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.

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!

Worthy Words

Quotation Marks

I admit that I’m a sucker for a good quote. Truth be told, medicine is exactly the type of enterprise that needs quotes. It’s a basically noble endeavor that’s nevertheless rife with the sort of frustrations, obstacles, and everyday nonsense that tends to make us forget why we’re doing it.

Quotes help us remember. A few concise, perfect words from people smarter than us — they needn’t be real people, either, because sometimes fiction is more true than fact — can paint a picture that reminds us in a flash how to do this job, why we’re doing it, and to whom it matters.

To that end, we’ve set up a page to collect the best medicine-related quotes we can find (you can find it in the menu above as well). Some are about EMS, some aren’t, but if you’re on the job, I bet many of them will ring true. Take a look and check back when you can; we’ll try to keep adding the good stuff as we come across it.

Those who Save Lives: Harry Watts

Harry Watts

Who was Harry Watts?

You probably haven’t heard of him, unless you’re English — like he was — and you lived in the 19th century — like he did.

That’s because he was nobody special. He wasn’t a prince or a pope, he never invented a robot or discovered a mountain. Probably never even kicked a ball on television.

What did he do, then? He was born in Sunderland and lived poor. Poor as hell; no shoes poor, family-all-in-one-room poor. His father was a sailor. He had two sisters, and two brothers, one of whom drowned during a storm while Harry watched.

Starting work when he was young, Harry made his living first as a sailor, then as a rigger in the docks, and finally as a deep-water diver (the guys who wear big brass suits and suck air from a hose to the surface). He married and had two kids.

Oh, right. Also, all on his own, he saved the lives of 36 different people.

 

What, what?

While apprenticing on his first ship, he watched his fellow apprentice take a fall overboard. Harry’s automatic response was to dive in after him, pluck him up, and pull him to safety upon some floating timber. That was number one.

On his second voyage, he was waiting to receive the captain who was paddling back to the ship in a small canoe. He suddenly capsized, however, and was floundering in the waves. Harry grabbed a rope, swam out to the captain, and towed him back to the ship’s ladder. That was number two.

Number three was on the same voyage, when a boy was thrown into the water during a major storm, and the waters were too rough to lower a boat after him. Harry went in, and somehow, they both came out.

He rescued four and five on his next cruise — at the same time. So at the age of 19, he’d saved the lives of five human beings.

“Did you get any reward for these doings, Harry?” he was asked.

“Rewaard! Wey, sartinlees nut; nivver thowt o’ sich a thing. But we helped the two men wi’ dry claes an’ things.”

Indeed.

He got six more all together when an anchor line broke and dropped the anchor directly into a passing boat. There were six men aboard, and Harry went straight overboard while calling for help, landing directly on the wrecked boat in time to save them all.

Then one day at the dock, he saw a crowd gathering to watch a boy drowning in a rough sea. He leapt in, swam out to him, and brought the boy successfully back to shore on the verge of exhaustion.

At age 36, he made a career change from sailor to diver. At this point, he’d saved 17 people (plus one dog), most through risk to himself — sometimes grave. On one occasion he swallowed so much contaminated water from the Thames river (this during the cholera epidemic which had essentially turned it into a flowing sewer) that he was bed-bound for months and nearly died.

Many of those saved were sailors; many others were young children. And if you’ve never plunged twenty feet into rough water, wearing boots and heavy sailor’s clothing, and pulled out a panicked child (clinging like an octopus and trying hard to drown you)… well, you’re missing out. At this point, by the way, he had never received reward or recognition of any kind. As they say,

… There is a hackneyed platitude to the effect that virtue is its own reward, but it is safe to say that the average man does not find such a result sufficient. It might be so in an ideal world inhabited by ideal people, but in this work-a-day world, in addition to the approval of our conscience, we love to have the approval of our fellows and to know that our  acts are appreciated, and especially is this the case when we are actuated by altruistic motives. This is, of course, a form of vanity, but then vanity is almost a universal failing. [source]

But if Harry wanted applause, he certainly wasn’t clamoring for it. Just chugging along and saving lives as they presented themselves.

 

People take notice

Not long after that, he swam out to save two boys from drowning — while wearing one of his lead diving boots. (Yep.)

About a year later, he saved a couple more, and finally, there came the very first mention anyone had made of his efforts, a brief story in the newspaper:

Yesterday afternoon, about half-past three o’clock, a lad named Smith, about 16 years of age, son of an engineer employed on one of the Commissioners’ dredgers, narrowly escaped drowning. He was on board a dredger in the new Graving Dock, which was full of water, when he accidentally fell overboard. Mr. Harry Watts, in the employ of the Commissioners, gallantly jumped into the water and rescued him. The lad was very much exhausted, but restoratives were promptly used, and he was soon brought round. This is the twenty-second time that Watts has so nobly exerted himself in saving persons who have been in imminent danger of being drowned.

For a while, eyes turned away again. Then he hit number 25, and another story ran in the news, mentioning the man with “a perfect penchant for rescuing lives.” After that, people finally began to notice, and most of his saves received at least a little local attention.

He had countless saves while diving, such as the man who became tangled in a chain and was whipped overboard by a sinking weight — Harry dove in after and managed to free him underwater before they both drowned. Between rescues, he had plenty of interesting adventures, diving at the time being a trade full of explosives, accidents, and rockslides (he even had one memorable fight with a giant angler, or “devil fish,” which he ended up dispatching with a boat hook).

If that was his job, however, his hobby was volunteering with the Sunderland Lifeboat service; there was hardly a wreck nearby that Harry didn’t attend, they would say, and he was involved in rescuing over 120 sailors in extremis during storms. (Those don’t count on his score, of course, since they were team efforts. Just icing on the cake.)

He was 27, and up to 23 lives, when he received his first parchment award from the Royal Humane Society. A little while later when he ticked off number 25, they gave him their bronze medal as well, and when the local “Diamond Swimming Club and Humane Society” heard about that, they thought it just wasn’t cutting it, so they awarded him a gold medal of their own. The RHS gave him another parchment at number 26, and he continued to accumulate medals for his diving and rescue work — even one from the local temperance society for his good-natured efforts against the evil drink.

In fact, when he reached number 32, the local sailors (“gentlemen,” noted the newspaper, “because what constituted a gentleman was the performance of gentlemanly acts”) personally chipped in to cast him a silver medal in recognition of everything he’d done for them, despite the many years since Harry had personally sailed. Later, by widespread acclaim, his mayor wrote to the Queen to recommend Harry for the Albert Medal. Due to bureaucracy or who knows why, nothing came of the request.

An unfortunate turn came when Harry loaned his medals to the local church for an exhibition, and as night rolled around, the entire set was stolen by an unknown burglar. Harry was crushed, and the town of Sunderland felt it a slur on their name; the burglar was caught before long, but the medals were melted and gone. A popular movement arose, and within weeks they had struck replacements for the lot, and they returned them with dignity at a town ceremony. There, the thief himself expressed remorse, saying he wished he were drowned; Harry replied, “Mister, if ye were droonin’ aw’d pull ye oot bi th’ neck!”, and refused to press charges against the man.

He was 51 when he was approached to dive 150 deep to effect a mechanical repair. He was a little past such stunts for pay, he said, although of course he’d do so to save a fellow man, and he recommended some others who were younger and more willing. Their diver went down, and contact was soon lost; they returned to Harry and asked him to live up to his words, as nobody else was willing to go down to attempt a rescue.

He suited up and dived. The working depth was perhaps 120 feet, but it was upon a tiny platform across a bored-out shaft which continued another 300 feet past that; anybody who slipped was going a long way down until they looked like a recycled soda can. Feeling around, he located the other diver, who was dead (fainted, probably, then asphyxiated). He resurfaced, reported the news, then dived again to retrieve the body.

At the ripe age of 52, Harry was one of the divers who volunteered to recover bodies after the Tay Bridge disaster. He offered his services for no charge; when the diving commission attempted to pay him afterwards anyway (maybe because he was a million years old and a living legend), he politely refused and asked it be passed to a charity of their choice. (The man got around; somehow he was on hand at the Victoria Hall disaster as well, and widely applauded for his assistance in the aftermath.)

But never mind all that. His last life was saved at age 66. He and his wife were walking along the docks toward their home when he heard the cries of a drowning boy. His wife begged him not to, but he went; relenting, she cried, “Be quick, Harry!” and in he dove. Grab hold, haul over to a rope, out they came.

Thirty six lives. Not bad for a poor old seaman.

 

Harry finally rests

When he was 70, Harry retired at last. And although many people didn’t realize it, his wallet was thin; the diving commission didn’t offer a pension, and he’d quietly turned down others from grateful benefactors. That’s how things were when Andrew Carnegie passed through Sunderland to open a library.

Visiting the local museum, Carnegie saw an exhibit of Harry’s medals and asked after the man, now 84 and still full of vim. Surely he must be a war hero of some kind?

Nope. Just a life saver. When he learned who he was dealing with, and had the pleasure of shaking his hand, Carnegie inducted him into his Hero Fund on the spot.

At long last, Harry Watts no longer had to worry.

In Carnegie’s words,

I have to-day been introduced to a man who has, I think, the most ideal character of any man living on the face of the earth. I have shaken hands with a man who has saved thirty-six lives. Among the distinguished men whose names the Mayor has recited, you should never let the memory of this Sunderland man die. Compared with his acts, military glory sinks into nothing. The hero who kills men is the hero of barbarism; the hero of civilisation saves the lives of his fellows.

At the age of 85, Harry’s town of Sunderland was worried that after his death, such a remarkable, yet humble man might be forgotten in the distance and darkness of history. In response, the mayor and several of the town’s luminaries commissioned a biography to be written about his life. You can read it here, and much of this story came from it.

Not a bad goal. Live your life so that when you’re old, someone will insist on writing a book in your honor.

In their words,

The modest merits of this good citizen may, so far as the public are concerned, be summed up in the simple statement that he has saved upwards of 30 lives from drowning. When we consider what are the awards usually apportioned by mankind to the destroyers of their species, the presentation of a gold watch and chain, accompanied by a framed parchment from the Royal Humane Society, in the precincts of a disused School Room, must appear an inadequate acknowledgment of services so signal. But we are new at the business and shall improve as we go forward.

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?