twenty one

Patients with spina bifida may have underdeveloped limbs and are prone to falls. They may require special pillows or chairs and need to be transported in specific positions. Hydrocephalus is a common associated symptom, which is an increase in cerebral spinal fluid in the brain that can cause brain damage. Patients may have shunts placed to drain the fluid. Latex allergies and paralysis are also common in these patients. Obesity can lead to mobility difficulties and other health problems such as diabetes and heart disease. Treat obese patients with respect and be prepared to ask for help when lifting or moving them. It may be necessary to find alternative ways to transport obese patients from difficult locations. Always prioritize the safety and dignity of the patient and communicate and coordinate with the team. swallowing secretions that cause airway issues. Do not assume intellectual disability. Underdeveloped limbs are prone to injury, getting them jammed, catching them in doorways and things, so be careful. A tactical and static gate makes patients prone to falls. That's a common injury. As well as patients may have a special pillow or a special chair. They may need to be transported into a specific position. Listen to the patient or the family member and they'll explain the best way to do it. Pad to ensure comfort. Never force extremities into a position. Whenever a patient, whenever possible, take wheelchairs or walkers. Like in MedStar, if we take a patient emergency from their home and they have like a wheelchair, we'll send another ambulance or a chair van to get the wheelchair and bring it to the hospital so they can go home. Be prepared for seizures and keep suction available. Spina bifida, birth defect caused by incomplete closure of the spinal cord. See, this is the sacrum. And this is actually the spinal cord outside of the sacrum. Normally they have to have it surgically corrected, but unfortunately this baby will probably spend its life you know, in a wheelchair. You do this quite a bit. Just remember, if you have a baby like that, you can't lay them on their back, right? You have to lay them on their side. Associated symptoms, hydrocephalus. Hydrocephalus is an increase in cerebral spinal fluid in the brain. And what happens is it doesn't drain properly, too much is made and it causes the head to swell and it can cause brain damage. So what happens is they call, they put in shunts. They call it a VP or a VA shunt. The VP shunt is what we call a ventricular peritoneal shunt. They go from the ventricle, you know, the third ventricle of the brain, God bless you twice, where the cerebral spinal fluid is made. They take a drain from that and they run it behind the ear, down the neck and into the peritoneum. And it drains into the peritoneum and it's absorbed. Cerebral spinal fluid does not cause peritonitis. Or they can do it into the atria. They go ventricular atrial shunt. What that does is it drains. And usually within the first three to six months, they can develop an infection. More likely than two to six months, they can develop an infection. What happens is the patient will have increased intracranial pressure, will have neurological signs, fever, and a red streak or track that runs down the back of the ear and the neck. These patients may have possible or partial or full paralysis, loss of bowel and bladder control, and extreme latex allergy. These people can have anaphylaxis latex allergies. And paralysis, it can be caused by, you know, trauma, it can be caused by hypoxia, any number of things. Why latex allergy? Hmm? Why is latex allergy specific? I don't know. I don't know the specifics on that, what the causes of that. There's no one there that can do it. Innocent? What's that? Is it like all of them? Not all, but many of them. Let's put it this way. If the patient was spina bifida, don't use latex. That's the same thing to do. The inability to voluntarily move body parts, start by stroke, trauma, whatever. They may have normal sensation and even hyperesthesia, which means I touch your leg and you scream in pain and hurt so much. It can be very, very sensitive, even though they can't use it. It may cause communication challenges. Sometimes the diaphragm doesn't work. They have the phrenic nervous shut off, fracture of the spinal cord above C3, and they end up on a ventilator. Specialized equipment, they might have urinary catheters. There's two types. You can have the Foley catheter, which goes into your uterus, or you can have what they call a suprapubic catheter. Urostomy, they cut a hole in your abdominal wall and they insert the tube into your bladder directly and suture it closed. And then the urine leaves that tube and goes down into a bag, which is strapped to your leg. So that way, you can leave that in for long periods of time. The urinary catheter, urethral catheter, you have to change every month or you can develop an infection. Tracheostomy tubes, we talked about the tracheostomy, right? The surgical opening is called the tracheotomy. The hole we make is a stoma and the appliance we put in is called the tracheostomy. Colostomy bags, we talked about those. That's a collection of fecal matter, usually attached. You can have a colostomy or an ileostomy, anywhere along that. And then feeding tubes. You can have a G-tube, a J-tube, a PEG-tube. What that is, is that's a tube that goes directly into the stomach or into the jejunum, and you feed specific food into it for patients that can't eat food. What's the tube that they put in if you have it for more than a week and it causes pneumonia, like it's usually in the hospital? I know for my grandmother, they said if it's in there for more than a week. Endotracheal tubes, endotracheal tubes. If you're gonna be intubated for a week or more, they're gonna do a tracheotomy. They're not gonna put, the endotracheal tubes are the ones that can lead to pneumonia. ALS can put them, can place them? Endotracheal tubes, yes. Not tracheotomy tubes. We can remove them and put them back in, but we can't do them. That's an anesthesiologist. That's what they do. They put injury out. Difficulty swallowing, may require suctioning. Ask the patient or family member, say here is the best way to move the patient. They're gonna be able to tell you. Obesity. Obesity is a person who has excessive body fat. Obese is 30% over ideal body weight. I am considered obese. I'm supposed to be about 180, I'm 220. So I'm 40 pounds overweight. I'm considered obese. Severe obesity is two to three times the ideal body weight. I mean, I've taken patients, like I said, my biggest patient was 842 pounds. And that was just very big patient. Imbalance between calories consumed and calories used. May be attributed to low metabolic rate or genetic predisposition. Understand that most of your obese patients are very self-conscious, right? And they feel uncomfortable, and they feel embarrassed when you have to go help them. So keep that in mind, right? These are human beings. Treat them with respect, treat them with dignity. Make sure you have enough help. Don't attempt to lift somebody that's too big if you don't think you can do it. Don't be afraid to ask for help. Call a fire department, call the police department, call for other ambulances. Don't get hurt, right? Many times these patients can't lie flat. So if they're on the floor, they can actually suffer respiratory distress and even die on the floor. You don't want these patients lying flat. They need to sit up. Quality of life is negatively affected. Anybody ever see my 600-lb Life? If you've never watched it, it's addicting. Watch it. Because there are companies that that's all they do. They specialize, they get that Dr. Narwal, he does it. He's the one that, he calls the ambulance to pick these patients up. He uses the same company. These companies specialize in bariatric equipment. We're supposed to know what is the ideal presentation for each group of age of weight? If you want to. You don't have to. Associated health problems. Mobility difficulties, diabetes, hypertension, heart disease, and stroke. And you can see most of these people with these weight issues have emotional issues. You know, they've had some kind of emotional trauma or something like that, been exposed to something. And then they have what they call an enabler. Somebody who enables them by feeding them, getting them. And if the person enabling them isn't doing it maliciously, they're trying to appease them. They're trying, they understand they're having problems so they appease them. And they appease them with food. And that's the problem. People with PCOS, we really, it's hard for them to lose weight. With what? With the polycystic thing. PCOS, I think it's called. Polycystic ovarian syndrome? Yes. Oh, okay, okay. Oh, there you go. And they get the cysts, okay. I didn't know that. Okay, yeah, I can see that. Patients will be embarrassed when to have extra help or equipment. The way you go in may not be the way you come out. Especially if you go to calls in Worcester and they have those triple-deckers and those windy staircases. You're not getting a 400-pound patient down one of those staircases. So you're gonna have to find alternative ways. There's a couple of patients in Worcester, I don't know if they're still alive, but they used to, where they actually, the fire department hired a contractor to cut the wall up and then screw it in so the fire department could go up with the aerial scoop, remove the wall, and take the patient out that way. Because you couldn't, the patient was on the second and third floor and couldn't come down. There's just no way to get them out of the house. Do not miss dropping the patient or injuring a team member. Treat the patient with dignity and respect. Ask your patient how it's best to move them before you do so. We have these lifting sheets. They're, what do we call them? Some mega-movers. But they can hold over 1,000 pounds. What you do is you put a sheet, you lay it under the patient and it's got reinforced handles, and about eight of them, four on each side, and you can pick the patient up and move him with it. Avoid lifting the patient with one limb. You don't wanna lift him by the limbs. You'll just dislocate the limbs. Coordinate, communicate all moves with the team members prior to lifting or standing. Make sure when you're taking the patient to the hospital, you call early. Like when I called, took that 842-pound patient, I called before we even started extricating her. I called by patching. So it took us 20 minutes to get her from the second floor out to the ambulance. By the time I got her to the hospital, it was 30 minutes from the time I called. They had a bariatric stretcher, they had the bariatric room, and all the equipment that they needed. You don't wanna be backing into the ER. Oh, I'm just backing in right now with an 842-pound patient. They're gonna go, and their head's gonna explode at the ER. Look for pinch points and pressure points. They're avoiding being seen. And again, patients who are that big do not wanna lie flat. They need to sit up. You'll have to have specialized equipment. Plan your egress route. We have bariatric stretchers. Matter of fact, our manual bariatric stretcher will support 1,600 pounds in the flat position. We actually have ramps. Because of that patient in Gardner, when we had the Gardner contract, we actually had ramps, and we could ramp the patient up. Tracheal stoma provides, we talked about what the tracheostomy is in the stoma. It can be temporary or permanent, and it's used for patients who are gonna have extended ventilatory use. Because again, intubation, patients shouldn't be intubated more than a week. So this is the tracheostomy. This is the tracheostomy here. It's inserted, this cuff is inflated, and then you have a strap that goes around the neck. And if you see right in here, there's a little ridge in there. There's an obturator in there that helps with airflow. I can remove the obturator, stick a French catheter in there, and suction. The DOPE mnemonic helps you recognize obstructions. We use this for endotracheal intubation and tracheostomies. So displacement, dislodgement for damaged tube. Look at the tube, it's just working. And you always go from the tube to the oxygen source. Obstruction of the tube, most commonly it is a mucous plug. It's gonna suction it out. But the patient will stop going like this, they'll stop going. And they won't be able to breathe, and they'll be turning blue. And all you do is take suction, you suction that right out, fixes it right away. You just saved that patient's life. Pneumothorax, what happens is air can infiltrate around that and get down into the mediastinum and cause a pneumothorax or equipment failure. Common problems, bleeding or air leaking around the tube. If you have that, you may end up with that subcutaneous emphysema, the rice krispie popping under the skin. Tube can become dislodged, opening around the tube may become infected. Infections are fairly common. If you start seeing blood or mucus come out around the tube, that's a bad sign. Usually there's bandaging around it. Maintain an open airway, suction the tube if necessary to clear the mucus plug. Have the patient in a position of comfort. They're gonna want to sit up. Administer oxygen and transport. If you want to bag them, you hook the BBM directly to that tracheostomy tube. Home oxygen, there are two types. Oxygen from gas cylinders and an oxygen concentrator. Most of the time you're gonna see the concentrator. An oxygen concentrator, what it does is it scrubs and removes the pure oxygen from the air. It scrubs all the other gases out and just gives you concentrated oxygen. Concentrators usually go from one to six. I've seen those high as nine liters per minute. That's usually one to six liters. And you plug it in and it runs and the patient sets it. One thing I have to tell you is that for every 25 feet of O2 line, you have to increase your volume of gas by one liter per minute. So if you have a patient on a nasal cannula and they have a 50 foot cord so they can get all around the house, they're actually only getting one liter. You have to kick it up. For every 25 feet, you have to give it another liter of oxygen. Because you have to overcome that distance. Yes? The one that has the wheel, is that the concentrator? That's the concentrator, yeah. Sometimes you have compressed gas cylinders. You'll see the big, big tanks. Those could be compressed air or those could be liquid oxygen. If they're that big in liquid oxygen, that one tank will last months. Because it's 10 times the normal size of the tank. Sometimes, we've actually transported patients because the power went out. They didn't have a generator and they had an oxygen concentrator. They can't stay home. They need oxygen. We take them to the hospital just because they don't have oxygen. In the town, sometimes what we'll do is we'll drop off a couple of tanks. A couple of our, you know, de-cylinder tanks. We'll just leave a couple with the patient and then we'll go back and check on them. Because at two liters per minute, a de-cylinder tank will last a couple hours. So, we give them a couple of tanks and we go back and check on them in a couple hours. Power's not on, and we transport them. It takes the ambient air and scrubs out the nitrogen, leaving just the oxygen. Requires a reliable electricity source. That's why most patients who have an oxygen concentrator will have a tank with two taps to align around. Ask the patient why they're on home oxygen. Obviously, it's either interstitial lung disease or COPD. How long have they been on oxygen? Their baseline home oxygen requirement and what their oxygen saturation is. If a patient is on O2, they're gonna know what their oxygen saturation is. You'd be surprised. I've seen patients come on two liters, my oxygen saturation is 89%. 89%, if you were a normal person, I'd be ventilating you. But they live at 89%. Mechanical ventilators used when patients cannot breathe without assistance. Things like congenital defects, chronic lung disease, traumatic brain injury, and muscular dystrophy. You are a mechanical ventilator. So, if the mechanical ventilator you take the patient on doesn't work, you're gonna take over. You will transport patients on ventilators, but you don't work the ventilator. You can only transport. Somebody has to go who can run the ventilator. And the patient can't run it themselves. So, you can't have a patient say, I'm gonna run my own ventilator, it doesn't work that way. Somebody else has to run the ventilator. If the patient shuts off, he's gonna pass out. We can't work it. If a ventilator malfunctions, remove them from the ventilator and bag them. Apply a tracheostomy. Remember we talked about the tracheostomy mask? That mask that goes over the tracheostomy. You can hook oxygen to it with the venti adapter. That would be what a home ventilator would look like. And all it does is pump room air. It doesn't pump concentrated oxygen, it's just room air. Athia monitors used for infants who are premature and have severe gastroesophageal reflux. If you have a history of this or experience it, there's a light bulb there. And what it is, it's a band that goes across the chest and it measures heart rate, breathing rate, and sometimes pulse like temperature. And if it goes beyond too high or too low in either one, it sends off a piercing loud bell. And that, you know, you wake up and oh my gosh, check the baby. It's used from two weeks, I've seen it used from two weeks to six months. Sounds a little long, but the infant experiences bradycardia from apnea, detached or electrical. If you have a patient that you go for an emergency and the patient has an apnea or on and on, leave it on the patient because they can interrogate it. They can get information from it and get a history on the baby. Cardiac pacemakers, we've talked about these. You can have a pacemaker or a defibrillator. A pacemaker sets the heart rate at 70 beats per minute or whatever the doctor wants. A defibrillator will shock the heart if it goes ventricular fibrillation or ventricular tachycardia. You can have both. You can have a pacemaker defibrillator. You can have a dual chamber. I can have an atrial pacemaker, a ventricular pacemaker or a dual chamber pacemaker. So I can have a dual chamber pacemaker and a defibrillator all in one thing about this big and it lasts for about five years. And every month, I dial it to a computer program and put a little sensor on it and it interrogates it and sends it right to the doctor. And it tells what my rhythms were for that month. Never place electrodes directly over the pads. Put them about an inch down. We talked about LVADs. Remember, you guys watched the video on the LVADs. If you're interested in it, go over and watch those videos. Some great videos on LVADs. You can watch implantation. The surgeries are really, really interesting how they do it. Be prepared. Some of the newest of the LVADs or some of the newest of the VADs, you can do CPR with the VAD. So it's important to find out, call the VAD team because you don't know if it's a CPR one or not. So call the VAD team. External defibrillator vest, we talked about those. It goes on the patient and it's used for an interim between a cardiac event and getting a pacemaker. They'll wear these until they get the pacemaker or the defibrillator so that it'll shock them and they wear this all the time. If you have a patient that's in cardiac arrest and they have a pacemaker or defibrillator on, the vest on, leave it on. And it'll tell you when it's gonna shock and it'll give you a high-pitched ring and you'll know it's gonna shock. Central venous catheter. This is a, you can have what they call central lines and PIC lines. A PIC line is a perfectly inserted central catheter. My son puts them in. They go right in through here into the vertebral vein and they travel right up into the atrium. Or you can have a central line that's usually placed in the subclavian vein that goes into the atrium. Or sometimes you can have a port, port-a-cath, which is just kind of like a port that you stick needles in, but it's directly into the vena cava. And what happens, it's used for medication administration. And this is a central cath that goes into the, this might go into the vena cava directly or it might go into the subclavian vein. It's got three ports. This is a triple movement. One is used for blood draw. One is used for medication administration and one is used for fluid administration. Or maybe two would be used for dialysis or something like that. Sometimes these can develop vegetation. They get growths on them. They get bacteria that grows on them or they get infected. They start bleeding. People pull them out because they're sutured in. People get mad and they pull them out. Common problems, broken lines, infections, clotted lines, or bleeding around the tube. G-tube's a place in the stomach. You can, again, G-tube's in the stomach and probably a gastric tube. A J-tube is a jejunum tube. It's placed in the junum. You can have a PEG tube. And there's one right there. So the patient, this is where the patient feeds from, right? The patient can't take anything orally. So this is where the patient feeds from. It's important to look at that, see if there is any swelling, bleeding, any kind of exudate coming out of that because maybe it's leaking. Be aware that this could, if it's over, if they're overfed, if it's overfilled, it could lead to vomiting. So have suction available. They can become flogged. They can have vague symptoms, nausea. You can have coffee ground vomiting, which means it's bleeding. The PEG tube or the J-tube or G-tube is bleeding in the stomach and you're vomiting up that blood. They have an increased risk of aspiration. Have the patient sit up. It's the best way to avoid vomiting. Shunts, we talked about those, that VA is a VP shunt for hydrocephalus. It's placed beneath the skin behind the ear. You should be alert for the presence of the shunt. You get ventricular peritoneal and ventricular atrial shunt. One goes in the ventricular peritoneum, one goes in the atria, and it drains through the spinal cord. Blocked or infected shunts may cause changes in the mental status respiratory arrest. Infection occurs within about two to six months of the surgery. Shunts, if you have a problem with a shunt, patients will develop, especially infants, will develop a high-pitched cry. We call them, infants who develop intracranial pressure will have the bulging quontinals, but we call it cat's eyes and cat's cry. They're gonna have this high-pitched, almost like a cat's cry. It's gonna be a high-pitched, whiny cry, and the pupils are gonna become almost oval. We call it cat's eyes and cat's cry. It's a sign of increased intracranial pressure. If you see that or recognize it, and you see the bulging quontinals, that's increased intracranial pressure, that could be the sign of a blocked shunt. Headaches, projectile vomiting. When do we see projectile vomiting in? Cauchyne's triad, remember? Larger hypertension with a result in brachycardia, change in respiratory pattern, and projectile vomiting. Ultimate mental status, irritability, fever. If it's a blocked shunt, most likely it's infected, there'll be a serious fever and nausea. And remember, this goes right in the brain, so this is the potential for meningitis. Difficulty with coordination, they'll have an atactic gait. Poor vision, seizures, redness along the chunk tract, bradycardia, and heart disc remission. Vagal nerve stimulator. A vagal nerve stimulator is used for seizures when medications don't work. Remember, we talked about medications when we talked about vagal stimulators. What happens is, if the patient starts them a seizure, they put a wand over it, like a magnetic wand, and it usually sits right here. They put the wand over it, and that stimulates the vagus nerve to shut off the seizure. They work. They take patients who have 20 seizures a day and bring it down to maybe one a week. They're much better than medication, but you have to catch it, and you have to stimulate the vagal nerve stimulator to work. It's usually used in children older than 12 years. It's under the scale, about the size of a silver dollar. If you encounter that, call medical control. You don't activate it. Somebody who's trained to do so must do so. Colostomies or ileostomies, we've already talked about those. That's the drainage of fecal matter in the colon, from the colon, or ileostomy is from the ilium, and your urostomy is like the supercubic catheter. That's through drained urine. It allows for elimination of waste in an external bag or pouch because it bypasses the colon because the colon maybe has trauma, surgical repair, cancer, some reason you can't use it, and it can be temporary or permanent. You want to assess the dehydration. Patients with colostomies are more prone to dehydration because they're not reabsorbing that moisture that's going in a bag. Area around the stoma is prone to infection because it's got fecal matter. So redness, warm skin around the stoma, tenderness over the colostomy or ileostomy site, you might see bleeding. If you get that fecal odor, that means it might be leaking. Urostomy, we talked about that. It drains into a bag through the abdominal wall. Contact medical control. You don't really have to call medical control. There's a problem with it. If there's a problem with the colostomy, urostomy, ileostomy, call medical control. A lot of times you'll see in the colostomy bag or the urostomy bag, the collection bag, you'll see blood. And if you see blood in it, that's the same as if they were passing blood, defecating or urinating. So interaction with caregivers is an important part of patient assessment. They are experts on patient care. That doesn't mean you ignore the patient. You talk to the patient. You assess the patient, but you look to the caregivers for information. And you want to ask the things like, what is different today? Why am I cold? Home care occurs at home in the home environment. It represents a spectrum of populations. Infants, older adults. Again, if I stay home, it's as much as one-tenth the cost of a institutional stay. So if I'm in a care center, 24-hour day care, it can be as much as 10 times the cost of being home. Insurance companies love it when you're home. They'll pay for equipment all day at home because it's cheaper and it's safer. You're less likely to get infections or injuries when you're at home. Things like delivering meals, cleaning, laundry, maintenance, physical therapy, personal care, medication administration. You may be called to the home of a resident for a home health care provider, especially nurses. If you get a call from a home health care provider or a nurse and they say, this patient needs to go to the hospital, listen to them. Although I have had patients who told me, I am not going to the hospital. I don't care what the nurse says. If the home health nurse tells me the patient has to go to the hospital and the patient doesn't want to go and they're 80 times four, can I make them? No. Good, okay. But, listen to the nurse. Most of the time, the nurse is acutely aware of the patient and their status because they see them all the time. They'll be acutely aware of the changes to the patient. We talked about hospice, internally ill patients, terminally ill patients, maybe some hospice care facilities or homes. They'll have a DNR or they'll have the most and then it'll explain the scope of practice. Comfort care is kind of like the hospice care in Massachusetts or palliative care. Improves the quality of life. Patients basically just get maybe food or nutrition, fluids, and pain meds. And they might be on a ventilator. That kind of thing. Bring the documentation to the hospital. If you transport a patient to the hospital, bring the most with you, whatever reason. And write up the narrative as to what you did. Show passion, understanding, and sensitivity. Remember, the patients may not know, the family member may not know what to do, so they call you because they don't know what else to do. So have patient empathy and understanding. Ascertain the family's wishes regarding transport. You can allow a family member to go. I always take a family member if they want to go. There's nothing in the protocols that you can't take a family member or even two with you to the hospital. Follow your local protocols. We have taken patients many times, the hospitals will say, this patient's going home on palliative care or hospice. We don't know if they're going to make it. And so, okay, you take the patient. Patient dies in room. Happened to me. What do you do? Do you turn around and bring the patient back to the hospital? The book says, and OEMS says, you turn around and go back to the hospital. Well, what do you do? Bring them home. Bring them to where they're supposed to be. There's a hospice nurse that'll be there. They'll accept it. They understand it. Where did the patient want to go? Home. Where did the family member want them to go? Home. Why would you turn around and go back to the hospital? What you do is you pull up, and as you're unloading the patient and the hospice nurse comes up to see you, you say, I think he might have passed. This will pull up. So the hospice nurse will sign the book. This is the difference between street EMS and book EMS. Technically, if they pass away, you're not allowed to transport them anyway. You're not allowed to transport a dead body in your ambulance in Massachusetts. So that's why they didn't die until you just pulled up. Again, that's what you want to do. You want to honor the patient's final wishes. They wanted to go home. I'll get them home.