GEMSsite.com: What's New

According to the United States Census Bureau, 12% of the U S population is over the age of 65 with the number expected to rise to 20% by 2030. Nationally, approximately 34% of emergency medical calls (3.4 million responses) involve patients over the age of 60. In spite of these numbers, EMS training for the care of the elderly is minimal. The EMT-B and the paramedic curriculum contain minimal content pertaining to the care of the geriatric patient.

To fill these gaps, the American Geriatrics Society (AGS) recently joined with the National Council of State EMS Training Coordinators (NCSEMSTC) to develop Geriatric Education for EMS (GEMS), a continuing education program focusing on the special needs of geriatric patients for prehospital EMS providers, both ALS and BLS. Just as the pediatric prehospital population merits specialixed EMS courses (PEPP and PALS), so, too, do the elderly.

Program Content

     GEMS is the first EMS program of its kind to deal specifically with prehospital care for the aged. An overview in its textbook states:

     GEMS represents the most credible and complete source of prehospital medical information on older adults.

     The course textbook includes chapters on specific emergencies, including falls, trauma/musculoskeletal disorders, respiratory and cardiovascular disorders. Other chapters include "Normal Changes With Aging," "Assessment of the Older Person," and " Improving Quality of Life." Often the subject matter overlaps, but this merely serves to reinforce the student's knowledge base and skills. The program draws on previously learned concepts (EMT basic assessment and treatment, ABCs) and focuses on how they are modified when dealing with the older patient. The course is done with lecture, video, skill labs and the use of small group discussions of case presentations. The interactivity of the program has been well received by EMS across the country and even by providers in the United Kingdom (UK).

Attitude Adjustment

     Let's briefly survey some of what the course provides with sample (italicized) passages from its textbook:

     GEMS is all about how EMS providers deal with older patients. The first chapter includes a discussion of one of the primary obstacles we must overcome: our own attitudes.

     Older persons have unique health needs and problems that must be managed with skill and compassion. To care properly for older patients, you need to educate yourself about the clinical conditions associated with older patients, and you need to have the appropriate attitude when caring for an older patient.

"It is an honor to be involved in the life of an older person in any way. Your attitude as an EMS provider must reflect this."

     It is an honor to be involved in the life of an older person in any way. Your attitude as an EMS provider must reflect this. Just as it is your responsibility to manage the emotional needs of a pediatric patient, it is your responsibility to manage not only the emergency needs of older patients, but also their social, psychological, and environmental problems. With an attitude of compassion and caring, you can have a profound positive impact on the lives of older patients

     Ageism categorizes a person as senile, rigid in thought, comical, eccentric, stubborn, and unable to learn new things. Terms such as 'geezer,' 'old bag', and 'old goat' further perpetuate ageism. Referring to an older person as 'honey' or 'dear' or calling the older person by his or her first name are subtle forms of ageism…

     The reality is that most older persons are healthy, active, and continue to be engaged in society after retirement. Using derogatory terms, speaking in a condescending tone, and having a negative attitude toward older patients undermine the care you provide and will erode any trust you are trying to establish. There may be instances where you feel disgusted or disturbed by what you see on a call. This is no excuse for a negative attitude or a lower level of care. It unjustly punishes these patients simply for being old-something over which they have no control.

Changes With Aging

How does the body and mind change with age? Chapter two contains a substantial system-by-system breakdown of how time affects our anatomy and physiology. Here is a sample:

The human body has the ability to age around 115 years. In the body's everyday process of replacing dead cells with new ones, the ability to regenerate cells is surpassed by the amount of cell death. This large amount of cell death leads to tissue death, organ death, and finally death of the body. The top causes of death in older patients include heart disease, cancer, and cerebrovascular accident (CVA).

"For patients who have some degree of hearing loss, don't yell! Lean closer to them and speak into their ear. Also remember that those with limited vision are not necessarily hard of hearing."

The text not only identifies the physical changes but also identifies problems that result for EMS providers:

Musculature of the upper airway weakens with age. This may allow the tongue and soft tissue of the oropharynx to close in easily, narrowing the airway when the patient becomes overtaxed or less responsive. Changes in bones and teeth can alter the shape of the face and mouth, making an airway harder to maintain when attempting to ventilate these patients.

"What's That You Say?"

     Another significant obstacle in our dealing with older patients is communication. GEMS defines the problem succinctly:

     Communication disorders constitute the nation's number one handicapping disability. Studies indicate that more people suffer from hearing, speech, and language impairment than from heart disease, venereal disease, paralysis, epilepsy, blindness, cerebral palsy, tuberculosis, muscular dystrophy, and multiple sclerosis combined. Conditions such as stroke, cancer, degenerative neurological disease, and trauma can affect the older person's ability to communicate. The aging process brings about changes in vision, hearing, taste, smell, and touch. Also, there are many changes in communication abilities that accompany aging, dementia, and other diseases.

     Throughout the textbook, instruction is provided for EMS personnel on how to better manage the older patient. These instructions are called "Tips" and are boxed outside the central text. "Tips" contain recommendations or suggestions for EMS personnel and include issues such as communication, attitude, and medication. For example, an "Attitude Tip":

     -Avoid the temptation to assume that because the patient is older, it is normal for him or her to have altered mental status.

     -Patients in the early stages of dementia may be embarrassed by the loss of their cognitive abilities. If the patient resists your questioning, don't be rude in an effort to get a straight answer, but do further question the patient gently, explaining that you are there to help.

     "Medication Tips" include:

     The older patient is frequently prescribed many more medications than the younger patient, multiplying the risk of interactions and medication side effects, which can include difficulty breathing.

     "Communication Tips" include:

     For patients who have some degree of hearing loss, don't yell! Lean closer to them and speak into their ear. Also remember that those with limited vision are not necessarily hard of hearing.

     Even more interesting are "Controversies," boxed items which contain discussions of issues under debate in the medical community. For example:

     The rule of double effect is an ethical principal used to justify certain treatment decisions made by health care providers at the end of life. The rule of double effects means that it is morally acceptable to give a treatment that hastens death if the main intention is to provide relief of suffering. A common example of this is a practitioner escalating the dose of morphine with the knowledge that it may hasten death through respiratory depression, but with the intention of relieving pain and suffering.

Complex Assessments

     Yet another significant obstacle in EMS assessment is the patient's aging body with multiple health disorders:

     Seemingly minor ailments can be excessively burdensome to an already compromised older person. An upper respiratory infection can make the patient weaker, which then keeps the patient from getting up and having meals or drinking appropriate amounts. This leads to dehydration, which makes the patient's symptoms worse. Because the older person does not have the reserves that a younger person might, he may have a harder time compensating for illness and is often forced to seek medical care. This is also very common when a patient when a patient has a chronic condition, such as chronic obstructive pulmonary disease (COPD) and it flares up.

     Completing a thorough assessment on an older patient requires the EMT to sometimes look past the complaint. The trick is to consider all the information and determine what is happening. The textbook provides great tables, diagrams and photos to help the EMT recognize and treat the older patient appropriately.

End of Life Determinations

     Because three-fourths of all deaths in the US occur in persons over the age of 65, end-of-life care issues is a significant subject for EMS providers to study.[See "Reflections on My Father's Death,"page 34.] One of the areas that is explored in this program is the care of patients in the end stages of diseases who have decided that they do not wish to continue to deteriorate.

     Most people agree that people are entitled to make their own decisions about health care as long as they can understand the consequences of the decisions they are contemplating. This ethical principle is often called autonomy. Autonomy is the right of an individual to make choices freely, in accordance with the individual's own goals and values.

     The ethical principle of autonomy is recognized legally in various ways. In every state, patients who are capable of thinking clearly (also known as having decision-making capacity) may give consent to receive or refuse proposed treatments. The informed consent doctrine which was developed by the courts, allows a patient to decide against unwanted medical interventions. Even if an intervention would probably prolong a patient's life, the patient may refuse it. The right to refuse life-sustaining treatment is also protected under the U.S. Constitution and the constitutions of some states.

     The right to refuse life-sustaining treatment applies to resuscitation efforts. Thus, if a patient with intact capacity decides against attempted CPR in the event of cardiac or respiratory arrest, CPR should not be attempted. Instead the patient's decision should result in the creation of a DNR order.

Find a Course Near You.

     The GEMS program debuted in Chicago early this year, but a small group from New Jersey had already participated in its development. Last December, the GEMS Steering Committee visited Robert Wood Johnson University Hospital in New Brunswick, NJ, to get feedback on the program from a group of EMS instructors. The presentation was well received and several of the comments from our state's groups were incorporated into the program.

     Since the roll-out of the eight-hour course in February, the NJ Department of Health and Senior Services has awarded the course eight elective CEUs for EMT-Basics. Courses are just now beginning to be offered around the state. In addition, the American Geriatrics Society is now in the process of rolling out the coordinator programs across the country and several people from NJ have already become instructors.

     More information about the GEMS program is available at www.GEMSsite.com. The web site also has a searchable list of upcoming courses and local course coordinators. Additional questions can be directed to mike.pante@rwjuh.edu.

     Geriatric Education for Emergency Medical Services (GEMS) textbook excerpts and chart reprinted with permission of the American Geriatric Society and Jones and Bartlett Publishers, Inc.

Michael D. Pante is an EMS educator at Robert Wood Johnson University Hospital and a paramedic at Somerset Medical Center. He is a member of the GEMS Steering Committee and editor of the program's Instructor Resources.