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Patient Care

Responding to Special Needs

      It's suddenly a bad day. The cold rain that had been forecast unexpectedly turned in the midmorning to ice so heavy it snarled traffic and began to tear down power lines already covered with wet snow. After a number of minor motor vehicle crash responses, Attack One is dispatched to a local school for a report of an ill girl.

   When crew members arrive on scene, the buildings are completely dark. They recognize the school as one that accommodates students with special medical needs. They have been there in the past to deal with emergencies for students using special modes of conveyance, as well as ventilators, nebulizers, infusion pumps and other devices.

   Inside, a school official guides them to a classroom where a number of students have been placed. On the way, he explains that the school has a sophisticated backup power generator, but for some reason it didn't turn on when the power went out. The school's emergency maintenance personnel have been activated, but can't get to the school through the icy streets. The entire school system has now cancelled classes, and the buses and parents are trying to get in to pick up all the students.

   The student for whom the call was received isn't acutely ill, but is being supported by a ventilator. The ventilator has a backup battery that isn't functioning, and there is no backup power in the building. The child needs support from the device, and is also due soon for a nebulizer treatment from another device. School officials have contacted her parents, but they can't get to the school in any short period of time. They've instead asked if the child can be removed to the hospital for support. The child's first vital signs are normal, but the nurse overseeing her reports she will need some type of ventilatory assistance before long.

   The Attack One crew leader recognizes there are likely to be other medical needs among students in the school, so he breaks away to evaluate other children in the building who may have powered devices rendered nonfunctional. As he finds those students, he asks if they can all be colocated in one room to facilitate care and prepare for orderly discharge.

   The girl with the ventilator has a special wheelchair and will require a different ambulance for safe transport to the hospital. It will take significant time for the vehicle to make it through the icy streets to the school, so the Attack One crew prepares to assist ventilations and deliver a nebulizer treatment to the patient. She has a tracheostomy in place, and the bag-valve mask device and adaptor will fit the tube. The crew fits an inline adaptor for the nebulizer and delivers an albuterol mixture to the patient. They also establish communication with the local children's hospital to advise them of the situation and confirm they will be transporting the patient in her wheelchair and using the BVM to assist her respirations.

   By now the room includes several other children with devices that have lost power. Among these are two with infusion pumps and one who needs a nebulizer treatment. The nebulizer treatment can easily be administered using the device from Attack One's supply, but the child requires medications, typically in the possession of her caregiver, that are not within the crew's standard protocols. The medical control physician from the children's hospital approves delivery of these medications using the nebulizer, and the crew documents this approval in their care report. Upon getting her meds, this child is fine to go home with her parents.

   The infusion pumps are more problematic. The two devices are the same model, and both have a trouble alarm indicator unfamiliar to the caregivers responsible for the children. Both devices are stamped with troubleshooting tips, but the instructions do not include the problem shown, and neither device is functioning. The caregivers locate a hotline number on the devices, but cannot contact it—the school's phone lines are also out of service. The paramedic instead uses his cell phone to call the expert help available from the manufacturer. After establishing contact, he hands the phone to the nurse who is the lead caregiver, and she works through a sequence of inputs to the devices that gets them functioning again.

   There are several other children who have ostomy devices in place to drain urine or intestinal contents, and their caregivers need only minor assistance with lighting, gloves and disposable bags to complete those routine patient care functions. As these children's parents gradually arrive, the children are released to them.

   By now the specially equipped ambulance to transport the original patient has arrived. The crew loads the wheelchair into the vehicle and straps it in place, and assists the child's ventilations with the BVM as she is safely removed to the hospital.

Case Discussion

   There are a growing number of medical devices now being utilized to support life or provide treatment to patients in both the hospital and the home. There are far too many for the prehospital provider to study and be proficient at using and troubleshooting them all. Consider several points in the management of these devices and the patients they are attached to.

  • Do not attempt to use any machine you are not competent to use.
  • Heed any warnings posted on the machine or given to you by the patient or caregiver.
  • Listen to the patient and/or caregiver regarding management of the device. If they have already made contact with the service/manufacturer/agent of the device, follow that person's guidance, documenting their name, company and the directions you were given.
  • Take the device to the hospital with you. Maintenance personnel can be contacted there to repair it.
  • Convey any information and contact persons to ED staff.
  • Know what you have in your EMS toolbox that can be substituted to provide lifesaving treatment. For instance, a patient on a home ventilator can be supported by bag-valve mask.

Initial Assessment

   A 12-year-old girl with a malfunctioning ventilator.

   Airway: Tracheostomy tube in the neck, and a nonfunctional ventilator.

   Breathing: No distress on initial presentation, and the child is breathing spontaneously. But the ventilator ordinarily assists her ventilations to provide adequate volume, and now the battery pack is malfunctioning and there's no direct power source available. She has scattered expiratory wheezes.

   Circulation: Good capillary refill and pulse ox readings on fingers.

   Disability: Chronic neurologic deficits, but no change from baseline, according to school faculty and the girl's caregiver.

   Exposure of Other Major Problems: Significant congenital problems have left the girl wheelchair-bound and in need of ventilatory assistance.

Vital Signs

Time HR BP RR Pulse Ox.
1102 124 100/palp. 28 96%
1110 120 100/palp. 24 96%
1118 128 96/palp. 24 99%
1130 112 94/palp. 20 99%

AMPLE Assessment

   Allergies: Dilantin.

   Medications: Nebulized albuterol, Tegretol, Cipro, baclofen, valproic acid.

   Past Medical History: Significant congenital problems necessitate wheelchair and ventilatory assistance. The girl also has asthma, seizures and recurrent pneumonia. She has had multiple prior abdominal surgeries and requires tube feedings.

   Last Intake: Breakfast about 0730.

   Event: Child with chronic respiratory insufficiency whose ventilator is inoperable due to unexpected power failure and failed battery backup.

Customer Service Opportunity

   Ill individuals using medical devices to assist body functions in home-care settings are often accompanied by caregivers who have knowledge of the devices. EMS providers should make good use of on-scene resources and any telephone advice that could aid the patient. It is important to communicate to patients, families and caregivers that you're not going to damage their devices, but will only follow instructions given by the experts. Otherwise, stick to supportive care using equipment you're skilled with.

   James J. Augustine, MD, FACEP, is a medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

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