Chapter 46
Patients with
Special Challenges
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46-1
Objectives
46-2
Child Abuse and Neglect
46-3
Child Maltreatment
46-4
Physical Abuse
• Acts that caused or could have caused
physical injury to the child
– Hitting
– Kicking
– Shaking
– Burning
– Other acts of harm
46-5
Possible Abuse
• Consider the possibility of physical abuse
when the child:
– Has unexplained burns, bites, bruises, etc.
– Has fading bruises or other marks after an
absence from school
– Seems frightened of the caregiver
– Shrinks at the approach of adults
– Reports injury by an adult
46-6
Medical Conditions
• Impetigo
• Mongolian spots
46-7
Cultural Considerations
46-8
Possible Abuse
• Consider the possibility of physical abuse
when the parent or other adult caregiver
offers conflicting, unconvincing, or no
explanation for the child’s injury
46-9
Sexual Abuse
• Inappropriate adolescent or adult sexual
behavior with a child
• Includes fondling, rape, and exposing a child
to other sexual activities
46-10
Emotional Abuse
• Refers to behaviors that harm a child’s selfworth or emotional well-being
• Examples
– Name calling
– Shaming
– Rejection
– Withholding love
– Threatening
46-11
Neglect
• Failure to provide for a child's basic physical,
emotional, or educational needs or to protect
a child from harm or potential harm
• Types:
– Medical
– Physical
– Educational
– Emotional
46-12
Medical Neglect
• Failure of the caregiver to provide for the
appropriate healthcare of the child although
they are financially able to do so
46-13
Signs of Neglect
46-14
Care of Abuse
• Provide emergency care for the child as
needed
• Do not accuse in the field
• Reporting is required by state law
• Remain objective
• Report what you see and what you hear
– Do not comment on what you think
46-15
Care of Abuse
• Show a professional and caring attitude
• After the call, assess your own
emotional needs
46-16
Elder Abuse
• Elder abuse is any physical, sexual, or
emotional, abuse committed against an older
adult.
• Categories of elder abuse
– Domestic elder abuse
– Institutional elder abuse
– Self-neglect or self-abuse
46-17
Elder Abuse
• Physical abuse
– Inappropriate use of drugs and physical
restraints
– Force-feeding
– Physical punishment of any kind
46-18
Elder Abuse
• Sexual abuse
– Bruises around the breasts or genital area
– Unexplained vaginal or anal bleeding
– Torn, stained, or bloody underclothing
– Older adult’s report of being sexually
assaulted or raped
46-19
Elder Abuse
• Emotional abuse
– Insults
– Threats
– Intimidation
– Harassment
– Treating the older adult like an infant
– Isolating the older adult from his family,
friends, or regular activities
– Giving older adult the “silent treatment”
46-20
Elder Abuse
• Neglect : Failure to provide necessities
– Food
– Water
– Clothing
– Shelter
– Personal hygiene
– Medicine
– Comfort
– Personal safety
– Necessary home care services
46-21
Examples of Older Adult Neglect
•
•
•
•
Dehydration
Malnutrition
Untreated bedsores
Poor personal
hygiene
• Unattended or
untreated health
problems
• Hazardous or
unsafe living
conditions /
arrangements
• Unsanitary and
unclean living
conditions
• Older adult’s report
of being mistreated
46-22
Elder Abuse
• Provide emergency care for the patient as
needed
• Do not accuse in the field
• Reporting is usually required by state law
• Remain objective
• Report what you see and what you hear
– Do not comment on what you think
46-23
Homelessness
• Two main reasons for the
rise in homelessness over
the past 20-25 years
– A growing shortage of
affordable rental
housing
– An increase in poverty
• Homelessness and poverty
often go hand in hand
46-24
Factors that Contribute to Homelessness
•
•
•
•
•
•
•
•
Decreasing work opportunities
Stagnant or falling incomes
Less secure jobs that offer fewer benefits
Lack of affordable health care
Domestic violence
Mental illness
Racial discrimination
Addiction disorders, such as drugs and
alcohol
46-25
Common Illnesses among the Homeless
• Upper respiratory
tract infections
• Trauma
• Female
genitourinary
problems
• Hypertension
• Skin and ear
disorders
• Gastrointestinal
diseases
• Peripheral vascular
disease
• Musculoskeletal
problems
• Dental problems
• Vision problems
46-26
Homelessness
• Personal protective
equipment
• Treat the patient with
respect
• Talk with your patient
• Listen without making a
moral judgment
• Document objectively
46-27
Bariatric Patients
46-28
Bariatric Patients
• Bariatrics
– The branch of medicine that deals with the
causes, prevention, and treatment of
obesity and weight-related health
problems
• Increased risk for diabetes, hypertension,
heart disease, and stroke
46-29
Bariatric Patients
• Proper positioning and handling of the
bariatric patient is important.
• If conscious and hypotension is not present,
allow patient to assume a position of
comfort.
46-30
Bariatric Patients
• Know manufacturer’s weight limitations on
EMS equipment
– Backboards
– Stair chairs
– Stretchers
• Use bariatric unit, if available
• Request additional resources if necessary
• Unconventional methods of moving the
patient may be necessary
46-31
Patients with
Special Health Care Needs
46-32
Tracheostomy Tubes
• Possible complications
– Obstruction of the tube
– Dislodgment
– Bleeding
– Air leak
– Infection
46-33
Emergency Care of Tracheostomy Tubes
• Request ALS personnel
• If the tube is dislodged, ventilate as needed
with a bag-mask device
• If external bleeding is present, apply gentle
direct pressure to the bleeding site
• Allow the patient to maintain a position of
comfort
46-34
Home Mechanical Ventilators
• Mechanical ventilators are used to assist
breathing
• Ventilator malfunction
– Disconnect the patient from the ventilator
– Request ALS personnel
– Maintain an open airway
– Provide positive-pressure ventilation with
a bag-mask device
46-35
Apnea Monitors
• Strap worn around the chest
– Sensors in the strap are connected to a
monitor that has an alarm
• Monitor chest movement and hear rate
• Ensure an open airway
• If breathing is inadequate, provide positivepressure ventilation
• Reassess as often as indicated
46-36
Central Lines
• Central line
– IV line placed near the heart for long-term
use
• Peripherally inserted central catheter
– PICC line
– Smaller than those routinely used for
central lines
• Emergency care
46-37
Gastrostomy Tubes and Gastric Feeding
• Gastrostomy tube
– Special catheter placed directly into the
stomach for feeding
• “Feeding button”
• Emergency care
46-38
Shunts
• Hydrocephalus
• Ventricular shunt
• Blockage of the shunt produces signs and
symptoms of increased intracranial pressure
• Emergency care
46-39
Hospice Care
46-40
Palliative Care
• Palliative care
– Also called comfort care
– Care provided to relieve symptoms of
disease, rather than to cure the disease
– Usually provided for patients with a
terminal illness and their families
46-41
Hospice Care
• Hospice care
– A program of palliative and supportive
care services providing physical,
psychological, social, and spiritual care for
dying persons, their families, and other
loved ones
46-42
Hospice Care
• Many hospice patients have do not
resuscitate (DNR) orders
• Assess the patient
• Determine the existence of a valid DNR as a
part of your patient assessment
46-43
Questions?
46-44