The term “Special Healthcare Needs” means different things to different people. Collectively, patients with special healthcare needs encompasses the geriatric, bariatric, pediatric, sensory impaired, technologically dependent patients, behaviorally challenged patients and many others. Every group has special challenges, risk factors and needs as well as the fact that our approach to them as health care providers must be modified and adapted to improve our ability to assess and manage their unique conditions and situations.
By definition, the geriatric population is clinically defined as anyone older than 65 years of age. Each patient in this demographic is not the same. Some are very active and healthy while others are suffering from many age related changes. Age related changes involve every organ system in the body including their ability to compensate for low perfusion states, respiratory insufficiencies, medication metabolism, wound healing and many other insults to the body. Balance and coordination issues as well as gradually diminishing sensory perception may make this group more prone to falls and blunt force trauma. Co morbid conditions and medication intake also may make even a minor injury or medical condition a potentially life threatening event. When approaching this age group, keep in mind that how we address them and communicate with them may need to modified to ensure a good rapport is established. Thorough assessment of the geriatric population requires a high index of suspicion for underlying chronic conditions that may exacerbate the insult whether it be a medical or traumatic event. Environmental extremes are poorly tolerated by the geriatric age group due to their decreased ability to compensate for either internal or external temperature extremes. The lack of subcutaneous fat stores further puts them more at risk for negative consequences from these environmental stressors.
The Bariatric population is clinically defined as a Body Mass Index of greater than 40 or greater than 35 with obesity related disorders such as Type II Diabetes or Hypertension. Obesity can result in decrease movement and sometimes the patient may be bed bound. This lack of mobility can contribute to embolism formation, hypoventilation with hypercapnia, increased risk for opportunistic infection development and clinical depression. Assessing and managing the geriatric patient poses both a physiologic and logistical challenge to the EMS provider, Increased body mass and adipose tissue may make auscultation, patient positioning, vascular access and other medical interventions more difficult. Logistically, immobilization, access to patient, extrication of the patient, securing the patient to standard EMS transport stretchers and safe transport can be a challenge. Additional resources may be required to safely package and transport this unique group of patients. Bariatric patients are at an increased risk for time sensitive conditions such as acute myocardial infarction, traumatic insults and cerebrovascular accidents, all of which may be time sensitive events. The logistical challenges listed above may make rapid transport to the appropriate facility for treatment difficult if not impossible.
Pediatric patients pose a unique challenge to most EMS providers as they often account for small percentage of total EMS calls for service. Couple this with the fact that most medications are weight based, the lack of appropriately sized treatment and packaging equipment, the wide range of psychosocial and emotional development and the stress related to responding to and treating the critical pediatric patient, its no wonder that most EMS providers are less comfortable with routinely treating this age group. Physiologically the pediatric patient has a smaller functional residual capacity and higher metabolic rate so they are more prone to oxygen desaturation, respiratory failure and/or respiratory arrest and decompensation due to hypoxemia and hypovolemia. Younger pediatric patients respond to low perfusion states by increasing their heart rate rather than increasing their stroke volume. Their large body surface area to body mass ratio make them more prone to heat and cold related stressors. Capillary refill delay is often one of the first outward signs of compensation to hypo perfusion due to their ability to vasoconstrict and shunt blood to the core of the body early. Hypotension is often a late sign of perfusion insult in this group and frequently signifies a patient that has decompensated to the point that resuscitation and return to normal persuasion status may be difficult if not impossible.
The approach to sensory impaired and technologically dependent patients requires the EMS provider to seek input from the patient and/or family members or caregivers. They often know what does and doesn’t work as far as communication and intervention. Often sensory impaired patients are erroneously perceived as less intelligent. Nothing could be further from the truth, often these patients have a normal to high level of intelligence. EMS providers are tasked with finding out what the best way to communicate with the sensory impaired patient will work best. Technologically dependent patients and all the associated equipment can be very intimidating to the EMS provider. Equipment like gastrostomy tubes, shunts, colostomies, mechanical ventilators and central venous catheters often can distract the EMS provider from adequately assessing and treating this unique demographic. As stated earlier, reliance on the patient and/or caregiver’s input will make the assessment, treatment and transport of the special needs patient more successful. They often know what works and more importantly what doesn’t work as well as what has been attempted or performed prior to EMS arrival.
Psychiatric conditions range from minor to life altering and everything in between. Our approach to this group requires tact, empathy and respect as well as high index of suspicion for unexpected aggression of self harm. Behavioral and psychiatric conditions can be either chronic or acute, situation induced. Many medical conditions can mimic mental health presentations, so it is advisable to always rule out medical causes early even in the known psychiatric patient. Often their behavior is very erratic ranging from somnolent and non verbal to anxious and possibly aggressive. Mental health patients offer suffer from a stigma related to their condition so an empathetic and open minded approach to patient advocacy is often needed but frequently not practiced. Certain anti psychotic, anti depressant and/or anti anxiety medications make this group more at risk for certain environmental, cardiovascular and electrolyte related complications. EMS providers should always remember that their safety as well as the safety of the patient is of utmost importance and it is not always mandatory nor advantageous to rush the encounter.
Patients with “Special Healthcare Needs” have many unique issues as it pertains to assessment, management, interaction and risk factors. It is imperative for the responding EMS provider to approach each patient as a respected and valuable individual. Often these patients are misunderstood and looked at as “less than”. Our job is to accurately assess and manage this special group with a keen eye on potential risk factors, maintenance of patient dignity, use of available assets that may improve the care of the patient and safe and respectful packaging and transport to the appropriate destination for their specific condition. The more comfortable we are in treating and interacting with these specific populations will not only increase the comfort and competence of the EMS provider but also improve patient outcomes in the long run.
