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

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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.

On Twitter and Hope

Wow. I haven’t written a post like this in a long time. I think I’d been feeling scared of my own physical pain, and using that as a shield to protect me from some of the emotional stuff that has been circling in my own heart at times. And then, through a random set of circumstances this evening, all the fear and urgency of helping one of our own came rushing back.

Through the #FOAMed community on Twitter, I’ve met critical care providers on all levels and of all nationalities, and been able to discuss and learn from them. I’ve read books recommended, listened to podcasts, and added things to my bucket list. Today, when one of the doctors posted this, it through me for a loop

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The young woman who posted this is a beautiful human, living out in Dublin, Ireland. A physician from back east retweeted it, bringing to bear an amazing international response of caring people who were able to track down people who knew different parts of her life, calling, leaving messages, getting her address, and hopefully getting this woman the urgent help she needs.

It has me thinking of my own story, yet again.

It has me remembering being a young, naive EMT, just starting out and being so impressed by the paramedics that I did my first ride-along with. It brings back the first arrest that I remember, a horrific traumatic arrest the day after Christmas, 1996. It brings back the good memories of partners and dancing in the rig, responding to calls and having the best time of my life. It also brings back all of the trauma, heartache, sleepless nights (or days as the case was) because of the nightmares, and the unbelievable heartbreak of getting pages or phone calls that friends had taken their own lives. It reminds me that I was almost one of them, that I had chosen how, had a plan, and through only the grace of God, was I unable to find the right time to follow through with that. This led to a year away from work, then returning to the job I love, only to be faced again with the challenge of being injured and dealing with the chronic pain and multiple surgeries since.

All of this reminds me of the simple fact that we have a place and a role in this universe. We have the opportunity to love those in our world and sphere of influence. We have the chance to look out for our loved ones, our coworkers, and our friends. Often times, those categories overlap. That is fortunate, because that means we are more invested in each other’s lives than most people. When you work as closely as one does in medicine or public safety, there really aren’t many things that we don’t know.

More than that, we know each other. When you see someone showing signs that they might be struggling, we should make the effort to ask. It’s hard to do, without a doubt. It’s uncomfortable to enter into a conversation that really might well offend someone, as many in our professions are so good at putting up walls, compartmentalization, are those that try to be strong. I’ve been on the receiving end of these conversations. I’ve been on the initiating side of them. I’m thankful some of the senior medics looked out for me, and I’ve been thanked (although it took some time) by those I asked about or got a supervisor involved.

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There are so many resources out there that can help. Here are a few:

US and International Resources:

To Write Love On Her Arms – Resources

The Code Green Campaign – Resources

It can also be really hard to ask for help. If you find yourself in this darkness, understand that pain needs to be felt. This is a safety mechanism in our bodies and minds. There is no shame in going to the doctor if you tear your shoulder up, and there is equally no shame in asking for help sorting out the thoughts, feelings, and memories that we all carry. In fact, I would venture to share that almost anyone you share with will think it the greatest honor you can bestow on them. If you are willing to trust them with your life – quite literally – on the job, trust them with your life in this area, as well.

We are wired to help. We want to be there for you.

** As of this writing, I have no idea what the outcome of the situation in Ireland is. If you would, pray or send good thoughts to this young woman. Thanks…