Unique, Just Like Everyone Else

December 5, 2011 by 1 Comment

A few years back, a video of a lecture by Carnegie Mellon professor Randy Pausch made the YouTube rounds, becoming enormously popular; you’ve probably seen it. He later wrote a book discussing and unpacking many of the points he brought up in the lecture. If you haven’t watched or read them, I highly recommend both.

In any case, in the book Pausch describes the birth of his first child, how a complicated birth (a placental abruption) forced him to rush his wife to the Magee-Womens Hospital at the University of Pittsburgh Medical Center, and how his newborn child was brought into their neonatal ICU. He writes,

At Magee, they did a wonderful job of simultaneously communicating two dissonant things. In so many words, they told parents that 1) Your child is special and we understand that his medical needs are unique, and 2) Don’t worry, we’ve had a million babies like yours come through here. (91–92)

This is an elegant account of the demeanor we should all be trying to strike with the families of patients, and indeed with our patients themselves.

Many beginning providers, understandably unsure, will approach each patient like an antique porcelain vase: precious, delicate, and prone to breakage. This is the right attitude as far as priorities — we should take our care seriously — but that doubt is communicated in our body language and tone, and it’s not what sick and scared people want to hear. Imagine being the patient whose doctor says, “Man, look at that! I’ve never seen anything like that! Can we publish you?” or “Okay, I’m not going to lie, I’ve never done this in my life. But I did stay at a Holiday Inn Express last night…”

On the other hand, it can be very few moons indeed until you’re a “veteran” in the worst sense of the word, dragging your technically skilled but burned-out husk from patient to patient, seeing nothing but a stack of paperwork and a routine litany of tests and treatments. Her? Oh, just another abominal pain. Yawn. Her name? Search me. Is it lunchtime yet?

See, people want to be treated like people, and people are unique, precious (at least in their own eyes), scared, and need to be engaged with on the same human level as when you say “thank you” to your barista or read a bedtime story to your son. But people are also machines, and the trick to fixing broken machines is to fix a lot of them, and treat them all the same. We need to be able to reconcile these paired, antagonistic traits, because otherwise we can’t do what they called us to do. It’s not a matter of nailing one goal but missing the other: you miss both. You can’t reassure anyone if you don’t competently address their actual problem, and you can’t practice sound medicine if you don’t engage with patients as people.

That’s the trick that the obstetrics and neonatal teams at Magee pulled off, and it’s all the more important for us, who have to approach patients without the comforting backdrop (that is, comforting to them and to us) of a bright beeping hospital. It’s the trick of quiet confidence, of demonstrating without words that you know exactly what you’re doing, that you bring tremendous skill and experience to the table — but that those tools are being brought to bear for your patient, for the scared individual you’re kneeling beside. The “all the kings horses” response by fire and EMS, the loud and alarming transport to the hospital, the wires and tubes and countless gloved hands — it’s overwhelming and frightening if you’re thrown into it as an unknown environment, but if you understand that it’s all being done for you, then it’s comforting. It’s like calling for help and getting the Wolf. That’s exactly what you wanted in your time of need.

You may not want to date a cocky lawyer. But he’s the one you’d want at trial.

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Oldest Trick in the Book

November 30, 2011 by 12 Comments

 

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.

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The “Big Picture” Diagnosis

November 26, 2011 by 1 Comment

Our topic for today: diagnosis using a broad constellation of indicators, not a single red flag.

To mix things up, rather than read about it, let’s talk about it.

Here’s the quote I mentioned, from TOTWTYTR at the CCC blog.

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Russ Reina: Moments in the Death of a Flesh Mechanic

November 18, 2011 by 5 Comments

Russ Reina runs one of my “sister blogs” on the EMS Blogs network, EMS Outside Agitator. Although no longer working in EMS, he spent over a decade as a medic, way back in ’70s when the paramedic concept was first being introduced in the US; he later became involved with various other things including writing a film, working with Native American healing arts, and a book — Moments in the Death of a Flesh Mechanic: a Healer’s Rebirth. More recently he’s become active in the online EMS community via his blog, forums (he’s a moderator over at EMTLife.com), and similar venues.

Some time ago, Russ sent me a free copy of his book in exchange for my honest review. I read it, and enjoyed it, but it’s been sitting on my shelf since, because I haven’t been sure what to say about it.

To start with, let’s mention the elephant in the room. The stuff Russ talks about makes people uncomfortable. To be sure, he’s walked the walk, spending more hours on the road than many of us, and doing it in a time and place where that meant wielding tremendous responsibility in patient care. It’s hard to argue that he was a skilled and competent medic in his day, the kind of guy you’d be glad to have on scene or sitting beside you in the cab. But since then, he’s gone down a different road, and done a lot of… other stuff.

Tending fires in sweatlodges. Reiki. Personal growth and healing. If you click through his personal website, your first reaction is probably “… huh.” For the typical EMSer this is not really our wheelhouse, and at best, it places Russ firmly in the realm of alternative viewpoints. At worst it puts him in the same cart as the other EMS goofballs who do their job but are universally considered space cadets. (Admittedly this is a large cart, but still, it’s not great company.)

I confess that I share some of this attitude. I’m a simple, concrete guy at heart. But I also think that the things Russ talks about, and forces us to think about, are important — and that the reason we’re uncomfortable with them is the reason that we need to have that conversation.

The basic aim of his book is to weave together the calls he ran, the patients he sat beside, the lives and the deaths he saw, and look for the common threads. Not in the patients, but in him. As a paramedic, what was his role? When you take a step back from this job, when you stop for a moment and consider what it’s all about, what’s really going on?

If we’re diligent, and competent providers, we spend a great deal of time trying to improve the quality of our work: our knowledge base, our hands-on skills, our understanding of medicine and the human body — the how. But very little attention is ever given to the why. Why do we do this? It’s easy to be cynical — “well, the schedules are good, you get to cut people’s clothes off, and I was too dumb for anything else.” We’re professional cynics, and the job tends to beat the mushy stuff out of us. But although we rarely admit it, most of us did choose this job for real, human reasons. Something about helping people.

So we show up at the door wanting to help people. Then, usually a couple years later, most of us leave EMS to become nurses or electricians or vacuum cleaner repairmen. What happened between point A and point B?

You can call it burn-out, you can call it low morale. You can blame low pay and a “revolving door” culture and a million other things, most of which are valid and true. But the fact remains that even though people are coming to EMS with the right intentions, most of them aren’t surviving here for long, and of the ones who do stick around, many are empty shells, long since stripped of any human connection they once sought. This is an ill system. It’s not dying, we’re not end-stage, but we are not healthy or happy: the methods, mindsets, attitudes, and overall “immune system” necessary to keep us all going, to maintain our ideal homeostasis, is missing. Individually and collectively, as time passes we move down rather than up. Some rare individuals do find solid grounding and manage to put in 20 years as fully-functional people as well as caregivers, but they are the exception, and they do it by developing these tools on their own.

It’s not about competence. Many of our “walking wounded” are competent clinicians, adequate or even excellent technicians. Russ calls them flesh mechanics. We master the skills of of patching holes, adjusting rhythms, replacing fluids, and generally repairing the broken parts of the human body, all without ever acknowledging the people inside those bodies. To some extent, of course, this is an essential part of the job — it’s the M in EMS, it’s why we’re called to the scene. We ought to try and be excellent mechanics so we can save the most lives and mend the most harm. But this whole process is entirely separate and distinct from the motivations that brought us to the job to begin with. There’s a fundamental difference between tending to a car and tending to a person, and when we successfully manage to eradicate the human element, we quickly find ourselves unsatisfied and burned-out with our work. (It’s not like we’re getting rich doing it, or otherwise being externally rewarded.) Russ’s own journey of transitioning from a pure flesh mechanic back into someone who worked with people is the focus of his book.

Why do we do it? There are dozens of reasons you might pick. Some folks like to work and play at the boundaries, the liminal spaces between life and death. Some just really like meeting the people. Some, like Russ, have a more spiritual approach. Some find meaning from the teachings of traditional religion.

As for myself, I hate death, and suffering, and I want to guard people from it. And I think that I probably get an ego boost from fighting for the weak, and certainly from uncovering an interesting diagnosis. But most of all — and it’s the mindset I advocate for on this site — I simply adopt a deontological outlook: I believe that when we take a patient into our care, we assume a duty to do everything possible on their behalf. Not the duty to weigh the pros and cons, not to judge their need or worthiness, but simply to do it. Everyone deserves at least that.

But you might disagree. And that’s the key: many of us will disagree on how to handle the “why.” Unquestionably, I disagree with many of Russ’s views, or simply find them alien. However, I still think that it’s absolutely essential that we each find some meaning. There must be some human purpose to our work or we will not be happy, and eventually, we will not do it anymore. That’s the secret that Russ was able to uncover after enough years on the job and enough years away from it. Dozens of answers to the question are acceptable, but we at least have to ask the question; we do have to think about these things and not brush them aside. We have to operate on this level or we will not survive in the long run. Spirituality may or may not underly EMS as you understand it. But people — not just patients, not just broken machines — are unavoidably central to practicing medicine. You can do the job without that human connection, without the “why,” but it’s like showering with your raincoat on. You can’t feel it, and you won’t do a good job, and eventually you’ll give up and stop trying.

So to make a long story short, I think the task Russ has undertaken as an “agitator” is a tough one, and he won’t win many fans. Although he often clashes with the Rogue Medic, their jobs are not dissimilar; one is an continual gadfly working to force us toward better evidence-based medicine, and the other is a continual gadfly working to force us toward a healthier understanding of our job. I wouldn’t want to be either one. But I’m glad they’re here, because I also don’t want to watch good people being wasted in the cauldron of cynicism and pointlessness that is much of EMS today.

In any case, I do recommend his book. It’s an enjoyable read, well-written, with plenty of the entertaining stories that all veteran medics collect and that make the best EMS blogs and literature such good reads. It’s also a rare view of the early, Johnny-and-Roy days of paramedicine, and it’s fascinating to see what’s changed over the years and what hasn’t.

But mostly, I think it’s worth reading because Russ’s crusade really does have a vital purpose. If I have a quibble, other than the fact that his unorthodox background may turn many readers away from his message (although fairly little of that is present in the book), it’s that despite raising awareness to the problem, Russ is relatively silent as its to solutions. Of course, this may be the nature of the beast, where each of us needs to find his own answers. But on the large scale, I doubt the endemic disease of EMS will be cured in this way.

We can try, though. Let’s try.

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Decision Fatigue and Good Habits

September 19, 2011 by 6 Comments

Editor’s note: this post was eventually expanded into a cover feature in the May 2012 edition of EMS World.

There’s a concept from psychology that’s recently made the jump to the world of popular science (that misty realm ruled over by a benevolent Malcolm Gladwell; Bill Nye is his jester) known as decision fatigue.

The idea is that human beings have a limited reserve of willpower. Willpower isn’t a physical substance, something stored in a sac in your abdomen, but nevertheless it’s a real quantity. Every time you’re forced to make a decision, especially important or consequential decisions, it drains a little of this resource. Certain restorative acts, like sleep or eating, can help restore it. But if you start running low, then you start losing the ability to make weighty or difficult choices — you tend to pick the easy option, the default answer, the path of least resistance. Rather than the big picture, the long term, you start seeing only the immediate payoff. That little mental push that lets you do the right thing… well, if you spend all day pushing, by 9:00 PM you just might be out of push.

This phenomenon may ring intuitively true, but understand that it’s not horoscopes or tarot cards — this is a real behavior exhibited by all or most people. This is something you do right now, whether it’s obvious or not.

And this is very pertinent to those of us in EMS. Due to the nature of our work, we carry an unusually large burden of decisions. For the level of training and experience our job requires, we are granted a great deal of independent responsibility; in other industries, we would be working with a supervisor over our shoulder, a hands-on boss ensuring that we toe the line. Not so on the ambulance; we perform our duties on the road, alongside one partner, and typically have no direct oversight for the vast majority of our day. If you mess up badly enough, you’ll hear about it later; but to quote the luminary Peter Gibbons, “that will only make someone work just hard enough not to get fired.” We all know a few EMTs and paramedics who have learned all the hot spots, the danger zones, know exactly what they need to do (and what to avoid) in order to stay under the radar — and as long as they dance those steps, they can otherwise do, or skip doing, whatever the heck they want.

The point is, in this job you can do everything right. . . but only if you decide to.

Many of our decisions are small. When it comes down to it, even Old Man Lazybones, the 400-year-old medic who only wakes up to punch out and sometimes eat animal crackers, will generally mobilize for the cardiac arrest and the multiple stabbing. That stuff comes packaged with motivation. But what about all the little things in between? Do you change the stretcher linen between calls, or leave it? Do you sanitize that blood pressure cuff after using it on your “recent VRE” patient? Are you professional, caring, and thorough in your patient interviews, or are you starting to lapse into taxi driver mode? Do you document thoroughly, or cut a few corners? Is everything on the truck restocked for the next crew, or are you out the door? And so on, and so forth. There’s doing your very best, there’s just barely “not getting fired,” and there are many points in between, but no doubt, each time you’ll have to decide where you fall.

It’s tempting to say that what matters is simply the kind of person you are. The “good” EMT, the true professional, that guy will do the right thing. He’ll make the right choices. And the slacker, the hack, he’ll blow it off. And maybe that’s often true.

But the lesson of decision fatigue is that none of us is a saint, or an infallible machine. Every time we make one of those little decisions, every time we exert ourselves to do the right thing, we use up a little bit of our motivation. And after 8 hours, 12, 24 hours, five calls, ten calls, you’re going to start scraping the bottom of that well. The good medic will last longer, the hack won’t make it past lunchtime, but eventually, everyone starts cutting corners. Be honest with yourself, and you’ll see that it’s true. You can care, and you do care, but at some point, you’ll stop caring quite so much. In the long-term, we call it burnout, but in the short term we just call it “time to go home.”

One of the valuable observations from the research on decision fatigue is how the most successful subjects tended to cope with it. By and large, those with the best self-control didn’t survive by being the most stoic, just standing there and weathering a stream of decisions that would shake the best of us. Instead, what they did was set up their lives to minimize the drains on their self-control. They recognized that if they have to spend all day consciously choosing to do the right thing, eventually they’re going to start slacking. So whenever possible, they arrange their circumstances so that no decision needs to be made. When they grocery shop, they don’t just “buy what looks good,” because that’s a constant barrage of “cookies or carrots?” They go in with a list, and they buy what’s on the list, and that leaves no decisions to be made. And then, on the way home when they have to decide whether to yield for the slow-walking granny in the crosswalk, they aren’t already worn out from the battle of the cookies.

Good habits. Good habits will save us.

You can’t go through your shift constantly deciding to do the right thing. But you can create good habits, wherein you do the right thing automatically. This may sound like you’re creating work for yourself, but in fact it’s the opposite. “Work” is choosing to do it. Habits just happens. Waking up, brushing your teeth, driving to work, you don’t complain about having to do these, you just do ’em; they’re things you do, not things you decide to do. If every time you drop off a patient, you change the linen, then this stops being an “issue”; it’s just part of the call, part of your routine.

Setting up habits takes work, but maintaining them takes none, and you’ll quickly find that the type of EMT you are is defined by your habits as much as your decisions. Although I’m a huge proponent of good judgment, critical thinking, and wide leeway for field providers to make good decisions, the truth is that much of our work is routine. And the more of your routine you can manage by habit, the more willpower you free up for the tougher stuff. This doesn’t tie you down. It liberates you to think bigger, and aim higher.

Filed Under: Principles
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