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


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

ECRN Packet 2006 SOP Updates Disaster
Communication Patients With Special Challenges
and Interventions for Patients with Chronic Care
  • Condell Medical Center EMS System

Revised by Sharon Hopkins, RN, BSN EMS Educator
  • 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

Region X SOP Update Highlights Effective March
1, 2007
SOP Update
  • Many updates are in keeping with revised AHA
  • 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

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
  • 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

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

Revised SOPs
  • Table of Contents
  • organized into sections and each section
  • 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)

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

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
  • 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 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

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
  • appropriate for AV block or increased vagal tone

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
  • 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/SOPs are
    being followed based on report received
  • ECRN cannot order what is not already stated in
  • 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
  • Member Fire Departments transporting to Condell
  • Buffalo Grove
  • Lincolnshire/Riverwoods
  • Long Grove
  • Lake Zurich

  • 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
  • lt16 years old
  • (15 and younger)
  • Region 9 - NWC
  • lt13 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
  • With BVM to ETT 1 breath every 6-8 seconds (8-10
  • 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

  • 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 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

  • Region X - CMC
  • Albuterol nebulizer
  • Call Medical Control to consider use of CPAP for
  • Region 9 NWC EMSS
  • Albuterol Atrovent
  • Severe distress
  • Epinephrine 11000
  • 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

  • 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
  • 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

  • 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

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

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

  • 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
  • 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?

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
  • 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
  • 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
  • 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
  • Typically may not see patient activity for days

National Disaster Medical System NDMS
  • Federal response for a major disaster (ie
  • FEMA coordinating activities
  • Utilize POD system for hospital communications
  • Most likely will not see patient activity for
  • 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
  • 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 patients special
  • 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
  • Stuttering

Recognizing Patients With Speech Impairment
  • Reluctance to verbally communicate
  • Inaudible or nondiscernable speech pattern
  • Language disorders (aphasia)
  • Limitations in speaking, listening, reading
  • 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
  • gt58 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
  • 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

Patients With Special Challenges - Spinal Cord
  • Conditions result from nerve
    damage in the brain and spinal
  • MVC, sports injury, fall,
    GSW, medical illness
  • Paraplegia
  • Weakness/paralysis of both
  • 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 in-touch with reality
    patients are aware of their illness
  • depression, phobias, obsessive/compulsive

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

Assessment/Management Accommodations - Downs
  • 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 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

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 contd
  • Poverty/cultural deprivation
  • Malnutrition
  • Disease-producing conditions (lack of
  • 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

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

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

Patients With Special Challenges
  • Types of Cerebral Palsy
  • Spastic abnormal stiffness and difficulty with
  • Athetoid involuntary uncontrolled
  • 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
  • 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
  • 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

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
  • 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
  • Progressive/incurable
    autoimmune disease
  • Brain and spine myelin
  • May be inherited or viral
  • Begins in early adulthood
  • Physical/emotional stress
    exacerbates severity

Patients With Special Challenges - Multiple
  • 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

Patients With Special Challenges - Muscular
  • Inherited, incurable muscle disorder
    that results in a slow but progressive
    degeneration of muscle fibers
  • Life span generally not beyond teen
  • Duchenne muscular dystrophy
  • Most common sex-linked cause
  • Recessive gene that only affects males
  • Diagnosed after age 3

Patients With Special Challenges - Muscular
  • 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
  • Management care includes respiratory

Patient With Special Challenges - Myasthenia
  • 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
  • Controlled with drug therapy to enhance
    transmission of nerve impulses

Patients With Special Challenges - Poliomyelitis
  • Infectious disease caused by poliovirus
  • 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
  • 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
  • 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
  • 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 patients normal or
    baseline levels

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

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

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
  • 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
  • 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