Confronting High-Tech Home Care
"What the heck is that thing?"
The day may come when you ask that question in someone's home. Increasingly, advanced medical devices are making their way home with outpatients who may, for reasons related or un-, subsequently require your services.
It behooves EMS providers to know some of what's out there and some basic principles for dealing with occasions when they go wrong.
"More patients with these kinds of complex devices are at home now, and they're also becoming freer to travel," says Kathy Schrank, MD, medical director for Miami Fire-Rescue and Chief of Emergency Medicine at the city's Jackson Memorial Hospital. "We're not seeing large numbers yet, but we have had some problems within our system and even in emergency departments."
Among these devices are things like AICDs (automatic implantable cardioverter defibrillators) and defibrillator vests; complex pacers; ventricular assist devices (VADs); tracheostomies; ventilators; various pumps and medication-infusion systems; and home dialysis setups.
Each have their potential malfunctions and unique considerations. But there are some standard steps to follow, Schrank says, when you face one:
- Treat the patient (ABCs, etc.) first. Their problem may not have anything to do with their device. If it does…
- Tap the family's knowledge. Odds are, they know all about their loved one's condition and equipment, and have been taught what to do if something goes wrong.
- Ask for any manuals, written instructions or, most important, help-line numbers for the makers/dealers of such equipment. Usually, they will have personnel available, often 24/7, to assist patients in crisis.
"If you see some device you've never seen or heard of before, there is probably a backup person available instantly over the phone who can help," says Schrank. "That person is almost always going to be your best resource."
These personnel can offer a number of benefits. Beyond direct troubleshooting, they can often help calm panicky family members, with whom they may have established relationships. They can contact a patient's specialist or primary-care physician, and they can relay vital information ahead to receiving facilities.
There's also benefit to alerting your own medical control early in such calls. If help-line personnel can't help you locate and access appropriate assistance, perhaps your doc can. Transport should be handled under local protocol, but it's usually in the patient's best interests to bypass, when possible, hospitals where staff aren't familiar with the device in question.
It's also prudent to check the basics, like plugs and batteries, but needless to say, it's inappropriate to go randomly pushing buttons and flipping switches you don't understand.
At the system level, agencies should know what's out there and in their jurisdictions (remembering that as this equipment is increasingly portable, patients can also travel with it). Proactivity pays: Work with manufacturers and doctors to learn about their advanced devices and develop protocols for patients who use them. Make sure the experts understand your limitations as well; misconceptions about what EMS can do persist, even in other areas of healthcare. Consult these same sources in assembling training packages. They may even be able to help actually train your people.
"In every area that has children with trachs at home, for instance, there are special-needs clinics that handle these kids and their families," says Schrank. "Almost all of them will welcome EMS to come in and work so they can learn the devices, and do the trach changes and suctioning as patients come in for their routine care."
Finally, once the important information is amassed and care guidelines are developed, don't expect providers to remember everything when they'll see these things infrequently. Find a way to make the information quickly accessible to them in the field.
As well, remember that technology is moving fast—there are always new and more capable devices being developed. And when all else fails, fall back on the basics and common sense.
"The person on your crew with the most mechanical ability," Schrank notes, "may be as important as those with the best medical capabilities."
Home Medical Devices EMS Might Encounter
AICDS
These are increasingly common; around 100,000 a year are now implanted in the U.S. Potential problems include inappropriate shocks, battery failure and lead failure. Treat cardiac arrests with standard ACLS protocols; external shocks and compressions are OK, though make sure you're not compressing atop an implanted device (they should not be in the center of the chest). Transport whenever one has fired.
VADS
VADs are implanted pumps that help failing hearts deliver blood, effectively serving as a "bridge" to transplant or to extend a life. LVADs (left ventricular assist devices) are most common. Pumps may be implanted or external. When one malfunctions, call for expert assistance immediately and transport to an appropriate hospital. Chest compressions may be contraindicated in older models, unless a patient is unconscious with no palpable pulse.
TRACHEOSTOMIES
Keep yourself and the patient (especially children) calm. These tubes are typically easy to change, with large, well-formed holes. "It's an order of magnitude easier, actually, than placing an endotracheal tube," says Schrank, "but not if you've not handled it before." Accordingly, get some practice.
INSULIN PUMPS
Secondary surveys are beneficial to detect these, especially in unconscious patients. For hypoglycemic patients, shut them off when possible. If you can't, monitor glucose closely and give dextrose, and be sure to alert ED staff that it's there and running.
