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The Patient-Provider Experience: Moments of Peril
Have you ever been a patient in an ambulance, before or after becoming an EMS provider? Have you witnessed a loved one become a patient? How did it alter your perception of patient care? EMS World’s newest series, “The Patient-Provider Experience,” shares the stories of both patients and providers who have been impacted by their respective experiences with EMS—on or off the cot—and how these experiences changed the way they provide care.
The Patient
Late at night an unexpected call from my mother is never a good thing. “The paramedics came, and they can’t get a blood pressure on your father.” She waits nervously for my response.
She’s called me just as the medic unit pulls away. She says they’re using lights and sirens, and I can hear her voice tremble. She peppers me with details about the last several hours. Slowly the story starts to come together: The week prior (a separate late-night phone call) he’d had an episode of altered mental status, which resolved spontaneously. He had been well enough to ambulate to the ambulance and several hours later was discharged home from the ED. My mom explains they think he had a transient ischemic attack (TIA). He was supposed to get an MRI a few days ago, but he didn’t feel well and missed the appointment. Now he’s “not acting right” again.
The details unfold as I learn that a few hours ago, he fell while using the bathroom. With some assistance he was able to get back into bed. At that time he’d declined a trip the ED.
A few hours after his fall, my dad has become a 64-year-old male with a thready pulse and altered mental status, accompanied by pale and cool extremities. He stares blankly, eyes unmoving. Despite attempts to get him to respond, he is nonverbal and does not follow commands. The first-arriving medics call for assistance, and before long an engine, truck, medic unit, battalion chief, and EMS captain are on scene. He’s nonambulatory. He’s in the basement of a single-family home, and he’s morbidly obese. There are stairs at every entrance to get into the home. I’ve asked my dad a few times to avoid having medical emergencies in the basement, which is like asking the senior guy on shift to brew your coffee for you. Thankfully, early recognition of egress options by the first-arriving crew pays off, and the extra manpower gets my dad out of the house and into the waiting medic unit without significant delay.
The Provider
En route to the ED, Mom asks me what to do. “Is he going to die?” We get these questions from patients and their families, and we do our best to provide an answer that is suitable for the occasion, saying things like “we’re doing everything we can” and “we’re going to make sure he’s as comfortable as possible” and “he’s getting the best care possible right now.” When it’s your mom asking that question about your dad, the answers are the same, but you’re on the powerless side of the response, hoping the medics care as much as you do about attending CMEs and staying current with research and evidence-based practices. I reassured her the paramedics and EMTs were likely doing everything possible and that he’d be seen by some exceptional doctors very soon.
There’s a team of doctors and nurses swarming around my dad by the time my mom gets to the ED. He’s getting blood products, and my mom sees the concerned looks on everyone’s faces. They think it’s a GI bleed. He gets five units of blood, a bag of platelets, and so many bags of saline that I begin to question if my mom can count. He’s trying to exsanguinate, and from what it sounds like, he’s doing a pretty good job. My mom tries to explain he’ll be just fine, no need to fly across the country and come home. The salty paramedic within me is skeptical of persistent hypotension, profound anemia, and continuous hemorrhaging.
The team working on my dad confirms his code status, then reconfirms it. Standard fare for questions asked as you arrive at the ED, but I know he’s the kind of patient who would have had defibrillator pads in place by now. Not long after starting work as a paramedic, I asked my parents several questions about their wishes: Do you want to have a durable do-not-resuscitate order? What do you want done if your heart stops? We discussed end-of-life care as a family, and I’m the healthcare power of attorney for both parents. I felt like I had a pretty good grasp of their wishes and how to best honor them should the need arise.
I learn my mom told the ED staff that dad wants to be a full code. My heart breaks a little. I’m not ready to lose a dad, but I’m also acutely aware that most folks going into cardiac arrest are not likely to have return of spontaneous circulation with full neurological recovery. I’ve walked my parents through a cardiac arrest response, sat with them as we reviewed the research on outcomes following ROSC. I’ve explained the tragedies I’ve witnessed of people in long-term care facilities, still alive but barely there, existing as a breathing body with a pulse, at the mercy of their decubitus ulcers and recurrent bouts of sepsis as they slowly fade away. I thought one of the greatest gifts I could give to my parents was forgoing the dragged-out suffering possible with every “save.”
What do I know now that I didn’t know before as a paramedic or PA? These moments of peril are easy to talk about before they happen but infinitely harder to discuss in full swing, when it’s actually your loved one. My empathy for others going through something similar has been deeply enriched by my own experience. Sometimes people are simply not ready to let go, of themselves or their loved ones. Lay out your plans, have the hard discussions, and arrange for what you want done well before anything unpleasant happens. But be prepared to change plans—it’s OK if people change their minds. Fortunately my dad made a full recovery, and no CPR was needed in the ED or weeklong ICU stay that followed.
As a PA and paramedic, being a provider is not being a dictator. We can provide information, compassion, comfort, and high-quality care. At the end of the day, it’s the patient (and sometimes their family) who maintains the autonomy to make choices about their future. Honor them. We’re here to support them in that journey.
