I



Detailed Lesson Plan

Chapter 40

Patients with Special Challenges

255–300 minutes

|Chapter 40 objectives can be found in an accompanying folder. |

|These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. |

|Minutes |Content Outline |Master Teaching Notes |

| |Introduction |Case Study Discussion |

|5 |During this lesson, students will learn about assessment and emergency care for patients with special challenges. |What type of device is Mrs. Davidson talking about? What is it|

| |Case Study |used for? |

| |Present The Dispatch and Upon Arrival information from the chapter. |What would happen if the device malfunctioned? |

| |Discuss with students how they would proceed. | |

| |Recognizing the Patient with Special Challenges |Teaching Tip |

|5 |Any number of medical or traumatic conditions can cause loss of function to a body system. |Ask students what experiences they have with people who have |

| |Changes can be mild or substantial. |special challenges. |

| |Impairments may result from aging, birth defects, chronic illnesses, traumas, abuse and/or neglect, and more. | |

| | |Critical Thinking Discussion |

| | |Why is it important for EMS providers to be knowledgeable |

| | |about special health care needs? |

| | |Are there other populations who may have special challenges in|

| | |getting the health care they need? |

| | | |

| | |Weblink |

| | |Go to and click on the mykit link for |

| | |Prehospital Emergency Care, 9th edition to access a web |

| | |resource on minority health. |

| | | |

| |Sensory Impairments—Hearing Impairment |Discussion Question |

|2 |Occurs when there is a loss or diminishment in the person’s ability to hear sounds |What are some ways of improving communication with |

| |Deafness is a term that is commonly used to describe the inability to hear. |hearing-impaired patients? |

| |May involve one or both ears | |

| |Patient may be partially deaf or totally deaf. | |

| | Sensory Impairments—Vision Impairment |Discussion Question |

|5 |Etiologies |What are some causes of impaired vision? |

| |Loss from disease | |

| |Loss from injury | |

| |Loss from degenerative disorders | |

| |Glaucoma results in an abnormal increase in intraocular pressure that damages the optic nerve, resulting in | |

| |peripheral vision loss and eventual blindness. | |

| |Diabetic retinopathy occurs when the long-term effects of diabetes mellitus damage the small blood vessels in the | |

| |eye. | |

| |Injury to the eye can be caused by puncture or penetration injuries, blunt trauma to the face, or chemical and | |

| |thermal burns. | |

| |Aging may cause degeneration of the eyeball, optic nerve, and optic nerve pathways. | |

| |Cataracts are a condition in which the lens of the eye becomes cloudy from pathologic changes within the lens | |

| |itself. | |

| |Vision loss | |

| |Acute or slow onset | |

| |One or both eyes | |

| |Whole or certain field of vision | |

| |Reversible or permanent | |

| |Sensory Impairments—Speech Impairment | |

|2 |Articulation disorders—Caused by impairment of tongue or other muscles needed for speech (dysarthria), learning | |

| |words incorrectly, hearing impairment, or damage to nerve tracts | |

| |Voice-production disorders—Damage to the larynx, vocal cords, or related supporting structure from illness or | |

| |injury | |

| |Language disorders—Patient displays an impaired or absent ability to understand the spoken word (congenital | |

| |problems, hearing deficits, inadequate language stimulation, stroke, head trauma, brain tumor, significant | |

| |emotional stress). | |

| |Fluency disorders—“Stuttering” speech patterns | |

| |Sensory Impairments—Accommodations for Patients with Sensory Impairment | |

|6 |Hearing-impaired patient | |

| |If patient has hearing aid, ensure that it is on and working properly. | |

| |Position yourself so that the patient can lip read. | |

| |Communicate in writing, if necessary. | |

| |If patient is able to sign, have a person at the scene who knows sign language act as an interpreter. | |

| |Visually impaired | |

| |Speak clearly and always explain what you are going to do before you do it. | |

| |Follow local protocol and service policies when deciding whether or not to transport a service dog. |Teaching Tip |

| |You may need to act as the patient’s guide. |Discuss local protocol regarding transportation of service |

| |Speech impairment |animals. |

| |Ask questions in a way that allows patients to answer in as few words as possible. | |

| |Allow patients time to respond to your questions, and do not attempt to finish words or statements. |Critical Thinking Discussion |

| |Never pretend you understood something when in fact you didn’t. |How should you interact with a service animal? |

| |Use family or other communication techniques only when verbal communication has failed. | |

| | |Knowledge Application |

| | |Students should be able to integrate information from this |

| | |section into the assessment and management of patients with |

| | |sensory impairment. |

| |Cognitive and Emotional Impairments—Mental or Emotional Impairments | |

|3 |Impairment may range from mild to significant. | |

| |Patient with an extreme emotional dysfunction may be unable to focus on your questions or respond appropriately. | |

| | Cognitive and Emotional Impairments—Developmental Disabilities |Critical Thinking Discussion |

|3 |Conditions that interfere with how a body part or system operates |What are some organizations that help people with |

| |Often present as birth defects |developmental disabilities lead more productive lives? |

| |May not be noted until the child fails to reach certain developmental milestones | |

| |Can be a result of trauma in utero, during the birth process, or at any time after birth | |

| |May involve brain, spinal cord, nervous system, and endocrine system |Class Activity |

| |Common disabilities |Assign students to research a developmental disability outside|

| |Down syndrome |of class and make short presentations to the rest of the class|

| |Fragile X syndrome |at the next class session. |

| |Autism | |

| |Fetal alcohol syndrome | |

| |Phenyketonuria (PKU) | |

| |Kypothyroidism | |

| |Rett syndrome | |

| |Cognitive and Emotional Impairments—Accommodations for Patients with Mental, Emotional, or Developmental |Discussion Question |

|3 |Impairments |What are some guidelines for interacting with patients with |

| |Treat the patient with respect as you would any other patient. |developmental disabilities? |

| |You may need to gather history from primary care provider if you discern developmental or cognitive problems. | |

| |Use care providers’ experience with patients to help you determine diminishment in the patient’s mental status or | |

| |other condition when trying to gather chief complaint. | |

| |Provide clear explanations in an attempt to assist the patient in understanding the situation and what is occurring| |

| |during emergency care and transport. | |

| |Patients are still sensitive to body language and tone of voice. | |

| |Patients may be wary of strangers, and it is important to gain their trust. | |

| |Avoid loud noises or extreme changes in lighting, and keep the primary care provider near. | |

| |Cognitive and Emotional Impairments—Brain-Injured Patients |Weblink |

|3 |Causes can include infant abuse, meningitis, encephalitis, and head injury. |Go to and click on the mykit link for |

| |Cerebral palsy is an umbrella term for motor impairments (muscular stiffness, joint contractures, wringing of |Prehospital Emergency Care, 9th edition to access a web |

| |hands, drool, facial grimacing) that result from brain abnormalities that arise early in development. |resource on cerebral palsy. |

| |Brain trauma can range from mild to severe. | |

| |Cognitive and Emotional Impairments—Accommodations for Brain-Injured Patients | |

|3 |Presenting signs and symptoms should be categorized as either chronic or acute. | |

| |Gathering a history will reveal the type of injury sustained earlier and identify any changes in the patient’s | |

| |current condition as either chronic or acute. | |

| |Brain-injury patients may use a large amount of medical technology in order to survive, and the EMT must manage |Discussion Question |

| |this equipment during transfer. |What are some additional considerations in managing severely |

| |While emergency care will depend on the condition(s) for which you are summoned, remember to maintain a patent |brain-injured patients? |

| |airway, ensure adequate breathing, and keep peripheral perfusion intact. | |

| |Consider summoning ALS for a patient who is critically unstable or deteriorating. |Knowledge Application |

| | |Students should be able to apply this information to |

| | |interactions with patients with emotional and cognitive |

| | |impairments. |

| |Paralysis—Accommodations for Paralyzed Patients |Discussion Questions |

|15 |Complete loss of muscle function to one or more groups of muscles |What are some causes of paralysis? |

| |You may have to make accommodations for a patient’s preexisting paralysis while also treating him for the reason |What are some medical terms associated with paralysis? |

| |for the EMS call. |What are some considerations in assessment, management, and |

| |Patients who are paralyzed are susceptible to multiple additional problems (e.g. respiratory infections, urinary |transport of patients who are paralyzed? |

| |infections, necrosis, and emergencies from feeding tubes). | |

| |Paraplegic patient will display paralysis from the waist down and should be able to communicate with you normally | |

| |as long as there is no cognitive decline. | |

| |Concern is moving the patient from his bed or wheelchair to your cot. |Weblink |

| |Taking the patient’s wheelchair is often not allowed by the EMS agency, and you should coordinate with family or |Go to and click on the mykit link for |

| |primary care provider for this and other items to be brought to the hospital. |Prehospital Emergency Care, 9th edition to access a web |

| |Quadriplegic patient is paralyzed to all four extremities and may not be able to breathe adequately on his own. |resource on paraplegia. |

| |Keep settings on the home ventilator the same as when you arrived. | |

| |Keep suction and bag-valve mask nearby. | |

| |Look to see if the patient has a urinary catheter before moving him, and keep the urinary collection bag at a level| |

| |above the insertion site or at the same level of insertion. | |

| |Remain alert to the patient’s needs and medical equipment (especially while moving the patient). |Knowledge Application |

| |Never allow the necessary accommodations distract you from the reason for the initial call to EMS. |Students should be able to apply information from this section|

| | |to the care of paralyzed patients. |

| | Obesity—Accommodations for Obese Patients |Discussion Questions |

|15 |Bariatrics is the branch of medicine that deals with the management of obese patients. |What are some causes and risk factors for obesity? |

| |Traditionally, a person who is 20 percent or more over his ideal weight is considered to be obese. |What health risks are associated with obesity? |

| |A morbidly obese patient weighs 50 to 100 percent more than his ideal weight or is more than 100 pounds over his | |

| |ideal weight. |Critical Thinking Discussion |

| |As obesity and morbid obesity rates climb, EMS crews are encountering these patients more and more often. |What do you think accounts for the negative attitudes many |

| |Obesity may occur from consuming too many calories, physiologic problems, medications, or genetic factors. |people have toward people who are obese? |

| |“Extra” skin and adipose tissue can affect normal respiratory function when patient is in supine position | |

| |Allow patient to maintain position of comfort. | |

| |Ensure airway is maintained in neutral position. | |

| |Position patient with multiple towels or bath blankets under the shoulder blades and behind the neck (if no spine | |

| |injury is suspected) to provide cervical extension. | |

| |Use an oral or nasal pharyngeal airway to displace the tongue mechanically. | |

| |Turn your attention to oxygenating and ventilating the patient; spontaneous breathing may be impaired by body size | |

| |in semi-reclined or supine position. (Remember a breathing patient does not necessarily equal an adequately | |

| |breathing patient.) | |

| |Perform rapid circulatory assessment; look for mentation, or alterations in heart rate or blood pressure. |Teaching Tip |

| |Use additional personnel, special cots, and bariatric loading devices as appropriate when transporting the patient.|Demonstrate any bariatric equipment available to your EMS |

| |Inform receiving facility that a special stretcher or additional personnel may be needed. |system. |

| | | |

| | |Knowledge Application |

| | |Students should be able to apply information from this section|

| | |to the management of obese patients. |

| | | |

| |Homelessness and Poverty—Accommodations for Patients Who are Homeless or Poor |Teaching Tip |

|30 |Factors contributing to homelessness |Encourage students to volunteer for an agency that provides |

| |Poverty |services to the homeless. |

| |Substance abuse | |

| |Lack of affordable housing |Class Activity |

| |Mental illness |Have students organize a food or clothing drive, or collect |

| |Prison release back into society |school supplies for the disadvantaged in your community. |

| |Domestic violence | |

| |Mortgage foreclosures and forced evictions | |

| |Natural disaster |Discussion Question |

| |Disadvantages of homelessness |What are the health and health care consequences of poverty |

| |Reduced access to services because of lack of proper documentation or address |and homelessness? |

| |Increased risk of violence and abuse | |

| |Increased risk of illness/disease | |

| |Discrimination from others | |

| |Reduced access to healthcare | |

| |Limited or no access to education | |

| |Limited or no access to modern communications | |

| |Not seen as suitable for employment purposes |Weblink |

| |Homeless have no address to which EMS can respond; the following are locations to which you may respond. |Go to and click on the mykit link for |

| |Abandoned or condemned buildings |Prehospital Emergency Care, 9th edition to access a web |

| |Public places such as parks, train or bus stations, airport, college campuses |resource about the homeless. |

| |Vehicles | |

| |Outdoors in improvised shacks or on the ground with sleeping bags | |

| |In an unoccupied house | |

| |Homeless shelters |Knowledge Application |

| |Homeless are at risk for even greater emergencies due to poor nutrition, environmental exposure, lack of access to |Students should be able to apply the information in this |

| |medication, and vulnerability to violent acts. |section to the care of homeless and impoverished patients. |

| |Like the homeless, people who fall below the poverty level are at greater risk for illness and injury from the | |

| |environment that they are in and the lack of primary medical care. | |

| |Do not be judgmental; 90 percent of Americans will, at some time, live below the poverty level for at least a year.| |

| |Remember that you are treating the patient because he needs your help. | |

| |If the patient is worried about money to pay for the services, take the time needed to explain to the patient that | |

| |almost all health care providers offer a certain degree of reduced cost or free medical care. | |

| |Become familiar with hospitals and services in your community that provide medical care, shelter, food, or other | |

| |services to families in need. | |

| | |Critical Thinking Discussion |

| | |What are some resources for the homeless and impoverished in |

| | |your community? |

| | Abuse—Child Abuse | |

|5 |Abuse is any action or failure to act that results in unreasonable suffering, harm, or misery to a person, whether | |

| |physical or mental (e.g., child abuse, elder abuse, and partner abuse). | |

| |It is the EMTs responsibility to make notifications of any suspicion of abuse to the proper authorities according | |

| |to your state’s guidelines. |Discussion Question |

| |Child abuse occurs when a child (newborn to 18 years in most states) falls victim to abuse or neglect. |What are some indications of child abuse? |

| |Abuser can be parent, siblings, stepsiblings, stepparents, or anyone else responsible for the child’s care. | |

| |Physical abuse occurs when improper or excessive action is taken as to injure or cause harm. | |

| |Neglect is the provision of inadequate attention or respect to someone who has a claim to the attention. | |

| |Emotional abuse occurs when “a child is regularly threatened, yelled at, humiliated, ignored, blamed, or otherwise | |

| |emotionally mistreated” (most difficult to prove). | |

| |Sexual abuse is said to occur when a child is subject to an older child or adult’s advances that have a sexual | |

| |nature (contact and noncontact events). | |

| |Adult (care giver) who abuses a child often is evasive or hostile and may give contradictory information. | |

| |Abuse—Elder Abuse |Discussion Question |

|5 |Abuse can occur in care centers, other medical institutions, or home. |What are some indications of elder abuse? |

| |Those at highest risk | |

| |Bedridden | |

| |Demented | |

| |Incontinent | |

| |Frail | |

| |Those with disturbed sleep patterns | |

| |Geriatric neglect is the withholding of attention or medical care to which the victim is entitled (active or | |

| |passive). | |

| |Physical abuse can involve hitting, unnecessary restraining, shaking, or shoving. | |

| |Sexual abuse is said to occur when there are unwanted or unwarranted advances of a sexual nature. | |

| |Financial abuse consists of the care provider exploiting the material possessions, property, credit, or monetary | |

| |assets of the elderly patient for personal gain. | |

| |Emotional or mental abuse may include verbal assaults, verbal insults, ignoring the elderly patient, or threats of | |

| |physical harm. | |

| |Abuse—Accommodations for Victims of Abuse |Weblink |

|10 |It may be difficult for the EMT to determine whether pediatric or child abuse has occurred. |Go to and click on the mykit link for |

| |Signs of abuse may be physical (e.g., bruises, bite marks, lacerations, broken bones, rope marks, scalding burns) |Prehospital Emergency Care, 9th edition to access a web |

| |or emotional (e.g., depression, fear, inadequate or inappropriate coping skills or mental status). |resource about intimate partner violence. |

| |Priority is to provide emergency care for the injuries. | |

| |Take into account the age group during treatment (e.g., emphasize airway and respiratory components in pediatric | |

| |patient; trauma is usually worse in geriatric patient). |Knowledge Application |

| |Do not confront the family or care provider with suspicions of abuse; make suspicions known to the receiving |Students should be able to apply the information in this |

| |hospital’s staff so that they can follow up with the proper authorities. |section to the assessment and management of abused or |

| |Remain objective in your documentation for a suspected victim of abuse. |neglected patients. |

| |Follow local protocols or state laws regarding reporting of suspected abuse. | |

| |Technology Dependence |Teaching Tip |

|15 |Shifting of patients from an in-hospital setting for ongoing medical care to the home setting which has increased |Inviting an expert in home health care to speak about this and|

| |the number of health care providers who function outside of the hospital and increased the use of medical |the next several sections will provide students with important|

| |technology |information. |

| |Remain abreast of trends in home-based medical technology as many calls may be for medical equipment that has | |

| |failed or is no longer providing the needed support. | |

| |Determine what the medical device is supposed to be doing for the patient, how critical its function is to patient | |

| |survival, and what type of impact the device has on other medical or traumatic emergencies that patient may suffer.| |

| |Primary care provider may be helpful for information about equipment. Consider the following. | |

| |Where would I get the best information from regarding this piece of equipment? | |

| |What does this device do for the patient? | |

| |Can I replicate its function should the device fail? | |

| |Will this equipment have an effect on how I assess the patient, or on the findings I may discover? | |

| |Has this problem ever occurred previously, and if so, what fixed it? | |

| |Has anyone attempted already to remediate the problem? | |

| |Are there specific considerations I need to make when deciding on how to best prepare the patient for movement and | |

| |transport the patient? | |

| |Constantly assess the patient for the following and intervene if deterioration should occur. | |

| |Keep the airway open and patient. | |

| |Ensure good ventilations with supplemental oxygen. | |

| |Intervene as needed to support any lost function to the circulatory system. | |

| |Airway and Respiratory Devices—Medical Oxygen |Teaching Tip |

|5 |Home oxygen equipment is similar to oxygen equipment you would use on the ambulance (e.g., oxygen source, flow |Demonstrate any available airway and breathing devices to help|

| |regulator, oxygen supply tubing, oxygenation adjunct, in-line system for humidifying). |students learn about their use. |

| |Sources of oxygen for patients at home | |

| |Oxygen cylinder—Oxygen is compressed in a tank, adjusted by flowmeter, and administered to the patient via | |

| |oxygenation adjunct) | |

| |Oxygen concentrator—Extracts oxygen from the ambient environment and supplies it to the patient | |

| |Liquid oxygen—Atmospheric oxygen that has been cooled to l –183 degrees Celsius and stored under pressure in a | |

| |container; larger liquid oxygen storage unit is used to refill small portable oxygen containers. | |

| |Emergencies (relatively few) | |

| |Equipment fails to provide oxygen. | |

| |Patient’s condition changes or worsens, and oxygen the patient is receiving is no longer sufficient. | |

| |Airway and Respiratory Devices—Apnea Monitors |Discussion Question |

|5 |Designed to constantly monitor the patient’s breathing and emit a warning signal should breathing cease |Outline the assessment of a patient whose apnea monitor’s |

| |May also monitor heart rate |alarm has sounded. |

| |Determine how long the machine has been alerting a problem and what kind of interventions the care provider has | |

| |done prior to EMS arrival. | |

| |Be thoughtful to care providers as this equipment is often used for infants, and an emergency can be very | |

| |frightening to them. | |

| |Perform a normal scene size-up and primary assessment. (Be especially diligent to respiratory rate and tidal | |

| |volume.) | |

| |If breathing is adequate, provide oxygen to the infant and transport him to the hospital for evaluation. | |

| |If breathing is inadequate, provide airway control and positive pressure ventilation with supplemental oxygen while| |

| |you transport the infant. | |

| |Airway and Respiratory Devices—Pulse Oximetry | |

|5 |Medical equipment that monitors oxygen saturation and is often used by EMTs | |

| |Common reasons for pulse oximetry in the home | |

| |Patient with chronic pulmonary disease who needs to maintain a certain level of blood oxygen saturation | |

| |Medical need to keep oxygen saturation within a specific therapeutic range | |

| |Need to monitor oxygen in a patient with fluctuating oxygen demand | |

| |Remember that preexisting pulmonary conditions may rapidly deteriorate into respiratory distress or arrest. | |

| |Determine what the oxygen saturation trends were prior to arrival and what interventions were done. | |

| |Use your own pulse oximeter in assessing the patient. | |

| |Airway and Respiratory Devices—Tracheostomy Tubes |Weblink |

|10 |Surgical opening made through the neck and into the trachea to provide an alternative route for air to move into |Go to and click on the mykit link for |

| |and out of the body, bypassing the mouth and nose. |Prehospital Emergency Care, 9th edition to access a web |

| |Can be a temporary or permanent opening (stoma) |resource on tracheostomy. |

| |Reasons for tracheostomy tube or stoma | |

| |Patients with long-term upper airway problems | |

| |Medical conditions that result in long-term dependence on a mechanical ventilation | |

| |Patients who have cancer of the larynx or neck | |

| |Patients with neuromuscular disorders or congenital deformities | |

| |Patient in coma or with spinal cord injuries | |

| |Infants have just single lumen; however, children and adults have outer cannula and inner cannula. | |

| |Proximal end of the tracheostomy tube has an adapter that will fit a standard bag-valve mask or flow-restricted, | |

| |oxygen-powered ventilation device. | |

| |Patient may or may not be able to speak. (Use hand gestures or writing as appropriate.) | |

| |Emergencies | |

| |Tube may become plugged by mucus. | |

| |Inner cannula of the tube can become dislodged by movement or occluded by a foreign body. | |

| |Infection or bleeding at the insertion site | |

| |Emergency care—Tube partially or totally occluded | |

| |Use a whistle-tip (soft) suction catheter to clear the airway. | |

| |Measure the depth of insertion for the suction catheter. | |

| |Apply suction and slowly withdraw the catheter while twisting it between your fingers. | |

| |Do not suction for longer than ten to 15 seconds in an adult or five seconds in a pediatric patient at once. | |

| |Oxygenate between suctioning attempts, and rinse out the lumen of the suction catheter with sterile water between | |

| |attempts. | |

| |Keep in mind that manipulation of tracheostomy tube may be outside EMT’s protocol. | |

| |Enlist the help of the primary care provider. | |

| |If tracheostomy tube is patent, problem may be with the patient’s ventilator. | |

| |Airway and Respiratory Devices—CPAP and BiPAP | |

|5 |Continous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) machines are designed to | |

| |provide a therapeutic back-pressure during respiration via an airway circuit attached to a mask that covers the | |

| |mouth and/or nose. | |

| |CPAP device provides a constant pressure during the ventilatory cycle while the BiPAP machine provides a higher | |

| |pressure during inhalation and a lower pressure during exhalation. | |

| |Both keep the bronchioles open during exhalation, improving oxygenation and ventilation and decreasing the work of | |

| |breathing. | |

| |Commonly used in patients diagnosed with chronic obstructive pulmonary disease (COPD) and sleep apnea. EMS systems | |

| |may also use equipment for congestive heart failure (CHF). | |

| |Emergencies related to the devices are rare. | |

| |Use may use a BiPAP machine if your protocol allows and the patient meets your inclusion criteria. | |

| |If a patient uses a CPAP or BiPAP for sleeping and you are treating for some complaint, transport the device to the| |

| |hospital with the patient and alert the receiving facility that the patient uses it during sleep. | |

| |Airway and Respiratory Devices—Home Mechanical Ventilators | |

|5 |Device designed to assist a patient with breathing who cannot breathe adequately on his own | |

| |Causes for home mechanical ventilator | |

| |Brain’s inability to initiate a spontaneous breath | |

| |Structural defect to the thorax or lungs | |

| |History of debilitating stroke, brain damage, or long-term pulmonary problems | |

| |Negative pressure ventilators (e.g., “iron lung”) encircle the patient’s chest and generate a negative pressure | |

| |around the thoracic cage that ultimately draws air into the lungs (rarely used). | |

| |Positive pressure ventilators push air into the patient’s lungs. | |

| |Can come in a variety of sizes and have two or three controls: ventilatory rate (fixed or adjustable), tidal volume| |

| |(adjustable), and possibly a control that adjusts the amount of oxygen provided during ventilation (fixed or | |

| |adjustable) | |

| |Attaches to patient by large-diameter tubing (ventilator circuit); ventilator circuit attaches to tracheostomy | |

| |tube. | |

| |Alarms | |

| |High-pressure alarm—Activated when pressure needed to cause lung inflation exceeds the present value | |

| |Low-pressure alarm—Activated when tidal volume falls 50–100 mL below the set tidal volume | |

| |Apnea alarm—Sounds when the patient stops breathing | |

| |Low FiO2—Occurs when the oxygen source is disconnected or depleted | |

| |Remember that an alarm may indicate a change in the patient’s clinical condition, not necessarily a ventilator | |

| |malfunction; always troubleshoot the ventilator and the patient. | |

| |Airway and Respiratory Devices—Accommodations for Patients with Airway or Respiratory Devices | |

|10 |Dispatch may tell you the type of medical technology the patient uses. This will allow you to start planning your | |

| |approach to the patient while you are en route. | |

| |Perform scene size-up, and determine if additional backup may be necessary to move the patient and his equipment. | |

| |Conduct the primary assessment in the same sequence as for patients without airway or ventilatory devices (assess | |

| |mental status, airway, breathing, and so on). | |

| |If you find the patient has a tracheostomy tube, assess it for patency and clear it immediately if necessary. | |

| |If primary care provider is not available, select a soft or flexible suction catheter and insert it carefully into | |

| |the tracheostomy tube. | |

| |Use a sterile technique for suctioning, and use sterile gloves. | |

| |Avoid inserting the catheter farther than the length of the inner cannula of the tracheostomy. | |

| |Once the catheter is placed, apply suction while you withdraw the catheter (15 seconds for adults and five seconds | |

| |for child). | |

| |Roll the catheter between your fingers during extraction. | |

| |Be sure to wear the necessary protective equipment, and rinse out the suction catheter with sterile water. | |

| |For dislodgement of the tracheostomy in an adult, the cuff needs to be deflated with a 10 10 mL syringe prior to | |

| |removal of the tracheostomy. | |

| |For patient dependent on mechanical ventilator who is breathing inadequately | |

| |Remove the ventilator circuit. | |

| |Place a BVM on the 15/22 mm of the tracheostomy tube and attempt one or two ventilations. (If ventilations go in | |

| |easy, problem is likely ventilator failure or problem with ventilatory circuit.) | |

| |If you do not see immediate rise and fall of the chest and/or the BVM is hard to squeeze, and/or you don’t hear | |

| |alveolar breath sounds, the problem may lie with the patient. (Reassess the airway, clear as appropriate, and |Discussion Question |

| |reattempt ventilation.) |What are the special considerations for assessing and managing|

| |If problem persists, assess for clinical findings and provide management as appropriate for the offending problem. |patients receiving mechanical ventilation at home? |

| |Patient should be considered “unstable” and rapidly transported should there be some acute lost function to the | |

| |airway, breathing, or circulatory components. | |

| |Patient should be considered “potentially unstable” if there was a mechanical malfunction or clinical change that | |

| |precipitated a critical intervention by the EMT but now the current status seems stable. | |

| |Patient should be considered “stable” if there was no acute loss of function, no critical interventions were | |

| |warranted, and the patient is receiving primarily supportive care en route to the hospital. | |

| |Special considerations when transporting | |

| |If ventilator is still operating normally, use the BVM to ventilate the patient carefully while you move him to the| |

| |ambulance. |Knowledge Application |

| |Plug the patient’s ventilator into the onboard inverter and place it back on the patient. |Students should be able to apply the information in this |

| |If ventilator is not working, you may wish to take it with you to the hospital and explain any problems to the |section to the assessment and management of patients using |

| |receiving facility. |home care devices to support their airway and breathing. |

| |Be sure to document in medically correct and legally sufficient terms exactly what was done in managing the | |

| |patient’s airway and ventilation to save you from a claim or lawsuit being filed. | |

| |Vascular Access Devices—Central Intravenous Catheters |Teaching Tip |

|5 |A vascular access device (VAD) is a medical device that is used when a patient is in need of ongoing intravenous |If available, have several examples of VADs for students to |

| |medications (usually longer than seven to ten days). |examine. |

| |A central intravenous catheter is a catheter that is placed while the patient is in the hospital and is designed to| |

| |deliver medication into the central circulation of the body (long, thin, hollow tube that is inserted into the vein| |

| |of the arm). |Critical Thinking Discussion |

| |A peripherally inserted central catheter (PICC) is often inserted into the patient’s arm at the antecubital fossa |What is total parenteral nutrition (TPN)? Why might it be |

| |and from there is threaded into the body until the tip lies in the central circulation. |necessary? |

| |Vascular Access Devices—Central Venous Lines | |

|2 |Proximal port secured to the anterior chest, just below the clavicle | |

| |Portion of the device remaining outside the body typically has a medical port similar to a traditional intravenous | |

| |port. | |

| |Commonly sutured to the skin | |

| |Vascular Access Devices—Implanted Ports | |

|3 |Totally implantable venous access system (TIVAS) is a surgically implanted medication delivery device. | |

| |Disc-shaped devices that can be easily palpated beneath the surface of the skin after they are placed | |

| |Typically embedded into the upper chest on the right side | |

| |Vascular Access Devices—Accommodations for Patients with Vascular Access Devices |Discussion Questions |

|5 |Catheter may become obstructed by clot formation at the tip; thrombus may break off and lodge elsewhere in the |What are the complications associated with VADs? |

| |body. |What steps should you take if a VAD becomes dislodged? |

| |Person with a VAD may be placed on systemic anticoagulant therapy and be more susceptible to bleeding disorders. | |

| |VADs can allow air to directly enter the core circulation. Suspect accidental air embolism if patient with VAD | |

| |complains of symptoms (severe headache, altered mental status, sudden sharp chest pain). |Knowledge Application |

| |Keep the insertion site of the VAD dry and covered with a sterile dressing. |Students should be able to apply the information in this |

| |Note any redness, tenderness, warm skin, or purulent discharge that may indicate infection. |section to the management of patients with vascular access |

| |Note any bleeding from the insertion site as tension or tugging may cause the VAD to dislodge. (Cover with bulky |devices. |

| |sterile dressing and maintain pressure on the site.) | |

| |Renal Failure and Dialysis—Accommodations for Patients on Dialysis | |

|15 |Acute renal failure occurs when there is a rapid loss of renal function that results in poor urine production, | |

| |electrolyte disturbance, and fluid balance disturbance (caused by cessation of renal blood flow or toxic overload | |

| |in the bloodstream). | |

| |Chronic renal failure (CRF) or chronic kidney disease (CKD) occurs when there is a progressive loss of kidney | |

| |function over a period of months to years (caused by diabetes mellitus, longstanding hypertension, and inflammation|Critical Thinking Discussion |

| |or infection to the glomerulus). |How do diabetes and hypertension lead to chronic renal |

| |Dialysis is a medical procedure designed to support the lost function of the kidneys by removing toxins (although |failure? |

| |total replacement of all renal functions is not possible). | |

| |Hemodialysis is the type of dialysis in which blood is extracted from the body through a membrane that also uses a | |

| |dialysate fluid to help cleanse the blood. |Teaching Tip |

| |A dialysis shunt is a generic term for one of three different ways (AV shunt, AV fistula, AV graft) to join the |A tour of a dialysis center will help students understand the |

| |arterial and venous systems together in such a way that the repeated needlesticks required to take and return blood|dialysis process. |

| |to the body several times a week cause a minimal amount of damage to the body. | |

| |Peritoneal dialysis is a type of dialysis that is done in the home or the extended-care facility. | |

| |For patient receiving dialysis at a facility | |

| |Do not attempt to remove the patient prematurely (should be done under supervision of the dialysis center staff). | |

| |Never attempt to obtain a blood pressure in any extremity that has an AV shunt, AV fistula, or AV graft. |Discussion Questions |

| |Apply direct pressure to the AV shunt site if it is damaged and bleeding (either internally or externally), treat |What are the different types of shunts used for hemodialysis? |

| |for shock, and expedite transport. |What is the difference between hemodialysis and peritoneal |

| |Emergencies with peritoneal dialysis are usually not as severe and typically revolve around a displaced catheter, |dialysis? |

| |inflammation at the catheter insertion site, or infection of the peritoneal space. | |

| |Keep the catheter insertion site clean and dry. | |

| |Support any lost function. | |

| |Transport the patient to the hospital for evaluation. | |

| | |Knowledge Application |

| | |Students should be able to use information from this section |

| | |to care for patients who receive dialysis. |

| |Gastrointestinal and Genitourinary—Feeding Tubes |Teaching Tip |

|5 |Medical devices that provide nutrition to patients who cannot chew or swallow because of medical or traumatic |Show examples of several types of feeding tubes and urinary |

| |conditions resulting in paralysis or unconsciousness (enteral feeding) |catheters. |

| |Flexible tube inserted through the nose and ends in the stomach is called a nasogastric tube, or NG-tube. | |

| |Can help in decompressing the stomach | |

| |Can help in suctioning out ingested toxins |Weblink |

| |Used for short-term nutritional support |Go to and click on the mykit link for |

| |Flexible tube inserted through the mouth and ends up in the stomach is called an orogastric tube, or OG-tube (same |Prehospital Emergency Care, 9th edition to access a web |

| |functions as NG-tube). |resource on feeding tubes. |

| |Gastrostomy is performed for patients in need of long-term nutritional support. | |

| |Gastric tube (G-tube) is placed through the abdominal wall with the tip residing in the stomach. | |

| |Jejunal tube (J-tube) is inserted through the gastric wall with the tip placed in the jejunum. | |

| |Gastrointestinal and Genitourinary—Ostomy Bags |Critical Thinking Discussion |

|5 |Help remove feces from the body by directing feces through the abdominal wall and into a pouch or bag that is |Why might a patient with Crohn’s disease require an ostomy |

| |attached outside the body |bag? |

| |May be done temporarily or on long-term basis | |

| |Surgical opening is made through the abdominal wall and section of bowel is diverted through the opening. | |

| |Gastrointestinal and Genitourinary—Urinary Tract Devices | |

|5 |Urinary catheter is a device that is used to divert urine out of the bladder when there is some type of urinary | |

| |tract dysfunction. | |

| |Least invasive urinary catheter is called a Texas catheter because it attaches to the external male urethra in the | |

| |same manner as a condom would. | |

| |Internal catheters are threaded into the urethra (Foley catheter). | |

| |Commonly seen in home health care settings, hospitals, and extended-care facilities | |

| |Used for long periods of time | |

| |Suprapubic catheter is surgically inserted through the abdominal wall just superior to the symphysis and into the | |

| |urinary bladder (used when Foley catheter cannot be used). | |

| |Urostomy is performed when the urinary bladder is unable to collect urine. The urinary tract is surgically diverted| |

| |through a stoma created in the abdominal wall where a collection bag is attached. | |

| |Accommodations for Patients with Gastrointestinal or Genitourinary Devices |Discussion Questions |

|5 |Common problems |What are some complications associated with feeding tubes? |

| |Insertion site infection (UTIs) |What are some complications of ostomy bags and ostomy sites? |

| |Device malfunctions from misplacement |What precautions should you observe when transporting a |

| |Obstruction (food/medicine) |patient with a urinary catheter? |

| |Dislodgement | |

| |If problems are identified, patient will need transport to the hospital along with his medical device for |Knowledge Application |

| |evaluation and repair. |Students should be able to integrate this information into the|

| |If summoned for some other traumatic or medical emergency, perform your assessment and treatment in the same manner|assessment and care of patients with GI/GU devices. |

| |as for any other patient with a similar problem. | |

| |If patient has urinary catheter, drain the collection bag prior to transport, taking note of the volume of urine | |

| |removed and any irregularities. (Document information and share with receiving facility.) | |

| |Always position the collection bag below the urethra so that gravity causes urine to flow into the collection bag. | |

| |Intraventricular Shunts—Accommodations for Patients with Intraventricular Shunts |Discussion Question |

|15 |Hydrocephalus occurs when excess cerebrospinal fluid (CSF) accumulates (more common in pediatrics). |What is hydrocephalus? |

| |Excess CSF builds pressure within the skull (intracranial pressure or ICP) and can result in compression of brain | |

| |tissue. | |

| |Shunt is a long, hollow, and tubelike device that drains excess CSF and keeps the ICP at an acceptable level. | |

| |Intraventricular shunts may get infected. | |

| |Shunt extends to a distal site (neck, heart, abdomen, or external collection reservoir). | |

| |May result in systemic blood infection (sepsis) | |

| |May cause meningitis | |

| |Intraventricular shunts may become occluded. | |

| |Caused by body trying to block off shunt or one of two ends becoming dislodged | |

| |ICP may rise to dangerous levels as CSF accumulates in the brain. | |

| |Speed with which the patient’s symptoms develop as it relates to the ventricular shunt depends on the type of |Critical Thinking Discussion |

| |problem. |What are the indications of increasing intracranial pressure? |

| |Treatment is geared to supporting depressed or lost functions. | |

| |Manage the airway. (Be alert for occlusion by the tongue if mental status is diminished). | |

| |If breathing is inadequate, provide positive pressure ventilation with oxygen. |Knowledge Application |

| |Keep the patient in a lateral recumbent position to maintain the airway. |Students should be able to apply the information from this |

| |Rapidly transport the patient, and contact ALS if the patient is high priority. |section to the assessment and management of patients with |

| | |intraventricular shunts. |

| | Terminally Ill Patients—Accommodations for Terminally Ill Patients | |

|15 |Terminally ill patients have a disease process that is realistically expected to result in the death of the patient| |

| |(usually within six months). | |

| |Palliative care is used to describe medical interventions centered on reducing the severity of disease symptoms | |

| |(not on reversing progression of disease). | |

| |Hospice is a philosophy of care that is aimed at providing palliation of symptoms for the patients and support for | |

| |their families. | |

| |Common conditions | |

| |Cancer | |

| |AIDS | |

| |Alzheimer’s disease | |

| |Cystic fibrosis | |

| |CHF | |

| |COPD | |

| |Family may contact EMS when patient nears death instead of hospice provider. | |

| |Provide emotional support to both the patient and the family and determine clearly their intentions. | |

| |Communicate with the patient’s hospice program provider if the hospice does not already have a care provider at the| |

| |patient’s side to help determine the best course of action. | |

| |If you do transport patient to the hospital, make all efforts to minimize additional discomfort or pain and provide|Discussion Question |

| |emotional support or reassurance. |What are your obligations in caring for the terminally ill |

| |Not all patients who have a terminal illness receive hospice care; communicate clearly with the patient, family, or|patient? |

| |primary care provider about any advance directives that may be in place. | |

| | |Knowledge Application |

| | |Students should be able to apply this information to the care |

| | |of terminally ill patients. |

| |Follow-Up |Case Study Follow-Up Discussion |

|10 |Answer student questions. |Do you feel the patient’s presentation is more consistent with|

| |Case Study Follow-Up |infection or with obstruction of the shunt? What is your |

| |Review the case study from the beginning of the chapter. |rationale? |

| |Remind students of some of the answers that were given to the discussion questions. | |

| |Ask students if they would respond the same way after discussing the chapter material. Follow up with questions to |Class Activity |

| |determine why students would or would not change their answers. |Alternatively, assign each question to a group of students and|

| |Follow-Up Assignments |give them several minutes to generate answers to present to |

| |Review Chapter 40 Summary. |the rest of the class for discussion. |

| |Complete Chapter 40 In Review questions. | |

| |Complete Chapter 40 Critical Thinking. |Teaching Tips |

| |Assessments |Answers to In Review and Critical Thinking questions are in |

| |Handouts |the appendix to the Instructor’s Wraparound Edition. Advise |

| |Chapter 40 quiz |students to review the questions again as they study the |

| | |chapter. |

| | |The Instructor’s Resource Package contains handouts that |

| | |assess student learning and reinforce important information in|

| | |each chapter. This can be found under mykit at |

| | |. |

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MASTER TEACHING NOTES

• Case Study Discussion

• Teaching Tips

• Discussion Questions

• Class Activities

• Media Links

• Knowledge Application

• Critical Thinking Discussion

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