Door to Door

The moment I saw him, I knew something was wrong.

He had been sleeping all day, while I was at work, but now that I was home, he came out of the bedroom to greet me.

The first thing I noticed was that his legs were soaked. With urine.  And he didn't seem to realize it.  He stumbled, and nearly fell down the stairs.

I grabbed the phone.  Called the doctor's office.

Got the answering machine, telling me to call the back up Doc if I had an emergency.

Was this an emergency?

Well... it wasn't a good thing, that's for sure.

I called the back up number.

Got a message saying to press one for an emergency, and to wait on the line otherwise.

I waited.

And waited.

No answer.

So I hung up, called back, and pressed one.

The woman who answered wanted to know what my emergency was, and I told her I wasn't sure it was an absolute emergency. I explained what was going on, and we agreed that I should head for the ER, and she would let them know I was coming.

On our arrival, we were met at the door.

The patient was ushered back to be examined, while I filled out paperwork. Before I had the chance to sit back down after handing the paperwork to the person at the desk, the doc had come out to find me.  Sat down with me, briefly explained what she had found, asked what I wanted to do, had me sign papers giving permission for the procedures, and went back to start prepping the patient for surgery.

Total elapsed time, including the drive:

25 minutes.

The shortest time from noticing symptoms to definitive care I have ever seen.

The interesting part?

This wasn't a trauma center.  It wasn't even the local hospital.

It was the Vet Hospital's Emergency Department.

The patient is my cat.

If our situation had been reversed, if I was the one who was sick, things would have gone quite differently.

First, someone would have had to notice I was sick, if I wasn't able to express it myself.

Then, they probably would have had to argue with me about whether or not to call an ambulance.

Assuming I was too ill to put up much of an argument, they'd call.

I don't know if my kids would go to the station to get the rescue or not- probably not, unless they needed the AED.

So we'd wait for the ambulance.

That would take from 10-15 minutes or more, depending on the priority given to the call, how busy they are, and where, exactly they are coming here from.

They'd spend at least 5 minutes on scene.

The drive to the hospital is about 15-20 minutes.

Giving all those the best possible time, that's half an hour already. 

Once at the hospital, things would likely slow down.  The ER is busy, most of the time, and unless I was clearly critical at that moment, I'd be put in a room, asked to change into a gown, and a nurse would put me on the monitor there.  If an IV hadn't been started before, it would be now.  Blood would be taken for testing. I'd be asked a lot of questions. Might be asked to pee in a cup.

And then, most likely, I'd sit there. Might be for hours.

A doctor would come in at some point.  Might be before or after the results from the blood and urine tests.

May, or may not, order further testing.

If I had the same problem as the cat, and needed surgery... I honestly don't know how long that would take.  It's a relatively small hospital. I might need to be transferred to a larger hospital, more set up for emergency surgery.

That would be an hour trip.

At any rate, the total elapsed time from noticing symptoms to definitive care- to prep for surgery- would be considerably longer than it was for my cat.

Why is that?

There are several reasons that all contribute to the difference.

The most obvious reason is that at the vet hospital, there wasn't a waiting room and ER full of people who didn't really need to be there.  We didn't have to wait because there isn't the rampant abuse of the system.  

We drove ourselves to the vet, which reduced some of the time.  But paramedics can start some treatment, so it's hard to say which of those options is "better." It depends on the specific situation.

But don't forget the other likely reason for any delay of MY treatment...  I'd argue against considering it an emergency, and wouldn't want to go.

The cat didn't do that. :-)

Next... what's going on? Information flow... or not.

I Carry the Stories

I carry the stories of innumerable people.

Stories I can never tell.

Some, because to do so would be to betray a trust, to violate someone's privacy.

But most because there is no way to explain, no way to share, no words that adequately describe the truth.

How can you tell the story of a man who watches his life partner die before his eyes? How do you condense the dozens of years of shared experiences, of love, of arguments and struggle, of change, of fears and hopes, into mere words?

How do you convey the moment of panic a mother has when her infant stops breathing, and then, moments later, the flood of relief as the child breathes again?

How do you describe the scene of an accident, with an unrecognizeable vehicle, bodies thrown in multiple directions, and account for why it is that of two passengers, seated next to each other, fate has it so that one survives, and the other does not, through no fault of their own?

How do you look at someone who has clearly fallen into despair, someone whose life has gone in an unfortunate direction, who has landed in that place where nothing they do ever seems to work out, whether job or living situation or relationship, where no matter what they try, it comes back in their face? How do you offer them what little help you can provide, knowing it isn't really what they need, and then go on to your next thing, as if you never saw them? How do you tell their story? And to whom?

How do you explain to a friend why it is that as you travel through the area, you see each house, each building, each road, as a place where something has gone wrong, a tapestry of misfortune, and sometimes, it means that while you are remembering previous events, you miss the emerging crocus and daffodils that herald Spring?

How do you share the rush of seeing an infant's first breath, and then staying awake for days, unable to sleep, unwilling to miss even one second of this unfolding life?

How do you communicate to people that as bad as things can get, the good still outweighs the bad, the moments of joy still compensate for the tragedies, and that being there, and knowing what to do, is so far above the idea of standing by, helpless, that anything else is unimaginable?

Staying Positive

I've heard it said that people only put their hand on a hot stove once, before they learn not to do it again, but they'll get in relationship after relationship after relationship, and never learn.

A person's response to tragedy, or to pain, or to any other of a whole host of uncomfortable or strongly negative experiences varies, greatly.  From person to person, and from event to event.

A few nights ago, I went out to dinner with a couple of friends.  One is also in EMS; the other is not.  About halfway through dinner, we realized that our topics of dinner conversation were possibly a little unusual.  The two of us in EMS were sharing stories of various experiences, ranging from dead bodies to missing body parts to various bodily fluids... right.  Typical discussions for a very specific subset of people.

Not so much for everyone else, perhaps.

Our friend was amazingly tolerant.

He couldn't help but note the ease with which we moved from topic to topic.  From dead bodies to baseball.  From incontinence to the weather. From a horrific car crash to a favorite song.

It is clearly possible for us to witness horrific things, to be intimately involved in dealing with them, and then to walk away, wash our hands both literally and figuratively, and move on, to the next thing.  We all have some sort of shielding mechanism that keeps us from losing it, most of the time.

I've been thinking about this, and the whole concept of "staying positive."

I've had a lot of stuff happen in my life.  I've been around a while, and around the block a few times, so to speak.  Most of the time, I've been able to remain a fairly positive person.  Even when things suck, I'm able to stay focused on doing what needs to be done, and on making the best of it.  For the most part, my life is pretty decent.  Especially compared to all sorts of ways and times it could have gone in other directions.

I have a little checklist I give people who ask me for parenting advice, when they complain of being overwhelmed by everything.

It goes like this:

1. Is the house on fire?

2. Is anyone bleeding?

3. Is the roof going to cave in?

4. Do you have food and water available?

If the answer to the first three is "no" and the answer to the fourth is "yes," then relax.

Right now, for this moment, things are okay.

Sometimes, everything comes down to just this moment.  Are things okay right now?  Good.  Take a deep breath.  How about now? Still okay?  We're on a roll.

I use some variation of this little checklist any time I start to feel stressed.  How are things RIGHT NOW?

Unfortunately, sometimes, the answers aren't so great.

Even so, it's good to know where you are in the continuum.  Okay, or... not okay.

If things are really NOT okay, then it's time to take action.

---

The two of you who have been reading this blog may have noticed that I haven't written in a while.

There's a reason for that.

I made a decision a few posts ago that I want to stay focused on the positive on here for a while.

And then got slammed with some decidely not positive experiences.

You know how "they" say that if you can't say anything good, you shouldn't say anything at all?

Yeah.

Got caught there for a while.

My question is, why is that?  Why did that happen?

With all of the different things I've experienced, all the things I've seen or done, all the things I've felt, most of which I've been able to let go of, or get past, or move on from, or file away, or learn from, or whatever...

Why is it that THIS one, I've stayed stuck on?

Why is it that we can watch people die, and go home and have dinner, no problem...

but then turn around and have something way less overtly awful happen, and not be able to recover from it?

Back to how I started this post...

Why IS it that people learn so quickly to avoid SOME kinds of pain, and NEVER learn to avoid others?

Why is it that we learn to adapt to a wide range of high-stress incidents, but not ALL of them?

Further Information

I've noticed an interesting trend. One which I hope continues. It seems to be doing so.

When I took my EMT-B class, we were told about DNRs. More recently,  the MOLST form was created. I have yet to see a MOLST form on a call, but I've seen quite a few DNRs now. That was pretty much the only on-scene patient-provided paperwork we were specifically taught about.

Over the past couple of years, I've started seeing a wider variety of paperwork, and some of it is very useful.

At the beginning, we'd sometimes have patients give us a hand written med list. Definitely better to have a written list than to have to hunt through a drawer full of pill bottles. Then, we started getting more and more printed, rather than handwritten, lists. Even better. I would say that at this point, more often than not, a patient will have a list of some kind, and more and more of them are printed now than even a year ago.

The next interesting paperwork was when we got a call to a daycare home. The providers met us at the door with a folder of information about the child, including medical history and contact information for the parents. Very organized and easy to read. I discovered later that day that the state requires such paperwork, and I must say, it was extremely helpful to have. Score one for the state! We weren't going to get many answers from a pre-verbal child and the providers had several other children to continue caring for, so it would have been challenging for them to give us all the information verbally. It would be difficult for them to remember that amount of information about every child they care for, as well.

Then we got a call where the patient handed us an amazing printed out sheet of information. Apparently, there was a neighbor who liked doing things on the computer who had created these info sheets for friends and family. Color coded and everything. Demographic information, medical history, medications, doctor's name and contact info, etc. Very well done. Wouldn't it be amazing if every call had one of those? Almost like a patient coming with an instruction sheet. And almost- but not quite- as helpful as the times we've had patients with their own nurse present.

Relatively recently, we've come across a few patients who also give us printed out sheets of information. They list medical history, including information about infectious diseases, with a warning. We've seen these posted on the outside of the front door, so we see them before entering the house, and can add PPE if we need to. We've had them handed to us as we entered, or seen them taped to a table top. I think some of the reason for these is so the patient doesn't have to answer the same questions over and over, but some is out of their concern that we get the information as soon as possible, and I appreciate that. Some of these also have information about any likely causes of an altered mental status, in case the patient is unable to answer questions at all. Most of these patients have been people who live alone, so might not have anyone else present to answer for them.

I don't know if there are organizations out there encouraging this approach, but there might well be. We've been seeing it more and more. It really is helpful to have things spelled out sometimes. It makes for much quicker communication between us and the ambulance crew, too, if they can see the same piece of paper. Saves the patient having to explain, and potentially saves any embarrassment over discussion of sensitive issues. Even if they need to be discussed, we're all starting from a better understanding, so the patient can answer pertinent questions, rather than having to explain the entire thing.

I've also seen information about some interesting commercially available alternatives for providing more complete medical information. One is RoadID, which is a bracelet or similar item with phone numbers and/or access to a link to retrieve information online. There are also USB medic alert tags now, which contain further information. Another one I've seen information about is the Invisible Bracelet from the American Ambulance Association. That one uses a cell phone to text information, which would probably be the most useful for us, since we don't have internet access or a laptop at a call.  

I haven't seen any of these in the field, but it's only a matter of time.

Recognition

I wrote a post a while back, about a training class I went to, about the Number One Complaint, and about being "nice" to patients and their families.  I came away from that class wanting to focus on what we really have to offer out here. Afterwards, I put together a training session for our dept, about focusing on quality customer service.  Some of that was written in my pizza post.

Had a somewhat unusual thing happen this week.

In the obits, a "thank you" notice from the family of a patient.  For our "caring and compassion."

Wow.

So I guess maybe we HAVE been focusing on it.

Thing is, I remember that call.  Have thought about it a lot since it happened.

You know how sometimes, calls are sad?  For whatever reason, you feel for the family.

Well, this one really hit me. I guess there were some aspects to it that I felt personally, more than most.

It is likely that the family felt I was "caring and compassionate" because I really was. That wasn't acting, at all.  My heart broke for them all, and I was concerned about each of them individually.  I still am.

So for a call where really the only thing I had to offer was sincere caring, it was nice to have that recognized.

But it doesn't make it any easier, or any less heartbreaking.

It's personal

We have a regular patient who is getting on in years.  She has a variety of medical issues, and when we get called to her house, the immediate problem could be any one or more of those things.

She is one of my very favorite patients.  Partly because she is such a sweet person. And partly because I don't expect to ever reach her age, and it impresses the heck out of me that she is still going.  We're talking three digits.

We had a call there recently that is representative of one of my favorite kinds of calls.

We were called for something we hadn't been called there for before. A new issue?  Or what?

Turns out that because I know this patient, and am familiar with her various difficulties, I was able to pin down the actual problem rapidly, and then was able to communicate a LOT of information to the medics, so she could get the care she needed promptly.  I knew where to look, and how to tie everything together, how to make sense of the information I was getting.

To top it off, I was able to talk to the patient and keep everything relaxed.  This was particularly great because she isn't always able to hold a conversation, and I really enjoyed being able to have that chat.

None of this happened by chance.

Partly, it's one of the benefits of being at almost every call.  If there are repeat patients, I'll have seen them before, and be at least somewhat familiar with them.

But mostly, it has to do with a habit I got into right from the beginning.

Whenever we have a call, when I get home, I do some research.

Is there anything about this patient's presentation that I haven't seen before?

Signs or symptoms with which I am not familiar?

A condition I don't know much about?

Any findings from my assessment that I don't understand?

Anything the medic said or did that suggests something I should learn?

I look things up.  Read about them.  We discuss them.

I want to be able to provide a higher quality of service the next time I see a patient- and I almost always assume we'll see them again.  When we do, I want to know more about what ails them.  I want to know more about what their needs are.  I want to learn something from every patient contact.

So I have my own little highly personalized training plan going on. Tailored to the needs of our actual patients.

Even if it's something we see a lot of, I'll still refresh my memory.

And sometimes, if there's a patient we HAVEN'T seen for a while, I'll look up their medical conditions, so I don't forget by the time we see them again.

I tried to make a list once, of the various concerns people in the district have, and it started to be a long list. It's turned into a fairly decent way to keep myself refreshed on a lot of things.

And once in a while, it really pays off.  I'm able to pick up on something I might not have considered based only on what the chief complaint is.

That's the way it should be.

The Faster I Go, The Behinder I Get

Since becoming an EMT, I have spent a significant amount of time on continuing education.  I basically take every class I can get to, since the dept doesn't provide anything.

I've also rearranged my life to some extent, to be able to cover calls when there isn't anyone else available.

The trouble is that there often isn't anyone else available.

Small dept.  Even smaller EMS crew.  The short version is most of the time it's us, or rust.  Personally "us."  Me. My kids.

Over the past few years, I have personally been to about 90% of the calls.

During three of those years, I believe there were two calls total that had a patient, which were not attended by a member of my immediate family.  Two calls in three years.

But here's the thing.

We can't continue that response rate forever.  Between school and work and the possibility of more school and work, we aren't available as much of the time as we have been.  Even so, we scramble and shift schedules around and do as much as we can to continue that level of coverage because we believe it's important.

We need help.  It's as simple as that.  We need volunteers who want to be EMTs.  We need people who are committed to training.  

But in order to get that, things need to change. 

:::Deleted long diatribe that no one wants to read anyway:::

We're kind of dead in the water here.

What sucks most is that the harder I work, the worse it gets.

The more effort my family puts into training, practicing, and responding, the LESS help we get with trying to change anything.

The community, the public, has NO IDEA that we're in such dire straits.  They think the fire dept is GREAT.

From their perspective, they call, and we respond.  We have someone there in a very short period of time most of the time.  We get there fast, we seem to know what we're doing, and a least from the EMS side, we provide decent service. Friendly. Professional. Caring.

So from their perspective, where's the problem? If anything, they get a faster, more qualified response than much of the rest of the county.  If you looked at response times as a way to compare departments, this one would come out looking well above average. If you look at the training level of who is responding, we still come out ahead of a lot of them.

What they DON'T see is that this happens ONLY because of my immediate family.  It is nearly always US who show up so fast. (And that's true on the fire side as well.) 

It's a little bit better this year than the last few, since we have a new EMT trying to help us out, and one other who has started to go to SOME calls as opposed to NO calls, but most of the time, they aren't there.  

So here we are, my family, trying to hold down the fort.

The whole fort.

Without a lot of help.

And with ZERO support from the dept.

:::another diatribe deleted, for brevity:::

But no one sees any of this.

No one knows that they are very close to having no coverage at all.  And that sometimes, they pretty much don't have any.

It's as simple as this: if my family goes out to dinner together... we have to hope nothing happens out here that is a true emergency. 

Much of the time, it means no EMT will go to any call.  And on the fire side, it means a delay, not only of the extra time to get anyone on scene, but often a delay in calling in additional resources since for some reason I absolutely do not understand, other people in the department are slow to call for mutual aid. This dept no longer has the manpower to put out a structure fire without help. There aren't enough interior firefighters in the district for an interior attack because we can't get four on scene without mutual aid, or waiting for people to drive in from wherever they work or live outside the district. If my family is unavailable- there aren't four interior firefighters, period.

So mostly, we don't go out.

And the harder we work, the more effort we put in, in order to maintain coverage out here... the less likely anyone will ever step up and help us try to change things.

We've tried.

We're cast as being "negative" and being "against the fire department" if we try to communicate any of the problems.  No one wants to believe that there is a problem, at all.  The evidence the public has is that things are fine- and they WANT to believe that. Maybe need to.

But they aren't fine.

One member of my family may be leaving the area in a few months.

My work schedule is going to change, with me working a LOT more hours, and unable to respond out here.

Or maybe we'll just stop putting up with so much crap.

It's already starting- our overall response rate is dropping due to other committments, and there have already been several calls this year that did not get an EMT.  That is going to continue, and it is going to happen more often.

I'd really like things to change BEFORE we have no one out here going to calls.

But so far, no one will listen.

And the more we do, the harder we work, the more we rearrange things, so that we provide the best possible EMS service we can... the less likely it is anyone will believe things need to change.

But they do.  They REALLY do.

A Fate Worse Than Death

I had a patient recently who wanted to be sure I knew she had a DNR. Told me first thing, when I walked in the door.

I think that's a good idea. If she has one, it would be best if we knew about it.

But what puzzled me this time is that my patient was relatively young, and in fairly good health.  There was nothing wrong with her that suggested she might be in a position anytime soon where someone would need to decide whether or not to resuscitate.

Now maybe she's just a very organized, prepared sort of person, and knows that when the time eventually comes, she doesn't want to be resuscitated, and on the offchance that it happens sooner rather than later, she wanted to be sure her wishes were known.

Maybe.

I think it's something else.

I mentioned a bunch of posts ago- maybe it was a blog ago- something about a retirement facility near here where the residents' council refuses to have an AED on the premises. Most of them don't want to be resuscitated, so they don't see a need for an AED.  Never mind about any possible visitors, or anyone who doesn't agree with the majority opinion.

It seems odd to me.

And unfair.

Having an AED on the premises doesn't mean that anyone who doesn't want to be resuscitated would be, against their will.

But it might save the lives of those who don't have a DNR.

Then again, it might not.

And I think that's the issue, really.

There are some people with DNRs who have lived a long and full life, who have a whole host of medical conditions, and who have decided, rationally, that if it's time for them to go, it's time for them to go.  There are some whose conditions cause them a fair amount of discomfort, and they are ready to have that end.

But there are, it seems, a number of people- like my relatively young, healthy patient- who have decided for other reasons, that they don't want to be resuscitated.

I think it isn't that they are ready to die.

I think it's that they are afraid of what will happen if they don't.

There are horror stories about people who are resuscitated, and never regain consciousness.  People who live on, unable to care for themselves, who become "a burden to their family."

THAT is what people don't want.

It isn't that they don't want to be resuscitated, it's that they don't want an attempt made that does not result in a return to a neurologically intact quality of life.  They don't want to end up as "vegetables."

And who can blame them?

What is the success rate of CPR and AED use?

How often is a patient resuscitated, who survives to discharge, neurologically intact?

And how often do they NOT?

I don't have the numbers handy, but I can tell you that the survival-to-discharge number isn't very high.

But.

In some places, it's getting higher.

There are some remarkable numbers to be found in places where there is a focus on improving the entire cardiac chain of survival.

And in places where they are using therapeutic hypothermia.

Check out the Sudden Cardiac Arrest Foundation.  

And Medtronic's Heart Rescue Project  

Some encouraging stuff.

I wonder when it will translate into the average person, in an average place, having a much better chance of survival, to the point where we don't see healthy people already sure that they don't want to "be resuscitated" because they see that as a fate worse than death?

Soon would be good.