Critical Care

     Some calls stay with us longer than others. You know what I mean.

     My patient was a 50-ish female complaining of…well, she wasn't really complaining about anything. I found her contracted in bed with animated eyes and a sly smile. I learned from her daughter that mom had spina bifida and was in constant pain. She also seemed to be a little short of breath. When I announced, after a brief exam, that her fever and congestion could be signs of pneumonia, my patient exclaimed that she would gladly tolerate any illness responsible for attracting such a handsome man to her bedroom.

     I think she caught me looking around for a handsome man. She tugged at my hand to regain my attention, then told me I reminded her of her late husband, except he wasn't bald. Her mischievous expression dissolved during a coughing fit, but returned when I promised to carry her from her bed to our stretcher. As I lifted her scoliotic frame, she asked if that meant we were engaged.

     I transported her a second time after her illness had progressed. We indulged in the same playful banter just days before she died. I learned of the outcome when her daughter and I nearly sideswiped each other's shopping carts in a supermarket aisle. I was surprised at how many details I remembered about her mother. It took me a while to figure out why: She was the first patient whom I had cared about more than practicing medicine.

     I spent my first two years after medic school trying to master the science of our profession. I'm not sure I succeeded, or ever will, but I did develop a systematic approach to prehospital care that kept me out of trouble. By Year No. 3 I was pretty comfortable with everything we carried on our ambulances—except patients. I wasn't the most sociable medic, and found small talk distracting. Senior colleagues mostly validated my perspective by encouraging me to focus on procedures, not people. One partner who, to minimize inconvenience, had culled a personal subset of standing orders from our protocols, dismissed administration of analgesics because "we're not the ones in pain." I started to view EMS as a soulless, process-driven vocation not very different from the manufacturing sector I'd left behind.

     My impish patient from long ago helped dispel that gloomy image. At first, as she disarmed me with her ingenuous and entertaining remarks, I resisted evolution of our dialogue into something less formal. I did not want jocularity to get in the way of my routine. En route to the hospital, however, I discovered that I enjoyed her company, and sensed that her well-being had less to do with my needles and drugs than with our conversation. Other than monitoring vitals and providing comfort, all I did was listen to her and, occasionally, respond. Care was secondary to caring—a new concept for me that seemed to work for both of us.

     Do feelings interfere with our performance? Many of my colleagues would respond affirmatively. The "John Wayne" culture of essential services discourages emotion. Expressions of empathy for patients frequently are regarded as weaknesses to be wrung out of providers during primary training. Failure to recognize a middle ground between ineffectual sentimentality and robotic comportment leads to reinforcement of the Spartan self-image some of us cultivate. We are beginning to understand, however, that stoicism is less healthy than prompt, informal discussion of acute stressors with family and friends.

     None of the people I know who resigned after years of unhappiness in EMS blamed "caring too much" for their career change. Quite the opposite: Most of them complained of apathy, accompanied by a sense of hopelessness. Perhaps a more robust support structure would have reassured them that they still could make a difference, one patient at a time.

     It would be naive to portray all of our customers as selfless romantics who see us as their spiritual guides. Some merely want the facts—and maybe a sliver of speculation—about their medical conditions. We're not doctors, but we can offer patients an abridged version of differentials, prognosis and treatment options. Staying current in our field to answer such technical questions is another way of caring.

     Like most of you, I've had bad days in EMS, but I don't think any of them were caused by paying too much attention to my patients. I do regret not caring more about some cases, though. Perhaps I didn't know how. Sometimes it was hard to summon emotions as peers reinforced an ambivalent, just-another-job mentality. Besides, I had to get past my own protocol-driven agenda, and consider whether my patient of the moment might be better served by empathy and eye contact than by scripted procedures.

     Three-quarters of a career later, I'm willing to admit that I went to the funeral of that frail patient with the fun-loving demeanor. The memories I shared with her family did not render me nonfunctional, nor did they make me contemplate an alternative career path. Instead I felt empowered by my acceptance of compassion as beneficial, rather than detrimental to prehospital practice. I like myself better this way.

     Sometimes we just need to find reasons to care.

     Mike Rubin, BS, NREMT-P, is an EMS educator and consultant based in Nashville, TN, and a member of EMS Magazine's editorial advisory board. Contact him at mgr22@prodigy.net.