthritis - myasthenia gravis– cerebral palsy - poliomyelitis– cystic fibrosis - spina bifida– head injury– multiple sclerosis– muscular dystrophy

Patients With Special Challenges - Arthritis -

• Inflammation of a joint, characterized by pain, stiffness, swelling and redness

• Has many forms and varies in its effects– Osteoarthritis - results from cartilage loss and

wear of joints (elderly)– Rheumatoid arthritis - autoimmune disorder

that damages joints/surrounding tissue• Ask patient least painful method to assist

in moving & touching them

Patients With Special Challenges - Cerebral Palsy• Non-progressive disorder of movement

and posture due to a damaged area of brain that controls muscle tone

• Most occur before birth– cerebral hypoxia, maternal infection

• Damage to fetal brain in later stages of pregnancy, during birth, newborn or early childhood

Patients With Special Challenges

• Types of Cerebral Palsy– Spastic – abnormal stiffness and

difficulty with movement– Athetoid – involuntary &

uncontrolled movements– Ataxic – disturbed sense of

balance & depth perception– Mixed - some combination of the

above in one person

Patients With Special Challenges - Cerebral Palsy

• Signs and Symptoms– Unusual muscle tone noted during holding

and feeding– 60% have mental retardation/

developmental delay– Many have high intelligence– Weakness or paralysis of extremities

• Each case is unique to the degree of limitations

Patients With Special Challenges -

Cystic Fibrosis • Inherited metabolic disease of the lung and digestive

system– Childhood onset– Defective, recessive gene inherited from each parent

(become carrier if gene inherited from only 1 parent)– Gland in lining of lung produces excessive amounts

of thick mucous– Pancreas fails to produce enzymes required to break

down fats and their absorption from the intestines

Patients with Special Challenges - Cystic Fibrosis

• Signs and Symptoms– Patient predisposed to chronic lung infections– Pale, greasy looking, foul smelling stools– Persistent cough/breathlessness– Stunted growth– Sweat glands produce salty sweat– May be oxygen dependent, need of suctioning– May be a heart/lung transplant recipient

Patients With Special Challenges - Previous Head Injuries

• Traumatic brain injury affects cognitive, physical and psychological skills

• Physical appearance may be uncharacteristic

or may be obvious

Patients With Special Challenges - Previous Head Injury

• Signs and Symptoms– Speech and mobility may be affected– Short term memory loss– Cognitive deficit of language and

communication– Physical deficit in balance, coordination,

fine motor skills– Patients may use protective or helpful

appliances (ie: helmet, braces)

Patients With Special Challenges - Multiple Sclerosis

• Progressive/incurable autoimmune disease

• Brain and spine myelin destroyed• May be inherited or viral

component• Begins in early adulthood• Physical/emotional stress

exacerbates severity

Patients With Special Challenges - Multiple Sclerosis

• Signs and Symptoms– Fatigue, mood swings– Vertigo– Muscle weakness; extremities that feel

heavy and weak– Spasticity; difficulty ambulating– Slurred speech– Blurred vision– Numbness, weakness, or pain in face– Midlife incontinence; frequent UTI’s

Patients With Special Challenges - Muscular Dystrophy

• Inherited, incurable muscle disorder that results in a slow but progressive degeneration of muscle fibers

• Life span generally not beyond teen years

• Duchenne muscular dystrophy– Most common sex-linked cause– Recessive gene that only affects males– Diagnosed after age 3

Patients With Special Challenges - Muscular Dystrophy

• Signs and Symptoms

– Child that is slow to sit and walk

– Unusual gait

– Patient eventually unable to ambulate

– Curvature of the spine

– Muscles become bulky and replaced with fat

– Immobility causes chronic lung diseases

• Management & care includes respiratory support

Patient With Special Challenges - Myasthenia Gravis

• Chronic autoimmune disorder of CNS• Weakness to skeletal (voluntary) muscles • Caused by defect in transmission of nerve impulses to

muscles• Eye & eyelid •Throat• Face • Extremities• Chewing, talking, swallowing

• Symptoms vary by type & severity• Dependent on precise timing of daily medication• Can live normal or near normal life

Myasthenia Gravis

• Signs and symptoms– Women ages 20-30; men ages 70-

80– Drooping eyelid, double vision– Difficulty speaking, chewing & swallowing– Weakened respiratory muscles– Exacerbated by infection, medications and menstruation– Controlled with drug therapy to enhance transmission of

nerve impulses

Patients With Special Challenges - Poliomyelitis (polio)

• Infectious disease caused by poliovirus hominis– Virus is spread through direct

and indirect contact with infected feces and by airborne transmission

– Salk & Sabin vaccines in 1950 have reduced incidences

– In USA polio virus now injected and not oral form (virus shed thru GI system when given orally)

Patients With Special Challenges - Poliomyelitis

• Signs and Symptoms

– Paralysis of lower extremities

– Difficulty ambulating

– Chronic respiratory diseases

• Management & care

– Needs support for ambulation

– May need careful handling of extremities to avoid further injury

– Assessment may take longer due to body disfigurement

Patients With Special Challenges - Spina Bifida

• Congenital defect where part of vertebra fails to develop, leaving part of the spinal cord exposed

• Ranges from minimal severity to severely disabled

• Loss of sensation in all areas below defect

• Associated abnormalities– Hydrocephalus with brain damage– Cerebral palsy– Mental retardation

Interventions for the Specially Challenged and Chronic Care Patient

EMS, ED Staff, & Home Healthcare

• All have to compliment each other to provide high level of care to the patient

• By being integral parts to the overall care delivery system, the patient gets ultimate care

• If any one element decides their job is more important, the delivery of care diminishes

Delivery of Home Healthcare• Benefits of home health care

– Early disposition of acute health problems– Socialization of home-bound client– Family members can be more involved– Patient gets to stay at home while recovering from

illness or injury– Less stress to the patient– Trained healthcare provider knows the

equipment and the patient - can spot early changes in patient status

Delivery of Home Healthcare• Deficiencies in care

– Cost– Variety of levels and competencies of healthcare providers– Low pay to the provider– Incompetence of provider – Family members not in agreement with care

• Complications– Inadequate recognition of acute illness– Theft to the patient

In-hospital vs. Homecare

• Mortality and quality– Higher incidence of infection as an in-patient– Quality of care depends on competence of the

provider in each situation• Can be very supportive and actually

diminish the instance for hospitalization if the home care provider is aggressive

• Less stress on the patient to be cared for at home

Home Care

• Equipment– Nearly any piece of equipment found in a hospital can be

used at home• Complications and pathologies to summon EMS support

and transport to the ED– Inadequate respiratory support– Acute cardiac events– Acute sepsis– GI/GU crisis– Home dialysis emergencies– Displaced catheters or G/J-tubes

Home Care Airway Adjuncts

• Oxygen delivery devices• CPAP machine

(mask and nasal)• BiPAP machine• Tracheotomies• Home ventilators• Peak flow machine

Vascular Access Devices• Central venous access devices

– Hickman, Groshon– Directly into central circulation– Often surgically implanted

• Dialysis shunts - usually forearm, may be abdominal placement

• PICC access device – Peripheral line– Generally in upper extremity

• Peripheral venous IV

Nutrition (Delivery/Removal)

• Gastric emptying or feeding– NG tubes– Feeding tubes– PEG tubes (J-tubes)– Colostomy

• Urinary tract– Internal/external catheters– Suprapubic catheters– Urostomy - collection bag worn

PEG tubes

Assessing Complications of the Airway• Evaluate

Respiratory effortTidal volumePeak flowOxygen saturationBreath sounds

• Compare values based on the patient’s “normal” or baseline levels

Complications of Vascular Access Devices

Infection/sepsis Inadvertent removalHemodynamic compromiseHemorrhageEmbolusStable vs. unstable angina Improper fluid administration Inability of home caregiver to flush

device PICC line

PICC Catheter

Assessing Complications of GI/GU DevicesAbdominal pain Inability to flush deviceAbdominal distentionLack of bowel soundsPalpation of bladder indicating fullnessChange in color/character/amount of urineRedness/discharge at insertion sites

• EMS does not manipulate tubes in the field and does not flush tubes

• Patient must be transported for ED care

Ventilatory Devices• Recognizing device or patient failure

Inadequate oxygenationAnxietyHypoventilation

• Management– Reposition airway– Remove secretions - suction– Support ventilations with BVM

• If transport to hospital includes with patient’s ventilator - will it fit in rig?• Consider using home caregiver to continue assisting in providing care -

they know the patient

Rights of the Terminally IllRight to refuse careRight to comfortRight to advanced healthcareThey need family support as well as

integrated healthcare teamHospice careComfort care

Hospice care

• Definition– The ability to provide care for a patient in

a comfort type of environment as the disease process is in an advanced stage

• Patient usually terminal within 6 months• Care is patient and family centered• Palliative & comfort care is necessary

Hospice Care

• Employs team of caregivers • Advanced directives followed to honor

the patients wishes• Family is very involved in process of care• Disease process not limited to cancer care only• Family may call 911 for acute problem (dyspnea,

chest pain) that needs to be attended to with full care provided prior to arresting

• Involves great deal of emotional support

DNR Form• Do not attempt resuscitation

– Does not mean “do not treat medical conditions”

– The DNR form must be the State of Illinois form

– If the DNR is valid, EMS to withhold resuscitative efforts and follow specific orders on the DNR, if any

– CPR must be started in the absence of a valid, signed DNR form except for decapitation, rigor mortis without hypothermia, dependent lividity, body decompensation, incineration

DNR Form Format

• EMS may accept the older orange DNR form

• EMS may accept the current cherry colored DNR form

• EMS may accept a Durable Power of Attorney for Healthcare form

• EMS cannot accept a note scribbled on a prescription pad

• EMS cannot accept a Living Will

Components of Valid DNR

• Name of patient

• Name and signature of attending physician

• Effective date – once signed, form does not expire unless

revoked by patient or physician

• The words “Do Not Resuscitate”

• Evidence of consent

State of Illinois DNR Form Page #1

State of Illinois DNR Form Page #2

Living Wills

• Cannot be honored by EMS in the field

• If EMS is on scene and presented with a Living Will:they must initiate CPRcall into Medical Control and give a reportMedical Control can authorize EMS to stop

resuscitation and call the coronerEMS will ask for the name of the physician

authorizing the order to stop CPR for documentation purposes