1. 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 A Guide to Listening to your Gut and Doing the Right Thing Heather Barr, RN, Public Heath Nurse

2. 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

3. 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.

4. 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

5. 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.

6. Remember, render help that is commensurate with your training.

7. 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.

8. What makes the people you work with more vulnerable in medical emergencies?

9. 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.

10. 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

11. 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

12. 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

13. 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?

14. 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

15. 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

16. 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

17. 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)

18. 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.

19. 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

20. 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

21. 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

22. Pediatric signs

23. 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

24. 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.

25. 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

26. 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

27. 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.

28. 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

29. Common Pediatric Medical Emergencies Fever Seizure Meningitis Allergic Reaction Poisoning Asthma attack Croup Vomiting and Diarrhea

30. Calling 911

31. 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

32. Some Specific Medical Emergencies typically seen in settings like yours

33. What we will cover today: Seizure Stroke Diabetic emergency Overdose Alcohol withdrawal Shock

34. 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

35. 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.

36. 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

37. 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

38. 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.

39. 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

41. 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

42. 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.

43. Everyday First Aid- Seizure https://www.youtube.com/watch?v=7MPJauo 4DdY https://www.youtube.com/watch?v=7MPJauo 4DdY

44. Recovery Position http://www.youtube.com/watch?v=uCDa- AhrjHo http://www.youtube.com/watch?v=uCDa- AhrjHo

45. 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.

46. 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

47. 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

48. Stroke facts 4 th 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

49. Risk Factors Same as heart risks, damage to arteries, clogging of vessels. Smoking, diet, exercise, some drugs, previous history of a stroke

50. FAST FACE- droopy ARM- weak S- Speech T- Time- call 911

51. Stroke Skills Review FAST, call 911 Ease person into comfortable position or recovery position Airway, breathing (ABC) Reassure Nothing by mouth

52. Stroke https://www.youtube.com/watch?v=PCNTMIc OMpE https://www.youtube.com/watch?v=PCNTMIc OMpE

53. 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

54. 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

55. 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

56. Diabetic Emergency https://www.youtube.com/watch?v=wj5_ruu6 MYc https://www.youtube.com/watch?v=wj5_ruu6 MYc

57. 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.

58. 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

59. Some Common Opioid Prescription Drugs codeine (only available in generic form) codeine fentanyl (Actiq, Duragesic, Fentora) fentanylDuragesicFentora hydrocodone (Lorcet, Lortab, Norco, Vicodin)LorcetLortabNorcoVicodin hydromorphone (Dilaudid, Exalgo)Dilaudid meperidine (Demerol)Demerol methadone (Dolophine, Methadose)Dolophine morphine (Avinza, Kadian, MS Contin, Ora-Morph SR)AvinzaKadian oxycodone (OxyContin, Oxyfast, Percocet, Roxicodone)OxyContinOxyfastPercocetRoxicodone 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:Tylenol Lorcet, Lortab, Norco, Vicodin (hydrocodone and acetaminophen) Percocet (oxycodone and acetaminophen)

60. Opioids/ “painkillers” Opioids are available in pills, liquids, or suckers to take by mouth, and in shot, skin patch, and suppository form.skin 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. Opioidnervous system

61. Drug Overdose Video on using naloxone (Narcan) https://www.youtube.com/watch?v=- t8ezZR4Xjk https://www.youtube.com/watch?v=- t8ezZR4Xjk

62. 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

63. How can I get naloxone/Narcan?

64. 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)

65. Robert Clewis Center- Needle Exchange 2124 Fourth th 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

66. 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

67. 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

68. 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

69. 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

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

71. 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

72. 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

73. Great job! Your confident, calm comforting presence is very meaningful You are helping the person hang on and be brave

74. “Thanks for coming around and checking on us”