Chapter 45 Patients With Special Challenges


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Nancy Caroline’s Emergency Care in the Streets, Seventh Edition

Chapter 45: Patients With Special Challenges

Chapter 45

Patients With Special Challenges

Unit Summary

Upon completion of this chapter and related course assignments, students will be able to recognize patients with special challenges, including victims of abuse or neglect; homelessness and poverty; bariatric patients; patients who are technology dependent or require adaptive devices; hospice or terminally ill patients; patients with cognitive, developmental, or sensory impairments; and patients with chronic medical conditions. Students will be able to integrate assessment findings with principles of pathophysiology and a knowledge of psychosocial needs to both formulate a field impression and implement a comprehensive treatment plan for patients with special needs. Students will be able to identify signs and symptoms of various forms of abuse and neglect, discuss management and documentation concerns relative to these suspected cases, and describe the paramedic’s responsibilities under mandatory reporting situations. They will be able to describe specific concerns related to patients with terminal illnesses, under hospice care, and discuss situations where advance directives or do-not-resuscitate orders exist, particulary how to address issues concerning validity of the documents. The student will be able to discuss situations and concerns related to emergency management of bariatric patients, patients with communicable diseases, and those requiring medical technology or adaptive devices in the prehospital setting. Students will be able to identify and describe those medical devices and technologies encountered during interfacility transports that require additional training. Students will be able to discuss strategies for assessment, treatment, and transport of patients with cognitive, commumnication, or sensory impairments. They will be able identify chronic medical conditions encountered by paramedics, as well as discuss treatment and transport considerations for patients with chronic illnesses. Students will also be able to implement a comprehensive treatment paln for an acutely injured patient with special needs.

National EMS Education Standard Competencies

Special Patient Populations

Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs.

Patients With Special Challenges

Recognizing and reporting abuse and neglect (pp 2123-2129)

Health care implications of:

• Abuse (see chapter, Pediatric Emergencies, and see chapter, Geriatric Emergencies)

• Neglect (see chapter, Pediatric Emergencies, and see chapter, Geriatric Emergencies)

• Homelessness (pp 2122-2123)

• Poverty (pp 2122-2123)

• Bariatrics (pp 2130-2131)

• Technology dependent (pp 2132-2147)

• Hospice/terminally ill (pp 2129-2130)

• Tracheostomy care/dysfunction (pp 2132-2135)

• Home care (pp 2129-2130)

• Sensory deficit/loss (pp 2153-2156)

• Developmental disability (p 2151)


Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient.

Special Considerations in Trauma

Pathophysiology, assessment, and management of trauma in the

• Pregnant patient (see chapter, Obstetrics )

• Pediatric patient (see chapter, Pediatric Emergencies )

• Geriatric patient (see chapter, Geriatric Emergencies )

• Cognitively impaired patient (pp 2156-2157)

Knowledge Objectives

  1. Discuss how poverty and homelessness adversely impact patient health and EMS system performance. (pp 2122-2123)

  2. Identify ways to advocate for patients’ rights to health care services. (pp 2122-2123)

  3. Recognize signs and symptoms of neglect and various forms of abuse, including physical abuse, neglect, sexual abuse, and emotional abuse. (pp 2123-2129)

  4. Identify benign physical findings that may be confused with signs of abuse. (pp 2125-2127)

  5. Discuss the unique management and documentation concerns related to suspected cases of abuse or neglect. (pp 2127-2129)

  6. Describe mandatory reporting and how it relates to cases of suspected abuse. (p 2129)

  7. Describe specific concerns related to patients with a terminal illness, including situations in which hospice may be involved. (pp 2129-2130)

  8. Discuss situations in which advance directives and do-not-resuscitate (DNR) orders may exist, and how the paramedic should proceed in situations where the validity of such a document is in question. (p 2130)

  9. Describe specific clinical and management concerns related to bariatric patients. (pp 2130-2131)

  10. Discuss operational concerns related to emergency management of bariatric patients. (p 2131)

  11. Describe specific concerns related to patients with a communicable disease. (pp 2131-2132)
  12. Discuss medical technology and adaptive devices used in the prehospital setting, including long-term ventilators, apnea monitors, long-term vascular access devices, medication infusion pumps, insulin pumps, gastric tubes, colostomies, urinary diversion devices, dialysis shunts, surgical drains and devices, and cerebrospinal fluid shunts. (pp 2132-2147)

  13. Discuss the purpose of tracheostomy tubes and how to troubleshoot problems that may occur in a patient with a tracheostomy. (pp 2132-2135)

  14. Discuss the types of medical technology that may be used during interfacility transports, including hemodynamic monitoring, intra-aortic balloon pumps, and intracranial pressure monitoring. (pp 2147-2150)

  15. Identify strategies for providing care to patients with cognitive impairment, including patients with development delay, Down syndrome, mental retardation, and autism. (pp 2150-2152)

  16. Identify strategies for providing care to patients with communication impairment, including hearing, vision, and speech impairments. (pp 2153-2156)

  17. Identify strategies for providing care to patients with sensory impairment, including paralysis, paraplegia, and quadriplegia. (p 2156)

  18. Discuss concerns related to managing a cognitively impaired patient who experiences trauma. (pp 2156-2157)

  19. Identify chronic medical conditions likely to be encountered by paramedics, including arthritis, cancer, cerebral palsy, cystic fibrosis, multiple sclerosis, muscular dystrophy, myasthenia gravis, spina bifida, postpolio syndrome, systemic lupus erythematosus, and traumatic brain injury. (pp 2157-2162)

  20. Discuss treatment and transportation concerns for patients with a chronic illness. (pp 2157-2162)

Skills Objectives

  1. Demonstrate how to suction and clean a tracheostomy. (pp 2132-2135, Skill Drill 45-1)
  2. Demonstrate how to access an implantable venous access device. (pp 2137-2139, Skill Drill 45-2)

  3. Demonstrate how to replace an ostomy device. (pp 2140-2141; 2142, Skill Drill 45-3)

  4. Demonstrate how to catheterize an adult male patient. (pp 2143-2144, Skill Drill 45-4)

  5. Demonstrate how to catheterize an adult female patient. (pp 2143-2145, Skill Drill 45-5)

Readings and Preparation

• Review all instructional materials including Chapter 45 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, and all related presentation support materials.

• Review state statutes, regulations, and procedures for appropriate legal documentation requirements for the patient who wishes to limit or decline resuscitation efforts in the event of a cardiac or respiratory collapse emergency.

• Review local EMS protocols on accessing long-term vascular access devices or dialysis shunts.

• Identify any bariatric-specific equipment used by EMS agencies where students may complete clinical rotations or field internships.

• Identify types of medical technology or assist devices present in the community where students may complete clinical rotations or field internships.

• Develop patient scenario cards for use in group exercises later in the course. Incorporate a variety of special needs patient emergencies, signs/symptoms, age groups, and underlying causes.

Support Materials

• Lecture PowerPoint presentation

• Case Study PowerPoint presentation

• Skill Drill PowerPoint presentations

  • Skill Drill 45-1, Cleaning a Tracheostomy Tube
  • Skill Drill 45-2, Accessing an Implantable Venous Access Device

  • Skill Drill 45-3, Replacing an Ostomy Device

  • Skill Drill 45-4, Catheterizing an Adult Male Patient

  • Skill Drill 45-5, Catheterizing an Adult Female Patient

• Skill Evaluation Sheets

  • Skill Drill 45-1, Cleaning a Tracheostomy Tube

  • Skill Drill 45-2, Accessing an Implantable Venous Access Device

  • Skill Drill 45-3, Replacing an Ostomy Device

  • Skill Drill 45-4, Catheterizing an Adult Male Patient

  • Skill Drill 45-5, Catheterizing an Adult Female Patient

• Various types of tracheostomy tubes for practicing cleaning and troubleshooting, at least one per six students

• Various types of long-term vascular access devices for practicing access, at least one per six students

• Various types of ostomy devices for practicing removal and attachment, at least one per six students

• Various types of urinary catheters and placement kits for practicing catheterization, at least one per six students

• Obtain manikins that allow performance of skills and evaluation including tracheostomy manikin, implanted vacular access device manikins, ostomy manikins, and catheterization manikins (male and female), at least one per six students

• Bariatric appropriate equipment including backboards, stretchers, vascular access devices, cervical collars, and modified ambulances, when available


• Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, at for online activities.

• Contact a local home health provider to identify a guest speaker to discuss medical technology and assist devices when dealing with the patient with special challenges and provide additional information about various types of equipment and skills, including troubleshooting tips and types of devices likely to be encountered in the community setting.

• Contact a local social service or adult protective services agency to identify a guest speaker to discuss the incidence, signs and symptoms, and mandatory reporting laws for victims of abuse or neglect and to provide additional information on the appropriate agencies and jurisdictions to be contacted when suspected.

• Contact a local hospice agency to identify a guest speaker to discuss strategies for the assessment, treatment, and management of patients with terminal illness or hospice care. Have them share opportunities for students to volunteer if available to work with these patients in an in-patient setting such as a hospice in-patient facility or long-term care facility to allow students to appreciate the challenges in dealing with these patients.

• Identify and contact local support groups for persons with cognitive, communication, or sensory disabilities to identify a guest speaker or speakers that can discuss how to recognize and better communicate with patients and caregivers when encountered in the prehospital setting. Ask that they share resources for those students interested in learning sign language or volunteering with community events for these individuals.

• Contact the local public health department to identify a guest speaker from the infectious disease reporting department to discuss legal requirements for specific types of communicable diseases as they pertain to the patient as well as protection for the EMS provider.

• Provide copies of the local protocols on accessing long-term vascular access devices or dialysis shunts.

Content connections: Remind students of the importance of documentation when completing patient care reports for the treatment and transport of the suspected abuse or neglect patient. Refer students to Chapter 6 to review documentation recommendations. Discuss the significance of being aware of the potential medical, legal, and ethical issues involved when dealing with the patient who may be a victim of abuse or neglect. Refer students to Chapter 4 to review this material. Communicating with patients who may have a cognitive, communication, or sensory disability can be challenging. Encourage students to read Chapter 3 to review communication techniques that may assist them while managing a patient with developmental or other disabilities. Patients exhibiting violent or combative behavior or exhibiting behavior that suggests there may be risk to the providers should be monitored closely. Remind students to avoid placing themselves in potentially dangerous situations and to maintain a route of egress when working with these patients. Students should be reminded that some emergencies involving patients with special needs may mask underlying medical conditions. They should be encouraged to complete a comprehensive history and assessment to avoid missing other signs and symptoms that would affect patient management. Refer students to Chapter 15 to consider how alterations in the bariatric patient may affect routine airway management and ventilation of the patient. Refer students to Chapter 33 and Chapter 34 to consider how alterations in the bariatric patient may affect stabilization, packaging, and transport of these patients.

Cultural considerations: Have students review special considerations in trauma for special populations such as the pregnant patient (Chapter 41), the pediatric patient (Chapter 43), and the geriatric patient (Chapter 44). Students should be reminded to be receptive to caregivers on how best to approach the patient with special challenges, particularly those pediatric and geriatric patients. Assessment techniques should still be age appropriate. Mental status changes are relevant to the baseline for the patient, and caregivers should be consulted for the presence of existing medical conditions. Patients of other cultures may also have specific beliefs about death and dying that should be considered in the patient with a terminal illness. Students should be reminded there are also cultural practices that can mimic signs and symptoms of physical abuse. Care should be taken when assessing these patients and a comprehensive history obtained to include alternative medical treatments that may have resulted in the physical findings.

Teaching Tips

• Students may be not be familiar with various devices used by patients with special challenges including tracheostomies, ostomy devices, long-term vascular access devices, ventilators, ventricular assist devices, apnea monitors, and renal or genitourinary assist devices including catheters, shunts, and dialysis equipment. Be prepared to provide pictures and teaching aids to assist students in becoming familiar with recognition and access to these devices.

• Students may be embarassed by the focus of discussion on male and female genitourinary structures. Consider allowing students to work in smaller same-sex groups as they practice Skill Drills for male and female catheterization.

• Students may be uncomfortable discussing hospice care or care for the terminally ill patient. Be prepared to provide information for support counseling for those students who have difficulties.

Unit Activities

Writing activities: Ask students to research the prevalence of poverty, homelessness, and uninsured patients in their state. Have them review information on the Affordable Care Act and submit a paper that outlines the potential for improved access and funding for health care in these patient groups.

Student presentations: Assign students a chronic medical condition that has been presented in the chapter as a special challenge. Ask them to research the condition, identify long-term survival rates, common medical concerns/complications, and its prevalence in the community. Have them make a presentation on the condition including activities, agencies, or support groups that assist with supporting the patients, families, and/or caregivers for their condition.

Group activities: Using scenario cards prepared prior to the lesson, assign one scenario to each group. Have them practice application of material learned in Chapter 45 to apply critical thinking and clinical decision making for this type of patient. Students should be able to identify potential challenges to prehospital treatment for these patients. As time permits have groups swap scenario cards to consider as many types of patients as possible.

Visual thinking: Display pictures of medical technology and assist devices used by patients with special challenges. Have students identify the device, concerns or implications for the paramedic who encounters the device, troubleshooting techniques, and types of patients who may require the technology or device.

Medical terminology: Construct a game based on the Jeopardy format for the terms presented in the chapter. Categories of terms may include Chronic Conditions, Disabilities, Assist Devices, Signs/Symptoms, and Medical Technology. Remind students to construct their response in the form of a question.


You are the Medic

“You are the Medic” is a progressive case study that encourages critical-thinking skills.

Instructor Directions

Direct students to read the “You are the Medic” scenario found throughout Chapter 45.

• You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report.

• You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper.


I. Introduction

A. Patients may have a wide variety of special challenges.

1. To provide optimal care, it may be necessary to modify communications, assessments, treatment, or transport for patients with a:

a. Chronic medical condition

b. Sensory impairment

c. Cognitive or emotional disorder

d. Other anomaly

2. Impairments may include:

a. Mental retardation (1% to 3% of population)

b. Autism (slightly less than 1% of children)

c. Some form of developmental disability (13% of children)

3. Many life-sustaining therapies are now handled outside the hospital by families and patients.

a. Mechanical ventilation

b. IV medication administration

4. EMS is often called as last resort when:

a. Patient cannot otherwise access health care services.

b. Attempts to manage medical condition without assistance fails.

5. Caregiver abuse or neglect further complicates patient care.

a. Need to be able to recognize signs and cues of abuse or neglect

B. General strategies for patients with special challenges

1. Many times, patient and caregivers are experts in their condition or impairment.

a. EMS personnel should:

i. Have an open mind and willingness to listen

ii. Demonstrate confidence in enlisting patient expertise to determine best ways to provide optimal care.

(a) Helps provide optimal care

(b) Minimizes the risk of mistakes, complications, or injuries

b. Patients/caregivers with special issues often know more than EMS personnel about their condition, devices, or techniques.

i. It is a mistake to claim more knowledge than you have.

ii. Paramedics may know important nuances that would be helpful to the patient/caregiver.

2. Resources can be invaluable when faced with unfamiliar conditions, technology, or situations.

a. Online medical control

b. Electronic medical reference materials

c. Coworkers’ experience

II. EMS, Health Care, and Poverty

A. EMS providers and emergency departments must often deal with the economic and health care crisis in the United States.

1. Nearly 50 million people did not have health insurance in the United States in 2010.

a. Many with insurance are still forced to use government health programs.

2. US Census Bureau report Income, Poverty, and Health Insurance in the United States 2010 states that 46.2 million people were in poverty in the United States in 2010.

a. Definition of poverty calculated by factors:

i. How many people in the household

ii. Their ages

iii. Household’s combined total income

3. Poverty and lack of health insurance affect a person’s health habits.

a. Stop seeking or receiving preventative health services

b. Incidence and severity of disease increases significantly.

c. Health care often delayed until an emergency

4. Chronic medical conditions require ongoing medication to control the disease.

a. Patients may not get needed medications or care because of lack of insurance or poverty.

i. May have to choose between medical care and food, clothing, or shelter

ii. Interruptions of medication can lead to medical complications.

iii. Loss of job or depletion of savings during economic hardships may lead to loss of health care services.

5. Homelessness is a complicated economic and social problem, with homeless people prone to:

a. Numerous chronic medical conditions

b. Mental illness

c. Substance abuse

6. Medical care for homeless is more difficult because of:

a. Environmental exposure

b. Crime/violence

c. Malnutrition

d. Lack of hygiene

7. In homeless people, there are high rates of:

a. Pregnancy

b. Infectious disease

c. Mental illness

8. EMS and ED assistance sought if chronic medical condition becomes severe or no other options for chronic health care

a. By federal law, EDs must stabilize patients in emergencies or in labor, regardless of their ability to pay.

b. Significant stress placed on ED

i. Many EDs closed in recent years because of financial pressure and changes in health care industry

(a) May be forced to transport patients farther or experience longer delays when turning patients over to EDs

9. In some cases EMS providers may realize patients do not need transport, but feel obligated to do so because of fear of legal liability or regulations against patient abandonment.

a. Patient may request EMS services to get “free ride” to hospital or to bypass overcrowded ED waiting rooms

b. Even if other health care settings may be more appropriate, must be extremely careful to avoid legal liability

i. When people call for assistance, even if paramedics do not feel it is needed, the safest thing to do is provide assistance.

ii. Never refuse to transport if requested, unless EMS system and medical director specifically authorize the refusal.

10. Some health care organizations have come up with various creative approaches to providing health care services outside EDs for those with limited financial resources.

a. EDs well suited for patients in crisis but less optimal for issues of chronic medical conditions, such as:

i. Medication monitoring

ii. Prescription refills

iii. Diagnostic testing

iv. Referrals

v. Coordination among specialists

vi. Assistance with social needs and lifestyle modification

vii. Long-term care

b. May see changes in education and scope of practice, with EMS providers offering:

i. More primary care services

ii. Transport of 9-1-1 patients to health care settings other than EDs

11. Government agencies and private organizations provide health care services through a variety of community-based health care facilities.

a. Many immunizations are provided at little or no cost.

b. Hospitals are frequently able to provide:

i. Financial assistance

ii. Payment plans

iii. Low-cost health care services

iv. Help enrolling eligible people in government insurance programs

III. Care of Patients With Suspected Abuse and Neglect

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