Toastmasters for Trauma Patients

Almost everybody in healthcare has to occasionally deliver verbal reports to their colleagues or counterparts, and almost everybody starts out bad at it. It’s a weird skill and one that takes practice, even though all you’re doing is describing what the deal is with a certain sick person.

Here’s a little walk-through discussing one important aspect of a good verbal report — a clear, coherent structure of tone, cadence, and body language that gives your words “shape.” You shouldn’t sound like a robot, because robots are hard to understand. Be Martin Luther King Jr; that’s a man who knew how to make himself heard.

We’ll be practicing with the hand-off report Sam gave to University Hospital on the Mystic St and Beverly Rd call.

Somebody Should be Upset

Dog at grave

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:

  1. Good caregivers must demonstrate empathy and compassion for the suffering of their patients.
  2. 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?

Some Things to Say (part 3)

Thesaurus

Becoming smarter is always a smart idea. But after they boot you out of EMT class, not only do you still need to learn a few textbooks-worth of medicine before you’re a semi-competent provider, you also need to acquire a more mundane body of knowledge: how to sound like you’re competent.

You’ll be talking to other prehospital personnel, to nurses, to doctors, and to CNAs and LPNs; you’ll be writing out copious documentation; and of course you’ll be asking questions of patients themselves. And it’s one thing to know what you’re talking about, but it’s quite another to express it without sounding like a knob. Unfortunately, some things are just hard to say concisely and cleverly. More importantly, for some things there’s simply one right way to say it, and anything else isn’t really accurate. The world of medicine has come up with conventional phrases to describe most of these, but you need to learn them before you can use ‘em. It’s one of those subtle skills you develop as your experience grows.

Of course, providing shortcuts to experience is why we’re here. So here are a few terms that will make you sound a little more intelligent the next time you’re giving a report or writing a narrative.

 

Don’t say…

Pooping

Say…

Moving his bowels, having a bowel movement

“Have you been moving your bowels lately, Mr. McGillicuddy?”

 

Don’t say…

Peeing

Say…

Urinating, making urine

“She just started dialysis recently, but she does still make a small amount of urine.”

 

Don’t say…

Normal

Say…

Unremarkable

“Her vitals and physical exam are unremarkable.”

 

Don’t say…

It’s totally there, dude

Say…

Present, apparent, visible, palpable, appreciable

“A Foley catheter is present, and a 2cm hematoma is visible on the dorsum of the left hand. No other trauma is apparent. Breath sounds are appreciable bilaterally.”

 

Don’t say…

… and there’s tons of it.

Say…

Profound

“She reports profound vertigo elicited by any movement of the head.”

 

Don’t say…

CSM is totally good bro

Say…

Peripheral circulation and neuro function intact

“Does he have any neuro deficits?”

 

Don’t say…

Basically he seems okay

Say…

Stable, intact, atraumatic, without abnormality

“He appears grossly atraumatic, with no apparent injury to the head, and the neck and back are stable and non-tender.”

 

Don’t say…

You can hear it from Cincinatti

Say…

Audible from the bedside

“Coarse, biphasic crackles are audible from the bedside, and present in all fields upon auscultation.”

 

Don’t say…

We didn’t look too hard

Say…

Readily, grossly, obviously, generally, frankly

“He appears generally well, without obvious injury or gross neuro deficit. Radial pulses are not readily obtainable. No frank bleeding from the site.”

 

Don’t say…

Chow situation

Say…

Oral intake

“He has had minimal oral intake over the past three days”

 

Don’t say…

Pushes his feet

Say…

Plantarflex

“Equal strength bilaterally in grip and plantarflexion.”

 

Don’t say…

Shows

Say…

Demonstrates

“He demonstrates no speech slurring or pronator drift, but there is a mild left-sided facial droop at rest.”

 

Don’t say…

Eventually opened his eyes after we beat the shit out of him

Say…

Difficult to rouse

“He is found in bed, eyes closed and semi-Fowler’s. He rouses with difficulty to verbal stimulus, but repeatedly lapses back to sleep without ongoing stimulation.”

 

Don’t say…

AOx4

Say…

Describe it!

“He presents as alert, in no apparent distress, generally oriented with some confusion; he is conversational and aware of his circumstances, but is unsure of the date and demonstrates poor short-term recall.”

 

Don’t say…

Walks like a drunk

Say…

Ataxic

“He demonstrates slurred speech, generalized ataxia, and a sweet odor is detectable in his breath.”

 

Don’t say…

Pissed himself and shit everywhere

Say…

Voided, incontinent of bowel or bladder

“He’s incontinent of both bowel and bladder, and he did void his bladder en route.”

 

Don’t say…

“ehn rowt”

Say…

“on root”

En route is from the French, and it’s pronounced ‘on root.’ Saying ‘ehn rowt’ is some weird faux-accented hyper-compensation that the public safety world has all started doing, but that doesn’t make it right.”

 

Don’t say…

Agrees only after we asked about it

Say…

Endorses

“He denies pain of any kind, but does endorse mild tightness and discomfort in the left shoulder.”

 

Don’t say…

Sniffles and other cold-like symptoms

Say…

Coryzal symptoms

“He notes a headache and coryzal symptoms for the past two days, and nausea beginning today.”

 

Don’t say…

General systemic symptoms preceeding a seizure, syncope, etc

Say…

Prodrome

“He denies prodromal symptoms preceeding the fall, and bystanders observed no apparent loss of consciousness.”

 

Don’t say…

Without torture

Say…

Easily, freely

“He ambulates easily, and freely rotates his head past 45 degrees without pain.”

 

Well, that’s what I’ve got. Toss ‘em into your toolbox and use whatever works for you. Anybody else have some useful words to share?

More things to say in part 2

Glass Houses: Suicide in Both Seats

suicide

 

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:

  1. Those who feel alone, that they don’t belong anywhere
  2. Those who feel like a burden to others
  3. 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.

 

Further reading

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.