Scene Signs: We Can Do More Than Just Respond to Emergencies

We could be doing a lot more for the public than just waiting for their medical emergencies to happen—and we should be.

Long before a kid sustains a head injury because he’s convinced he doesn’t need a bike helmet, we should be turning him into a believer—and a proud wearer of his own helmet. Before a high school student dies on the way home from his first prom, he needs to understand the effects of the alcohol that somebody will surely offer him. And before a woman in her 70s has the slip-and-fall injury that breaks her hip, maybe we can help her eliminate the hazards that will produce it.

What if next time you respond to a private residence, you make a few simple observations that will take almost no time at all and will cost nothing, but might detect the threat of a medical crisis long before the patient has a seizure, a diabetic crisis or an episode of acute pulmonary edema? You could be like San Diego County paramedics Paul Maxwell and Josh Krimston, who got tired of seeing kids drown, and persuaded the California legislature to pass an ordinance mandating fenced enclosures around swimming pools. Any of us could have done it. They did it.

It’s not enough for us to keep on responding to the same catastrophes, day after day and year after year. We need to become advocates. Every EMS system needs to establish formal follow-up pathways that link the observations of field providers to area social services, designated caregivers and, if necessary, law enforcement. These pathways need to be supported by policies, so when a field provider identifies a threat or a hazard, something happens.

It’s work. But it’s part of our job.

More than that, EMS advocacy is good business. What makes more sense: paying to care for the fractured hip of someone who will likely die within the year due to related medical complications, or correcting the situation that will cause the fall in the first place, thereby enabling the person to stay home and drink his or her own coffee for years to come?

I propose the use of a mental checklist like the one that follows, and a scoring system like the one Chris Hendricks poses on page 47. Both are tools that could be used to help EMS providers consistently identify suspicious circumstances in a home environment. Their observations could then be referred to ED physicians, family caretakers or social service agencies to facilitate short-term remediation. A mechanism like Chris’s PEAT (Physical Environment Assessment Tool) scale could support long-term data collection as well, some of which could be used to trigger improved building standards.

Checklist data could be fed to someone in the EMS system who would be responsible for allocating resources. During periods of low system demand, “re-visits” could be conducted to monitor the status of patients whose environments have been reported as risky.

Following are some specific assessments that field crews should make during every visit to a private residence:

Environmental factors might include the lack of strong grab rails in the shower and bathtub areas, especially in the residence of someone who lives with orthopedic instabilities or ataxias like Parkinsonism, alcoholic encephalopathy or Huntington’s disease.

Unstable or uneven walkways, loose railings and unstable stairs are also suspect. Even something as simple as a burned-out light bulb could lead to an injury under the right (or wrong) circumstances; an alert crew could correct that on the spot.

Is this occupant likely to be capable of managing his own nutritional needs? Open the refrigerator: Is it running properly? Does it produce an odor; does it appear clean? Does it contain milk, and if so, does the milk smell fresh? Does it contain fresh fruits and vegetables? (People who live on canned goods ingest excessive amounts of sodium, which can exacerbate heart disease, hypertension and CHF.)

Does this occupant know what her medications are for; when to take them; and in what amounts? If not, does she seem to have a system for keeping track of her medicines, and is she following it—are her most recent dosages tracked? A system like this might be administered by a caretaker, but somehow it needs to produce the desired effect: that the occupant is receiving the right amounts of the right medicines in the prescribed way. Polypharmacy is a grave threat to health among the elderly, and self-medication is an impossible challenge for some of them.

We all have to maintain calendars. Does this occupant seem capable of doing that? Is the calendar turned to the current page? Are there physicians’ appointments scheduled during the past week or the coming week? This information can be very important to an ED physician, and it should be important to a good crew as well. Consider taking the calendar to the hospital.

Contacts Management

Does this occupant have an organized way of managing their most important contacts? Examples include a caretaker, one or more physicians and close family members. Is there a telephone, and if so, does it have a dial tone? (If not, this occupant may not have a good system for managing bills.) Is the phone attached to a recording device? If so, does the recording device contain a couple of messages, or more than a dozen? (Depending on the occupant’s medical acuity, a crew might want to listen to the recorder. Sometimes it can help establish the time frame for a critical event.) Pay attention to small notes written in the vicinity of the telephone; they can convey the most immediate details of an occupant’s life.

Does this occupant have a system for managing the mail? Are there more than a few letters in the incoming mail box, and is there more than one day’s worth of unopened mail lying around the house?

The number of newspapers lying in the yard can often be useful for establishing the time frame for a current emergency. (Check out the mailbox, while you’re at it.)

A very clean bathroom is a reliable indicator of recent cleaning, because bathrooms get dirty quickly. But by itself, a dirty bathroom might not communicate very much, because lots of people don’t clean their bathrooms often enough. Fresh towels are important, however. And so are soap, a system for maintaining dentures (if the occupant has dentures) and a fairly well-organized placement of med containers. Loose wall hardware is a definite hazard, especially in the bath/shower area, and will eventually come crashing down. When it does, it can surprise an elderly occupant and trigger a fall.

Corrective lenses are critically important to some people, and they are valuable communicators to an EMS crew. If the occupant has a pair of glasses and is not wearing them, a crew should ask questions about the nature of the lenses. If they are designed for constant wearing and are not wearable for some reason, that can produce falls—especially if the lenses are made to strong specifications. It’s also a good idea to compare the lenses to one another. They can suggest blindness in one or both eyes, reading difficulties and severe astigmatism. Misaligned, broken or badly scratched eyeglasses can also be the primary reason why an occupant is not reading her mail—a situation that will evolve into an emergency.

Non-functional hearing aids (or hearing aids that fit so poorly their owners don’t wear them) account for many emergencies for people who can’t hear their fire alarms, doorbells or phones ringing. Sometimes these devices are very expensive to repair or replace, even when a portion of the cost is covered by Medicare. Sometimes they’re simply impossible to locate, especially when an occupant can’t see well and has broken or misplaced his glasses (and wouldn’t think of asking for help with such a thing).

Does the occupant have an apparent system for managing the trash, or does it accumulate in or around the home? Garbage tends to attract disease vectors like rodents, insects and other pests. Very severe failures in this area need to be brought to the attention of police or social services, depending on how they are managed in your area.

Animals can be very beneficial to the elderly, especially live-alones. But animals require food and water several times a day, as well as a system for managing wastes. If there are pets in the home and they appear to be well cared for, a crew can make fairly accu-rate inferences about the time frame surrounding an emergency. If pets are not well cared for, they can deteriorate quickly. And if an occupant is not caring for him or herself, the pets are likely to suffer early. (Remember to provide food and water for animals before transporting a patient who is a sole occupant.)

Lots of people don’t make their beds every day. But if the bed is made, you can consider that another time marker—or a clue about the recent involvement of a caretaker.

The presence or absence of a walker, cane or wheelchair can be an important indicator of an occupant’s dependence on others. Often, these devices are stamped or stickered with a vendor’s contact information. Very often, a vendor can provide information about the contact who ordered and/or paid for a device.

Other Hints

Other key findings that aren’t pictured here include (but are not limited to) the following:

1. Presence and condition of an automobile: Is there a car in the garage? If so, what is its condition, and does it appear to have been driven lately? A car that is covered with dust and boxes or has more than one flat tire suggests that the occupant doesn’t drive. But a car that has been kept clean (especially the glass) is likely to have been driven lately. Does this occupant drive routinely? Does she appear to be capable of driving routinely, based on the condition of the car (e.g., widespread damage, etc.), her mentation, sense of balance and ability to manage her other affairs? Crews should be very careful about rendering an unsolicited opinion about this circumstance, because it can have a tremendous impact on the life of the occupant as well as the safety of the public.

2. Patterns of change in mentation (as elicited during history-taking): Is a finding of impairment something that has only been observed recently? Is it related to an isolated event, and was its onset sudden or gradual? Remember, an on-scene “historian” may not be available or accessible later.

3. Relationships with cohabitants (as observed on scene by EMS providers): Remember that your observations of the way people behave on scene may be the only available evidence of possible neglect or abuse. Does a cohabitant or relative seem unduly controlling, apathetic or hostile toward the patient? Do they seem a little too nice, considering the condition of the environment? (Abusive people often do.)

Conclusion

Obviously, the scope of this topic exceeds the capabilities of a small photo-essay in a professional journal. But I think it contains the essential elements of a checklist that could be modified to suit the needs of any EMS jurisdiction—and a training process to support it. Furthermore, we hope it motivates some system status irritants out there to become prevention advocates on behalf of their patients.