Informed Dissent

I have a case I’d like to discuss with you. Except for a few members of the patient’s family, you’ll be the first to hear about it. I’m going to withhold certain details that might reveal the patient’s identity.

The 57-year-old female—we’ll call her Helen—had complained of intermittent severe lower abdominal pain for several weeks. She was diagnosed with perforation of a very important organ—less important than her stomach, more important than her gallbladder—and admitted to a hospital in the capital city of a mid-southern state known for its music and whiskey. I won’t say what kind of major surgery Helen had; you’ll find a clue in this sentence.

Not only is my wife a good sport, she’s also a former EMT and EMD who’s not shy about critiquing healthcare—particularly her own. Helen agreed to let me trash her confidentiality so we could discuss how some of her inpatient experiences relate to prehospital practices.

Until the day of her operation, Helen was treated well by the medical-industrial complex. It wasn’t until she entered the hospital that The System, aware Helen now bore the mark of the infirm around her wrist, took steps to subordinate her by exploiting patients’ lowest common denominator: neediness.

The more help she needed, the longer it took to get help. I’m not sure why; I can only speculate some of her caregivers saw their work as inherently confrontational. By enforcing pointlessly inflexible policy, they asserted control.

Want to speak with your attending physician—the one on a first-name basis with your intestines? Don’t call direct; if you do, your doctor’s receptionist will transfer you back to a floor nurse to take a message for—you guessed it—your attending physician.

Due for another shot of morphine in five minutes? Don’t even think about pressing the call button yet. I’d have more respect for such contrived precision if my wife wasn’t routinely kept waiting 20 minutes or more after her meds were due.

I’ve seen EMS providers’ rote adherence to procedures degenerate into us-against-them clashes with patients prehospitally, too. I might have fostered some of those negative vibes when I thought I was merely enforcing treatment or transport policies. For example, am I favoring safety or convenience if I automatically discourage bathroom breaks for patients before transport or bar family from bench seats? The easier it becomes to say no, the harder it is to remember why.

I admit most of the inpatient absurdities Helen endured were more annoying than dangerous, but some were scary. A few hours after waking up in recovery, Helen noticed part of her left thigh was numb. Her doctor said not to worry, then resumed rounds. A few days later Helen suddenly developed edema in that leg. Her nurse said not to worry while giving report to her relief.

I didn’t know the etiology of Helen’s complications, but I probably wasn’t going to be convinced by anyone that numbness and edema so far from a surgical site met popular criteria for normal. What Helen and I needed was someone with advanced medical training to focus on her long enough to at least give us the impression her complaints were understood and would be addressed.

Lack of focus can be a problem prehospitally, too. Most of us have been seduced by calls that sound more interesting than the ones we’re on. Sometimes we have to remind ourselves that victims of “routine” illness or injury probably won’t appreciate whatever shortcuts we think we’re taking for the greater good.

Is it possible to spend enough time with every patient? Probably not, but I can’t see setting an arbitrary limit of, say, 15 minutes, as the sign at a doctor’s office stated. Surely face time should be dictated by something besides a ticking clock.

I realize fiscal realities intrude on almost all good intentions. However, after watching Helen struggle to be recognized as an individual, rather than a transaction, I’m thinking medicine wasn’t meant to be a business. Sometimes it seems too difficult to care for people properly and profitably. Early physician-theologians had it right when they offered primitive healthcare as charitable acts instead of provider-centric indulgences. Wellness lags technology when patients are merely processed.

Like you, I have a whole new year to get a better handle on this.

Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.