Good Morning,

It's Labor Day. Many of you are working while others have a long weekend off. Thank you for all that you do every day.

We encourage you to register for our regular email blasts including our Monday Morning Medical Director's Message, PharmPhriday, and Zoom in the Afternoon.

As we continue with our Monday morning messages, our goal is to communicate solid, helpful information. Next week, Dr. Bare will be addressing the topic of geriatrics.

On the first Wednesday of every month, we present Zoom in the Afternoon. The presentation is a "touch-base" or educational tidbit lasting no more than twenty minutes. Please set your calendars to join us at 1 pm on the first Wednesday of every month for continued monthly Zoom talks. Dr. Dussel will present next month on Wednesday, October 4th.

Fridays are PharmPhriday highlighting a specific drug from the drug-box including its history, usage, and side effects.

Lastly, continue to utilize our website uhems.org for the latest courses, events, and updates.

Enjoy your Labor Day.

Sincerely,

University Hospitals EMS Training and Disaster Preparedness Institute  

Geriatric Trauma - September 13, 2021

Good morning, 

For those reading this email, the average age of our patients will continue to increase until our retirement. Caring for the medically complex geriatric population who may also have communication barriers brings with it many challenges.

Today we will talk about Compassionate Trauma Care of the baby boomer generation and provide some pearls and tips to optimize our care and patient interactions. One positive when seeing the geriatric trauma patient is that these patient populations are not usually hypochondriacs. If anything, they tend to under report illness and trivialize complaints. There is real pathology when we see these patients and with a thorough history and physical, we can uncover it.

Also recall that physiologic age is more important than chronological age. Most importantly, the atypical presentation in this age group is the typical presentation. Always keep that in mind when evaluating these folks whether it be for acute disease or injury.

Try your best to eliminate distractions and extraneous noises in the environment. Address your patient by title and last name. Sit close to the patient to optimize eye contact and hearing. Ask if there is one side that is better for them to hear you. Phrase questions simply and clearly, human touch may also put them at ease.

Similar to pediatrics, carefully explain all EMS procedures and interventions. Respect modesty during the physical exam and EKG. For our prehospital providers, bring items that will help them function, interact and feel most comfortable in the hospital. This includes teeth, eyeglasses, walkers, artificial limbs, and address books. Also bring any medical data the patient has prepared for you which may be in a bedroom drawer or on the refrigerator.

It is incredibly challenging to determine in the pre-hospital setting which patients do not need ambulance transport for ED care. Think twice about lift assists and non-transports.

Be sure to document when a patient refuses a c-collar. This is often missed in the elderly trauma patient. Try to determine the mechanism of injury .

Always ask why the patient fell.

Review all medication lists, check and double check anticoagulation medications especially.

Remember the ABCDE‘s of geriatric trauma. 

• A is for airway.

• B is for blood thinners, crucial to get an accurate med list for HIA trauma activations 

• C is for c-collar. This is often the biggest prehospital omission we make in caring for the geriatric trauma patient. 

• D is for distracting injuries or medical illness—elderly patients often have multiple injuries from a simple fall or low blood sugar. 

• E is for the event—try to get the most accurate assessment and mechanism of injury. This is very helpful for your ED partners and rapid trauma evaluation.

In summary, the geriatric trauma patient presents a challenge and opportunity for optimization for all healthcare providers. Think of your parents, your grandparents and yourself one day. Help us elevate the standard of care for all these patients from the field to the trauma bay.

Take a moment this week to reflect on all those heroes and victims we lost to 9/11 and now the Covid Pandemic. Never forget you are all the light in the darkness of this pandemic. Be proud of the work you do, the lives you save, and be sure to convey this to your colleagues early and often.

Sonny Bare, MD

Western Reserve Hospital and partner of UH Health System                  

Geriatric Falls - September 20, 2021

Geriatric Falls and Signoffs – AVOID THE PITFALLS

The geriatric population is experiencing the fastest growth rate of all ages. Baby Boomers are currently responsible for this rapid rise. In 2019 there were approximately 54 million elderly people in the U.S. (age 65 and older)representing 17 % of the population. By 2040 our country is likely to have 81 million elderly people.

Our September 2021 continuing education presentation highlights many of the unique characteristics of the elderly population which makes them a CHALLENGING and often difficult subsegment of the patient population. Factors such as declining levels of alertness, impaired cognitive function, co-morbid illnesses, reduced responsiveness to pain, atypical presentations for a life-threatening disease, and polypharmacy create barriers for EMS providers and emergency department staff.

Geriatric falls (often coined as the euphemistic “Lift Assist”) represent a potential physical hazard for the elderly victim and a medical-legal pitfall for EMS. It is a fact that geriatric falls represent the number one cause of injury-related deaths in the elderly population. Falls from a standing position, out of a wheelchair, and rolling out of bed can lead to lethal complications. Signs and symptoms may not be obvious initially. Many geriatric patients are taking powerful anticoagulants (Eliquis, Xarelto, Pradaxa, Coumadin, Savaysa) which result in acute and sub-acute internal bleeding.

Most geriatric falls are due to intrinsic issues (factors within the body). Orthostatic hypotension due to dehydration or GI bleed, dizziness, neurological conditions, sepsis, arthritis, hypoglycemia, overmedication of opiates, and/or benzodiazepines, arrhythmias, syncope, and a host of other medical conditions are intrinsic factor examples. Extrinsic factors are those in the environment (loose rugs, objects lying on the floor, furniture, pets) which cause the patient to trip, slip, or lose their balance.

Assume that most patients who end up on the floor have an intrinsic issue until proven otherwise. Obtain a “mechanism of fall” history on every patient who has gone to the ground. Patients who tripped or slipped, deny injury, and have no tenderness to palpation of head, neck, ribs, spine, pelvis, and extremities, most likely will sign off. Please obtain a set of vital signs on these patients unless the patient specifically refuses vital signs. If so, document refusal of vital signs and document the patient’s alertness and orientation status. (A patient is considered to have the CAPACITY to make a sound decision if they are Alert and Oriented times 4). The fourth orientation sphere is awareness of the situation, circumstances, and risks of refusing medical evaluation and treatment. If the patient is significantly intoxicated, a call to medical control to discuss the sign-off attempt is warranted.

For those who have fallen NOT DUE to extrinsic factors, a history specifically targeting symptoms such as dizziness, weakness, chest pain, shortness of breath, palpitations, acute onset of abdominal, head, or back pain should be documented. Vital signs, including pulse oximeter level, should be obtained on every patient encounter. Have a very low threshold for obtaining glucose level and EKG. 

Many geriatric patients are reluctant to visit the emergency department after a fall. They fear they might ultimately be placed in a long-term care facility and lose their independence. They often minimize their symptoms and insist on signing off even though they have concerning mechanisms of injury and obvious physical signs (hematoma to head, neck tenderness, rib tenderness, etc). Anticoagulants and falls are a dangerous combination. Patients should be ADVISED of RISKS of signing off. There may be internal injuries or medical conditions that could lead to serious or fatal consequences. The EMT should document the alertness level, orientation level, AND brief advisement concerning RISKS of signing off. Without the risk advisement, the family of the deceased victim could claim in court “the paramedic told us that my mother would be ok -- if we would have known she could have a head bleed, we would have insisted she go to the ER!"

Andrew P. Garlisi MD, MPH, MBA, VAQSF

Geriatric Polypharmacy - September 27, 2021

Geriatric Polypharmacy:

September’s Continuing Education presentation focuses on Geriatric Trauma. We have learned that the Geriatric patient represents a unique subset of the patient population due to the effects of aging. Cognitive, co-morbidity, communication, and polypharmacy issues ALL contribute to the challenges we face in providing emergency care to the aging population. So unique is the geriatric patient population that Geriatric Specialty Centers and Geriatric Emergency Departments are becoming more prevalent. The Silver Tsunami Era is upon us.

Geriatric polypharmacy is prevalent, clinically important, and yet often ignored. Over one-half of medication use is by those age 60 and older. Nearly 20% of hospital admissions of the elderly result from adverse drug effects. The average nursing home resident uses an average of 6 different prescription medications daily with more than 20% taking at least 10 different drugs. The explosive growth in drug development has rapidly expanded the number of prescription drugs in the United States. Hundreds of new products are added to the formulary every year. Immune therapies are experiencing an exponential increase.

Antibiotics, anticoagulants, antihypertensives, cardiac drugs, sedatives, antidepressants, and opioid pain medications top the list of commonly prescribed drugs in the elderly population. Adverse effects of these drugs are magnified in those with reduced liver and kidney function, which is more common among the elderly. It behooves the EMT to learn the names of commonly prescribed medications that your patient is prescribed. EMTs should be familiar with commonly used antihypertensives such as lisinopril, losartan, metoprolol, and amlodipine. Common diabetic meds include metformin, glyburide, glipizide, and glimepiride. Anticoagulants include edoxaban (Savaysa), dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and warfarin (Coumadin). Immune therapies such as Humira and Remicade place the patient at increased risk of sepsis.

Signs and symptoms of disease in geriatric patients may often be triggered, compounded, or even entirely masked by medications, even herbal remedies and nutraceuticals now being extensively used. Antihypertensives can cause orthostatic hypotension which can lead to dizziness, syncope, and fall. Beta-blockers often blunt the tachycardia that serves as an early warning system for subtle GI bleeds, dehydration, and sepsis. Drugs such as Humira and Remicade render a patient immunosuppressed and susceptible to infections. Any traumatic injury risk is compounded by the presence of anticoagulants. An elderly person who falls from a standing position and hits the head is at greater risk of intracranial bleed –even what appears to be a “minor” head injury on scene could later result in catastrophic consequences. Patients who refuse ED transport should be warned of potential risks of signing off –these risks must be documented in the EMS medical record.

Polypharmacy in the elderly invites drug-drug interactions which complicates an already-confusing clinical picture in a geriatric patient with confounding signs and symptoms.

Andrew P. Garlisi MD, MPH, MBA, VAQSF