Recognizing and Responding to Some Common Medical Emergencies

in Settings that Serve People Who Are Homeless

A Guide to Listening to your Gut and Doing the Right Thing

Heather Barr, RN, Public Heath Nurse

Audience

• No medical or nursing background

• Or, if you have some kind of training this is a review

• Germane to the settings serving people who are homeless

Medical Emergencies• Is this First Aid for Mountaineers? No. No broken bones, tourniquets, Splints. This training is about feeling a little more comfortable recognizing when a person is having a medical emergency and feeling a bit more confident in offering help, comfort and advocacy .

What you will learn about today• Why this population is medically vulnerable• Why you’re especially able to recognize &

respond effectively in medical emergencies.• Tips for staying calm, remaining present• Using Trauma Informed Care in medical

emergencies• Communicating with 911• What to do- a few very practical skills• Some usual suspects-typical emergencies, or

symptoms of potential emergency• Good Samaritan Law

Good Samaritan Laws

• Protect those who do offer aid subsequent protection against legal action. As long as the rescuer is not willfully negligent or reckless in giving aid, and gives aid in a reasonable manner, then the rescuer will not be held legally liable for the outcome. Note that if a victim refuses assistance, forcing help on them against their wishes does not offer the rescuer shelter from legal liability. In this case, the rescuer should phone 911 immediately and let police and/or medical personnel handle the situation.

Remember, render help that is commensurate with your training.

Why you’ve got this….• You are an advocate, you have special

understanding of and knowledge about the people in your care and their challenges in life. What you know is important.

• You know your own personal abilities & limitations

• You can be a clear, intentional, confident, committed advocate.

What makes the people you work with more vulnerable in medical

emergencies?

Special Considerations• Histories of Trauma• Mental health issues• Substance use issues• May not respond to pain in typical way• May have communication problems• May be in very poor health at baseline• Possible bad past experiences with EMS, Law

Enforcement, hospitals (possible trauma triggers)

• May be alone.

The person may need advocacy -why?

• May present a complicated picture to EMS

• May be misinterpreted/ misunderstood by EMS, police, medical staff, others (misidentified as intoxicated, other misperceptions)

• May have a complex medical history with or without diagnosis or treatment

• May be alone, may be unknown to you, too

Why are you such an important and valuable advocate?

• You know about the impact of trauma• You might know about the person’s medical history• You might know what the person looks like on a

good day, and recognize a change in behavior, health. You can attest to a change .

• You know more about substance use, mental illness and homelessness than most

• You stand up for people on a daily basis.• You can help others understand this person,

especially if you know them, and even if you don’t

Trauma Informed Care• Understand trauma triggers (pain, noise, people,

sirens, medical situations)• Do no harm, avoid re-traumatizing• Know some ways to mediate the traumatic effect of

the current situation • Get person’s permission to intervene, provide care…• Provide safety physical and emotional/psychological, • Offer limited choices, give some kind of control,

provide safety, physical and emotional/psychological, • …But act on behalf of people when they unable to

speak or care for themselves or when they are alone

How Can I Stay (or become ) Calm in an Emergency?

• What helps you remain calm?

• What is your experience with medical emergencies/situations?

• Have you had first aid or CPR training?

Calm yourself• Take a deep breath, decide and commit

• Take a few seconds to assess the situation. What’s happening?

• Is it safe to intervene? DO NOT BECOME ANOTHER EMERGENCY

• Who is available to help, standby and or dispatch

• Check the time, ask someone the time

Feel Prepared: equipment• Have a mini kit:• Watch or time piece• Cell phone• Gloves• Rescue breathing shield• Note pad, pen• Naloxone• Soft candy or glucose tabs

Feel Prepared• Run scenarios in your mind, watch videos• Do case staffings before and after emergencies• Have good medical intake forms, and know your

clients who frequently need ambulance, have chronic conditions, EOL DNR Advance Directive

• Run practice drills frequently.• Take a First Aid Class• Update your CPR • Do de-briefing after any emergency at your

agency

Feel Prepared

• Remember the important thing is comforting and advocating

• Remind yourself about being a comforting voice to a person in crisis.

• Don’t be nervous about not knowing everything (no one does)

Speed of the event• Some emergencies unfold over time, fever,

infections may start slowly and reach emergency level in a matter of hours

• A person with untreated or poorly controlled diabetes may take days to reach an emergency level

• Worsening chronic conditions may take time to notice

• A person with a head injury may not present with symptoms hours after the incident.

In a matter of seconds• Notice the “oh-oh feeling”: Listen to that, it is your ‘gut feeling” and

it is usually right • The brain would like for everything to be OK, so it may feed you

some bad info. Inform your brain that you need it to act right now. • Focus on what you are picking up on, what has alerted you • What do you see? (Objective data)We call these things signs. • What is the person telling you? (Subjective data) We call those

symptoms.

• Tell yourself to pay attention to signs and symptoms Prepare to take charge

Many emergencies have similar signs• Behavior is odd, not the usual, or unsafe • Extreme agitation • Extreme lethargy• Very upset, appears frightened • Seems confused, not making sense• Speaking slurred, strange, too loud, too quiet• Weak, unable hold object, squeeze hand, raise limb• Walking is unusual, staggering, slow, guarded• “Guarding” a body part or area of the body• Moving erratically or very slowly• Breathing is fast, slow or loud• Skin looks pale, • Skin looks flushed• Heart rate is fast or slow, or irregular • Not responding • Changes in consciousness/mentation/behavior/personality

The signs are things you notice

• Signs get your attention. That’s good!

• Try not to diagnose, just pay attention to the signs and describe what you notice.

• Treatment is based on signs, clusters of signs

Pediatric signs

Pediatric Signs

• Change in eating, nursing• Vomiting• Decreased or absent urine output• Change in skin –flushed, pale, blotchy• Change in lip/facial color- pale or bluish tinge• Change in behavior, playing• Change in mood• Inconsolable crying• Agitation, lethargy, increased fussiness• Complain of pain, not feeling well

Simple Skill: A B C

• Airway—clear and protect

• Breathing be ready to assisit

• Circulation check the pulse

• In any emergency, always be assessing these continually.

Many emergencies have the same or similar symptoms (feelings, complaints)

I feel…• Sick, feel awful, feel funny, f’ed up, scared• Nauseous• Pain • Weak• Tired• Cold, hot• Can’t see, can move, can’t feel, can’t talk

Action and Assessment• You have to quickly build trust. What helps that happen quickly? • Tell them who you are, what you can do, can’t do. Your intention to help • “Hi, looks like you are having some trouble; I’m Joe, and want to help you, OK?”

• Reassure, caring, confidence, steadfastness, follow-thru: “I’m going to stay with you till the EMT’s get here. Want to make sure you are safe, alright?” • Take charge, clear the area, (safety) secure the area enlist help, • “I am concerned about you, can you tell me what’s happening, what do you think is

going on?” • Gather a little very useful more information. The person, friends, witnesses. This is

helpful if the person might lose consciousness before help arrives. • Explain to the person why you think 911 is a good idea

General Information you could ask for

• What happened? Let the person speak, listen for clues

• Name and DOB if possible• Where do you usually go to the doctor?• Been there lately?• Do you take medication for anything?• Have you taken any kind of drugs? Alcohol?• Have another person ask witnesses what they

saw.

What are some examples of medical emergencies?

• Seizure• Stroke • Diabetic emergency• Overdose• Alcohol withdrawal• Shock • Trouble breathing, asthma • Allergic reaction• Heat and Cold emergencies• Injuries: broken bones, strains, sprains, cuts, head injuries• Heart attack• Poisoning• Sepsis, overwhelming infections, bad wounds• Dehydration• Abdominal pain • Chest pain• Loss of consciousness• Psychiatric emergency• Assault• Rape

Common Pediatric Medical Emergencies

• Fever• Seizure• Meningitis• Allergic Reaction• Poisoning• Asthma attack• Croup• Vomiting and Diarrhea

Calling 911

Call 911• My name is:___________ • I am at _(address, cross street, landmark)• There is a person here who is having a medical emergency• He is (brief demographic) name 45 -55 year old male,

known as Benny, Benjamin Burt• Describe what you saw found on the ground• What he is doing (breathing shallow, not responding)• What he said/complained about (friend said he said Oh,

god, and then fell)• What you (and co-worker, other volunteer)are doing now

(checking if he is breathing, giving rescue breaths, asking his friend what else happened

Some Specific Medical Emergencies typically seen in settings like yours

What we will cover today:

• Seizure• Stroke • Diabetic emergency• Overdose• Alcohol withdrawal• Shock

Seizure

• Disruption in the brain’s electrical activity• Caused by infection, injury, drugs, epilepsy, head

injury, stroke, tumor • Person may seem “out of it”, stop talking, stare,

wander. They may not speak, but could be aware.• Person may have odd or violent movements, fall

down, lose consciousness, make sounds, have breathing difficulty.

• Usually brief, call 911 if lasts longer than 5 minutes in any case

Seizure-timing, prevent injury, comfort• Note time seizure began, time it. Over 5 min?• Remain calm, ask for help keeping the person

safe, out of harm’s way, move furniture, get a blanket, keep people away.

• Calmly and constantly reassure• Ease the person down, positioned on side,

(rescue position) mouth toward ground, move away from danger, furniture, cushion head. Provide privacy.

• Calmly tell the person you will stay with them till they recover.

Is this person known to you?

• Intake information- medications, Health Care Provider, typical type of seizure, plan of care, when to call 911

• Provide medical background information to EMS

Call 911?• If this is their first seizure• If they seize again• If they have had seizures before, but have

never been seen by health care provider• If this seizure lasted 5 minutes or longer• If they were injured during the seizure• If they were recently injured, especially Head

injury• If they are possibly in alcohol withdrawal• If they request it

Is this person not known by your or agency?

• Because you don’t know their background, you should call 911 for them. You don’t know why they had a seizure.

• They can negotiate with 911 when they are alert.

Post- seizure• Comfort• Orient• Reassure• Offer face cloth, tissues, water, help change clothes

if needed• Provide privacy• Allow for rest• Talk about plan for next time• Offer assistance with arranging follow up care if

appropriate.• If client is transported, call to check on them if they

are “your” client

Seizure Care Skills Review

• Time check at start of seizure or when you notice something is wrong

• Comfort, calm, care, safety• Position in recovery position- comfort, airway• Monitor breathing- if tonic/clonic, may have short

cessation of breathing.• Privacy• Stay with them till EMS arrives or until they regain

awareness, alertness if they have seizures like this typically and are known to you

Don’t do these

• Don’t put anything in the person’s mouth.

• Don’t worry about “swallowing the tongue”.

• Don’t restrain.

• Don’t ask a lot of questions.

Everyday First Aid- Seizure

• https://www.youtube.com/watch?v=7MPJauo4DdY

Recovery Position

• http://www.youtube.com/watch?v=uCDa-AhrjHo

Stroke

• Hemorrhagic, or “bleeding “ stroke, Due to long standing uncontrolled high blood pressure, damage to the blood vessels, resulting in a burst blood vessel

• Ischemic- blocked blood flow due to clot

• Disrupted blood flow deprives the brain of oxygen and nutrients.

Stroke is a disruption in blood flow to the brain resulting in a sudden impairment in

brain function

• Aneurysm• Blood clot• Embolism• Atrial Venous Malformation

Stroke Signs and Symptoms• Dizziness• Headache-often sudden “worst headache”• Vision changes, one or both eyes• Weakness, numbness on one side• Paralysis, unable to move one side of the body• Dizziness, trouble walking, balance is off• Slurred speech, trouble talking• Trouble understanding, confusion• Seizure• Loss of consciousness

Stroke facts• 4th leading cause of death, 133,000 a year die

• 795,000 strokes per year one every 40 seconds

• Twice as many women die of stroke that breast cancer

• 80% are preventable

Risk Factors

• Same as heart risks, damage to arteries, clogging of vessels.

• Smoking, diet, exercise, some drugs, previous history of a stroke

FAST

• FACE- droopy

• ARM- weak

• S- Speech

• T- Time- call 911

Stroke Skills Review

• FAST, call 911• Ease person into comfortable position or

recovery position• Airway, breathing (ABC)• Reassure• Nothing by mouth

Stroke

• https://www.youtube.com/watch?v=PCNTMIcOMpE

Diabetic Emergency• Could be high or low blood glucose• Low blood glucose can be fatal• Always give sugar if conscious, able to swallow

and not choke• Stay with person after assisting them. If they

don’t improve, call 911

What causes low blood sugar?

• Not eating, especially after taking diabetes medication, especially if that is insulin.

• Too much exercise without eating.• Too much insulin.• Having another illness

Signs and Symptoms of Diabetic Emergency

Symptoms vary, but common ones include: • hunger• convulsions• clammy skin• profuse sweating• drowsiness or confusion • Irritability, grouchy• weakness or feeling faint• sudden loss of consciousness

Diabetic Emergency

• https://www.youtube.com/watch?v=wj5_ruu6MYc

Diabetic Emergency Skills Review• Watch for symptoms; check and monitor ABC• Offer assistance• Help them sit down• Ask if they took insulin, if they ate• Offer a sweet beverage or soft candy or

glucose tab.• See if they feel better. If not, 911?• Ask if they are OK, have a doctor, if they need

to be seen.

Drug Overdose• Most common cause of death among homeless people

found outside.

• Often involve multiple drugs. Heroin, opioids, prescriptions, methadone, sedatives, tranquillizers, and alcohol.

• Sometimes other medications in addition or alone- heart, diabetes, blood pressure meds, psych meds.

• Narcan/naloxone reverses effects of opiates

Some Common Opioid Prescription Drugs

• codeine (only available in generic form)• fentanyl (Actiq, Duragesic, Fentora)• hydrocodone (Lorcet, Lortab, Norco, Vicodin)• hydromorphone (Dilaudid, Exalgo)• meperidine (Demerol)• methadone (Dolophine, Methadose)• morphine (Avinza, Kadian, MS Contin, Ora-Morph SR)• oxycodone (OxyContin, Oxyfast, Percocet, Roxicodone)• oxycodone and naloxone (Targiniq ER)• Fentanyl is available in a patch. A patch allows the medication to be

absorbed through the skin.• Some opioids, such as oxycodone, are often combined with Tylenol

(acetaminophen) in one pill. Examples of these combination drugs are:• Lorcet, Lortab, Norco, Vicodin (hydrocodone and acetaminophen)• Percocet (oxycodone and acetaminophen)

Opioids/ “painkillers”

• Opioids are available in pills, liquids, or suckers to take by mouth, and in shot, skin patch, and suppository form.

• How It Works• Opioid analgesics suppress your perception of

pain and calm your emotional response to pain by reducing the number of pain signals sent by the nervous system and the brain's reaction to those pain signals.

Drug Overdose

Video on using naloxone (Narcan)

• https://www.youtube.com/watch?v=-t8ezZR4Xjk

Review: Overdose• Signs/symptoms• Breathing- slow, shallow, or absent (ABC)• Unconscious, sternal rub• If no response, shallow or absent breathing, check

airway, chin tilt, give rescue breaths• Call 911, have someone do that if possible• Give Narcan• Check breathing, clear airway, chin tilt, give breaths• If no breathing repeat Narcan• Stand by till help arrives

How can I get naloxone/Narcan?

Kelley-Ross Pharmacy Eighth and Madison PolyClinic Building 206- 324-6990

• Alison, Ryan or Josh, the friendly pharmacists • $25 counseling fee-not covered by insurance. Can

counsel groups for one $25 fee. Call to arrange larger groups at your site.

• Medicaid and many private insurers will cover cost of the drug, not the counseling. The drug need not be used on the insured only! Anyone can get it and use it on anyone in need. Good Samaritan law applies.

• $50 for 2 intramuscular needle & syringes in a kit.• $50 for 2 intra-nasal doses, and $10 cash for

applicators (Medicaid does not cover the cost of the applicators)

Robert Clewis Center- Needle Exchange2124 Fourthth Ave (Blanchard)

• Any person who is concerned about overdose can go to RCC to get training and prescription.

• Send any client or worker, friend for counseling.

• 1:15 - 4:15 Monday –Friday. Takes 15-20 minutes

• Can have up to 3 in a group for counseling, but not more

• No charge! Prescription and training is free, at this time.

• No capacity to offer training to off site groups

Alcohol Withdrawal• Anxiety• Irritability , jumpiness, mood swings,

depression• Insomnia, bad dreams• Nausea• Shakiness• Sweats, clammy• Pupil changes• Headache• Hallucinations• Increased BP and heart rate• Delirium tremens (DT’s)• Confusion, disorientation• Hallucinations worsen• Fever• Agitation, hyperactivity• Seizures• Cardiac issues

Alcohol Withdrawal• Happens only to people who are addicted to

alcohol and abruptly stop drinking.• Wide range of symptoms• Time line variable, more severe 3-5 days into

abstaining• Can be life threatening• Call 911

• Detox involves medications for anxiety (librium) monitoring BP and rehydration

Alcohol Withdrawal

• Symptoms can be hard to distinguish from other medical problems

• It is really good to know your clients’ health and drug/alcohol history- is this included in your intake?

• If early in withdrawal, encourage them to get medical help ASAP

• If they seize and you suspect alcohol withdrawal call 911

• Stay with the person, calm and reassure, they are likely to be frightened and perhaps combative

Shock• Loss of blood- internal or external bleeding.

Vital organs aren't getting enough blood or oxygen. If untreated, this can lead to permanent organ damage or death.

• Dilation of blood vessels and “pooling” of blood in periphery

• Rapid blood loss from vomiting blood (esophageal varices rupture) Aortic aneurysm, trauma

• heatstroke, allergic reaction, severe infection, poisoning, severe burns or other causes

Shock

• Cool clammy skin• Confused• Pupils may be dilated• Pulse is weak and fast• Complain of cold• Complain of thirst• Nausea

Shock Skills

• Call 911• Recovery position• Cover with a blanket• Nothing by mouth • Elevate legs slightly, if possible to increase blood

flow to heart/core• Monitor airway, breathing, pulse• Reassure, be gentle, comfort and stand by till 911

arrives

Check your preparedness level

• Kit

• Agency – intake, diabetics, people with history of seizures, medically fragile, “advance health care directives” “end of life care plans”, care for responders.

• ABC, breathe, muster your calm caring self

• De-brief

Great job!

• Your confident, calm comforting presence is very meaningful

• You are helping the person hang on and be brave

“Thanks for coming around and checking on us”