Can`t Pee, Eh?

     It's 4 a.m., and you're pretty tired. You've been running nonstop for the past seven hours, confronting the advanced clinical challenges of a lady with a migraine who couldn't decide if she wanted to go to the hospital, an 18-year-old kid with constipation, a drunk who really was just drunk, a guy who had paid the price for provoking a bar fight, and a wedding planner who woke up with a strange rash he wanted you to see. Now you're on your way to the private residence of a 78-year-old man who's called 9-1-1 because he can't pee.

     You arrive to find Larry Findall, the gentleman described, seated on the edge of his bed in his pajamas, pale and diaphoretic and obviously in pain. He's alone in the home. His only history is osteoarthritis and a 15-year-old diagnosis of benign prostatic hyperplasia (BPH). He says he became totally unable to void urine for the first time in his life about six hours ago. Every attempt feels like he's peeing razor blades. He's ashamed to have bothered you, but he just couldn't wait any longer for help. He's shivering and afebrile. There are no other complaints, and you note no discharges. He takes no meds, has an allergy to Demerol and is afraid to drive after dark. He's lost his credit cards, he's on Medicaid, he doesn't have the cash for a cab ride, and he's asking you to please "help him out."

     Q. These are the kinds of calls we run every shift, while the units around us are handling cardiac alerts and trauma calls. We've begged our administrators to organize a training program for the public to teach them what an emergency is, but they have better things to do. How can we convince them their inaction is wasting emergency resources?

     A. I hear you talking—truly. Sometimes you find yourself running call after call that no one could possibly define as an emergency, and yet there you are. It happens to EMS crews all over the world, and it happens in EDs as well. Several American EMS systems tried your solution in the mid-1980s and learned that—like it or not—people pretty much define their own emergencies. Always have. Always will. But don't let your guard down too much or you'll miss some emergencies whose owners (like Mr. Findall) really need you to understand what's happening to them.

     Q. Right, like being unable to urinate is an emergency. What are we going to do for this guy anyway? Take him to the hospital? He could get that much service from his next-door neighbor.

     A. We've all been conditioned to believe that patients should be patient; that's why we call them patients. It's a sad, neolithic, condescending view of people who suffer. I wish we could eliminate the word. But the truth is, there are plenty of emergencies that aren't mentioned in any paramedic text; urinary outflow obstruction is one. It can be triggered anytime and without warning by a urinary tract infection, prostatic enlargement, a neoplasm, a stone or the gradual development of a stricture. Whatever the cause, it's torture. This guy could use some sympathy, prompt gentle transport, warm blankets, pain relief and maybe some Valium en route to the closest Foley.

     Q. Interesting. But there are many forms of discomfort that don't justify calling 9-1-1, and I still think this is one of them. Pain is not an emergency. We've been up all night for this kind of stuff. How is this guy's pain going to affect his survival?

     A. Mr. Findall's situation is clearly different from the other calls you've run in the last seven hours. Is pain an emergency? Depends on whose it is, I suppose. As for survival, EMS doesn't stand for Emergency Medical Survivals. It stands for Emergency Medical Services. I think this guy deserves your best stuff, and considering his age, he probably paid for it a long time ago.

     Q. I just hope we're not tied up on something like this when somebody has their big one a few blocks away. How would you tell that other family, "Sorry I couldn't be there; I was taking care of an old man who couldn't pee."

     A. It's actually easy. You remember who you are: a caregiver—no more, no less. You do what you can do for each person who calls. And you embrace the freedom that comes with that kind of humility.

     Thom Dick has been involved in EMS for 39 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at boxcar_414@yahoo.com.

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