Transcript Region X - CMC - Advocate Health Care

ECRN Packet 2006:
SOP Updates
Disaster Communication
Patients With Special
Challenges and
Interventions for Patients
with Chronic Care Needs
Condell Medical Center EMS System
Revised by:
Sharon Hopkins, RN, BSN
EMS Educator
Objectives
Upon 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 Update
Highlights
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 Grove
Lincolnshire/Riverwoods
Long Grove
Lake 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
Region 9 - NWC
• <16 years old
(15 and
younger)
<13 years old
(12 and
younger)
Advanced Airway Tools
Region X - CMC
• ETT
• Combitube
Region 9 - NWC
ETT
King 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 injury
 Benzocaine to eliminate
gag reflex
 Morphine for pain
 Versed & Etomidate for
sedation
 Versed for post-sedation
continued sedation
Allergic Rx/Anaphylaxis
Region 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 EMSS
 Mild - Benadryl
 Moderate
 Epinephrine 1:1000
 Benadryl
 Albuterol & Atrovent if wheezing
 Severe
 Epinephrine 1:10,000
 Dopamine if B/P <90
 Glucagon possibly
 Benadryl
 Albuterol & Atrovent if wheezing
Asthma/COPD
Region X - CMC
• Albuterol
nebulizer
• Call Medical
Control to
consider use of
CPAP for COPD
Region 9 NWC EMSS
Albuterol & Atrovent
Severe distress:
Epinephrine 1;1000
Albuterol & Atrovent
Magnesium if
distress persists
Acute Coronary Syndrome
Region 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 EMSS
 12 lead faxed to receiving
hospital
 Aspirin
 NTG 3 doses
 Morphine if pain persists
 NTG taken with Viagra,
Levitra, or Cialis can lead
to untreatable hypotension
Bradycardia
Region X - CMC
• Narrow QRS
– Atropine
• Wide QRS
– TCP
– Atropine if TCP
ineffective
• Valium for
comfort during
TCP use
Region 9 NWC EMSS
TCP if clinical
deterioration
Versed and Morphine for
comfort during TCP use
If TCP ineffective or
delayed, give Atropine
Glucagon 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 EMSS
Vasopressor 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 35 minutes
Region 9 NWC EMSS
Vasopressor 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 EMSS
CPAP
Aspirin
NTG - no dose limit
Morphine
Hypertension
Region X - CMC
• Lasix
• NTG only on
Medical Control
order
• Valium if seizures
Region 9 NWC EMSS
Morphine
NTG
Versed if seizures
Seizures
Region X - CMC
• Valium IVP, IM,
or rectally
Region 9 NWC EMSS
Versed 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
Libertyville
Grayslake
 Round Lake
Mundelein
Wauconda
Lake Forest Fire
Lake Bluff, Knollwood
Murphy 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)
PODCMCAssociate 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:
infection
injury
earwax
– Sensorineural deafness due to:
congenital problem, birth injury
disease, tumor, viral infection
medication-induced
aging
prolonged 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 Impairment
 Language 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 Impairment
 Voice production disorders
– Disorder affecting closure of vocal
cords
– Hormonal or psychiatric disturbances
– Severe hearing loss
– Hoarseness, harshness, inappropriate pitch,
abnormal nasal resonance
 Fluency Disorders
– Not well understood
– Marked by repetition of single sounds or
whole words
– Stuttering
Recognizing Patients With Speech
Impairment
 Reluctance to verbally communicate
 Inaudible or nondiscernable speech pattern
 Language 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 “intouch” 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)
Genetic
Phenlketonuria (PKU)-single gene disorder
caused by a defective enzyme
Chromosomal 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 important
Phone & 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 effort
Tidal volume
Peak flow
Oxygen saturation
Breath sounds
• Compare values based on the patient’s
“normal” or baseline levels
Complications of
Vascular Access
Devices
 Infection/sepsis
 Inadvertent removal
 Hemodynamic compromise
 Hemorrhage
 Embolus
 Stable vs. unstable angina
 Improper fluid administration
 Inability of home caregiver to
flush device
PICC
Catheter
PICC line
Assessing Complications of
GI/GU Devices
 Abdominal pain
 Inability to flush device
 Abdominal distention
 Lack of bowel sounds
 Palpation of bladder indicating fullness
 Change in color/character/amount of urine
 Redness/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 oxygenation
Anxiety
Hypoventilation
• 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 Ill
 Right to refuse care
 Right to comfort
 Right to advanced healthcare
 They need family support as well as
integrated healthcare team
 Hospice care
 Comfort 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 CPR
call into Medical Control and give a report
Medical Control can authorize EMS to stop
resuscitation and call the coroner
EMS will ask for the name of the physician
authorizing the order to stop CPR for
documentation purposes