Maggots: Are You A Medical Advocate for the Elderly?

“EMS Reruns” is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don’t have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we’ll pay you $50. We don’t know everything, but we do know a lot of smart people. If we need to, we’ll contact just the right experts and share their advice with you. Send ideas c/o emseditor@aol.com.

You’re at the Golden Hills Nursing Home, and you’d rather be anywhere else. It’s the worst facility in your response area. You’ve thought for years that nothing would surprise you here, but today you’re shocked. You’ve never seen or smelled anything this bad in your life.

You and your partner are standing on opposite sides of a patient’s bed, looking down at a small, frail man lying on his right side in a fetal position. He’s wearing a fresh diaper, but his flanks, pelvic abdomen, back and upper thighs are caked with dried feces that obviously extend under the diaper. There’s a dirty yellow urinary catheter taped to his left anterior thigh. A collection tube connects the downstream end of the catheter to a bag under the bed, and both the tube and the bag appear to be at least several weeks old. There’s a lot of particulate matter in the collection tube, and the man’s skin is hot and dry.

It’s about 90 degrees in the room, and flies are everywhere. The man’s back and hips are covered with purulent decubitus ulcers the size of pancakes, and you see at least 100 live maggots in and around the ulcers and on the stained bedsheets. Just then, a CNA named Jenny enters the room and directs you to a different patient in one of the other three beds in the room. This one’s lucky; he’s normally ambulatory, so he doesn’t have a Foley and you don’t see any skin lesions. But he stinks. He’s obviously dehydrated today, he’s not talking, and he’s also clearly febrile.

Q. You’re outraged. Isn’t there something you can do to close this place down?

A. Actually, there is. But for now, concentrate on helping the patients (that’s your job), rather than punishing the perpetrators (that’s not). Both of these patients need immediate care, and you’ve been invited to help one of them get it.

Q. How can you help the patient you haven’t been called for—the one with the ulcers?

A. Talk to him. Avoid making a scene, but even if he doesn’t seem to hear you, quietly tell him you’re going to do whatever you can to get him to a hospital. Then, politely point out your observations to Jenny. Remember that she’s at the bottom of her industry’s food chain, and she may not be able to authorize transport. But you can prompt her to think. Offer to send another ambulance for him, anyway. And finally, remember that you have another patient to take care of.

Once you have your patient safely out of there, advise the receiving facility of your findings. If you have any reason to believe the receiving facility won’t act on behalf of the other patient, you can contact the National Center on Elder Abuse (NCEA). It’s a nonprofit resource for professionals, as well as family members. The organization, which is funded by the federal government, maintains a website full of useful information about elder abuse and neglect, and what you can do as a professional when you encounter it. NCEA also maintains a list of current hotlines for every state. For more information, visit www.elderabusecenter.org.

Q. Why do some nursing homes do such a terrible job of taking care of people?

A. The nursing home industry has worked hard in recent years to improve the care of elderly patients, and to provide patients and their families with the kind of service they deserve. But just like some EMS agencies, some facilities suffer from crappy leadership and poor dedication.

Q. What if the nursing home doesn’t get disciplined and finds out you reported them? Can’t they simply call a different agency next time they need to transport someone?

A. That could happen. If it does, maybe the other crews are reading this journal, just like you are, and they’ll take their responsibility as seriously as you do. But as an Irish philosopher, Edmund Burke, said, all it takes for evil to thrive is for good people to do nothing.

You’re better than that.