"I know exactly where I am going to retire," exclaimed Grant. "What are you talking about?" asked Cindy.

"Well, I'm reading about the EMS folks of Grand Island Fire Department in New York State. They have created a program called Senior Assistance Team. Their number of EMS calls for patients over the age of 50 started to escalate, so they created an assistance program with the goals of education on both the local and county programs that were available for seniors, such as Meals on Wheels and the Senior Center in Grand Island; re-education on fire prevention and checking of smoke and carbon monoxide detectors, along with checking on the senior population's general welfare."

"Well, if the program is for people over 50, you had better put your house on the market and get ready for the move," Cindy responded with a huge smile.

"You have no idea how right you might be," Grant stated with his hands crossed on his chest. "Their program is composed of teams of two EMS or Fire personnel who visit the elderly with the purpose of checking on the person's welfare, their smoke and carbon monoxide detection alarms, providing written material on home safety, answering questions and spending time with the family."

"You're kidding me? Why do they spend all that time?" quizzed Cindy. "Well, think about it," Grant said, leaning forward in his chair. "Most of the time when we arrive on these calls, the person is frightened, hurting, and they won't talk, especially if they have been abused. By the time we arrive at the hospital, I have finally been able to get them to open up and talk, a little. If the person has had a positive experience with one of our staff, before the call, they may have a little more trust in telling us the real story."

Programs to educate and protect the aging population have blossomed over the past decade. Fire and EMS departments have discovered this opportunity not only to create educational programs for the general public but also to educate their own medical providers on the signs, symptoms and initial care of the elderly with suspected abuse.

The "graying of America" has brought many challenges for the EMS community. Access, or the lack of, to health care along with the expanding ability to live longer due to medications, interventional procedures, and advanced EMS care are increasing the number of EMS calls involving the baby boomer generation. EMS has been required to evaluate their approach in caring for this age group.

One important key in the assessment of the needs of this very special patient has been education, even to the point of states passing legislation on the mandatory education of health care providers in the identification of dependent adult abuse. The law describes abuse as the willful infliction of injury, unreasonable confinement, intimidation or cruel punishment, resulting in physical harm, pain, or mental anguish. Also willful deprivation of goods or services that are necessary to avoid physical harm, mental anguish, or mental illness.

It is very difficult to imagine a situation that could become so detrimental as to cause an individual to cause harm to our elderly. Stress, financial difficulties, misunderstanding of the aging process, or a caretaker having been abused themselves are only a few of the causes that create a potential situation for elder abuse.

Looking at the "typical" abused elderly, the profile paints a picture of a female in her 70's, frail, financially embarrassed, with multiple impaired health issues including sensory impairments such as poor vision and hearing, incontinence and dependence on others for obtaining health care. These individuals become easy targets to an abusive relationship.

Types of elder abuse can be categorized as physical abuse or neglect, psychological abuse or neglect, financial or material abuse or neglect, or the violation of personal rights. This material may sound very familiar. The types are identical to that of child abuse with the exception of financial abuse. The young child has not had the opportunity to earn cash to place them at risk for financial exploitation.

The reasons for elder abuse can unfortunately be placed into the circle of abuse. Many elder abusers were once abused as children. Without the provision of adequate debriefing and therapeutic mental emotional health options, these victims will be at risk to abuse if the environment is "ripe for retaliation." The typical scenario will find the child who was abused, now an adult, providing care for the person who neglected or abused them physically or mentally. With the addition of stress, drug abuse or mental disease, the abuser may not have developed appropriate methods of coping and may turn their anger toward the elder person in the form of physical or mental violence, stealing of life savings or monthly social security checks or withholding medical care.

Caring for a parent can be either a rewarding opportunity, or a nightmare for the family member without proper resources. Imagine caring for your mother, 24/7. She is bed ridden, occasionally incontinent, and mildly demented to the point that some days she believes that you are stealing her money. You have maxed your vacation time at work to get her to the many doctor visits. Many nights, she attempts to get out of bed and falls, then calling your name for assistance, but when you arrive, she fights you as if you are a home intruder. This will eventually cause resentment due to the new parental role. Without needed resources, anyone has the potential to strike out.

EMS providers are an important part of the detection and prevention of elder abuse. Barriers to this identification of abuse are not surprising. Ageism, the attitude toward the elderly, that you have mentally formed will either allow for compassionate or distanced care as a pre-hospital provider. If you have fond memories of your grandmother and were nurtured by elderly members of your family, you will enjoy and even engage in conversation with the nursing home transfer to the hospital. Unfortunately, our American society with busy lives, geographic mobility, hectic schedules and availability of optional placement of our elderly, does not allow for the children to experience the stories, recipes, emotions and love of the elders.

As EMS providers we can become frustrated with the health care system. All too often, we are called to the home of a patient who has been discharged from the hospital prematurely due to high bed census or insurance regulations. You are frustrated with another call, another run report and another missed evening with the family. That frustration should be channeled toward legislation changes, not displayed as anger toward the system.

Check to see of your EMS system has a protocol that includes the 5 elements of caring for the abused elder patient; detection, documentation, reporting, safe discharge plan and follow-up. The detection program should include the initial and ongoing education for staff on presenting signs and symptoms of the elderly abused patient. (Table 1). The famous statement, "If it hasn't been documented, it hasn't been done" still haunts medics as they complete the run report. That haunting has been a welcomed ghost when sitting on the stand before a prosecuting lawyer, in a courtroom, with your completed and well written run report.

Every health care provider should be familiar with their state law on reporting of suspected abuse. Official forms that have pre-designated screening questions (table 2) along with EMS department protocol and procedure must be available and previously practiced.

Safe discharge planning for EMS providers includes the delivery of a complete and concise verbal and written report to the hospital nursing and medical staff. Always remember, if you suspect that an abuse or neglectful situation has occurred, it will be your lawful duty to report the abuse through proper channels as your department has established. You may have described your ideas to the nurse but it is still your responsibility to make the report.

Before leaving the hospital, stop and visit one more time with the patient. This will allow for personal connection with that person and a link for future follow-up, just like the program that was developed by the EMS system in Grand Island, New York.

"Hey, what are you guys talking about?" asked Danny, entering the squad room.

"Grant wants to retire in New York where the local EMS department will make sure he is taken care of in his golden years," Cindy giggles.

"Wow, that will take the heat off your wife, especially when she has her heart set on -- where was that condo in Arizona she wants to move to after the kids are gone, Grant?"

"I guess I had better make a phone call to Sedona EMS and find out if they have a Senior Assistance Team," Grant replied, picking up the phone.

Table 1
Signs and Symptoms of Elder Abuse
1. Multiple injuries in various stages of healing
2. Unusual soft tissue injuries that do not match the mechanism
3. Facial injures
4. Head injuries
5. Dental injuries
6. Burns with representative shape or demarcation
7. malnutrition
8. Dehydration
9. Sexually transmitted infections

Table 2
Predestinated Screening Questions for Suspected Elder Abuse
1. Has anyone at home ever hurt you?
2. Has anyone ever touched you without your consent?
3. Has anyone ever made you do or say something you did not want to say or do?
4. Has anyone ever taken away your things without asking you?
5. Has anyone ever scolded or threatened you?
6. Are you afraid of anyone at home?
7. Have you gone without food, medicine or medical care?

Roberta (Bert) J. Baldus is a 20-plus year veteran in the pre-hospital setting and a nurse since 1975.

Bert is from Iowa and currently resides in Ankeny.