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

The 10 Easiest Ways to Violate HIPAA

  1. Leave paperwork face-up on the dashboard or front seat.
  2. Leave your computer unsecured wherever the hell you please.
  3. Tweet a picture of the badass MVA you just did, with a victim obviously identifiable to anybody who reads the news (“A car struck a tree on Route 421 today, driver Jim Smith was rushed to the hospital…”).
  4. Tell everybody about the celebrity you just transported.
  5. Tell everybody about the coworker you just transported.
  6. Crack jokes and make comments about the patient you just dropped off while in the elevator, or in the public ambulance bay outside — usually while the patient’s family is eavesdropping.
  7. Post a Facebook status about the crazy shooting you ran, sharing intimate details about the patient who was probably the only person shot in your town that day.
  8. Leave paperwork in the truck at end-of-shift.
  9. Let a facesheet (demographics page) escape into the wind as you fruitlessly chase it down the street.
  10. Answering curious questions about the patient’s status or destination from the random person on scene, I’m not sure who that is, probably just the nosy guy who lives downstairs.

The Laws of EMS

One more post about glucometry is pending, but for now, something lighter.

Decades of medical interns have been raised on the Laws of the House of God. The House of God was a cynical and dark look into the world of modern medicine, and its “Laws” were about as uplifting as condensed soup, but they rang true enough that you’ll still hear them quoted in the halls of medicine today (including those of the real-life “House of God,” where I find myself more shifts than not).

In any case, laws come in handy. Although I’m a believer in the nuanced and detailed analysis, as I age and my neurons gradually turn to cotton candy, I increasingly see the value in basic rules of thumb to guide us through the tangled web of life, and especially of this job.

A good law is simple. It’s always true, or almost always, and the exceptions prove the rule. It’s not specific to a certain region or company, but is something you can keep under your hat and carry with you throughout your career. It’s clear and it say something fundamental about the kind of provider you want to be. But most of all, a good law is not just an empty platitude, but rather an actionable guide-post that can answer real questions in real situations. When times are hard or temptations loom, it’ll tell you what to do.

With no further ado, then, here are mine. I believe in them, I follow them, and like good unguent, I wholeheartedly prescribe them for universal application. I am not wise, but whenever I do a good job of faking it, it’s by following these principles.

 

THE LAWS OF EMS

  1. Help your patient in any way you can.
  2. Be nice to everybody. It’s your job.
  3. If you can’t save their life, make their day a little better.
  4. Protect your partner.
  5. Have a reason for everything you do.
  6. Leave the patient better off than when they met you.
  7. It should get calmer when you show up.
  8. Good habits make doing the right thing easy.
  9. Tomorrow, nothing will remain but your documentation.
  10. Everything’s a bigger deal to the person on the stretcher.

 

But that’s just me. What laws do you believe in?

Editor’s note: this post was expanded into a feature piece for EMS World Magazine in the March 2014 issue.

Because it’s Cold Out There

http://www.youtube.com/watch?v=3pO2mdVpN20

We rarely think about it. If we did, we’d probably lose our marbles.

But it’s true.

The universe doesn’t care.

We are born, we live for a little while, and eventually, we die. In the duration, we will have hopes and fears, passions, desires, successes and defeats, joy and pain. The whole gamut is out there. And as a rule, the inexorable pull of the world is downward — into darkness, into chaos. Scientists call it entropy. We just call it life.

But it means that at any given moment, if we want to be happy — comfortable, fulfilled, free from suffering — we have to be waging a constant battle. If we ever stop paddling, we start to sink.

There’s a certain point in your youth (maybe this is the moment that you become an adult) when you realize this battle is nobody’s but your own. When you’re a child, your parents agree to fight in your ranks until you can walk and talk and drive a car. But once you step out onto the world stage, the only one wearing your colors is you. As self-centered people, we find this hard to believe; we feel like we’re important players in the grand scheme. But the truth is that although everybody else feels the same way about themselves, they certainly don’t feel the same way about you.

Nobody cares about your problems like you do. Not even remotely close. They’re busy with their own battles, which are just as burdensome to them as yours to you. So we learn that if we want to solve our problems, change our circumstances, or just keep from backsliding in the constant undertow of life, we’re on our own. The tools we bring to the table are the only ones available, and our to-do list has only our name at the top. There is no oversight, unless we have strong religious views; no referee ensures that the dice land fair; and if the game proves too difficult, we don’t get to quit and try another.

Isn’t this horrible?

Of course it’s horrible. What could be more horrible than to be utterly alone in an uncaring universe?

So we try to build ties. From the little twirling piece of driftwood we’re clinging to, we throw out ropes to the other flotsam and jetsam. We bring them close and tie knots in the hope of building a raft that can stay afloat during the next storm. Maybe this way, we think, if I capsize, someone will pull me back in.

This is hard work, though. Because our own problems are bad enough, and to tie ourself to someone else means we’re taking on some of theirs, too. It means when they get hit, it’s our job to try and keep them afloat. That’s a lot of responsibility, and our plate was already full to begin with. (Everybody’s plate is full, no matter how big it may look from the outside.) So at the best, we only make a few really strong ties.

Oh, we might have a lot of weak ones. Folks we know, and who will occasionally drift by to exchange favors or chat. Maybe a group that we’ll cruise with for a while. But make no mistake: they might be floating alongside us, but they haven’t tied any knots in that rope. If you start to founder, the best you can hope for is a little sympathy as they sail on ahead, and maybe toss you a spare life preserver. It’s not their problem.

The ones who really throw in their lot with you — who say that in thick or thin, in sickness or health, they’ll be at your side, fighting to keep you afloat — they’re few and far between. Maybe a little family, one or two close friends. A significant other. That’s all.

 

What do you think happens when you get older?

If you have the good fortune to live to a very old age, then a lot of things will change. Life is not going to suddenly become easy; if anything, it will become harder. And where are those ties you’ve built?

Dead. Moved away. No longer capable of anything more than clinging to life.

The luckiest among us will make it to the very last pages of life with our partners-in-crime still at our side. The spouse of fifty years, the close and loving family, the lifelong friend. But for most of us, these lifelines are lost over the years, one by one. And eventually, we may have nobody. Nobody to fight for us, to love us, or even to note our passing.

 

The next time you transport the 80-year-old man with dementia, who never seems happy and complains about everything –

The next time you’re called to the home of the little old lady with toe pain, whose husband died recently after a lifetime spent together –

The next time you pick up the same homeless man from under the bridge, drunk once again –

Try to imagine what it would be like to be truly alone.

Nobody to lean on. Nobody to throw you a rope when you start to founder. Most of all, nobody who gives a damn you exist. Imagine what it would be like to know that you could walk into the sea tomorrow and nobody would even know you’d died — let alone that you’d lived.

We can’t be everything for these people. But one day, hopefully not soon, you might just find that you’ve become one of them. So do what you can, knowing that nobody else is likely to. Knowing that, even when it has little effect, the difference between having somebody to fire a few shots for you, and having nobody — can be all the difference in the world.

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.