The Challenged Patient Ray Taylor Ray Taylor Valencia Community College Valencia Community College Department of Emergency Medical Services Department of Emergency Medical Services

Physical Challenges Physical Challenges Developmental Disabilities Developmental Disabilities Pathological Challenges Pathological Challenges Other Challenges Other Challenges Topics

Introduction Challenged Patients Challenged Patients –Hearing –Visual –Speech –Obesity –Paralysis –Mental and physical impairments –Arthritis –Cancer –Neuromuscular

Hearing Impairments Types Types –Conductive deafness –Sensorineural deafness

Conductive Deafness Blockage of the transmission of sound waves through the external ear canal to the middle or inner ear Blockage of the transmission of sound waves through the external ear canal to the middle or inner ear Etiologies (Curable) Etiologies (Curable) –Infection –Injury –Earwax

Sensorineural Deafness Deafness caused by the inablility of nerve impulses to reach the auditory center of the brain because of nerve damage to either the inner ear or to the brain Deafness caused by the inablility of nerve impulses to reach the auditory center of the brain because of nerve damage to either the inner ear or to the brain Etiologies (Many incurable) Etiologies (Many incurable) –Congenital –Birth injury –Disease –Medication induced –Viral infection –Tumor –Prolonged exposure to loud noise –Aging

Recognizing Deafness Asking questions repeatedly Asking questions repeatedly Misunderstood questions or inappropriate responses Misunderstood questions or inappropriate responses Presence of a hearing aid Presence of a hearing aid Sign language or gestures Sign language or gestures

Hearing aids come in various shapes and sizes. Figure 5-1

Accommodations for Deaf Patients Address patient face to face. Address patient face to face. Speak slowly in a normal voice. Speak slowly in a normal voice. –Do not shout –80% of hearing loss is related to the loss of high pitched sounds –Use low pitched sounds directly into ear canal Reduce background noise as much as possible. Reduce background noise as much as possible. Help find or adjust hearing aids. Help find or adjust hearing aids. Use pen and paper. Use pen and paper. Utilize an interpreter. Utilize an interpreter. Use of picture that illustrate basic need/procedures Use of picture that illustrate basic need/procedures

Visual Impairments

Causes Disease Disease Congenital conditions Congenital conditions Infection Infection Degeneration of eyeball, optic nerve or nerve pathways Degeneration of eyeball, optic nerve or nerve pathways

Individuals who are visually impaired can maintain active, independent lives. Figure 5-2

Accommodations Retrieve visual aids Retrieve visual aids Describe everything that you’re going to do Describe everything that you’re going to do Provide sensory information Provide sensory information If ambulatory, guide by leading, not by pushing If ambulatory, guide by leading, not by pushing Allow leader dogs to accompany patient Allow leader dogs to accompany patient –Do not pet or handle dog while in harness

Speech Impairments

Types of Speech Impairments Language disorders Language disorders Articulation disorders Articulation disorders Voice production disorders Voice production disorders Fluency disorders Fluency disorders

Etiology of Speech Disorders Language disorders Language disorders –Stroke –Head injury –Brain tumor –Delayed development –Hearing loss –Lack of stimulation –Emotional disturbance

Etiology of Speech Disorders Articulation disorders Articulation disorders –From damage to nerve pathways passing from brain to muscles in larynx, mouth or lips –Delayed development from hearing problems, slow maturation of nervous system

Etiology of Speech Disorders Voice production disorders Voice production disorders –Disorder affecting closure of vocal cords –Hormonal or psychiatric disturbance Fluency disorders Fluency disorders –Not fully understood

Recognition Language disorders Language disorders –Slowness to understand speech –Slow growth in vocabulary and sentence structure Articulation disorders Articulation disorders –Speech can be slurred, indistinct, slow, or nasal

Recognition Voice production disorders Voice production disorders –Hoarseness –Harshness –Inappropriate pitch –Abnormal nasal resonance Fluency disorders Fluency disorders –Stuttering

Accommodations for Speech Impairments Never assume the person lacks intelligence. Form questions that require short, direct answers. Never pretend to understand when you don’t. Let the patient write answers to questions.

Obesity 40% of people in the US are obese. 40% of people in the US are obese. Excess weight can exacerbate the complaint for which you were called. Excess weight can exacerbate the complaint for which you were called. Obesity can lead to many serious medical conditions Obesity can lead to many serious medical conditions

Obesity Etiologies –When a person has an abnormal amount of body fat »20-30% heavier than normal weight –Person’s caloric intake is higher than the amount of calories required to meet his energy needs –Genetic factors –Low basal metab

Accommodations for Obese Patients Don’t dismiss signs or symptoms, such as shortness of breath, as being a result of obesity. Don’t dismiss signs or symptoms, such as shortness of breath, as being a result of obesity. Adipose tissue presents an obstruction—EKG electrodes may need to be placed on the arms and legs. Adipose tissue presents an obstruction—EKG electrodes may need to be placed on the arms and legs. Do not compromise your health or safety—ask for assistance when lifting or moving a patient. Do not compromise your health or safety—ask for assistance when lifting or moving a patient. Use appropriately sized diagnostic devices Use appropriately sized diagnostic devices

Paralysis Paraplegia Paraplegia –Weakness or paralysis of both legs Quadriplegia Quadriplegia –Paralysis of all four extremities and trunk

Paralysis The patient may have a home ventilator; be sure to keep the airway clear and patent. The patient may have a home ventilator; be sure to keep the airway clear and patent. If the patient is in halo traction, be sure to stabilize the traction before transport. If the patient is in halo traction, be sure to stabilize the traction before transport. Be aware of other assistive devices— colostomy, canes, wheelchairs, etc. Be aware of other assistive devices— colostomy, canes, wheelchairs, etc.

Mental Challenges Mental illness Mental illness –Any form of psychiatric disorder –Etiologies »Psychosis Caused by complex biochemical brain disease Caused by complex biochemical brain disease »Neuroses Disease related to personality Disease related to personality –Recognition »Behavior may be unaffected »May present with signs and symptoms consistent with illness

Accommodations Obtaining a history Obtaining a history –Don’t be afraid to ask about »History of mental illness »Prescribed medications »Compliance with medications »Concomitant ingestion of alcohol, other drugs

Assessment and Management Assessment Assessment –Be sure to solicit permission before beginning Management Management –Treat as you would any patient that does not have a mental illness, unless call is related specifically to the mental illness »Patients with mental illness also experience myocardial infarctions, hypoglycemic episodes

Developmental Disabilities

Description Description –Impaired/ insufficient development of the brain, causing an inability to learn at the usual rate Recognition Recognition –History Accommodations Accommodations –Obtaining a history –Assessment –Management –Transport

Developmentally disabled people may have trouble communicating, but can often still understand what you say. Figure 5-3

Remember that a person with a developmental disability can recognize body language, tone, and disrespect just like anyone else. Treat them as you would any other patient.

Developmental Disabilities Down Syndrome Down Syndrome –A chromosomal abnormality resulting in mild to severe mental retardation, and a characteristic physical appearance Fetal Alcohol Syndrome (FAS) Fetal Alcohol Syndrome (FAS) –Mother with persistent alcoholism during gestation »Shortly after birth infants experience alcohol »Deficient growth and mental capacity

Recognition of Down Syndrome Eyes slope up at outer corners; folds of skin on either side of nose cover the inner corners or eye Eyes slope up at outer corners; folds of skin on either side of nose cover the inner corners or eye Small face and features Small face and features Large and protruding tongue Large and protruding tongue Flattening on back of the head Flattening on back of the head Hands short and broad Hands short and broad

Recognition of Fetal Alcohol Syndrome Small head with multiple facial abnormalities Small head with multiple facial abnormalities –Small eyes with short slits –Wide, flat nasal bridge –Midface that lacks a groove between the lip and nose –Small jaw

Pathological Challenges Arthritis Arthritis Cancer Cancer Cerebral Palsy Cerebral Palsy Cystic Fibrosis Cystic Fibrosis Multiple Sclerosis Multiple Sclerosis Muscular Dystrophy Poliomyelitis Previous head injury Spina Bifida Myasthenia Gravis

Arthritis Inflammation of a joint; characterized by pain, stiffness, swelling, redness Inflammation of a joint; characterized by pain, stiffness, swelling, redness Accommodations Accommodations –Decreased range of motion/mobility may limit physical exam –Be sure to solicit current medications before considering the administration of medications Management Management –Limited ability to be mobile –Make equipment fit patient, not vice-versa, pad all voids

Rheumatoid arthritis causes joints to become painful and deformed.

Cancer Primary site of origin of the cancer cells determines the type of cancer Primary site of origin of the cancer cells determines the type of cancer –Carcinoma –Sarcoma Treatments for the disease do tend to produce telltale signs Treatments for the disease do tend to produce telltale signs –Alopecia (hair loss) –Anorexia –Radiation tattoos –Physical changes

Cancer Management Management –Patient’s risk for infection »Chemotherapy leaves patient neutropenic –Veins may have become scarred –Use of med ports »Requires specialized training

Cerebral Palsy Nonprogressive disorders of movement and posture Nonprogressive disorders of movement and posture Types Types –Spastic »Abnormal stiffness and contraction of groups of muscles –Athetosis »Involuntary, writhing movements –Ataxia »Loss of coordination and balance

Cerebral Palsy Etiologies Etiologies –Most occur before birth –Prepartum »Cerebral hypoxia »Maternal infection –Postpartum »Encephalitis »Meningitis »Head Injury

Recognition Spastic: muscles of one or more extremities are permanently contracted Spastic: muscles of one or more extremities are permanently contracted Athetoid: involuntary writhing movement Athetoid: involuntary writhing movement Quadriplegia Quadriplegia Mental retardation in about 75% of all people with with CP Mental retardation in about 75% of all people with with CP Many people with athetoid and diplegic CP are highly intelligent Many people with athetoid and diplegic CP are highly intelligent

Cystic Fibrosis (Mucoviscidosis) An inherited metabolic disease of the lungs and digestive system, manifesting itself in childhood An inherited metabolic disease of the lungs and digestive system, manifesting itself in childhood –A defective, recessive gene Recognition Recognition –History –Patient may be oxygen dependent –Salty taste in mouth –Productive cough Management Management –May require respiratory support, suctioning, oxygen

Multiple Sclerosis A progressive autoimmune disease of the CNS, whereby scattered patches of myelin in the brain and spinal cord are destroyed A progressive autoimmune disease of the CNS, whereby scattered patches of myelin in the brain and spinal cord are destroyed Unknown etiology Unknown etiology Recognition Recognition –Fatigue, vertigo –Clumsiness, muscle weakness –Slurred speech, ataxia –Blurred or double vision –Numbness, weakness or pain in face

Multiple Sclerosis Spinal cord affected Spinal cord affected –Tingling, numbness, or feeling of constriction in any part of the body –Extremities may feel heavy and become weak –Spasticity may be present

Multiple Sclerosis Accommodations Accommodations –Recognize characteristic presentation –May be accompanied by »Painful muscle spasms »UTI »Constipation »Skin ulcerations »Changes in mood, from euphoria to depression

Muscular Dystrophy An inherited muscle disorder of unknown cause in which there is slow but progressive degeneration of muscle fibers An inherited muscle disorder of unknown cause in which there is slow but progressive degeneration of muscle fibers Little or no movement of muscle groups Little or no movement of muscle groups Management: possible respiratory support, patient should not be expected to ambulate Management: possible respiratory support, patient should not be expected to ambulate

Patients with multiple sclerosis and muscular dystrophy may use a cane to aid ambulation. Be sure to take such devices with you on the ambulance. Figure 5-6

Poliomyelitis Caused by a virus, which usually results in a mild illness Caused by a virus, which usually results in a mild illness In more serious cases, it attacks the CNS: may result in paralysis or death In more serious cases, it attacks the CNS: may result in paralysis or death Patients with severe polio may present with paralysis (including respiratory) Patients with severe polio may present with paralysis (including respiratory)

Poliomyelitis Accommodations Accommodations –If lower extremities are paralyzed, patient may require catherterization –If respiratory paralysis, patient may require tracheostomy –Patient should not be expected to ambulate

Patients with Previous Head Injury Recognition Recognition –Physical appearance may be uncharacteristic –Speech and mobility may be affected –Short term memory loss

Spinal Bifida A congenital defect in which part of one or more vertebrae fails to develop, leaving a portion of the spinal cord exposed A congenital defect in which part of one or more vertebrae fails to develop, leaving a portion of the spinal cord exposed Unknown etiology Unknown etiology Recognition: History Recognition: History Transport: patient should not be expected to ambulate Transport: patient should not be expected to ambulate

Myasthenia Gravis A disorder in which muscles become weak and tire easily A disorder in which muscles become weak and tire easily Eyes, face, throat, and extremity muscles most commonly affected Eyes, face, throat, and extremity muscles most commonly affected Etiology: Autoimmune disorder of unknown etiology Etiology: Autoimmune disorder of unknown etiology Recognition Recognition –Drooping eyelids, double vision –Difficulty speaking –Chewing, swallowing may be difficult –Movement of extremities may be difficult –Respiratory muscles may be weakened

Other Challenges Culturally diverse patients Culturally diverse patients Terminally ill patients Terminally ill patients Patients with communicable diseases Patients with communicable diseases Financial challenges Financial challenges

United States society is becoming diverse, with the largest number of immigrants coming from Asia and Latin America. Figure 5-7

If a patient refuses care because of cultural or religious beliefs, be sure to have the patient sign a Refusal of Treatment and Transportation form. Figure 5-8

Financial Challenges Treat the patient, not the financial condition of the patient.

Homeless people sometimes refuse care, thinking they cannot afford to pay the medical bills. Become familiar with public hospitals and clinics that provide services to the needy. Figure 5-9

Summary Physical Challenges Physical Challenges Development Disabilities Development Disabilities Pathological Challenges Pathological Challenges Other Challenges Other Challenges