Unique, Just Like Everyone Else

A few years back, a video of a lecture by Carnegie Mellon professor Randy Pausch made the YouTube rounds, becoming enormously popular; you’ve probably seen it. He later wrote a book discussing and unpacking many of the points he brought up in the lecture. If you haven’t watched or read them, I highly recommend both.

In any case, in the book Pausch describes the birth of his first child, how a complicated birth (a placental abruption) forced him to rush his wife to the Magee-Womens Hospital at the University of Pittsburgh Medical Center, and how his newborn child was brought into their neonatal ICU. He writes,

At Magee, they did a wonderful job of simultaneously communicating two dissonant things. In so many words, they told parents that 1) Your child is special and we understand that his medical needs are unique, and 2) Don’t worry, we’ve had a million babies like yours come through here. (91–92)

This is an elegant account of the demeanor we should all be trying to strike with the families of patients, and indeed with our patients themselves.

Many beginning providers, understandably unsure, will approach each patient like an antique porcelain vase: precious, delicate, and prone to breakage. This is the right attitude as far as priorities — we should take our care seriously — but that doubt is communicated in our body language and tone, and it’s not what sick and scared people want to hear. Imagine being the patient whose doctor says, “Man, look at that! I’ve never seen anything like that! Can we publish you?” or “Okay, I’m not going to lie, I’ve never done this in my life. But I did stay at a Holiday Inn Express last night…”

On the other hand, it can be very few moons indeed until you’re a “veteran” in the worst sense of the word, dragging your technically skilled but burned-out husk from patient to patient, seeing nothing but a stack of paperwork and a routine litany of tests and treatments. Her? Oh, just another abominal pain. Yawn. Her name? Search me. Is it lunchtime yet?

See, people want to be treated like people, and people are unique, precious (at least in their own eyes), scared, and need to be engaged with on the same human level as when you say “thank you” to your barista or read a bedtime story to your son. But people are also machines, and the trick to fixing broken machines is to fix a lot of them, and treat them all the same. We need to be able to reconcile these paired, antagonistic traits, because otherwise we can’t do what they called us to do. It’s not a matter of nailing one goal but missing the other: you miss both. You can’t reassure anyone if you don’t competently address their actual problem, and you can’t practice sound medicine if you don’t engage with patients as people.

That’s the trick that the obstetrics and neonatal teams at Magee pulled off, and it’s all the more important for us, who have to approach patients without the comforting backdrop (that is, comforting to them and to us) of a bright beeping hospital. It’s the trick of quiet confidence, of demonstrating without words that you know exactly what you’re doing, that you bring tremendous skill and experience to the table — but that those tools are being brought to bear for your patient, for the scared individual you’re kneeling beside. The “all the kings horses” response by fire and EMS, the loud and alarming transport to the hospital, the wires and tubes and countless gloved hands — it’s overwhelming and frightening if you’re thrown into it as an unknown environment, but if you understand that it’s all being done for you, then it’s comforting. It’s like calling for help and getting the Wolf. That’s exactly what you wanted in your time of need.

You may not want to date a cocky lawyer. But he’s the one you’d want at trial.

Oldest Trick in the Book

I’ve never been to nursing school. But I like to imagine it goes something like this:

On the first day, you walk into class, surrounded by other bright-eyed, eager young students ready to learn the art and science of nursing. Textbooks weigh down your bag, and your pencils are sharp and ready.

Before you stands your instructor, an impressive-looking MSN whose carriage suggests many, many nights spent awake amidst the cool blue lights and quiet beeps of a MICU. As you watch, she strides to the whiteboard and writes in block letters:

Lesson One: The ID Flip

Lesson two is eye-rolling.

Most hospitals, just like most ambulance services, require that clinical staff wear an ID badge at all time. This identifies them by name and role (nurse, doctor, PA, etc.), and often gives them access to secure areas as well.

Long ago, some canny soul discovered that when patients know your name, they can complain about you. If they decide that they don’t like you, whether justified or not, they can call people — like your boss — and unleash angry, entitled, and very personalized tirades about “Sarah Roberts, that mean witch who told me to shut up and stop smoking heroin.”

“Well,” we figure; “if they don’t know our name, they can’t complain.” So although the powers-that-be did insist that badges be worn, we started hanging them in odd places, like from our belt, or inside a pocket. Or covering them with stickers and other things. But the best of all answer of all was elegantly geometric, made especially easy by free-spinning retractable ID clips: simply twist the card so it faces your chest, and the only thing visible is whatever text happens to be printed on the back. Technically, you’re still wearing the thing, and if the boss notices you can just say “whoops, it got twisted,” but nobody can actually read your name, and, ninja-like, you can move through the ward unseen, a bescrubbed ghost.

The nurses have turned this into an art-form, and in some places it’s like finding a four-leafed clover to see an RN with a visible ID (usually I figure they’re new there). But we’ve become awfully fond of this in EMS as well.

People, I realize that the world’s a rough place, that patients can be impossible to please, and that even the best of us need to take steps to ensure we still have a job tomorrow. I do understand this. But there’s a certain point where you have to stop digging trenches, and realize that if you’re giving great care, following procedure, behaving professionally, and generally toeing the line, then you should be willing to stand behind your work. If you’re employed at the kind of place that’s willing to take any complaint as reason to show you the door, I assure you that no amount of ID-flipping will save you. Your days are numbered. Of course, even a good service will eventually start clearing their throat and looking at you pointedly if your personnel file begins to grow particularly fat, but at that point, maybe you really should consider managing your douche coefficient.

Besides, this should all be moot, because when you meet your patient you’re introducing yourself by name anyway. Because that’s just common courtesy when you greet people. And patients are people. Right?

Strive to do the kind of work that allows you the confidence to stand behind it. When someone points at you with forehead veins a-pulsing and demands to know your name so your supervisor can “hear about it,” tell them and tell them proudly. Sometimes, doing the right thing won’t be a defense against trouble — but you can be sure that playing “who, me?” will run out of rope even sooner than that.

Clip your ID somewhere obvious — mine goes on my shoulder — where patients and staff alike can easily see it, and know what to call you and what role you’ll be playing in this show. When I see somebody with a visible ID, I take this as a good sign about their responsibility and willingness to own their work. And those are qualities we need in EMS.

Russ Reina: Moments in the Death of a Flesh Mechanic

Russ Reina runs one of my “sister blogs” on the EMS Blogs network, EMS Outside Agitator. Although no longer working in EMS, he spent over a decade as a medic, way back in ’70s when the paramedic concept was first being introduced in the US; he later became involved with various other things including writing a film, working with Native American healing arts, and a book — Moments in the Death of a Flesh Mechanic: a Healer’s Rebirth. More recently he’s become active in the online EMS community via his blog, forums (he’s a moderator over at EMTLife.com), and similar venues.

Some time ago, Russ sent me a free copy of his book in exchange for my honest review. I read it, and enjoyed it, but it’s been sitting on my shelf since, because I haven’t been sure what to say about it.

To start with, let’s mention the elephant in the room. The stuff Russ talks about makes people uncomfortable. To be sure, he’s walked the walk, spending more hours on the road than many of us, and doing it in a time and place where that meant wielding tremendous responsibility in patient care. It’s hard to argue that he was a skilled and competent medic in his day, the kind of guy you’d be glad to have on scene or sitting beside you in the cab. But since then, he’s gone down a different road, and done a lot of… other stuff.

Tending fires in sweatlodges. Reiki. Personal growth and healing. If you click through his personal website, your first reaction is probably “… huh.” For the typical EMSer this is not really our wheelhouse, and at best, it places Russ firmly in the realm of alternative viewpoints. At worst it puts him in the same cart as the other EMS goofballs who do their job but are universally considered space cadets. (Admittedly this is a large cart, but still, it’s not great company.)

I confess that I share some of this attitude. I’m a simple, concrete guy at heart. But I also think that the things Russ talks about, and forces us to think about, are important — and that the reason we’re uncomfortable with them is the reason that we need to have that conversation.

The basic aim of his book is to weave together the calls he ran, the patients he sat beside, the lives and the deaths he saw, and look for the common threads. Not in the patients, but in him. As a paramedic, what was his role? When you take a step back from this job, when you stop for a moment and consider what it’s all about, what’s really going on?

If we’re diligent, and competent providers, we spend a great deal of time trying to improve the quality of our work: our knowledge base, our hands-on skills, our understanding of medicine and the human body — the how. But very little attention is ever given to the why. Why do we do this? It’s easy to be cynical — “well, the schedules are good, you get to cut people’s clothes off, and I was too dumb for anything else.” We’re professional cynics, and the job tends to beat the mushy stuff out of us. But although we rarely admit it, most of us did choose this job for real, human reasons. Something about helping people.

So we show up at the door wanting to help people. Then, usually a couple years later, most of us leave EMS to become nurses or electricians or vacuum cleaner repairmen. What happened between point A and point B?

You can call it burn-out, you can call it low morale. You can blame low pay and a “revolving door” culture and a million other things, most of which are valid and true. But the fact remains that even though people are coming to EMS with the right intentions, most of them aren’t surviving here for long, and of the ones who do stick around, many are empty shells, long since stripped of any human connection they once sought. This is an ill system. It’s not dying, we’re not end-stage, but we are not healthy or happy: the methods, mindsets, attitudes, and overall “immune system” necessary to keep us all going, to maintain our ideal homeostasis, is missing. Individually and collectively, as time passes we move down rather than up. Some rare individuals do find solid grounding and manage to put in 20 years as fully-functional people as well as caregivers, but they are the exception, and they do it by developing these tools on their own.

It’s not about competence. Many of our “walking wounded” are competent clinicians, adequate or even excellent technicians. Russ calls them flesh mechanics. We master the skills of of patching holes, adjusting rhythms, replacing fluids, and generally repairing the broken parts of the human body, all without ever acknowledging the people inside those bodies. To some extent, of course, this is an essential part of the job — it’s the M in EMS, it’s why we’re called to the scene. We ought to try and be excellent mechanics so we can save the most lives and mend the most harm. But this whole process is entirely separate and distinct from the motivations that brought us to the job to begin with. There’s a fundamental difference between tending to a car and tending to a person, and when we successfully manage to eradicate the human element, we quickly find ourselves unsatisfied and burned-out with our work. (It’s not like we’re getting rich doing it, or otherwise being externally rewarded.) Russ’s own journey of transitioning from a pure flesh mechanic back into someone who worked with people is the focus of his book.

Why do we do it? There are dozens of reasons you might pick. Some folks like to work and play at the boundaries, the liminal spaces between life and death. Some just really like meeting the people. Some, like Russ, have a more spiritual approach. Some find meaning from the teachings of traditional religion.

As for myself, I hate death, and suffering, and I want to guard people from it. And I think that I probably get an ego boost from fighting for the weak, and certainly from uncovering an interesting diagnosis. But most of all — and it’s the mindset I advocate for on this site — I simply adopt a deontological outlook: I believe that when we take a patient into our care, we assume a duty to do everything possible on their behalf. Not the duty to weigh the pros and cons, not to judge their need or worthiness, but simply to do it. Everyone deserves at least that.

But you might disagree. And that’s the key: many of us will disagree on how to handle the “why.” Unquestionably, I disagree with many of Russ’s views, or simply find them alien. However, I still think that it’s absolutely essential that we each find some meaning. There must be some human purpose to our work or we will not be happy, and eventually, we will not do it anymore. That’s the secret that Russ was able to uncover after enough years on the job and enough years away from it. Dozens of answers to the question are acceptable, but we at least have to ask the question; we do have to think about these things and not brush them aside. We have to operate on this level or we will not survive in the long run. Spirituality may or may not underly EMS as you understand it. But people — not just patients, not just broken machines — are unavoidably central to practicing medicine. You can do the job without that human connection, without the “why,” but it’s like showering with your raincoat on. You can’t feel it, and you won’t do a good job, and eventually you’ll give up and stop trying.

So to make a long story short, I think the task Russ has undertaken as an “agitator” is a tough one, and he won’t win many fans. Although he often clashes with the Rogue Medic, their jobs are not dissimilar; one is an continual gadfly working to force us toward better evidence-based medicine, and the other is a continual gadfly working to force us toward a healthier understanding of our job. I wouldn’t want to be either one. But I’m glad they’re here, because I also don’t want to watch good people being wasted in the cauldron of cynicism and pointlessness that is much of EMS today.

In any case, I do recommend his book. It’s an enjoyable read, well-written, with plenty of the entertaining stories that all veteran medics collect and that make the best EMS blogs and literature such good reads. It’s also a rare view of the early, Johnny-and-Roy days of paramedicine, and it’s fascinating to see what’s changed over the years and what hasn’t.

But mostly, I think it’s worth reading because Russ’s crusade really does have a vital purpose. If I have a quibble, other than the fact that his unorthodox background may turn many readers away from his message (although fairly little of that is present in the book), it’s that despite raising awareness to the problem, Russ is relatively silent as its to solutions. Of course, this may be the nature of the beast, where each of us needs to find his own answers. But on the large scale, I doubt the endemic disease of EMS will be cured in this way.

We can try, though. Let’s try.

Ensuring Appropriate Triage

It’s no secret that I’m a strong believer in patient advocacy, and that I feel one of the most important roles for EMS is to ensure that patients get directed to the right destination with the right priority and resources. Bob Sullivan at EMS Patient Perspective recently gave a post that hits on all of these points, discussing how to ensure that “undertriaged” patients don’t fall through the cracks at the ED. These details on how to work the system are some of the most valuable things we learn with experience, and to a large degree they’re what allow the ten-year veteran to help patients in ways the novice can’t. Give it a read!

Live from Prospect St: The Reluctant Tumble (part 2)

You kneel beside Joe and ask, “So, would you like to go to the hospital?”

“No!” he vociferously replies — a theme that will be repeated often over the next few minutes.

You explain the risks — that given his anticoagulation (Coumadin), and given that he struck his head and seemingly lost consciousness, there is a non-trivial possibility of bleeding into or around his brain. That although he feels well now, it’s not impossible for such a problem to develop insidiously and not manifest with symptoms until it’s too late. That you can take him to the hospital of his choice, in total comfort, he can receive some quick tests, and if nothing is wrong he’ll be back home before he knows it.

Joe wants to hear none of this. He just came out of the hospital, enjoyed it not at all, and that was just the latest episode in a long series of hospitalizations. “They ruined my hip” on one occasion, he opines, and he’s already been fooled before by “home before he knows it.” No sir; he’s not going anywhere.

You try, your partner tries, the neighbors try, the proxy tries. No way, no how.

Well, okay. But this is not the sort of incident to just brush aside, and you’re well aware of the risk inherent to patients refusing transport, particularly in a risky circumstances like this. So you pick up your phone and hit your hotkey for medical control.

“Needletown Hospital; this is Dr. Scrubs. How can I help you?”

“Hi doc, this is Maverick from Poketown BLS 48. We’re on scene with a high risk refusal.”

You fill him in with the story. He asks a couple questions, then requests to speak with Joe, and finally talks to the proxy for a few minutes. When the phone gets back to you, Dr. Scrubs informs you that he really thinks Joe needs to go.

Well, okay. You dive back in, bolstered with a physician’s opinion, and attempt to get Joe on board the hospital train. He’s not having it. The whole entourage keeps hammering away at him, but he’s simply not budging.

You call back Dr. Scrubs, bringing him up to speed. “We’re making no headway here. He just doesn’t want to go.”

He asks to speak to Joe, and the sounds of his best MD magic come wafting over the speaker, but Joe just has less and less polite things to say, until finally he comes out with, “You’ll have to handcuff me before I’m going anywhere! And just go ahead and try it!” He hangs up on the doctor.

You call back. “I gotta tell you, doc, I don’t see us convincing this guy. If you tell me that we must take him, then I’ll take him, but I think we’d have to do violence to him and start a battle royale here. Is that what you want?”

Dr. Scrubs replies, “Well, I think he needs to be seen, and it sounds like his proxy does too. I’d like to hear your opinion.”

You pause, then carefully say, “I do not think that it would be inappropriate to leave him, although obviously it would be preferable if he came in. I don’t know that I’d make the same decision, but I might, and I don’t see the situation as so high-risk as to justify anything really extreme.”

“Head injury, on Coumadin, loss of consciousness, you don’t think he needs to be seen?”

“We obviously can’t clear him here. But he’s stone normal by our assessment from every angle, and he’s not going to be left alone.”

“Well, I don’t think that’s a great idea. And he wasn’t really able to logically explain to me the risks of his decision. Anyway, his proxy agrees, so I’m not sure if I see the problem.”

“Doc, the problem is that although he does have someone here who says she’s his health care proxy, by our assessment he is at this time totally oriented, competent, and exercising sound judgment. So I’m not really comfortable kidnapping him, unless you want to sign a Section [your state’s involuntary mental health process, for those who are a danger to themselves or others].”

“Sure, I’ll do that. I can fax it to your dispatch and to the receiving hospital.”

“So you want us to tackle him?”

“Do what you have to do.”

You hang up the phone and look around. Police have left the scene, but could be easily recalled. Joe sits before you, a 79-year-old in fair condition, but no Evander Holyfield.

What do you do?

What are the legal considerations?

What are the ethical considerations?

The Art of the Transfer (part 3)

Continued from part 2…

There’s another benefit of patient transfers beyond the merely educational. You get to meet the people.

Oh, you meet people on emergencies. Depending on the nature. Dead people don’t talk much. (You get a look at their houses, maybe.) And really sick people, well, you’re pretty focused on the medical stuff then. Patch this, pump that, push the magic potion. When did it start? Have you felt this way before? What Russ Reina calls the business of being a “flesh mechanic.”

But on a routine transfer, and to a lesser extent on the non-emergent “emergencies” (when you have little to do and no hurry to do it), you get to actually chat with the human being upon your stretcher. Imagine that! They don’t just have a name and date of birth — they have a trade, a family, a history, a life.

Everyone has a story. Some of them are more interesting than others on the surface, such as the retired spy or the film star, but everyone has a story, and they’re all worth hearing, if you care.

Most of these people are old. If you’re not old, you may think this means they have less to say to you, but really, it’s the opposite. You’re 25 and they’re 90; all of the problems you’ve got, all the changes in the world you think are new, every dilemma you’ve ever faced, they’ve seen it and heard it and done it. They’ve been alive for several of you. Do you think people live that long without knowing their way around?

I once heard it suggested that you don’t really grow any wiser as you age, because although you learn from your mistakes, there are still an infinite number of future mistakes to be made. You never “run out” of new errors.

Perhaps that’s true. But even if the 90-year-old benefits little from his wisdom, that doesn’t mean you can’t borrow some of it. And even if his experiences or decisions differ from yours, they were just as important to him as yours are to you, and you can bet the stories are worth hearing.

Where else can you meet such a range of people? And not just meet, but find yourself forced into spending one-on-one time with them? If you’re a misanthrope, this is not a good career for you. Multiple times a day you’ll be placed in a small box with a stranger for a period lasting minutes to hours. It’s like speed dating.

But if you like people — enjoy meeting them, appreciate their company, take pleasure in their lives — then there’s no better job to have.

Some Things to Say

We’re not idiots. Everyone knows how to communicate. You just flap your jaws and blow.

In this business, though, we often find that it’s not enough to communicate; we have to do it efficiently. Likewise, it’s not enough to ask the right questions eventually. We need to do it promptly, because we’re not going to be here all day.

Heck, never mind efficiency. Sometimes there’s just a right thing to say, and everything else is wrong things. As Mark Twain put it, it’s the difference between the lightning-bug and the lightning.

So when you find a good bunch of words, you hold onto it, because like a master key, it’ll come in handy again. Here are two little phrases that everyone should have in their toolbox.

Has anything been bothering you lately?

I borrow this from Thom Dick, who suggested instead “Have you been upset about anything lately?” This is good, but to my ear leans more toward psychological troubles — very legitimate, but perhaps not what you’re after.

The patient has chest pain. Okay. Abdominal pain. Difficulty breathing. Clicky elbow. Can’t pee. So you assess their complaint from every angle, real and metaphoric, and you see what there is to see about it. But what’s the context? Is this the final stage of a grab-bag of other problems? Before it was abdominal pain, was there nausea and discomfort? Have the past few days produced a gradually increasing malaise? Is that onset truly sudden, or were there precursors?

Forget all that. Did your cat just get run over? Is your insurance refusing your reimbursements? Did your medication run out last week and you haven’t been able to afford to refill it? Are you living on ramen noodles and water?

Has anything else been bothering you? We can’t list every malady, but this question encompasses them all, and it can reveal entire storylines you wouldn’t have learned without an open-ended query. Patients have a habit of not mentioning anything that doesn’t seem directly related to their chief complaint, but those blips can make or break a clinical picture. I never call a history complete without asking it once.

How can I help?

Patients have a lot of complaints. Sometimes it’s the very reason they called you. Sometimes it’s just a complaint. They’re sick. Stuff hurts. Feels bad. Has problems.

They may share these complaints with you. And you may be able to help. Chest pain, you say? Why, I have just the morphine for that!

The trouble is, sometimes we’re not sure if we can help. Or it doesn’t seem like we can. Chest pain’s one thing. But what can you do when they complain of feeling “awful”? What about an uncomfortable stretcher — sure, let me just grab the plush memory foam? Heck, on my BLS truck, we don’t even have the morphine. We’re not magicians here.

But if you’re drawing a blank, try the wild card: ask!

Hey, sorry you’re having problems. How can I help? Often they have a solution. They’ve dealt with their problems for longer than you have. Next time, maybe you’ll have that answer on tap. But you don’t have to know all the answers; you just have to be able to ask. Funny thing, too; even when you really can’t do anything, they’re glad you cared enough to try. Sure is better than just sitting there trying to ignore their whining.

How can I help? Hey — isn’t that our whole business? They give us textbooks on how we can help. But sometimes helping’s easier than a CPAP or a trauma alert. Sometimes we can cheat, because the answer’s up for grabs. You just gotta ask.

More at Some Things to Say (part 2)

A Few More Weeks

His name is Richard.

For the past ten years, he’s lived in a nursing home in a town near Boston, not too far from where he grew up. In his 60s, he’s still mentally intact, and except for the incontinence that forces him to wear a diaper, he outwardly appears well. But wending through his brain is a host of malignant tumors that will soon kill him. “The doctors” give him less than six months.

Today, we’re bringing him to see his neurologist, in an outpatient clinic for one of the large Boston hospitals. As usual, it’s been scheduled right in the middle of rush hour, so we poke along slowly through the heavy traffic and chat. I’m driving today, with a relatively new partner in back.

Richard tells us about his time in the military, running maintenance on the early WWII radar stations that would ping back from a flock of seagulls just as fast as an enemy bomber. “Seagulls are all we ever got,” he confides to us. He has a wry sense of humor and the physical carriage of someone who has been through the wringer and remains standing, even if his tanks are now mostly running on empty.

He bitterly and inconsolably describes to us how much he hates his current living situation. He spent years living on two of the facility’s other floors, and was happy — the staff were kind and competent, and he got the care he needed. Recently they relocated him to his current floor, and he can’t say enough bad things about it. The nurses are negligent and dismissive, he is ignored and manhandled — he suspects he may have run afoul of the administrator who manages the facility. I ask why he doesn’t go elsewhere; he says he wants to stay close to his doctors here. “There must be a dozen other places at least as close,” I don’t say.

When we arrive on the floor, the receptionist calls ahead inside, and then informs us that Richard won’t need to be seen today. The appointment should have been cancelled, she tells us, since he was already seen recently on other business; he can instead be rescheduled for six weeks from now. Richard throws up his hands and shakes his head, exclaiming how he knew it all along; we all wonder aloud why it couldn’t have been confirmed ahead of time over the phone.

Back into the traffic, which has only gotten thicker. I try to ease us around the potholes and I fade the radio back into the patient compartment, giving Richard some classic Beatles. He rocks out hard.

We deliver him back to his room, shake hands and head out again. As we make up the stretcher, I find myself wondering whether this nice guy, who doesn’t ask anybody for anything except his basic needs of survival, really has to die somewhere he hates.

On a notice stuck to a corkboard, I find the number for the network’s ombudsman, an impartial representative designated to act as a patient advocate for resident complaints like this one. Standing outside in the rained-on mulch, I call their office, describing Richard’s situation and asking if he can’t be transferred, if only to another floor. They promise to speak with him when they round on this building early next week.

We drive back towards the city.

It’s several weeks before I can check on him again. I do visit his room several days later, but he’s asleep, and I hate to wake him. His diaper is obviously soiled.

Three weeks after we transported him to the doctor’s appointment that never happened, I bring in Davis, one of our regular dialysis patients, who happens to share the room with Richard. A different name is on the door now, and I ask Davis hopefully if his roommate has been transferred elsewhere.

“He passed away,” he tells us, and wheels himself inside.

The Tough Ones

People can be pills.

That is, EMS is the business of dealing with people. Even at their best, some homo sapiens will not be your favorite; you’d have to be a saint to love every single person you’ve ever met. And unfortunately, the patients we’re handed in this job are rarely at their best. That’s why they’re in an ambulance. Expecting someone to present a winning smile while they’re dying may be unreasonable.

The trouble is that showing compassion and doing your very best for people is a lot easier when you like them. It’s just human nature; we’re always nicer to the people we identify with, get along with, and find affable and likable.

. . . a lot of ordinary people look totally uncool, especially in their BVDs. In fact, they’re pretty ugly without their clothes on, or at least a little make-up. Some of them are fairly dim bulbs, actually. And on the worst days of their lives, a lot more have BO, bad breath, wrinkles, loose skin, irregular teeth, big bellies, short penises, hair where there shouldn’t be hair, and no hair where there should be. They’re inarticulate, clumsy and, well, kind of ordinary. They don’t match any of those pictures of perfectly proportioned people you’ve seen in your textbooks or on TV.

And guess what? Their families love them dearly, just the way they are!

. . . What you are is a caregiver. What you’re not is a judge. . . . You can be one or the other, but you can’t be both — not at the same time, anyway. As a caregiver, you can’t let yourself slip into the trap of judging people you don’t know anything about, because it does bad things to you. (People Care, 16)

See, the tough thing is that although it’s very human to treat the likable people better, that’s not how this job works. You’re allowed to like whomever you want; that’s your right as a person. But your responsibility as a caregiver is to do your best for all of them, like or loathe. It’s a learned skill, because it’s not at all natural. But it helps if you remember that your standards for likability are far from the ultimate test of someone’s personal worth. Everyone’s fighting their own battles, and patients shouldn’t be expected to look pretty for you in the midst of theirs. You’re not here to add to their burdens.

We have a built-in bias that tells us that people who are smelly or fat or dumb are overall bad people. It’s hard to overcome it. And because people who are choking, or incontinent, or hospitalized tend to be especially rough around the edges, it’s very easy indeed to file them under the category of “unpleasant objects.”

Special mention should be given to patients who are, to put it simply, jerks. Even those of us who can look past physical and mental defects may have trouble treating the world’s biggest asshole like our own dear mother. Once again, we have to remember that we’re not playing this game on a personal level, and the question isn’t whether the patient will be invited to our birthday party. The question’s whether they deserve our best care — and whether or not that’s difficult, whether or not we want to give it, the answer is “yes.” That’s how this works. If they’re a patient, they get our best. Some nasty physical ailments are harder to treat than others; some personalities are likewise harder to tolerate. But we don’t get to pick and choose, so we just have to suck it up and be compassionate professionals across the board.

Try to develop the mindset that to be human carries an inherent sacredness, value, and dignity. And that even the most despicable and worn-out creature on your stretcher has the same needs and feelings, and likely the same sense of self-worth, as any CEO or socialite. To quote Antoine de Saint-Exupéry, “I have no right to say or do anything that diminishes a man in his own eyes. What matters is not what I think of him, but what he thinks of himself. Hurting a man in his dignity is a crime.” (From How to Win Friends and Influence People, 214.)

All of this isn’t easy. Striving toward it is a constant effort. But if you can take a patient who you truly loathe, and treat him just the same as you would your own child — or your partner — or yourself — then that’s something to celebrate. Because quite frankly, the patient is somebody’s child, or somebody’s partner, and odds are good that their opinions of his human worth may differ from yours.

. . . until the curtain was rung down on the last act of the drama (and it might have no last act!) he wished the intellectual cripples and the moral hunchbacks not to be jeered at; perhaps they might turn out to be the heroes of the play. (George Santayana on William James [from Linda Simon’s William James Remembered])

Patient Advocacy

What does it mean to be a patient advocate?

I first learned this term from my original EMT textbook, and since then, it seems like it’s been the favorite buzzword of the medical profession. It’s a little bit like “leveraging synergies”; it sounds surely good while having no clear meaning at all.

I think this is a shame, because to me, patient advocacy is actually a very meaningful concept, and in EMS, a very important one. Perhaps this isn’t true for doctors and nurses, radiologists and cath technicians — although I’d like to think it is — but on the ambulance, it’s more than just a pretty ideal.

This was what the textbook had to say:

As an EMT-B, you are there for your patient. You are an advocate, the person who speaks up for your patient and pleads his cause. It is your responsibility to address the patient’s needs and to bring any of his concerns to the attention of the hospital staff. You will have developed a rapport with the patient during your brief but very important time together, a rapport that gives you an understanding of his condition and needs. As an advocate, you will do your best to transmit this knowledge in order to help the patient continue through the EMS and hospital system. In your role as an advocate you may perform a task as important as reporting information that will enable the hospital staff to save the patient’s life — or as simple as making sure a relative of the patient is notified. Acts that may seem minor to you may often provide major comfort to your patient. (Limmer 11)

Not half bad, really. But raise your hand if your eyes glossed over that paragraph.

You see, as a prehospital provider, you occupy a unique role in a patient’s course of care. Your time with this patient, from initial contact until transfer of care, is one of the only periods when they’ll have the one-on-one, undivided attention of a healthcare provider. Think about that for a moment. Ms. Smith may previously be, or soon will be, under the auspices of a veritable pantheon of specialists — cardiologists, endocrinologists, orthopedists, neurologists, and more. On this occasion alone, she might pass through the hands of an ED physician who stabilizes her, an internist who admits her, a surgeon who operates on her — never mind a supporting battalion of nurses, techs, CNAs, therapists, and witch doctors. It takes an army to treat a patient.

But that army has other responsibilities, too. That ED doc has two dozen other patients screaming for his attention, most of whom have already been waiting for hours. The internist is running a code in the next bed. Those nurses are overworked, underpaid, and really want to get home.

As a rule, they all have the best intentions, and they all want to look out for the patient. True bad apples or apathetic mercenaries are a rarity in this business. But everyone’s simply spread thin. Even when they have the resources to give their undivided attention to an individual patient, it’s rarely their responsibility to do so. The cardiologist is here to provide a consultation on Ms. Smith’s heart — not to champion her care like the Hospitalist Prince of North 6 and butt into everyone’s else’s work. It’s just not his job.

But what about you, the humble stretcher monkey who brings her in? For that brief period of time, you really have no business except Ms. Smith’s well being. That’s why you’re here; that’s what you were dispatched to look after; and it’s your legal, medical, and moral responsibility to do everything you can for her, until such time as you transfer that responsibility into the aforementioned healthcare cloud (or she refuses further care). Assuredly, you have a defined scope of practice, and company policies to follow, but we’re not talking about cutting out her gallbladder or taking her to a dive bar. We’re talking about — say it with me — patient advocacy. And everyone upstairs agrees that’s part of your job.

Your job is to be her champion. Not because you’re Superman. But because she’s so vulnerable right now, she doesn’t need Superman; she just needs anyone who will step up. Anybody who’ll stand there and say, you are not alone. We all need that, and we all deserve it — but many of these patients, after countless years and battles, have no one else to turn to.

Let’s steal a quote — this is from Danielle E. Sucher at Legal Agility, responding to the question of why she practices criminal defense.

I don’t like hurting people. Is that so hard to understand? When I go to bed at night, I can sleep easily, knowing that I fought for freedom, and for less suffering rather than more. That I stood by someone accused so that he would not have to stand alone.

I can’t know whether anyone is truly guilty or innocent, or what they deserve, and frankly, I don’t care. We all deserve at least one person on the damn planet willing to stand there next to us and fight on our behalf.

[Source]

Patients have problems. You can’t help with all of them. You can’t cure their cancer, or pay their bills, or make the world fair and right. But you can do an awful damned lot, because it’s astonishing how large the gap is between what the patient would do and what they can do in their current, largely powerless position.

You have resources. One’s this big ambulance, and everything in it. But you also have the resource of knowledge: you know how the system works. You know where to go for certain things, you know who to contact to get what you need, and you know what’s available for the asking. These would serve you very well if you should need to visit the emergency room or become hospitalized, or if your mother should, or your child. If Ms. Smith were your mother, you wouldn’t just shuffle through the process of putting Person A into Slot B, ignoring her needs and looking for ways to avoid going the extra mile; you’d fight like hell to keep her as happy, as comfortable, and as looked-after as possible. Because patients can’t fight for themselves, any better than defendants can argue their own cases. And because although other professionals will be involved in this process, they won’t be fighting for the patient either. I have immense respect for the docs and the nurses, but sometimes, you’re standing in a place to do things they can’t. A few of them may go above and beyond, but they all have their jobs to do, and this isn’t it.

But it is yours.