Recognizing and Responding to Medical Emergencies in Settings

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
• No medical or nursing background
• Or, if you have some kind of training this is a
• Germane to the settings serving people who
are homeless
Medical Emergencies
• Is this First Aid for Mountaineers?
No. No broken bones, tourniquets,
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
• 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 &
• You can be a clear, intentional, confident,
committed advocate.
What makes the people you work
with more vulnerable in medical
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
• 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
• 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
• …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
• 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
• 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
Rescue breathing shield
Note pad, pen
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
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
• Worsening chronic conditions may take time to
• 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
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
Many emergencies have the same or similar
symptoms (feelings, complaints)
I feel…
Sick, feel awful, feel funny, f’ed up, scared
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
What are some examples of medical
Diabetic emergency
Alcohol withdrawal
Trouble breathing, asthma
Allergic reaction
Heat and Cold emergencies
Injuries: broken bones, strains, sprains, cuts, head injuries
Heart attack
Sepsis, overwhelming infections, bad wounds
Abdominal pain
Chest pain
Loss of consciousness
Psychiatric emergency
Common Pediatric Medical
Allergic Reaction
Asthma attack
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
• 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:
Diabetic emergency
Alcohol withdrawal
• 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
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
• If they are possibly in alcohol withdrawal
• If they request it
Is this person not known by your or
• 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
Post- seizure
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
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
Recovery Position
• 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
Blood clot
Atrial Venous Malformation
Stroke Signs and Symptoms
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
Loss of consciousness
Stroke facts
• 4th leading cause of death, 133,000 a year die
• 795,000 strokes per year one every 40
• 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
• 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
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
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
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
• Sometimes other medications in addition or aloneheart, diabetes, blood pressure meds, psych meds.
• Narcan/naloxone reverses effects of opiates
Some Common Opioid Prescription
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
• 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)
Review: Overdose
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
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 Exchange
2124 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
Irritability , jumpiness, mood swings,
Insomnia, bad dreams
Sweats, clammy
Pupil changes
Increased BP and heart rate
Delirium tremens (DT’s)
Confusion, disorientation
Hallucinations worsen
Agitation, hyperactivity
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
• 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
• 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
• 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,
• heatstroke, allergic reaction, severe infection,
poisoning, severe burns or other causes
Cool clammy skin
Pupils may be dilated
Pulse is weak and fast
Complain of cold
Complain of thirst
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
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
• 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
“Thanks for coming around and
checking on us”

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