(Transcript is automatically generated).

Matt: [00:00:00] Now you're dealing with maybe somebody that's even combative with you because they're just so scared and confused. 

Erik: So I think it's really important, you know, keep your hands up, keep, you know, speak in a tone to the care provider and to the patient. Yep. Uh, that's, that's calm, 

Matt: calm, slow. Yeah. Nice and knowledgeable.

Sound like you're confident in what you're doing.

Narrator: You're listening to EMS with your [00:00:30] hosts, Erik Axene and Matt Ball. 

Matt: So we're talking about a unique topic today. Mm-hmm. Patient, population. 

Erik: Yes. Um, you know, uh, I think, uh, I have some friends with, with, uh, children with special needs. Mm-hmm. I don't think any of us could begin to understand the difficulties. Um, yeah.

Not only that the parents might experience in taking care of a special needs patient. 'cause oftentimes unfortunately they don't live long enough to become an adult. But, and then we also have the special [00:01:00] needs patient population of adults. Yep. That we can be, never begin to understand how difficult it would be to live in this world.

Right. With a, uh, uh, a special need. 

Matt: Yeah. Well, I think it's important to define what exactly is a special needs. Like what Yeah. What category do people fall under that would be considered a special needs patient. 

Erik: Yeah. I think if I were to define special needs mm-hmm. It's, it's, uh, you know, in the EMS context anyway, it's a patient with, you know, intellectual, [00:01:30] um, challenges.

Yeah. Development, behavioral challenges, developmental challenges, um, that I think And physical challenges. Physical challenges, yeah. Those would be, I think, uh, the quick and dirty definition of a special needs patient in the EMS context. Right. 

Matt: And it's important for us as. In hospital and out of hospital providers to understand Yeah, you know, their world a little bit and how they respond to things, how they communicate.

You know, like autistic [00:02:00] kids, you know, you know, some of them are nonverbal. So how do we communicate as first responders with these, these, these patients, you know? Um, that's super important for us to know how, because we can't do a proper assessment if we can't. Properly communicate with our patients.

Erik: Right. And some of these patients, as we get to that, we'll talk about how we really communicate. Sometimes you can't communicate with the patient, you're gonna be talking to their caregivers. That's right. Which is a huge thing. You don't, if you don't access that, you're really missing the boat. 

Matt: Yes. This is one patient population, just like any [00:02:30] kids like mm-hmm.

You know, I think most pre-hospital providers are pretty good about incorporating the parents. Typically the parent is on scene when you have a pediatric patient or else that kid's gonna be freaking out. Um, and I think that's similar to a patient with special needs right. Is that that caregiver is their safe space Yep.

And we want to utilize them that this is the time that, you know, that caregiver's riding in the back of the ambulance with me. Yep. Because that is my patient safe space that's gonna keep them calm and allow me to do what I need to do as a paramedic. Yep. [00:03:00] Um, in the back of the box and help with assessment mm-hmm.

And communication and all those different, and understanding what's their baseline. Yep. You know, what, what are they always nonverbal. Or, you know, can they talk, are they able to answer these questions? 

Erik: I think you brought up a really good point is that this, there's a, there's a spectrum of disease within each of these categories of special needs.

So yes, like we said, within that EMS context, the physical challenges, this, physical barriers, uh, it could be, uh, an adult that without legs or it could be a [00:03:30] child vision impaired. Yeah. Like the am the, uh, well, I think it's called, uh, amniotic band syndrome. Uh, I know there's a couple NFL athletes that had, uh, uh, poor limb development because of, of some amniotic or gestational sort of complications.

Right. So those physical, I mean, uh, mentally the brains are, that wasn't affected, right? It's just they, they don't have. A fully functional arm, right? Or whatever, right? Um, the intellectual stuff, the intellectual disabilities, the [00:04:00] intellectual barriers where maybe it's because of cerebral palsy or, uh, some, some traumatic brain injury.

Matt: Autism, developmental delays, right? 

Erik: Developmental delays. Uh, those, those intellectual and developmental delays create some barriers in communication, some barriers in treatment. You know, where this adult, uh, I'll never forget. Great story. 

Matt: Okay? 

Erik: Uh, I went to a special friends prom. Oh yeah. Yeah. And I was in the

Matt: Tim Tebow thing?

Erik: Yeah, it was like that. But it wasn't with Tim Te Oh. It wasn't the actual, okay. But Tim does a great job. 

Matt: [00:04:30] Oh, he does. He's a phenomenal human. Yeah. 

Erik: Uh, he really is. I got to see, uh, we did a fundraiser with him. We got to meet him and, and, uh, we, um, got to see some video footage of his special friend's prom that he's a part of.

But we did one at our church. Oh, okay. And I'll never forget, it was so special. In fact, this, this my special friend that I took to the prom. 

Matt: Oh, you actually took somebody to 

Erik: Yeah. Well, what the, it kind of match us up. With, with a special friend. Okay. And I went to the prom and, and it's like a fair kind of a thing.

Yeah. Yeah. Where we [00:05:00] would, uh, um, take 'em to different booths and play games and, and it was just a fun Yeah. Party atmosphere. We took lots of pictures. It's really celebrating them and having a good time. Yeah. They don't get to do a lot of these things living in their group homes. Right. And whatever. So, um, my special friend, um, has some developmental and intellectual barriers mm-hmm.

Um, that make it difficult, but I remember when I, I, um, I met him, uh, tons of joy. I mean, [00:05:30] love playing games. Yeah. We had a really good time together and, uh, I, I was, uh, it was interesting. I, he's 47 years old. 

Matt: Oh, okay. 

Erik: I had no idea. I mean, he looked younger than that. Yeah. Um, but, um, but, uh, functionally though.

Matt: Yeah. 

Erik: Um, and trying to treat him if there was a medical emergency with him as a 47-year-old male. Right. Um, it would be difficult for me to communicate with him. Like I could a, a maybe a, not normal, but a typical 37 year, 47-year-old who I could [00:06:00] articulate, Hey, you're having a heart attack. Right. With, with speaking to my friend, uh, who's 47 with some intellectual barriers, uh, it would be very, very difficult for him to understand what's going on.

Right. Comprehend what's happening, and you'd be communicating to this individual much different than you would someone like you about the same age. Yeah. Um, right. 

Matt: I'd like to go back a few years. Yeah. Right. I know. 

Erik: But, but I think that's true. So whether it's a physical barrier or intellectual, developmental, and I [00:06:30] can't remember the fourth one we talked physical about Oh, sorry.

Yeah. Yeah. 

Matt: Physical, 

Erik: uh, these, these, uh, these delays, uh, or barriers, I like the word barrier. Yeah. Um, really creates some, some challenges for us in the EMS community Sure. In treating this very real patient population that oftentimes actually has more medical needs because of some of their comorbidities.

Right. Some of these patients are trach dependent because of some physical and developmental and cognitive congen, whatever the barrier might be. Uh, a G-tube dependent, you [00:07:00] know, feeding. They can't eat like us, but they, um, eat with, you know, get their nutrition through a G-tube. Yep. Um. You know, like with some trach or ventilator, you know, there's a lot of challenges for us in the pre-hospital environment to treat these patients with very real medical conditions.

Matt: Yeah. Yeah. I think the biggest thing is back to communication. 

Erik: Mm-hmm. 

Matt: With all of these, whatever their, their barrier is, whether it's vision impaired or hearing impaired, or developmentally impaired, whatever it is. Yeah. [00:07:30] Communication is gonna be the number one thing that is gonna be difficult for us as first responders in dealing with these patients, and that's where their care caregiver, whether it's, you know, a, a, a caregiver from a group home or the parent.

Is gonna be crucial Yep. In bringing them in because if they are hearing impaired, that person probably knows sign language. That's right. And can communicate. Right. Uh, if they're vision impaired, then obviously they can hear 

Erik: what did you do in the back of an ambulance if [00:08:00] you had a patient that was hearing impaired.

Yep. Um, what would you do to, to communicate with them? Is there anything you can do? 

Matt: Oh, always. Well, uh, there's no, we don't have any resources for hearing impaired uhhuh. Um, we don't have any resources that I know of. Like we have language line if somebody speaks a different language. But obviously, you know, we do have some people in my department that actually spoke sign language a little bit enough to get by.

Yeah. Um, or you could write stuff down, obviously with somebody is hearing impaired. You could, which I've only had a, a very [00:08:30] small one or two patients in my career, and so we would write stuff down a lot. But again, too, like that's been an issue too. You might think there's something medically going on with the patient.

And because they're not answering you. Yeah. And you might think they're altered or they're overdosed on something and it's like, no, they just can't hear you. Right. You know? Yeah. And then the typical fire response is, well just talk louder. No, man. Yeah. So, uh, writing things down for hearing impaired, you know, vision impaired, you know, obviously they can hear you and normally they don't have any, 

Erik: you could, you could have to do more [00:09:00] talking.

Yes. Just to help them to understand what's happening, 

Matt: physical touch. Like, you know, hey, you're gonna surprise them if you reach over and you go to start an IV on them, or I'm coming to grab your hand. Like, you're gonna have to explain, use, uh, use a lot more verbal because they don't have that sense of sight to see what you're doing.

Erik: I think we sometimes forget that a sighted, a person without a visual impairment, um, it, there's a lot of communication just by what we see and do. Yes. You know, that's another point. We've actually talked about this in previous episodes, where most of the communication [00:09:30] that we have is in tone and body language.

Right. So when you're visually impaired, uh, you don't get a lot of that. You're gonna have to over-communicate what you're doing, what you're planning to do, where they can see reaching for an iv, they know what's gonna happen. Yeah. Where when you can't, you've gotta, you know, talk about it. That's right.

That's interesting. My daughter's taking sign language. Oh, cool. Um, instead of Spanish, uh, she's decided to get, uh, American Sign Language and I'm excited for her to have that. Yeah. The capability to be able to communicate with hearing impaired folks, I think that's a, a neat skill. 

Matt: [00:10:00] Super cool. 

Erik: I've noticed though, too, in the ER, I've had patients now in the er we have, uh, like iPads where we can Yeah.

Have a virtual experience where there's a sign language person mm-hmm. And that helps to, I think, make the efficient or, or the communication more efficient. Sure. Right. This is better Yeah. Than writing it down. Yes. Oh, for sure. But at least it's something, right? Yeah. But they're also, oftentimes I've found just expert at reading lips.

Matt: Oh, you are? Or they are? They are. Oh yeah. Not me. Yeah. Yes. Yeah. They are very good at that. 

Erik: Yeah. I [00:10:30] was, uh, I was spying on my, my neighbors the other day through the window, and I could read their lips and they were talking about some weird neighbor they had. 

Matt: It's like, that guy's an idiot. Joking. It's just joking.

And they're pointing in your, it's a bad joke. No. And, but I think the other thing is, but you know, when you have like that autistic patient uhhuh Yep. That is nonverbal. Right. You know, and not only are they nonverbal, um, they're processing information coming in differently Yep. Than you and I process information.

And [00:11:00] so being very cautious in how we're communicating. Yes. But that's where, again, that caregiver is hugely important in getting them on board and helping you communicate with them to communicate with your patient. Yep. Finding out what's going on with them, if there's anything you need to do that's hugely important.

Some of them do not like to be touched. Right. Patients with, some patients with, you know, autism, they do not like to be touched. Yep. And so if you're in a situation where you know you have to put your hands on them for a treatment [00:11:30] purpose. Crucial how you communicate that with them. 

Erik: You know, if I could give you advice, uh, only because as a teacher I had to teach a lot of kids with autism.

And uh, and it was a challenge oftentimes where, and I told you before we filmed, uh, you know, I couldn't redecorate my room. 

Matt: Oh yeah. 

Erik: Without, be very careful even to change our, the environment, uh, 'cause that could trigger some, some things. But you have to think about if, if, if there is a 9 1 1 call. For a patient that happens to be autistic, can you [00:12:00] imagine how much of a break from their normal pattern?

Just that as alone? 

Matt: Yeah. 

Erik: I mean, if you can see somebody struggling or maybe even physically res, you know, having to be restrained by their caregiver just to get 'em to the ambulance. Do we really need a blood pressure and a heart rate? Yeah. We know their heart's beating. I think they're okay. Yeah. Having, putting, putting on the blood pressure cuff could really throw 'em over the edge.

Yes. Or the pulse ox on the finger even, you know, you know what, uh, let's not worry about the vital signs right now. You [00:12:30] know, I, I think that's just a, a, a for me and in the ER oftentimes that's just not a battle. I'm going to a hill I'm gonna die on. Yeah. I, I just, you know, eventually when you're gonna need some vitals, but, you know, maybe let's build some rapport and some trust first.

Exactly. You know, I think you gotta be very careful. On how you spend your equity on patient contact with them. Yeah. Too much contact, too much changes and crazy things. 

Matt: Yep. 

Erik: Could push 'em over the edge. Just push light 

Matt: sirens right on their apparatus. Like, turn those off if, [00:13:00] if needed. Yep. Turn those off.

Don't overstimulate. Yeah, that's it. Again, have the caretaker with you to keep them calm. You separate them from their caregiver. That could be a huge, another huge thing that could, you know, set them off and now you're not getting anything done. You know, now you're dealing with maybe somebody that's even combative with you because they're just so scared and confused.

Erik: Right. Regardless of the physical or emotional, or not emotional necessarily, or behavioral, I guess. Mm-hmm. Um, uh, intellectual, developmental, whatever it is that's [00:13:30] creating a barrier for care. Um, I think that being patient and, and this isn't gonna happen the way a normal patient. Is treated. Yes. It's gonna be a different process now.

Yes. So forget about expectations on what you would have in a typical patient interaction. 

Matt: Forget about your sample history, forget about OPQR, 

Erik: right? Yeah. Uh, we'll get to communication later, but, uh, you know, just don't expect those, those, those steps that you take for granted that are easy mm-hmm in a typical patient interaction, [00:14:00] not gonna be the same, are not gonna be the same, probably not gonna be the same.

And I think being patient and willing to, to take your time. 

Matt: Mm-hmm. 

Erik: Now listen, if there's an emergent thing, I've had special needs that need to be intubated emergently. That is what it is. So, I'm sorry, but there's no time for. You know, being nice and talkative and, you know Yeah. And building rapport with verbal whatever.

You gotta save lives, right? Yeah. That, that's, that's a, a choice that you're gonna have to make a decision, you're gonna have to make early on. But yeah. Uh, [00:14:30] we're not talking about those. 

Matt: Mm-hmm. No, we're just talking about the, the standard patient and just dealing with them. Mm-hmm. You know, from their standpoint, what keeping them comfortable and communicating with them, that's a huge part of it.

Erik: The other thing that I think is maybe the most important thing that we could talk about with taking care of a, uh, a, a patient with special needs mm-hmm. Is to recognize how absolutely important it is more than most patients to involve caretakers and to respect caretakers. Yes. Parents, whoever it [00:15:00] is, facility, you know, assistants and whatever that are there.

Matt: Maybe they have a nurse that's with them or whatever. 

Erik: Right. This is. Becomes paramount. You absolutely. This is not a load and go thing where you didn't get all the information you need you absolutely crucial to understand the baseline of the patient. Yep. To understand that all of the concerns that the staff had in calling 9 1 1.

Yep. 

Matt: If they are on a vent, if they have that G-tube or something like that, typically, I've had numerous patients, little kids that had trachs [00:15:30] and they're on a vent. Right. Well, even as a nurse, like I don't deal with vents much. Yeah. I don't deal in a critical care environment. So that mom typically is an expert on how to run that vent.

Yeah. They know exactly what they need to do. They know exactly what their O2 SATs normally are. 'cause you might be seeing 90% thinking, oh my gosh, we gotta get Nope, that's normal. Yeah. That's his normal. Yeah. Right. But they know how to run that equipment. If I've had numerous ones, we get called a lot a mucus plug.

Yeah. You know, they know how to swap those things out. Right? Yeah. Oh yeah. Um, but you know, I think that's [00:16:00] undertrained on. You know how to deal with those patients. You can put a BVM right on that thing. It's called, you know? Mm-hmm. And you can just bag your patient that's on there. Suction is your best friend.

Yeah. But again, like you said, the caretaker, the parents, a lot of times with the pediatric population, the parents are experts. They are absolute experts because not only, I mean, obviously they love and care for their children. Yep. Right? So they want to know everything that they need to know about, you know, caring for their child.

So definitely utilize them. Take them in the back. Yep. With you on the way to the hospital. [00:16:30]

Erik: One short story I'll say, before we end this first part of our, our podcast, 

Matt: I keep be honest, I don't know. I'm bored you. Oh my gosh, doctor. No, I don't know what it is. I'm yawning today. Go ahead. Your story. 

Erik: No, no.

It's, uh, I, I, it's a pretty common experience that I've had in the ER anyway, is when we get a patient with a very complex medical history. Mm-hmm. Uh, a g-tube dependent, trach dependent. Yep. I mean all of the vents and everything. Yep. It makes this patient with all of these medical [00:17:00] barriers look very sick.

Matt: Yeah. 

Erik: And a lot of my doctor colleagues will immediately start pressing the transfer button to a pediatric facility that can handle these, these things. Right. But I, one thing I would do is I would, I would hesitate, uh, to, to, because you know, you may not be pushing the transfer button Right. But you're pushing the button to go, okay, let's, let's get this patient to the ER right now.

Matt: Yeah. 

Erik: Diesel, right? Yeah. That's basically what a doctor is tempted to do when transferring somebody out. Mm-hmm. But one other thing I would [00:17:30] say is, and tied to what we just said is respecting the caregivers Yeah. Is to, it's been so often that I've had a patient that would come in and they've got the, the, the chair, the, the mechanical kind of, uh, um, uh, wheelchair, you know, out there.

Yep. And the ventilator and the, the feed bags are hanging. Yep. And they got all the bags of stuff that they need to, wires everywhere with came. Yeah. Right. Um, it's, it's actually. Not tempting, but it's, it's easy, um, to just think to [00:18:00] yourself, wow, this patient's sick. I'm gonna, I'm gonna get them admitted and I need to transfer them.

Yeah. But if I talk to the caregiver and say, no, actually what you're seeing right now is the baseline. My kiddos actually, I think they're okay. Yeah. Here's my concern. Yeah. They yanked on their G-tube. I'm concerned that maybe the GT tube's not hooked up. Right. Right. You know, there may actually be a pretty benign issue, even though the patient looks medically fragile and And scary.

Matt: Yeah. 

Erik: Is to really put a lot of weight. On that caregiver story and get that [00:18:30] context. There's no more important thing that you can do than to communicate with the caregiver with some of these patients that can't communicate for themselves. 

Matt: Yeah, for sure. No, that's good. 

Erik: There's a lot of really interesting things we're gonna talk about today.

There's some legal implications here mm-hmm. That you want to really be careful of. Mm-hmm. That we'll tell some stories. Uh, there's also a lot with caring for managing if just physically moving. Yes. There's a lot to talk about. We'll hit those up I think. Uh, here next. 

Matt: Alright, so part one we kind of [00:19:00] defined what special needs patients are, the different types of a special needs patient physically, developmentally delayed.

Yeah. Emotional, mental. 

Erik: And, and those needs. I like it. We kept using the word barriers. Barriers, those really special barriers. Barriers you don't normally have to overcome. Right. To treat patients. Right. 

Matt: And in this part we're gonna talk about, and we talked about it a little bit there, but the biggest one is communication.

Erik: Yeah. 

Matt: Right. And a lot of that is not just the words that come outta your mouth. There's a lot of things, and you mentioned it in the first part about how we [00:19:30] communicate. Right? 

Erik: Reminded me of Chris Tucker. 

Matt: Chris Tucker, you understand the words. Do you understand the words that are coming outta my mouth?

Uh, Chris Tucker. He's funny. Anyway, sorry. Um, but yeah, so how we approach the scene, right? Mm-hmm. Like coming up to that scene, like a huge thing and, and, and really this goes to any call is as first responders, we gotta remain calm. Like if we start freaking out, I've been on these calls. Mm-hmm. Or we've all, you know, been on those.

Fires where, you know, command gets on scene and they're yelling and screaming and [00:20:00] everything just gets amped up. Everybody's like, holy cow, what's going on? Right. Being calm. Yes. And you just the opposite. You have that incident command that's super calm and you can watch these videos and it's always impressive.

One of the most impressive videos I've ever seen was the Beacon Hill Fire famous fatality fire. Super unfortunate event happened in Boston, and you can hear the radio transmissions between the firefighters that are trapped and that guy is so calm. I mean, I've heard a lot of [00:20:30] transmissions in my years of these, you know, mayday and stuff.

Yeah, yeah, yeah. And even like guys that are, you know, heavy duty firefighters, FDNY, Dallas, Boston, Houston, you know, when you get put in that scary of a situation. You know, that's terrifying. Right? But this fire, this guy was so calm, so calm the whole time. Like never freaked out. And but again, that's how we have to approach these patients, right?

Yeah. If we come in there and we see a kid laying in a bed with a G-tube and he's got a trach and he's got all these, like you said earlier. Yeah. Why are some buttons, we have a tendency [00:21:00] to go, holy cow, I'm outta my lee here. Yeah, yeah, yeah. I don't know what I'm supposed to do. And we start freaking out.

Even if you're, it's like the, I always think of the duck on the water. Everybody's heard that analogy on top. He's nice and smooth and calm. And underneath those feet are just like inside your brain's going A mi million miles a minute. Yep. But outside. Calm down. Stay calm. Stay calm. Don't freak out. Yep.

And then the other thing we talked about extensively was utilizing the parent and the caregiver. 

Erik: Yeah. And that's really part of the challenge here, uh, as we talk more about communication, is that you're not just dealing [00:21:30] with one patient. 

Matt: Yeah. 

Erik: And that's, it's even true for pediatrics from time to time.

There are some barriers there with age and Yep. And cognitive ability, but that's normal and expected. Yeah. But with this patient population, the challenges and barriers are pretty diverse. Yeah. And it's so important that when you're communicating and a lot of the communication and all of it sometimes might be with the caregiver.

Matt: Yep. 

Erik: And having a, a respect for the caregiver and building that trust with the caregiver and the rapport with the caregiver where the patient will feel comfortable [00:22:00] seeing you getting along with the person that they know and trust. 

Matt: Yep. A hundred percent or the, yeah. The caregiver, A lot of times that could be an LVN, if you're dealing with a pediatric patient with a lot of comorbidities, they're gonna have probably an LVN Normally that's not an RN, could be an in-home RN, but a lot of times it's an LVN.

But they're still extremely knowledgeable on that patient. They have probably been dealt with that patient for months, if not years. Yep. They know everything about that patient. Right. And they can tell you that 

Erik: I have a story. I, I was treating a patient once and, and, uh, [00:22:30] uh, I could see they didn't speak English after I came in speaking English.

Mm-hmm. And so I immediately assumed they were Spanish speaking and I started speaking in Spanish and they were, they were Persian. 

Matt: Oh, okay. 

Erik: I'm like, oh gosh, I feel like such an idiot. Just, you know, stereotyping them and like most of the time it's Spanish, and then they're Persian and, 

Matt: yeah. 

Erik: You know, one thing I have done, I was an attending up at a medical school just north of us.

Mm-hmm. And, uh, huge medical school and, uh, teaching my, my baby [00:23:00] doctors. Mm-hmm. Uh, I remember one of the things that I, I, I would see, uh, in patients that, and sometimes it was from a language barrier. Mm-hmm. But I also, I'm thinking of a specific story right now with a patient that had special needs. 

Matt: Okay.

Erik: Uh, who was fully cognitive. Everything was fine. It was a traumatic brain injury in the past. It just affected their speech. 

Matt: Okay. 

Erik: Um, but they would talk. To them really loud. And you know, it's like, wait a minute, this, this person, this adult Yeah. 

Matt: [00:23:30] Totally understands why he's not hearing impaired. Why are you talking to him this way every single time you get a patient almost without fail in the fire service.

Yeah, I bet everybody that's in the fire service listening to this podcast has been on a call. Yeah. Where somebody speaks Spanish or another language and instantly somebody on the call just starts talking louder. And I've literally looked at a dude one time and I'm like, bro, they're not deaf. I know they just don't speak English, you know, but it's just our natural, well, even if they're, they talk louder, it'll get through to 'em.

Right. 

Erik: Even if they're hearing 

Matt: impaired. Talking louder isn't gonna help. Right. 

Erik: Or if they're, [00:24:00] they're visually impaired, like you don't have to talk. In fact, when somebody's blind there, their sense of better pain is even more acute. Better. You're blowing out their eardrums, bro. Calm down. It's funny how we tend to do that.

Be aware of that. Yes. You know, is that we have that tendency sometimes to not fully understand the situation of the patient. So be slow to really take your time to understand the context of things. Right. And you know, as you start to get to know the patient a little bit, you get to know the caregiver, you start to get the context.[00:24:30]

Don't just jump in like a bull in a China store and, you know, talk in Spanish to that Persian speaking. Right. That kind of thing. Right, right. It's, uh, it's important to get the context because your communication is key in these things. You need the information. Yeah. To properly care for them that seven minutes of time or if you have longer transports in a rural area mm-hmm.

Can really make the difference. 

Matt: Huge difference. Huge difference. Yep. Huge difference in your overall care and the patient's experience as a whole. Yeah. So walking [00:25:00] into these situations calmly, once you real, you know, you see like, oh, this is somebody with special needs. Maybe they're in a wheelchair, or whatever the case may be, is there a caregiver on site, uh, go to that caregiver and like you said.

You know, Hey, what are you calling us for today? Right? Mm-hmm. Don't freak out 'cause they got all these things. Maybe all that's fine, right? Oh, they're just, I wanna make sure that their G-tube is still in the right place. Like, oh, okay. That's all you're calling for. You just need to, yeah. The other thing is destinations like transport destinations.

Mm-hmm. Like what hospital's gonna be best for you. Yeah. And [00:25:30] be mindful of that, that you might have to drive an extra 10 minutes. Yeah. Right. To take the patient to the appropriate facility. 

Erik: Right. Yeah. And be very careful. We have a tendency to see somebody in that electric chair with the G-tube with the vent and think pediatric.

Matt: Yes. 

Erik: The patient's 35. Exactly. 

Matt: Yes. 

Erik: Be careful. Yes. You know, you don't wanna show up at the pediatric hospital with a 25-year-old. Yes. Because you assume they were a kid. Yes. When not all kids. That are trach dependent with a [00:26:00] G-tube are pediatric. That's right. A lot of them are, yeah, be very careful with age because they are still categorized by age.

Now some of these kids, uh, you have to be very careful because some of them actually have a special agreement with a children's hospital. Yeah. To maintain their treatment as a 25-year-old. Yeah, 

Matt: yeah. 

Erik: Because of the special needs and because the specialists are there that know how to treat 'em, they're oftentimes transferred to the adult doctors, but some of them at what might be defined as an adult is still being cared for at the pediatric hospital, [00:26:30] absolutely important.

You communicate and understand and involve the caretaker in all these. Decisions on transport. Yep. Decisions on, on treatment. Yep. Right. Yep. Decisions on whatever, everything. There's so many things that, uh, we gotta be careful on in communicating Yep. To these patients and caregivers. 

Matt: When I was in nursing school, I was doing a clinical, at a pediatric facility.

Mm-hmm. And we were up on a meds search floor, and they had this patient in there, nonverbal, I think, I believe he was autistic. And he [00:27:00] was only like maybe three years old. He was a little guy. And, uh, nonverbal didn't talk. He had this thing, he would grind his teeth. Mm-hmm. I mean, like you could hear that noise and he would just sit there constantly, like you could look at his teeth and ground it.

Erik: Oh yeah. It makes me cringe. 

Matt: Oh yeah. It was, I felt terrible, that sound. But he was an orphan. 

Erik: Oh, really? 

Matt: And he would come into this facility all the time. I don't remember the story behind what happened with his parents or anything, but I remembered over my 12 hour clinical in there. Mm-hmm. Kind of forming a little bit of a bond.

You, [00:27:30] because you can kind of sense like when you're, when you're communicating with them Yeah. Or when they're responding positively to you or negatively, you can sense that. Right. Even though this little guy couldn't say anything to me, I could sense that he was responding positively to me, by the way, his body.

So not only do we have to be cognizant of how we're communicating, we have to be mindful of watching their body language. Right. Yeah. And like, again, hopefully, like we didn't have any caregivers. The nurses that were there were his caregivers. [00:28:00] Right. So we, we didn't have somebody to tell us this is his norm.

We just had to kind of go off of instinct to figure out. Oh, this is a positive thing. Oh, he doesn't like that. Right? Yeah. And so, but again, most of the time pre hospitally, I would say most of the time you're gonna have somebody there, LVN, caregiver, parent a lot of the times and they're gonna be able to tell you, like are like, ask them, mom.

Are they nonverbal? Mm-hmm. Is your autistic son or daughter, are they nonverbal? Yeah. Okay. What are their triggers? Because that's a huge thing. Yeah. Triggers, yeah. With the autistic [00:28:30] population is. You know, again, we talked about it in the first part. Loud noises, lights, they don't like change. Some of them absolutely do not want to be touched.

Mm-hmm. Right. Maybe they have a favorite toy or a favorite thing that they like to hold or do. They're very tactile with their hands. Right. Let them have those things to keep them calm. Right. Right. But again, back to the caregivers communicating with them. Mm-hmm. Finding out those that important information to help keep your patient calm is gonna make that call go a lot smoother.

Erik: You know, the other thing that I think is important, we. We, I think [00:29:00] we've kind of really nailed it, uh, as far as the history and how important it's to get a good story mm-hmm. To involve the caretaker. Yeah. Because the history is so much more important in these, these patient interactions with all these barriers we're dealing with, getting a full story is crucial, whereas with a normal, uh, typical, not normal, typical patient interaction, uh, you can get by maybe with a truncated history right here, that's really not acceptable.

You have to have a full history. Yeah. The other thing that I'll say we haven't talked about much yet [00:29:30] is physical exam. Yeah. Those, those objective things. Yeah. We, we, uh, as providers, um, you know, sometimes we'll do a real cursory physical exam because we know the chief complaint is x, y, z, like a ankle maybe, or a trauma with a, a broken arm.

Matt: Right. 

Erik: We, we will do a truncated physical exam or a focus physical exam. In these cases, we really can't because most of the time the chief complaint is, you know, something's wrong. I I can't figure it out. Yeah. Uh, normally [00:30:00] Johnny is acting a certain way. Right now he's acting really agitated or Yeah. He's really not acting right.

He's really seems a bit altered here. This isn't his normal, um, behavior. Yeah. And so your physical exam becomes so much more important now, just like the history we're noticing the, the cyanosis at the fingertips or looking in the mouth and you, and you see these lesions or, uh, 

Matt: listening to breath sounds, 

Erik: listening to breath sounds.

Yes. Listening to the heart. Listening, uh, palpating the abdomen. Mm-hmm. [00:30:30] Wow. He push on the belly. He's real firm and rigid and, and you touch him, moves away. Yeah. Yeah. He's crying now and you know, well he's, you know, you might be dealing pain an appendicitis, right? That's right. Who knows? The, the thing is, is that, again, the caretaker is so important now.

Mm-hmm. Asking the caretakers specifically. In the caretaker's defense, they may assume you just know this. 

Matt: Yeah, yeah. Right. 

Erik: Yeah. Because they're not gonna be able to communicate everything to you in a few minutes. Right, right. You, you're gonna really have to ask them, how does Johnny tell [00:31:00] you that he's in pain?

Matt: Mm-hmm. 

Erik: Right? So as you're doing a physical exam, Johnny, you're looking for that, that cue. Yeah. Right. Crying. Oh, that's exactly why I called, because I think he's in pain somewhere. Yeah. I don't know where, uh, but something's wrong, right? Yeah. And, uh, so understanding that, and, you know, the, the caretaker will be able to help you understand too, uh, not just pain.

Um, but, uh, you know, when, when Johnny's happy, he does this right? When, when, when [00:31:30] you know when he's hungry, he does that, you know, you can, they're the caregiver understands how they communicate. Yeah. And, and you need to get that information quickly so you can understand some of what's going on with Peyton.

Now they're, hopefully they're with you, so they can kind of interpret for you. But yeah, I think that's a really big part of it is, is understanding the value of a physical exam with these patients that. Can't verbalize where they're hurting. Mm-hmm. Like a normal or typical patient might be able to. Right, right.

There's that, that communication [00:32:00] barrier. 

Matt: And be gentle as you're doing these things, as you're palpating things, like be a little bit extra gentle. Yeah. Because, you know, it could, again, especially if that patient doesn't like to be touched. Yeah. Right. You gotta go through there and don't be, you know, Mr.

Knuckle dragon fireman guy and just grabbing a hold of things like be gentle, be calm, keep, keep your, uh, keep calm while you're doing these things. Uh, that'll help a, a, a huge amount. 

Erik: And on that point, I think there's some tactics that I was taught that I think are really. I use 'em on my pediatric [00:32:30] patients a lot, but there's some tactics I think that can be really helpful here.

You're, if you're just listening to our podcast, you're not gonna be able to see what I'm about to do, so I'll pretend like you're visually impaired. You're about to choke me earlier, right? No. Is that I my stethoscope, right? Uh, if I'm gonna listen to the heart and the lungs, I, I have my stethoscope out and then, uh, I don't take my stethoscope off or put it back around my neck and then put my hands on the abdomen.

They got used to me putting my stethoscope on their [00:33:00] chest. And on their, over their heart and listening and, and it's not painful. They're, they're kind of, trust me with this apparatus I have in my hand. And, and, uh, when I go to listen to the abdomen, I'll use that as a chance to palpate. 

Matt: Mm-hmm. 

Erik: I'll use my stethoscope to lightly palpate as I am listening.

Mm-hmm. So it's really not much different than what was happening up top. Right. And I keep that stethoscope on to, to maybe have the caregiver help me to lean them forward in their chair a little bit so I can listen to the lungs, which I need to [00:33:30] do. But as I'm doing that, I'm lifting up the back of the shirt and I'm, and being able to, to view.

Is there a bed sore back there? Whatever. Right? Right. Uh, so being really strategic in combining physical exam regions together in a way where there's not a huge transition between things. Right. Because you have to respect the fact that maybe this autistic patient, when you do something different, they gotta get used to that new thing again.

Right. But if you do multiple physical exams with that stethoscope, where normally you wouldn't do that [00:34:00] by trying to group together physical exam things, uh, in, in mult, you know, multiple body regions Yeah. With, with the same technique. 

Matt: Yeah. 

Erik: It can help to facilitate the transition into the different areas.

Whereas if you're doing your physical exam like you normally do with a typical patient 

Matt: not gonna work 

Erik: where you're, it's almost truncated. Yeah. It creates. A new thing. Yeah, a new thing. A new thing. Uh, so trying to be sensitive to that can be a tactic I've used. And these are the kids, but it can be good too with an [00:34:30] adult that's got some autism or some other developmental delays.

Matt: Yeah. And if you start seeing, seeing him getting irritated or the caregiver's telling you, Hey, you know, he doesn't like that. Like okay, you know, obviously you have to weigh out priority. Like, do I need to be doing this right now or is this not so important? I don't need to be, like you said earlier about a blood pressure.

Yeah. You know, because you put that blood pressure cuff on their arm. Okay, now they've got that. Now it starts squeezing really tight and they're not understanding why is this squeezing my arm so hard? Yeah, right. And I could make them and you're not gonna get a good [00:35:00] reading anyway. Yep. So. What's the point?

Right. You know, if they start moving their arms, 

Erik: so, so key. 

Matt: So yeah, it's, 

Erik: I think, you know, one thing that before we leave communication, I think we, we really should address the behavioral health issues in agitated patients. Right? Yes. Uh, oftentimes in agitated, patient is agitated because of some behavioral issues.

Matt: Mm-hmm. 

Erik: And, and I think we, we, we sometimes call it verbal deescalation. Right. But really what we're doing is what we learn [00:35:30] in kindergarten 

Matt: Yeah. 

Erik: Is, is understanding that most of what we communicate is tone. Mm-hmm. And body language. Yeah. This might be a good time to talk a little bit about the palms.

Matt: Mm-hmm. Oh yeah. Right. 

Erik: Subconsciously. That's right. No, I mean, we kind of make fun of each other with our little quirks that we have in the studio and the way we communicate. Right. But the reality is, is that when somebody sees your hands when you're talking, that's a subconsciously they're, that's a way to build trust.

Matt: Yeah. You're [00:36:00] non-threatening. Yeah. You're, 'cause you know, you look at it from a defensive perspective, if I think about a police officer Yeah. That's why you never, you know, police are always telling people, get your hands outta your pockets. Yeah. Because that's where the damage is gonna come from. Right.

Right. It's not gonna come from your head or, I mean, I guess they could kick you or whatever, but you can see their legs, right? Yeah. But it's what's in somebody's hand. Do they have a knife? Do they have a gun? Do they have some sort of weapon? Mm-hmm. If you've got your hands up like this, it's showing like, hey, and it's kind of that universal, it's almost like choking.

Right. It's that universal sign of, Hey, this is what's going on. [00:36:30] This is like a universal sign. Like, almost like I come in peace. 

Erik: Yeah. You can trust me. 

Matt: Yes. Exactly. Yeah. And that's a, a nonverbal way of communicating that to people. Hey, I'm not here to hurt you. 

Erik: So that's one tactic is to use your hands.

Don't, don't talk to them like this. Don't talk 'em with your hands behind your back. These are subconscious things that are really shooting your trust 

Matt: right 

Erik: down the drain. Right, right in the foot. Um, the other thing that's important to remember too is that we should all be aware of what our neutral face is.[00:37:00]

It sounds silly. No, it's, and we haven't talked much about this. It's a thing. Or have we talked? I think we've talked about this. No, 

Matt: I mean, it's been, RBF is is a thing. What? What's that? Resting ____ faced. Oh yeah. So funny. Yeah. A lot of people say, oh, that girl's got RBF. Oh, that's funny. Funny. It's just like they're not trying, there's a couple of nurses at the hospital that, okay, they're super nice people.

Greatest, but when they're just calm or they're focused Yeah. It looks like, oh man, she's mad. You know? No, that's. Gotta be funny to hear. 

Erik: You have to be, it's nothing. They've done [00:37:30] nothing wrong. Yes. These people with that, that uh, that kind of, the Yeah. They're, uh, we work with, with, uh, an individual, 

Matt: they should say RGF, resting grump face maybe is the better resting grump face.

Yes. Maybe that's a better way. 

Erik: Uh, so you, you really should be aware of what your resting face or your neutral face is. Right. Uh, because, you know, look at yourself in the mirror and just relax your face. Yeah. Like, do you have a, a 'cause some of us, and it's just have a, that, that neutral [00:38:00] face looks pretty negative.

Yes. Or scary or angry or whatever it might be. You gotta be aware of that though. Yeah. Um, and then intentionally try to. Turn that. Put a smile on your face. But you don't, you don't wanna do it in the way that's Yeah. Artificial. That's fake. Fake smile. Know they did a study on this and, and they actually could, we can, our eyes can see authenticity.

Yeah. With smiles. That's a fake smile. That's a real smile. Yes. It's interesting. It's really true. Oh yeah. We are subconsciously, [00:38:30] again, most of what we communicate isn't what we say. Yeah. When I say communicate, we think words. Yep. But most of what we communicate is body language. Yeah. And, and, uh, inflection tone.

Tone inflection. 

Matt: Yes. Yesterday we were on a plane coming back. My wife and I were on a plane and we were taking off from LA and my wife looks down, the guy was on the ground doing the flashlight thing, you know, signaling the pile in the back. And I was reading a book or doing whatever, and my wife's like, he just looks happy.

Yeah. And I'm like, who? And she goes, the guy [00:39:00] on the ground. Yeah. And I'm like, what? And I looked out and it was just this dude. And he just had, he wasn't smiling or doing, he just had this face where go, where he looked like a peaceful, happy guy. Yep. We're not saying I've never met this guy, but she just Exactly.

To your point. Yep. Just by seeing this guy at a airplane window could tell that guy just looks like a happy dude. You know, and it was all about how his face was. 

Erik: This is really important. Now, when we're dealing with a patient that's going to get most of the communication by, and a, a typical patient might be maybe 50 [00:39:30] 50 with, uh, verbal tone, right.

And, uh, body language. But with these patients with special needs, there's a lot of subconscious communication. A hundred percent, right? Yeah. So I think it's really important, you know, keep your hands up, keep, you know, speak in a tone to the care provider and to the patient. Yep. Uh, that's, that's 

Matt: calm, calm, slow.

Yeah. Nice and knowledgeable. Sound like you're confident in what you're doing. Hey, it's okay. We got this under control. 

Erik: The other thing that I think I would wanna share before we leave this [00:40:00] communication piece is that when we have those patients with behavioral barriers that we're trying to treat. 

Matt: Yeah.

Erik: Is to remember with verbal deescalation, the SAVE mnemonic that we talked about before. Mm-hmm. Um, you know, being supportive to that patient that can understand what I'm saying. Maybe like my friend I mentioned that's 47 mm-hmm. Is, and he's, um, having a medical emergency and now we've come into his home and he's on this, in this ambulance now in a new environment.

Really scared is when we're communicating with our hands and calm [00:40:30] voice is now the words that we say we gotta be really intentional. And I like the SAVE mnemonic. Mm-hmm. Is when we're trying to communicate something. The s is support. Mm-hmm. The something, Hey, you know, Johnny, I'm, I'm, I'm your friend. I want to help you.

Yeah. Um, it's, um, thank you for letting me come to your home, you know. Being supportive. There's a lot of different ways to say it. This is again, going back to what you learned in kindergarten. Mm-hmm. That's the S in SAVE. Do you remember the A what? The A [00:41:00] was? I don't remember what. Acknowledge. Acknowledge.

That's right. Acknowledge, yeah. And so by acknowledging them, wow, Johnny, this must be scary. Have you ever been in an ambulance before? Yep. Whoa. Let me show you some of these drawers here. And you know. Really acknowledging the fact that this is a new environment for them. Yeah. And that's really, and then to validate it, which is the V to say this must be scary for you.

Yeah. To be out of your home. Yeah. Uh, you know, and to be the fact that this is the first time in an ambulance. Yeah. And to recognize that and to validate it, [00:41:30] and then to name the emotion. That's right. E emotion naming and to say, wow, this must be scary. Yeah. Or Wow, this, this, this, this, this might be overwhelming.

Overwhelming or whatever. Yeah. And, and use small, simple words, don't, that's not a time to improve, impress people with vocabulary. You know, like, this must be scary. 

Matt: Yeah. 

Erik: Right. But that SAVE mnemonic though, and this can be used in any verbal deescalation situation, obviously with a, an angry psychotic, you know, [00:42:00] guy on an overdose or something.

Matt: This look, you must be really angry. 

Erik: That's different. 

Matt: You look like you wanna cut my head off. 

Erik: Yeah. That's where physical restraints and chemical restraints come in. Right. So 

Matt: it's just like when you, you talked about the face, like you just got one of those faces. I just want, you know what I mean? Uh, no, that's, it's super important to, to, you know, be.

Have the mindset of deescalating. Yeah. You know, and you know, I know a lot of times you're just run of the mill pediatric patients. One of the things most providers do get the [00:42:30] glove right? Yeah. Blow up the glove, make a little Turkey on it, like. For the most of the pediatric patients I've had, it's something like, oh, this guy's kind of funny.

Right? Yeah. He's being funny. He's being goof. Must not be too serious. Right. Yeah. I'm not having to say that they're realizing that based on the fact that, oh, he's taking time to blow up this toy and then give it to me and he's making funny noises or he draws a face on it. Yeah. Like, and then he gives it to me as a gift, like that's somebody I can trust.

Yeah. Like that simple little thing. Yeah. Now the kid's kind of distracted by this thing and, oh, this isn't quite [00:43:00] so scary. It's not so overwhelming. Mm-hmm. This isn't so bad. A lot of those same techniques can work with our, our special needs patients as well. 

Erik: And I think you'll kind of like you and I, we've kind of got our own style.

Matt: Yeah. Right. 

Erik: You know, you'll have your own style of communication and these special needs patients, uh, to overcome those treatment barriers. We've gotta have that intentional plan. Yeah. Using some of what we've talked about today to be able to communicate with the patient and the caregiver. Yeah. And understand and respect their position Yep.

And where they are. I think that's huge. [00:43:30] It's so important. So, um, let me ask you a question. Do I have a positive or negative face? 

Matt: Like Mm. It's pretty negative. What do mean? No, I'm just kidding. 

Erik: Really. What do you think of? 

Matt: No, you have a positive face. 

Erik: I was gonna say you do too. I, I think when I see you. Uh, yeah, you seem to have a, I don't know, maybe it's 'cause I know you and I know you're so positive, but, um, 

Matt: yeah, my wife would probably differ with you.

That guy's a jerk. 

Erik: What my wife would say, 

Matt: that guy, an idiot. Yeah. I have that face that, yeah, that guy's an idiot. That's, you know, and no, it's, that's super important. And, and [00:44:00] again, if I have, I have had partners on an ambulance where whether somebody has special needs or not, the patient can read that body language like, woo, man.

Yeah, yeah. That guy looks angry or she looks really mean, you know? So it's very important to be mindful. Be aware of that. Yeah. 

Erik: Yeah. Cool. Well, uh, let's, uh, head into our last section. We're gonna talk about some of the legal implications and some other things here as we close this out. Alright. When we get into these situations, it's easy to get freaked out.

Oh, yeah. Right. Very much so. Take it easy, slow down. Yeah. Communicate with a [00:44:30] caregiver. Remember some of these skills. Get the information that you need. Yep. Uh, because when we don't, when we rush and get freaked out about a patient situation that maybe a little uncomfortable with Yep. Or maybe not as familiar or have lack of experience in 

Matt: Yeah.

Erik: Um, that's ourselves. We tend to rush and 

Matt: skip things. Yeah. Get ourselves in some trouble. 

Erik: Here, here's a, a quick story. Okay. Um, and I shared this with you. Uh,

Matt: you've got your serious face on now. 

Erik: Oh, I it's a, 

Matt: this is a serious story. 

Erik: No, this is a serious story because this [00:45:00] patient, uh, the, the paramedics that were caring for this patient ended up, um, I don't think they lost their jobs, but the department was sued by the state.

Sued by the state sued. They got, anyway, I don't, I'm not gonna say where the department was. Yeah. Uh, but it was a prominent department and there was a patient that they were going to care for that had some significant, um, uh, medical disabilities, physical disabilities based on a disease process. And, and this patient could not communicate [00:45:30] in the typical ways.

Mm-hmm. And because of the emergent situation, um, the care providers, which is totally understandable, I've been there. It's when you get a crucial, a crazy situation, sometimes you just wanna load and go, 

Matt: yeah, 

Erik: well, that's what they did. And like a bull in a China store, they loaded the patient up to get him to the hospital, but nobody thought to ask if the patient could communicate.

And if they would've talked to the care provider, they would've known that on the his his, [00:46:00] um, uh, oh, the electric card or whatever he could communicate Oh, yeah. With the computer. And if he could have communicated, they would've known. He did not wanna be transported. Oh. And so they were sued and they lost.

Oh. Because they then they were, they were guilty of kidnapping. They, they took somebody, transported them against their will. Yeah. And they didn't know what was going on. And if they would've asked, um, it was so benign and easy, they could have taken [00:46:30] care of it right there. And they would've left no need to transport.

They were just missing a piece from the ventilator. All they needed was this. That's all they needed. Well, these. The, the, uh, and I read the, the court documentation and it, and it, and I could see it happening. Oh, yeah. Very easily. Ev nobody's, they're all the tension's high and Yeah. And it's like, load them, get 'em on.

Let's go give 'em a dose of diesel. Yep. I hate that saying, but they were, they were convicted of kidnapping. Mm. So, so again, um, you know, [00:47:00] communication was the last thing we talked about. Yep. Yep. But, but if the patient can communicate, you better be able to document that you did it. 

Matt: Right. 

Erik: Speaking of documentation, that's something else we gotta talk about today too, right?

Matt: Yes. 

Erik: Yeah. Yeah. Uh, we'll get to that in a minute, but the communication and making sure legally mm-hmm. You are respecting your patient with dignity. Yes. And you're also giving them their autonomy. 

Matt: Yes. 

Erik: We absolutely have to do it just like we teach. Our ACDC thing, right? Mm-hmm. If to determine if someone can make an [00:47:30] autonomous decision, right?

The A, we have to absolutely build a case for consent, 

Matt: right? 

Erik: Legal. Yep. And mental Yep. You know, capacity, right? 

Matt: Yep. 

Erik: Uh, to get that consent so they can make an autonomous decision, A and C, and then ac dc DC we gotta be able to disclose the information to the patient so they can then communicate it back.

Yeah. We have to determine whether or not, uh, you know, a patient's able to make the decision for themself. Mm-hmm. Uh, that's what the ACDC acronym [00:48:00] helps us to do. Yeah. And if a patient cannot consent, if they don't have that capacity to be able to do so, then we make the decision for them. Right. But we have to remember though, that oftentimes these patients with these special needs mm-hmm.

Their brain is fine. Oh yeah. And if they can make an autonomous decision, we have to respect their autonomy. Yep. And we can't just assume certain things like that group, did I? And I don't blame 'em. I mean, I can see how that can happen easily. Yeah. And that was a rare situation. 

Matt: Kind of a shame that [00:48:30] that that went that far.

Erik: Yeah. 

Matt: You know, 'cause I'm sure that they weren't doing it out of No, you know, being. Rude or mean to this patient? No. They probably thought they were trying to do what was best for the patient. 

Erik: Yeah. Save their life. 

Matt: Yeah, exactly. 

Erik: It was, yeah. Right. Uh, so, uh, remembering though that, uh, the, uh, these patients oftentimes, even though you, um, it may be difficult to communicate if they can communicate, uh, another story real quick.

Matt: Mm-hmm. 

Erik: One of my dear friends had a drowning accident near drowning, or I guess what we [00:49:00] call that now, submersion injury. 

Matt: Yeah. 

Erik: Uh, in a hot tub. Um, and now, uh, I think he's a manager of a bank now. Mm-hmm. But growing up it was so difficult to understand him. He had difficulty walking because of the brain injury.

Mm-hmm. Uh, uh, I had difficulty communicating verbally. Uh, you have to really get to know him to understand him. Yeah. Well now he's some financial guru at a bank or something, but, but, uh, you know, he just a walker and all that. Yeah. But his brain is fully intact and able to [00:49:30] make decisions. But boy, if you, if you thought for one minute when you got to their house and you thought that maybe this, this individual wasn't able to communicate, so we're just gonna grab him and put him on and go, I don't care.

Matt: That's gonna be illegal. Well, I think of like Steven Hawkings. Right, right. You know, I mean. Brilliant guy, you know, at least from a scientific brilliant, brilliant guy, had all his mental faculties about him. Yeah, he just had problems. But he would communicate through the iPad, like you were saying in this [00:50:00] situation.

So, yeah. Yeah. Very important to slow down when you get on these scenes. Slow down. Take your time, do a good assessment. Use the caregivers or whoever's on site to help you so that you don't get yourself in a legal bind with these patients. Yeah. And also the documentation. Yep. Right. You know, like how did you communicate with this patient?

Yeah. Document how you did that. If they were non-verbal document that they were non-verbal. Yeah. Did they have capacity? Yes. How did you determine that they had capacity? Right. Right. Because maybe they can't repeat it back to you, 

Erik: or [00:50:30] the caregiver says, or the caregiver is, no, they're not acting right.

Normally this patient will be able to communicate with you and I to tell you how they're feeling right now. Right. This is not normal. They are altered, you know? Right. Then the whole ACDC acronyms matter. Yeah. That you are now making decisions for them with a caregiver. Yeah. You're making decisions for them.

You are. Now they're served or maybe a caregiver 

Matt: has medical power of attorney. 

Erik: True. That's, you know, or that's, or could be the 

Matt: parent so they can, you know, force them to, not force them, but they can say, yeah. He needs to go. Right. They can have the legal authority to make that decision. 

Erik: That's a good point.

Super important. Legal power of [00:51:00] attorney is a huge thing, and that doesn't just mean special needs. This is, could be, that's 

Matt: geriatric patients, right? Is a huge one. 

Erik: Obviously PD patients, you know, you know what's common in all of these situations. This is really what we're talking about, and I think this is, this is probably the, if the most important thing that we could say here is that in any patient we see, regardless of, of, of intell, you know, intellect mm-hmm.

Behavior, uh, you know, physical abilities or disabilities, uh, age, location. [00:51:30] Uh, socioeconomic class, whatever. Right. Gender, you know. Right. Orientation of any kind. Right, right, right. Creed. Anyway, you get my point. 

Matt: Yeah. 

Erik: What we're talking about here is dignity and respect. Yep. That's, that's it. We should do this with all patients.

Yeah. And I think what's so special, no pun intended with the special needs population, is that it really creates an environment where this is so important because sometimes it may not be fully obvious on how we communicate or how, [00:52:00] uh, you know, how do we really give a, a sense of dignity here and respect to this patient population or this individual's, you know, situation.

Mm-hmm. And that, I think is something we should be doing with every patient. Yeah, for sure. But it, but this is a unique challenge though, with the special needs patient. 

Right. Uh, really loving them when they can't care for themselves. Which reminds me of one of the most important things we could talk about is the fact that this is one of the most vulnerable patient populations.

Matt: Yeah. Abuse is a big problem, especially in [00:52:30] facilities where they have multiple special needs patients. A lot of these patients I've, numerous TBI patients in their thirties, forties, fifties, are in nursing homes for the elderly, right? Yep. Yep. And you go in, you got this 35-year-old that suffered a TBI from a car wreck.

Yep. And now they're, you know, in a nursing home. Yep. And they can easily be victims of abuse. 

Erik: That's, uh, really sad. It's that you would do this, oh, this, this, uh, there aren't a lot of things that just kind of make me angry. 

Matt: Yeah. 

Erik: [00:53:00] Um, but it just, it really sickens me. Yeah. That this really happens. 

Matt: Yeah. 

Erik: So, you know, in our pediatric lecture when we talked about child abuse, remember the, uh, acronym we taught our students, Ten Four Faces P 

Matt: mm-hmm.

Erik: Some of the components of that are important here too. They're not children of course, but you know, like, 'cause certain things don't apply. Like, you know, on a side note by, if you have any bruising in a four month older, less. Not normal. Not normal. Okay. But we're not talking about four month olds here, but, but there are some bruising patterns though that I [00:53:30] think we can share here that are important.

Mm-hmm. If you have that patient, that nonverbal patient, and you're moving them and you see lots of bruises in different stages of healing, remember bruises at about 24 hours are red. Yep. And then they get blue purple after about 24 or 48 hours, and then they turn to a yellow green and then they go yellow brown after 10 to 14 days.

If you see lots of different colors, a rainbow of colors, of different bruising patterns, uh, it's red flag. Red flag, if you see bru, bruising [00:54:00] patterns of hands. Mm-hmm. Or maybe, uh, teeth, teeth, cigarettes. Yeah. Or, or even uh, instruments, uh, or cords or whatever. There could be some pretty nasty stuff happening and, and you may be the one to see it and to report it.

So, uh, anyway, I think it's worth mentioning only because this patient population is so vulnerable. Yeah. I think it's, it's, uh, really behooves us to make sure we, we, we mention that 

Matt: and one of the biggest forms of abuse, I think, and I've [00:54:30] seen has been negligence neg. Yeah. It's not actually them putting their hands on the patient, but you get a patient that's got these horrible ulcers Yeah.

That obviously have not been treated or cared for in a long time. Mm-hmm. And they're. Infectious and Yep. It's like, oh my gosh, this patient is not being turned or moved properly. Yep, that's right. They're not, you know, padding, you know, doing all the things that they're taught to do. They're not doing any of those things with these patients.

Or maybe they're super skinny, like they're not being nourished properly. Right, [00:55:00] right. So I think a lot of times the abuse is more from a neglect standpoint, or the other one is they're sitting and laying in their feces or urine for days. And I have, I've had one patient, and this was not in a facility, this was in a home, a hoarder house.

But it was so bad that the sheets of the bed were attached to her, and I mean, attached to her, they had to be removed surgically in the er. We had to take the bed sheet with us, really? Because the feces had [00:55:30] bound the sheet together to her skin. She'd been laying in it for so long. It was Wow. Yeah. It was just horrendous, you know?

So I think that's probably the biggest, at least in my experience, I'm not saying globally, but in my experience, neglect, the biggest form of abuse I've seen has been neglect. Especially when you go into these facilities where they're dealing with, you know, maybe over a hundred patients and they all have, and that can be, that's tough, man.

That takes a special person to work in those places because that's not an easy thing to deal with [00:56:00] day in and day out. 

Erik: You know, I'm really glad you brought that up. It's, it's not just the non-accidental trauma, which is the physical abuse, it's the neglect, which is just as, 

Matt: yes, dangerous could be just as detrimental and patient wise.

Yeah. 

Erik: And the third tap we talked about in that lecture. Uh, plays in here too, is the emotional abuse. Yes. Not all caregivers are created the same. No. There may be caregivers that are state appointed that are, they should not be that caregiver. 

Matt: Yep. 

Erik: That, that, uh, is emotionally abusive. So really, um, being [00:56:30] mindful of that caregiver, not letting the patient speak or communicate Yep.

In certain situations could be bad. Uh, but if, if there are red flags you see that, you know, it's not right. You know, uh, talking to adult protective services or child protective services is key. 'cause in some states you're a mandatory reporter, right? Yep. So you gotta, you gotta be careful 

Matt: in this new role that I have, you know, I've, I've contacted a PS only a few times.

Yeah. Uh, in my career when I was out in the field and now in this new role fed [00:57:00] numerous times where crews have called me like, Hey, I don't know if we should call a PS, or, you know, they think it's almost like this taboo thing. And so I was kind of wondering, and I actually called a PS and I was like. Tell me, like gimme some more history about like if we call you, is there like a line, you know that Yeah.

What'd you learn? And so basically it was like, you can cost for anything. If you even think that there's something going on, like even if it's like not a negligent thing or a criminal thing or anything like that, but just an adult that [00:57:30] needs help, like call us. Call us, and we'll go out and do an assessment.

Yeah. We'll go out, we'll put our eyes on it, uh, from their standpoint and look at it and see like, okay, do they need some help with cleaning? Do they need some help with finances or whatever, you know, food services or whatever. It doesn't always have to be from a neglect standpoint, but if you even think that they're, that's what we're here for.

That's our job, right? Yeah. Is to go out and do an assessment and say like. Do we see signs of abuse? That's what they're trained much more than we are as first responders. They're [00:58:00] much more trained in looking for specific signs of abuse. And, and so if, if you're a first responder and you're afraid to call APS, don't be.

Yeah. Like that's what they're there for. They want to do their job. You're not gonna get anybody in trouble necessarily if they go out and they're like, no, we appreciate you bringing this to our attention. Yep. You saw something that you thought was off and you wanted to do what was best to protect your patient.

We'll go out there, do an assessment and take it from there. 

Erik: And remember we miss this a lot. 

Matt: Oh, a lot. So. Well, I think a lot of it's from fear. Like, you know, oh [00:58:30] gosh, is something bad gonna happen? And I don't wanna be the person throwing somebody under the bus. Yeah. Well maybe it was a well-meaning caretaker or parent.

Right. Who knows? APS can be a great resource for 'em. 

Erik: And these patients are so vulnerable and so exposed. Yes. We need to be an advocate for them if they are in a bad situation. Yes. That's huge. 

Matt: Always think of when you go into these nursing homes. I know. Dealing with nursing home patients and nursing homes in general.

It's not the patients, but dealing with nursing home calls. Mm-hmm. Right. It's an unfortunate reality that nursing homes sometimes abuse nine [00:59:00] one one. They call 9 1 1 a lot. When they shouldn't be calling 9 1 1, they should be calling a non-emergency transfer service or something like that. So I get it.

Like in the last, one of the last districts I worked in, we had eight nursing homes just in my district. Yep. So I've made a lot of nursing home calls, but it's not the patient's fault. No. Right. And just always think of if this was my grandma or grandpa or mom or dad or whoever, my loved one mm-hmm. That this was my patient, like, how would you want them to be treated?

Yeah. Right. And so, just always kind of, and you're only gonna be with 'em for a short amount of time, [00:59:30] so. You know, it's not like you gotta deal with this for hours and days and months or whatever. Like be, be kind. Show them dignity. Show them autonomy. And if you see any red flags that there could potentially be some abuse patterns.

Don't be afraid to report it. 

Erik: That's huge. Yeah. So we talked a little bit about the different populations. We talked about communication. Mm-hmm. And then we talked about some of the legal considerations here. But ultimately I think just to bring it home. Yeah. Bring it home. Respect your patients. Give them the autonomy that they have the right to have.

Right. Yeah. And then also [01:00:00] remember this is a vulnerable patient population that really may need some advocacy. 

Matt: Yeah. 

Erik: May need to report abuse. Yeah. I mean, if you're gonna see a patient population where abuse is happening, this may be the The one that's right. It's a very vulnerable patient population. 

Matt: Yep.

Well, that's a good topic. Very important. It is. See you the next one. 

Erik: Be safe out there.

Narrator: Thank you for listening to EMS, [01:00:30] the Erik and Matt Show.