Silent Siren, page 17
When I started in paramedicine, I was so overwhelmed with remembering all my interview questions and all the components of my examination that it was very easy to forget I had a human being in front of me, one who had no idea who I was or what my qualifications were, but who was forced by sudden circumstance to trust in my care. My approach was initially to tower authoritatively over my patient and repeat carefully rehearsed questions in a staccato manner. I often could not remember the answers to these questions, as I was immediately preparing to ask another one.
My approach has changed as of late. As a seasoned paramedic comfortable with his own skills and with a greater sense of the nature of the job, I kneel down to the patient’s level, smile, and extend my hand in greeting. “Hi. I’m Matt. How can I help you?” is usually what I say. Using my name helps the patient identify with me as a human being. I don’t think it’s necessary for me to use my full title and agency as that much is obvious. Saying, “How can I help you?” allows people to open up more so than if I was to ask, “What’s wrong?” Such an approach subtly increases the patient’s anxiety that, in fact, something is dreadfully wrong.
Of course, it wouldn’t make sense for me to introduce myself in the same manner to a patient leaning forward, sweating profusely, and gasping for air. How I can help is perfectly obvious. I will usually say something like, “I can see you’re having a tough time breathing. We can help you with that. I need to listen to your lungs.” Every patient deserves a slightly different approach and a smile goes a long way.
I’m on Med 4 in Burlington, and my partner and I are called to a local nursing home for an elderly woman suspected of having a stroke. She was reported to have been unconscious for a short period of time before regaining her sensorium.
We arrive at the alley approach to the nursing home, load the stretcher with Lifepak and med kit, and make our way up the narrow ramp into the nursing facility.
An RN leads us down a smelly corridor lined with somnolent residents in wheelchairs, some of whom cry out and reach for us, others who are insensate, locked within narcotic-induced hazes. We approach a double room, where a small woman lies in a hospital bed, looking somewhat dazed. The nurse thrusts a fistful of paperwork in my hands and gives me the rundown: “seventy-seven-year-old female, was shaking, turned blue and was unresponsive for about two minutes. She goes to United General.”
I sift through the paperwork that lists the patient’s resuscitation status, medications, and allergies. I look for some medical history to give me a clue as to what may have happened to her today. Is she a diabetic? Does she have a seizure disorder? Something catches my eye—the medication Glucophage. The woman is a Type II diabetic.
I ask, “Did you check her blood sugar?”
The nurse replies, “No. Why?”
“She’s a diabetic.”
“No she’s not.”
I indicate the paperwork in front of me. “Says here.”
The nurse inspects the paperwork. “Wrong patient,” she says.
Oh dear.
I assess our elderly patient while I wait for the correct paperwork to arrive. She is alert, but having difficulty speaking. She has had a stroke in the past but now her entire right side is flaccid.
The nurse bursts back in the room with a new stack of paperwork. I glance through it and notice one of the medications is insulin. Again, I ask if the staff has checked her blood sugar. I glance at the top of the page and note the name, “Roger Epps.” Our little old lady certainly didn’t look like a Roger Epps. I had received the wrong paperwork—again.
On the third attempt, the paperwork and the patient match up and we wheel her out the door to the ambulance. My partner starts an IV on the patient, draws some blood, and checks her blood sugar—just in case.
The ambulance pulls slowly down the gravel alley and turns right to head towards United General Hospital. I only have five minutes to get my paperwork together and learn all I can about this woman’s medications, allergies, and medical history. My face is buried in flowcharts and doctor’s dictations.
I look up from my paperwork to grab the portable phone and notice tears streaming down the face of my elderly patient.
“What’s wrong?” I ask. “Why are you crying?”
“I’m scared,” she says.
“Why are you scared?”
“Stroke.”
Instantly I feel awful. I had been so wrapped up in the medical minutiae of her case that I had forgotten there was a human being behind all those diagnoses—a human being frightened of her own infirmity, her own mortality.
I set my paperwork aside and strip the latex gloves off my sweaty hands. Taking one of her frail old hands in both of mine, we were no longer patient and medical practitioner. I was just one human being caring for another. It didn’t matter that I couldn’t recite her medications by rote; they would be on her chart at the hospital. All that mattered was that I cared and comforted her in her time of crisis.
Sometimes the human touch is our most powerful medicine.
Tones
The alarm tones are taking years off my life. Even after all these years of waking up at 0300 hours to bells announcing fire, sickness, and injury, it continues to be a psychologically horrible experience. It goes with the territory, I guess. We are paid to be on-call twenty-four hours a day, and something has to arouse me from slumber and spur me to action. Since my idea of Heidi Klum awakening me with a kiss on the cheek is unlikely to come to fruition, I will likely have my sleep rudely interrupted for another twenty years.
At Bainbridge Island Fire Department, where I served nineteen years, the tones were accompanied by loud overhead speakers and fluorescent lights that flicked on automatically in the sleeping quarters—just so you wouldn’t sleep through an alarm. When I went to work for Evergreen Medic One, I was based at Redmond Fire’s new Station 19 that employed “calming tones” designed to minimize the stress to the heart and the cortisol jolt that occurred every time an alarm was sent. The pager chirped as usual, but the overhead speakers chimed rather than blared. A mellifluous “Blong…Blong…Blong” seemed to say, “It would be ever so nice if you got out of bed. Somebody seems to be having heart trouble in your area.” The chimes were accompanied by a red light in the corner of the room whose intensity would gradually increase until it lit up the room with a soft, non-threatening glow.
Here at Central Skagit Medic One, our four medic units are based out of two rented houses and two volunteer fire stations. I suspect it’s too difficult and/or expensive to wire overhead speakers and lights, so we rely on our bedside pagers to wake us up. Usually they do. At Med 3 quarters, we are based at the McLean Road fire station, which still employs a station-mounted air raid siren. Each time we receive a call with McLean Fire, whether it is a stubbed toe or a multiple-vehicle collision, the siren howls as though it were announcing a nuclear missile attack. I don’t imagine the neighbors like that very much, but, then again, they should have known what they were getting into, living in the vicinity of a fire station.
Health Care is Broken
We get called to Mira Vista nursing home in Mount Vernon for an elderly woman with a fever. Only a few blocks from Skagit Valley Hospital, its proximity makes it nearly pointless to initiate advanced therapy on any but the sickest of patients. It simply doesn’t make sense to “set up shop,” putting in IVs and hooking up various wires and tubes, when the hospital is nearly within spitting distance.
The patient we have come to see today is reasonably alert, has stable vitals, and has paperwork that states she wants no heroics. She wants “comfort measures only.” In other words, she is waiting to die and wants to be left alone to do so in peace. She has a history of urinary tract infections and has some burning on urination—fairly straightforward stuff.
The charge nurse at the facility has followed protocol and contacted her primary physician, who is either too lazy or too busy to deal with the patient himself, so he says something to the effect of, “Just take her to the hospital.”
This is all too typical of a problem that clogs up emergency rooms and raises the cost of health care for all of us. The logical choice would be for the doctor to call in a prescription of antibiotic to her pharmacy and have it sent to the nursing home, thus obviating the need for an expensive ambulance ride, ER visit, and inconvenience for the patient. In this situation, as in many others, transporting a patient to the ER instead of finding a solution that will allow the patient to stay where she is, is the equivalent of trying to flip pancakes by shaking the entire stove—completely unnecessary.
It isn’t the horrors that paramedics and EMTs see that burn us out. It is the abuse to the system, the unnecessary ER transports, and the sense that we are being used as a horizontal taxi ride for those who see it as their God-given right to be transported in a mobile critical care unit for the sniffles. The problem is rampant at the emergency room as well; the uninsured and illegal immigrants use the emergency room as their primary care provider, bringing in their sniffling children and four-day headaches that could much more efficiently and inexpensively be dealt with by a primary care practitioner.
In my experience, I have identified three distinct phases of enthusiasm for the typical paramedic or EMT. A rookie paramedic comes to the street with a head full of knowledge, some of it useful, some simply esoteric. He believes that he will “make a difference” and “save the world.” Sure, he will save lives. There will be diabetics to bring back to consciousness, trauma patients that will be whisked from the arms of death by his quick actions. However, the majority of calls are mundane. In two years or so, the new medic will realize that most patients would make it to the hospital in the back of a taxi as well as they would in the back of an ambulance. He will likely become disillusioned, maybe angry. As he attempts to right the wrongs he sees in healthcare and abuse of “the system,” he will gradually slide towards a phase I call Primary Burnout. He will either leave the field at this point or find a new way to frame what he does for a living. He may realize that paramedicine is at least 50% social work. Most of what we do involves knowing how to relate to people and make them feel comfortable in very scary situations.
If the paramedic survives Primary Burnout, he will eventually reach, after several more years, Acceptance Phase, in which he stops fighting so vehemently against system abuse and, when called for a system abuser, will simply say, “You wanna go to the hospital? Okay, get in the bus.” A senior medic I know is fond of saying, “This isn’t something we can fix here. Let’s get moving.”
Secondary Burnout occurs when an emergency responder has simply had enough. He no longer feels challenged by the job, feels tired and sore from years on the street, and decides to hang up the stethoscope.
I’ve got to think it’s similar in the mortuary/death investigation business—one too many SIDS deaths, a prematurely aged back from hundreds of difficult body removals, and the sense that, after so many years around death, one finally has to embrace life for a change.
I consider myself to be a compassionate person, able to express empathy towards a patient and his anxious family. People are drawn to the field of EMS for many different reasons, some to “give back to the community,” some from a desire for glory, others for the camaraderie. Those who don’t enter this business with a strong desire to alleviate suffering and a love for humanity will not make it more than a few years. The occasional high-profile rescue or the dramatic resuscitation of the twenty-five-year-old model/actress/marathon runner does not come close to making up for the long hours, the low pay, the mind-numbing routine nature of most of our calls, and the abuse of the system heaped upon us by ignorant patients, and sometimes ignorant fellow providers.
I don’t find myself taking work home with me, though. Perhaps it’s because I started in this field so young and the things I saw seemed normal to me, I have developed what I call a “semipermeable membrane” to deal with stresses at work. Through this membrane I am able to express caring and compassion, but the sadness and pain I see on a daily basis doesn’t affect me on a personal level. I realize that it’s not my emergency. I didn’t cause it to occur. The best I can do is to intervene from the outside and make things better. Maybe the membrane I keep around myself is atypical of others in the business, but it makes sense to me, and I am able to sleep well at night.
Silent MI
I’m at Med 3 on McLean Road in rural Mount Vernon when the call comes in for CPR in progress in downtown Sedro-Woolley. For us to be called such a distance out of our response area, the system must be taxed. It meant neither Sedro-Woolley’s Med 1 nor Med 4 out of Burlington, two closer rigs, are available. I hope Sedro-Woolley Fire Department’s Aid 5519 would get on scene soon enough to get CPR started without the patient suffering irreversible brain damage.
My partner, Danny, and I get en route to the call, at least ten minutes away. Our BLS unit, Aid 5, gets on the air and says they are close and asks for permission to respond. I grant permission; we need all the help we can get on a cardiac arrest and I find it is always best to work with those we are familiar with and who know the way we work.
The man lies in the living room, right in front of the open door. Aid 5 has done yeoman duty, having already attached the patient to the heart monitor, started an IV, and checked a blood sugar. Half my work is already done, and I am grateful for their quick action. I also notice that, though the man’s color is awful, he is breathing and attempting to talk.
Sedro-Woolley Fire tells me they found the man unconscious and not breathing on the couch. After a couple of minutes of rescue breathing, the man began breathing on his own, fighting the bag-valve mask.
According to his son, he is in the logging business and had been up inspecting a site all day, when he complained of not feeling well. He had requested his son to drive home, which was unusual for him. His daughter-in-law found him unresponsive on the couch and started CPR.
Though the man is conscious and breathing, I am concerned about his ashen color and the fact that he continues to profusely sweat. We load him onto the stretcher and into the ambulance. I ask my EMT partner, Brett, for a fast ride to Skagit Valley Hospital.
As we pull away from the curb, siren wailing, I try to get a better idea of the man’s condition. His blood pressure is normal. His heart rate is normal. Nothing looks abnormal from a cursory examination of his EKG strip.
“Do you have any pain?” I ask. “Any discomfort at all? Any difficulty breathing?”
The man denies any symptoms at all. Still, his profuse sweating worries me that something very dire is occurring.
I decide to do an advanced EKG, known as a 12-lead, as we race down I-5 to the hospital. This could give me an idea if something was wrong with the man’s heart.
It’s difficult to get the six extra patches to stick on his chest with his profuse sweating, but by keeping my fingers pressed against all of them, the EKG monitor gets a good read-out. EKG paper spits out below the screen with the words “Acute MI suspected.” I confirm it visually by noting the characteristic elevation of certain waves in a set of leads. The man is having a heart attack with the blood supply to the right side of his heart completely cut off.
I get on the cell phone to call in a “STEMI” or ST-elevation MI. This notification will alert the ER staff to stand by with a cardiologist and for them to ready the cardiac catheterization lab.
Once in the ER, I hand the chief attending physician the EKG strip I obtained in the ambulance. He examines it as ER technicians hook the man up to their own EKG and confirm my findings. When the ER staff runs their own 12-lead, no abnormalities are found, almost as if he is no longer having a heart attack.
As it turned out, the man was having a rare form of heart attack known as a “stuttering MI” in which blood flow is intermittently restored to the heart muscle and the EKG returns to normal, though the blockage still exists.
On the basis of my field 12-lead, a cardiologist examines the man and has him rushed to the catheterization lab, where his blockage is removed with angioplasty.
I’ve come to trust the little voice in my head that says, “Something isn’t right,” even if all the vital signs check out and the patient has no complaints. Had it not been for that field EKG, the man would likely have sat in the ER without a diagnosis until his heart had stopped. At that point, it may have been too late.
Monkeys with Needles
A well-known pioneer in EMS has been known to say, “I could teach a monkey to do this job,” and he’s right—to a point. While impressive for an outsider to watch, the skills of intravenous catheterization, defibrillation, and endotracheal intubation, even drug dosing, are simply manual skills that can be perfected with time and multiple repetitions.
What cannot be taught is clinical judgment. You can teach a monkey to intubate; you just can’t teach him when to intubate. I’m willing to bet that a monkey—and I’ve met some medics who might fall into this category—can memorize a decision-making flow chart presented in an American Heart Association guide and execute each step exactly as outlined. If the ability to attain psychomotor skills and memorize charts and protocols were all there was to being a good paramedic, Bubbles the Chimp and thousands of his friends would be driving the nation’s ambulances and intubating with their very long arms.
