The Challenged PatientThe Challenged Patient

Ray TaylorRay Taylor Valencia Community CollegeValencia Community College Department of Emergency Medical ServicesDepartment of Emergency Medical Services

Physical ChallengesPhysical Challenges Developmental DisabilitiesDevelopmental Disabilities Pathological ChallengesPathological Challenges Other ChallengesOther Challenges

Topics

IntroductionIntroduction Challenged PatientsChallenged Patients

– HearingHearing– VisualVisual– SpeechSpeech– ObesityObesity– ParalysisParalysis

– Mental and Mental and physical physical impairmentsimpairments

– ArthritisArthritis– CancerCancer– NeuromuscularNeuromuscular

Hearing ImpairmentsHearing Impairments TypesTypes

– Conductive deafnessConductive deafness– Sensorineural deafnessSensorineural deafness

Conductive DeafnessConductive Deafness

Blockage of the transmission of sound Blockage of the transmission of sound waves through the external ear canal to the waves through the external ear canal to the middle or inner earmiddle or inner ear

Etiologies (Curable)Etiologies (Curable)– InfectionInfection– InjuryInjury– EarwaxEarwax

Sensorineural DeafnessSensorineural Deafness Deafness caused by the inablility of nerve impulses to Deafness caused by the inablility of nerve impulses to

reach the auditory center of the brain because of nerve reach the auditory center of the brain because of nerve damage to either the inner ear or to the braindamage to either the inner ear or to the brain

Etiologies (Many incurable)Etiologies (Many incurable)– Congenital Congenital – Birth injuryBirth injury– DiseaseDisease– Medication inducedMedication induced– Viral infectionViral infection– TumorTumor– Prolonged exposure to loud noiseProlonged exposure to loud noise– AgingAging

Recognizing DeafnessRecognizing Deafness

Asking questions repeatedlyAsking questions repeatedly Misunderstood questions or inappropriate Misunderstood questions or inappropriate

responsesresponses Presence of a hearing aidPresence of a hearing aid Sign language or gesturesSign language or gestures

Hearing aids come in various shapes and Hearing aids come in various shapes and sizes.sizes.

Figure 5-1

Accommodations for Accommodations for Deaf PatientsDeaf 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 shoutDo not shout– 80% of hearing loss is related to the loss of high pitched sounds80% of hearing loss is related to the loss of high pitched sounds– Use low pitched sounds directly into ear canalUse 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/proceduresUse of picture that illustrate basic need/procedures

Visual ImpairmentsVisual Impairments

CausesCauses DiseaseDisease Congenital conditionsCongenital conditions InfectionInfection Degeneration of eyeball, optic nerve or Degeneration of eyeball, optic nerve or

nerve pathwaysnerve pathways

Individuals who are visually impaired can Individuals who are visually impaired can maintain active, independent lives.maintain active, independent lives.

Figure 5-2

AccommodationsAccommodations Retrieve visual aidsRetrieve visual aids Describe everything that you’re going to doDescribe everything that you’re going to do Provide sensory informationProvide sensory information If ambulatory, guide by leading, not by If ambulatory, guide by leading, not by

pushingpushing Allow leader dogs to accompany patientAllow leader dogs to accompany patient

– Do not pet or handle dog while in harnessDo not pet or handle dog while in harness

Speech ImpairmentsSpeech Impairments

Types of Speech ImpairmentsTypes of Speech Impairments

Language disordersLanguage disorders Articulation disordersArticulation disorders Voice production disordersVoice production disorders Fluency disordersFluency disorders

Etiology of Speech DisordersEtiology of Speech Disorders Language disordersLanguage disorders

– StrokeStroke– Head injuryHead injury– Brain tumorBrain tumor– Delayed developmentDelayed development– Hearing lossHearing loss– Lack of stimulationLack of stimulation– Emotional disturbanceEmotional disturbance

Etiology of Speech DisordersEtiology of Speech Disorders

Articulation disordersArticulation disorders– From damage to nerve pathways passing From damage to nerve pathways passing

from brain to muscles in larynx, mouth or from brain to muscles in larynx, mouth or lipslips

– Delayed development from hearing Delayed development from hearing problems, slow maturation of nervous problems, slow maturation of nervous systemsystem

Etiology of Speech DisordersEtiology of Speech Disorders Voice production disordersVoice production disorders

– Disorder affecting closure of vocal cordsDisorder affecting closure of vocal cords– Hormonal or psychiatric disturbanceHormonal or psychiatric disturbance

Fluency disordersFluency disorders– Not fully understoodNot fully understood

RecognitionRecognition

Language disordersLanguage disorders– Slowness to understand speechSlowness to understand speech– Slow growth in vocabulary and sentence Slow growth in vocabulary and sentence

structurestructure Articulation disordersArticulation disorders

– Speech can be slurred, indistinct, slow, or nasalSpeech can be slurred, indistinct, slow, or nasal

RecognitionRecognition

Voice production disordersVoice production disorders– HoarsenessHoarseness– HarshnessHarshness– Inappropriate pitchInappropriate pitch– Abnormal nasal resonance Abnormal nasal resonance

Fluency disordersFluency disorders– StutteringStuttering

Accommodations for Accommodations for Speech ImpairmentsSpeech Impairments

Never assume the person Never assume the person lacks intelligence.lacks intelligence.

Form questions that require Form questions that require short, direct answers.short, direct answers.

Never pretend to understand Never pretend to understand when you don’t.when you don’t.

Let the patient write Let the patient write answers to questions.answers to questions.

ObesityObesity

40% of people in the US are obese.40% of people in the US are obese. Excess weight can exacerbate the complaint Excess weight can exacerbate the complaint

for which you were called.for which you were called. Obesity can lead to many serious medical Obesity can lead to many serious medical

conditionsconditions

ObesityObesity EtiologiesEtiologies

– When a person has an When a person has an abnormal amount of body fat abnormal amount of body fat

» 20-30% heavier than normal 20-30% heavier than normal weightweight

– Person’s caloric intake is Person’s caloric intake is higher than the amount of higher than the amount of calories required to meet his calories required to meet his energy needs energy needs

– Genetic factorsGenetic factors– Low basal metabLow basal metab

Accommodations for Accommodations for Obese PatientsObese Patients

Don’t dismiss signs or Don’t dismiss signs or symptoms, such as shortness of symptoms, such as shortness of breath, as being a result of breath, as being a result of obesity.obesity.

Adipose tissue presents an Adipose tissue presents an obstruction—EKG electrodes obstruction—EKG electrodes may need to be placed on the may need to be placed on the arms and legs.arms and legs.

Do not compromise your health Do not compromise your health or safety—ask for assistance or safety—ask for assistance when lifting or moving a patient.when lifting or moving a patient.

Use appropriately sized Use appropriately sized diagnostic devicesdiagnostic devices

ParalysisParalysis ParaplegiaParaplegia

– Weakness or paralysis of both legsWeakness or paralysis of both legs QuadriplegiaQuadriplegia

– Paralysis of all four extremities and trunkParalysis of all four extremities and trunk

ParalysisParalysis The patient may have a home ventilator; be The patient may have a home ventilator; be

sure to keep the airway clear and patent.sure to keep the airway clear and patent. If the patient is in halo traction, be sure to If the patient is in halo traction, be sure to

stabilize the traction before transport.stabilize the traction before transport. Be aware of other assistive devices— Be aware of other assistive devices—

colostomy, canes, wheelchairs, etc.colostomy, canes, wheelchairs, etc.

Mental ChallengesMental Challenges Mental illnessMental illness

– Any form of psychiatric disorderAny form of psychiatric disorder– EtiologiesEtiologies

» PsychosisPsychosis Caused by complex biochemical brain diseaseCaused by complex biochemical brain disease

» NeurosesNeuroses Disease related to personalityDisease related to personality

– RecognitionRecognition» Behavior may be unaffectedBehavior may be unaffected» May present with signs and symptoms consistent with illnessMay present with signs and symptoms consistent with illness

AccommodationsAccommodations

Obtaining a historyObtaining a history– Don’t be afraid to ask aboutDon’t be afraid to ask about

» History of mental illnessHistory of mental illness» Prescribed medicationsPrescribed medications» Compliance with medicationsCompliance with medications» Concomitant ingestion of alcohol, other Concomitant ingestion of alcohol, other

drugsdrugs

Assessment and ManagementAssessment and Management

AssessmentAssessment– Be sure to solicit permission before beginningBe sure to solicit permission before beginning

ManagementManagement– Treat as you would any patient that does not Treat as you would any patient that does not

have a mental illness, unless call is related have a mental illness, unless call is related specifically to the mental illnessspecifically to the mental illness

» Patients with mental illness also experience Patients with mental illness also experience myocardial infarctions, hypoglycemic episodesmyocardial infarctions, hypoglycemic episodes

Developmental Developmental DisabilitiesDisabilities

Developmental DisabilitiesDevelopmental Disabilities DescriptionDescription

– Impaired/ insufficient development of the brain, Impaired/ insufficient development of the brain, causing an inability to learn at the usual ratecausing an inability to learn at the usual rate

RecognitionRecognition– HistoryHistory

AccommodationsAccommodations– Obtaining a historyObtaining a history– AssessmentAssessment– ManagementManagement– TransportTransport

Developmentally disabled people may have Developmentally disabled people may have trouble communicating, but can often still trouble communicating, but can often still

understand what you say.understand what you say.

Figure 5-3

Remember that a person with a Remember that a person with a developmental disability can recognize developmental disability can recognize

body language, tone, and disrespect body language, tone, and disrespect just like anyone else. Treat them as just like anyone else. Treat them as

you would any other patient.you would any other patient.

Developmental DisabilitiesDevelopmental Disabilities

Down SyndromeDown Syndrome– A chromosomal abnormality resulting in mild to severe A chromosomal abnormality resulting in mild to severe

mental retardation, and a characteristic physical mental retardation, and a characteristic physical appearance appearance

Fetal Alcohol Syndrome (FAS)Fetal Alcohol Syndrome (FAS)– Mother with persistent alcoholism during Mother with persistent alcoholism during

gestationgestation» Shortly after birth infants experience alcohol Shortly after birth infants experience alcohol » Deficient growth and mental capacityDeficient growth and mental capacity

Recognition of Down Recognition of Down SyndromeSyndrome

Eyes slope up at outer Eyes slope up at outer corners; folds of skin on corners; folds of skin on either side of nose cover either side of nose cover the inner corners or eyethe inner corners or eye

Small face and featuresSmall face and features Large and protruding Large and protruding

tongue tongue Flattening on back of the Flattening on back of the

headhead Hands short and broadHands short and broad

Recognition of Fetal Alcohol Recognition of Fetal Alcohol SyndromeSyndrome

Small head with Small head with multiple facial multiple facial abnormalitiesabnormalities– Small eyes with short Small eyes with short

slitsslits– Wide, flat nasal bridgeWide, flat nasal bridge– Midface that lacks a Midface that lacks a

groove between the lip groove between the lip and noseand nose

– Small jawSmall jaw

Pathological ChallengesPathological Challenges

ArthritisArthritis CancerCancer Cerebral PalsyCerebral Palsy Cystic FibrosisCystic Fibrosis Multiple SclerosisMultiple Sclerosis

Muscular DystrophyMuscular Dystrophy PoliomyelitisPoliomyelitis Previous head injuryPrevious head injury Spina BifidaSpina Bifida Myasthenia GravisMyasthenia Gravis

ArthritisArthritis Inflammation of a joint; characterized by pain, Inflammation of a joint; characterized by pain,

stiffness, swelling, rednessstiffness, swelling, redness AccommodationsAccommodations

– Decreased range of motion/mobility may limit physical Decreased range of motion/mobility may limit physical examexam

– Be sure to solicit current medications before Be sure to solicit current medications before considering the administration of medicationsconsidering the administration of medications

ManagementManagement– Limited ability to be mobileLimited ability to be mobile– Make equipment fit patient, not vice-versa, pad all Make equipment fit patient, not vice-versa, pad all

voidsvoids

Rheumatoid arthritis causes joints to become Rheumatoid arthritis causes joints to become painful and deformed.painful and deformed.

CancerCancer Primary site of origin of the cancer cells determines Primary site of origin of the cancer cells determines

the type of cancer the type of cancer – CarcinomaCarcinoma– Sarcoma Sarcoma

Treatments for the disease do tend to produce Treatments for the disease do tend to produce telltale signs telltale signs – Alopecia (hair loss)Alopecia (hair loss)– AnorexiaAnorexia– Radiation tattoosRadiation tattoos– Physical changesPhysical changes

CancerCancer ManagementManagement

– Patient’s risk for Patient’s risk for infection infection

» Chemotherapy leaves Chemotherapy leaves patient neutropenicpatient neutropenic

– Veins may have Veins may have become scarredbecome scarred

– Use of med portsUse of med ports» Requires specialized Requires specialized

training training

Cerebral PalsyCerebral Palsy Nonprogressive disorders of movement and Nonprogressive disorders of movement and

postureposture TypesTypes

– SpasticSpastic» Abnormal stiffness and contraction of groups of Abnormal stiffness and contraction of groups of

musclesmuscles– AthetosisAthetosis

» Involuntary, writhing movementsInvoluntary, writhing movements– Ataxia Ataxia

» Loss of coordination and balanceLoss of coordination and balance

Cerebral PalsyCerebral Palsy EtiologiesEtiologies

– Most occur before birthMost occur before birth– PrepartumPrepartum

» Cerebral hypoxiaCerebral hypoxia» Maternal infectionMaternal infection

– PostpartumPostpartum» EncephalitisEncephalitis» MeningitisMeningitis» Head InjuryHead Injury

RecognitionRecognition

Spastic: muscles of one or more extremities Spastic: muscles of one or more extremities are permanently contractedare permanently contracted

Athetoid: involuntary writhing movementAthetoid: involuntary writhing movement QuadriplegiaQuadriplegia Mental retardation in about 75% of all Mental retardation in about 75% of all

people with with CPpeople with with CP Many people with athetoid and diplegic CP Many people with athetoid and diplegic CP

are highly intelligentare highly intelligent

Cystic Fibrosis (Mucoviscidosis)Cystic Fibrosis (Mucoviscidosis) An inherited metabolic disease of the lungs and An inherited metabolic disease of the lungs and

digestive system, manifesting itself in childhooddigestive system, manifesting itself in childhood– A defective, recessive geneA defective, recessive gene

RecognitionRecognition– HistoryHistory– Patient may be oxygen dependentPatient may be oxygen dependent– Salty taste in mouthSalty taste in mouth– Productive coughProductive cough

ManagementManagement– May require respiratory support, suctioning, oxygenMay require respiratory support, suctioning, oxygen

Multiple SclerosisMultiple Sclerosis A progressive autoimmune disease of the CNS, A progressive autoimmune disease of the CNS,

whereby scattered patches of myelin in the brain whereby scattered patches of myelin in the brain and spinal cord are destroyedand spinal cord are destroyed

Unknown etiologyUnknown etiology RecognitionRecognition

– Fatigue, vertigoFatigue, vertigo– Clumsiness, muscle weaknessClumsiness, muscle weakness– Slurred speech, ataxiaSlurred speech, ataxia– Blurred or double visionBlurred or double vision– Numbness, weakness or pain in faceNumbness, weakness or pain in face

Multiple SclerosisMultiple Sclerosis Spinal cord affectedSpinal cord affected

– Tingling, numbness, or feeling of constriction Tingling, numbness, or feeling of constriction in any part of the bodyin any part of the body

– Extremities may feel heavy and become weakExtremities may feel heavy and become weak– Spasticity may be presentSpasticity may be present

Multiple SclerosisMultiple Sclerosis

AccommodationsAccommodations– Recognize characteristic presentationRecognize characteristic presentation– May be accompanied byMay be accompanied by

» Painful muscle spasmsPainful muscle spasms» UTIUTI» ConstipationConstipation» Skin ulcerationsSkin ulcerations» Changes in mood, from euphoria to depressionChanges in mood, from euphoria to depression

Muscular DystrophyMuscular Dystrophy An inherited muscle disorder of unknown cause in An inherited muscle disorder of unknown cause in

which there is slow but progressive degeneration which there is slow but progressive degeneration of muscle fibersof muscle fibers

Little or no movement of muscle groupsLittle or no movement of muscle groups Management: possible respiratory support, patient Management: possible respiratory support, patient

should not be expected to ambulateshould not be expected to ambulate

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

ambulance.ambulance.

Figure 5-6

PoliomyelitisPoliomyelitis

Caused by a virus, which usually results in Caused by a virus, which usually results in a mild illnessa mild illness

In more serious cases, it attacks the CNS: In more serious cases, it attacks the CNS: may result in paralysis or deathmay result in paralysis or death

Patients with severe polio may present with Patients with severe polio may present with paralysis (including respiratory)paralysis (including respiratory)

PoliomyelitisPoliomyelitis

AccommodationsAccommodations– If lower extremities are paralyzed, patient may If lower extremities are paralyzed, patient may

require catherterizationrequire catherterization– If respiratory paralysis, patient may require If respiratory paralysis, patient may require

tracheostomytracheostomy– Patient should not be expected to ambulatePatient should not be expected to ambulate

Patients with Previous Head Patients with Previous Head InjuryInjury

RecognitionRecognition– Physical appearance may be Physical appearance may be

uncharacteristicuncharacteristic– Speech and mobility may be affectedSpeech and mobility may be affected– Short term memory lossShort term memory loss

Spinal BifidaSpinal Bifida A congenital defect in which part of one or A congenital defect in which part of one or

more vertebrae fails to develop, leaving a more vertebrae fails to develop, leaving a portion of the spinal cord exposedportion of the spinal cord exposed

Unknown etiologyUnknown etiology Recognition: HistoryRecognition: History Transport: patient should not be expected to Transport: patient should not be expected to

ambulateambulate

Myasthenia GravisMyasthenia Gravis A disorder in which muscles become weak and tire A disorder in which muscles become weak and tire

easilyeasily Eyes, face, throat, and extremity muscles most Eyes, face, throat, and extremity muscles most

commonly affectedcommonly affected Etiology: Autoimmune disorder of unknown etiologyEtiology: Autoimmune disorder of unknown etiology RecognitionRecognition

– Drooping eyelids, double visionDrooping eyelids, double vision– Difficulty speakingDifficulty speaking– Chewing, swallowing may be difficultChewing, swallowing may be difficult– Movement of extremities may be difficultMovement of extremities may be difficult– Respiratory muscles may be weakenedRespiratory muscles may be weakened

Other ChallengesOther Challenges Culturally diverse patientsCulturally diverse patients Terminally ill patientsTerminally ill patients Patients with communicable diseasesPatients with communicable diseases Financial challengesFinancial challenges

United States society is becoming diverse, United States society is becoming diverse, with the largest number of immigrants coming with the largest number of immigrants coming

from Asia and Latin America.from Asia and Latin America.

Figure 5-7

If a patient refuses care because of cultural or If a patient refuses care because of cultural or religious beliefs, be sure to have the patient religious beliefs, be sure to have the patient

sign a Refusal of Treatment and sign a Refusal of Treatment and Transportation form.Transportation form.

Figure 5-8

Financial ChallengesFinancial Challenges

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

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

Figure 5-9

SummarySummary

Physical ChallengesPhysical Challenges Development DisabilitiesDevelopment Disabilities Pathological ChallengesPathological Challenges Other ChallengesOther Challenges