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More people with chronic diseases are living at home due to improvements in medicine and technology. Patients have special challenges such as altered body function and sensory deficits. It is important to focus on treating the patient, not just the equipment. Developmental and intellectual disabilities can affect patients' daily living skills. Patients with intellectual disabilities may have difficulties adjusting to change or disruptions in routine. Patients with autism spectrum disorder have communication and sensory issues, and it is important to create a calm environment for them. Down syndrome is a genetic chromosomal defect that can result in varying levels of intellectual impairment. Advanced maternal age is a common factor in the occurrence of Down syndrome. Today, more people with chronic diseases live at home. They have shorter hospitalizations and improvements. We can do the improvements in medicine and technology. Today, people stay home where they used to be, institutionalized, out of much reduction in hospitals. Now they go home. They have home ventilators, home tuning tubes, all kinds of different equipment to allow patients to be able to move and get around. So patients have special challenges. Patients have disease resulting in altered body function, sensory deficits. Geriatric patients can have chronic diseases which can lead them to becoming incapacitated. Some patients depend on mechanical ventilators to intervene as functions on the devices. This is the main takeaway from this. Do not be distracted by the equipment. Focus on the patient. I go to a patient on a ventilator. He's on a home ventilator. They're not attached to oxygen or room air. It goes to his trachea. Mom says to me, the ventilator's not working. He's turning blue. He's not breathing. I did everything I could. I can't figure out what's wrong with it. Do you play with the ventilator? No. She knows more than you do. She can't get it going. Unless you have that ventilator at home, you don't know. You disconnect it, and what do you do? You're the ventilator. You're a mechanical ventilator. You do the ventilation. Disconnect the patient from the equipment and move. Treat the patient, not the equipment. Developmental disabilities or intellectual disabilities. We'll take intellectual disabilities. We're talking about developmental disabilities. Conditions of impairment and development with physical ability, learning, language development, or behavioral coping skills. They can run the gamut. You can have patients that are physically disabled but have perfectly functioning brains. There was a patient in Barry that had... It was funny because it was one of my students in the previous class that was her cousin's children. But this kid had Duchenne's muscular dystrophy, which is one of the most debilitating of the muscular dystrophies. And you look at him, and he was almost like... I hate to explain it this way, but you ever see a snake charmer? Like the Indians do snake charming and get the snake that kind of comes up? That's kind of the way he looked. He was just all twisted up like that, and he had a ventilator. And we would transport him because he needed an ambulance to transport because he was bed-compiled. And he had a ventilator, so we would transport him. The mother would come along. She knew how to run the vent, so she would run the vent. We were just there to function in case there was a problem and to move him. And we would always ask mom, what's the best way to move him? Is there any pain today? Your parents or caregivers are your best source of information. They're your best resource. Use them. And this kid was smart. He was sharp as a tack. He knew exactly what was going on. You could have a conversation with him. He just didn't have the physical attributes. Intellectual disability, subset of developmental disability. This causes significant limitations in intellectual functioning and skills for the activities of daily living. So these patients will have, they'll live in an age range, right? A patient lives at a three-year-old level, a six-month-old level, a five-year-old level, a ten-year-old level. You can see that. If you're communicating, interacting with a patient, imagine how they're interacting and what age group you would expect that particular activity would be. Some people live at a tenth-grade level. Some people live at a ten-year-old level. Some people six months. Right? Somebody who needs constant care is like a two-year-old or less, functioning age-wise. Possible causes could be genetic factors. It could be some genetic predisposition. Congenital infections, malnutrition, environmental factors, fetal alcohol syndrome. Alcohol is one of the few things that can cause actual physical birth defects. Most of your drugs or addictive drugs will cause a patient to be born on them. Many of them have some intellectual disability, but alcohol will actually cause physical deformity. Traumatic brain injury and poisoning. Rely on patients and family members for information. They're going to be your best resources. Patients may have difficulty adjusting to change or a break in the routine. These patients, especially like autism, we're going to talk about autism, they are very rigid and strict. I eat from 12 to 12.15. From 12.15 to 12.30, I watch cartoons. From 12.30 to 1.30, I nap. And you're going to come in, because parents called you for an emergency, and you're going to pull them out of their routine? You may end up with some problems. So always ask the parents, what's the best place to approach the patient? What works the best? What keeps the patient calm? I used to work at the dental school in Templeton, and we had a gentleman that if he was not in his routine, everyone suffered. If there was one little thing that was out of place in his routine, he had to watch out, because he was so used to his routine and doing the same thing every day. I remember hearing a story, one student had her brother had autism, and he was the same way. And he had a set pair of socks every day. Same socks, mom had to wash the same socks, but on Wednesday he had this pair, on Thursday he had this pair. And if you gave him Wednesday socks on Thursday, he would get on the floor, scream and yell and kick and punch, and they'd end up having to take him by ambulance. Because he would be so, his routine is gone. So you have to keep that in mind. Patients with intellectual disabilities are susceptible to the same diseases as everybody else. They get the same diseases. It's an intellectual issue, not a physical issue. Autism spectrum disorder. We call it a spectrum now. We used to say autism, but now we realize it's a spectrum. And patients can have all different, like you can have patients with, what do they call it, Asperger's. Asperger's patients can actually function. We actually have people at MedStar that have worked to have Asperger's, and they function perfectly fine. They just, at that end, they don't understand the verbal cues. They don't get the subtle innuendos. They don't get jokes and things like that. Everything has to be very specific. They don't understand those. Whereas patients can degrade also, and you can get to patients who are autistic who don't function above a two-year-old level. And they literally, they're adults, but they live like a two-year-old. So, it's a spectrum of conditions. Intellectual disability characterized by deficits in social communication along with restrictive, repetitive patterns, interests, and activities. Some of these patients with autism, when they get anxious, they laugh. When they get scared or hurt, when they're in pain, they laugh. And you think, oh, he's laughing. He must be having fun. No, he's in pain. He's scared. They don't communicate the same way. Often have abnormal sensory responses. Sometimes they're very sensitive. Sometimes they're very sensitive, like the least sound can set them off. And sometimes you can have the sirens blaring, and they just concentrate on one thing. They have increased sensitivity to noise. Keep the environment calm. Minimize stimulation. The important thing is to recognize these conditions. And don't just walk up and go, hey, I want to shake your hand, and grab their hand. Oh, set them off. Sometimes they have a real problem with physical contact, unless they initiate it. I know in the book it says that the CDC says that vaccines don't cause autism. Is there any link between vaccines and autism? The CDC says no. So the CDC is the king, right? They know everything. Look at what they did about the COVID vaccine. What do you say? I don't trust the CDC. That's just me. Did you vaccinate your kid? Unfortunately, I did. I wish I did. I vaccinated my kid for everything else, but I shouldn't have gotten the COVID vaccine. And I'm sorry I didn't. I followed, I listened to everybody else. I was stupid. I was a sheep. I followed everybody else. Increased sensitivity to noise and physical stimulation. Demonstrate the techniques before you do them. Don't just throw the BP cup on them or the stethoscope on them. Show them the equipment. Let them play with it. Maybe let them listen to your lung sounds for you, right? This is a good way for you to gain their trust, to interact with them. Let them play with the equipment. Now, if they start ripping it apart, why do you got to stop them there? Use short, simple, direct phrases and allow extra time. This isn't going to be a load and go. You're not going to scoop and screw with these patients unless they're unresponsive. You're going to have to spend some time because you can really, really upset them to a point where they can almost, it can almost be detrimental to them. They can get so upset. Down syndrome is a genetic chromosomal defect that can occur during fetal development. It's funny, it's one chromosome. If I take away one chromosome from the human DNA chain, you have a chimpanzee. If I add one chromosome to a certain one, you can develop down syndrome. It's one chromosome. That's all it is. It's different. It can result anywhere from mild to severe intellectual impairment. There is some heredity to it. And the most common, they say the most common causing factor is advanced maternal age. If you're over 36 years old, they can test for it. What they do is they test your urine for a specific protein. If it's positive for that, they can do a process called amniocentesis. They stick a needle in, into the amniotic fluid, draw it out, and they can test it. And that will tell you if the patient has down syndrome. And then, you know, people use that whether they want to terminate the pregnancy or not. I won't get involved in that, but that's what people do it for. Increased maternal age and a history of family history are known risk factors. Down syndrome is, you can have people range from like living at a one or two year old level to people living on their own. I've known people. I've had friends who had down syndrome, and they lived on their own. And they went to work, and they moved two of them to an apartment. You can do it. People get married. Down syndrome, people get married. You can have a man and a woman, down syndrome, get married, have a child. That's perfectly fine. In GEMS, I made this a year ago, there's a doctor. I don't know where he is. I don't know if it's in the U.K., but both his parents have down syndrome. He's a cardiothoracic surgeon. Imagine that. He's a surgeon. They both have down syndrome. Unbelievable. So, physical abnormalities. They're going to have the large head with the rounded, flat occiput. You can tell a down syndrome patient. You can really tell. And large, protruding tongues, slanted, wide-set eyes. If you talk to a down syndrome patient that can actually talk to you, and you ask them if there's something wrong with them, they're going to say no. This is the way they are. They're normal, just like everybody else. They're just a little bit slower than everybody else. And I will tell you, down syndrome patients, for the most part, are extremely affectionate. They'll hug you. They'll hang all over you. They're very, very nice. It's funny because we had, when I opened my check cashing business, I had a guy that had a group home for people with down syndrome. These were older people where their family members died. So, they had nobody to take care of them. So, he would bring them in. And it was state-funded, but it was his house. And he had Kevin and Mary. Kevin was about my age now. So, this was back a few years ago. But he was in his 50s. And Mary was about 60, 62. I will tell you that down syndrome patients are very sexually active. He's walked in a couple of times where Mary and Kevin were becoming a little friendly. So, Kevin used to come to me and collect the bottles. Because I would keep the bottles. And I used to cash them in because, you know, we didn't drink soda and stuff. So, he'd come in and say, hey, bottles, bottles. So, I'd always give him the bottles. I thought, hey, this kid's an up-and-coming entrepreneur. He's collecting bottles. He'd come all the time and collect bottles. So, I remember about three, maybe two months later, Mark came in. The guy's name was Mark, who cared for me. We were talking. He says, I've got him on a strict diet. I said, he's exercising and everything. But all that, I can't help it. All I ever see of him, he's gaining weight. I can't get him to lose weight. And I didn't think about it until one day, Kevin had gotten the bottles. And then I saw him walking down the street with an ice cream. He was catching the bottles and buying them again. For two months, I was contributing to his weight gain. I never told Mark, but I just stopped giving him the bottles. I said, we don't have any more bottles. But anyway, this is funny. Very friendly. Very friendly. Increased risk of medical complications. Things like leukemia, congenital heart problems. Intubation can be difficult. Even bagging them can be difficult because of the shape of their face. They have very large protruding tongues. Jaw thrust maneuver, you may have to still, even with an NPA or an OPA, you may have to do the jaw thrust maneuver anyway. Because you just might not be getting the airway open enough. Management of seizures is the same. They do have a higher risk of seizures than the average person, so keep aware of that. The atlantoaxial joint, which is basically C1, C2, is unstable in about 15% of these patients. So these trauma patients, even minor trauma, can cause a life-threatening cervical spine injury that needs intubation. So be very careful. Make sure these patients fall. Put a collar on them. They're very important. And there are increased risk of complications from experiencing this. So interactions. Most of us don't deal with these type intellectual disabilities or physical disabilities. We don't deal with them all the time. So people tend to be apprehensive. I find, go into it, just be yourself. Just talk to them the way you talk to everybody else. If you find apprehension, back off. If you don't think they're understanding, you can change the way you speak. Just talk to them like everybody else. If you do that, you'll find they'll be very receptive to you. Establish that rapport. Introduce your team members. Explain what you're doing. Show them the equipment. Let them play with it. Be slow and deliberate. And always stay in contact with your patient. Talk to caregivers, family members, friends. They can give you great information as to how to best handle and treat the patient. They'll also be good for history. Brain injury. Patients with prior brain injury may be difficult to treat. Traumatic brain injury. We have them every day. And it doesn't have to be military coming back from combat. I mean motor vehicle crashes, falls. Traumatic brain injuries happen all the time. Talk with the patient. Talk with the patient and family. Establish what is considered normal. What's different today? Why am I here? What's abnormal? Explain procedures and reassure the patient. Visual impairment. Patients can have anywhere from severe blurriness to legally blind to completely blind. Some patients see shadows, shapes, maybe just colors. Some are color blind. All different levels of blindness. 2200 vision is considered legally blind. Patients with 2200 vision can see. They can see shapes and outlines. But everything is blurred. They can't make anything out. Possible causes could be congenital defects. Could be born that way. Disease, injury, or degeneration of the optic nerve, nerve pathways, retinal detachment, or anything like that. So if we ask the patient, what is their level of blindness? Visual impairments may be difficult to recognize. If you have somebody who has been blind most of their lives. I listen to Christian music. I listen to Christian music. And there is a Christian musician called Blessing Offer. He's blind. He's been blind since he was five. Plays the piano like you wouldn't believe. And when you watch him in concert, he's got a bottle of water, he's got something else, and he's got his keyboard, and he's got his microphone. And he just knows where everything is. He grabs a water, drinks, he's playing the piano, he's talking, he's moving the microphone. It's like Stevie Wonder. Stevie Wonder. Stevie Wonder. What about Ronnie Milsap? He plays the piano and the guitar and sings and writes music. He's blind. So what happens is that's right. Your other senses pick up. Did you ever see somebody, when they listen, I do it all the time. When I listen on my stethoscope, I'll go put the stethoscope on and go like this. Why do I close my eyes? When you shut off one sense, the other sense becomes heightened. So people who want to really listen, close your eyes. It'll help you. So there's different ranges. What's that? If you close your hearing, you might see that. That's one of the reasons why when you're looking for something, you turn the radio down. Yeah, I've done that. Quiet, I'm looking for something. Because you can't focus on what you think. Absolutely. You get better vision. Yeah. I don't want to, alright, here's a, I'm going to give you a, what do they call that when you tell the ending of a movie? Spoiler alert. Spoiler alert. Anybody ever see The Book of Eli with Denzel Washington? Are you going to talk again? Did I already tell you? No. Alright, okay. Watch it. It'll explain it. And I'm not going to go any further. Okay. Patient interaction. Make yourself known as you walk in. Don't just walk up to the patient who's blind and go like this. Hey! Introduce yourself and your team. Redream visual aids, like if they need a cane or a walker or something, right? Keys, whatever they need. Remember, you're going to bring them to the hospital. They've got to get home. So they need that stuff. Patient may feel vulnerable, disoriented. They're not going to be in their home or work or wherever you pick them up from. They are going to be once you take them out of that and put them in the stinky ambulance with the radio on, and then you've got to bring them into the ER. They're going to be very much disoriented. So always keep talking to them. Hands on them. Explain what's going on. Always let them, always orientate them to what's going on. The patients that have their dogs for visual aids, do they come with you in the back of the ambulance? Oh, sorry. That's all right. You're stealing my thunder! Transplant physicians take canes and walkers, make arrangements for care if you have a service animal. Patients should be gently guided. Never pull the push and communicate obstacles in advance. Allow the patient to walk. Like if it's not contraindicated, allow them to walk. And I think I talked about that earlier when we talked about service animals. The only authorized service animal in Massachusetts is a dog. You can't have emotional support chickens or you can't have service monkeys. You can't have any of that. What's that? Not a cat. Only a dog. But if you have the dog, you can transport the dog to the hospital. It can go in the ambulance as long as it's a certified service dog. It goes in with you, with the patient, right after the patient. Are pit bulls, can they be service animals? Any dog can be. Any dog can be trained. It has to be trained. As long as it's been trained. I have a special collar for that. Hearing impairment. Problem range from slight hearing loss to total deafness. Many older people have some hearing loss automatically. Sensory and neuronal deafness is caused by nerve damage. That's that prismacosis, that high sound or the loud sound degrading of hearing. Conductive loss caused by faulty transmission of sound waves. My wife had that because she had the aural sclerosis and they had to do a stichectomy and put in a prosthetic stich. Clues of a person could be hearing impaired. Questions of hearing aids. That's a good one. Poor pronunciation of words. Have you ever heard somebody who is deaf for a long time and they talk like this? Because they can't hear themselves pronounce words. Considering the fact they can't hear and they talk like that, that's pretty good, right? They're literally looking at you talking and they're learning like that. That's why they sound like that. Failure to respond to your presence or questions. One of the best pieces of equipment you can have is a pad of paper and a pen. Literally you can have a conversation writing it back and forth. And when the nurse asks you what happened in the ambulance, read it for yourself. Communicate in the ambulance. Assist with the patient in finding and inserting hearing aids. I don't play with batteries so I'll put a hearing aid in. Face the patient when you talk. Most people can read lips. Do not exaggerate your words when you talk because it looks like you're yelling and they'll tell you I'm deaf. You don't have to yell. I can't hear in any way. And stay about 18 inches away from the patient. American Sign Language is useful. I know one word. I told you that so don't use that. And again, the reverse stethoscope works pretty good. Hurt, sick, can help. Hurt, sick, whatever. Sick, hurt, can help. There they are. Hearing aids make it sound louder. Maybe external or internal. We talked about the cochlear implants and that black, gray, or white disc that's magnetically attached to the skull. The device should fit snugly. There's some different types right here. Different types here. And again, if there was a disc in the back, that would be it. Cerebral palsy is characterized by poorly controlled body movements. It is caused most commonly by hypoxia in utero during birth or shortly after birth. Most of it is hypoxic events. Damage to the brain. Oxygen deprivation, traumatic brain injury, and you can have infections like meningitis during early childhood. Or if mother has an STD, what we call STIs now, right? It's actually transmitted infection and they deliver vaginally. It can be transmitted to the baby and the baby can get severe infection, meningitis. Anything that causes a traumatic brain injury to the baby can produce cerebral palsy. Cerebral palsy has a range. Some patients, you ever see the patients that walk down the street and you're always walking behind them and you feel like they kind of fall? That's cerebral palsy. Most, and I know it says here that there's a large portion of them that do not have full functioning mental acuity. I find the vast majority of cerebral palsy patients I've dealt with are 100% on intellectually. They have physical defects. Poor posture, uncontrolled spastic movements, visual and hearing impairments, difficult to communicate, and unsteady gaze. These patients sometimes have, they don't have control of their extremities. You have to be careful you don't jam an extremity in a door or you don't jam it under them. You have to be very careful. I actually have a video that I'd like to play from a guy I like. He's actually kind of a comedian. He does a good job in that manner. He does a good job in that manner. Do you want to see the comedian with the cerebral palsy? Yes. I'm going to find the video. 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