Emergency medical providers are regularly called upon to care for special populations with unique healthcare needs. While it is estimated approximately 20% of the population in the United States has some form of disability,1 those patients with developmental conditions, in particular, may pose distinct challenges in the prehospital setting. These conditions may either have unique medical issues associated with them, or may force the EMS provider to use different approaches for common issues.
It is important for EMS providers to recognize the basic elements of many disabilities. Detailed appreciation of certain aspects, such as pathophysiology or long-term management, can be helpful in some cases, but is often less pertinent in the emergent situation. On the other hand, these groups are at a greater risk than the general population for conditions such as respiratory failure or infections (e.g., urinary tract infections associated with long-term indwelling Foley catheters, or respiratory infections which may result from motor weakness or severe scoliosis). Still, the initial stabilization of these infections and many other conditions is largely the same.
Therefore, this article will instead focus on the unique factors affecting prehospital care or possible complications, reviewing some common disabilities healthcare providers should be prepared to encounter in the field. We will focus on those aspects of care which are managed differently from the general population. In all aspects of care for patients with disabilities, awareness, preparation and flexibility in a provider’s approach are crucial.
It is important to note, however, that each condition will only be covered as a brief overview. This article intends to be a primer, with EMS providers encouraged to explore each of these disabilities in more detail as pertinent to the specifics of their practice setting.
Cerebral palsy (CP) is a non-progressive disorder of movement and posture caused by a brain injury in early development. Cerebral palsy is not a disease; it is a collection of symptoms, and most common is the spastic variety (70%–80%).2, 3
Issues affecting patient care: Medical conditions associated with cerebral palsy include malnutrition due to swallowing and feeding problems; mental disabilities; seizures; urinary incontinence; difficulty with hearing, vision or speech; and spasticity with joint contractures.3 To decrease this spasticity, patients may have a baclofen pump implanted. EMS providers should note the possibility for pump failure.4
Orthoses are braces that support or correct musculoskeletal deformities, and may similarly address flaccidity, spasticity or contractures. They are generally named for the body parts they cover, such as the ankle-foot orthotic (or “AFO”).5 Still, spasticity may persist, and it is important to position these patients with supportive pads under areas of high pressure, or in the gaps between the body and the stretcher. Do not attempt to straighten a spastic extremity for any reason, such as taking blood pressures, starting IVs or splinting. Extremities should be splinted in their baseline position. Spastic extremities may also give unreliable blood pressure readings.
Because individuals with CP may have dysarthria, healthcare providers should be prepared to communicate with augmentative communication devices such as a communication board. Communicating in whatever way is easiest for the patient will assist patient care. The provider must be careful, however, not to make assumptions regarding intelligence based on communication difficulties. Although there are high rates of cognitive disabilities associated with CP, many individuals are highly intelligent.3,6 As with all patients with disabilities, the provider must gauge an individual’s ability to comprehend and interact on a case-by-case basis.