Emergencies for Patients with Special Challenges

Foundational concepts

A disability is a condition — physical, emotional, behavioral or cognitive — that interferes with a person's everyday activities. Diseases that leave a patient disabled are described by when they began. A congenital disease is present at birth, while an acquired disease develops afterward, whether from an infection, another medical condition or trauma.

A chronic disease complicates the picture in two different ways, and you should be prepared for either. The chronic condition itself can worsen acutely, or the patient can develop an entirely unrelated acute illness that hits harder than it otherwise would because of the coexisting chronic condition. The same illness is simply a larger insult to a patient who has less reserve to absorb it.

Common chronic conditions

A handful of chronic conditions turn up often enough in the field that you should know in advance what each one changes about your assessment, your equipment and the way you communicate. The table below sets out those conditions and the points that matter most.

Table 37.1Common chronic conditions

Autism — the ABCS approach

Patients with autism spectrum disorder (ASD) are encountered often enough that a structured approach is worth committing to memory. The ABCS approach gives you four things to attend to on every such call:

• Awareness. Patients with ASD react differently from what you may expect, and stress narrows their range further. Even a patient who normally speaks may go silent when frightened or in pain, so consider picture cards when speech fails.
• Basic. Keep everything simple. Give direct instructions, ask closed-ended questions, and minimize sensory stimulation by turning down radios, reducing lights and shutting off sirens wherever you can.
• Calm. Calm creates calm. Avoid anything that looks like a show of force, designate one primary contact person to speak with the patient, keep a familiar caregiver alongside you, and allow extra time.
• Safety. A familiar environment is a source of security, so preserve as much of it as the situation allows. Narrate each step before you carry it out. Restraint is a last resort, used only when there is imminent danger.

Overstimulation can produce an escalation, or meltdown: involuntary, tantrum-like behavior that is not defiance and must not be treated as misbehavior. Assessment calls for the same patience, because patients with ASD may voice atypical complaints and may have a high tolerance for pain. A careful, unhurried examination is what keeps a serious condition from being missed in a patient who is not able to report it in the usual way.

General approach principles

Establishing a baseline comes first. What counts as normal is specific to the patient, so the most useful question is the one put directly to the patient or the family: what is different today. The answer is often the most efficient path to the real problem, and it keeps you from mistaking a long-standing deficit for an acute change.

Routine care still applies. Patients with special challenges get the same everyday illnesses as everyone else, and the priorities of the primary assessment are universal, whatever diagnosis or device you find in front of you.

Finally, follow your protocols. If the care a patient needs falls outside your training or your scope of practice, confer with medical direction rather than improvising.

Respiratory devices

Respiratory technology in the home ranges from a mask the patient wears at night to a machine that breathes for the patient entirely. The table below lists the devices you are most likely to meet and what each one means for your care.

Table 37.2Respiratory devices

When a ventilated patient deteriorates, the causes to work through are recalled with the mnemonic DOPE: displacement of the tube, obstruction of the tube, pneumothorax or pneumonia, and equipment failure. Your first action tests several of them at once. Remove the ventilator circuit and ventilate the patient with a bag-valve mask (BVM), which rules out equipment failure while checking for displacement and obstruction at the same time.

Cardiac devices

Implanted and wearable cardiac devices are common in the community, and each one changes something about your assessment or your resuscitation. The table below summarizes the four you are most likely to encounter.

Table 37.3Cardiac devices

When you apply AED pads to a patient with an implanted pacemaker or AICD, or with a central line, offset the pads away from the device rather than placing them directly over it.

Gastrointestinal & urinary devices & dialysis

A patient who cannot take food by mouth may be fed through a nasogastric, gastrostomy or jejunostomy tube (NG/G/J-tube). Dislodgement of the tube, infection at the site and clogging of the tube all warrant evaluation at the hospital. Do not attempt to replace a tube that has come out; cover the opening with an occlusive dressing and transport the patient.

An indwelling urinary catheter, or Foley, asks only one thing of you: keep the drainage bag below the level of the patient at all times, including while you move the patient to the stretcher.

Patients in kidney failure are maintained on one of two forms of dialysis, and each brings its own concern. In hemodialysis, the blood is filtered through a surgically created fistula, most often in an arm. Never take a blood pressure (BP) on the fistula arm. A fistula that bleeds can bleed massively, so apply direct pressure and do not release it until a physician advises you to.

In peritoneal dialysis, fluid is exchanged through a catheter in the abdomen, and the two problems to watch for are dislodgement of the catheter and peritonitis. Fluid that drains cloudy suggests infection, so bring the bag with you to the hospital for testing.

Central IV catheters & VP shunts

A central intravenous catheter — a peripherally inserted central catheter (PICC), a Groshong catheter or an implanted port — delivers medication into a large vein. EMTs generally do not access these lines. Handle them gently, avoid tugging on the catheter or contaminating the site, and hold a high suspicion for sepsis in any patient who has one, since a central line is a direct route for infection into the bloodstream.

A ventriculoperitoneal (VP) shunt drains excess cerebrospinal fluid (CSF) from the brain to the abdomen. When the shunt malfunctions, the fluid accumulates, intracranial pressure (ICP) rises, and the patient presents with altered mental status, seizures or respiratory compromise. Management is supportive: standard airway care and prevention of hypoxia, transport, and consultation with medical control.

General principle & child abuse

Patients with special needs, at any age, are more vulnerable to abuse than the population at large, for the plain reason that they depend on other people for their daily care. Certain findings raise suspicion whatever the patient's age: a story that is inconsistent with the injury you are looking at, multiple injuries at different stages of healing, a pattern of repeated injury, and a caregiver who is indifferent to what has happened. Suspicion is not accusation. You never accuse anyone at the scene; you report according to the rules of your jurisdiction.

In children, the physical findings have a characteristic look. Patterned marks may match the shape of the weapon that made them, and fractures may be found at various stages of healing. Head injury is among the most lethal of abuse injuries, and in shaken baby syndrome it shows itself as a bulging fontanelle and unconsciousness. Burns with a specific line of demarcation, such as a cigarette burn or a glove or stocking pattern, point the same way.

Behavior tells you as much as the injuries. Be alert to a caregiver who will not leave you alone with the child, to a story that conflicts between tellers or changes in the retelling, to a child who is afraid to explain what happened, and to injuries found both front and back or on both sides of the body.

Elder & dependent adult abuse

Elder abuse is conventionally divided into 3 types — physical, psychological and financial — with physical neglect standing alongside them as a further form of harm. Falls are genuinely common in the frail elderly, which is exactly what makes them convenient cover, so do not assume that an injury is a simple fall merely because a fall would explain it.

Dependent adults face the same risks. These are adults whose developmental or physical disability leaves them reliant on a caregiver, and the red flags cluster around that caregiver: an unexplained absence, a patient who is malnourished, and interference with the care you are trying to provide.

The EMT's role in suspected abuse

Your role is a bounded one. The EMT is not the police, not an investigator, not a social worker and not a judge. Where the scene allows it, interview the caregiver and the patient separately, and conduct both interviews without judgment. Control your own emotions while you do it: make no accusations, and let nothing in your face or your voice show suspicion.

In many states the EMT is a mandated reporter, and you should know whether yours is one of them. Report and document in the language of possibility, describing the abuse as suspected or possible. Record the facts you observed and the statements you heard, and leave the conclusions to the agencies whose job it is to draw them.

Intimate partner violence & human trafficking

Intimate partner violence (IPV) follows a pattern the EMT needs to understand rather than judge. The moment of greatest risk to a victim is the moment of leaving, which is much of the reason a patient may stay in the relationship or refuse your help even when the injuries are plain. Assess the patient away from the partner, and away from the children, whenever the scene allows it. Offer advocacy and hotline information every time, including on repeat calls to the same address.

Human trafficking is exploitation through force, fraud or coercion, and it is present in every U.S. state. The warning signs are found in the scene as much as in the patient: a companion who controls the encounter, a companion who insists on speaking for the patient, ID documents held by someone other than the patient, and a submissive or fearful affect.

Treat the medical problem first. Never disclose your suspicion to the victim or to anyone else on the scene, and report immediately to law enforcement instead. The National Human Trafficking Hotline is 1 (888) 373-7888.