Refresher Class Session - M Special Populations Elder/child abuse Patients with special needs 1

Introduction  People over the age of 65 make up the fastest- growing segment of the population.  Almost 40 million in 2008, or 12.8 of the population.  Changes in physiology due to aging have an effect on pathophysiology as compared to younger adults.  Geriatric patients typically have more than one disease and take more than one medication 2

Introduction  Cardiovascular disease is leading cause of death, followed by cancer, strokes, and COPD.  They use 1/3 of all prescriptions.  The average geriatric patient takes 4.5 medications per day. 3

Pathophysiology  Human body changes with age: cellular, organ, and system functions  Change in normal physiology starts around age 30  Process can be slowed with diet and exercise, but it cannot be stopped entirely. 4

Pathophysiology  Cardiovascular system  Degenerative process to the myocardium  Damage to valves  Thickening of the walls  Loss of artery elasticity  Decrease in baroreceptor activity 5

Pathophysiology  Respiratory system  Size and strength of respiratory muscles decrease  Alveolar surfaces degrade, impairing gas exchange  Chemoreceptors begin to fail  More turbulent airflow through the bronchioles 6

Pathophysiology  Nervous system  Nerve cells degenerate and die as early as mid- 20s  Reflexes slow, proprioception falters  Brain atrophies with resultant increase in CSF  Regulation of basal bodily functions becomes less sensitive 7

Pathophysiology  Gastrointestinal system  Sense of taste and smell diminished  Cardiac sphincter becomes weaker  Hepatic function decreases  Lining of GI system degenerates, resulting in lesser absorption of nutrients 8

Pathophysiology  Endocrine system  Hormones that elevate blood pressure and those that regulate fluid balance become deranged  Stimulation of adrenergic sites diminishes due to failure of sensitivity of receptor cells  Musculoskeletal system  Loss of minerals from the bones  Vertebral disks narrow  Joints lose flexibility  Synovial fluid thickens 9

Pathophysiology  Renal system  Decrease in nephrons, kidneys shrink  Diminished ability to filter blood  Fluid and electrolyte disturbances  Integumentary system  Skin becomes thinner from a loss of subcutaneous layer  Replacement cells generate more slowly  Sense of touch dulled, less perspiration  Less effectiveness as an external barrier 10

 Bucket next to bed  Home O 2 setup  Medications at scene  Tripod Position  Abnormally hot/cold room 11 Clues to Illness Found in the Scene Size-Up

 Pain  May not complain of pain due to preexisting conditions  May not feel pain due to disease process ie diabetes  Prickling/burning pain = superficial structures; aching-type pain = internal organs  Fainting may indicate a serious illness  Mental Status  Hypoxia causes agitation and aggression  High CO2 causes confusion and disorientation  Sudden onset of AMS is not normal - -indicates serious illness or injury 12 Special Considerations in the Primary Assessment of the Geriatric Patient

 Airway  High incidence of choking and aspiration of food  Cervical arthritis makes head-tilt/chin lift difficult  Loose dentures may cause airway obstruction  Breathing  Expect higher resting rates  Lower tidal volume = risk of early onset of hypoxia  Retractions less likely  Circulation  Expect higher resting heart rate (unless on meds)  Irregularly Irregular pulse may be normal  Skin  Normally dry and less elastic; Turgor not reliable  subcutaneous fat & skin vessel >> to ”urban hypothermia”  Fever less common 13 Special Considerations in the Primary Assessment of the Geriatric Patient

Emergency Medical Care  Manual cervical spine considerations  Assess and maintain the airway  Determine breathing adequacy  High-flow via NRB with adequate breathing  High-flow via 10-12/min if inadequate  Maintain saturation >95%  Assess circulatory components  Pulse check, skin characteristics  Control major bleeds 14

Emergency Medical Care  Initiate transport with ALS intercept  Position the patient  Sitting up if able to maintain own airway  Lateral recumbent with altered mentation  Supine if immobilized  Constantly monitor airway, breathing, and circulation  Mental status changes key to determining improvement or deterioration 15

Summary  Geriatric patients, like pediatric patients, have an altered physiology that needs to be considered given illness and injuries.  The normal decline in the body systems render them susceptible to a multitude of emergencies.  Carefully manage and closely watch elderly patients, as they may deteriorate suddenly. 16

Special Challenges 17

Introduction  Due to lifestyle changes and medicine, the life span of humans is lengthening.  Advances in medicine allow technology to go home with the patient.  Congenital disease patients live longer at home, due to medicine.  EMS may not know what the medical technology is, but they must always know what to do. 18

Epidemiology  No specific registry nor definition for what “specially challenged” is.  Underreporting is also believed to occur, especially with abuse.  Over 3 million pediatric abuse cases and over half a million elder abuse cases.  8 million disabled people are receiving health care from professional providers. 19

Pathophysiology  Mental Illness  Mild to severe disabilities  Commonly include the following features Cognitive disabilities Speech impediments Behavioral disorders Movement disorders 20

Causes of Mental Retardation  Down Syndrome  Fragile X Syndrome  Autism  Fetal Alcohol Syndrome  Phenylketonuria (PKU) hypothyroidism  Rett Syndrome 21

Pathophysiology  Disabilities  A problem of the patient that was caused by a disease  Results in sustained medical care for the person  Common disabilities seen in EMS include: Paralysis Obesity Traumatized patients 22

Pathophysiology  Disabilities – Paralysis  Loss of function of single or multiple muscles  Damage to nervous system (spinal cord)  Neuromuscular diseases 23

Pathophysiology  Disabilities – Obesity  Over 40% of U.S. population is obese  Obesity may be due to lifestyle choices or medical conditions  Obesity creates a multitude of secondary emergencies  Obesity also creates a patient handling and movement concern for EMS 24

Effects of Excess Weight on Organ Systems 25

Pathophysiology  Disabilities – Traumatized patients  Head and/or brain trauma  Commonly there are residual effects Mild – speech or gait impairments Severe – unresponsive, seizures, technology dependent  Most patients fall between these two extremes 26

Pathophysiology Technology Assistance/Dependency  Medical equipment designed for patient care Enhance quality of life Sustain life  EMS must remain aware of common types of equipment  Some EMS systems track where patients live who are technology dependent 27

Technology dependent patients; Infants and Children with Special Needs 28

Pathophysiology  Vascular Access Devices  Devices implanted into the skin  Allow for ongoing or multiple medication administrations into the patient's vascular system  Dialysis  Replaces kidney function  Hemodialysis – done at facility  Peritoneal dialysis – done at home 29

Pathophysiology  Home Mechanical Ventilators  Assist or provide total ventilatory needs to a patient who cannot maintain own ventilatory effort  Negative and positive pressure units  Controls include rate, volume, and occasionally oxygen levels  Alarms (may be reason EMS is summoned) High pressure alarm Low pressure alarm Apnea alarm Low FiO2 alarm –“Fraction of inspired oxygen,” which refers to the amount of oxygen the patient in breathing in. 30

Pathophysiology  CPAP and BiPAP  Designed to provide “back pressure” via mask that attaches to face  Helps to keep small bronchioles open during breathing, and the airway open during sleep  Commonly found with obese patients and certain chronic lung diseases 31

Children with Special Needs  Premature babies with lung disease  Heart disease  Neurologic disease  Chronic disease or altered function since birth 32

 Apnea Monitor  Monitors patient's breathing status  Some monitor heart rate  Common to neonates and infants  Audible alert for when patient stops breathing  Tracheostomy Tube  Provides artificial opening into airway  Placed through anterior neck  Bypasses mouth and nose 33 Pathophysiology Technology Assistance/Dependency

34 The EMT can ventilate a patient with a tracheostomy by attaching the bag-valve device to the tracheostomy tube's 15/22 mm adapter. A tracheostomy tube for older children and adults has an outer cannula and an inner cannula

Tracheostomy Tube 35

Tracheostomy Tube  Complications  Obstruction  Bleeding  Air leak  Dislodged tube  Infection  Maintain open airway.  Suction.  Maintain a position of comfort.  Transport. 36

37 Home Artificial Ventilation The tubing from the home ventilator attaches to the patient's tracheostomy tube.  Assure airway.  Artificially ventilate with oxygen.  Transport.

Central Intravenous Lines  IVs that are very long  Tip in vein near heart  Complications  Cracked line  Infection  Clotting off  Bleeding  If bleeding is present, apply pressure.  Transport. 38

Gastrostomy Tubes  Gastrostomy Tubes (Feeding Tubes)  Provide nutrition to patients who cannot chew  “Enteral feeding” or “tube feeding”  Types NG tube – nose to stomach OG tube – mouth to stomach G-tube – through skin to stomach J-tube – through skin to jejunum 39

Gastrostomy Tube  Tube placed directly into stomach for child who usually cannot be fed by mouth 40

Managing Gastrostomy Tubes  Assess for mental status changes.  Assure patent airway.  Suction as needed.  Provide high-concentration oxygen.  Transport patient sitting or lying on right side with head elevated. 41

Intraventricular Shunt  Medical illnesses or anatomic defects that allow excessive CSF to accumulate  Increased CSF can cause damaging ICP issues  Tube running from brain to abdomen to drain excess cerebrospinal fluid.  Assure airway.  Ventilate as needed.  Transport. 42

Family Response 43

Family Response  When you care for an injured or ill child, you must also care for the child’s family.  Parent may react with anger/hysteria toward EMT–B.  Calming the parent calms the child.  Parent is concerned about child's injury/illness as well as child’s fear/pain.  Response worsened by feeling of helplessness. 44

Family Response  Encourage the parent to be involved in child’s care (e.g., holding oxygen mask, cup, or tubing).  Have the parent help calm child.  Parents of “high-tech kids” are medical experts on their child’s condition.  In general, other parents may not have medical training, but they are experts on their children and what will calm them. 45

Assessment Findings  During your assessment, ask about the medical equipment  Where do I get the best information regarding this equipment?  What does this device do for the patient?  Can I replicate its function should it fail?  Will this equipment change assessment findings?  Has this ever occurred before? What fixed it?  Has anyone attempted to remedy the problem?  Do I have movement or handling issues with this equipment? 46

Emergency Medical Care  Manual cervical spine considerations  Assess and maintain the airway  Determine breathing adequacy  High-flow via NRB with adequate breathing  High-flow via 10-12/min if inadequate  Maintain saturation >95%  Assess circulatory components  Pulse check, skin characteristics 47

Emergency Medical Care  Initiate transport with ALS intercept  Position the patient based on condition and medical equipment  Consider immobilization needs  Constantly monitor airway, breathing, and circulation  Try to use medical equipment if it is portable and working correctly 48

Summary  Patients with special needs are those who usually have some medical technology helping them with life.  When this equipment malfunctions, typically it is EMS that is called.  The role of the EMT is to manage the patient's problem(s), incorporating this technology into their assessment and management. 49

Abuse and Neglect 50

Abuse Improper or excessive action so as to injure or cause harm 51 Child abuse is the physical, sexual, or emotional harm or risk of harm to a child under the age of 18. Child Abuse (NJ EMS Field Guide)

Pathophysiology  Abuse  Child abuse Physical, emotional, sexual  Elder abuse Physical, emotional, sexual  Passive versus active Neglect 52

Neglect Giving insufficient attention or respect to someone who has a claim to that attention 53 Neglect occurs when a parent or Caregiver fails to provide proper supervision or adequate food, clothing, shelter, education, or medical care although financially able or assisted to do so. Neglect (NJ EMS Field Guide)

Physical abuse of an elderly person can have dire consequences because of the patient's frailty. 54

Signs of Abuse  Multiple bruises in different stages of healing  Injury not consistent with mechanism described  Injury matches item used to cause it Fresh burns  Parents seem not to care as much as they should  Conflicting stories  Child afraid to describe how injury occurred 55

What does abuse look like 56

Hand Marks Bruising of the ear from being pulled. Bruising of the ear from being "boxed” 57

Loop mark bruises inflicted by a doubled-over cord. Bruises inflicted with belt. 58

Handling Abuse and Neglect  Head injuries are most lethal.  Shaken baby syndrome  Do not accuse anyone in the field.  Required Reporting  Follow state laws and local regulations.  Document objective information (what you SEE and HEAR, not what you merely THINK). 59

Reporting Child Abuse  If you suspect child abuse, or a child tells you about abuse, don’t delay.  You must report it! Everyone in New Jersey is required to report suspected abuse.  To make a report, call the NJ Division of Youth and Family Services’ toll-free Child Abuse Hotline 24 hours a day, 7 days a week: NJ-ABUSE ( ) TTY

Reporting FAQs  Do callers have immunity from civil or criminal liability?  Any person who, in good faith, makes a report of child abuse or neglect or testifies in a child abuse hearing resulting from such a report is immune from any criminal or civil liability as a result of such action. Calls can be placed to the hotline anonymously.  Is it against the laws of New Jersey to fail to report suspected abuse/neglect?  Any person who knowingly fails to report suspected abuse or neglect according to the law or to comply with the provisions of the law is a disorderly person. 61

Reporting Elder Abuse  The Office of the Ombudsman for the Institutionalized Elderly investigates and responds to complaints of abuse, neglect, and exploitation of individuals 60 years of age and older who reside in licensed facilities within New Jersey, both public and private.  To make a report, call:

Prevention of Domestic Violence Act Applies  To a person 18 years of age or older or a person who is an emancipated minor that has been subjected to domestic violence by a spouse, former spouse, or any other person who is a present or former household member.  If you or the abuser are the parents of any children, whether or not you have ever lived together;  If you are pregnant with the abuser’s child;  If you and the abuser now live together or have lived together in the past; or you and the abuser now have or did have, at one time, a dating relationship.  You and the abuser do not have to be married or be girlfriend/boyfriend. He or she can be a family member, your gay or lesbian partner, your roommate, your caretaker, or any other adult who lives with you now or has lived with you. 63

NJ State EMS Field Guide 64 Google: NJ State EMS Field Guide