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Journal Watch: Homeless Patients' Views of EMS

Reviewed This Month

Homeless Shelter Users and Their Experiences as EMS Patients: A Qualitative Study

Authors: Leggio WJ, Giguere A, Sininger C, Zlotnicki N, Walker S, Miller MG. 

Published in: Prehosp Emerg Care, 2020 Mar–Apr; 24(2): 214–9.  

You may wonder why we’re not reviewing research related to the novel coronavirus this month. The fact is, studies regarding COVID-19 are being published at a rapid pace, and our knowledge changes daily. As with most things in our lives these days, this is not typical. While we try to review timely research, by the time this Journal Watch is published, any COVID-19 studies we reviewed may no longer represent the most up-to-date information. As we progress through this pandemic, we will make all attempts to review relevant studies and discuss results with implications that will not change daily. 

It may also be the case that some of you simply need a break from COVID-19. So this month we have a bit of a change of pace. 

This month’s is a qualitative study. Therefore we will not be discussing p-values or statistical significance. We won’t be talking about confidence intervals or measures of effect. Instead we will be discussing how a specific patient population views the care we provide. The study objective was to “explore how patients living at a homeless shelter, receiving services from a homeless shelter, or both experienced care from EMS.” 

This is an important population to study because they frequently interact with EMS and often have chronic health conditions. Research has also indicated that the relationship between EMS providers and this population has been challenged by a reliance on EMS to access care and mistrust of providers due to patients’ feelings of not being taken seriously. 

This study was conducted in Omaha, Neb. Study participants were homeless shelter users who received care from EMS at the largest homeless shelter in the area. Interviews were conducted on two separate dates, one in September 2017 and one in November 2017. One thing I like about this study is that while some interviews were conducted by “EMS faculty,” many were conducted by undergraduate EMS students. Kudos to the study team—this is a fantastic way to foster a culture of support for and involvement with EMS research. 

Investigators worked closely with leadership at the shelter in developing interview questions. They were designed to facilitate an open dialogue instead of direct questioning that may have been interpreted as intrusive or interrogatory. There were five open-ended interview questions: 

1) How often have you interacted with ambulance providers? 

2) How would you describe the role of ambulance providers in your healthcare? 

3) Tell me more about the circumstances or events involved in your past interaction or interactions with ambulance providers. 

4) As a patient, how would you describe the treatment you received from ambulance providers?

5) Describe what stood out, if anything, from your experience or experiences with ambulance providers. 

The participants had to be able to understand and answer questions in English. Their answers were analyzed and coded to identify themes. The final summative analysis identified four main themes: awareness of EMS, frequency and medical histories, perceived positive experiences, and perceived negative experiences.

Results

When discussing their awareness of EMS, interviewees described EMS as the first healthcare providers to arrive. Some expressed a sense of appreciation, viewing EMS as consisting of people who save lives and take care of patients. They also indicated the care provided and courteousness of the interaction differed based on the EMS crew that responded. 

Interviewees reported being treated or interacting with EMS as few as one time and as many as 100 times. Some indicated they interacted with EMS monthly or yearly. Interestingly, most reported they did not call EMS for themselves—it was often bystanders or workers at the homeless shelter who called 9-1-1. Those with seizure histories reported more frequent interactions with EMS. Other histories included respiratory illness, cardiac conditions, gastrointestinal discomforts, recurring illnesses, known infections, and traumatic events. 

When discussing perceived positive experiences, participants spoke of EMS providers’ professionalism and quick response times. Interviewees further indicated that being polite, concerned, and nonjudgmental toward them were important parts of EMS professionalism. Some specific comments included: 

  • “Not looking down on me. Worried about what’s wrong, asking me questions to find out what the problem is, that kind of stuff.”
  • “They ask questions, let you know they are concerned, want to know how you [are] doing on the way there, to the hospital, things like that. They do a good job.”
  • “Pretty much they’re not judging us by our class status of living.” 

Perceived negative experiences centered around feelings of not being taken seriously. When asked for examples, participants cited EMS providers acting aggravated or judgmental toward them. They described how these interactions did not live up to what they expected from a healthcare provider and said they came away from the experience feeling ashamed, awful, and judged. Some specific comments included: 

  • “I felt like they felt like they were a taxi service. That was the experience I got. And not even a nice taxi service, not like an Uber. They were like they were pissed.”
  • “I felt shamed. I felt judged. It was just awful. I can’t imagine if someone hated their job that much that they would take it out on patients.”
  • “They don’t take me very seriously. They think I’m on narcotics or drunk or something stupid. And they tend to be more rude and cocky that way.”
  • “They pigeonhole us as alcoholics and don’t want to treat us like human beings.” 

Limitations

As always, there are some limitations to this study, including only interviewing patients from a single homeless shelter. It is likely these results cannot be generalized to all shelters in all systems. The results also are based on memory and recall of participants. Finally, non-English speakers were not included. 

I want to congratulate the authors on publishing this interesting study. One of its most glaring results was that positive and negative experiences for this population were not centered around procedures or medications or first-attempt IV success. Overall, positive experiences were those where these subjects felt respected, and negative experiences were where they did not. As we move through these crazy times, this study is a great reminder that a little kindness goes a long way.    

Antonio R. Fernandez, PhD, NRP, FAHA, is a research scientist at ESO and an assistant professor in the department of emergency medicine at the University of North Carolina–Chapel Hill. He is on the board of advisors of the Prehospital Care Research Forum at UCLA.

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