Detailed Lesson Plan

Chapter 40

Patients with Special Challenges

255–300minutes

Chapter 40 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes / Content Outline / Master Teaching Notes
5 / I.Introduction
A.During this lesson, students will learn about assessment and emergency care for patients with special challenges.
B.Case Study
1.Present The Dispatchand Upon Arrival information from the chapter.
2.Discuss with students how they would proceed. / Case Study Discussion
  • What type of device is Mrs. Davidson talking about? What is it used for?
  • What would happen if the device malfunctioned?

5 / II.Recognizing the Patient with Special Challenges
A.Any number of medical or traumatic conditions can cause loss of function to a body system.
B.Changes can be mild or substantial.
C.Impairments may result from aging, birth defects, chronic illnesses, traumas, abuse and/or neglect, and more. / Teaching Tip
Ask students what experiences they have with people who have special challenges.
Critical Thinking Discussion
  • Why is it important for EMS providers to be knowledgeable about special health care needs?
  • Are there other populations who may have special challenges in getting the health care they need?
Weblink
Go to click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource on minority health.
2 / III.Sensory Impairments—Hearing Impairment
A.Occurs when there is a loss or diminishment in the person’s ability to hear sounds
B.Deafness is a term that is commonly used to describe the inability to hear.
1.May involve one or both ears
2.Patient may be partially deaf or totally deaf. / Discussion Question
What are some ways of improving communication with hearing-impaired patients?
5 / IV.Sensory Impairments—Vision Impairment
A.Etiologies
  1. Loss from disease
  2. Loss from injury
  3. Loss from degenerative disorders
B.Glaucoma results in an abnormal increase in intraocular pressure that damages the optic nerve, resulting in peripheral vision loss and eventual blindness.
C.Diabetic retinopathy occurs when the long-term effects of diabetes mellitus damage the small blood vessels in the eye.
D.Injury to the eye can be caused by puncture or penetration injuries, blunt trauma to the face, or chemical and thermal burns.
E.Aging may cause degeneration of the eyeball, optic nerve, and optic nerve pathways.
F.Cataracts are a condition in which the lens of the eye becomes cloudy from pathologic changes within the lens itself.
G.Vision loss
  1. Acute or slow onset
  2. One or both eyes
  3. Whole or certain field of vision
  4. Reversible or permanent
/ Discussion Question
What are some causes of impaired vision?
2 / V.Sensory Impairments—Speech Impairment
A.Articulation disorders—Caused by impairment of tongue or other muscles needed for speech (dysarthria), learning words incorrectly, hearing impairment, or damage to nerve tracts
B.Voice-production disorders—Damage to the larynx, vocal cords, or related supporting structure from illness or injury
C.Language disorders—Patient displays an impaired or absent ability to understand the spoken word (congenital problems, hearing deficits, inadequate language stimulation, stroke, head trauma, brain tumor, significant emotional stress).
D.Fluency disorders—“Stuttering” speech patterns
6 / VI.Sensory Impairments—Accommodations for Patients with Sensory Impairment
A.Hearing-impaired patient
1.If patient has hearing aid, ensure that it is on and working properly.
2.Position yourself so that the patient can lip read.
3.Communicate in writing, if necessary.
4.If patient is able to sign, have a person at the scene who knows sign language act as an interpreter.
B.Visually impaired
  1. Speak clearly and always explain what you are going to do before you do it.
  2. Follow local protocol and service policies when deciding whether or not to transport a service dog.
  3. You may need to act as the patient’s guide.
C.Speech impairment
  1. Ask questions in a way that allows patients to answer in as few words as possible.
  2. Allow patients time to respond to your questions, and do not attempt to finish words or statements.
  3. Never pretend you understood something when in fact you didn’t.
  4. Use family or other communication techniques only when verbal communication has failed.
/ Teaching Tip
Discuss local protocol regardingtransportation of service animals.
Critical Thinking Discussion
How should you interact with a service animal?
Knowledge Application
Students should be able to integrate information from this section into the assessment and management of patients with sensory impairment.
3 / VII.Cognitive and Emotional Impairments—Mental or Emotional Impairments
A.Impairment may range from mild to significant.
B.Patient with an extreme emotional dysfunction may be unable to focus on your questions or respond appropriately.
3 / VIII. Cognitive and Emotional Impairments—Developmental Disabilities
A.Conditions that interfere with how a body part or system operates
B.Often present as birth defects
C.May not be noted until the child fails to reach certain developmental milestones
D.Can be a result of trauma in utero, during the birth process, or at any time after birth
E.May involve brain, spinal cord, nervous system, and endocrine system
F.Common disabilities
  1. Down syndrome
  2. Fragile X syndrome
  3. Autism
  4. Fetal alcohol syndrome
  5. Phenyketonuria (PKU)
  6. Kypothyroidism
  7. Rett syndrome
/ Critical Thinking Discussion
What are some organizations that help people with developmental disabilities lead more productive lives?
Class Activity
Assign students to research a developmental disability outside of class and make short presentations to the rest of the class at the next class session.
3 / IX.Cognitive and Emotional Impairments—Accommodations for Patients with Mental, Emotional, or Developmental Impairments
A.Treat the patient with respect as you would any other patient.
B.You may need to gather history from primary care provider if you discern developmental or cognitive problems.
C.Use care providers’ experience with patients to help you determine diminishment in the patient’s mental status or other condition when trying to gather chief complaint.
D.Provide clear explanations in an attempt to assist the patient in understanding the situation and what is occurring during emergency care and transport.
E.Patients are still sensitive to body language and tone of voice.
F.Patients may be wary of strangers, and it is important to gain their trust.
G.Avoid loud noises or extreme changes in lighting, and keep the primary care provider near. / Discussion Question
What are some guidelines for interacting with patients with developmental disabilities?
3 / X.Cognitive and Emotional Impairments—Brain-Injured Patients
A.Causes can include infant abuse, meningitis, encephalitis, and head injury.
B.Cerebral palsy is an umbrella term for motor impairments (muscular stiffness, joint contractures, wringing of hands, drool, facial grimacing) that result from brain abnormalities that arise early in development.
C.Brain trauma can range from mild to severe. / Weblink
Go to and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource on cerebral palsy.
3 / XI.Cognitive and Emotional Impairments—Accommodations for Brain-Injured Patients
A.Presenting signs and symptoms should be categorized as either chronic or acute.
B.Gathering a history will reveal the type of injury sustained earlier and identify any changes in the patient’s current condition as either chronic or acute.
C.Brain-injury patients may use a large amount of medical technology in order to survive, and the EMT must manage this equipment during transfer.
D.While emergency care will depend on the condition(s) for which you are summoned, remember to maintain a patent airway, ensure adequate breathing, and keep peripheral perfusion intact.
E.Consider summoning ALS for a patient who is critically unstable or deteriorating. / Discussion Question
What are some additional considerations in managing severely brain-injured patients?
Knowledge Application
Students should be able to apply this information to interactions with patients with emotional and cognitive impairments.
15 / XII.Paralysis—Accommodations for Paralyzed Patients
A.Complete loss of muscle function to one or more groups of muscles
B.You may have to make accommodations for a patient’s preexisting paralysis while also treating him for the reason for the EMS call.
C.Patients who are paralyzed are susceptible to multiple additional problems (e.g. respiratory infections, urinary infections, necrosis, and emergencies from feeding tubes).
D.Paraplegic patient will display paralysis from the waist down and should be able to communicate with you normally as long as there is no cognitive decline.
  1. Concern is moving the patient from his bed or wheelchair to your cot.
  2. Taking the patient’s wheelchair is often not allowed by the EMS agency, and you should coordinate with family or primary care provider for this and other items to be brought to the hospital.
E.Quadriplegic patient is paralyzed to all four extremities and may not be able to breathe adequately on his own.
  1. Keep settings on the home ventilator the same as when you arrived.
  2. Keep suction and bag-valve mask nearby.
  3. Look to see if the patient has a urinary catheter before moving him, and keep the urinary collection bag at a level above the insertion site or at the same level of insertion.
  4. Remain alert to the patient’s needs and medical equipment (especially while moving the patient).
F.Never allow the necessary accommodations distract you from the reason for the initial call to EMS. / Discussion Questions
  • What are some causes of paralysis?
  • What are some medical terms associated with paralysis?
  • What are some considerations in assessment, management, and transport of patients who are paralyzed?
Weblink
Go to and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource on paraplegia.
Knowledge Application
Students should be able to apply information from this section to the care of paralyzed patients.
15 / XIII. Obesity—Accommodations for Obese Patients
A.Bariatrics is the branch of medicine that deals with the management of obese patients.
B.Traditionally, a person who is 20 percent or more over his ideal weight is considered to be obese.
C.A morbidly obese patient weighs 50 to 100 percent more than his ideal weight or is more than 100 pounds over his ideal weight.
D.As obesity and morbid obesity rates climb, EMS crews are encountering these patients more and more often.
E.Obesity may occur from consuming too many calories, physiologic problems, medications, or genetic factors.
F.“Extra” skin and adipose tissue can affect normal respiratory function when patient is in supine position
1.Allow patient to maintain position of comfort.
2.Ensure airway is maintained in neutral position.
3.Position patient with multiple towels or bath blankets under the shoulder blades and behind the neck (if no spine injury is suspected) to provide cervical extension.
4.Use an oral or nasal pharyngeal airway to displace the tongue mechanically.
G.Turn your attention to oxygenating and ventilating the patient; spontaneous breathing may be impaired by body size in semi-reclined or supine position. (Remember a breathing patient does not necessarily equal an adequately breathing patient.)
H.Perform rapid circulatory assessment; look for mentation, or alterations in heart rate or blood pressure.
I.Use additional personnel, special cots, and bariatric loading devices as appropriate when transporting the patient.
J.Inform receiving facility that a special stretcher or additional personnel may be needed. / Discussion Questions
  • What are some causes and risk factors for obesity?
  • What health risks are associatedwith obesity?
Critical Thinking Discussion
What do you think accounts for the negative attitudes many peoplehave toward people who areobese?
Teaching Tip
Demonstrate any bariatric equipmentavailable to your EMS system.
Knowledge Application
Students should be able to apply information from this section tothe management of obesepatients.
30 / XIV.Homelessness and Poverty—Accommodations for Patients Who are Homeless or Poor
A.Factors contributing to homelessness
  1. Poverty
  2. Substance abuse
  3. Lack of affordable housing
  4. Mental illness
  5. Prison release back into society
  6. Domestic violence
  7. Mortgage foreclosures and forced evictions
  8. Natural disaster
B.Disadvantages of homelessness
  1. Reduced access to services because of lack of proper documentation or address
  2. Increased risk of violence and abuse
  3. Increased risk of illness/disease
  4. Discrimination from others
  5. Reduced access to healthcare
  6. Limited or no access to education
  7. Limited or no access to modern communications
  8. Not seen as suitable for employment purposes
C.Homeless have no address to which EMS can respond; the following are locations to which you may respond.
  1. Abandoned or condemned buildings
  2. Public places such as parks, train or bus stations, airport, college campuses
  3. Vehicles
  4. Outdoors in improvised shacks or on the ground with sleeping bags
  5. In an unoccupied house
  6. Homeless shelters
D.Homeless are at risk for even greater emergencies due to poor nutrition, environmental exposure, lack of access to medication, and vulnerability to violent acts.
E.Like the homeless, people who fall below the poverty level are at greater risk for illness and injury from the environment that they are in and the lack of primary medical care.
F.Do not be judgmental; 90 percent of Americans will, at some time, live below the poverty level for at least a year. Remember that you are treating the patient because he needs your help.
G.If the patient is worried about money to pay for the services, take the time needed to explain to the patient that almost all health care providers offer a certain degree of reduced cost or free medical care.
H.Become familiar with hospitals and services in your community that provide medical care, shelter, food, or other services to families in need. / Teaching Tip
Encourage students to volunteer for an agency that provides services to the homeless.
Class Activity
Have students organize a food or clothing drive, or collect school suppliesfor the disadvantaged in your community.
Discussion Question
What are the health and health care consequences of poverty and homelessness?
Weblink
Go to and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource about the homeless.
Knowledge Application
Students should be able to apply the information in this section tothe care of homeless and impoverishedpatients.
Critical Thinking Discussion
What are some resources for the homeless and impoverished inyour community?
5 / XV. Abuse—Child Abuse
A.Abuse is any action or failure to act that results in unreasonable suffering, harm, or misery to a person, whether physical or mental (e.g., child abuse, elder abuse, and partner abuse).
B.It is the EMTs responsibility to make notifications of any suspicion of abuse to the proper authorities according to your state’s guidelines.
C.Child abuse occurs when a child (newborn to 18 years in most states) falls victim to abuse or neglect.
D.Abuser can be parent, siblings, stepsiblings, stepparents, or anyone else responsible for the child’s care.
E.Physical abuse occurs when improper or excessive action is taken as to injure or cause harm.
F.Neglect is the provision of inadequate attention or respect to someone who has a claim to the attention.
G.Emotional abuse occurs when “a child is regularly threatened, yelled at, humiliated, ignored, blamed, or otherwise emotionally mistreated” (most difficult to prove).
H.Sexual abuse is said to occur when a child is subject to an older child or adult’s advances that have a sexual nature (contact and noncontact events).
I.Adult (care giver) who abuses a child often is evasive or hostile and may give contradictory information. / Discussion Question
What are some indications of child abuse?
5 / XVI.Abuse—Elder Abuse
A.Abuse can occur in care centers, other medical institutions, or home.
B.Those at highest risk
  1. Bedridden
  2. Demented
  3. Incontinent
  4. Frail
  5. Those with disturbed sleep patterns
C.Geriatric neglect is the withholding of attention or medical care to which the victim is entitled (active or passive).
D.Physical abuse can involve hitting, unnecessary restraining, shaking, or shoving.
E.Sexual abuse is said to occur when there are unwanted or unwarranted advances of a sexual nature.
F.Financial abuse consists of the care provider exploiting the material possessions, property, credit, or monetary assets of the elderly patient for personal gain.
G.Emotional or mental abuse may include verbal assaults, verbal insults, ignoring the elderly patient, or threats of physical harm. / Discussion Question
What are some indications of elder abuse?
10 / XVII.Abuse—Accommodations for Victims of Abuse
A.It may be difficult for the EMT to determine whether pediatric or child abuse has occurred.
B.Signs of abuse may be physical (e.g., bruises, bite marks, lacerations, broken bones, rope marks, scalding burns) or emotional (e.g., depression, fear, inadequate or inappropriate coping skills or mental status).
C.Priority is to provide emergency care for the injuries.
D.Take into account the age group during treatment (e.g., emphasize airway and respiratory components in pediatric patient; trauma is usually worse in geriatric patient).
E.Do not confront the family or care provider with suspicions of abuse; make suspicions known to the receiving hospital’s staff so that they can follow up with the proper authorities.
F.Remain objective in your documentation for a suspected victim of abuse.
G.Follow local protocols or state laws regarding reporting of suspected abuse. / Weblink
Go to and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource about intimate partner violence.
Knowledge Application
Students should be able to apply the information in this section to the assessment and management of abused or neglected patients.
15 / XVIII.Technology Dependence
A.Shifting of patients from an in-hospital setting for ongoing medical care to the home setting which has increased the number of health care providers who function outside of the hospital and increased the use of medical technology
B.Remain abreast of trends in home-based medical technology as many calls may be for medical equipment that has failed or is no longer providing the needed support.