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Rural Ramblings
by Jules Scadden

Patients with Hearing Impairment

By Jules Scadden

You respond to a residence for an unconscious male. You know the resident is an elderly male who has not been seen around town very much since his wife died. On arrival, you are met by an elderly female who identifies herself as Mr. Kelly’s sister. She states she arrived last night to visit and this morning was unable to wake him for breakfast. Assessing his level of responsiveness, you squeeze his shoulder and say his name in a very loud, strong voice. Mr. Kelly’s sister touches you on the shoulder and says, "Why are you shouting? My brother has been deaf for more than 30 years."

Effective communication is one of the most challenging aspects of life, particularly when trying to provide medical care. Communication becomes increasingly challenging for EMS when the call involves special patient populations, notably pediatrics, geriatrics and individuals with physical and mental disabilities. This special group is often described in EMS as "challenged" patients. However, a woman who lost her hearing while still in high school once told me, "I’m not challenged by my hearing loss; this is normal for me. I’m challenged by society’s misconceptions and the restrictions they place on the Deaf community."

In the United States, approximately 15 percent of the population has some degree of hearing loss, with 1 in 100 of those being profoundly deaf. Deafness is considered a hidden disability, but many within the Deaf community see themselves as a group with a shared language, culture, and life experience rather than having a hearing disability.

Types of hearing impairment
Hearing impairment or deafness is generally broken down by the type, degree, and pattern of hearing loss. The three types of hearing loss are classified as conductive, sensorial, and mixed, and are dependent on the location or part of the auditory system that is affected or damaged.
Conductive hearing loss is due to interference with the conduction of sound traveling from the outer ear to the structures of the inner ear. Causes include fluid buildup in the middle ear, impacted earwax, foreign bodies in the ear canal, ear infections, or deformities of the outer ear, ear canal or middle ear. Patients with conductive hearing loss have difficulty hearing comparatively minimal sound levels, such as a whisper. This type of hearing loss can sometimes be medically or surgically corrected.

Sensorineural hearing loss is a permanent loss of hearing due to damage of the cochlea (inner ear) or nerve pathways from the inner ear to the brain. Sensorineural hearing loss not only involves the individual’s ability to hear faint sounds, but it also affects the ability to hear clearly. Causes include disease, injury during birth, genetic syndromes, and prolonged exposure to noise, viruses, head injury, tumors, and aging. Mixed hearing loss is a combination of sensorineural and conductive hearing loss from damage of the outer and inner ear structures or the auditory nerve.

The degree or severity of hearing loss is measured by the softest intensity at which the patient can perceive sound. The extent of the patient’s hearing loss varies and can be dependent on the type and “shape” of hearing loss. A patient may be able to hear well in one ear but can discern certain levels of (if any) sounds in the other ear (unilateral hearing loss). Bilateral hearing loss involves both ears, although the degree or type of loss may vary from ear to ear.

Progressive hearing loss is the “shape” most commonly associated with the elderly. It is a gradual loss of hearing over time. Patients who complain of a sudden, acute loss of hearing require immediate evaluation and medical attention to determine the cause and best treatment.

Clues to hearing impairment
A hearing deficit may not be immediately apparent or may be attributed to the stress of the situation. It is essential to look for clues to hearing impairment at the scene and while conducting the historical interview. Obvious clues to hearing impairment include the presence of hearing aids, amplifying equipment within the home, flashing lights near doors and telephones, and in some cases, the presence of a “hearing companion,” such as a dog.

More subtle, personal clues include poor diction or monotonous speech that is difficult to understand. Further, the patient may be lacking in response until the EMS provider makes direct eye contact. While it is true that many deaf and hearing impaired patients can read lips, not all can. Patients with an acute hearing loss are less likely to have learned to read lips.

Communication
While addressing patients with a hearing disability, always face the patient and make direct eye contact. Speak normally, and do not exaggerate lip movement in an attempt to help the patient “see” the words. Ask the patient, “Do you read lips?” Do not yell, but be sure to adjust the volume of speech to the environment and the degree of hearing loss associated with the patient. American Sign Language may be used if the provider is trained and the patient attempts to communicate using ALS. The use of only a few signs by untrained providers may result in increased confusion and the exchange of inaccurate information. Writing the question or message on paper and having the patient answer verbally can also be extremely effective.

Summary
There are a number of challenges that may be encountered while conducting patient assessment and during the history gathering process. Effective communication involves the giving, receiving, and understanding of information between individuals. Hearing impairment or deafness can be a barrier to effective communication, creating a challenge for both the EMS provider and the patient. EMS providers should adjust their methods of communication in emergencies involving patients with a hearing disability. Communication is most effective when we listen to our patients and ensure our patients are hearing us even when the ears are not involved.

References
Elling, B., Elling, K.M. (2003) Principles of Patient Assessment in EMS Delmar Learning

Guthmann, D.S,Ed.D, National Association on Alcohol, Drugs and Disabilities, “Access to Treatment Services for Deaf and Hard of Hearing Individuals” www.mncddeaf.org

Deaf and The EMS http://home.moravian.edu/

National Institute on Deafness and other Communication Disorders-- http://www.nidcd.nih.gov/

About the author

Julie K. (Jules) Scadden, NREMT-P, PS has been actively involved in EMS for 18 years, and is the CQI/IT/Data Coordinator with Sac County Ambulance Service in Northwest Iowa. A passionate advocate for EMS, Jules has served on numerous advisory boards and committees on state and national levels. She is one of the founders and past Secretary for the National EMS Museum Foundation and is currently serving as the President of the Iowa CPR Education Foundation and the Board Secretary of the National EMS Memorial Bike Ride, Inc. ("Muddy Angels"). Jules is an EMS Instructor serving as adjunct faculty for areas community colleges and is a frequent presenter at EMS conferences speaking on topics covering special patient populations and Children with Special Challenges. Jules is a co-author of Fundamentals of Basic Emergency Care, 3rd edition. To contact Jules, email jules.scadden@ems1.com.

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