Either Lead, Learn, or Please Stop Talking

The Internet is a wonderful educational resource.

I hope this doesn’t come as a surprise to anybody, but it’s good to be reminded. As little as 20 years ago, it simply wasn’t possible to learn things in the same way or to the same extent as today, because you had to seek out the information like Indiana Jones hunting a lost jewel-encrusted kumquat. Now there are a thousand PhD’s worth of knowledge available for anyone with a modem (although it behooves us to remember that much of it is still more easily found offline, and some remains completely undigitized even now).

I have always relied heavily upon this resource, and the majority of the synapses currently rattling around my noggin wouldn’t be there if it weren’t for the ’net. I went to school, sure, but when it came to pursuing my interests and hobbies, that’s not where the money was. It even filled the bowl of my early work history — I worked in web design, various sectors of freelance writing, even as a certified locksmith, all of it made possible by self-education via an endless tap of bits and bytes.

When I first became involved in EMS, I expected that to remain true. But it wasn’t.

EMS 2.0: Good, bad, and ugly

Although somewhat inchoate in my early days, the EMS 2.0 movement was already getting legs, and was driven by an online community of paramedical luminaries hoping to remodel our damaged field into a modern, functioning system.

More recently, the larger arena of the medical community — with emergency medicine leading the way — has embraced FOAM, the general principle of free online medical knowledge-sharing. This is good stuff, and it’s just what we need.

But when I was a green EMT — and we all know how unprepared a freshly certified newbie can be — I turned to the web in the hopes it would help me learn, improve, and become better at my job. To some extent, it did. But I was also stymied.

Everywhere I turned I found veteran EMTs and paramedics advocating for increased education and training within our field. They seemed to passionately believe in making prehospital providers become better clinicians. Yet whenever I would ask medical questions to try and do exactly that — become better — I wouldn’t get answers. I would get further diatribes about the shortcomings of EMS education. Or suggestions to read a textbook (only rarely was one recommended). Or, if I pressed the point, the advice to go to paramedic or even medical school, because this sort of inquiry was likely to make me a fish out of water in my current profession.

Truth be told, I rarely got any answers where I didn’t dig them up myself. And I found this strange. Why would people purportedly so interested in advancing their profession seem to have so little motivation to actually do it?

Time has passed, and I have more perspective. In retrospect, the folks on the other end of the screen often didn’t know the answers to the questions I was asking, or only knew the answers in an incomplete or experiential way. Time has also brought along some actual progress, and there are more true FOAM resources out there.

Yet in the prehospital world, noisemaking still seems to predominate over knowledgemaking. For every blog post, website, forum thread, or social media group dedicated to transmitting information, there are ten whose primary occupation is posting long, repetitive screeds about the gaps in EMS education and the sorry state of our profession.

Now, everybody has a life outside of the internet (well, most everybody), and some of these people are indeed practicing what they preach. They’re teaching and precepting, writing and organizing, even lobbying to accomplish the changes we all dream of achieving.

Many others, though, seem to have endless time and energy for complaining about how dumb everyone else is, and very little for correcting that dumbness. More disturbingly, in recent times, the tone of these complaints has taken a strange turn toward arrogance. Novices foolish enough to poke out their heads are decried for not being up to the level of the complainer (interestingly, the level of the complainer is usually presumed to be the appropriate one — nothing more and nothing less). I imagine a great deal of this stems from frustration. But it certainly doesn’t contribute to a solution, nor does it speak very highly of the veterans behind the keyboards, who are missing the opportunity both to educate and to model professionalism. (Hint: there is no degree of expertise that ever makes arrogance appropriate.)

Yes, ideally we will move to a place where everybody staffing an ambulance has a strong initial education in anatomy, physiology, pathology, and medicine. Yes, this will probably entail degree-granting programs and a fundamental paradigm shift from our current model of training. But until then, there are thousands of EMTs and paramedics on the road or in the classroom with a grossly limited knowledge-base, and a significant number of them are motivated to do better than that. Are you going to blow them off until the day of rapture, or are you going to try and help?

I didn’t want to write this post, because I didn’t want to be part of the problem. This site aims to be zero percent complaining and 100% educating. But we’re just a drop in the bucket, because there are a lot of smart people out there who could do far more good than a hundred EMS Basics, and I wish they would remember it.

The Long-term Care Ombudsman: Advocates on Call

Although we like to talk around here about exciting topics like shock and airway management, the reality is that for many EMS providers — particularly at the BLS level — a large part of this job isn’t stabilizing emergencies. It’s routine work like dialysis trips and stable transfers from nursing facilities. Some folks find this stuff dull, and it can be dull, but the best way to make it interesting is to approach it just like the exciting stuff and try to be excellent at both aspects of the job.

How can you excel at bringing Mr. Smith to his third doctor’s appointment this week? You can learn to be a really good patient advocate on his behalf, something that almost all residents of long-term care facilities need. We’re well-positioned to fill this role because we have a one-on-one relationship with our patients. Unfortunately, we often lack the know-how and leverage to resolve most of their problems.

Our feature in the August 2014 issue of EMS World talks about how to use the ubiquitous Long-Term Care Ombudsman program to help. It’s easy, it works, and even if you didn’t know about it, there’s one available in your area. Give it a read and think about bringing it to bear the next time the guy on your stretcher has something to say!

Worthy Words

I admit that I’m a sucker for a good quote. Truth be told, medicine is exactly the type of enterprise that needs quotes. It’s a basically noble endeavor that’s nevertheless rife with the sort of frustrations, obstacles, and everyday nonsense that tends to make us forget why we’re doing it.

Quotes help us remember. A few concise, perfect words from people smarter than us — they needn’t be real people, either, because sometimes fiction is more true than fact — can paint a picture that reminds us in a flash how to do this job, why we’re doing it, and to whom it matters.

To that end, we’ve set up a page to collect the best medicine-related quotes we can find (you can find it in the menu above as well). Some are about EMS, some aren’t, but if you’re on the job, I bet many of them will ring true. Take a look and check back when you can; we’ll try to keep adding the good stuff as we come across it.

Those who Save Lives: Harry Watts

Who was Harry Watts?

You probably haven’t heard of him, unless you’re English — like he was — and you lived in the 19th century — like he did.

That’s because he was nobody special. He wasn’t a prince or a pope, he never invented a robot or discovered a mountain. Probably never even kicked a ball on television.

What did he do, then? He was born in Sunderland and lived poor. Poor as hell; no shoes poor, family-all-in-one-room poor. His father was a sailor. He had two sisters, and two brothers, one of whom drowned during a storm while Harry watched.

Starting work when he was young, Harry made his living first as a sailor, then as a rigger in the docks, and finally as a deep-water diver (the guys who wear big brass suits and suck air from a hose to the surface). He married and had two kids.

Oh, right. Also, all on his own, he saved the lives of 36 different people.

What, what?

While apprenticing on his first ship, he watched his fellow apprentice take a fall overboard. Harry’s automatic response was to dive in after him, pluck him up, and pull him to safety upon some floating timber. That was number one.

On his second voyage, he was waiting to receive the captain who was paddling back to the ship in a small canoe. He suddenly capsized, however, and was floundering in the waves. Harry grabbed a rope, swam out to the captain, and towed him back to the ship’s ladder. That was number two.

Number three was on the same voyage, when a boy was thrown into the water during a major storm, and the waters were too rough to lower a boat after him. Harry went in, and somehow, they both came out.

He rescued four and five on his next cruise — at the same time. So at the age of 19, he’d saved the lives of five human beings.

“Did you get any reward for these doings, Harry?” he was asked.

“Rewaard! Wey, sartinlees nut; nivver thowt o’ sich a thing. But we helped the two men wi’ dry claes an’ things.”

Indeed.

He got six more all together when an anchor line broke and dropped the anchor directly into a passing boat. There were six men aboard, and Harry went straight overboard while calling for help, landing directly on the wrecked boat in time to save them all.

Then one day at the dock, he saw a crowd gathering to watch a boy drowning in a rough sea. He leapt in, swam out to him, and brought the boy successfully back to shore on the verge of exhaustion.

At age 36, he made a career change from sailor to diver. At this point, he’d saved 17 people (plus one dog), most through risk to himself — sometimes grave. On one occasion he swallowed so much contaminated water from the Thames river (this during the cholera epidemic which had essentially turned it into a flowing sewer) that he was bed-bound for months and nearly died.

Many of those saved were sailors; many others were young children. And if you’ve never plunged twenty feet into rough water, wearing boots and heavy sailor’s clothing, and pulled out a panicked child (clinging like an octopus and trying hard to drown you)… well, you’re missing out. At this point, by the way, he had never received reward or recognition of any kind. As they say,

… There is a hackneyed platitude to the effect that virtue is its own reward, but it is safe to say that the average man does not find such a result sufficient. It might be so in an ideal world inhabited by ideal people, but in this work-a-day world, in addition to the approval of our conscience, we love to have the approval of our fellows and to know that our acts are appreciated, and especially is this the case when we are actuated by altruistic motives. This is, of course, a form of vanity, but then vanity is almost a universal failing. [source]

But if Harry wanted applause, he certainly wasn’t clamoring for it. Just chugging along and saving lives as they presented themselves.

People take notice

Not long after that, he swam out to save two boys from drowning — while wearing one of his lead diving boots. (Yep.)

About a year later, he saved a couple more, and finally, there came the very first mention anyone had made of his efforts, a brief story in the newspaper:

Yesterday afternoon, about half-past three o’clock, a lad named Smith, about 16 years of age, son of an engineer employed on one of the Commissioners’ dredgers, narrowly escaped drowning. He was on board a dredger in the new Graving Dock, which was full of water, when he accidentally fell overboard. Mr. Harry Watts, in the employ of the Commissioners, gallantly jumped into the water and rescued him. The lad was very much exhausted, but restoratives were promptly used, and he was soon brought round. This is the twenty-second time that Watts has so nobly exerted himself in saving persons who have been in imminent danger of being drowned.

For a while, eyes turned away again. Then he hit number 25, and another story ran in the news, mentioning the man with “a perfect penchant for rescuing lives.” After that, people finally began to notice, and most of his saves received at least a little local attention.

He had countless saves while diving, such as the man who became tangled in a chain and was whipped overboard by a sinking weight — Harry dove in after and managed to free him underwater before they both drowned. Between rescues, he had plenty of interesting adventures, diving at the time being a trade full of explosives, accidents, and rockslides (he even had one memorable fight with a giant angler, or “devil fish,” which he ended up dispatching with a boat hook).

If that was his job, however, his hobby was volunteering with the Sunderland Lifeboat service; there was hardly a wreck nearby that Harry didn’t attend, they would say, and he was involved in rescuing over 120 sailors in extremis during storms. (Those don’t count on his score, of course, since they were team efforts. Just icing on the cake.)

He was 27, and up to 23 lives, when he received his first parchment award from the Royal Humane Society. A little while later when he ticked off number 25, they gave him their bronze medal as well, and when the local “Diamond Swimming Club and Humane Society” heard about that, they thought it just wasn’t cutting it, so they awarded him a gold medal of their own. The RHS gave him another parchment at number 26, and he continued to accumulate medals for his diving and rescue work — even one from the local temperance society for his good-natured efforts against the evil drink.

In fact, when he reached number 32, the local sailors (“gentlemen,” noted the newspaper, “because what constituted a gentleman was the performance of gentlemanly acts”) personally chipped in to cast him a silver medal in recognition of everything he’d done for them, despite the many years since Harry had personally sailed. Later, by widespread acclaim, his mayor wrote to the Queen to recommend Harry for the Albert Medal. Due to bureaucracy or who knows why, nothing came of the request.

An unfortunate turn came when Harry loaned his medals to the local church for an exhibition, and as night rolled around, the entire set was stolen by an unknown burglar. Harry was crushed, and the town of Sunderland felt it a slur on their name; the burglar was caught before long, but the medals were melted and gone. A popular movement arose, and within weeks they had struck replacements for the lot, and they returned them with dignity at a town ceremony. There, the thief himself expressed remorse, saying he wished he were drowned; Harry replied, “Mister, if ye were droonin’ aw’d pull ye oot bi th’ neck!”, and refused to press charges against the man.

He was 51 when he was approached to dive 150 deep to effect a mechanical repair. He was a little past such stunts for pay, he said, although of course he’d do so to save a fellow man, and he recommended some others who were younger and more willing. Their diver went down, and contact was soon lost; they returned to Harry and asked him to live up to his words, as nobody else was willing to go down to attempt a rescue.

He suited up and dived. The working depth was perhaps 120 feet, but it was upon a tiny platform across a bored-out shaft which continued another 300 feet past that; anybody who slipped was going a long way down until they looked like a recycled soda can. Feeling around, he located the other diver, who was dead (fainted, probably, then asphyxiated). He resurfaced, reported the news, then dived again to retrieve the body.

At the ripe age of 52, Harry was one of the divers who volunteered to recover bodies after the Tay Bridge disaster. He offered his services for no charge; when the diving commission attempted to pay him afterwards anyway (maybe because he was a million years old and a living legend), he politely refused and asked it be passed to a charity of their choice. (The man got around; somehow he was on hand at the Victoria Hall disaster as well, and widely applauded for his assistance in the aftermath.)

But never mind all that. His last life was saved at age 66. He and his wife were walking along the docks toward their home when he heard the cries of a drowning boy. His wife begged him not to, but he went; relenting, she cried, “Be quick, Harry!” and in he dove. Grab hold, haul over to a rope, out they came.

Thirty six lives. Not bad for a poor old seaman.

Harry finally rests

When he was 70, Harry retired at last. And although many people didn’t realize it, his wallet was thin; the diving commission didn’t offer a pension, and he’d quietly turned down others from grateful benefactors. That’s how things were when Andrew Carnegie passed through Sunderland to open a library.

Visiting the local museum, Carnegie saw an exhibit of Harry’s medals and asked after the man, now 84 and still full of vim. Surely he must be a war hero of some kind?

Nope. Just a life saver. When he learned who he was dealing with, and had the pleasure of shaking his hand, Carnegie inducted him into his Hero Fund on the spot.

At long last, Harry Watts no longer had to worry.

In Carnegie’s words,

I have to-day been introduced to a man who has, I think, the most ideal character of any man living on the face of the earth. I have shaken hands with a man who has saved thirty-six lives. Among the distinguished men whose names the Mayor has recited, you should never let the memory of this Sunderland man die. Compared with his acts, military glory sinks into nothing. The hero who kills men is the hero of barbarism; the hero of civilisation saves the lives of his fellows.

At the age of 85, Harry’s town of Sunderland was worried that after his death, such a remarkable, yet humble man might be forgotten in the distance and darkness of history. In response, the mayor and several of the town’s luminaries commissioned a biography to be written about his life. You can read it here, and much of this story came from it.

Not a bad goal. Live your life so that when you’re old, someone will insist on writing a book in your honor.

In their words,

The modest merits of this good citizen may, so far as the public are concerned, be summed up in the simple statement that he has saved upwards of 30 lives from drowning. When we consider what are the awards usually apportioned by mankind to the destroyers of their species, the presentation of a gold watch and chain, accompanied by a framed parchment from the Royal Humane Society, in the precincts of a disused School Room, must appear an inadequate acknowledgment of services so signal. But we are new at the business and shall improve as we go forward.

Somebody Should be Upset

Anybody who’s spent time in medicine (and it doesn’t take long, because nowadays this is often covered in initial training) has heard two contradictory lessons:

Good caregivers must demonstrate empathy and compassion for the suffering of their patients.
Good caregiver must not become too close or attached to their patients.

The reasoning behind both truisms is simple enough. If you don’t care about your patients, you can’t practice good medicine, because that requires caring about what’s ailing them and wanting to do something to help. On the other hand, if you become entangled in the suffering of everybody who sits down on your stretcher, you will die a thousand times in the course of your career. That’s too much tragedy for anyone to bear.

So, you should care, but not too much. We’ve all known providers who don’t care. They’re bad. Bad at medicine, bad people, they don’t like their jobs and patients don’t like them. We’ve all known providers who cared too much, too. They’re good at their jobs, for about six months, then they flame out and quit. See how long you last when you have an extended family of hundreds, it grows each shift, and they’re all dying.

You can find your own strategy to walking this tightrope. Experienced, durable providers seem to become skilled at connecting with their patients, but compartmentalizing it appropriately, so that when things go badly, it doesn’t hit them too hard. You do your best, they survive or they don’t, and you move on to the next patient. It’s not your emergency.

This is probably the right approach. However, I’ve always found it a little bit distasteful. Click here to watch a clip from House that helps demonstrate why.

“When a good person dies, there should be an impact on the world. Somebody should notice. Somebody should be upset.”

Doesn’t that seem right?

A human being, with a lifetime of living behind them, has disappeared forever. There’s no life that isn’t complex enough and full enough and astonishing enough that we couldn’t put it up on a pedestal and watch it for days and discuss it and applaud it and munch popcorn while savoring all the decisions and revisions that we didn’t make, but which are awfully familiar. Even the mistakes aren’t usually so alien that we don’t recognize a little bit of ourselves in them.

When a person like that — and they’re all like that — drops off the face of the world, it should raise an alarm. People should put down their newspapers and look up. It should be a big goddamned deal. There are billions of human on the planet, and they’re all going to die eventually, many in the hands of medical providers, some of them in yours. But the numbers don’t change the fact that for the person who died, their life was their whole life. There should be grief.

Maybe it’s better when there’s family and friends and others to care. If a passing leaves a room full of loved ones in tears, maybe that makes it easier to walk away, knowing the job of mourning is well in hand. No silent snuffing of a candle here; the loss was recognized. That’s not very rational, but it’s how it feels to me. When somebody dies and nobody seems to know, or care, it seems like your duty to give a crap.

Isn’t it an insult to blow it off? When you were chatting with that patient and building your rapport and connecting as fellow people, would you have told them, “Listen, there’s something you should know. We’re getting along now, and we’re friends, and I want the best for you, and I’d fight for it too. We can laugh together or shake hands or hug. If you walk out of here, maybe we’ll even maintain a relationship. But if you die, I’m going to document it, wash my hands, and walk away like you’re just another number. Hope that’s okay.”

Isn’t that a little two-faced and deceptive — like acting friendly to someone, then badmouthing them as soon as they leave? How can you behave both ways and see both as compatible?

I don’t know, and maybe it’s not our job to be professional mourners. Maybe it’s not our job to mark each person’s passing. But in some sense, if we truly care about our patients, it seems like it is, and that’s quite a burden to add to our responsibilities.

What do you think?

Those who Save Lives: The Royal Humane Society

Mostly, people get into healthcare because they want to help people. And there’s no bigger and better way to help than saving lives.

Of course, that’s not really a cool thing to talk about, and we’re nothing if not cool, so most new folks clam up about lifesaving pretty quick. Then before long they’ve transitioned all the way to full-on Nicholas Cage burnout mode and managed to forget about that heroic stuff completely. To quote Dr. Saul Rosenberg: “I think the current generation of young people are terrific…. so much smarter, and so much broader, and so much more altruistic. At least until they come to medical school.”

But the fact is that there’s something very basic and very noble about the simple act of saving a life. To help shine light back on that deed rather than on the more ignoble parts of the job we do, I’d like to talk about some notable lifesavers throughout the years. Maybe we can learn a few things from them. Or maybe, at least, we’ll be reminded about the things we used to admire.

Today, let’s talk about…

The Royal Humane Society

In London in 1774, there were a whole lot of people drowning.

It wasn’t hard to understand. Most folks couldn’t swim, and many lived and worked on or near the water, especially the Thames river that flows through the city. Shipping and other water-based commerce was common, along with recreational activities like ice skating (sometimes on thin ice). To make a long story short, death by drowning was a frequent occurrence.

The science of resuscitation was in its infancy, and little was known about what could be done to bring back near-drowning victims. There were some interesting new ideas, but even if they were effective, there wasn’t much opportunity to use them — victims were usually presumed already dead and therefore beyond help.

(Any of this sound familiar? The problem of bystander intervention remains the toughest part of saving lives even today.)

William Hawes and Thomas Cogan were a couple of English physicians who believed that, with the current techniques and their best efforts, some of the drowned victims might be saved. (Hawes had, in fact, been paying out rewards to anyone who brought him recently-drowned bodies still “fresh” enough to be revived.) They thought that medicine could do better. So with some friends and colleagues, they sat down and founded the elegantly named Society for the Recovery of Persons Apparently Drowned, a sort of club with the goal of saving Britons from drowning.

The Society gave out cash rewards to anyone who attempted a rescue, more if they succeeded, and even awarded money to homeowners and publicans who allowed victims to be treated in their buildings. People being people, this quickly led to two-man scams where a “rescuer” and a “victim” would stage a drowning, then split the reward. So monetary prizes were soon discarded, except in rare cases, in lieu of certificates recognizing the lifesavers.

Gradually, the Society (after a few years switching to the the shorter name) began setting up stations and “receiving houses” near the water, where volunteers stored equipment and launched rescues. They were undoubtedly responsible for popularizing the concept of resuscitating the near-dead, and were among of the first to develop any type of rescue service for civilian medical emergencies. Kinda like the grand-daddy of EMS. In their literature, the Society asked:

Suppose but one in ten restored, what man would think the designs of the society unimportant, were himself, his relation, or his friend — that one?

The Society still exists, and has shifted from solely recognizing water rescues to acknowledging all manner of lifesaving heroism using a range of different medals and certificates. Awardees have included Alexander the First and author Bram Stoker.

Read through some of the most recent winners. They’re all good yarns. Humane Societies (not to be confused with the folks who protect animals) now exist in many countries of British descent, such as Australia and Canada, as well as other regions (including my own state of Massachusetts).

If you are honored by the Royal Humane Society, you’ll receive a medal stamped with their emblem: a fat cherub holding a sputtering torch, blowing at it with puffed cheeks, doing his best to fan a dying flame. Across the top:

lateat scintillula forsans

“A small spark may, perhaps, lie hidden.”

Love in the Time of Melena

wine riot

Most regular folks don’t realize it, but an ambulance company is basically a dating service.

I can’t speak for the fire department, which is pretty dude-heavy in most places, plus you ride around with a crowd. But private EMS is another matter altogether. Mostly, it’s just you and your partner, and at many companies, that means many hours of posting — backed into a nook somewhere quiet, sitting together in the cab with diesel idling.

Really, it’s a date. Am I wrong?

It starts when you check your schedule and learn who you’ll be working with. The folks who work with a regular partner (like Scenarioville’s Sam Spectacular) miss out on this thrilling daily game of chance, but even they can pick up someone else’s shift, or roll the dice when their usual partner stays home with strep (or a hangover).

Who’s it gonna be? An angry old plowdriver who smells like castor oil? Some 18-year-old kid who narrates Yelp-style reviews of every female butt you drive past? Or maybe — just maybe — your one true love?

Well, go shake their hand and find out.

On the agenda for today’s date (which, by the way, might be lasting from 8 to 24 hours):

Activities you can do together, emphasizing teamwork, problem-solving, and communication
Banter and wisecracking (required)
A mandatory dresscode with provided uniforms, so your awful fashion sense can remain a secret
Eating one or more meals together
Many hours of conversation as you’re forced to sit side by side — but no need for eye contact, since you’re both facing forward, and no awkward silences, since the radio’s crackling and you can always kill time playing with Facebook
A perfect excuse to get their phone number (“I’m gonna get some coffee — not sure if there’s reception in there — call me if we get something, mmkay?”)

Maybe things won’t work out. That’s okay, because it’s not actually a date, so it just reverts to a shift at work — no harm done.

But maybe there’s a spark! And a good thing, too, because some folks in EMS are pretty maladjusted, and may not get a whole lot of social contact otherwise. Fortunately, we’ve got an employer-sponsored matchmaking service to help hook us up with the other weirdos.

Now, things won’t always be happily ever after. And it’s hard to imagine a more awkward experience than the first shift you work with someone after the ugly break-up. Folks have gone to supervisors and legitimately said, “If ya put him on my truck, I’m quitting.” Bosses who’d make you work with a broken femur have caved in such situations.

But if it goes smoothly, you’ll get to spend most of your day with your significant other. Of course, maybe that’s a little more time than you’d like. I know couples who stridently avoid working together on the grounds that “I already see his ugly mug in the morning and when I get home — if I have to listen to him tell me I’m lifting the stretcher wrong, there’s gonna be workplace-related violence.”

Don’t stay partnered up, and you’re running a different risk, however. Because if Jenny EMT isn’t working with you, she’s working with someone else. Maybe a guy.

16 hours every Monday and Wednesday. Dating somebody else. Have fun with that mental image.

No, folks, one thing’s for sure. Dating in the ambulance is a flat-out bad idea.

That’s us in the picture above, by the way. She microwaved SpaghettiOs for lunch, and sashayed into rooms towing our admit and asking, “Did somebody order a roommate?” I made her a glove balloon and let her steal my ice cream.

Happy Valentine’s Day to all. This job isn’t all frowns.

Glass Houses: Suicide in Both Seats

Of all the skills we’re called upon to wield without adequate training, care for psychiatric complaints tops the list. In particular, it’s a rare shift when you don’t handle a person — whether on the initial emergency response or a subsequent interfacility transfer — who has thought about, or even attempted to commit suicide.

Probably because these patients aren’t very medically exciting and can be challenging to deal with (due to varying degrees of cooperativeness), many of us aren’t big fans. We also tend to have a cynically individualistic sort of streak, which says that deep down, patients are responsible for themselves. If someone wants to be healthy and they get unlucky, we’ll help out. But if they can’t be bothered to try, we can’t be bothered either, and if they’re actively trying to hurt themselves, surely we have better things to do than interfere with natural selection.

But before we throw stones, we should probably understand the disease we’re discussing. Just like you can’t treat CHF without grasping its pathophysiology, properly treating the suicidal patient — or even deciding not to care — demands knowledge before judgment.

Depression itself is hard to grasp from the outside. This easy walkthrough may shed some light, but if you haven’t been there, you probably shouldn’t pretend you understand it. Nevertheless, it’s one of those conditions that invites amateur opinions, because it seems like the sort of thing we all know something about.

Maybe depression is too loosey-goosey; maybe it’s better if we stick to concrete facts, yeah? And there’s nothing more concrete than suicide. Let’s talk about suicide.

Start by reading through this article at the Daily Beast. It’s long, but it’s real good, and you may start to change your mind about a few things by the end.

For instance, in 2010, in the developed world where we have good statistics, suicide killed more people in the prime of their life (ages 15–49) than anything else. Read that again. Of all the terrible insults we study and treat, from gunshots to heart attacks, car crashes to cancer, suicide was more deadly than every single one. Over a hundred thousand suicide deaths that year. Almost a million across all age ranges. Every murder, every war, every natural disaster you read about in 2010 — throw them all together, and they still don’t equal the number of suicides. There were probably even more that weren’t reported, and even that’s just the successful suicides, of course; those that were attempted but didn’t quite succeed make up a much larger group, perhaps twenty-five times larger. (Yes, 25 times.) And there are more and more every year.

When we talk about CPR, we often talk about quality of life. When a 98-year-old bed-bound dementia patient dies, we might ask whether we should jump through hoops to save them; even in the best possible case, they’re not going to return to a very long or very fruitful existence. But when the 20-year-old college student drops dead on the lacrosse court, we want very badly to bring him back, because if we can he might live another 70 wonderful years.

Well, the people committing suicide are the second kind. They’re often middle-aged, middle-class folks who could be happy and live long — if they can get past their illness. But dead people won’t get past anything.

Of course, we see a lot of depressed people, and most of them won’t kill themselves even if they’ve thought about it. Figuring out who’s most at risk of taking that step is a worthwhile goal, and the Daily Beast article describes three risk categories that you may find useful:

Those who feel alone, that they don’t belong anywhere
Those who feel like a burden to others
Those who have the willingness and capacity to go through with self-annihilation

Who feels alone? Everybody, at times. We need connection. Married people kill themselves less often than the unmarried, twins less often than only children, mothers raising small children almost never. Sometimes those who seem to have everything in life may have the weakest connections, which is why they say that money doesn’t equal happiness.

The life-saving power of belonging may help explain why, in America, blacks and Hispanics have long had much lower suicide rates than white people. They are more likely to be lashed together by poverty, and more enduringly tied by the bonds of faith and family. In the last decade, as suicide rates have surged among middle-aged whites, the risk for blacks and Hispanics of the same age has increased less than a point — although they suffer worse health by almost every other measure. There’s an old joke in the black community, a nod to the curious powers of poverty and oppression to keep suicide rates low. It’s simple, really: you can’t die by jumping from a basement window.

When nothing ties you down, when nobody cares what happens to you, what’s stopping you from shuffling off into the abyss? “I’m walking to the bridge,” one note said. “If one person smiles at me on the way, I will not jump.” Did you smile at your last psych patient?

Who’s a burden? Anyone who’s not achieving, contributing, responsible for something or someone. The unemployed, the chronically cared-for, those with debilitating diseases or intractable poverty. We do this job because we like taking care of people, but that means there’s always someone being taken care of, and nobody loves being on that side of the equation. Some people will go to their graves rather than add to the work or worry of those around them. A few will send themselves there.

Finally, who’s actually willing to end their own lives? It takes something special to close the deal, a particular resolve; no living creature’s natural instinct is to die. Even if you have the desire, it’s not easy to pull the trigger. It’s those with the gift or the learned ability to follow through with difficult deeds, the “athletes, doctors, prostitutes, and bulimics . . . All have a history of tamping down the instinct to scream.”

Think about those categories. None of those are particularly insane thoughts to have. All it takes is their juxtaposition, and suddenly, something unthinkable becomes a very real possibility. Honest. It happens hundreds of thousands of times every year.

Suicide in EMS

“Well, what the heck,” you’re thinking. “That’s nice, but I’m not going to fix them, so why do I care? I’ll bring ’em where they’re going and say good luck; God and the doctor can take care of the rest.”

Fair enough. But I have a homework assignment for you.

Find that guy at work. You know the one. His nickname is “Doc” or “Papa.” He’s been doing this for twenty-plus years, since the days when ambulances were dinosaur-drawn wooden wagons. Ask about the other old-timers, the endless sea of faces he’s worked with over the years.

He’ll have good stories. Tons of them. Partners and coworkers and crazy SOBs. Hijinks were had, shenanigans performed, laughs all around.

But then ask what happened to those guys.

Because a lot of the time, they’re not running around on the ambulance anymore. Ol’ Doc is the exception. They’re not semi-retired, spending their afternoons fly-fishing and golfing. They didn’t jump careers to become bankers or meteorologists.

They’re dead. Or maybe in jail. Or shot robbing a 7-11 for $13. Or they were committed to a psych hospital so many times nobody knows what happened to him. Maybe they overdosed. Living on the street. Living who knows where.

And yes, some of them committed suicide.

Seems a little rich to judge your psych patients when, the way the odds go, you’re probably going to be the next one.

I suppose you could argue that EMS was different back then. Russ Reina talks about the time when most “ambulance drivers” were people who couldn’t find a job anywhere else, drifters and ex-cons. Not like now. Now we’re all as well-adjusted as Mr. Rogers. Right?

Yeah, sure.

Let’s be real. A lot of the people doing this job can’t stay employed even in our own dysfunctional field, and would never stand a chance anywhere else. Drug abuse and PTSD are common. And our social support networks often don’t extend past a partner or two.

Do we belong anywhere? Maybe you do in the police or fire service. But those of us who enter private EMS usually don’t last long before being sucked into a loop of working more and more overtime until we no longer have hobbies, no longer spend time with friends, no longer travel or expand our horizons. If we have spouses, significant others, or family, we neglect them. If we don’t have those relationships, we sure as hell don’t develop them from the driver’s seat of an ambulance. The last step — which doesn’t take more than a few years — is when we start to view every one of our patients as a nuisance. Burnout takes away the last string tying us to other people; if patients aren’t worth helping, aren’t hardly people at all, then the circle of humans in our life may become no larger than our uniform belt.

Are we a burden? In many cases, that shoe drops when we find ourselves off the clock. If our life has become the ambulance, what happens when we lose the ambulance? Your company goes belly-up. We piss off the wrong boss and get tossed out on our ass. Or, inevitably, we get injured. Suddenly, the only reason to get out of bed in the morning is gone. Sounds nice at first, but you realize quickly that having nothing to do actually means you’ve got no reason to be alive.

And are we afraid of dying? Who could be less afraid? We spend every day minimizing death, trivializing the human condition, ingraining a culture that teaches we should be able to order nachos after bandaging a burn victim. We drive fast; we laugh at seatbelts. Sometimes we snort cocaine and have sex in ambulances. (No, not you. But you know who.) There’s nothing beyond the pale for an EMT. Including pulling the trigger.

So is suicide a big deal? Yes. Should we try to understand it? Yes. Does it matter for us? Yes.

But more importantly: do we get to judge it? Do we get to pretend we’re above it? Are the kind of people who attempt it so bizarrely pathological that we’re nothing like them?

You can decide. But you only get to say that if you’re willing to say you don’t care about a disease that kills more healthy patients than anything else. Willing to write off hundreds of thousands of people every year.

And willing to say you don’t care that your partner could be next. Or your boss. Or yourself.

Check out The Code Green Campaign for mental health support for EMS. — ed. 1/17/15

A Saving People Thing

This isn’t a criticism, Harry! But you do… sort of… I mean — don’t you think you’ve got a bit of a — a — saving people thing?

Harry Potter and the Order of the Phoenix, JK Rowling

In a few weeks, I will be leaving the ambulance indefinitely.

I’m moving a couple states away to return to school, a Physician Assistant program that begins in June. And while I hope to try and work an occasional shift with a more local service, it remains to be seen whether that will be possible. So I’m now approaching a crossroads where, after approximately four years of wearing a patch on my shoulder (many different patches, to be sure), I might soon be giving it up forever.

It’s a strange sensation. It’s been pointed out that, unlike other professions — butcher and baker and candle-stick maker — EMS has a unique ability to dominate the lives of its men and women. How many doctors and nurses do you see with bumper stickers, tattoos, and T-shirts proudly advertising their trade? For many of us, you don’t work as an EMT or a paramedic, you are one; it’s part of our identity. (That’s why it can be so devastating when, through life or injury or the whimsy of employment, we suddenly find ourselves without a uniform to wear — many of us don’t know what to replace it with.) There are prominent physicians of many years who still include “NREMT-P” among their credentials. That’s like an attorney listing his high school oyster-shucking job on his CV.

There are probably many reasons for this. Buckman has observed that becoming an EMT is one of the fastest and easiest routes to “feeling important” — one quick class, and you can break traffic laws and tell everyone you’re a lifesaver. We like that, I’m sure. There’s a lot of ego in this business.

But I suspect that it also attracts people who embrace its fundamental nature. At the bottom, this job is about going to people in distress and helping them. And there is something in us — I think in everyone, although stronger in some — that wants to do that. It resonates with us as humans. (Of course, many other things resonate with humans, including sex and bacon and a great parking spot. But that’s all right. We’re complex creatures.)

The point is, this business allows us to play that role in a unique way. I believe that someday I may enjoy sitting in an office and treating patients who walk in the door, or waiting in an emergency department, or roaming a hospital floor. But that’s different; you are the all-knowing Man on the Mountain, and your patients come and form a line to beg for your wisdom. On the ambulance, people call for help, and we go to them. We take the trouble; we’re the humble servant. Yes, they have to ask, but once they do, we bring the noise, we say: “There, there. We’re here now. Everything’s going to be all right.” In the simplest, most fundamental template of this job, people have problems and they call us; we hear the call and we drive toward them; we walk into their home or business or any of the places that people go; we see a human being in distress; and we kneel beside them and ask, “How can I help?”

By coming to people in their time of need, we get closer to the heart of it all. By our willingness to kneel, we open ourselves for the dying eight-year-old to ask: “Mrs. Nurse, will you hold my hand? I’ve never died before and I’m scared.” And that’s special, and it’s not such a bad thing to elevate it, even though — as Thom Dick reminds us — no matter how much we love it, it won’t love us back.

No matter where I go from here, for me, EMS will always be about that feeling of kneeling beside someone. Or the experience of sitting on the ambulance bench, alone, just my own thoughts and a trusting and vulnerable patient.

That moment when I walk into the room, and all eyes turn to me.

The mental perk-up as the radio crackles, and the extra acuity that dials in as I recognize my call sign and my gears start turning.

Opening my mouth to give a report to a trauma bay filled with nameless people wearing scrubs.

Holding an old lady’s hand as we bounce down the road.

Touching a shoulder as I say good-bye.

Iced coffee from Dunkin’ Donuts, titrated to my tiredness.

The smell, sound, and non-stop rumbling of a diesel engine.

Black shoe polish.

Sitting beside a partner and feeling like it’s the two of us against the world.

There’s a lot that’s wrong with this job. But there’s something that’s right about it, too, and it’s something important. And that’s why we keep coming back.

I’ll be busy soon, and this site will have to take a back burner. Updates will come less frequently, and I can’t guarantee new scenarios or new posts or new Library material on any reliable schedule. But wherever I end up, I don’t plan to turn my back on it. Because even if you leave the ambulance, I’m not sure if you ever stop being an EMT.

Child-rearing and You

Despite my forays into educational writing like this, I have never been an FTO.

Field Training Officers or preceptors are responsible for training and supervising new hires, who typically work for several weeks as an additional third crewmember (or “third rider”) while learning the ropes. For various reasons, I’m not sure I’d be good at this, and I’ve never pursued it. On the other hand, regardless of what I want to pursue, I’ve never been able to avoid working with new partners.

By “new,” I mean minty-green new — folks who have never worked on an ambulance, or in some cases, never worked a job at all. Since this kind of EMT is usually paired with a fairly senior partner early on — and since not many people stick with this job long enough to be “senior” — if you’ve been doing this for a few years, you’ll usually wind up with a new guy sitting next to you. It is what it is.

Standard operating procedure is to drink lots of coffee, grumble, boss them around, and let them gradually absorb whatever useful knowledge you inadvertently leak out. Unfortunately, this is both stressful for the new guy, and something less than fully enriching; they learn as many bad habits as good practices, and become jaded faster than they become competent.

I am not a gifted teacher when it comes to in-person training. But like most things in this job, by learning it the hard way, I’ve developed some useful insights. So here are a few pointers for bringing along your new guy and molding them into the very bestest EMT they can be.

Make your expectations clear

For you, it’s Wednesday, you’re tired, and for some reason your left knee keeps clicking. But for them, it’s their first day on an ambulance, and everything is new.

The best thing you can do is to clarify how this game is going to work. What’s going to happen when you walk into a call? How are you going to assign responsibility? What do they know, what do they need to know, and how will that process occur?

I once punched in to find a partner I hadn’t met before. Ten minutes into checking the truck, we got sent out to a seizure at the department store. I drove, she teched. But each time I tried to let her “do her thing,” she just froze like a deer in headlights. Turned out, this was the first shift she’d worked — ever — and her entire training period had been spent running routine transfers. She wasn’t just unpracticed, she hadn’t even seen most of what takes place on an emergency call, never mind attempted it.

Although you could call this a gross failure of the training process (I did), the underlying lesson is that you never know what you’re dealing with. Your partner may have years of experience at another service; he may have just finished high school and never worked a full-time job; he might be a new EMT, but just spent twenty years as a veteran CNA. Maybe he’s a few months in, comfortable with certain situations, but wholly new to others. You need to know where they’re coming from. Not only will they resent the stress and panic induced by stranding them when they don’t know what to do, but they’re just as likely to resent your butting-in (whether explaining something or actually taking over) when they do know what to do; the dividing line can be nearly invisible, but is very real.

Some points to consider:

Who drives? Many seniors tend to do most of the driving while their newbie techs in back. The theory here is that you should “learn the back before you learn the front” — that is, patient care before driving and navigation. I find this arbitrary, since driving is as important to this job (and sometimes as difficult to do well) as anything else. It’s reasonable to focus on one skillset before developing the other, but I think driving should start early, because eventually they’re going to be forced into it anyway (driving for an ALS unit, perhaps), and they need to be ready. Start almost immediately by letting them drive between calls on routine matters; this acclimates them to handling the ambulance and navigating your service area. Once they’ve figured that out, they can do some emergency driving on responses. When you’re comfortable they can safely get from Point A to Point B, let them drive while occupied with patients — if they know where they’re going, or at least have a reliable GPS. But don’t throw them into this without some instruction on how to drive smoothly and safely, or you’ll spend the trip getting angry while you slide around the bench, and they won’t know why.
Who does what on emergency scenes? Working with experienced partners, I cleave to the golden rule: the tech runs the call, while the driver shuts up and helps out. This makes it easy to avoid stepping on each other’s toes or going different ways. If you’re the tech and your new partner is driving, this still works, because you’ll make the calls and tell them what to do, and they can watch your amazing wizardry in action. But what if they’re the tech? I always try to let them take the reins, but if they pulled the tags off their first uniform yesterday, they’re probably just going to stand there. I give ’em a few beats and then take over (you can’t stand there forever staring at the patient). But between calls, go over what needs to happen, and try to gradually work them toward familiarity with their role.
How will feedback be given? Like in any relationship, communication is only ever bad when it’s not undertaken promptly and directly. From day one, make it clear that if they ever have a question, they should ask it (at the appropriate time); if they’re ever uncertain, they should request assistance (you’ll only be mad when they screw up because they didn’t ask); and if they want help, you want to provide it. Conversely, explain that after calls you’ll give suggestions and feedback, which should be taken constructively; they have a lot to learn and must embrace that. If you tend to adopt a direct or brusque manner, as many of us do, warn them that it’s not personal and you’re not rebuking them, you’re just too old and tired to sugarcoat everything. Reassure them that you’ll never talk shit to others when they mess up; when anybody asks, you’ll just make vague remarks like “oh yeah, he’s good.” Above all, remind them that although you’re here to support them, patient care comes first, so there will be times when “teachable moments” need to take a back seat.

Practice, Practice, Practice

The main problem for most new folks isn’t “knowledge,” it’s application. They may have memorized the EMT textbook (although that book, of course, is a little light), but there are a thousand tiny things that comprise the everyday functioning of this job, and they know none of it.

That’s one of the goals behind Scenarioville. To get good at this job, you need practice. And even in a busy system, in a given week you may only do one or two seizures, or drunks, or chest pains, or any other type of call, with a lot of other stuff in between. If they’re weak with something, it takes a long time to to practice enough to get any better.

You can fill that gap with drills, as realistic as possible. In your downtime, make ’em go through the paces. Trouble giving radio patches? Hand ’em the mic (turn it off first) and have ’em pretend they’re talking to the hospital, complete with pressing the right buttons and hearing static-filled replies from you. Do they need to practice driving? Find a parking lot and give them tasks to accomplish, such as backing in a straight line, turning corners, or navigating tight gaps. Bad at lifting? Give ’em workout homework (get thee to the gym and start deadlifting!). Watched them fumble with a skill? Make ’em do it: take a blood pressure off you (with various locations, sizes, and methods), assemble the nebulizer or apply a dressing, or execute a thorough neuro, abdominal, or trauma assessment. In some cases verbalizing a skill is all you can manage, but whenever possible, do it for real; a disposable neb is a small cost to pay for skill mastery, and the first time they open the package shouldn’t be on a sick person.

If they’re interested, you can certainly chat about deeper medical topics like V/Q mismatching and the citric acid cycle. But they can get that from a book. When it comes to practice, something more interactive is needed. Often, I’ll do verbal scenarios, describing a call and forcing them to make decisions as they go. Nothing is quite as frightening as a totally unscripted, unstructured situation, where you stop and stare and ask, “What do you do?” And don’t let them get away with vague invocations like “scene safety” or “manage the airway”; force them to describe exactly what they mean. Oh, you’ll check for a pulse? How? Where? What are you looking for? Okay, where’s that piece of equipment? How do you size it? Are you sure we’ve got one?

History-taking is the most difficult skill to acquire. Force them to talk directly to you as if you were the patient, because they need to be comfortable with that. With experience, you develop a patter, and you have go-to lines at each juncture — what you say in greeting, what to ask for certain complaints, how to unpack certain responses. They haven’t acquired those moves yet, but they need to develop them, so by presenting them with those situations in a practice setting, they have a low-stress way to hone their own tools.

Every new partner I’ve had has gone through a similar learning curve. At first, they don’t know anything. After a while, the first things they get comfortable with are the “skills,” simple, concrete tasks they know how to execute. As a result, when they walk into a scene and don’t know what to do, they immediately start doing whatever task they’ve mastered — taking a blood pressure, writing down meds, etc. The challenge is getting them to move beyond rote psychomotor skills to the nuanced business of actually approaching the patient, greeting them, assessing them medically with questions and focused physical examination, deciding what’s wrong, and making decisions accordingly. This is tough, and occasionally I’ve had to take things away from people (cuffs, glucometers, nasal cannulas, pens) so they couldn’t “hide” in them.

In the end, the key to mastery is repetition. A single repetition is nothing. When the two of you run a call and you realize they need to practice something, debrief afterward by discussing the details, make them describe the considerations and goals, and spend the rest of the day verbalizing scenarios similar to the call you did. Once they’re absolutely sick of it, you’re starting to make progress, because boredom means they know what to do, and that’s the whole idea.

Managing your own blood pressure

One of the biggest challenges, of course, is not losing your mind.

Even smart students will sometimes drive you out of your gourd. Usually, this is because they don’t know something you figure they should. In fact, everybody should know that. In fact, how in god’s name can you be old enough to drive a car without being able to figure this out? It’s common sense!

The trouble is, it isn’t common sense. When you started out, you had to learn it. But that was so long ago, you’ve forgotten how much you originally had to learn; many of the routine aspects of the job are now second-nature to you. But they’re not second nature to your partner; he has to consciously learn them all, and think about them when he does them, and he can only internalize so many at a time. So while he’s trying to remember to do X, Y, and Z, he might forget A and B. Even if A is something that he does know. And maybe he never even learned C. See?

When they develop confidence, they improve exponentially, because once they relax they can actually think; most dumb stuff is the result of blind panic. (The secret of veteran providers is that they often don’t know what to do, but they use their noodle and do what makes sense. This isn’t a difficult skill, but you can’t do it while holding your breath.)

My own pet peeve is when I tell ’em something, and next week tell ’em again, and six months later I swear I’m telling ’em the same thing, and they’re staring at me like they’ve never heard it. Ain’t you listening to me, Jethro? Well, they are listening. But I’ve also been talking a whole lot, and between the V/Q mismatches and everything else, they’re not going to remember all of it; it’s going in one ear and most of it out the other. So either I can slow the flow a little, or expect to repeat myself. Either way, my problem, not theirs.

The point is that there’s a great deal to learn just to master the basics of this job, never mind acquiring true clinical acumen. Combined with the fact that many new hires are young, and haven’t developed the general problem-solving skills that only come with years and failures and overall life experience (being a good employee, talking to other humans, empathizing with suffering, avoiding dangerous situations, and so on), and you get a perfectly intelligent person who sometimes seems like they’ve had a lobotomy.

Take deep breaths, try to remember what it was like when you were in their shoes… and warn them early that you will occasionally get fed up, sometimes act short, and at the 15th hour of a shift, will not always be gentle Grandpa Patience. Advise them that you’re not perfect and will not always act out the principles you espouse. And request that, although you like to teach and you like your job, when you’ve been working for 60 hours straight you may need some quiet time.

Most of all, look around at all your competent coworkers who once upon a time made their partners pull out their hair and ask whether they were working with a trained monkey. Because it does get better, and years ago, that monkey was you.

Tag: people