On Fallibility

Not very long ago, a dear friend who’d been a patient of mine was diagnosed with an aggressive cancer. As soon as I heard, I thought of the last time I’d treated her and wondered if there was any connection between her illness that day and the hideous disease that had almost certainly entered her bones by then. So much of her complaint had seemed predictable at the time, based on her pre-cancer history, that I’d neglected to ask myself a very important question: What else could it be?

Zebras—we’re talking zebras, not horses; the same zebras we’re not supposed to think of when we hear something that sounds like them. It’s a good rule, the one about hoofbeats meaning horses—until it’s not. So many rules in EMS are like that. We might as well replace them all with Do the right thing, or Try to do the right thing, or maybe just Try.

Trying is easier than doing when you have limitations. The Lovely Helen says I have many. I don’t disagree, but rather console myself with the expectation of getting smarter as I get older. I’m not sure how many years that will take. So far I can tell you it’s not mistakes that decrease with age; it’s second chances.

For many years I made the most of my mulligans and resolved any lingering cognitive dissonance about choosing an EMS career versus a longer corporate one by vowing to do better on my next call. Now that there are no more next calls, I can tell you that my worst day in the business world was not half as sleep-depriving as being unable to offset old clinical errors with another round of Name That Disease.

The really nasty, insidious part is wondering how much difference the right answer would have made. I can’t think of an analogy in the 9-to-5 world. I mean, how much sympathy would you have for a boardroom full of executives second-guessing their sales forecasts?

There were many missed opportunities during the 9-1-1 years. I’m thinking of a patient for whom breathing became an unnatural act before I got there. How long before, I can’t say. Was her brain still capable of intricate function? I don’t know that either. This was when we were trying to save lives with lidocaine and epinephrine, so a tube was a good thing to have in case the god of flashback didn’t contribute much to resuscitation. I just wish I could have found the right hole.

The question is, did I kill her? I prefer the notion of it having been “her time”—what we now call qualitative futility. Who knows, she may have frolicked into the light fully aware of my fallibility. I’ll certainly never know.

Without an opportunity to try again, I now have no choice but to replay some of this. Yes, I know failure is accepted in EMS, but it’s not expected, nor should it be.

Part of the problem, I think, is the way we measure ourselves, which is not much at all. The only routine clinical feedback I had during most of my career was when my patients got at least some of their circulation back. We called that a save, and there was much gladness, even if saved patients died a few moments later. With pulses as our raison d’être, no wonder epi was such a popular drug.

I’d like to think EMS is about results, and pulses are only part of the picture, but then how do we explain this missive from the American Heart Association to ACLS students?

“Your success will not be measured by whether a cardiac arrest patient lives or dies, but rather by the fact that you tried and worked well together as a team. Simply by taking action, making an effort and trying to help, you will be judged a success.”

Maybe that’s why doctors seemed so understanding when they pronounced my patients.

Is there a trend here? Does trying hard override failure? If so, I’m golden.

Or perhaps anxiety about missed opportunities to excel is just part of what author, actor and director Miranda July calls feeling “secretly fraudulent.” Have you ever felt that way—like one of these days people will discover you don’t belong in EMS?

If so, retirement brings relief. At first.

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