Devil in the difference

     Something awakens you from a sound sleep. You find yourself wide-eyed and alert, wondering why you're staring at the ceiling above your bunk. You can hear water dripping in the shower across the hall, the soft clicking of the clock in the day room, the faint hum of an idle computer, and a casual breeze stirring the poplar leaves outside your window. Otherwise, nothing. You glance at the digital numbers on the nightstand next to you, and they say you've slept for a whole hour since your last wake-up. You should be in dreamland. You're resolved to get back there, real soon.

     But as you roll over and close your eyes, the alarm goes off for your fourth wake-up. This time, it's a shortness of breath on Second and Palomar, in a subsidized housing area about two miles from your station. You're there in no time at all, and, as you enter a small apartment on the first floor, you're surprised to see a young first responder going for an IV. The apartment is homey and neatly kept, and the apparent sole occupant is an 80-year-old woman, who is seated on the couch wearing a robe. Her hair is neatly combed, considering it's 5 in the morning, and she appears to be in much more distress over the IV than she is about her breathing.

     It becomes clear that the first responders have not obtained vitals, have not questioned her about her complaint, are not aware of her history, have not gathered her meds and haven't applied oxygen. In fact, they can't tell you the patient's name. But those two bandages on the lady's forearms are telling you a tale of missed IVs, and that guy with the needle is ready for Biopsy No. 3. The lady is clearly apprehensive, and when you politely suggest postponing the IV, the driller reacts as though he's just been cardioverted.

     The lady's name is Elizabeth Wilkins. She appears to be breathing normally. She is expressing spontaneous speech at about 12 syllables per sentence with normal skins, and she is well oriented. Her respirations are silent, her chest movements are symmetrical and you see no accessory muscle use or retractions. Her vitals and lung sounds are normal. She really has no medical history at all, and it turns out she hasn't slept much since her husband died in his sleep about two weeks ago. His funeral was three days ago, and the last family members left town yesterday. This is her first night alone, and she's having a real bad time. You decide to spend a few minutes with her, and you spring the first responders.

     Before you end your shift, their captain's on the phone. He's cranky. He wants to know how his guys are going to get any experience if you won't let them practice their skills.

     Q. You're pretty tired, and you're a little cranky yourself. The first responders on this call sacrificed more than a few skills for that stupid IV. This is an argument you could win, even with a numb brain. Should you let him have it?
     A. Hmm, better not say too much until you've all had some sleep. When we're tired, we tend to say stuff we regret later, and the telephone is never your best tool when you're emotional. Maybe it would be a good idea to get together for coffee next shift. Might also be a good idea to let your supervisor know what's up, just in case there are more communications prior to your next duty day.

     Q. Next shift, you stop by the other crew's station, and they seem friendly at first. But the talk is soon serious. Beneath his politeness, the young EMT whose IV you interrupted is clearly angry. How, indeed, is he supposed to "get his sticks"?
     A. Not at the expense of people who don't need them, and that's a fact. The patient in question didn't need an IV, didn't need to go to the hospital, and certainly couldn't afford to pay for either experience. If you had transported her, she would surely have suffered both of those indignities on top of her sudden bereavement. If this EMT is honestly concerned about his skills, he will accept your suggestion to sign up for some free clinical time in your local ED. If he doesn't, what you're dealing with is probably not concern for patients. It's ego, and we all need to keep those two things in balance.

     Q. Is there a simple way to do that?
     A. I think there is. It's to remember what our certs give us permission to do. They authorize us to do things for people, not to them. Anytime you cross that line, you're automatically in the wrong-in every context and in every culture.

     And, by the way, in every courtroom.