When Johnny Met Rosie—Women in EMS Part 12: I Can Hear What You’re Not Saying

“If writers wrote as carelessly as some people talk, then adhasdh asdglaseuyt[bn[ pasdlgkhasdfasdf.”

—Lemony Snicket

We are a society, a culture, a generation of people who want instant gratification—even in our medicine. The cure must cure, the pain must stop, the bad thing must go away at once, we want our answers, and we want them now. Woe unto those who prevent this! Woe, I say!

Yes, well, that might work with a Hot Pocket, but it certainly does not hold true in medicine.

I am haunted by a line of highlighted text: YOU NEED TO CONTACT YOUR PHYSICIAN. It hovers over the fine print: Diagnosis: 2 cm right breast mass to be excluded. Right. Got it. Might be cancer, might not, I’ve had my cry, let’s get on with it, shall we?

First cosmic joke, get the notice on a Saturday. Well, now, that’s not going to help matters any, and no matter how terrified I am on a primal level, I am still not about to walk into an ED and demand a diagnostic ultrasound of my boob, stat. Though it might almost be worth it, just to see how they would triage that.

Left hovering in the realm of unknown, I’m expected to return to my life, and everyone has a Monday, including me. Bright and early I call the doctor’s office as requested—only to be told the nurse handling my case isn’t in that day and the woman on the phone is not familiar with it. I explain and am promised a call back, which never comes.

Start again on Tuesday. While I still do not get my “case worker,” I do get someone who will listen to what’s going on and check my file. She says she will speak directly to my doctor and find out what’s going on and call me back.

Yeah…didn’t happen. A few hours later I call again. She says that she hasn’t had time to talk to the doctor but did go through my file and says, “Looks like you had a spot on your x-ray.”

For the record, people, “spot on your x-ray” sounds no more reassuring than “breast mass to be excluded.” In fact, it conjures up visions of dark rooms and huge light boxes and doctors in long white coats shaking their heads sadly as they look at a rib cage with strange and mysterious markings on it.

She goes on to say I need more tests and normally they just let the patient handle it, since the patient knows what their own schedule is. I take a deep breath and remind her that I do not know what the additional tests are even supposed to be, so how would I know whom to contact and what to schedule? She blithely brushes past this fact and says she’ll have the “call center” contact me by tomorrow to set up the appointments. Conversation over.

Wednesday is, well, a Wednesday. One would think my phone would ring; one would be wrong. Now not only is my case worker not available, neither is my doctor, and some man named Bill is supposed to be setting up my appointments. I do not think Bill exists; I think they just wanted to blame it on someone, and let’s face it, men are convenient for that. (My husband is making me point out that the previous statement is said in jest and does not reflect the opinions of this marriage.)

Thursday comes, and it’s time for the daily phone call. I lock myself in my office for some privacy and take some deep, cleansing breaths. I want to open the conversation with conviction, something like dialogue from The Princess Bride:

Count Tyrone: “Come, sir, we must get you to your ship.”

Westley: “We are men of action, lies do not become us.”

I have now had five days of inaction, five days of playing out inconceivable (yes, I know what the word means) scenarios in my head, torturing myself privately for lack of information or a plan of attack. My mind tells me it can feel the intruder, even though I really cannot. I play out some scripts in my head of what to say when I get deferred again, what tactics or even threats to use.

(Author’s note: I have been known in the past to open a customer service conversation with, “Before I begin, you should know I’m nearly homicidal at this point, so please do not speak until you’ve listened to my story.” I have been known to end the same conversation with, “If you tell me I have to call one more agency, I am going to bring my flu-ridden children down there to sneeze all over your kiosks and maybe even lick the touchscreens.” However, I do not recommend this as a regular course of action. While it will get your luggage back in a timely fashion, it also puts you at risk for being charged with terroristic threats.)

As soon as I get someone on the phone, I’m told my original case worker is still out. I want to be angry, but I find I cannot. I’m scared, plain and simple, and this is becoming too much for me. My voice quivers uncontrollably, my rational brain mocks me for being a dumb girl, but I just want to cry. I lay my head on the desk as I’m talking to her. Nicole goes and gets my file, and I take the time to try and get my big-girl voice back. I can feel the hot tears slipping out against the cool desktop. She comes back on the line.

“Bill never called you?” I confirm that, adding that nobody has gotten back to me all week. “Oh, you poor thing! That’s just wrong! Nobody should wait like that. Here, let me see what I can do.”

I pick my head up off the desk.

Within minutes she has me scheduled for a diagnostic mammogram—she pulled a favor with the center and got me in the next morning. I cannot begin to express how grateful I am for this simple thing; this five-minute interaction has made a complete difference in how I perceive my day and things around me. She hasn’t given me hope, she’s given me action.

When you think about it, that’s what many people are looking for. The nature of our business is action. Hope? Hope is a side effect; we aren’t there to make promises or create miracles. We walk into someone’s emergency, and the expectation is that we will recognize it as such and take action. Perception is a big portion of our jobs. I tell students all the time, “Even if you aren’t sure what to do, keep doing.” This is because the patient and their family will be reassured by the simple fact that something, anything, is being done—when they didn’t know what to do.

Back to the Women’s Center I go. Considering I was just here a week or so ago, a few of the reception girls glance at me twice and smile “Hello again.” One raises an eyebrow and goes to look for my file. Yes, that’s right, I’m here because they found something.

When I get into the mammography room, the tech obviously knows why I’m there. She looks at my face and smiles brightly. “Come on in. This happens a lot, having to come for a second look, more than you think.” Then she says something that made the whole thing even more surreal.

“Please don’t worry. You shouldn’t worry unless we tell you that you have something to worry about.”

I stare at her for a minute, my brain turning the phrase over in my head. No, no, you don’t understand, that’s my line. I am the one who’s supposed to say that. Because I do and have for years. When a patient looks frightened, one of my phrases is, “Do I look worried? If I don’t look worried, you shouldn’t be worried.” Trust me when I tell you that in 25 years of reassuring frightened little old ladies, I have developed a pretty good poker face.

Which means, perky tech lady, you likely have too. Not only did you not reassure me, but I’m pretty sure if I had hackles, they would be up.

I wonder if that means I should stop saying that to my patients—that perhaps it’s not as helpful as I think it is.

We go through the procedure, which is just like a standard mammogram with a smaller plate and a few more views. I have to remind the tech at least once that if I were meant to stay in that position, I might have pursued a career less suited to combat boots and more toward ballet shoes. I readjust my cape while we wait for the image to come up, though I’m not feeling very superhero-like at the moment. It comes up on the screen, and within seconds she says, “A-a-and I’m 100% sure you’re going to ultrasound next.” Her posture had changed. She was expecting it to be clear, and it wasn’t. I know this.

I can hear what you’re not saying.

Damn.

Flipping my cape with some bravado, I ask to see it. What is that causing me all this fear? She shows me my old films and the current one. There’s no doubt something is there. I know where it is now; it’s actually 2.5 centimeters and right up against my chest wall. It doesn’t look totally terrifying, but I am not sure what I was expecting. It’s not bright white, opaque, no tentacles or sprouted with tiny teeth. It’s a shady definable area. Here you see it, there you did not. Well, at least now I know what I’m looking at.

Back to the holding area, in my fabulous cape with one snap. There is another woman there, studiously staring out the window, sporting another stylish frock much like mine. Her back is ramrod straight, she will not turn her head, and she has absolutely no interest in acknowledging my presence or pleasantries. She uses her thousand-yard stare to watch the falling leaves. I acknowledge this and give her a semblance of privacy.

I can hear what you’re not saying.

Damn.

Off to ultrasound, and because of where this is, it is not easy to get a clear image of it. This results in some more amusing poses, tilted stretchers, arms here, twist this way, move that way, OK, don’t move, etc. She keeps moving the probe over the same area again and again. I point out that this is way less fun than looking for a baby used to be. We joke back and forth, and eventually she asks if it’s OK to bring another tech in for another set of eyes. She wants to be sure, because of the awkward position it’s in.

Bring in the fraulein, a more experienced tech originally from Germany. I take both those items into account as she proceeds to maul my anterior chest with strength that suggests she may have thrown a shot put or two in her heyday. They take a lot of films. She heads back out, and my original tech finishes up. I’m mopping the gel up and wincing a little…if I didn’t know what area it was in, I sure do now. As she closes out the computer, I ask her the obvious question: “Well, anything?”

She stops smiling and looks up. Very professionally she informs me that only the radiologist can tell me the results. She then smiles politely and gives me my privacy to lose the cape and get dressed.

The radiologist doesn’t have to tell me. You just did. I can hear what you’re not saying.

Damn.

Leaving, I’m satisfied I’m doing what I can at this point, but there is no sense of relief. Because of the nonverbal communication from everyone I was just involved with, I leave with the same fears I walked in with and no indication of whether the answers will be positive or negative. When I lie in bed that night, I can feel exactly the area they looked at with such interest, and yes, I can feel something. It’s there all the time now. Not like it wasn’t before, but I mean it’s there. Right there, about a centimeter lateral to where you would decompress me if you ever had to decompress me. I’m aware of it all the time; I doubt that will ever go away, even if it gets removed or treated.

All the great clinicians I’ve had the fortune to work with had an innate ability to not only read situations but read people as well. I consider myself pretty good at it, the ability to read body language and nonverbal communication. If this whole experience teaches me nothing else, it has already shown me the importance of being aware of what you are telegraphing and how much it can impact patient care.

We see it all the time, among all levels of providers. Rarely is it done with intent, I’m sure; it happens out of simple ignorance to how important it can be to the total clinical picture. How do you look? Are you half-asleep, barely put together, untucked, unshaved or unbrushed? How are you standing? Are your hands in your pockets, are you bored (even when it’s a low-priority call), are you joking and holding a conversation with the police or other providers that’s unrelated to anything there?

In the back of the ambulance, do you forget I’m there? Do you move to the captain’s chair and work on your chart, leaving me essentially alone in my field of vision? Do you talk to your crew mates about local gossip or other calls without consideration that I’m still frightened or uncomfortable? Do you do things to me in rapid succession without explaining them to me so I’ll understand? I don’t know what you mean by those big words, and I’m frightened. Do you forget that sound carries, and while you may have been unfailingly polite for the entire call, I now get to hear what you really think when you give your report to the receiving nurse?

Because, as I am being reminded in a very hard way, I can hear what you’re not saying.

Damn.

Tracey A. Loscar, NREMT-P, is the training supervisor in charge of QA at University Hospital EMS in Newark, NJ. Contact her at taloscar@gmail.com. She is also a member of the EMS World editorial advisory board.