i am not broken

Four days ago, I was looking through Twitter when I couldn’t sleep. This is a pretty common thing for me to do, and then I’ll switch to listening to podcasts. At least 70% of my Twitter feed is medical, and I usually an interesting thread, or something funny. Because let’s be honest, we medical folk are pretty damn funny.

That night though, I came across something that usually would give me no problem. It was a tweet about airway management, which is always a fun topic. I couldn’t quite read the slide though, so I enlarged the picture. The pictures were of patients with various degrees of facial or neck trauma. As soon as I saw the two pictures on the left of the slide with the two patients with massive facial trauma, I felt the hair stand up on my arms, felt my breath catch in my throat, and my heart start to race. I think that if I had been more prepared, I wouldn’t have an issue with this.

But that night, it caught me off guard. I knew immediately that I would be having nightmares that night, and probably for the next few nights to come. Maybe some olfactory or auditory intrusive memories, too. You see, the call that affected me the most psychologically in my career involved this kind of facial trauma. I’ll write about it eventually, but not tonight. Suffice to say, this was enough to push hard on that part of my brain to release all those same chatecholamines and stress hormones, even though I knew I was safe at home in bed, with the dog sleeping, and house safe.

I wanted to share this tonight, because this afternoon, I took a nap and for the first time, had no nightmares. It took a solid four nights of knowing that each time I fell asleep, I’d be feeling something like A Nightmare on Elm Street. Each time I’d lay down in bed, I would dread the inevitable time my eyes would close and there was nothing I could do to prevent it.

I also knew well all the reasons this would happen. I understand (to a decent degree) the reason my brain reacts like this. I know that its a limited process that I have no choice but to go through, and I know that when I do experience these moments that I will survive them. But there’s one thing that I also know that trumps all of these…

I still have to go through the darkness.

Once this process starts, once the first dominoe falls, there is nothing I can do to stop it. So instead, I choose to face it head on. I will let friends know and be intentional about not isolating myself. I will exercise and eat well. I will remember the good things in life, and feed my heart with music and good books and people. And I won’t give up because I also know that I am not broken, even though I am bruised.

Image from Creative Commons

Advertisements

Lessons Learned in EMS: The Final Five 16-20

Here are the last five lessons of the 20 lesson series. I hope that you’ve found these both interesting and helpful.

15: Learn who to share with, and what to share with whom

This is another lesson about mental health and processing the things that we see every day at work. I would venture to say that this applies not only to the things that haunt us, but also how we share the day-to-day traumas and tragedies that we are called to. I would think that this would not only allow us to process effectively, but also protect those we love outside of our professional environments.

I have found that sharing comes in two different ways for me. First, I share and process (or debrief, if you like that word more) the technical and graphic things with co-workers. I will tell them the gory details of a call, such as how a patient was found, or the extent of injuries. I will process with them things like my thought process on how or when to decompress someone, or the difficulty managing a crashing CHF patient. My brothers and sisters in public safety have the unique ability to understand what I am talking about. They too have managed these challenging scenarios and comprehend the fear, the rush, and the pride of a job well done. I want that space to vent about things like this safely and with people who don’t understand. I want this space because it feels safe and not like people are voyeuristically trying to see what our jobs are like or what “the worst thing you’ve ever seen” is. They are just family, able to understand our unique living environment.

Speaking of family, we do have those real people in our lives that we go home to at the end of a shift. They might be a spouse, significant other, or roommate. We might have to come home from a horrific call and then figure out quickly how to integrate back into “normal” life. For this, I suggest pre-establishing ideas about how to take time when you get home to switch gears. I also strongly suggest to people that they not share the gory details of your shift, unless the person you are going home to is also on the job somehow. Alternatively, I suggest that you share with these people the emotions of the job. While they might not understand the emotions of fighting to save a patient and then watching them die, they will understand if you can reframe that experience into asking them to think about something like a job they fought for and then weren’t hired. They might be able to understand the idea of fear when one is processing being assaulted if they have ever been in a car crash before. There are always similarities in emotions. To be honest, the only universal human emotion is probably sadness, so this shouldn’t be a huge step. This also protects these individuals from unnecessary trauma hearing about the horrors, but allows them a place in our healing, which is as good for them as it is for us.

16: Practice doesn’t make perfect, perfect practice makes perfect

As I was walking out of the ED one night to get back in the ambulance, I told my intern that, “Practice makes perfect!” I was quickly rebuked – in a wonderfully respectful way – by a physician that I knew well. He ran after us and pulled us aside, and said, “Tim, I heard what you said… But remember, practice makes habits. Perfect practice makes perfect!”
What a gift that this doc gave me. It was insight that I hadn’t put words to, and yet seems to be an easy thing to understand, even if its really hard to accomplish. To me, this meant no short cuts. Do things the right way, every single time. From personal preparation (ambulance, equipment, and protocol knowledge) to the phycho-motor skills of something like intubation (i.e., opening the mouth, gently inserting the laryngoscope, viewing the epiglottis, then the glottic opening, etc.), deliberate and consistent action, rooted in deliberate and consistent practice, allow for perfection.

And let’s be honest for a second: we will never be perfect. It’s the fruit just out of reach, the mountain we just can’t climb. (Wasn’t there a Howard Jones song about this?) Does that mean that its not worth striving for? Not at all… Get after it and never quit trying to improve either your knowledge or skills to create as close to perfection as possible in your practice of paramedicine.

17: Make use of your time at the hospitals between calls

There is always the temptation for people after a patient is dropped off to sit in the ambulance bay and check Twitter or Facebook. Or, lets be honest, to take a nap. Some of the best times of learning that I ever experienced though were during those long hours at night in between calls, and visiting with the hospital staff. This is similar to my suggestion about asking our brothers and sisters in law enforcement and the fire service to teach us. I learned about pediatric codes and tricks to neonatal resuscitation. These lessons were critical in my career and directly affected the care I gave to so many critically ill children. I grew in my understanding of EKGs by having physicians go over 12-leads with me, learning the minutia of the bumps and squiggles. I distinctly remember sitting in the trauma room with the attending surgeon, who graciously took her time explaining more of the kinematic of blunt trauma to the flank, and the concerns that mechanism raised for her.

There was a secondary benefit to all of this as well. These relationships paid off more than anything I could imagine. It gave me credibility to bring patients in to the hospital and be deeply trusted by the staff. They knew that I was serious about my medicine, and they knew that what I said to be true about what I saw in the field, absolutely was.

The perfect example was the gentleman who called for diffuse abdominal pain, but was pink, warm, and dry, with vital signs that would be typical for a calm, healthy man in his late 20’s. I don’t know what triggered it, but all of a sudden I asked the crew to increase the patient’s oxygen to get it above 96% SpO2, and to start two large IV’s, and do serial 12-leads. We were only a few blocks from the hospital, and I had my partner call them and tell them we were coming in lights and sirens with a critical medical patient. When she asked why, I told her to tell the ED that I just had a bad feeling about the patient. We wheeled in less than five minutes later, and the attending met us at the door, a little frustrated with the lack of information. I think she was looking to chew some paramedic butt out for the nonsense of a reason for a critical patient, but when she saw me, and I said I just had a bad feeling, Dr. K paused and said, “OK, thats odd, but its good enough for me… Take him to Trauma Bay 1 and let’s work him up.” There’s no better feeling than knowing you are trusted. (Turns out, the patient had just had gastric ulcer surgery, and while I thought he might have an MI, he was actually hemorrhaging massively internally. He ended up crashing during a bronchoscope, losing about 1.5 L of blood from upper and lower ends, and died in the ICU after the trauma surgeon tried to salvage him.) This just goes to show, that even though my diagnosis was way off, trusting one’s gut instinct, coupled with the respect of my hospital colleagues, meant the patient had the best chance he was going to get. That vote of confidence from Dr. K still sticks with me to this day.

18: As a paramedic, train your partner if they are an EMT. If you are an EMT, learn all you can from your paramedic

I find this to be so important. The relationship between partners is probably the most important thing to develop each shift. Investing in this relationship really is a force multiplier when it comes to patient care. I always took the time to park somewhere when we weren’t running calls, I would sit in the back and go over things like doing 12-lead EKGs with my partner. I wanted them to understand not only what we did, but why we were doing it. I wanted to make sure that they knew how to set up pediatric drip sets, or all the things that I would need to incubate someone. Again, the dividends payed off so much for my patients by doing this.

A hunter and his friend were lost and trying to drive to the hospital after a night of boar hunting, and saw the ambulance parked behind the fire station. The driver pulled in and came knocking on the door almost at shift change at 0700. My partner and I casually walked out, thinking it was just a random person asking directions, and he said the passenger in his truck might be having a heart attack. As soon as we opened the door to the truck and we saw the passenger, we knew this was a very sick individual. He was ashen and profusely diaphoretic. My partner, Jon, ran to grab our monitor and bag and hit the siren to get the firefighters out to help us. In under 90 seconds, Jon and I had a nasal cannula on the patient, SpO2, a blood pressure, 12-lead, and aspirin and a first dose of nitroglycerin.

90 seconds. The only way we were able to accomplish that was communication and training. I taught Jon everything I thought would help me out if we were ever with a really sick cardiac patient on our own. When he didn’t know something or understand a concept, we would stop and take a break, working through it until we flowed. It can be done, but it does take work on both ends.

19: Don’t give in and be the lowest common denominator at work. Fight to give the best, most creative care possible to your patients.

It has been my experience that there is often a tendency of older paramedics and EMTs to talk about how things have “changed, and not for the better,” or how “its not as good as the old days.” I have two thoughts on that.

First, its never as good as the old days. It’s been proven in studies that our perception changes over time, and that the old days had just as many problems as our current situations. Let that sink in. Don’t be fooled by that. We tend to block a lot of the negativity out of our systems.

Secondly, we have the absolute power to control our attitude. In the immortal words of Michelle Obama, “when they go low, we go high.” I have worked with some really negative people. It is my choice if I choose to feed off them, or I work deliberately to make them have a good day. When assigned with a negative partner for one day, I’ve bought coffee, engaged in conversation, and made them engage with me. When I’ve been assigned with someone for six months or a year, I have done all the same things. I have fought deliberately to include that person in time around the table at the station after dinner, and treated them as well as humanly possible. I also communicate explicitly to them that I do not want to be negative and hate my job. I love my job, and will continue to, so we might as well have fun. And in every case, I have ended up converting that partner’s attitude and we have had a great time.

Finally, learn your protocols as well as possible so that you can raise the level of care in your agency. It is tempting sometimes when you are tired to not push hard, and to just do what the line items say in the policy manual. I remember being dispatched to a nursing facility for someone with acute COPD exacerbation. We had just gotten magnesium sulfate on the ambulances to use in cases of severe pre-eclampsia or eclampsia. Knowing that the magnesium is used in hospital for severe shortness of breath also, I decided to contact my base physician when my patient was having such incredible difficulty breathing. The mag was in our scope of practice, just hiding in a different protocol. I explained my thoughts and rationale (always present a problem along with the solution!), and he agreed with me and let me give the mag, even though it was slower acting. Knowing a I had a long transport and a sick patient, i was able to elevate the level of care given because I was well aware of my protocols. Never give up pushing that attitude, because with that, comes pride, and pride in yourself and your medicine makes having a good attitude so much easier!

20: HAVE FUN

That is the perfect segue to my last thought. HAVE FUN. We have the most unique opportunity to help people on a regular basis. We are able significantly impact multiple people’s lives every day. We work with some of the most selfless and amazing humans, who will risk everything for strangers. We are given tremendous responsibility, but also incredible autonomy. We are living little kid’s dreams, and we should never forget that. We are doing a job that for most of us, we identify with much more than just way to earn a paycheck, but something that is deeply fulfilling at the level of our souls. We are given everything we need to create, at least in our down time, to have a perfect day, almost any day. I believe that a lot of this has to do with our expectations. For example, one of the best pieces of advice I ever received was to expect to be held over on a late call. If I had the expectation that I wasn’t ever going to get off “on time,” then I could change my perspective to that of when I did get off on time, which was more often than not, I could really celebrate an extra hour or two of freedom (or sleep). Simple things like reframing our situations contribute to this. Remember that our job exposes us to how quickly life can change. We all know this. Don’t forget to appreciate all the little things each day. Take time to laugh hard, to love hard, to be present with the ones we love.

 

These are my thoughts on the most important 20 Lessons I’ve Learned in EMS over the almost 24 years since I received my EMT. Thank you again for all who have read, and for all who have inspired these thoughts. You have made my career absolutely unforgettable and I couldn’t imagine better people to work with.

Lessons in EMS: 11-15

Well, my plan had been to publish one of these each Friday. I’m not sure that’s the best day to do that, so its a work in progress. Also, this past couple weeks has been intense in physical therapy. I had a really significant neck/shoulder/back injury a while back, and the last few months the neck pain has been out of control. In an attempt to avoid another round of steroidal epidurals, or a trip to the neurosurgeon, I’m doing PT a few times a week, for about three hours at a time. While that might not seem like much, it has wiped me out. I’m seeing results, but just didn’t have the capacity to write last week. All that to say, it feels good to sit back down at the keyboard, and if I can, I’ll start to get ahead on posts so that, even if I’m having a rough week, I’ll still be able to publish an entry.

Time to jump back into the Lessons Learned in EMS!

11: Learn to feel the emotions

I think that everyone, whether in public safety or not, that our job is emotionally taxing. No one ever calls us to invite us to a party, at least night for a good reason. The crucible of working in the public eye, of being judged by unreasonable expectations thanks to Hollywood, the long hours and physical strain, and the toll on the body of boredom to extreme stress is not something everyone can do. In fact, I used to be really uncomfortable when people would say that to me, Now, after all these years and time spent as an instructor and preceptor who has had to fail people, I think that is actually accurate. We do a job that not everyone can do, even if their heart is in the right place.

With that in mind, I wanted to talk a bit about how to deal with the feelings that will come up in this job as an EMS provider. It’s not so much a question of if, as much as a question of when. If you want, you can search #itookhome and get an idea of what I mean. This is another mention of the idea of PTSD, and I’m certain it won’t be the last on this blog. My thought today is less typical than you might here. I don’t know if I’ve ever heard it expressed before, so please, if it doesn’t sit well, find someone to process through these moments with.

Some of these calls will stick with you, and haunt you the rest of your life. I have my share, and I’m going to share some of those in later posts. There are some though, that even though people are shocked that it doesn’t bother me, I just don’t have the same emotional response to.

Some of the calls that haunt me are absolutely understandable. They are the ones that we all think of as “the worst call possible”… A bus load of pregnant, hemophiliacs crashes into a glass building and catches on fire. That sort of thing. But a few are just holding a child as they process their illness, or an older man who reminded me of my dad, who was himself on the cusp of entering hospice. There was one call for a child who drowned that didn’t bother me at all, not with nightmares or flashbacks or intrusive sights or sounds. I absolutely felt bad that this had happened to this beautiful girl, but I was actually really proud of my crew, and the firefighters and police officers that responded. We ran as a cohesive team, providing excellent care.

A couple people told me I “should” feel bad about that call. No! I refuse. As a pediatric advanced life support instructor I never told my students that a pediatric call would be more or less stressful or emotional than any other. I prepared them as best I could to handle whatever situation came at them, as calm, cool professionals. I think to some degree, we set ourselves up for struggle if we assume that a certain type of call will absolutely be our triggers.

When you feel bad about a call – ANY call – feel bad. Embrace the emotions. Talk about it. Find healthy coping mechanisms. When you don’t feel bad about a call – ANY call – don’t force yourself into that emotional space, and certainly don’t let anyone else force you into that. Be aware that it may come back at a later time to bite you, and be ready for that. The emotions and the adverse effects of this job are all too real. Don’t run from them, but don’t force them on yourself either.

12. Learn from other public safety professionals

Some of the best lessons I’ve learned as an EMT, then as a paramedic, came from our brothers and sisters in other branches of public safety. In our modern era of responding to mass shootings, cars driven intentionally into crowds, or even the most basic call of a possible intoxicated individual on a bus bench (I’m certain this call is a universal one), our physical safety is most important. Ask a police officer to teach you the proper way to search someone for weapons. Ask them to show you the easiest and best compliance holds for someone’s wrist. Ask the firefighters to show you where they keep the medical equipment in the engine. Learn how they store their gear. Even go so far as to ask them if you can learn how to pull hose, because there is a technique that works.

I know that people have made fun of me for this at times in my agency. However, the numerous knives and four guns I’ve pulled off patients tends to get people to laugh a little less. I also have been enroute to major structure fire and had the winds shift on the cul-de-sac that we were in, and while some firefighters were pulling the hose from the front of the engine, the driver/operator handed me a hose bundle and told me to run it to the hydrant because we needed water for our own protection.

My point is that sometimes, we just don’t have the ability to foresee how quickly a scene can change from safe to not safe. We need to have as many tools, even if they are simple ones, in our mental kit, to help us adapt to those changing dynamics and to overcome them and go home safe at the end of our shift.

13. At some point, start to learn above your comfort level

One of the best things that I ever did for myself, after I had my feet pretty well under me, was to stop getting paramedic-level CE’s. I’ll admit, I was really nervous the first nursing conference I went to. It turned out to be such a great experience! Not only were there incredible opportunities to network and build professional relationships that benefit me to this day, but the clinical education was amazing. I know medicine is a profession that no one can ever learn completely. There is both too much knowledge and too much craft to it. To be honest though, paramedics really only scratch the surface. I choose a flight nursing/ED/critical care conference to attend. The first time I went, I probably only understood 50% really well, and conceptually was able to track at about 85%. I then started buying nursing textbooks. (The one that I love most is called “Critical Care Nursing: A Holistic Approach” and I have no financial ties to that book or publisher.) Now I had a tool – other than the Google and Wiki – which allowed me to cross-reference my notes and dig deep. I also noticed that the nurses who had attended the conference loved having a paramedic there! They were more than willing to answer my questions – and I had a lot of them! – and offered to continue to mentor me after the conference was over. I was now able to do more thorough and in-depth history and physical assessments, and I began to conceptualize what the hospital treatment would be for my patient. This meant I could make better decisions about where to transport a patient.

It’s uncomfortable to surrender what “expertise” you may have garnered and feel like the awkward new kid again on the first day at a new school, but the payoff is absolutely worth looking a little foolish for.

14. Choose who gets to speak into your life

Speaking of those nurses offering to be mentors to me, here’s an important thought about which voices you listen to. In public safety, everyone is a critic. I admit that I am. I will place myself in a scenario and wonder how I would have handled that case. I think people have a tendency to express those opinions also, for better or worse. Actually, its for worse. Armchair quarterbacking can really shake one’s confidence and lead to paralysis-by-analysis. Even more detrimentally, it can cause someone to take responsibility for something that might have been out of their control in the moment, and cause unnecessary mental anguish. (The subtext to this paragraph is: Don’t armchair quarterback!)

To counter this, I found a very successful strategy. I chose five people who are widely respected at work, and who I personally respect a lot. One is a physician, one is a nurse, and three are other paramedics. I have talked with these people ahead of time, and treat them as mentors and our conversations as miniature Morbidity and Mortality Rounds. I will proactively come to them with cases that I struggled on, that I am unsure of how I handled myself, or that I am receiving pushback on from other providers. In my mind, I go into it with the clear goal of identifying if there are any system issues, cognitive issues, or scene issues that contributed to how I ran the call. I do this really informally in the conversation, but these are my clear personal goals.

These five people have a free pass to say anything they want to me. They can critique me, ask any question, offer any suggestion, or any encouragement. They can also ask me to look further into something, and I take that as homework and treat it seriously.

With this team assembled and a phone call away, I feel that I can then ignore the rest of the voices chirping in my ear. Everyone else can say whatever they want. I am not responsible to those people or their opinions. I choose to submit myself though to the opinions of my team, these other well-respected people. This holds me accountable, teaches me, and keeps my inner dialogue and critiques in a healthy perspective. I absolutely credit these people with making me the thinking paramedic I am today, and believe sincerely this is one of the best pieces of advice I can offer anyone.

15. We don’t get to choose the war we fight, we fight the war we are given

Expectations can lead to so much disappointment. I know this sounds kind of cynical, but its a pragmatic approach to working and to the work environment that has kept me calm while others are about to be sent for alone time in a padded room.

We have very little control of our lives at work. We come and go and are sent at the time of another’s choosing. We operate under agency policies, protocols, and state and federal law. Even things such as sleeping and eating are often interrupted because of someone else’s decisions. When we arrive on the scene of a call, we rarely get to control our environment or the people on the scene. When it is time to go home, we all know how disheartening it is to get that late call and be held over.

What we can control is our level of expectation. I am solely responsible for my attitude. The vast majority of the time, I can combat a negative turn in a attitude by realizing this is all out of my control. Maybe this is why I like having a clean truck and uniform, because in those things, I can express my own control. I can choose fun music, I can choose to be a good partner, I can choose to be polite. In doing all of this, I find myself enjoying work more than I did when I was new and got frustrated not being able to do what I wanted, when I wanted. I think that was a huge sign of me maturing as a human being, not solely as a paramedic.
Not sure when the next post will be, but I imagine it will be either Tuesday or Wednesday. Thanks again so much for reading and for the kind words and support! This has been a great experience putting these thoughts to paper!