Those who Save Lives: Kevin Briggs

The Golden Gate Bridge in San Francisco has numerous claims to fame. Once the longest suspension bridge in the world, and still probably the most iconic, it’s a central feature of the SF Bay Area — my own home.

Less admirable is the fact that it remains among the most popular bridges in the nation for suicidal people to jump from. In fact, it’s one of the most “utilized” suicide spots in the entire world, with over 1,600 jumps made so far, most of them fatal. (Exact numbers are hard to come by for a good reason: bridge administrators and media outlets stopped keeping an official tally when they realized it was incentivizing people to ring in big milestones with their own attempts — lucky number 1,000 and so forth.) Someone still tries to jump about once every two weeks, which sounds insane, but is true.

Sergeant Kevin Briggs was a California Highway Patrol officer who spent a large part of his career patrolling that same bridge, which led to an interesting twist on his job description: suicide prevention. See, often times he was the one to notice a pedestrian who looked like they were considering jumping, or were even in the process of climbing over the rail. Sometimes he’d be called in by others who saw it first. Jumpers tended to stand on the “chord,” a ledge of piping just beyond the safety rail and the last solid ground before open air. Kevin would talk to them there, and try to convince them it was a bad idea.

It wasn’t something he had any training to do, at least not at first, or experience with, although he picked that up quickly. He had suicide in his family — as many of us do, since it’s incredibly common — but otherwise, he fell into the role the way many of us fall into our callings. Eventually, he made it his niche, leading a trained team of interveners.

Over the years, he spoke to hundreds of jumpers. At first, he’d approach benignly — “How are you feeling today?” and “What’s your plan for tomorrow?” For those without plans, he’d help them make some, because people with a plan tended to stick around to fulfill it.

Later, he became more direct, asking up front whether they’d come to hurt themselves. Or the simple question: “Others in similar circumstances have thought about ending their life. Have you had these thoughts?”

Either way, the encounters tended to unfold similarly. And as a rule, they went well. Of the countless desperate people he met, only two ended up jumping once he’d managed to make contact.

The jumpers met the pattern recognized by psychiatry as comprising the depressed and suicidal. They exhibited hopelessness — the outlook that things are terrible and will never get better. Most of us can ride out terrible storms, but if there’s no prospect of the storm ever ending, why bother? (“What do you do,” asked one, “when hope isn’t there?”) Then helplessness — the belief that there’s no remedy, solution, decision, medicine, or lifeline that can make a difference. People withdraw socially and lose interest in things they once enjoyed. They retreat from the world. They show up at the bridge because there’s no reason to be anywhere different.

Inexplicably, we in EMS seem to have developed the belief that most suicidal patients are “crazy” — as in psychotic — or dangerous — as in homicidal. As a rule, neither is true. These people aren’t out to hurt anybody. (One of the “ones who got away” politely shook Briggs’s hand and apologized before jumping.) They just want to escape the pain. With alcohol, with drugs, with sleep, with death.

How did Kevin Briggs have so much success? It’s a question that gets more perplexing the more you consider it. By definition, these are people who have lost all hope, exhausted all options, discarded alternatives until they’re ready to embrace the most permanent solution possible. And yet, a total stranger was able to approach them at their final moments and convince them to see things differently. How?

Through no secret system. He didn’t argue, cajole, or debate them. Nor did he tell anybody he knew how they felt or blame them for their actions. Mostly he listened to understand. Used their name to keep them anchored to reality. Occasionally, he’d share personal stories, things nobody else knew, as if bestowing them upon someone made them responsible for his secrets. In the end, merely being there seemed to make the difference.

Many interventions were successful within 10 minutes. Some lasted many hours. The longer the conversation went on, the better his odds, Briggs would say. The human connection grew stronger and stronger. People ready to jump away from nothing would reconsider, because now they were leaving something behind. It’s impolite to leave a conversation. It’s wrong to fail when someone cares about your success. Kevin had made it clear that he cared if they died, and they didn’t want to let Kevin down.

The most important secret of all is that this medicine wasn’t temporary. Another common truism in EMS is that preventing suicide is a Sisyphean task, because if someone wants to take their life, eventually they’ll succeed no matter how many times we slap the gun from their hand. Surely if they don’t jump here, they’ll just jump from the next bridge instead. But that’s not what the facts show. 94% of the ones who reconsidered jumping never tried again, instead living out long and fruitful lives. And the ones who jumped and survived nearly all described the same thought: the moment they stepped from the bridge, they regretted what they’d done. Despite what they’d thought, they didn’t really want to die. “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable — except for having just jumped,” reported one.

Much like reperfusing the STEMI, stabilizing the CHF exacerbation, or patching up the gunshot wound, this business was one of pulling people back from a preventable brink — people with the real potential to eventually leave it behind them.

As one mother wrote Briggs: “Thanks so much for standing up for those who may be only temporarily too weak to stand for themselves.” That sounds like our job, doesn’t it?

Sgt. Kevin Briggs recently retired from the CHP to continue pursuing suicide activism. And last year, work was finally approved on an anti-jumping safety net to be built beneath the Golden Gate Bridge. Maybe soon his brand of heroism won’t be necessary there. But it’ll be needed somewhere. Others are doing their part. Shouldn’t we do ours?

(By the way, the Code Green Campaign, which is trying to make a dent in the number of suicides among EMS providers, has so far been forced to announce a new one every 3.5 days this year. Fire safety isn’t doing any better. But heck, suicide’s not our problem, right?)

Sources and more reading:

Read about more lifesavers at Those who Save Lives: The Royal Humane Society and Those who Save Lives: Harry Watts

Either Lead, Learn, or Please Stop Talking

computer-punch

 

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.

What the Heck is a General Impression?

I’m tired of all the mumbo-jumbo.

Here’s my beef. Every medical provider, particularly those who work in the acute setting (such as prehospital medicine, critical care, or the emergency department), talks about a concept familiar to us all: the overall, gut sense of how ill a patient appears. In EMS training this is often described as the “general impression,” the “view from the door,” “big sick vs. little sick,” or other euphemisms. It’s your basic opinion of whether a patient is doing okay or not, and it’s formed within the first moments of contact.

Whatever you call it, it’s important. In fact, this one factor is often what really drives your management decisions. If a patient looks truly sick, it may not matter what the vital signs show or how the history sounds; they’re getting zipped over to the hospital with bells on. Conversely, if they look really well, it’s hard to get excited even if they complain of “12 out of 10 pain” and their pulse is 100.

Here’s the rub: everybody acts like this quality is completely impossible to describe. If you tell me the patient “looked sick” and I ask what you mean, you’ll probably wave your hands and reply that it’s ineffable; that you “had to be there”; that you know it when you see it, but that it can’t be quantified and can’t be analyzed.

If true, that would mean it can’t be taught, either. New providers would have to learn to recognize this mystical patient presentation by dint of long, hard-earned experience.

And perhaps this is true. Certainly there are other aspects of patient evaluation and management that actually are too complex to reduce to simplicities. Indeed, one of the central skills of medicine, and one that humans are uniquely equipped to perform (hence the last one that computers will take from us), is our ability to extract a diagnosis from a large number of variables by recognizing subtle patterns.

But I doubt that’s true here. Why? Because you form your general impression within the first moments you meet a patient. There just aren’t very many factors that can come into play, because you haven’t obtained much information yet. The view from the door isn’t going to include ECG findings or subtleties of the OPQRST.

So I have a theory, and here it is. The entire mythical gestalt of your general impression actually involves only three things: the patient’s behavior, their breathing, and the appearance of their skin.

Behavior

The first thing you notice when you meet a person is their behavior. This mostly means two things: their mental status and their level of distress.

A sick patient may be unconscious, or visibly lethargic; healthy people are awake and alert, because the brain is one of the last things the body allows to shut down. They’re also not obviously loopy, such as profoundly confused or combative, unless they have a chronic condition such as dementia.

And if sick people aren’t so sick they can’t complain at all, then their complaints reflect their acuity. They scream, they moan, they are visibly distressed by pain or fear. They say things like they’re dying or can’t breathe or can’t see or can’t move.

Some interpretation is needed here, because appropriate behavior can depend on the circumstances. Malingerers may say they can’t breathe when they clearly can. Panic attacks may present with greater distress than the physiology warrants. A child is most reassuring when grabbing at your stethoscope and stealing your gauze. And an infant may be normal when he cries vigorously and sick when he sits in silence. But it all comes down to how the patient is behaving.

Breathing

The patient’s breathing can be evaluated from across a parking lot. You can’t auscultate or measure their oxygen saturation, but you can get a general idea.

Are they breathing at all? Are they laboring, wheezing, gasping agonally, gurgling through pulmonary edema? Are they chatting easily with the firefighters, or is sucking down air the sole focus of their attention?

Skin

Skin appearance is an idiot-proof and instantly recognizable finding.

The most common sick skins involve pallor and diaphoresis. Shocky or otherwise sympathetically-charged patients are starkly white and sweating like they’re in a sauna. It’s one of the most characteristic appearances of acute illness.

Cyanosis is next up. “Shortness of breath” in a patient who’s pink, warm, and dry is one thing, but it’s quite another when they’re turning blue.

Less common findings include the red-hot skin of fever, the yellow skin of severe jaundice, the dry skin of dehydration, and the dependent lividity of the very dead.

That’s all, folks

When you talk about a patient who looks sick, or “doesn’t feel right,” or has some other nebulous problem like being “toxic,” you’re not tapping into some vast, indescribable vault of clinical judgment. All you’re doing is using shorthand that refers to the patient’s behavior, breathing, and skin. (Notice how these factors are emphasized in our initial assessment.)

A gut belief that a patient has a big problem after a full work-up (including an H&P and diagnostics) is a different phenomenon, and suggests that your intuitive side is recognizing a larger pattern that your conscious self hasn’t yet been able to label. But that’s a distinct process from the instantaneous triage you perform when you first walk into a room.

There may be exceptional cases where something different sets off your alarm bells. But I bet most of the time, it can still be linked back to one of these three categories. (An example might be the frequent flier, well-known to you, who is usually stoic but today seems worried and wants transport. That’s a discrepancy in their behavior, ain’t it?)

Don’t believe me? Just think of how you tell the stories of your sick patients. I’ll bet you say things like, “I walk in, and he’s bent over gasping; his skin is completely soaked and looks whiter than copier paper.” Those are the factors that we recognize as important, and that’s why they’re so vividly evocative. They’re the colors we use to paint the picture of badness.

I may raise some ire by dismissing the voodoo surrounding the clinical gestalt, but here’s my challenge: if you believe there’s more behind your general impression of “sick or not sick,” then reply in the comments and tell me what it is. Maybe I’m missing or forgetting something. Maybe I’m doing it wrong and you’re doing it right. But if you can’t point to what’s missing, then I’m betting there’s nothing more to it after all.

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!

Murder by Checklist

Reader Steve Carroll passed along this recent case report from the Annals of Emergency Medicine.

It’s behind a paywall, so let’s summarize.

 

What happened

A young adult male was shot three times — right lower quadrant, left flank, and proximal right thigh. Both internal and external bleeding were severe. A physician bystander* tried to control it with direct pressure, to no avail.

With two hands and a lot of force, however (he weighed over 200 pounds), he was able to hold continuous, direct pressure to the upper abdomen, tamponading the aorta proximal to all three wounds.

 

Manual aortic pressure

 

Bleeding was arrested and the patient regained consciousness as long as compression was held. The bystander tried to pass the job off to another, smaller person, who was unable to provide adequate pressure.

When the scene was secured and paramedics arrived, they took over the task of aortic compression. But every time they interrupted pressure to move him to the stretcher or into the ambulance, the patient lost consciousness again. Finally en route, “it was abandoned to obtain vital signs, intravenous access, and a cervical collar.”

The result?

Within minutes, the patient again bled externally and became unresponsive. Four minutes into the 9-minute transfer, he had a pulseless electrical activity cardiac arrest, presumed a result of severe hypovolemia. Advanced cardiac life support resuscitation was initiated and continued for the remaining 5-minute transfer to the ED.

The patient did not survive.

 

When the cookbook goes bad

The idea of aortic compression is fascinating, but I don’t think it’s the most important lesson to this story.

Much has been said about the drawbacks of rigidly prescriptive protocol-based practice in EMS. But one could argue that our standard teachings allow for you to defer interventions like IV access if you’re caught up preventing hemorrhage. Like they say, sometimes you never get past the ABCs.

The problem here is not necessarily the protocols or the training. It’s the culture. And it’s not just us, because you see similar behavior in the hospital and in other domains.

It’s the idea that certain things just need to be done, regardless of their appropriateness for the patient. It’s the idea that certain patients come with a checklist of actions that need to be dealt with before you arrive at the ED. Doesn’t matter when. Doesn’t matter if they matter.

It’s this reasoning: “If I deliver a trauma patient without a collar, vital signs, and two large-bore IVs, the ER is going to tear me a new one.”

In other words, if you don’t get through the checklist, that’s your fault. But if the patient dies, that’s nobody’s fault.

From the outside, this doesn’t make much sense, because it has nothing to do with the patient’s pathology and what might help them. It has everything to do with the relationship between the paramedic and the ER, or the paramedic and the CQI staff, or the paramedic and the regional medical direction.

Because we work alone out there, without anybody directly overseeing our practice, the only time our actions are judged is when we drop off the patient. Which has led many of us to prioritize the appearance of “the package.” Not the care we deliver on scene or en route. Just the way things look when we arrive.

That’s why crews have idled in ED ambulance bays trying over and over to “get the tube” before unloading. That’s why we’ve had patients walk to the ambulance, climb inside, and sit down, only to be strapped down to a board.

And that’s why we’ve let people bleed to death while we record their blood pressure and needle a vein.

It’s okay to do our ritual checklist-driven dance for the routine patients, because that’s what checklists are for; all the little things that seem like a good idea when there’s time and resources to achieve them. But there’s something deeply wrong when you turn away from something critical — something lifesaving — something that actually helps — in order to achieve some bullshit that doesn’t matter one bit.

If you stop tamponading a wound to place a cervical collar, that cervical collar killed the patient. If you stop chest compressions to intubate, that tube killed the patient. If you delay transport in penetrating trauma to find an IV, that IV killed the patient.

No, let’s be honest. If you do those things, you killed the patient.

Do what actually matters for the patient in front of you. Nobody will ever criticize you for it, and if they do, they are not someone whose criticism should bother you. The only thing that should bother you is killing people while you finish your checklist.

 

* Correction: the bystander who intervened was not a physician, but “MD” (Matthew Douma), the lead author, who is an RN. — Editor, 7/22/14