Chapter 35 Patients with Special Challenges

Question 1

Key Terms

development disorders that affect, among other things, the ability to communicate, report medical conditions, self-regulate behaviors, and interact with others

Answer 1

Autism Spectrum Disorders

Question 2

Key Terms

a device implanted under the skin of the chest to detect any life-threatening dysrhythmia and deliver a shock to defibrillate the heart

Answer 2

Automatic Implanted Cardiac Defibrillator (AICD)

Question 3

Key Terms

the branch of medicine that deals with the causes of obesity as well as its prevention and treatment

Answer 3

Bariatrics

Question 4

Key Terms

a catheter surgically inserted for long-term delivery of medications or fluids into the central circulation

Answer 4

Central IV catheter

Question 5

Key Terms

a device worn by a patient that blows oxygen or air under constant low pressure through a tube and mask to keep airway passages from collapsing at the end of a breath

Answer 5

Continuous Positive Airway Pressure (CPAP)

Question 6

Key Terms

the process of filtering the blood to remove toxic or unwanted wastes and fluids

Answer 6

Dialysis

Question 7

Key Terms

a physical, emotional, behavioral, or cognitive condition that interferes with a person’s ability to carry out everyday tasks, such as working or caring for oneself

Answer 7

Disability

Question 8

Key Terms

a tube used to provide delivery of nutrients to the stomach. A nasogastric _______ ____ is inserted through the nose and into the stomach; a gastric _______ ____ is surgically implanted through the abdominal wall and into the stomach

Answer 8

Feeding tube

Question 9

Key Terms

a battery-powered mechanical pump implanted in the body to assist a failing left ventricle in pumping blood to the body

Answer 9

Left Ventricular Assist Device (LVAD)

Question 10

Key Terms

a condition of having too much body fat, defined as a body mass index of 30 or greater

Answer 10

Obesity

Question 11

Key Terms

an external pouch that collects fecal matter diverted from the colon or ileum through a surgical opening (colostomy or ileostomy) in the abdominal wall

Answer 11

Ostomy Bag

Question 12

Key Terms

a device implanted under the skin with wires implanted into the heart to modify the heart rate as needed to maintain an adequate heart rate

Answer 12

Pacemaker

Question 13

Key Terms

a surgically created opening into the body, as with a tracheostomy, colostomy, or ileostomy

Answer 13

Stoma

Question 14

Key Terms

a surgical opening in the neck into the trachea

Answer 14

Tracheostomy

Question 15

Key Terms

a tube inserted into the bladder through the urethra to drain urine from the bladder

Answer 15

Urinary Catheter

Question 16

Key Terms

a device that breathes for the patient

Answer 16

Ventilator

Question 17

Critical Decision Making

Patients with special needs pose challenges for EMTs at all levels. For each of the following situations, explain how you would handle it and where you might turn for help or advice.

You are treating an unresponsive diabetic patient when you notice he has an insulin pump. You believe you should turn it off but are not sure how.

Answer 17

The patient’s family is the first place to look for answers. You may also contact medical direction for advice. Many devices have an obvious switch to turn it off.

Question 18

Critical Decision Making

Patients with special needs pose challenges for EMTs at all levels. For each of the following situations, explain how you would handle it and where you might turn for help or advice.

You are treating a patient who had just performed peritoneal dialysis at home. She complains of excruciating pain with even the least movement.

Answer 18

In this case the patient may be the best source of information. Although you should be considerate of the pain she is in, she will be able to answer your questions about how the dialysis works and also give you information on how best to move her with minimal pain.

Question 19

Critical Decision Making

Patients with special needs pose challenges for EMTs at all levels. For each of the following situations, explain how you would handle it and where you might turn for help or advice.

You are called for a possible respiratory infection in a child. You arrive to find the patient has a trach and a ventilator. You are not sure how to transport the ventilator.

Answer 19

The parents or visiting health care workers are the best source of information. Since health care workers aren’t always present, parents are trained in operation and troubleshooting the devices. If the ventilator can’t be transported, transport the patient without the ventilator and ventilate the patient through the trach tube en route. Be sure to alert the hospital that you are about to arrive with a patient who needs a ventilator.

Question 20

Short Answer

List several advanced medical devices you might find when responding to patients with special challenges at home.

Answer 20

The following are advanced medical devices that may be found in homes of patients with special challenges:

• Respiratory devices
  a. Continuous positive airway pressure (CPAP)
  b. Tracheostomy tube
  c. Home ventilator
• Cardiac devices
  a. Implanted pacemaker
  b. Automatic implanted cardiac defibrillator (AICD)
  c. Left ventricular assist device (LVAD)
• Gastro-urinary devices
  a. Nasogastric (NG) tube
  b. Gastric tube (G-tube)
  c. Urinary catheters
  d. Ostomy bags
  e. Peritoneal dialysis
• Central IV catheters
  a. Peripherally inserted central catheter (PICC) lines
  b. Central venous lines (Groshong, Hickman, Broviac)
  c. Implanted port (Port-a-Cath, Mediport)
• Devices to assist physical impairment
  a. TDD/TTY phone
  b. Computer that speaks words
  c. Cane, walker, or brace
  d. Wheelchair

Question 21

Short Answer

What health problems are associated with obesity?

Answer 21

Obesity is associated with an increased risk for cancer, diabetes, hypertension, heart attack, stroke, liver and gallbladder disease, arthritis, sleep apnea, and respiratory problems.

Question 22

Short Answer

If a tracheostomy tube is blocked and your protocols allow, describe a method of clearing the blockage.

Answer 22

To clear a blockage in a tracheostomy tube, carefully insert a whistle-tip suction catheter. Determine the correct depth of insertion by measuring the suction tubing against the length of the obturator, which is the same length as the tach tube itself. If you can’t locate the obturator for measurement, stop insertion of the catheter is being withdrawn, using a twisting motion as it is slowly removed. If the patient requires further suctioning (indicated by visible or audible mucus), insert the suction tip into a container of sterile water to remove left in the catheter and repeat. If the patient is on a ventilator, he may need to be ventilated by BVM between suctioning.

Question 23

Short Answer

If a ventilator that a patient relies on to breathe malfunctions, what life support care should you perform?

Answer 23

In the case of a mechanical failure or during transport of the patient, a bag-valve-mask device can take over the function of the ventilator. During this procedure, you should adjust the rate, volume, and pressure of the BVM to the patient’s comfort level. This can be done with guidance from the patient. If the patient can’t provide guidance, observe for adequate chest rise and improving skin color. (Note: If the BVM does not fit the tube attachment, use the face mask from the BVM to cover the stoma, secure the mask from the BVM to cover the stoma, secure the mask to provide a good seal against the neck, and ventilate as normal.)

Question 24

Short Answer

What are some specific health problems associated with homelessness?

Answer 24

Homelessness can be associated with mental health problems, malnutrition, substance abuse, HIV/AIDS, tuberculosis, bronchitis and pneumonia, environmental emergencies, wounds, and skin infections.

Question 25

Short Answer

List and briefly describe the “ABCS” for dealing with a patient who has autism?

Answer 25

A mnemonic to use when dealing with patients who have autism is ABCS: awareness, basic, calm, and safety. These mean:

• Awareness: Be aware that ASD patients behave and react differently from most patients.
• Basic: Keep instructions, questions, treatments, and the environment simple.
• Calm: Be calm and patient; don’t lose your temper, yell, or try to force the patient.
• Safety: As much as possible, interact with the patient in his familiar surroundings where he feels safe.

Question 26

Short Answer

If a patient cannot hear or cannot speak, describe several methods that might facilitate communication with him.

Answer 26

The first thing that should be done when approaching the patient is to determine his ability to hear and/or speak. If a patient with hearing loss can read lips, then use this approach. If not, then communicate by writing questions and information on a piece of paper. TDD/TTY phones, if available, can be used to relay information. These approaches will also work for patients who are unable to speak. In addition, some patients who are aphasic (unable to speak) may have a computer that speaks words they type into the device.

Question 27

Critical Thinking Exercises

A call to a patient with special needs may require some creative problem solving. Describe how you would handle each of the following situations, and explain your reasoning.

You are called to respond to a patient who has an arteriovenous (A-V) fistula that is used during his triweekly visits to the dialysis center. The patient presents as pale, sweaty, anxious, and almost incoherent. Could the cause of the condition be related to the A-V fistula? How might you determine if this is the case? What actions should you take?

Answer 27

The fistula may be ruptured, causing significant blood loss, which is indicated by swelling at the site. Apply direct pressure and do not release it until advised by a physician to do so.

Question 28

Critical Thinking Exercises

A call to a patient with special needs may require some creative problem solving. Describe how you would handle each of the following situations, and explain your reasoning.

You are called to a nursing home to transport a seventy-nine-year-old patient who had a severe stroke 6 months ago. She has a feeding tube in place, a colostomy bag, and a urinary catheter. Today she is presenting with a fever, a heart rate of 120, respirations of 24, and a blood pressure of 100/60. What are your primary concerns with this patient? What are your considerations for dealing with her feeding tube, colostomy bag, and urinary catheter?

Answer 28

The patient’s signs, symptoms, and circumstances likely indicate an infection that may be leading to septic shock. The initial patient care concerns are the patient’s airway, breathing, oxygenation, and circulation. The nursing home staff can assist you in preparing the feeding tube, colostomy bag, and urinary catheter for transport. The urinary catheter can be temporarily placed at the patient’s level to move her but should be positioned lower than the patient for transport.

Question 29

Critical Thinking Exercises

A call to a patient with special needs may require some creative problem solving. Describe how you would handle each of the following situations, and explain your reasoning.

Think back to your training in basic life support. What BLS training might you draw upon to help you deal with a patient with special needs whose life-sustaining equipment has malfunctioned?

Answer 29

If an airway or ventilation device has failed, provide an open airway (use suction as necessary) and use a bag-valve-mask device to ventilate. If a pacemaker or AICD has failed, provide CPR and use the AED as indicated by the patient’s condition.

Question 30

Critical Thinking Exercises

A call to a patient with special needs may require some creative problem solving. Describe how you would handle each of the following situations, and explain your reasoning.

Your patient is a paraplegic, paralyzed from the waist down after a vehicle collision. She called EMS today because she thinks she has pneumonia. She lives alone and has a service dog that assists her. She insists that she must take the dog with her. How should you handle this situation?

Answer 30

If at all possible, you must allow the dog to accompany the patient. You may refuse only if the dog is a threat to you or others.

Question 31

Critical Thinking Exercises

A call to a patient with special needs may require some creative problem solving. Describe how you would handle each of the following situations, and explain your reasoning.

Your patient is a ten-year-old girl with autism who does not speak. She has fallen from a chair she was standing on and seems to have injured her ankle. When she sees you coming in, she becomes visibly terrified. How can you best assess and treat this child?

Answer 31

Understanding that this young patient has autism, think about how you can implement the “ABCS” mnemonic. First, simply have an AWARENESS that the patient will likely react differently than most. Second, keep your instructions and questions BASIC and your treatment simple. Third, be as CALM as possible and avoid adding to the patient’s level of anxiety. Finally, try to keep the patient in an environment that is SAFE and comfortable, preferably a place she recognizes and is used to.

Question 32

c

What risk factors do the homeless and poor have for developing serious health problems? Why might patients in this group be less able to compensate for illness and injury?

Answer 32

The homeless and poor may be malnourished, live in unsanitary conditions, and may not have been able to seek help for health problems early in their course.

Question 33

Pathophysiology to Practice

The homeless and poor may be malnourished, live in unsanitary conditions, and may not have been able to seek help for health problems early in their course.

What is the difference between congenital and acquired diseases? What are examples of each?

Answer 33

A congenital condition is one that is present at birth, such as certain heart defects. An acquired disease occurs after birth and may be the result of exposure to an infectious disease, another medical condition, or trauma. Acquired diseases include AIDS and atherosclerotic heart disease.

Question 34

Pathophysiology to Practice

The homeless and poor may be malnourished, live in unsanitary conditions, and may not have been able to seek help for health problems early in their course.

Why might a patient who is paralyzed be more prone to bedsores, pneumonia, and other infections?

Answer 34

The lack of sensation means that the patient cannot feel pain associated with excess pressure on the skin or with developing sores. If he is not properly cared for, he may not be moved often enough to relieve pressure on the tissues to prevent development of bedsores. Weakness of the chest muscles can impair the cough reflex, making it difficult to clear infectious material from the airway, resulting in respiratory infections.