EMS Geriatric Emergencies - GEMS Diamond Assessment System

The GEMS Diamond Assessment System was developed by the National Association of Emergency Medical Technicians (NAEMT) in collaboration with experts in geriatric care. 

It was created as part of an effort to enhance the education and training of EMS Providers in understanding and managing the unique challenges associated with caring for geriatric patients in prehospital settings. 

This system is integrated into educational programs, such as the Geriatric Education for Emergency Medical Services (GEMS) course, which provides specialized training for emergency medical professionals. 

A Comprehensive Tool for EMS Providers

The GEMS Diamond Assessment System is an essential framework designed to assist EMS providers in navigating the complexities of caring for geriatric patients. 

This tool emphasizes a multifaceted approach that incorporates clinical, environmental, and social elements to ensure comprehensive patient evaluation. 

Here's what EMS providers need to understand about the GEMS system:

G – Geriatric Patient: Geriatric patients often present atypically, meaning that symptoms of serious medical issues may differ from those seen in younger populations. 

For example, conditions like myocardial infarction may present as generalized weakness or confusion rather than the classic chest pain. 

EMS providers should recognize and anticipate normal physiological changes associated with aging, such as decreased skin elasticity, altered pain perception, and slower cognitive responses. 

Importantly, geriatric patients deserve respect and should be approached with patience and empathy, never infantilized.

E – Environmental Assessment: The patient's environment can offer critical clues about their health status and potential risks. 

EMS Providers should take a quick but thorough look at the surroundings to assess whether it’s safe and conducive to the patient’s well-being. 

Indicators to consider include:

- Condition of the Home: Is it clean or cluttered? Is there evidence of neglect, such as dirty living conditions, unventilated spaces, or broken fixtures?

- Safety Hazards: Check for things like trip hazards, excessive clutter, or broken glass.

- Adequacy of Care: If the patient lives with a caregiver or in a nursing home, observe whether the care appears sufficient. 

Signs of elder abuse or neglect, such as the patient being confined to one room or visible signs of poor hygiene, should be taken seriously.

- Signs of Substance Abuse: Empty liquor bottles may indicate alcohol misuse, a common issue in geriatric populations.

- Medication Review: Take note of any outdated medication bottles lying around, as polypharmacy can lead to dangerous drug interactions.

M – Medical Assessment: Geriatric patients often have multiple chronic health issues that can obscure or complicate the assessment of acute symptoms. 

This makes obtaining a detailed and accurate medical history vital, regardless of the patient's chief complaint. 

Conditions such as heart disease, diabetes, and chronic pain syndromes are prevalent and can mask or exacerbate other medical issues. 

EMS providers must exercise vigilance in differentiating between baseline conditions and new or worsening symptoms.

S – Social Assessment: The social well-being of a geriatric patient is an aspect often linked to their overall health. EMS providers should evaluate whether the patient has a support system. 

Key questions include:

Does the patient have friends or family who visit regularly?

Is there evidence of social isolation, which can contribute to or exacerbate depression?

Can the patient manage daily activities such as bathing, dressing, toileting, and eating independently? If not, is there adequate support in place?

Is there regular access to essentials like food and clean water?

A comprehensive social assessment also includes observing the patient's interactions and listening for signs that they may be experiencing loneliness or neglect.

Conclusion

The GEMS Diamond Assessment System serves as a vital guide for EMS providers when managing geriatric patients. 

By focusing on the unique needs and considerations outlined — Geriatric, Environmental, Medical, and Social — providers can deliver a well-rounded, empathetic approach to care. 

In addition to using the GEMS framework, EMS Providers must remain mindful of the importance of thorough injury assessments, effective communication strategies, and maintaining respect for the autonomy and dignity of older adults. 

These practices not only improve the quality of care but also foster trust and cooperation with patients, their families, and caregivers.

As the geriatric population continues to grow, the ability to deliver tailored, patient-centered care becomes increasingly vital. 

By incorporating the GEMS Diamond Assessment System into their practice, EMS providers can confidently navigate the challenges of geriatric emergencies, ensuring safer outcomes and making a meaningful difference in the lives of their patients. 

The GEMS structure exemplifies the intersection of clinical expertise, empathy, and respect that defines high-quality care in emergency medical services.

Further Reading

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

NAEMT (2023) Geriatric Education for Emergency Medical Services (3rd Ed). Burlington, Massachusetts: Jones & Bartlett Learning

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

Peterson, L. K., Fairbanks, R, J., Hettinger, A. Z., & Shah, M. N. (2009) Emergency Medical Service Attitudes Toward Geriatric Prehospital Care & Continuing Medical Education In Geriatrics. Journal of the American Geriatrics Society 57 (3): 530-5. Accessed November 8, 2024

Shah, M. N., Rajasekaran, K., & Sheahan, W. D., Wimbush T., & Karuza J. (2008) The Effect Of The Geriatrics Education For Emergency Medical Services Training Program In A Rural Community. Journal of the American Geriatrics Society 56 (6):1134-9. Accessed November 8, 2024

EMS Discussion - Use of Lights & Sirens

EMS Providers should be aware of the ongoing discussion surrounding the use of lights and sirens during emergency calls. There is a growing concern about the risks associated with their use, such as an increased likelihood of accidents and harm to patients.

EMS Providers should stay updated on local and national guidelines regarding when to use lights and sirens to ensure the safety of both themselves and the public.

Those operating emergency vehicles must consider alarming statistics showing that ambulance crashes significantly impact clinicians, patients, and the public, with the risk of a crash increasing by over 50% when lights and sirens are activated.

It is crucial for EMS Leaders to implement well-researched guidelines supporting the restricted use of lights and sirens to enhance the safety of all individuals involved in emergency responses.

In an outstanding demonstration of collaboration on provider, patient, and community safety, 13 national and international associations have partnered on the release of a Joint Statement on Lights and Siren Vehicle Operations in Emergency Medical Services (EMS) Responses (NAEMT, 2022).

The statement articulates principles guiding the use of lights and sirens during emergency vehicle responses to medical calls and initiatives to decrease their use safely. EMS vehicle operations using lights and sirens pose significant risks to both providers and the public. Therefore, their use should be limited to situations where time saved is expected to be clinically important to a patient’s outcome (Merill, 2022).

Communication centers should utilize structured call triage and categorization to identify subsets of calls based on the response resources needed and medical urgency. Physician oversight is crucial in developing response configurations and modes for these protocols.

Agency Leadership should monitor the rates of lights and sirens use, appropriateness, compliance, and outcomes related to their use. Municipal Leaders should be aware of the increased crash risks, and quality care metrics should drive contract agreements.

States and provinces should monitor and report on emergency vehicle crashes to better understand the risks associated with lights and sirens use.

Collaboration between EMS and Fire Agency Leaders is essential in understanding public perceptions and improving education about the risks associated with lights and sirens to create safer expectations.

According to a recent presentation by NEMSQA, 87% of EMS responses were made with the use of lights & sirens, while transports nationally used them 51% of the time. The time savings averaged 102-216 seconds during a response and between 42-228 seconds for transports (from multiple recent studies); yet life-saving interventions are being done in only 6.9% of responses (according to an ESO study of 7.5M records).

At the same time, our odds of being involved in an accident increase by 53% in responses and 184% during transports (not to mention accidents in our wake that do not involve an EMS unit). Furthermore, litigations that involve ambulance incidents are 86% when using L&S.

The data presented highlights concerning statistics surrounding the use of lights and sirens in EMS responses and transports. While time savings are evident, life-saving interventions are performed in only a small percentage of responses.

The increased risk of accidents during both responses and transports underscores the need for a shift towards safer practices. Litigations involving ambulance incidents predominantly occur when lights and sirens are used.

It is crucial to view the use of lights and sirens as a clinical treatment and to follow the guidance to "use only as needed" to ensure the safety of patients, the community, and EMS providers. Prioritizing safe ambulance operations is vital for everyone's well-being and to ensure a safe return home after each shift.

Further Reading:

Merrill, L. (2022) 14 Groups Issue Joint Statement on EMS Use Of lights, Sirens https://www.ems1.com/ambulance-safety/articles/14-groups-issue-joint-statement-on-ems-use-of-lights-sirens-AAfswfKx2gaog3dy/ Accessed February 28, 2024

National Association of Emergency Medical Technicians (2022) Joint Statement on Lights & Siren Vehicle Operations on Emergency Medical Services (EMS) Responses https://naemt.org/docs/default-source/advocacy-documents/positions/joint-statement-on-red-light-and-siren-operations-with-logos---final.pdf?sfvrsn=e586e893_4 Accessed February 28, 2024

National EMS Quality Alliance (2024) Improving Safety in EMS: Reducing the Use of Lights and Siren https://nemsqa.memberclicks.net/assets/LSChangePackage/Improving%20Safety%20in%20EMS%20Reducing%20the%20Use%20of%20Lights%20and%20Siren.pdf Accessed February 28, 2024

Zavadsky, M. (2023) Culture Shift: Reducing Lights and Siren Vehicle Operation https://www.ems1.com/safe-transport-point-b/articles/culture-shift-reducing-lights-and-siren-vehicle-operation-XDonsygscixIghQT/ Accessed February 28, 2024