ECRN Packet 2006: SOP Updates Disaster Communication Patients With Special Challenges and Interventions for Patients with Chronic Care Needs - PowerPoint PPT Presentation

Loading...

PPT – ECRN Packet 2006: SOP Updates Disaster Communication Patients With Special Challenges and Interventions for Patients with Chronic Care Needs PowerPoint presentation | free to download - id: 44abff-NzgxY



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

ECRN Packet 2006: SOP Updates Disaster Communication Patients With Special Challenges and Interventions for Patients with Chronic Care Needs

Description:

... with anaphylaxis Suspected Elder Abuse effective 1-1 ... tumor, viral infection ... Signs and Symptoms Child that is slow to sit and ... – PowerPoint PPT presentation

Number of Views:777
Avg rating:3.0/5.0
Slides: 109
Provided by: CondellMe4
Learn more at: http://www.advocatehealth.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: ECRN Packet 2006: SOP Updates Disaster Communication Patients With Special Challenges and Interventions for Patients with Chronic Care Needs


1
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
2
Objectives
  • Upon successful completion of this module, the
    ECRN should be able to
  • identify key changes in the Region IX X SOPs
  • 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

3
Region X SOP Update Highlights Effective March
1, 2007
4
SOP Update
  • Many updates are in keeping with revised AHA
    guidelines
  • Synopsis in notebook by EMS radio
  • All ECRNs to read the document and sign off in
    the notebook
  • EMS providers were updated during February
    in-station CE

5
Whats New With The SOPs?
  • AHA changes
  • CPR 1 and 2 person adult 302
  • CPR 1 person infant and child 302
  • CPR 2 person infant and child 152
  • Switch compressors every 2 minutes , youll 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

6
SOPs and Antidysrhythmics
  • Any SOP that had listed Lidocaine now also
    includes Amiodarone in adult and pediatric SOPs
  • It is EMS choice for which antidysrhythmic to use
  • ED should continue with same drug choice
  • heart more irritable when mixing antidysrhythmic
    drugs

7
Revised SOPs
  • 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 childs weight indicates more
    to be given)

8
Revised SOPs
  • 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 theyre
    alive give them 0.5) with a maximum still of 3mg

9
Revised SOPs
  • 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

10
Revised SOPs
  • 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

11
Revised SOPs
  • 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

12
Revised SOPs
  • Pediatric Allergic Reaction/Anaphylaxis
  • Benadryl 1 mg/kg added to the SOPs
  • 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

13
ECRN Responsibilities
  • Answer radio promptly
  • Identify that appropriate interventions/SOPs 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

14
Highlights of Changes to Region 9 NWC
EMSS SOPs
  • Member Fire Departments transporting to Condell
  • Buffalo Grove
  • Lincolnshire/Riverwoods
  • Long Grove
  • Lake Zurich

15
NWC EMSS SOPs
  • 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

16
Pediatric Ages
  • Region X - CMC
  • lt16 years old
  • (15 and younger)
  • Region 9 - NWC
  • lt13 years old
  • (12 and younger)

17
Advanced Airway Tools
  • Region X - CMC
  • ETT
  • Combitube
  • Region 9 - NWC
  • ETT
  • King LTS-D airway

18
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 lt10 seconds
  • Switch compressors at end of every 2 minute cycle

19
  • 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

20
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

21
Allergic Rx/Anaphylaxis
  • Region X - CMC
  • Stable - Benadryl
  • Stable with airway involvement
  • Epi 11000
  • Benadryl
  • Albuterol if wheezing
  • Anaphylaxis
  • Epinephrine 11000
  • Benadryl
  • Albuterol if wheezing
  • Region 9 NWC EMSS
  • Mild - Benadryl
  • Moderate
  • Epinephrine 11000
  • Benadryl
  • Albuterol Atrovent if wheezing
  • Severe
  • Epinephrine 110,000
  • Dopamine if B/P lt90
  • Glucagon possibly
  • Benadryl
  • Albuterol Atrovent if wheezing

22
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 11000
  • Albuterol Atrovent
  • Magnesium if distress persists

23
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

24
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)

25
Ventricular Fibrillation Pulseless Ventricular
Tachycardia
  • Region X - CMC
  • Vasopressor used
  • Epinephrine 110,000 every 3-5 minutes
  • Region 9 NWC EMSS
  • Vasopressor used
  • Epinephrine 110,000 every 3-5 minutes or
  • Vasopressin one time in place of 1st or 2nd dose
    Epinephrine

26
Asystole/PEA
  • Region X - CMC
  • Vasopressor used
  • Epinephrine 110,000 every 3-5 minutes
  • Region 9 NWC EMSS
  • Vasopressor used
  • Epinephrine 110,000 every 3-5 minutes or
  • Vasopressin one time in place of 1st or 2nd dose
    Epinephrine

27
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

28
Hypertension
  • Region X - CMC
  • Lasix
  • NTG only on Medical Control order
  • Valium if seizures
  • Region 9 NWC EMSS
  • Morphine
  • NTG
  • Versed if seizures

29
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!

30
Pre-eclampsia
  • Region X - CMC
  • To control seizure activity
  • Valium
  • Region 9 NWC EMSS
  • To control seizure activity
  • Magnesium
  • For persistent seizures
  • Versed

31
Disaster Communication Steps
32
Disaster Communication
  • Everyones 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?

33
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

34
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

35
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

36
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

37
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

38
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

39
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

40
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

41
Special Challenges and Chronic Care
42
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

43
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

44
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)

45
Patients With Visual Impairment
  • Etiologies
  • Injury
  • Disease
  • Degeneration of eyeball, optic nerve
    or nerve pathways
  • Congenital
  • Infection (C.M.V.)

46
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
47
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 patients special
    needs
  • Carefully lead patient when ambulatory
  • patient holds your arm
  • call out obstructions, steps and
    turns ahead of time

48
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

49
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

50
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

51
Patients With Special Challenges -Obesity
  • Definition
  • body weight 20 over the average weight of people
    same size, gender, age
  • gt58 million Americans are obese
  • 2nd leading cause of preventable death
  • Etiologies
  • Caloric intake exceeds calories burned
  • Low basal metabolic rate
  • Genetic predisposition

52
Obesity Risk Factors
  • Hypertension
  • Stroke
  • Heart disease
  • Diabetes
  • Some cancers
  • Kidney failure

53
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

54
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

55
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

56
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

57
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

58
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

59
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

60
Patients With Special Challenges - Downs 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

61
Assessment/Management Accommodations - Downs
Syndrome
  • Congenital heart, intestinal, hearing defects
  • Limited learning capability
  • Generally affectionate and friendly
  • Utilize patience with assessment
  • Explain procedures before beginning task

62
Emotional or Mental Impairment
  • IQ Mild impairment 55-70
  • Moderate impairment 40-54
  • Severe impairment 25-39
  • Profound impairment lt 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

63
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

64
Etiologies Emotionally/Mentally Impaired contd
  • Poverty/cultural deprivation
  • Malnutrition
  • Disease-producing conditions (lack of
    cleanliness)
  • Inadequate medical care
  • Environmental health hazards
  • Lack of stimulation

65
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

66
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

67
Narrative must be filled out by the witness to
the statements or the behavior. The rest of the
form can be a group effort
68
Signatures important Phone address may be work
69
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

70
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

71
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

72
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

73
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

74
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

75
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

76
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

77
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)

78
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

79
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 UTIs

80
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

81
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

82
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

83
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

84
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)

85
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

86
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

87
Interventions for the Specially Challenged and
Chronic Care Patient
88
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


89
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

90
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


91
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

92
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

93
Home Care Airway Adjuncts
  • Oxygen delivery devices
  • CPAP machine
    (mask and nasal)
  • BiPAP machine
  • Tracheotomies
  • Home ventilators
  • Peak flow machine

94
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

95
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
96
Assessing Complications of the Airway
  • Evaluate
  • Respiratory effort
  • Tidal volume
  • Peak flow
  • Oxygen saturation
  • Breath sounds
  • Compare values based on the patients normal or
    baseline levels

97
Complications of Vascular Access Devices
PICC Catheter
  • Infection/sepsis
  • Inadvertent removal
  • Hemodynamic compromise
  • Hemorrhage
  • Embolus
  • Stable vs. unstable angina
  • Improper fluid administration
  • Inability of home caregiver to flush
    device

PICC line
98
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

99
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 patients
    ventilator - will it fit in rig?
  • Consider using home caregiver to continue
    assisting in providing care - they know the
    patient

100
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

101
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

102
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

103
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

104
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

105
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

106
State of Illinois DNR Form Page 1
107
State of Illinois DNR Form Page 2
108
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
About PowerShow.com