When Your Patient Needs Services Beyond EMS

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When Your Patient Needs Services Beyond EMS
Region 8 EMS Systems Content Produced by the
Loyola EMS System
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Objectives

• Recognize signs when an EMS patient needs
  additional community resources and services
• Review various resources in your community that
  handle abuse, neglect, domestic violence,
  shelters and basic social service needs
• Discuss ways in which EMS providers can utilize
  and interact with law enforcement and hospital
  personnel in caring for patients experiencing
  behavioral, emotional, or substance abuse
  problems.
• Review patient assessment, treatment options, and
  transportation issues when confronted with a
  patient needing special services utilizing case
  scenarios.

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Introduction

• Face of Healthcare industry in U.S. changing
• EMS Providers main providers for growing
  populations of poor homeless and uninsured
• EMS becoming new primary care providers
• Emergency Departments being flooded with patients
  who cannot afford to go anywhere else
• EMS professionals routinely tolerate drunkenness,
  disorderly conduct, psychosis and abuse of the
  EMS system
• Many patients have no emergent healthcare needs
• Many patients have needs for services that go
  beyond typical EMS resources

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• EMS provider available to assist the person in
  crisis 24 hours a day/ 7 days per week/ 365 days
  per year
• Places additional burden on an overburdened
  system
• Consumes expensive resources
• EMS carries a high expectation of performance
• Growing fear of liability about what can be done
  and cant be done by EMS providers in the street
• Tremendous wealth of resources exists in each
  community in public and private sectors
• Knowledge will help channel people towards
  appropriate agencies

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http//www.outsidethebeltway.com/archives/2007/06/
subsidize_ityou_get_more_of_it/
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Chicago CountyHealthcare System

• Budget cuts for Cook County Health system
• People will need to seek care elsewhere
• System serves the poor and underinsured from
  Chicago and suburbs
• Cause for ER overcrowding
• Wait times extensive for routine procedures
• Many suburban clinics do not offer much needed
  specialty services
• System supplies free or deeply discounted
  medication for those in need

http//www.ccbhs.org/
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Dental Services

• Availability of Dental Services declining
• Medicaid does not cover routine preventive dental
  care for adults
• Many dental schools closing
• Emergency Rooms have cut dentists from their
  staff
• Tooth decay leading chronic illness among
  children

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Mental Health

• State mental health hospitals were shut down in
  the 1970s and 1980s
• Many mental patients left homeless
• Greatest problem trying to find place to take
  patient once they are calmed down
• 40 who suffer from mental illness dont receive
  the treatment they need
• 20-25 of adult homeless suffer from some form of
  severe and persistent mental illness
• One half of severely mentally ill are estimated
  to have a co-occurring substance abuse problem

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DuPage County

• 10 of population over 65
• 56,000 residents live at or below the poverty
  level
• New immigrants account for 15 of population
• Latino population increased 30 in last 5 years
• In 2001 2800 homeless persons received services
  in DuPage County
• 79 of families homeless due to domestic violence
• Addiction primary reason for homelessness in
  DuPage County
• Of the homeless seen 40 were children

www.dupagehealth.org
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The following case studies are provided to
stimulate discussion and help increase your
knowledge of the available resources within your
community, institution, and county
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What Is the Need?

• Signs Patient Needs Additional Resources
• Poor living conditions
• Lack of food, heat, cooling measures
• Inability to care for self or spouse, children
• What Community Resources are available?
• Types of services
• Transportation
• Shelters
• Meals on Wheels

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Case 1

• 46 year old female
• History of obesity, hypertension, heart disease
  and diabetes
• 5 1 and approximately 375 pounds
• Lives alone in a small apartment on the second
  floor
• Frequently calls EMS for symptoms of chest pain
  and shortness of breath
• Initially admitted to the hospital and
  extensively evaluated. Testing reveals no acute
  cardiac disease
• Now frequently requesting EMS to be evaluated and
  then refuses transport
• Tells you she has no family in the area. EMS is
  being called 2-3 times a day
• Patient tells you it is your job to come and
  check on her when she calls 911

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Case 1

• What are possible suggestions for the best way to
  deal with this patient?
• Is the patient overusing or abusing the system?
• What are some of the patients concerns/ issues?
• What are the community resources available in
  your area for this patient?
• Why is it important for EMS to get involved?
• Is it important for EMS to watch their responses
  to this patient?
• Is it possible to set up a committee consisting
  of hospital, social services and fire department
  personnel to discuss the effects of the patient
  frequent calls?

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Case 2

• You are called for a well being check on an 83
  y/o male
• Family, who are out of state, have not heard from
  the patient in 4 or 5 days and are concerned
• You enter the residence to find an elderly male,
  seated in a recliner, alert and oriented x 3
• The home is very cluttered with old newspapers
  and garbage and there is a very narrow path to
  navigate to reach the patient
• The temperature in the home is cold. On
  investigation, you find there is no electrical
  service in the home
• The patient appears malnourished and you note
  little food in the home
• The patient is refusing to be transported for
  evaluation, stating he didnt call you and he is
  fine

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Case 2

• Do you call in the refusal and return to the
  firehouse?
• Do you attempt to take the patient against his
  will because you feel he needs to be evaluated?
• Is there any social service, or service agencies
  in your town that could be made available to the
  patient (e.g. senior services, meals on wheels)?
• Do you have code enforcement come in and condemn
  his home as a fire hazard?
• Do you attempt to contact family members or
  neighbors and apprise them of the patients
  condition and unsafe living environment?
• Do the local police need to become involved?
• Does this need to be called in to any other
  authorities for documentation?

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Case 3

• You are called to the local nursing home, for the
  70 year old female with altered mental status
• A semi-responsive female covered in dried feces
  and saturated with urine
• You note the patient is in soft restraints and
  the staff informs you that this is for the
  patients protection
• The nurses aide tells you that the patient is
  always trying to get out of bed so they had to
  restrain her
• Multiple bruises on her arms and legs and several
  pressure ulcers on the buttocks area

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Case 3

• Should anyone confront the nursing home staff
  about the patients condition?
• Do you transport the patient and note your
  findings to the ER staff and let them handle it?
• Is it an acceptable practice of a nursing home to
  restrain patients for their protection?
• Is it the responsibility of the individual
  transporting the patient to report their findings
  to any outside agency?
• Should you contact the patients family about
  your findings?
• Is this the norm because the patient is in a
  nursing home?
• How important is the history of this patient?
  (medical as well as event related)
• Do you need to document your finding with any
  outside agencies?

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Case 4

• Police are dispatched to the local bar for a
  combative and abusive male patient
• The police arrive to find a 30 year old male very
  distraught and agitated
• The police notify EMS
• Upon arrival you find your patient mildly
  agitated but cooperative with you and your
  partner
• Patient has an odor of ETOH but is alert and
  oriented x 3
• The bartender and several bar patrons state the
  patient verbalized wanting to end it all
• He denies wanting to harm himself and states I
  was just having a bad day

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Case 4

• The patient is alert and oriented so he is
  capable of refusing treatment.
• Are the bar patrons reliable witnesses?
• What is the responsibility of your local police
  in this situation? Should they assist EMS in
  transporting this patient to the hospital for
  evaluation?
• Are there ways in which you as an EMS provider
  can interact with your local law enforcement to
  safely handle this patient?
• What are your options if the patient refuses
  treatment?
• What can you do if the patient becomes combative?
• How important is it for EMS to interact with this
  patient and is an assessment necessary. (i.e.
  v/s, SPO2, blood sugar or a trauma assessment)

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Case 5

• Your dispatch receives a 911 call from a child
  stating she hurt herself.
• EMS and Law Enforcement respond.
• You find scantily clad 3 and 5 year old girls
  with no adult supervision.
• The children appear unkempt and thin for their
  age
• The home is littered with empty beer bottles and
  empty fast food containers
• Upon further inspection of the home you note the
  refrigerator to be empty and the environment cold
• The older child tells you mommy went out a long
  time ago
• As you are bringing the children out to the
  ambulance, the mother returns home and refuses to
  have you transport the children for evaluation

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Case 5

• What are your responsibilities as an EMS
  provider?
• Who can take protective custody of the children
  if necessary? What are your options? Police? ER
  Physician
• What things would be important to include in your
  documentation?
• What types of questions might you ask the mother?
• Discuss the difference between neglect, abuse,
  and poverty.
• Discuss what resources are available in your
  community to assist this family if needed?
• Should this call be documented with any other
  authorities?

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Strip of the Month

• Third Degree Heart Block

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Third Degree Block

• Absence of conduction between atria and
  ventricles
• Results from complete electrical block at or
  below the AV node
• Can result from an acute myocardial infarction,
  digitalis toxicity, or degeneration of the
  conduction system
• Atrial rate (visible P-waves) is unaffected
• Ventricular rate is consistent with escape
  pacemaker site
• gt 40 if the escape pacemaker is junctional
  (supraventricular)
• lt 40 if escape pacemaker is lower in the
  ventricles (infranodal)
• Ventricular rates can be faster or slower than
  normal rates (ie can be accelerated junctional
  rate, gt 60)
• QRS width is usually indicative of site of escape
  pacemaker
• lt .12 if pacemaker junctional
• gt .12 if site is infranodal

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Note the heart rate and QRS width on this
complete heart block
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Third Degree Block

• Can severely compromise cardiac output
• Decreased heart rate
• Loss of coordinated atrial kick
• Definitive treatment is pacemaker insertion
• Per Region 8 SOPs transcutaneous cardiac pacing
  is the treatment of choice

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VERSED (Midazolam)
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Versed

• Potent short acting benzodiazepine
• Is a sedative and a hypnotic
• Onset of action is approximately 2 minutes IVP
• Onset approximately 15 minutes if administered IM
• It has no effect on pain
• More potential to cause respiratory depression
  and respiratory arrest
• Routes
• IV
• IM
• IO
• IN

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Whats in your drug box?

• 10 mg in 10 ml easiest for IV / IO use (1 mg per
  ml concentration easiest to calculate)
• IM injection should be limited to 5 ml (Mosby
  Paramedic Text)
• 10 mg in 2 ml good for IN (2 ml total fluid, 1 ml
  per nostril)

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The End