Emergency Care Textbook Professional Responders-part-17.pdf

17 Special Populations Key Content Pediatric Patients.................... 316 Stages of Development....... 316 Anatomical and Physiological Differences........................ 317 Assessing the Pediatric Patient............................... 318 Pediatric Illnesses................. 318 Other Pediat...

17 Special Populations Key Content Pediatric Patients.................... 316 Stages of Development....... 316 Anatomical and Physiological Differences........................ 317 Assessing the Pediatric Patient............................... 318 Pediatric Illnesses................. 318 Other Pediatric Conditions......................... 321 Geriatric Patients..................... 323 Dementia and Alzheimer’s. Disease............................... 323 Osteoporosis......................... 324 Bariatric Patients..................... 324 Palliative Patients.................... 324 Patients with Disabilities........ 325 Introduction Patients in special populations may require special consideration around assessment, communication, treatment, and/or transportation, or they may require no changes to any of these. Depending on the situation, patients in special populations may be at higher risk of abuse and neglect. If you suspect that abuse or neglect have occurred, provide care as usual and report your concerns to the proper authorities. SPECIAL POPULATIONS As a responder, you are likely to encounter individuals who fit the description of special populations. What makes these people special are their needs and considerations. This chapter focuses on children, geriatric patients (older adults), bariatric (obese) patients, terminally ill patients, and patients with mental or physical impairments. Understanding the special needs of a patient can make communication and interaction easier, allowing you to provide more effective care. 315 Some patients are at risk because of their unique situations, and these risks are often obvious. Homeless patients, for example, are at a higher risk of environmental illnesses because of their greater exposure to the environment. When providing care for a patient, always try to consider any unique factors that could be relevant. Every patient is different. PEDIATRIC PATIENTS Pediatric patients have unique needs and often require modified assessment and care. Children often do not readily accept strangers, making it more challenging to accurately assess them. Young children can be especially difficult to assess since they are often unable to communicate what is wrong. It is often difficult for adults to imagine how a young child with a serious illness or injury feels. Children often experience uncertainty and fear very strongly. Fear of the unknown, of being ill or hurt, of being touched by strangers, or of being separated from parents or guardians can compound an already complex situation. Being aware of the child’s fears and knowing how to manage them will help you to provide more effective care. If you have any reason to suspect abuse or neglect (e.g., if you see physical evidence or a patient makes a disclosure), you have a moral and legal obligation to report your suspicions. SPECIAL POPULATIONS Stages of Development 316 A pediatric patient is one in the age range of birth to 18 years old. Pediatric patients can be broken into five stages of development, each with distinctive physical and cognitive milestones. Some of these stages are defined more by developmental characteristics than by strict age ranges, so the ages presented here should be considered a rough guideline. A 2-year-old patient would be considered a toddler based on his or her age but may be more like a preschooler in terms of his or her developmental characteristics. NEONATES (0 TO 28 DAYS) Neonates, also called newborns, are patients between birth and 28 days old. They are extremely vulnerable to injury and infection and must be handled with great care at all times. INFANTS (29 DAYS TO 1 YEAR OF AGE) Children up to 1 year of age are commonly referred to as infants. Infants younger than 6 months old are relatively easy to examine. Generally, your presence will not bother this age group. Older infants, however, will often exhibit stranger anxiety. They are uncomfortable around strangers and may cry and cling to a parent or guardian. TODDLERS (1 TO 2 YEARS OF AGE) Children 1 or 2 years of age are sometimes called toddlers. These children are frequently uncooperative. As a result, they are often best examined in a parent or guardian’s lap. A toddler may be concerned that he or she will be separated from a parent or guardian. Reassurance that this will not happen may comfort a concerned child of this age. PRESCHOOLERS (3 TO 5 YEARS OF AGE) Children aged 3 to 5 are generally referred to as preschoolers. Children in this age group are usually easy to examine if approached properly. Pay attention to their natural curiosity. Allow them to inspect equipment or supplies, such as oxygen tubing or bandages. This can put to rest many fears and distract them during your assessment. SCHOOL-AGED CHILDREN (6 TO 12 YEARS OF AGE) School-aged children are those between 6 and 12 years of age. They are usually co-operative and can usually communicate effectively about the injury or condition you are examining. You should be readily able to converse with them, but avoid technical medical terminology. Children in this age group are becoming conscious of their bodies and often do not like exposure. Respect the child’s modesty as much as possible. ADOLESCENTS (13 TO 18 YEARS OF AGE) Adolescents are between 13 and 18 years of age. They are typically more like adults than children in most respects. Direct your questions to the adolescent patient, allowing input from a parent or guardian as required. Occasionally, an adolescent may be hesitant to provide a complete and accurate history in the presence of a parent or guardian, especially if it includes elements that the parent or guardian may disapprove of (e.g., alcohol use or sexual activity). If you notice hesitation or conflicting information, tactfully try to create a safe and private environment for the adolescent patient. Adolescents are generally going through puberty: Changes to body image may increase anxiety and stress, especially if the patient’s body must be exposed for assessment or interventions. Adolescents often respond better to a responder of the same gender. Respect the adolescent’s modesty as much as possible. Anatomical and Physiological Differences When assessing a child or an infant, note that they have many anatomical and physiological differences when compared with adults. These differences are summarized in Table 17–1. This is an overview, generalized across the age range of pediatric patients: Use judgment and consider the developmental stage of the individual patient when applying these principles. For the most part, differences between adults and children are less extreme as children get older: A 17-year-old is technically a pediatric patient, for example, but his or her anatomy and physiology will have much more in common with a 19-year-old’s than with a 2-year-old’s. For adults, a normal resting heart rate ranges from 60 to 100 beats per minute. Infants and toddlers, on the other hand, have normal resting heart rates TABLE 17–1: ANATOMICAL AND PHYSIOLOGICAL DIFFERENCES IN PEDIATRIC PATIENTS Respiratory DIFFERENCE CLINICAL SIGNIFICANCE Tongue is larger Can block airway more readily Airway is narrower Can become obstructed more readily Nose and face are flatter Obtaining a good mask seal can be difficult Trachea is smaller with less cartilage development Neck is more easily hyperextended, can close off airway Respiratory rate is higher Muscles become more easily fatigued Respiration primarily occurs nasally (in neonates) Airway management is more difficult Abdominal muscles are used for respiration Evaluating respiration is more difficult Ribs are more flexible Lungs and other organs in the chest are less protected; significant internal injuries may occur without external signs Circulatory A faster heart rate can be sustained for a longer period Can compensate longer before signs of shock are evident; decompensating phase occurs more quickly and suddenly Nervous Brain tissue is thinner and softer Head injury is often more serious Thermoregulatory Larger relative surface area More vulnerable to effects of cold stress Integumentary Skin is thinner Burns are often more severe Musculoskeletal Head is proportionally larger Neck flexion or anterior head displacement occurs when supine Neck is shorter SMR can be more difficult Bones are softer Bones fracture more readily SPECIAL POPULATIONS BODY SYSTEM 317 from approximately 100 to 160 beats per minute. As the child ages, his or her resting heart rate will become slower. An adolescent’s resting heart rate will be approximately the same as an adult’s. Pediatric patients also have higher respiratory rates. Average resting respiration rates for preadolescent children are 20 to 40 breaths per minute; adolescent patients’ respiratory rates are similar to those of adults. Assessing the Pediatric Patient SPECIAL POPULATIONS When assessing a child, follow the same general steps as those for assessing an adult. Where possible, take time to explain to the child and the parent or guardian what you plan to do. Knowing what is happening can help alleviate anxiety and fear for both the child and the adult involved. 318 During the secondary assessment, interview the child and any bystanders (e.g., the child’s parent or guardian). The manner in which you interact with the child and the parent or guardian is very important. Establishing a good rapport will help to reduce anxiety and panic in both the child and the parent or guardian. There are a few basic guidelines that will help you assess an injured or ill child: Observe the child before touching him or her. Look for signs that indicate changes in the child’s level of responsiveness, any breathing difficulty, or apparent injuries or conditions. Getting a good and thorough first impression is important, as signs and symptoms may become masked as soon as the child becomes anxious or upset. When speaking to the child, lower yourself to eye level. Communicate clearly with the parent or guardian and the child. Explain what you wish to do. Talk slowly and use simple words when speaking with the child. Ask questions that can be easily answered. Remain calm. Caring for seriously ill or injured children can be very stressful. Your own calmness will show confidence and help keep the child and parent/guardian calm. Keep the child with loved ones unless it is necessary to separate them. This is especially true for younger children (under age 7 or 8). Often, a parent or guardian will be holding Figure 17–1: Sometimes, the head-to-toe examination is best performed in reverse order, as a toe-to-head examination, on a responsive child. a crying child. In this case, you can assess the child’s condition while the parent or guardian continues to hold the child. Gain trust through your actions. If the family is excited or agitated, the child is likely to be excited or agitated, too. If you are able to calm the family, the child will often calm down as well. While performing the secondary assessment, it may be easier to do the head-to-toe examination before you check vital signs. Sometimes, the head-to-toe examination is best performed in reverse order, as a toe-to-head examination, on a responsive child (Figure 17–1). The child is more likely to accept you first touching the feet and progressing to the head. The assessment should be otherwise the same. Sometimes, it can be more difficult to assess a child than an adult. When doing so, you can ask yourself, the child, and the parents or guardians the questions in Table 17–2. Pediatric Illnesses While many illnesses and injuries affect children and adults alike, others are more prevalent among (or exclusive to) children. Some conditions occur in adults as well, but are much more serious or have TABLE 17–2: QUESTIONS TO ASK WHEN ASSESSING A CHILD Behaviour Face Skin QUESTIONS QUESTIONS Cough Does the cough: Occur frequently, and is it dry? Bring up sputum? Sound unusual? Appetite Does the child have: Little or no appetite? An unusual level of thirst? Vomiting Does the child: Appear pale or flushed? Show signs of pain or anxiety? Have bluish lips? Have any swelling? Is the child: Unable to keep food or water down? Nauseated? Frequently vomiting? Projectile vomiting? Temperature Does the child have: Hot and dry skin or cold and moist skin? A rash or spots? An unusual skin colour? Itchy skin? Any bruising or swelling? Does the child: Complain about feeling very cold? Complain about feeling very hot? Shiver uncontrollably? Bowel movements Are the child’s bowel movements: Abnormally frequent and liquid? Abnormally infrequent, dry, and hard? Abnormal in content, such as undigested food, mucus, or blood? An unusual colour or odour? Is the child: Confused? Unusually sleepy? Unusually irritable or fussy? More active or more subdued than normal? Not interested in other children or play? Crying nonstop, even when cuddled? Eyes Does the child: Rub and scratch his or her eyes? Have red and inflamed eyes? Have discharge in his or her eyes? Have dull or unusually bright eyes? Have swollen or puffy eyes? Have yellow eyes? Complain of seeing spots? Ears Does the child have: Trouble hearing? Swelling in or around the ears? Ringing in the ears? An earache? Any discharge? Loss of balance? A tendency to pull, cup, or poke his or her ears? Tongue Does the child have a: Dry and cracked tongue? Red and raw tongue? White or yellow coating on his or her tongue? Respiration Does the child have: Rapid, shallow respiration? Painful respiration? A strange odour on his or her breath? Throat AREA TO WATCH Does the child have: A sore throat? Difficulty swallowing? Unusual drooling? A red and inflamed throat? A voice that sounds different? unique risks in children. Some conditions cause irritation and discomfort, while others can cause lifelong complications or death. Some childhood illnesses and conditions are contagious. Vaccination is a fundamental prevention strategy. Vaccines have been incredibly effective in preventing childhood diseases and improving child mortality rates. Common childhood vaccines include diphtheria, tetanus, pertussis, measles, mumps, and rubella. Infants who are 6 months or older are the most vulnerable to these diseases. CHICKENPOX Chickenpox (varicella) is a viral infection that is most contagious 1 to 2 days before the onset of the rash, and for approximately 5 days after onset, or until the chickenpox lesions have become crusted. The contagious period may be prolonged in an immune compromised person. Signs and symptoms of chickenpox include fever and an itchy rash. The rash initially presents as smooth red SPECIAL POPULATIONS AREA TO WATCH 319 spots, which develop into blisters 3 or 4 days after appearing. MEASLES Measles is a highly contagious viral infection that is transmitted both through direct contact and airborne transmission. The virus infects the mucous membranes before spreading throughout the body. Measles can be prevented by immunization. The signs and symptoms of measles usually occur as follows: 10 to 12 days after exposure: ◆ High fever (usually lasts 4 to 7 days) ◆ Runny nose ◆ Cough ◆ Red, watery eyes ◆ Small white spots inside the cheeks 14 days after exposure: ◆ Rash (usually appears on the face and upper neck) About 3 days after rash appears: ◆ Rash usually spreads to the hands and feet The measles rash usually lasts for 5 to 6 days and then fades. Patients are considered contagious from 4 days before until 4 days after the rash first appears. Most measles-related deaths are caused by complications associated with the disease. Complications are more common in children under the age of 5 or adults over the age of 20. The most serious complications associated with measles include: Blindness. Ear infections. Encephalitis (an infection that causes brain swelling). Severe diarrhea and dehydration. Severe respiratory infections, (e.g., pneumonia). SPECIAL POPULATIONS MUMPS 320 Mumps is a contagious disease caused by a viral infection. The virus is transmitted through direct contact and airborne transmission from infected people. Initial symptoms usually appear 2 to 3 weeks after infection. Typically, mumps starts with a few days of fever, headache, muscle aches, tiredness, and loss of appetite, followed by swollen salivary glands. There is no specific treatment for mumps. The virus usually causes mild disease in children, but in adults can lead to further complications such as meningitis. Mumps can be prevented by immunization. ECZEMA Eczema is not contagious. A child with eczema may have the following signs and symptoms: Pimples Scaly skin Scabs Inflamed skin and one or a combination of rashes Dry skin or a watery discharge from the skin Burning or itching skin IMPETIGO A child infected with impetigo will have inflamed skin and crusted, broken clusters of pimples around the mouth and nose that may be flat and pitted (filled with straw-coloured fluid). Impetigo is contagious and can spread to anyone who comes into contact with the infected skin or other items that have been touched by the infected skin (e.g., clothing, towels, and bed linens). RINGWORM Ringworm is a contagious fungal infection that is characterized by red, scaling rings on the skin. A child with ringworm is contagious until 48 hours after treatment begins. SCABIES Scabies is a highly contagious skin parasite. Scabies is caused by an infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). The adult female scabies mites burrow into the epidermis, where they live and deposit their eggs. A child with scabies will have many tiny blisters, scratch marks, and scaly crusts (found mainly in skin folds), as well as extreme itchiness. The microscopic scabies mite is almost always passed by direct, prolonged, skin-to-skin contact with an infected person. An infected person can spread scabies even if he or she has no symptoms. Humans are the source of infestation; animals do not spread human scabies. A heat rash may present as a rash of tiny, pinpoint blisters surrounded by blotches of pink skin. It may appear on the face or on the parts of the body that are usually heavily clothed. Heat rashes occur in hot weather, or whenever an infant or child is overdressed. CONJUNCTIVITIS (PINK EYE) Bacterial and viral conjunctivitis are highly contagious and are transmitted through direct contact. Pink eye is contagious until 24 hours after treatment is started. Signs and symptoms of pink eye include: Pink colour around the white of the eye. Swollen eyelids. Pus in or around the eyes Itchy or sensitive eyes. PINWORMS Pinworm is an intestinal infection caused by tiny parasitic worms. Pinworms are contagious. Tiny eggs deposited around the anus by a female worm spread the infection. When a child has pinworms, he or she will be constantly scratching around the anus and will be unusually irritable. CROUP AND EPIGLOTTITIS Infections of the respiratory system are more common in children than in adults. These can range from minor infections, such as the common cold, to life-threatening infections that block the airway. Signs and symptoms of a breathing emergency in children include: Unusually fast or slow breathing. Noisy breathing. Pale, grey, cyanotic skin. Intercostal in-drawing (a retraction of the spaces between the ribs during breathing). Decreasing level of responsiveness. Croup and epiglottitis are infections of the respiratory system that may be superficially similar, but because epiglottitis is generally much more serious, it is important that you be able to distinguish between the two conditions. Croup is usually triggered by an acute viral infection of the upper airways. It is generally not life threatening. The infection causes swelling of the throat and tissues below the vocal cords. Croup is generally not life threatening in itself, but it can lead to severe shortness of breath and hypoxia. Croup is commonly identified by its distinctive harsh, barking cough, often described as being like the bark of a seal. Croup is often preceded by 1 or 2 days of illness, sometimes with a fever. Croup occurs more often in the winter months, and the signs and symptoms of croup are often more evident in the evening. The child may show improvement when exposed to cool air (e.g., outdoor air or cool steam from a vaporizer). To care for a child experiencing croup, allow him or her to remain in the position that makes respiration easiest. A child with croup should be examined by a physician. Epiglottitis is a potentially life-threatening bacterial infection that causes severe inflammation of the epiglottis, which is the flap of tissue above the vocal cords that protects the airway during swallowing. When the epiglottis becomes infected, it can swell to the point of completely obstructing the airway. A child with epiglottitis may: Appear severely ill (with high fever). Need to be sitting up. Strain to breathe. Appear very frightened. Drool (swelling of the epiglottis prevents the child from swallowing). Although superficially similar to croup in some respects, epiglottitis is a much more serious condition than croup because it can quickly cause a life-threatening airway obstruction. A child with epiglottitis should be placed in the rapid transport category. For either condition, do not attempt to place any objects in the child’s mouth or examine the mouth. Supplemental oxygen may be indicated. Other Pediatric Conditions DEHYDRATION Dehydration in children is most commonly caused by prolonged vomiting and diarrhea, which may itself be caused by a contagious illness, but dehydration is a sign of an underlying condition, not an illness in itself. SPECIAL POPULATIONS PRICKLY HEAT RASH 321 You may suspect dehydration if a child: Has a dry mouth and tongue. Has sunken eyes. Does not have tears when crying. Is listless or irritable. In infants, the fontanel (soft spot) on the top of the head may be sunken. An infant will also produce fewer wet diapers than usual. A dehydrated child who is also experiencing persistent vomiting or diarrhea will be difficult to rehydrate, as fluids will not be adequately absorbed by the body. This is a life-threatening emergency: Any dehydrated pediatric patient with diarrhea or persistent vomiting should be in the rapid transport category. PERSISTENT VOMITING A child who experiences persistent vomiting will have nausea and stomach pain, and may become dehydrated. The underlying condition that causes persistent vomiting may be contagious. DIARRHEA Diarrhea itself is not contagious, though the underlying condition causing it may be. A pediatric patient with diarrhea is at an increased risk of dehydration, which can become a medical emergency that requires rapid transport. EARACHES SPECIAL POPULATIONS Earaches are not contagious but can be very painful. A child with an earache may exhibit the following signs and symptoms: A worried appearance Pulling at the ear or covering it with a hand Sore ears or fluid discharging from the ear Fever Chills Dizziness and/or nausea Deafness 322 HIGH FEVER A high fever is defined as a core body temperature above 39°C (102°F). It most commonly indicates some type of infection. Because a young child’s temperature-regulating mechanisms have not fully developed, even a minor infection can result in a high fever. A case of prolonged or excessively high fever can result in febrile seizures (see page 252). SHAKEN BABY SYNDROME Shaken Baby Syndrome (SBS) refers to a variety of injuries that may result when an infant or a young child is violently shaken. Shaking causes the child’s brain to move within the skull, forcing blood vessels to stretch and tear. This brain injury may result in death, permanent brain damage, or long-term disability. SBS can also cause fractures, contusions, and internal bleeding. Permanent damage can occur after a single event, and physical signs of injury may not be present. Often, there is no intent to harm the child, but SBS is a common cause of infant mortality and longterm disability. Inconsolable crying is the most common trigger. Other common triggers are feeding problems and difficulties with toilet training. Indicators of SBS range from extensive retinal damage in one or both eyes (which may result in blindness) to minor neurological problems (e.g., irritability, lethargy, tremors, and vomiting) to major problems (e.g., seizures, coma, and death). Treat the infant for the injuries found and place him or her in the rapid transport category. Treat the situation as a case of suspected child abuse. SUDDEN INFANT DEATH SYNDROME (SIDS) Sudden infant death syndrome (SIDS) is defined as the sudden death of a seemingly healthy infant during sleep, without evidence of disease. You will not be able to diagnose SIDS, as its causes are not clear. SIDS is loosely connected to a prone sleeping position, asphyxiation from bedding, overheated sleeping environments, and air quality; however there are no scientific links to indicate these are direct causes. Treatment for SIDS is purely preventive. SIDS may sometimes be mistaken for child abuse; however, the two are unrelated. SIDS is not believed to have a hereditary link, but it can recur in families. Treatment for SIDS is the same as for any patient in cardiac arrest. SIDS can be an especially traumatic event for both the child’s caregivers and the responder, regardless of the outcome. Proper psychological support is critical for everyone involved. GERIATRIC PATIENTS Geriatric patients are generally considered those 65 years of age and over. Burns are a special concern to older adults because their skin is thinner and more fragile. Their immune systems are less effective, so infections become more frequent, and the risk of localized infection increases. Bowel obstructions are common due to the weaker muscles of the bowel. Older people are susceptible to problems involving the thermoregulatory system, so they are more at risk of heat and cold-related illness. Figure 17–2: The size of the brain decreases with age. establish a baseline for the particular patient, against which you can compare his or her signs and symptoms. A geriatric patient who suffers a head injury may not exhibit signs and symptoms immediately: You may suspect a head injury as the cause of altered behaviour even if several days have passed since the event. Dementia and Alzheimer’s Disease As a person ages, the size of the brain decreases, which results in increased space between the brain and the skull (Figure 17–2). This allows more movement of the brain within the skull, which can increase the likelihood of brain injury (e.g., concussion). Geriatric patients are at increased risk of confusion and a decline in cognitive ability. While some deterioration in mental function is normal as a patient ages, Alzheimer’s disease is not a normal part of aging. It is a progressive, degenerative disease that destroys brain cells and causes deterioration of memory and cognitive ability. Alzheimer’s is the most common form of dementia, accounting for 60 to 80% of dementia cases. Usually, symptoms develop slowly and worsen over time, ultimately becoming severe enough to interfere with daily tasks. Because geriatric patients may present with confusion or decreased mental acuity as a result of a chronic condition, it may be difficult to determine whether acute illness or trauma is the cause of unusual behaviour, or whether the behaviour is actually normal for the patient. Interviewing friends and family can help you Each patient is affected differently by Alzheimer’s disease. It is difficult to predict the order and progression of symptoms, or the speed of their onset. Alzheimer’s disease will eventually affect all aspects of a patient’s life and is ultimately fatal. There is currently no cure, though medication can help reduce signs and symptoms. Older adults are at increased risk of injury, with a common cause of injury being falls. Bones increasingly become weaker and more brittle, so falls are more likely to result in fractures. SPECIAL POPULATIONS Many changes occur as the body ages (Figure 17–2). Overall, there is a general decline in body function. One of the first body systems affected by age is the respiratory system. Respiratory capacity typically begins to decrease around age 30. By the time a person reaches age 65, the respiratory system may be only half as effective as it was during youth. The heart also suffers the effects of aging. The amount of blood pumped by the heart with each beat decreases, and the heart rate slows. Blood vessels harden, causing increased work for the heart. The number of functioning brain cells also decreases with age. Hearing and vision usually decline. Reflexes become slower, and arthritis may affect joints, causing movement to become painful. 323 If you are providing care for a patient with dementia, try to determine whether the confusion is the result of the acute injury or illness or of a pre-existing condition. Sometimes, confusion is actually the result of decreased vision or hearing. Speaking with the patient’s family or caregivers can help you compare his or her psychological state to daily norms and determine whether the injury or illness has resulted in a change. Be thorough in your assessment. Geriatric patients may describe one chief complaint, but other potentially serious conditions may be present as well. Avoid assumptions, and do not downplay signs or symptoms that seem insignificant, as they may indicate a serious underlying condition. Some geriatric patients may intentionally minimize their symptoms for fear of losing their independence (e.g., being placed in a nursing home). Osteoporosis Osteoporosis is a degenerative bone disorder, characterized by low bone mass and deterioration of bone tissue. Osteoporosis can begin at any age but is most common in older adults. Osteoporosis affects women more commonly than men. Normally, bone-building cells constantly repair damage that occurs as a result of everyday stresses, keeping bones strong. When the calcium content of bones decreases, the bones become frail, less dense, and less able to repair themselves. SPECIAL POPULATIONS This loss of density and strength leaves bones more susceptible to fractures (especially of the hips, vertebrae, and wrists). Instead of being caused by significant force, fractures may now occur spontaneously, with minimal aggravation, trauma, or force (e.g., the patient may be taking a walk or washing dishes when the fracture occurs). Some hip fractures thought to be caused by falls are actually spontaneous fractures that cause the patient’s fall. 324 BARIATRIC PATIENTS Bariatrics is the science of providing healthcare for those who have obesity. The most accepted and consistent measurement for identifying and defining bariatric patients is the Body Mass Index (BMI). This is defined as the person’s weight in kilograms divided by the person’s height in metres squared. It is the ratio of weight per square metre, (e.g., 24 kg/m2), though the units are often omitted. The World Health Organization (WHO) defines an obese patient as one with a BMI greater than 30. It has been well established that obesity is a major risk factor for numerous diseases and is associated with multiple adverse health conditions. The most common health concerns seen in bariatric populations are diabetes mellitus, hypertension, and hyperlipidemia (too much fat in the blood). All of these are associated with an increased risk of vascular disease. Depending on which blood vessels are affected, there can be an increase in strokes, cardiac disease, congestive heart failure, and peripheral edema and ulceration. In addition, elevated intra-abdominal pressure, and restricted lung volumes may compromise respiration. Overall, obesity has the potential to negatively impact every organ system. Evaluation of bariatric patients presents many challenges. It can be more difficult to determine the cause of complaints. Excess body mass can also make it difficult to determine which organ system is affected. Chronic medical problems are frequently present and create the challenge of an unknown baseline of illness, which makes determining the current state of an acute illness problematic. These patients may have complex medical histories involving multiple conditions, surgeries, and medications. When assessing a bariatric patient, the information needed is the same as for any other patient: signs/symptoms, allergies, medications, past medical and surgical history, last oral intake, and events leading to present illness. Responders should be aware of equipment requirements, limitations, and challenges (e.g., a larger adult BP cuff or a specialized bariatric stretcher). PALLIATIVE PATIENTS Palliative patients are those with terminal illnesses. Treatment consists of improving quality of life and making patients as comfortable as possible. Many illnesses can be terminal, and a patient of any age can be affected. Often, palliative care situations are emotionally charged and require empathy and compassion toward the patient and his or her family and friends. Many palliative patients prefer to remain at home, regardless of the nature of the medical emergency you are responding to. You must recognize that palliative patients are in a different situation than most other patients. Some terminally ill patients will have advance directives specifying the level or type of interventions they consent to. A well-known example is a do not resuscitate order (or DNR). These may also be referred to as living wills. Be sure that you are aware of any special instructions for the patient, and be respectful of his or her wishes. In some cases, a responder may have to take control to calm the people at the scene. Care for a patient with a terminal illness will usually be based on support, calming, and comfort measures. Sometimes, the terminally ill patient and family will have received counselling to deal with death or dying. PATIENTS WITH DISABILITIES Special populations also include those with physical, intellectual, or developmental impairments. The loss or absence of a limb, either from birth or as a result of trauma, is considered a physical impairment. Likewise, the paralyzing effects of a stroke are a physical impairment. An intellectual or developmental impairment affects mental functioning and cognitive processes. Any impairment, physical or mental, may interfere with normal activity and participation in life. However, you should never make assumptions about what a person with a disability can or cannot do. Service Animals Patients with disabilities may be assisted by service animals, often (but not always) dogs. Service animals undergo extensive training and assist with a wide variety of tasks (depending on the animal and the patient). Remember that when a service animal is in its harness, it is working. Avoid interacting with the animal, including talking to it and petting it. During care, try to keep the service animal as close to the patient as possible. Keeping the animal close may provide comfort and reassurance to the patient. If possible, keep the service animal with the patient if he or she is transported to a medical facility. Assistive Devices Some people require special equipment to assist them with regular functions, such as seeing, hearing, communicating, or moving. Patients may be reliant on these devices, so be mindful not to limit their use during assessment or treatment unless it is absolutely necessary to do so. Ensure that the patient’s assistive devices stay with him or her during transport. Assistive devices you may encounter include white canes (used by patients with visual impairments for orientation and mobility), communication boards (used by patients with language difficulties to communicate), and hearing aids (which amplify sound for patients with hearing impairments). Examples of mobility aids include wheelchairs, walkers, canes, crutches, and prosthetic devices (Figure 17–3). Patients with physical disabilities may also live in homes that include ramps, automatic door openers, grab bars, and specially designed bedrooms and/or washrooms. Visual Impairment People who have a visual impairment are either unable to see effectively or unable to see at all (blindness). Some people are born blind. Others lose their sight due to injury or illness. Visual impairment can occur because of problems in the visual centres of the brain or in the optic nerves: The causes are not restricted to problems with the eyes themselves. SPECIAL POPULATIONS Terminal illnesses are those that will ultimately be fatal regardless of interventions or treatment. 325 Figure 17–3: A patient using a mobility device. Figure 17–4: You can help a patient with a visual impairment walk by having him or her hold onto your arm. People with visual impairments usually adapt well to their condition. It should be no more difficult to communicate with a patient who has a visual impairment than with a patient who has full sight. It is not necessary to speak loudly or in overly simple terms for a visually impaired patient to understand you. Your assessment of a visually impaired patient should be largely identical to your assessment of any other patient. though communication can present unique challenges. If you are called to assist someone who has a visual impairment, explain what is happening and what you are doing. This will help alleviate anxiety. If you must move a patient with a visual impairment who can walk, stand beside the patient and have him or her hold onto your arm (Figure 17–4). Walk at a normal pace and alert the patient to any potential hazards (e.g., stairs). The biggest obstacle you must overcome when caring for a patient with a hearing impairment is communication. Most people have adapted to their hearing loss by learning to speak, lip read, sign, or any combination of these. Many people with a hearing impairment are able to speak. If you do not understand what a patient is saying, ask him or her to repeat it. Do not pretend to understand if it is not clear. SPECIAL POPULATIONS Hearing Impairment 326 Hearing impairment can occur as a result of injury or illness affecting the ear, the nerves leading from the ear to the brain, or the brain itself. As with visual impairment, hearing impairment may also be genetic and present from birth. Some responders become anxious when called to treat a patient with a hearing impairment. Patients with a hearing impairment can be cared for in basically the same manner as other patients, At first, you may not be aware that a patient has a hearing impairment. Often, the patient will tell you. Others may point at their ear and shake their head “no.” A child may carry a card stating that he or she has a hearing impairment. You may also see a hearing aid in a patient’s ear. If the patient is able to read lips, communication will often be easier. Position yourself where the patient can see you, look at the patient when you speak, speak slowly, and enunciate your words carefully (Figure 17–5, a). If both you and the patient know sign language, communicate in this way if you are able to (Figure 17–5, b). If the patient knows sign language and has a friend or family member present, he or she may be able to translate for you. Address your questions to the patient. If the patient cannot speak, read lips, or communicate with you through sign language, you can write messages on paper or a digital device (e.g., a smartphone or tablet) and have the patient respond (Figure 17–5, c). Deafblind A person who is deafblind has both a visual and a hearing impairment. This often results in difficulties in communicating and managing daily activities. Many people who are deafblind will be accompanied by an intervenor who helps with communication. Speech or Language Impairments Some people have problems communicating because of a disability. Cerebral palsy, post-stroke impairments, hearing loss, and other conditions may make it difficult to pronounce words or may cause slurring or stuttering during speech. These conditions may also prevent the person from expressing him- or herself, or from understanding written or spoken language. Some people who have severe difficulties may use communication boards or other assistive devices. The following are some general guidelines for caring for a patient with a speech or language impairment: Do not assume that because a patient has one impairment, he or she also has another. For example, if a patient has difficulty speaking, it doesn’t mean he or she has an intellectual or developmental impairment as well. a b c Figure 17–5, a-c: There are many ways you can communicate with someone who has a hearing impairment: a, allow him or her to read your lips; b, use sign language; and c, write down what you want to say. SPECIAL POPULATIONS The following are some general guidelines for caring for a deafblind patient: Remember that people who are deafblind may have some sight or hearing capabilities, while others may have neither. A person who is deafblind is likely to explain to you how to communicate with him or her. He or she may give you an assistance card or a note explaining how to communicate. Identify yourself to the intervenor when you approach the person who is deafblind, but then speak directly to the person as you normally would, not to the intervenor. Avoid touching a patient who is deafblind suddenly or without permission. 327 Ask the patient to repeat information if you don’t understand. Ask questions that can be answered “yes” or “no” if possible. Try to allow enough time to communicate with the patient, as he or she may speak more slowly. Do not interrupt or finish the patient’s sentences. Wait for him or her to finish. Physical Impairment Physical impairments are generally the result of problems with either the muscles or bones or the nerves that control them. Causes include stroke, cerebral palsy, multiple sclerosis, muscular dystrophy, and brain and spinal cord injuries. Depending on the nature and severity of the problem, you may care for the patient in much the same way you would care for any other patient. In some cases, extra patience and compassion may be required. SPECIAL POPULATIONS A patient with a physical impairment may present with reduced range of motion. Try to determine the exact extent of the patient’s chronic impairment so you can determine which signs and symptoms are the result of the acute injury or illness you are assessing. If you are unable to determine whether a condition is new or preexisting (e.g., if the patient is unresponsive), care for the condition as if it is new. 328 Mental Impairment A person with a cognitive impairment may be referred to as having an intellectual or developmental disability. As with physical impairments, mental impairments can be diverse. Some types of cognitive impairment, such as Down’s syndrome, are genetic. Others result from injuries or illnesses that occur during pregnancy, after birth, or later in life. Some occur from undetermined causes. You may be able to determine quickly that a patient has a mental impairment. However, in some situations, it may not be evident. Always approach the patient as you would any other patient in his or her age group. When you speak, try to assess the patient’s level of understanding. If the patient is confused, rephrase your statement or question in simpler terms. Listen carefully to what the patient is saying. If a guardian or caregiver is present, he or she may be able to help with communication, and can also help you determine the normal mental state of the person (as a baseline for assessing the effects of the acute injury or illness you are evaluating). A sudden illness or injury can interrupt the normal routine of the patient’s life and cause a great deal of anxiety and fear. Anticipate this risk and offer as much reassurance and empathy as possible. Take time to explain to the patient who you are and what you are going to do. Try to gain the patient’s trust. SUMMARY Shaken Baby Syndrome Special population: infants or young children Treatment: treat according to injuries found Treat case as suspected child abuse? Yes Sudden Infant Death Syndrome (SIDS) Special population: infants Treatment: follow treatment for cardiac arrest Treat case as suspected child abuse? No Service Animals Avoid interacting with the animal. Keep animal close to the patient during treatment, if possible. Assistive Devices Keep device with patient during assessment and treatment unless it creates a barrier to action. Keep device with patient during transport. Visual Impairment Assess and treat the patient as you would treat a patient without a visual impairment. Explain what is happening and what you’re doing. To move the patient if necessary: Stand beside the patient and have him or her hold onto your arm; walk at a normal pace; alert the patient to any potential hazards en route. Hearing Impairment If the patient cannot speak, read lips, or communicate with you through sign language: Write messages on paper or a digital device. If the patient can speak: Ask the patient to repeat anything you don’t understand. If the patient can read lips: Position yourself so that he or she can clearly see your mouth, speak slowly, and enunciate. Deafblind Identify yourself to the intervenor if the patient has one. Refer to the patient’s assistance card if available. Avoid touching the patient suddenly or without permission. Speech or Language Impairment Ask the patient to repeat anything you don’t understand. Ask closed-ended questions. Don’t interrupt or finish the patient’s sentences. Physical Impairment Practise patience and compassion; act according to the patient’s range of motion. Mental Impairment Try to assess the patient’s level of understanding when you speak, and rephrase your statements if necessary. Speak to his or her guardian or caregiver if present. SPECIAL POPULATIONS PATIENTS WITH DISABILITIES 329 330