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.
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