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

1
ECRN Packet 2006SOP UpdatesDisaster
CommunicationPatients With Special Challenges
and Interventions for Patients with Chronic Care
Needs

• Condell Medical Center EMS System

Revised by Sharon Hopkins, RN, BSN EMS Educator
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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 UpdateHighlights Effective March
1, 2007
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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

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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)

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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

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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

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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

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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

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Highlights of Changes to Region 9 NWC
EMSS SOPs

• Member Fire Departments transporting to Condell
• Buffalo Grove
• Lincolnshire/Riverwoods
• Long Grove
• Lake Zurich

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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

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Pediatric Ages

• Region X - CMC
• lt16 years old
• (15 and younger)

• Region 9 - NWC
• lt13 years old
• (12 and younger)

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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

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• 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

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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

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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

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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

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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)

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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

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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

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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

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Hypertension

• Region X - CMC
• Lasix
• NTG only on Medical Control order
• Valium if seizures

• Region 9 NWC EMSS
• Morphine
• NTG
• Versed if seizures

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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!

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Pre-eclampsia

• Region X - CMC
• To control seizure activity
• Valium

• Region 9 NWC EMSS
• To control seizure activity
• Magnesium
• For persistent seizures
• Versed

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Disaster Communication Steps
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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?

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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

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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

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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

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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

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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

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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

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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

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Special Challenges andChronic Care
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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

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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
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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

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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

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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

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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

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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

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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

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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

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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

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