Six Considerations for the Assessment and Management of Homeless Patients

On a hot summer afternoon, an ambulance is dispatched to a park to evaluate a patient complaining of weakness. The EMS crew finds an adult male sitting on the grass next to a shopping cart filled with miscellaneous items. The on-scene police officer reports that the patient is cooperative and appears to be alert but slightly confused.

The EMS crew approaches the patient and begins their assessment. The patient says he did not sleep well the prior night, doesn’t think he has eaten since yesterday, and feels very weak. He mentions he has been in the sun all day. The EMS crew finds his skin warm and dry to the touch, with his heart rate slightly elevated. He is wearing a coat, several long-sleeve shirts and pants with boots, despite the temperature and humidity. The patient appears to have been sweating earlier.

The assessment reveals the patient is alert and oriented to person; he is confused about the year and can’t remember the name of the park. His identification card indicates he is 85 years old, has a history of heart problems and is allergic to “some medications.” An empty nitroglycerin bottle is found in his pocket. His primary complaint is generalized weakness. He doesn’t think he has sustained any recent trauma and denies having chest pain, shortness of breath, nausea, vomiting or diarrhea. He reported sharing “some drinks and some smokes” with a friend the night before. He also states he has been sitting in the park “most of the day.”

With the patient sitting, the providers take an initial set of vital signs. His respiratory rate is 20 with clear lung sounds, no obvious signs of distress, regular heart rate of about 102 and blood pressure of 112/80. No jugular vein distention or peripheral edema are noted.

Prior to moving him, the crew assesses the patient for orthostatic vital signs. After having him stand from a sitting position, the EMS crew reassesses his vital signs. The patient’s heart rate is now 122, blood pressure 102/70 and he has a slightly labored respiratory rate of 26. The patient states that he feels dizzy as the EMS crew helps him sit on the stretcher. The patient asks someone to move his cart behind a bush so he can get it when he comes back to the park.

After moving the patient to the ambulance, the crew checks the patient’s blood glucose and applies the EKG monitor. The blood glucose reading is 48 and the EKG shows a sinus tachycardia at 108. His blood pressure has risen to 118/78 and respirations are 20 with clear lung sounds. The patient says he still feels weak and tired. The EMS crew establishes intravenous access, initiates a 750-cc bolus of normal saline and administers 25 grams of dextrose intravenously.

The patient is assessed and observed in the emergency department for 6 hours with no subsequent nausea or vomiting. Repeat orthostatic vital signs improve, as do the symptoms of weakness. The patient is diagnosed with a hypoglycemic episode and dehydration and is discharged.

Introduction

Homeless individuals, including adults and children, can be found in any community.^1–4 EMS providers will likely respond to and care for a homeless individual at some point during their career. Due to this potential, providers should be aware of the unique challenges and more common medical conditions the homeless patient may present.

1. Layers of Clothing/Coverings

A thorough patient assessment should be performed, which may require exposing the patient’s skin. The homeless patient may be wearing multiple layers of clothing/coverings. If it is necessary to expose the homeless patient’s skin, such as to palpate the patient’s chest and/or abdomen, apply EKG pads or auscultate breath sounds, providers should try to avoid cutting or tearing the patient’s clothing/coverings since they may be the only garments the individual has.

It may also be necessary to check the patient’s clothes (e.g., pockets) for clues to what may have caused the illness/injury, but take caution. The patient may have a variety of objects in their possession, such as objects for cutting (e.g., knife), rocks or drug paraphernalia such as syringes. Providers should consider wearing gloves that will provide protection from possible foreign objects, as well as potential body fluids.

2. Logistics, Extrication

Homeless individuals may be using a variety of materials, such as sheets and cardboard boxes, for shelter. Such scene logistics can present challenges for providers. Is the patient surrounded or protected by things like boxes, newspapers, blankets or other materials? Does the scene appear to be safe? Are bystanders present? Is the patient trapped? Will technical extrication be needed? Is the patient in a confined area such as a dumpster, bus stop, car or under a bench? Are there pets, chained or loose?

The homeless patient may have a variety of personal belongings in a confined space. A grocery cart, bicycle, trailer, crutches, portable shelter, bedding and cooking supplies may be on scene. It is important to consider that these may be their only possessions. It may not be possible to transport the patient’s personal belongings, but leaving them behind can have significant consequences for them.

3. Mental Illness and Substance Abuse

Mental illness encountered can include conditions such as depression, bipolar disorder, schizophrenia, post-traumatic stress disorder, manic-depressive illness and other personality disorders.^7–10 While it may not be possible to differentiate which mental illness the patient has, providers will need to remain aware of this potential, especially if the patient is incoherent or presenting with an altered mental status. Half of homeless patients with mental illness also abuse alcohol and/or drugs. Because of this potential, providers should remain aware of the various signs and symptoms associated with mental illness and/or substance abuse, such as slurred speech, incoherent conversations and ataxia.^7–10

4. Concurrent Illnesses

Homeless individuals may have concurrent illnesses or medical conditions. Conditions that may be found among adults include dermatologic conditions (rashes, skin lice), respiratory infections, visual disturbances, heart disease, diabetes, decaying teeth, foot complications, sexually transmitted diseases/infections, HIV/AIDS and renal complications.^11–15 Children may experience “failure to thrive,” developmental delays, respiratory infections, ear infections, skin infections, neglect and abuse.^16–18 The presence of concurrent illnesses is likely to influence the patient’s signs and symptoms as well as the treatment that is provided.

5. Head Injuries

The rate of head injuries among the homeless and transient population is more than 20 times the general population. ²¹ Homeless males who consume significant amounts of alcohol over time tend to experience more head injuries and are also more likely to sustain a cerebral hemorrhage.²¹ The potential for the homeless patient to have a head injury and/or cerebral hemorrhage can add a layer of complexity when evaluating and treating the patient. Because of the potential for concurrent illnesses, including head injuries and cerebral hemorrhages, it may not be clear which condition is causing the patient’s signs and symptoms. Providers will need to consider multiple factors when managing the patient.

6. Environmental Exposure

The homeless are at risk for exposure to the elements, such as hot and cold weather. Heat-related conditions can include heat rash, heat cramps, syncope, heat exhaustion and heatstroke. Exposure to cold temperatures can result in conditions such as frost nip, frostbite and hypothermia. Removing the patient from the environment (e.g., moving the patient to an ambulance or indoors) is a basic first step in treatment.^22–24

Lifestyle Considerations

Lack of access to well-balanced meals hampers the ability of the homeless to maintain a healthy diet. In some cases, the food that is available for the homeless (e.g., at shelters) may be high in salt, sugar and starch and may lack needed nutrients. This can lead to nutritional insufficiencies that can potentially influence underlying conditions or result in complications such as electrolyte imbalance and fluid retention.⁵

Lack of housing for the homeless negatively impacts the ability to care for oneself. For example, wound care can be problematic for the person who has limited access to clean water and bandages, which leads to the potential for infection. The ability to store medicine or dispose of used syringes in a biohazard container may not be possible. Access to prescription medication refills, compliance with medications and the overall ability to monitor the homeless patient’s condition may be very difficult.

Dental and oral hygiene may be compromised if toiletries are not available. A lack of oral hygiene potentially lowers the individual’s immune/defense system and has also been shown to be a potential contributor to atherosclerosis, endocarditis and stroke.⁶

Sexually transmitted infections (STIs) occur more frequently among the homeless compared to the general population, especially in females. This is due in part to limited reproductive health services, prostitution and “survival sex,” which is intercourse in exchange for food, drugs and temporary shelter.^15,19,20

The HIV infection rate among the homeless is also greater than the general population. This has been attributed to limited access to condoms, survival sex, prostitution, sexually transmitted infections and intravenous drug use.

The pregnancy rate for homeless women is twice that of the general population.^15,19,20

Community Paramedics

Community paramedic programs are proving very beneficial for the management and care of homeless patients. A community paramedic program can help identify homeless patients who utilize emergency services on a frequent basis and determine the underlying reason for their recurrent misuse or abuse of the 9-1-1 system. Community paramedics can also provide treatment on scene, thereby potentially avoiding unnecessary transport and use of the emergency department and supporting the potential reduction in the overall inappropriate utilization of healthcare services.^37–39

Common Medical Conditions of the Homeless

Cardiac and Cardiac-Related Conditions—Angina, myocardial infarction, endocarditis and hypertension.^25,26

• Symptoms—Substernal chest pain, chest pain that radiates to the shoulders, neck or jaw, dyspnea, shortness of breath, nausea, vomiting and general weakness.^25,26
• Assessment—Patient assessment should include a complete set of vital signs, including an EKG when cardiac conditions are being considered. Overall appearance, such as skin that appears ashen, pale, or gray that is cool and moist to touch, should be noted.

Respiratory Conditions—Emphysema, pneumonia, bronchitis and tuberculosis may be encountered, especially if the patient is a smoker.^27–29

• Symptoms—Specific symptoms can vary depending on the condition. Common findings include chills, fever, fatigue, chest pain, sore throat, coughing, night sweats, weakness, a loss of appetite, unexplained weight loss and shortness of breath. Tachypnea, dyspnea, accessory muscle use, tripod positioning, pursed-lip breathing, cyanosis, bradypnea and a failing respiratory drive, such as agonal respirations, may be present. Inability to speak in complete sentences due to breathlessness may be observed.
• Assessment—Assessing complaints should include a complete set of vital signs as well as EKG and capnography. Breath sounds should be auscultated with each patient encounter. Providers should be especially attentive for the presence of wheezing, rales, rhonchi or the absence of breath sounds.^27–29

Digestive and Gastrointestinal Conditions—Gastrointestinal (GI) bleeding.

• Causes—Upper GI bleeding tends to originate in the esophagus, stomach or duodenum. It can be caused by peptic ulcers, gastritis, esophageal varices, Mallory-Weiss tears, cancers and/or the inflammation of the GI lining from ingested substances such as alcohol. Lower GI bleeding tends to originate in the duodenum, large intestine, rectum and anus. Causes can include diverticular disease, gastrointestinal cancers, inflammatory bowel disease (IBD), infectious diarrhea, polyps, hemorrhoids and anal fissures.³⁰
• Symptoms—Depending on the type and location of the GI bleed, the patient’s symptoms may start with vomiting blood or having bowel movements that may include black, tarry stools. Vomited blood may have an appearance similar to coffee grounds. Hemoptysis often indicates an upper GI source. Bright red or maroon stool can be the result of a lower GI source or from brisk bleeding from an upper GI source. Long-term GI bleeding may go unnoticed and can result in fatigue, anemia or black stools. Additional symptoms can include weakness and shortness of breath.³⁰

Complications from Alcohol (Cirrhosis)—Cirrhosis may lead to or contribute to a variety of complications including variceal bleeding in the esophagus and stomach, altered mental status, kidney failure, diabetes, changes in blood counts and the ability to clot, and decreased muscle mass.

• Symptoms—Cirrhosis can lead to a loss of appetite, a lack of energy or feeling of fatigue, bruising easily, skin that has a yellow hue or the presence of jaundiced eyes, skin that is itchy, edema of the ankles, legs or abdomen, urine that has a brown or orange tint, mental status changes, bloody stools and fever. ³¹

Hepatitis—Hepatitis A, B, and C may be the result of numerous factors including the effects of the homeless lifestyle and the potential lack of hygiene. Hepatitis is caused by an exposure to a substance such as feces (hepatitis A), blood (hepatitis B & C) and other bodily fluids (hepatitis B & C).

• Symptoms—Common symptoms can include jaundice skin, abdominal pain, decreased appetite, nausea, fever, diarrhea, fatigue, joint aches and muscle pain. Additional symptoms can include the redness on the palms of the hands, blood vessels just below the skin that look like tiny red spiders on the patient’s chest, shoulders and face, edema of the abdomen, legs and feet, as well as possible variceal bleeding in the gastrointestinal tract. ³²

Conclusion

The treatment of the homeless patient is influenced by many factors. The patient’s chief complaint, medical history, events surrounding the current episode, presence of concurrent illnesses/conditions, potential for alcohol/illicit drug involvement, and local protocols are a few of the factors that will need to be considered.^33–36

By remembering the more common conditions that may be encountered, including the potential for multiple underlying medical conditions, providers will be more likely to be attentive to the patient’s needs. A thorough assessment combined with provider judgment will be key in ensuring that the patient receives optimal prehospital care.

References

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2. U.S. Department of Housing and Urban Development Office of Community Planning and Development., The 2013 Annual Homeless Assessment Report (AHAR) to Congress (2013), www.hudexchange.info/resources/documents/ahar-2013-part1.pdf.

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20. Urbina I. Running In the Shadows: For Runaways, Sex Buys Survival. New York Times, www.nytimes.com/2009/10/27/us/27runaways.html?pagewanted=all&_r=0.

21. Shepherd L. St. Michael's Hospital. Researchers shocked by new statistics on head injuries among people who are homeless. Science Daily, www.sciencedaily.com/releases/2013/05/130516142650.htm.

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30. emedicinehealth. Gastrointestinal Bleeding, www.emedicinehealth.com/gastrointestinal_bleeding/article_em.htm#gastrointestinal_bleeding_overview.

31. WebMD. Digestive Disorders Health Center: Understanding Cirrhosis of the Liver, www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information.

32. WebMD. Hepatitis Health Center, www.webmd.com/hepatitis/hepa-guide/hepatitis-a-topic-overview.

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Paul Murphy, MS, MA, Paramedic, has administrative and clinical experience in start-up and established healthcare organizations.

Chris Colwell, MD, is the Director of Emergency Medicine at the Denver Health Medical Center (Denver, CO) and the Medical Director of the Denver Paramedic Division and the Denver Fire Department.

Gilbert Pineda, MD, FACEP, is the Medical Director for the Aurora Fire Department and Rural/Metro Ambulance (Aurora, CO) as well as an Attending Physician in the Emergency Department at The Medical Center of Aurora (Aurora, CO).