TRANSITION SERIESTRANSITION SERIES

Topics for the Advanced EMTTopics for the Advanced EMT

CHAPTERCHAPTER

Special ChallengesSpecial Challenges

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ObjectivesObjectives

• Discuss basic descriptions of the size of the problem regarding special challenge cases.

• Discuss pathophysiology of unique emergencies that may be seen by EMS.

Objectives (cont’d)Objectives (cont’d)

• Discuss a general assessment approach and treatment strategies for these patients categorized as “special challenges.”

IntroductionIntroduction

• Due to lifestyle changes and medicine, the life spans of humans are lengthening.

• Advances in medicine allow technology to go home with the patient.

Introduction (cont’d)Introduction (cont’d)

• Congenital disease patients live longer at home, due to medicine.

• EMS may not know what the medical technology is, but they must always know what to do.

EpidemiologyEpidemiology

• No specific registry or definition for what “specially challenged” is.

• Underreporting is also believed to occur, especially with abuse.

Epidemiology (cont’d)Epidemiology (cont’d)

• Over 3 million pediatric abuse cases and over half a million elder abuse cases.

• 8 million disabled people are receiving health care from professional providers.

PathophysiologyPathophysiology

• Abuse– Child abuse

Physical, emotional, sexual

– Elder abuse Physical, emotional, sexual

– Passive versus active Neglect

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

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Mental Illness– Mild to severe disabilities– Commonly include the following

features: Cognitive disabilities Speech impediments Behavioral disorders Movement disorders

Causes of Mental Retardation

Causes of Mental Retardation

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Disabilities– A problem of the patient that was

caused by a disease, that results in sustained medical care for the person.

– Common disabilities seen in EMS include: Paralysis Obesity Traumatized patients

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Disabilities – Paralysis– Loss of function of single or multiple

muscles– Damage to nervous system (spinal cord)– Neuromuscular diseases

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Disabilities – Obesity– Over 40% of the U.S. population is

obese.– Obesity may be due to lifestyle choices

or medical conditions.– Obesity creates a multitude of

secondary emergencies.– Obesity also creates a patient handling

and movement concern for EMS.

Effects of Excess Weight on Organ Systems

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Disabilities—Traumatized patients– Head and/or brain trauma– Commonly there are residual effects

Mild—speech or gait impairments Severe—unresponsive, seizures,

technology dependent

– Most patients fall between these two extremes.

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Technology Assistance/Dependency– Medical equipment designed for patient

care Enhances quality of life Sustains life

– EMS must remain aware of common types of equipment.

– Some EMS systems track where patients live who are technology dependent.

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Apnea Monitor– Monitors patient's breathing status– Some monitor heart rate– Common to neonates and infants– Audible alert for when patient stops

breathing

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Tracheostomy Tube– Provides an artificial opening into the

airway.– Placed through the anterior of the neck.– Bypasses the mouth and nose.

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

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

Pathophysiology (cont’d)Pathophysiology (cont’d)

• CPAP and BiPAP– Designed to provide “back pressure” via

mask that attaches to face.– Helps to keep small bronchioles open

during breathing, and the airway open during sleep.

– Commonly found with obese patients and certain chronic lung diseases.

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Home Mechanical Ventilators– Assist or provide total ventilatory needs

to a patient who cannot maintain own ventilatory effort.

– Include negative and positive pressure units.

– Controls include rate, volume, and occasionally oxygen levels.

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Home Mechanical Ventilators– Alarms (may be reason EMS is

summoned) High pressure alarm Low pressure alarm Apnea alarm Low FiO2 alarm

Vascular access devices include central IV catheters such as a PICC line, central venous lines such as the Broviac catheter, and implants ports such as the MediPort system.

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Vascular Access Devices– Devices implanted into the skin.– Allow for ongoing or multiple medication

administrations into the patient's vascular system.

• Dialysis– Replaces kidney function.– Hemodialysis—done at facility.– Peritoneal dialysis—done at home.

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Feeding Tubes– Provide nutrition to patients who cannot

chew.– “Enteral feeding” or “tube feeding”– Types

NG tube—nose to stomach OG tube—mouth to stomach G-tube—through skin to stomach J-tube—through skin to jejunum (middle

section of the small intestine)

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Intraventricular Shunts– Medical illnesses or anatomic defects

that allow excessive CSF to accumulate.– Increased CSF can cause damaging ICP

issues.

Pathophysiology (cont’d)Pathophysiology (cont’d)

• Intraventricular Shunts– Shunt is placed in ventricle of brain and

extends to blood vessel in neck, heart, or abdomen.

– Occasionally there may be an external reservoir.

Assessment FindingsAssessment Findings

• During your assessment, ask about the medical equipment.– Where do I get the best information

regarding this equipment?– What does this device do for the

patient?– Can I replicate its function should it fail?– Will this equipment change assessment

findings?

Assessment Findings (cont’d)Assessment Findings (cont’d)

• During your assessment, ask about the medical equipment– Has this ever occurred before? What

fixed it?– Has anyone attempted to remedy the

problem?– Do I have movement or handling issues

with this equipment?

Emergency Medical CareEmergency Medical Care

• Manual cervical spine considerations• Assess and maintain the airway.• Determine breathing adequacy.

– High-flow via NRB with adequate breathing.

– High-flow via PPV @ 10-12/min if inadequate.

– Maintain saturation >95%.

Emergency Medical Care (cont’d)Emergency Medical Care (cont’d)

• Assess circulatory components.– Check pulse, skin characteristics.

Emergency Medical Care (cont’d)Emergency Medical Care (cont’d)

• Initiate transport with Paramedic intercept.

• Position the patient based on condition and medical equipment.– Consider immobilization needs.

• Constantly monitor airway, breathing, and circulation.

• Try to use medical equipment if it is portable and working correctly.

SummarySummary

• Patients with special needs are those who usually have some medical technology helping them with life.

• When this equipment malfunctions, typically it is EMS that is called.

Summary (cont’d)Summary (cont’d)

• The role of the Advanced EMT is to manage the patient's problem(s), incorporating this technology into their assessment and management.