Go and See

I recall a story from the New York Times, Health Section not terribly long ago that struck me as ironic and cheesy; but, it had a point, though not one made by the article's author. The writer's point seemingly highlights the beneficence of physicians roused from sleep on an airplane by the fabled "is there a doctor on board?" announcement. How noble. As an interesting aside, it's not unreasonable for the airlines to rely on such an announcement either. The flight crew is trained in basic first aid and CPR, then told to ask exactly that question. As some research has indicated, at least one doctor is on board somewhere between half and 90% of all flights.

The article lands itself column [and server] space because of how "heroic" it must be for a doctor to act outside of the sterile, white-walled, safe environment of an official exam room or hospital ward. Images of ballpoint pens stabbed into the neck come to mind. (I hear it works.) Ironically, the figurative ballpoint-pen-to-the-neck is exactly what EMS professionals are asked to do every day. The gift of it is not the part that they get paid to do (though some also volunteer)--i.e. respond when called, and help--but it's what they get to witness every day; and, where they get to witness it.

Back on Manhattan's Upper East Side, the mantra (at my high school) was consistent, if nothing else. "You have to meet them where they are..." the chat would always begin. The Jesuits are big on being a "man for others," but not on your own terms. A person-in-need's true problems don't exist in a vacuum, or in the gym of a high school, or policy-making war room. You can't honestly discuss someone's troubles or passions from opposite sides of the serving table in a soup kitchen line. You could undoubtedly pontificate about them. Certainly, though, you could never understand them without experiencing them. After a recent visit back to Regis started the wheels turning about memorable classes. "CSPI," Mr. DiMichele's senior elective on contemporary social and political issues, had one read called Nickel and Dimed, an investigative narrative by Barbara Ehrenreich chronicling her attempt to understand what it was truly like to be poor, working manually taxing jobs for little pay, struggling to make rent, and choosing between necessities. I don't plan to summarize the book. Suffice to to say: she gets it. If anyone is to effect change, they have to meet the problems where they are, "get it," and understand how they can be practically addressed.

Ehrenreich literally completes the storied "mile in someone else's shoes." In grad school, when introduced to the concepts of Lean process improvement, step one sounded shockingly familiar. "You won't get it, or know what you're supposed to get, until you go to where they are." Or as the Toyota process improvement model more simply puts it, "go and see." It strikes me, this is what is great about EMS; more specifically, what I have been struggling to put my finger on, struggling to craft into words, to explain why I value my ten years on ambulances so much. How it is that you--so quickly--get remarkably close to people that you spend 8, 12, 16, 24 hours within four feet of each other.

We get to go and see.

Doctors--or to speak for myself, med students--are trained in silos. Schools across the country have made small efforts, and increasingly so, to develop a better teamwork approach. This will somehow get us to, theoretically, better understand the tiers of people responsible for the care of any one patient. I'm skeptical. I see how my classmates react to "nurses' mistakes" in videos for some team-based exercise. I watched as residents degraded nurses and techs I worked with everyday in Pittsburgh. I, and my EMS partners, have been spoken to as though we were twelve years old. It's an interesting dynamic how we treat each other. It's a dynamic I have blogged about extensively, and a dynamic I hope to spend my career helping to correct.

The next step, then, is to realize how that passes through to the people we care for. It is hard to understand someone's life, someone's illness, and someone's experiences when the only time you get to encounter them is among four white walls, fluorescent lighting, and a sterile environment. Optimistically, some medical schools, such as the newly formed Hofstra North Shore-LIJ Medical School have taken some steps to change that. First year medical students at Hofstra, those traditionally spending the majority of their time in classroom settings rather than clinical ones, are required to participate in a buffed-up EMT course as a part of their initial training. I am, as you may imagine, a huge advocate for this program, but not for the reasons you may imagine. It turns out, this happens to be the same reason I think the article from the NYT/Health I opened this post with has some dramatic and creative thinking value. This program doesn't just help new medical students tackle basic physical exam and history taking. It doesn't just help new healthcare providers (just like their colleagues in EMS) experience asking difficult questions and physically touching other people. It doesn't just help new caregivers work with a vulnerable person who has called for help, perhaps at the most difficult moment of their entire life.

It helps them go and see.

It turns out people's lives don't exist in a four-white-walled sterile room. Their problems began long before they typically see the doctor. Their lives became complicated and their pathology developed because of where they live, and how they live, not why they made a clinic appointment. Hofstra medical students get to go and see the lives I have had the chance to witness in my ten years of doing EMS in five states and systems from the slow rural to the busy city. I've watched asthma patients gasp for air, as they try to convince me--in one-to-two word phrases--why their air conditioning can't be on (they can't afford it) during a hot, humid July afternoon. I've explained the value of peanut butter and jelly sandwiches to diabetic patients who can't afford a diet that will prevent them from calling the ambulance again soon--a diet that will prevent them from going blind, losing their legs, or having a fatal heart attack. I've felt the shriek of a mother who just lost a child. I've transported the same seizure patient every week because he can't afford his medication (and when he can, splits it with his friend, who also has seizures). I've been in the back of the ambulance with victims of hate, illegal weapons, legal weapons, accidents, domestic violence, mental illness, suicide, addiction, and a system that may have determined their destiny long before they had a chance to do anything about it. You can read plenty of statistics and anecdotes about "when people say they're going to die, they probably will." Then you hear it: "make sure you tell my kids I love them." (The worst kind of patient death is the one where you spoke to a patient moments earlier.) Just a few weeks ago I watched a nun die alone (but for my ambulance crew and the doctors and nurses at the hospital), her closest family was several states away--and they wouldn't be coming. These experiences shape my attitude, my life, and my politics. They shape who I am, how I think, and how I approach every patient that comes next. Beyond that, they form my ability to think critically, broaden my life experiences, and help me make decisions in my personal affairs. They're invaluable, often inexplicable, and certainly irreplaceable. 

Plenty of medical schools provide experiences in "the real world" working "with the community" we serve. In fairness, I should mention that here at Tulane medical students operate a dozen or so free clinics around the City of New Orleans. Most other medical schools operate some form of a free clinic for people who would otherwise be dejected by the healthcare system our country's policymakers fight so passionately about. I have already had some unique experiences at these clinics (several of which are at homeless shelters, substance abuse rehab facilities, and certainly in less fortunate neighborhoods) and enjoy talking to the patients even though they tend to be surrounded by four white walls. My ability to "talk-the-talk" with many of them, though, is no accident.

Every day EMS providers make a difference. Every day EMS providers are subject to abuse, tough patients, tough scenes, and complicated scenarios. Many calls are routine, others emotionally and physically taxing. Indeed a good EMT knows that the most challenging part of any call isn't the medicine or the protocols, it's the logistics and the decision-making. We often intervene during a very narrow window of time that actually makes a difference in outcome, but every once in a while we get the chance to truly save a life... Story time to wrap things up...

(Typical disclaimer: Names, numbers, times, street addresses, details may be fictionalized to protect privacy and identification. The essence of the story and players in it are preserved.)

Clear from the base and time for the day to start. I was supposed to be working a "tac unit" (basic life support 911) this particular morning, but two late "bang-outs" (coworkers calling in sick) put Richie and I together on a "medic unit" (advanced life support, paramedic, 911) on a day where the flu meant staffing was bare bones. It would probably be busy.
M40: "Medic 40, Central. 10-8, post 7" 
Dispatch: "Medic 40, post 3."

Post 3. Great! Coffee and breakfast before we get bumped up to a busier post. As fate would have it, second in line at Dunkin Donuts...
Dispatch: "Central to Medic four zero."
M40: "40"
Dispatch: "Medic 40, 444 North Jones Street, back up the BLS, 80-year-old male unconscious, EMD in progress."
M40: "40's responding."
Dispatch: "0822"

The dispatchers were giving pre-arrival instructions over the phone. This usually tips the scale of "are they really unconscious?" in the affirmative direction. At this time of the morning it's more than likely a cardiac arrest.

Dispatch: "Central to Medic40, ETA? CPR in progress, K."
M40: "We're pulling up, Medic 40 is 25" (on the scene)

Indeed it was. An elderly male lay in bed, in cardiac arrest who was discharged from the hospital an hour earlier and brought home. Definitely a sick individual with semi-permanent tubes for urinating and feeding already in place. The fire department and our agency's BLS unit were doing CPR on the bed, an AED was applied and I heard the automated voice "no shock advised" as I entered the room. "Let's get him on the floor guys," I said directed to the FD as I walked in the room. (CPR isn't effective on a cushioned surface and we would have a lot more room on the floor.) To the family: "Does he have any advanced directives? Do not resuscitate, DNR? Do not intubate, DNI?" ("No, please help him.") "What happened this morning?" ("He just stopped talking a few minutes ago, we did CPR and called 911.") "What kind of medical history does he have?" (They produced a long list and a large tupperware full of medications.) "Diabetic, hypertension, CHF, pancreatic cancer, ..." I started listing to my partner as I scanned the medication bottles. By now he was on the floor, our student was doing his first ever chest compressions, and I was slapping new defibrillator/monitor pads on his chest as my partner placed an IV line in the patient's neck. I tossed a ResQPOD to the firemen at the airway. "Joe, put that between the mask and the bag."

"Asystole," I said and reached in the bag for the drug kit. I passed the epinephrine bristo-jet up to my partner at the head and spiked a bag of saline to flow into the IV line. "Finger stick is 110" (his blood glucose level didn't cause the arrest). At this point you start running the "Hs and Ts" as they're known in ACLS, or advanced cardiac life support, the dozen or so possible and potentially reversible causes of asystolic (flatline) cardiac arrest. This patient hadn't been down very long, and given the way his lungs sounded, we assumed this may have been a respiratory problem first. Richie intubated ("lung sounds are good, tube's good"), attached the capnography, and we continued. Rhythm check. "Rich, I'd call that V-fib, you agree?" "Yeah, everybody off, let's shock that." "CLEAR!" (Yes, we really say that, especially in a crowded room.) This 80-year-old had some fight left in him, and an organized rhythm appeared on the monitor. ("Does he have a pulse with that?") "Yeah, a weak radial down here, let me try for a BP." Our supervisor was walking in now to back us up. He mixed up the next round of medications as I packaged the patient with the FD.

Supervisor: "302, Central. Medic 40 is going to be 10-2 to John's with one status-post-cardiac arrest, notification made, I'll be code 5."

Save #1 of the morning was in the books.

Dispatch (on the phone, not over the air): "Ryan, can you guys free up?"
M40: "We can be in another 60 seconds or so, just got finished cleaning up, what's up?"
Dispatch: "I have another unconscious around the corner from you at [...], you're the only ALS available, BLS and the supervisor are enroute."
M40: "Ok, put us enroute."
Dispatch (back on the radio): "Medic40 will be responding from 817 to [...] for the unconscious."

This one was a little easier. Big open nursing home room, nursing home staff were doing good CPR (not typical, by the way), and an IV had been placed before we even arrived. "Whose patient is this?" I asked generally of the people in the room. I suspected the scared looking Asian nurse in the doorway would be the one I was looking for. "Was he complaining of anything? Advanced directives? DNR? DNI? What happened this morning? How long has he been down?" ("He said his stomach hurt. He's full code. Only a few minutes.") "Ok, history, meds, allergies; do you have his chart?" (She provided it.) "Ry, let's just get him on the stretcher and work him on there." "Ok." Same routine. The AED chimed in it's opinion, "stand clear, analyzing, do not touch the patient." (Cool, 20-30 seconds to get other equipment out while it does it's thing.) "Shock advised, charging." (No sh*t, this guy has a shot, too.) "Ever shocked someone before, Mitch?" (Our student reported he hadn't.) "Button is all yours, as soon as it says so, press it." Zap. "Ok, compressions!" Richie started a bigger IV line, I put the pads on. ResQPOD went on the end of the ET tube. Rhythm check: V-fib again. "Ok defibrillate again." As the machine charged "302" (our supervisor) walked in: "where's your stretcher? I'll get it set up." "He's already on it, Mike. Ok everyone CLEAR!" Zap. Sinus tach. Eyes open, reaching for the tube. More post-arrest drugs, more careful monitoring.

Supervisor: "302, Central. Medic 40 is going to be 10-2 to John's with another status-post-cardiac arrest, notification made, I'm 10-8."

Save #2 of the morning was in the books. We got the typical banter from coworkers when we got to the ER. Richie and I were "taking all the glory" for the morning. "No place to go but down from here, guys." It was true, two in arrests in a row happens, (two in a shift could even be considered typical,) but not that often is it two saves.

M40: "Medic 40, Central. 10-8 from John's, got anyone breathing for us?"
Dispatch: "Medic40, post 1." (It's ok, I knew from her tone she got my joke.)

About a half hour later, documentation just completed from the first two...

Dispatch: "Central to Medic four zero."
M40: "four zero"
Dispatch: "100 [...] Avenue, cross of [...] Street, for the 26 year-old-male unconscious, possibly not breathing, caller is refusing EMD."
M40: "40 responding from post 1." (I imagine my chuckle could be heard/understood.)
Dispatcher (on the phone again, almost immediately): "Wish I were kidding, guys. Another one for you."

We could hear the YFD engine over their frequency (Richie and I liked to scan) asking their dispatcher to let the ambulance know the patient wasn't breathing. South Yonkers is known for its old construction homes. Narrow stairwells and homes on hills can mean complicated extrications. This patient was a solid 350 pounds and on the third floor. Lucky for him, though, he had a pulse, albeit a very slow one. He was not, however, breathing more than an unacceptable agonal breath every 10 seconds. Looks like Mitch would get some more skills practice. "What do you want to do, Mitch? He's not breathing so well, huh?" ("Bag him?") He was doing really well this morning. I tossed him a BVM and an oral airway. It wasn't a difficult picture to put together. The room was filled with drug paraphernalia and this patient was apparently well known to the ESU cops in the room with us. After plugging in the oxygen, I put the monitor on and set up a Reeve's stretcher to get him out of this scene. His vitals were predictable. Hypotensive, bradycardic, and hypoxic. He bought himself some Narcan. By the time we arrived at the hospital he was breathing on his own again and semi-conscious.

The last one doesn't necessarily count as a "save," in the true sense of the definition, but this was the third person in a row (it wasn't even noon yet) that wasn't breathing before my partner and I had anything to say about it.


The "three-in-a-row morning" as I have come to refer to it in my memory is certainly one shift that will be on my EMS career highlight reel for some time to come. Moments like these define lifetimes (our's and the patients') and remind us why we weed through the nonsense of a typical EMS shift's worth of drunks, insignificant complaints, and minor car accidents. One lesson I learned from one of my personal idols and favorite TV characters, Mark Greene from NBC's ER, is that no matter how hard it may be to deal with a difficult patient or personality, it's always more difficult to be that patient. It's why I think EMS--aside from everything else about the job--is unparalleled life experience. It's why I'm inspired by emergency medicine. It's why I'm inspired by people who don't hesitate to stand up every day to a more figurative "is there a doctor on-board?"

You get to experience so many people's lives in so many different settings. We get to learn what motivates people, what harms people, what steers people. We get a completely unadulterated view on human behavior. Every patient teaches us something that, whether we realize it or not, will help us talk to another one. Our partners experience it with us and become our close friends because we live through extremely emotional, mentally difficult, and notably vulnerable situations together. We get to be there, if you're lucky, for someone's first breath and also someone's last. And there is nothing like it. The job is great, and the experience invaluable, because when you're out there it's obvious: this job isn't about the tragic and dramatic ways that people die, it's actually about how people live.

We get to go and see.