Emergency 101
May 27, 2013 4:32 PM   Subscribe

My very awesome and super feisty elderly neighbor apparently fell down our building's stairs today just as I was getting home and when I got to her she was 100% conscious but bleeding profusely from a wound on her head. Another neighbor had already called for the paramedics and as I was walking up they arrived. The wound was assessed and it was decided that she needed to go directly to the ER. What could/should I have done to make sure she had what she needed and that her rights were being respected?

The wound was bad enough that I obviously didn't disagree that she should be taken to have it assessed at the local ER, but she was very frustrated by how everyone was sort of steamrolling over the fact that she was in no pain and that she had not lost consciousness at any time. I did my best to make sure that she got her purse, her phone, and her keys so that she would have her wallet with her, and one of the paramedics came with me to get all her medications, too. I also made sure to ask her permission before I got her purse, went through her home, etc, because I felt that even though we are neighbors it would have been presumptuous of me to have gone through her things. Now I am concerned that this is going to cost her a fortune since both the fire department and the paramedics came out AND she was transported and probably treated at the local ER.

How could I have helped my neighbor more and what can I do in the future if I am in this situation with anyone again? What should I make sure someone has if I am able to find it among their things, and how can I make sure that they feel like they aren't just being spirited away to the land of expensive medical bills without their consent?

There was so much blood. :(
posted by These Birds of a Feather to Health & Fitness (32 answers total) 1 user marked this as a favorite
Better to err on the side of caution when there's blood and a head injury involved. Especially with the elderly. I would rely on the judgment of experienced people in this case.
posted by quodlibet at 4:38 PM on May 27, 2013 [10 favorites]

Response by poster: Just for the record, I don't ever intend to fight with an EMT over a diagnosis OR a decision to transport. I'm just thinking that I really don't know what I'm supposed to know how to do in this kind of scenario, and I want to be prepared in the event I ever come across my parents or an elderly family member. Right now I have a nagging feeling that this neighbor is going to come home and be upset about how everything went, and that makes me really nervous and sad because I could have done more if I'd known what else to do.
posted by These Birds of a Feather at 4:46 PM on May 27, 2013

(If it will make you feel better, head injuries, even minor ones, tend to really bleed profusely. It's scary looking. )

I agree with quodlibet, you err on the side of caution. Better to lose money than health.
posted by St. Alia of the Bunnies at 4:47 PM on May 27, 2013 [5 favorites]

And on preview, elderly folks might fuss, it's part of the job description, but nevertheless what you do in a similar situation is call the health professionals and let THEM make the call.
posted by St. Alia of the Bunnies at 4:48 PM on May 27, 2013

This might be a good time to contact a social worker. The hospital probably has one on staff and can discuss your concerns. If the hospital doesn't have someone who will talk to you about the general issue (they won't discuss a particular patient, by the way), you might contact your areas local "agency on aging" who might be able to point you in the right direction.

In the long run there is no one size fits all answer to this, because everyone has different preferences for how their home and belongings are dealt with. And also for how much control of the situation they want to feel they have. You will be able to find some guidelines, but I don't know what they are.

For peace of mind, it might help you to kind of broach this topic now with some of the people you know. Get an idea of what a given person actually wants, so that you might be more comfortable in the next situation. (Of course, this requires confronting some difficult topics, and kind of makes people look at their own mortality/fragility, which can be tough. But I think we need to have more of these conversations, as a society.)

Good on you for wanting to be considerate!
posted by bilabial at 4:53 PM on May 27, 2013 [2 favorites]

You did great. You made sure she had her essentials, and were respectful in how you handled it (asking permission).

I can't think of anything more you could've reasonably done to help.

Please don't be hard on yourself. Those unexpected emergencies (especially with all the blood) are scary and upsetting. You kept it together and did your neighbor a solid.
posted by nacho fries at 4:54 PM on May 27, 2013 [5 favorites]

I think you did everything right. The only other things I can think of are offering to call any family members she might like you to notify about her situation, and asking if she has a medication list (which would negate the need for bringing the actual meds, if the list is up to date).

After she comes home, if she is upset about having had to go to the ER, "you were bleeding profusely from a head wound - thank goodness you got it checked out." Some people have the misconception that if they end up with no serious diagnoses, a trip to the ER was wasted. Those people overlook the fact that ruling out serious diagnoses is a valuable thing. If she is upset about the cost, "that's what health insurance is for." It won't cost her a fortune - she has Medicare.
posted by treehorn+bunny at 4:55 PM on May 27, 2013 [14 favorites]

(I am presuming you are in the US, based on your comments about cost...)

You and your neighbors did the right thing: Calling the paramedics. Heads have a high need for blood, so when there's a cut, it always looks terrible (SO MUCH!) But even so, it was right to have her go to the ER.

The cost of a superficial head wound with ER visit pales in comparison to finding her the next day unconscious on the floor because she had an internal bleed, or a fractured hip, or a concussion. Those hospital bills (and your guilt) would be much, much higher in that situation versus this one.

Your neighbor can be mad all she wants; you still did the right thing. She has the right to refuse all medical attention (and to sign the papers stating as much) but it's the job of the hospital to suss that all out, Not You.

(FWIW, my family just went through this with a loved one, who, as she was losing consciousness, distinctly said, "DO not call 911!" My mother did anyway because she couldn't sit by and watch my loved one die. FWIW, the loved one also did not have an advance directive, a healthcare proxy, or any sort of document stating her wishes because she didn't believe in them, so it was everyone' job to save her life whether she 'wanted' it or not because nothing was written down. That said, maybe ask your neighbor where she keeps such documents and an updated medications list, so that if there is another incident like this one you can hand them to the paramedics and they can take them to the hospital.)

What you went through was traumatic (at least, I presume it is for people who do not work in healthcare [like I do]). You did the right thing. Give yourself at least that, and bring your neighbor dinner when she gets home.

I would also encourage you to have a talk with your family about these issues, and cite this as the reason why. Good luck.
posted by absquatulate at 4:56 PM on May 27, 2013 [2 favorites]

As a Canadian living in the U.S., I am always so frustrated that people, especially the elderly, have to worry about money when they need medical treatment. I have worked with hospice patients who were dying, yes, months away from dying, and they were still filling out reams of paperwork, paying bills from their food budget...you get the picture. Awful.

Anyhow, enough of a derail. All you can do in situations such as this is exactly what you have done, help the person, advocate for them, ask lots of questions. If you can, you should accompany the person and be with them so you can do the same at the hospital (I am not saying in this particular instance with the neighbor, but in future with family members). And like absquatulate said, you should talk to your relatives before to find out what their wishes are.
posted by nanook at 5:06 PM on May 27, 2013

Best answer: I will add that steamrollering over the fact that she was in no pain and did not lose consciousness was the right thing to do by the EMS. Those are important facts in the medical history but they are not diagnostic, and they do not mean that hemorrhaging head wounds in the elderly (many of whom are on medications that cause them to bleed more readily and prevent clotting) do not need urgent medical attention.

Elderly people I see in the ER are often worried about the costs of getting medical treatment or about 'wasting people's time' by going to the ER. They often minimize their own pain and needs because they fear being a burden to others, or because they give inordinate priority to other things over their health ("I can't be admitted to the hospital for this chest pain, I have to go home and feed my cat!" "I have chest pain, I guess I need to see a doctor, but I don't want the expense and bother of an ambulance - I'll drive myself to the primary care office."). I find that reminding people that just because a catastrophic outcome did not occur, it doesn't mean that taking risks with their health was a good idea. And sometimes I try the reminder that their children or grandchildren would definitely have wanted them to get checked out/prioritize their health - they can usually recognize if you put it in those terms that yes, their family cares about them and would want them to seek care.

Finally, perhaps I did not answer your question directly before. People cannot be transported for medical care without their consent in the manner that you describe. Anyone who has the capacity for healthcare decisionmaking can refuse transport by EMS. If EMS is OK with that, they will just leave, but if EMS feels that they really need to be transported (as I'm sure they would have in this case), they are typically required to call a physician in the ER for 'medical control'. What I usually do as the physician in this situation is to ask to speak to the patient on the phone and try to determine whether they understand the consequences of refusing care and whether they have the capacity to make that decision. I can usually convince them they need to be seen, but in a few cases I have allowed them to refuse transport (i.e. a diabetic who accidentally gave themselves too much insulin, had a hypoglycemic episode, but now has eaten something and has a normal blood sugar and no complaints). Of course, my name goes on the record, so liability-wise I have to feel very certain that they do not need to be evaluated to allow them to refuse transport. I hope that helps to answer your question about being spirited away without consent.
posted by treehorn+bunny at 5:17 PM on May 27, 2013 [20 favorites]

You did everything right.

Don't let the fact that she kept on saying that she didn't think anything was wrong and didn't think people should fuss put you off - a lot of times people with head injuries don't necessarily think that something's "wrong" until later. (Exhibit A: Natasha Richardson hit her head while skiing, got up and thought everything was fine - and then several hours later died of an untreated head injury. Exhibit B: This askme, in which someone got banged on the head but still weren't sure that they needed medical attention despite the fact that they were HEARING THINGS.) Better safe than sorry; if it truly was something that she didn't need to be hospitalized for, the paramedics would have said so.
posted by EmpressCallipygos at 5:18 PM on May 27, 2013 [3 favorites]

Best answer: I have a lot of thoughts on this, I guess. Sorry for the multi-post, but I thought of something else that an elderly person might want. If they have a DNR order or other advanced directive and there is any chance of a hospital admission or serious outcome, they should try to bring that document along with them. It is not absolutely necessary (because that paperwork can be faxed or otherwise brought in later), but if, god forbid, they lost consciousness and needed to be coded, they would be coded unless they had expressly stated their wishes for such a situation to the medical staff or the paperwork was available/in their records already at that same hospital. Having a neighbor along who says "she didn't want CPR!" would not be acceptable.
posted by treehorn+bunny at 5:22 PM on May 27, 2013 [1 favorite]

Response by poster: Treehorn+Bunny, would it have been appropriate for me to have asked the EMTs to stop questioning my neighbor all at the same time? They were talking over each other the whole duration of the assessment and she was getting very frustrated and flustered because when one would ask her a question she'd gear up to respond, only to be directed to do something else and answer yet another question. Is it protocol for all the EMTs to sort of attack at once, or did I witness something that may have been more than a little hinky?
posted by These Birds of a Feather at 5:24 PM on May 27, 2013

i think you handled that situation beautifully. i had something very similar happen when i was in my early 20s. i heard my elderly neighbor go tumbling down a flight of, thankfully carpeted, stairs and he hit his head on the wall at the bottom. there was even a big hole in the wall but fortunately his head was not bleeding and he was conscious. i was the only one there and i called 911 immediately. the only thing i regret is that i was so freaked out by the whole incident that at one point i briefly left the poor guy alone to go outside to look for the ambulance. i should have stayed with him the entire time but i felt so helpless just standing there not being able to do anything. head injuries are serious business in the elderly. he stayed in the hospital for 2 weeks i believe. i can't remember if his fall happened right before or after something else did medically for him, but he ended up going to a nursing home shortly after that. i know i've heard that doctors are finding that concussions can be more serious than they were conventionally taught years ago so it is good to be cautious. better to be dealing with money problems than brain injury problems. i hope your neighbor is okay.
posted by wildflower at 5:38 PM on May 27, 2013

In my opinion, it's always OK to ask the professionals to slow down and let her answer. That's one of the best reasons to have a friend at your side when in a medical crisis - they're on your side, with a clear head, and without a larger "to do" list directing their actions. Writing down what people say and do and instruct her to do would also be incredibly helpful.
posted by SMPA at 5:42 PM on May 27, 2013 [1 favorite]

Is it protocol for all the EMTs to sort of attack at once, or did I witness something that may have been more than a little hinky?

Hinky, no. But not protocol, either. Remember that EMTs are people too. How many times at your workplace have routine tasks (and that's what this was for those EMTs, a routine task) turned into shouting matches -- not out of anger, but just because each person had his or her own idea of what needed to be done first? I'm with SMPA -- the best thing you could have done right then was say, "Hey, let's slow down a second here. She's conscious, she's lucid, and she's not bleeding out."

But what you did was a close second-best. You did more than the vast majority of people would have done. I hope that if I were in the same situation, I'd have the presence of mind and compassion to do what you did.
posted by Etrigan at 5:47 PM on May 27, 2013

What's appropriate around EMTs at work is to be quiet and stay out of their way unless asked for something by the EMTs. Sounds like you did that, so good on you, you did it right. Plenty of people self-report that they're fine after an incident and then go home to die of a brain bleed or whatever. Just trust that the EMTs know their shit and stay out of their way unless asked to help.

I get what you're saying and I get how emergency healthcare can really seem callous and heartless and cold. Anyone who's been around START at an MCI knows it gets a hell of a lot worse. But for real, this is their job, they don't get a kickback or anything, they just want to make sure ain't nobody gonna die if they can help it. That's a stressful hellish job even without well-meaning lookie-lous who think they have the pt's best interest in mind bouncing around interfering with them.
to slow down.
posted by Sternmeyer at 5:52 PM on May 27, 2013 [2 favorites]

Others have already said it, but sure, you can definitely try to help out in that way.

I'm only on the receiving end, but usually with EMS they're used to having a single member of the team be the point person for the history to "give report" to the receiving team at the ER. The multiple-people-questioning thing can happen if there's a trainee and the more experienced team member is trying to ensure that all the important questions get asked, or something like that, but it's suboptimal, of course, if people are talking over each other. You could say something like "Mrs X seems a little overwhelmed right now with all these questions - so that you can get the story more quickly and easily, could the person who's going to give report ask the questions right now, and then if anyone else has anything to ask, it can be asked when that person is done?"
posted by treehorn+bunny at 5:57 PM on May 27, 2013 [1 favorite]

Mod note: Don't derail this with off-topic snark about health insurance please.
posted by jessamyn (staff) at 6:17 PM on May 27, 2013

Two points:

When I was an university the dean of my college fell off his bicycle. He felt okay and went home, fell asleep and died on his couch because of internal bleeding.

I once helped an elderly woman with a severely twisted ankle get home (she refused any other option). Five years later I am still haunted by the fact that I made the wrong decision. She likely suffered greatly because I was foolish enough to listen to her.
posted by srboisvert at 6:17 PM on May 27, 2013

Response by poster: Please do not derail this conversation into telling me that I should never NOT refer someone to an EMT. That is not what this question is about, and I have already said multiple times that I am never going to fight against transport.
posted by These Birds of a Feather at 6:29 PM on May 27, 2013

Best answer: You did fine, listen to my cousin Treehorn, she's an ER doctor and really knows her business. Back in the Stone Age I was an EMT, I still keep up my CPR and Red Cross first responder certification. I can even work the AED.

I recommend that you get first responder training, not because you're going to swoop in and save someone, but it makes you feel less helpless in these situations. Check with the safety officer where you work and see if they sponsor the training where you work.
posted by Ruthless Bunny at 7:00 PM on May 27, 2013 [1 favorite]

As a career Paramedic, I'll reiterate that treehorn+bunny's answers are spot-on. Patients have the right to refuse care (except under specific conditions), but I have also been in the position of leaning rather heavily on a patient to allow me to treat and transport him/her, because it would be an unconscionable breach of my ethical obligations to walk away from a potentially serious medical condition. It's not like I get paid more if my patient goes to the ER, but my experience with a wide range of ugly things is telling me they genuinely need care.

As for your neighbor's frustrations, I'm very sympathetic; I see this happen from time to time, and I know it's unpleasant for patients. Most people who work with me know by now that I prefer to be the single point of contact with the patient - the one "voice" of all the blue-uniformed people who have suddenly invaded their house - because it puts them at greater ease. In situations when a patient doesn't want treatment but we're uncomfortable with the idea of them not receiving care, other members of the crew will sometimes chime in, trying in their own way to convince the patient to agree to be transported. They mean well, and in fact, sometimes another crewmember can strike the right tone when I haven't been able to do so.

It sounds as if you did all the right things. I've come across situations off-duty when I stepped in to provide medical assistance, and as soon as the EMTs or Paramedics came, I gave them the info I had and retreated to allow them to do their jobs. You helped them get the information they needed to provide the best care they could, and you did it with respect for her rights and privacy. I'm always happy when there are people on scene who are willing to help us out the way you did.
posted by itstheclamsname at 7:09 PM on May 27, 2013 [5 favorites]

The only thing I can think of that you didn't mention is, if you were able to do so, asking her whether she'd like you to accompany her to the ER to help with paperwork/hold her stuff/just sit with her and be someone she knows. I don't think you did anything wrong by not offering, especially given how much other awesome stuff you did for her. And she may very well have said no, since she was already downplaying her needs in the situation. But if it ever happens again, and if you can/want to do so, it never hurts to ask.
posted by decathecting at 7:48 PM on May 27, 2013

Sounds like you did an exemplary job.
posted by Dansaman at 9:04 PM on May 27, 2013

Falling is a scary thing when you're old - the odds are against you and very often you have a serious injury, which you don't want, thank you very much. If she fell down stairs and hit her head and was bleeding profusely, she was rattled beyond belief and scared - scared that she may have hurt herself badly enough she wouldn't be allowed to come home again, to continue her ordinary, peaceful life. It's sudden and it's terrifying - and it probably hurt a bit, too.

You did exactly what you should do. By calmly offering to get her things and shut her place up and watch over things, you did way more than you realize to ease her fear, which was probably as significant an injury as her head injury.

Head injuries bleed a LOT. She probably knew that (most old people have seen head injuries at some time or other), but still it's a disturbing mess, especially when it's your own blood. She knew, really, that she had to go to the ER, but it was frightening. Also, old people want everyone around them to think of them as hale and hearty - they are as embarrassed by their frailties as anyone at any other age.

Because she's old, you should know that Medicare will probably take care of most of the bill for her care and what they don't cover, she can make arrangements for small payments to pay off to the hospital - don't fret about that part. It's those who are too young for Medicare who have the horror of facing the $20,000 hospital bill for a twisted ankle, which is an obscenity no matter how you look at it.

I'm old and nervous about falling, but if and when I do fall I have a neighbor who is as kind and helpful as you, I'll be just fine. Thank you for helping her.

Oh - and it's possible that the EMTs who were pressuring her with questions were doing so as part of an assessment of her neurological status - the commenters above are correct that they know exactly what they're doing, at least most of the time.
posted by aryma at 9:45 PM on May 27, 2013 [1 favorite]

Wait, I'm confused, did she refuse transport or not?
posted by Violet Hour at 10:41 PM on May 27, 2013

Response by poster: She did not refuse transport because she wasn't given the chance to, though now that I've heard from her I am glad any objections she had were overridden as she had a 7cm cut that went all the way to her skull. Unfortunately she was at the hospital for 5 hours and wasn't seen until the last 15 minutes of said 5 hours. Thankfully the catscan she had revealed no strokes, but I'm still worried and she is too. Sigh. One of our other neighbors who knows her very well apparently decided to accompany her so I do feel a little bad for not offering to go with her myself, but I wouldn't have been much help as I haven't known her for very long.

Thanks for all your responses. Two other things I forgot that I could have grabbed but didn't were her cell phone charger and her spare pair of glasses, but thankfully she didn't need them. I think I'll be much more prepared now that I've read everyone's input.
posted by These Birds of a Feather at 11:01 PM on May 27, 2013 [2 favorites]

In my scant experiences with people who collapse, they are often as much embarassed as they are hurt/helpless/confused when they come to or regain their wits. In fact, I'm struck how very similar the reactions were from the 3-4 people I've seen go down: their immediate impulse is to deny they are hurt, refuse help, and attempt to get back up - even repeatedly if they are incapable of it.

I think there's a dignity-robbing aspect to it all that makes fall victims (from those who faint to those who slip and lose consciousness, even briefly) want to restore order and composure, instead of acting like the victims of a sudden accident. Maybe it's related to that vaguely paranoid feeling many of us get when we awaken from dozing off in a room full of awake people - I WASN'T SLEEPING NUH UH NOT ME NO-SIR!

Anyway, what I'm suggesting is that her reluctance to submit to pro inspection and help might not just be fiscal, but a defensive unconscious human reaction to suddenly losing agency and poise around others.
posted by IAmBroom at 11:44 PM on May 27, 2013 [2 favorites]

She did not refuse transport because she wasn't given the chance to

Did they force her onto a stretcher and into the ambulance? People are generally allowed to refuse if they are not unconscious, but if you just go along and do everything they say, you're going to end up getting an ambulance ride. They don't want to take on the liability of saying you don't need to go to the hospital.

Last time I was tended to by some EMTs, they wanted me to sign something acknowledging that I was refusing to be transported to the hospital, after they tried to encourage me to go with them.
posted by yohko at 1:51 AM on May 28, 2013

You live in the wealthiest country in the world and the elderly have to live in fear of needing life saving emergency care. Getting people to accept the care they need is hard enough when it is free like it is in most of the first world. You did all you could. All you can do for the future is maybe skill up on first aid, carry on being a good neighbour and support health care reform.
posted by BenPens at 3:15 AM on May 28, 2013 [1 favorite]

Anecdotal support that you did the right thing. My 72 old mother tripped walking down the street, got helped to her feet by some friendly neighbours who then let her go on her way when she said she was alright. My mother, has a crazy high pain tolerance that even doctors comment on, then walked around on a broken foot for almost 2 weeks insisting it was only sprained . I am in another country unfortunately so I couldn't drag her off to the doctors to get it checked even though I kept insisting over the phone she go. Anyway she ended up needing to go into hospital as she had messed things up more by being brave and not wanting to make a fuss. This is in a country where she wouldn't have to worry about the cost and she has ambulance insurance. I wish the neighbours, kind as they were, had called an ambulance as they would have saved my mother a lot of extra hospital time. You did the right thing, if I was her daughter I would hug you so hard for all your help.
posted by wwax at 9:29 AM on May 28, 2013 [1 favorite]

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