EMS

The day after

I work a strange schedule: 24 hours on, 48 hours off. In practical terms, I get up at 4 every third day, schlep to the firehouse to be on duty at 6AM, and work until 6AM the next morning. When I roll out of the station, I have exactly 48 hours to recover before starting the process over again.

Most days when I get off work, I go home, try to recoup a little sleep with a short nap, and have a day in which I write and run errands with low expectations for myself. I'm coming off a shift in which I've usually been privy to some horrible shit, and the primary goal of the day is to avoid and suppress it. I have a bunch of rituals designed to reinforce the firewall between the world of perpetual emergencies and the quiet of home, but it is work to maintain the defenses.

Over time, I've noticed something about the day I get off work. It's like the third rail of my days. I'm more likely to have an argument with my wife - so much so that I avoid discussions of meaningful topics. I'm overcome by strange and sweeping emotions. I have sudden, compelling ideas - maybe I should buy a strange wig at Goodwill and wear it to the Odesza show! - and tend to see myself as damaged, if not outright psychopathic for my ability to tolerate such constant doses of human suffering. 

Then I get a normal day, in which things feel pretty normal. Then I go to work. Those are the normal days.

 

An entire exercise regimen in futility

The turn of the year is often a time for reflection, correction of mistakes and hopeful chartering of new ways forward. I'd love to do all that, but first I have to talk about futility. 

I ran a call a few days ago for a young man in his 20s who had stopped breathing. His father was reportedly attempting CPR on him before our arrival. No matter how long you've been in EMS, a call like this one prompts feelings that range from restless anticipation to piercing anxiety. Every decision we make has luminous importance, world-altering weight. 

The picture on our arrival was a depressingly familiar one: a young person who had stopped breathing due to a probable narcotic overdose. Once relatively rare, this is now commonplace, a "bread and butter" call for us. We administered naloxone, a drug that counteracts the effects of opioids, and the patient almost immediately started breathing on his own and woke up. He denied taking drugs, even when reminded that this disclosure was protected by privacy laws - also a commonplace reaction. 

He had walked out of the Emergency Room, over the protests of the staff, before we even finished the paperwork on the call.

I may well see this young man again. I see many people fall down the rabbit hole of addiction, from the early calls when they collapse at work, to when mom or a boyfriend finds them unconscious in the bathroom, to when they are dead and we're trying to resuscitate them. I can try to keep them alive, but of course I can't do much more than that. It feels hopeless sometimes. At 6AM, driving home on the turn of the year, it felt abjectly futile. 

If you hope to achieve something in this world, then futility is the most important thing you must ignore. My written words will be pulp someday; trees will grow where the mightiest buildings now stand. You avert your eyes from the futility of your endeavors as we slide our gaze past the sun.

But right now, I'm seeing futility everywhere I look. At times, I perceive its shimmering edges - and something else behind it, distorted as if through a flawed lens. But mostly, it obstructs my view of the world and dares me to step forward and through it. 

Make no mistake, I love my job - love it. I recognize that there is an ebb and flow to the way we deal with the stresses of the job. I'd just like to believe that for one of those people, the day they almost died was the day things changed for them, when they started the hard climb upwards. I don't want the credit; I just want to look up and see them there. 

Thankless jobs

Within the world of fire/rescue, there are two particularly thankless jobs. First, 911 dispatchers, who are the first point of contact for the emergency system, and who must sort out the chaotic, frightening moments of an unfolding emergency*. The other thankless position is the one who arranges to have the correct staffing at every fire station, every day. Both these positions have this in common: when they do their jobs exceptionally well, no one pays any attention. When they screw up, letting their humanity show over the phone or radio, or short-staffing a station, everyone calls them out on the mistake. 

I would have thought that was the textbook definition of a thankless job: one in which good performance goes unrewarded, but bad performance is immediately condemned. This chart proposes more axes of thanklessness, including pay, public opinion, stress, and environment. 

For obvious reasons, I found it interesting that this and other lists classified fire/rescue as "thankless." It's true, I don't always get thanked for what I do, but I also enjoy having a career that's lauded and seen as worthwhile. More importantly, firefighting is listed as one of the careers with highest job satisfaction. That list, which discusses the "crummiest careers" and what makes them so rough, is worth a read. Not surprisingly, we don't reward the people who have to deal with our junk (literally and metaphorically) nearly as much as we should.

[* If you want to hear why I have so much respect for dispatchers, listen to this audio of a dispatcher handling emergency radio traffic after three police officers were shot while responding to a domestic disturbance. She is calm and controlled on an extremely tense and emotional incident.]

You aren't just what you think you are

@History in Pictures is a great twitter feed that mines photo archives for stunning moments from the past - some grandiose, some intimate, some curious, some utterly bizarre. Just one example:

There are many different ways to unpack and interpret this image, some of them outside my experience and understanding. Certainly, there are some who would pose the question - why protect an avowed racist from the impact of his beliefs? Why should he receive governmental protection that is less commonly afforded to those he vilifies and would gladly oppress? On the other hand, if we aren't willing protect the rights of all citizens, who decides whose freedoms will be protected, and whose will be ignored?

Looking at this image, though, I mostly feel sympathy for the police officer. Although my job is wildly different from law enforcement, I also wear a uniform, and I'm often perceived foremost as my role, not as a man who will go home at the end of my shift.

That's not such a bad thing. People who call me should be able to count on me to fulfill the duties of my role. They shouldn't have to negotiate with a fallible man, and potentially face criticism if I disapprove of their decisions or lifestyle. The uniform should represent something reliable, fixed, steadfast. 

My uniform provides a benefit to me as well. Although I'm not a wild fan of the superhero genre, I understand on a visceral level why we envision them wearing costumes. My uniform is protective - it shields my psyche from what I see on the job, In theory, it's something I can remove when I return to my everyday life. 

I've been in situations, like this officer, in which I do what I'm there to do, regardless of my opinions. I treat all patients, regardless of who they are or what they've done. I do my job, because in certain moments, my job is actually more important than I am. It outranks me, my personal preferences, and my opinions, because someone has to do it, and on that particular day, I happen to be the one. 

Maybe your job isn't your job, but I'd be willing to bet you've got work to do out there, things that are bigger than you and me. 

The unsaved

dummies, 2015

dummies, 2015

Space is at a premium at the fire academy. The department is growing so quickly that for the first time in our history, we're running two simultaneous recruit schools. The building is brimming with fresh-faced firefighters-in-training, every one of which is required to say "good morning, sir" [or ma'am] as you pass them in the hall. Trying to get from one place to another is like navigating a sprawling psychological experiment designed to force you to greet as many people as possible. 

I was at the academy for a day to help teach a class in Pediatric Advanced Life Support. No rooms were available for breakout sessions, so I convened my group in a glorified closet that holds CPR dummies and training supplies. Shelf upon shelf of removable faces dreamed rubbery dreams beside us as I ran the other paramedics through scenarios.

Those slack and expressionless faces have helped teach hundreds of people, uniformed and civilian, what to do when someone's heart stops. Even laid out to dry following disinfection, they summon the images of the many people whose lives have been saved by a stranger who knew CPR.  

Pseudoseizures

Seizures are a fairly common 911 call. Fever and epilepsy are the most common causes, but I've also seen patients seize due to head injury, overdose, or withdrawal from drugs or alcohol. 

Recently, I've encountered more patients with a previous diagnosis of "pseudoseizures" or
"behavioral seizures." That was new to me, and based on how these patients were often treated in the ER, I assumed these terms were non-confrontational euphemisms for "faking it." Consider one patient, whom I delivered to the hospital twice in one shift. The patient had been prescribed a number of medications, none of which had been effective in stopping their frequent seizures.  They were going to the ER by ambulance several times a week, where they usually spent a few idle hours before being sent home again. Their seizures weren't associated with any of the signs we usually associate with epileptic events, and the ER staff mostly rolled their eyes and wrote it off as a waste of precious resources. It seemed like a pointless exercise. 

Pseudoseizures, I learned, are not so easily dismissed as fakery. The current term for them is Psychogenic Non-Epileptic Seizures (PNES). They are not associated with the electroencephalographic patterns of epileptic seizures, nor the typical physiological signs we often see in epileptic seizure patients. They are caused, researchers believe, by the mind itself. 

Yet we now differentiate them from malingering, or consciously displaying symptoms for personal gain. That difference is critical: from the patient's perspective, they may be experiencing a distressing event not unlike a seizure. We'll never know for certain, because like the experience of pain, their truth will forever remain their own property, a place we may speculate about but will never visit for ourselves. The entire diagnosis of PNES rests upon a fundamental trust that patients are telling us the truth. 

What is perhaps most interesting (and sad) about the syndrome is that the prognosis for PNES patients is relatively poor. If the seizure events were merely the response to transitory stresses in their lives (or if the people were merely faking), you would assume the symptoms would resolve after a while on their own. Changes in their situation and stressors would eliminate the need for such a disruptive event. But it appears that's not the case. Something about the seizure-like event becomes written into the person's story, and grows difficult to erase. 

When someone's heart stutters and stops, I can reach within them and apply electricity; I can open an access point their vascular system and deliver medications to their core. How do we fix a system we cannot see, or know, and for which the tools we possess may never fit their faltering machinery?

Everything is in your head

I recently responded to an incident in which a large number of people were exposed to a substance that's essentially harmless, but not something you typically get on your skin. A significant number were reporting a burning sensation and other symptoms. Ultimately, their symptoms resolved and none required emergency care. 

I think their condition likely had two causes. First, fear and anxiety at having been exposed to a foreign substance caused them to pay close attention to the normal sensations coming from their bodies. Their perceptions were filtered through biased cognitive processes, with pain as the result. Second, the reactions of the people around them actually influenced their perceptions of their own bodies.

It's easy to dismiss mass psychogenic illness as "hysteria" but I think it's an indicator of the powerful role our innate social impulses play in our health. We gather data and form our experiences not only through our nervous system, but also through other people.

Someone asked me recently if I'd ever seen a connection between my demeanor on an emergency incident and the patient's outcome. "Almost every single call," I replied. Fear and anxiety are hidden amplifiers of patients' symptoms. While I never hesitate to perform whatever medical interventions are necessary, sometimes calm and compassion are the most powerful tools at my disposal.

It's as if we have a second, invisible nervous system that extends out from our bodies and connects with others. 

I'm not going all woo-woo hand-wavey here. I can't cure a developing heart attack with niceness. But take this example: in a heart attack, cardiac muscle tissue doesn't receive enough oxygen-rich blood, and becomes hypoxic. Eventually, deprived of oxygen, it will die. A fast-beating heart uses up more oxygen, rapidly exhausting the limited supply. If my demeanor helps ameliorate a measure of that anxiety, and slows the heart down a little, might it help preserve a little precious cardiac tissue? 

Maybe, maybe not. I can't find research that addresses the patient's anxiety level during the event and compares it to long-term survival. But that's just one of the ways I see a little human compassion having far-reaching effects in EMS. We spend a lot of time training people how to perform other critical skills. But no one ever trained me in basic techniques for demonstrating compassion and reducing anxiety in patients. It's time for that to change.