Emergency Medical Services and People with Paralysis
Nearly 5.4 people in the U.S live with paralysis, a physical disability that limits movement and function in part of the body. Symptoms vary widely from person to person: some individuals may be paralyzed from the waist down and able to move their upper body, while others may have high-level spinal cord injuries that require the use of a power wheelchair and a ventilator.
Prehospital care plays a critical role in treating an array of medical emergencies. Emergency medical service (EMS) professionals can strengthen response and improve patient outcomes by better understanding the specific needs of people living with paralysis.
The following information provides an overview of paralysis-related health conditions, transportation tips, and etiquette guidance.
Disability-Specific Secondary Conditions and Concerns
Whether caused by traumatic spinal cord injury, genetic condition or disease, paralysis can trigger a range of secondary health conditions.
To best serve the needs of people living with paralysis, it is critical for first responders, including firefighters, to be alert for signs of common complications.
See the list below for definitions, warning signs, and treatment tips.
Spinal Cord Injury (SCI)
People living with paralysis sustained through traumatic spinal cord injury experience a range of cardiovascular, bowel and bladder, and thermoregulatory challenges. First responders should be ready to identify and treat the following conditions:
Autonomic Dysreflexia People with spinal cord injuries at or above the T6 level are at risk for developing autonomic dysreflexia (AD), a potentially life-threatening case of acute hypertension triggered by the body’s unchecked response to pain or discomfort.
First responders should be aware that people with spinal cord injury often have low blood pressure, so a systolic pressure of 130 – 135 may indicate AD.
Symptoms include sudden high blood pressure, pounding headache, flushed face, sweating above level of injury, nasal stuffiness, nausea, and a pulse that is slower than 60 beats per minute.
Urinary and bladder complications are the most frequent causes of AD, but it can also be caused by extreme heat or cold, broken bones, sunburn, or even an ingrown toenail; AD may also indicate the presence of an undiagnosed injury that the person cannot feel, such as a fracture.
First responders should check catheter lines for blockage and ask about bowel/bladder management programs to assess if the AD has been triggered by constipation or full bladder.
Patients suspected of having AD should be assessed/transported sitting up. Tight clothing should be loosened. Pillows may be placed around the body to prevent any pinching or pressure and limit discomfort.
First responders should monitor hypertension and be aware of interventions that may cause pain, including placement of an IV.
Respiratory Complications: People with high level injuries (above C3) who use a ventilator to breathe are at increased risk of lung infections such as pneumonia and collapsed lungs. Additionally, a ventilator malfunction will require emergency breathing support.
Deep vein thrombosis (DVT): People living with SCI have an increased risk of developing deep vein thrombosis, a blood clot that forms in a deep vein. It most often occurs in the legs and pelvis but can also appear in the upper extremities. First responders should ask if there is a history of DVT and be alert for symptoms, including redness or swelling in the extremities, shortness of breath, and sudden chest pain. A pulmonary embolism can occur if a clot breaks loose and travels to the lungs.
Urinary Tract Infections (UTI): UTIs are a common secondary condition. Be alert for symptoms, including fever, chills, changes in muscle spasms, urine that is dark and/or smells bad, nausea and headache. An untreated UTI can trigger AD.
Fracture: People living with SCI frequently experience lower bone density and develop osteoporosis. Be aware of an increased risk of fractures from falls, even those that seem mild.
Cerebral Palsy
Cerebral Palsy (CP) is a group of disorders characterized by impaired coordination and movement; individuals with CP may live with mild to severe paralysis. In addition, seizure disorders, intellectual disabilities, swallowing problems, and/or communication challenges may also be present.
- First responders should be aware of an increased risk of choking and aspiration pneumonia. Extra care should be taken when administering oral medication.
- When transporting a patient living with CP, first responders should not force the limbs impaired by joint stiffness to bend or straighten. Ask the patient what is comfortable and work around their needs when positioning their body on the stretcher.
Spina Bifida
Spina bifida is a neural tube defect that can cause muscle weakness or paralysis.
- Common secondary conditions to be aware of include latex allergy and urinary tract infections.
- Some children born with spina bifida have hydrocephalus, an accumulation of fluid around the brain. The condition is treated by the surgical insertion of a shunt to drain the fluid. First responders should be aware of post-surgical shunt complications including infection. Symptoms include fever, pain, redness, swelling and drainage from the incision.
- Shunts can also break, or become dislodged or blocked, which can be life-threatening. Signs of shunt dysfunction include headaches, vomiting, seizures, lethargy, and/or changes in vision, speech, balance, coordination or behavior.
Understanding Wheelchair Etiquette
- Unless there is a medical emergency that requires urgent response, do not push a person’s wheelchair without asking permission
- Do not touch or grab a person’s wheelchair; it is considered an extension of the person’s personal space
- Do no move a person’s wheelchair out of their reach
- Always bring the wheelchair with you when moving a patient or call the ER ahead of time to request that one be ready upon arrival.
Transport/Carrying Tips
- If the patient is alert and responsive, ask what help they need before beginning any evacuation/transfer; if time is critical, tell the person what you are going to do and why.
- If they are in bed, ask if they need help transferring to their wheelchair or mobility device. They may need help with the transfer but be able to move independently from there.
- Do not assume that a person who uses a wheelchair cannot transfer or navigate independently in their wheelchair. Ask questions to assess their abilities: Can you stand or walk without the help of your wheelchair or walker? Do you have use of your arms? Offer your help but seek their input: Please let me know what assistance you need.
- Do not pick a person up without asking them first.
- Do not put pressure on the arms, legs or chest.
- Do not use the fireman’s carry, which can compress the chest and create breathing difficulties.
- Be alert for catheters or colostomy bags and be careful not to dislodge.
Carrying Techniques for Manual Wheelchairs
Do not move a person from their wheelchair unless it is necessary. Use one of the following techniques, always keeping the wheelchair facing forward.
One-person assist
- Grasp the wheelchair handles
- Stand one step above and behind the wheelchair
- Tilt the wheelchair backward until a balance (fulcrum) is achieved
- Maintain a low center of gravity
- Descend frontward
- Let the back wheels gradually lower to the next step
Two-person assist
- One person is positioned as in above instructions
- Second person is in front and facing the wheelchair
- Stand one, two or three steps down, depending on the height of the other responder
- Hold onto the frame of the wheelchair
- Push into the wheelchair
- Descend the stairs backwards
Carrying Techniques for Power Wheelchairs
Power wheelchairs can weigh more than 100 lbs. and be more unwieldy than manual wheelchairs; the patient may need to be transferred (via transfer board) to a stretcher for transport to the ambulance. (See carrying techniques above.)
Two to four people will be needed to lift the wheelchair. First responders should ask the wheelchair user what parts can be temporarily removed, how they should position themselves, where to grab hold and what, if any, angle to tip the chair backward. Turn the power off before lifting it.
Communication Considerations
When possible, first responders should sit down or kneel to conduct an eye level conversation with a person seated in a wheelchair.
If the person is alert and responsive, always speak directly to them – even if a caregiver is present; never assume a person living with a disability cannot speak for themselves.
If the person uses a ventilator or lives with CP, speech may be more difficult to understand. First responders should always address the person directly (see Communication Tips below) but be ready for family members or a caregiver to provide information if treatment is time sensitive.
If the person uses a communication device, it should remain with them and be transported to the hospital.
Conduct your conversations in a normal tone of voice. Use person first language to describe the case when communicating with the hospital or dispatch. For example, a patient may be “a 51-year-old male living with multiple sclerosis who uses a wheelchair;” a patient is not “a 51-year-old wheelchair-bound male with multiple sclerosis.”
While it may seem insignificant, word choice can help create trust, strengthening a first responder’s ability to provide the best care.
Service Animals
According to the Americans with Disabilities Act, a service animal is any breed or sized dog trained to perform a task related to a person’s disability, such as opening doors, picking up objects, and helping to pull clothing off.
First responders should not request proof that the dog is registered or certified as a service animal or require it to perform the task related to the person’s disability. No documentation is required to prove that the animal is a service dog.
A service animal must wear a harness or a leash but does not have to be muzzled.
Service animals should be kept with the patient during treatment and transported to the hospital. Only if the dog is out of control, or a threat, can it be removed from the situation.
Do not pet or offer treats without permission.
Additional Resources
Outreach
Inviting people living with paralysis to speak with first responders about disability can strengthen emergency response. Contact nearby Centers for Independent Living (see contact information in ‘Support’ section below) for help finding local advocates.
Training
Disability Awareness Training for EMS
Institute on Disability Awareness at Niagara University
Phone: 716-286-8139
Email: ida-info at niagara.edu
This educational course trains first responders in etiquette and interaction skills, the role of caregivers and service providers, federal and municipality roles and responsibilities, the perspective of the disability community, and current trends and topics.
To schedule training, or learn more about trainings for law enforcement, emergency management, or probation officers, visit the website at Niagara University at https://apps.niagara.edu/ems-disability-awareness-training/
READING:
EMS Response to Patients with Special Needs; Katherine Koch
Fire Engineering Books
This textbook provides guidance for EMS professionals to better support patients with a wide range of disabilities, including spinal cord injury and mobility impairments. Topics include specific disability-related health conditions to be aware of, how to use person-first language, wheelchair etiquette tips, and suggestions for interacting with service animals.
Author Kathy Koch is a paramedic and professor of special education at St. Mary’s College of Maryland.
Tips for First Responders
University of New Mexico Center for Development & Disability
This resource offers guidance on response for a variety of disabilities, including physical, intellectual, hearing and vision related.
Support
Not all EMS calls are medical emergencies. To better serve the non-medical needs of people living with paralysis, compile a list of local disability-related organizations and government agencies for future referrals if appropriate. Potential support organizations include:
Centers for Independent Living
https://www.ilru.org/projects/cil-net/cil-center-and-association-directory
Elder Care Support Services
https://eldercare.acl.gov/Public/Resources/LearnMoreAbout/Support_Services.aspx
Christopher & Dana Reeve Foundation Paralysis Resource Center
https://www.ChristopherReeve.org/Ask
Reeve Foundation Information Specialists are available to supply information on various aspects of paralysis for free at the above URL or by calling 1-800-539-7309.
Sources: University of New Mexico Center for Development & Disability, EMS Response to Patients with Special Needs by Katherine Koch, Americans with Disabilities Act, National Institute of Neurological Disorders and Stroke, Model Systems Knowledge Translation Center, Merck Manual.
