Beyond Mechanics

EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don't have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. We don't know everything, but we do know a lot of smart people. If we need to, we'll contact just the right experts and share their advice with you. E-mail ideas to Nancy.Perry@cygnusb2b.com.

     Well, so much for dinner. Your shift is celebrating birthdays for two EMTs. Several of the families are visiting, and so are the local first responders. You've just finished burning the beef for some carne asada when the alarm goes off. You make your apologies and head for the rig. In no time you're six blocks away, climbing the steps to a small, neat-looking second-story apartment.

     Seated on the sofa within is a 70-year-old woman attended by a man about the same age. Her skin is cool, slightly moist and grey in color. The man tells you he just returned from the store and called immediately because his wife "didn't look right." She appears unfazed by you and her gaze is directed straight ahead, but she is clearly well oriented to her situation. She says she is having severe chest pain with some shortness of breath, both of which came on while she was sitting right there reading. You and the engineer both feel for her non-existent radial pulses, and, not finding them, you quietly slide her onto the floor. The captain starts setting up an IV, and the firefighter reaches for the O2.

     The lady has no brachial pulses, either, but she does have weak carotids with a rate of about 70. The ECG reveals a regular sinus rhythm with narrow complexes, no ectopy and marked S-T elevation in II, III and avF. You just have time to determine that fact when she turns her head, faces you with expressionless eyes and says, "My dear, I think I'm going to die here today."

     Q. How do you respond, and why would she say such a thing?
     A. Why she would say it doesn't make much difference, although she may simply be voicing an evolving realization. But there are several important things you can do. Bring up that blood pressure, certainly. Get her to an ED, soon-preferably one with a therapeutic cath lab. But just as important, recognize the fact that she may be right about dying. When people tell you the kind of thing she just did, they usually do exactly that. Maybe it's a good idea to invite her husband a little closer and ask if he wants to hold her hand. If it's her time to die, don't keep the two of them apart. If it's not, this man may be able to offer her something stronger than your chemicals. Even if he can't, the emergency belongs to him, too. He may have to live for a long time with its aftermath, one way or another.
     Also, confirm her suspicions that she's really sick. She's not a child. Maybe instead of that old "not-on-my-shift" schtick that we've probably all used, it would be better to meet her gaze and give her the facts. Tell her about her blood pressure and her ECG, and about the medicine you're preparing for her. The reason: She may have some prayers in mind for a moment like this.

     Q. But the husband's just going to get in the way, especially if this lady codes. Whoever heard of inviting a spouse to hold a patient's hand during a code?
     A. There are many levels of healing, and many things that aren't addressed in Western medical training programs. But that doesn't mean they don't exist or aren't important. The protocols and techniques of EMS are essential, but we can be much more than a lot of bloody mechanics. It takes talent to be a caregiver, to intuitively recognize and respond to the larger needs of people in crisis. And it takes lifelong education, not just a few hundred hours of training.

     Q. Isn't it kind of a mistake to support a patient's perception that they're about to die? After all, we're in the life-saving biz.
     A. I agree. It wouldn't be a great idea to give this woman permission to die (like we could give it, or she needs it). But there's a difference between doing that and simply letting her know she is gravely ill and that we're doing everything possible to help her. In years past, many of us were taught to not even share people's blood pressures with them.

     I think they deserve to know what we know.