When I started as a paramedic, my preceptor told me to be successful as a paramedic; you need a big ego to be able to do what is asked of you. You need to be able to seize control of a scene, act decisively and with faith in your every decision. You need a big ego to be able to stare down death and defeat it.
Maybe that is why so many medics leave the field because they learn that they often can’t do what is asked of them. They can’t always beat death, they aren’t always sure of the decisions they make, and often, they aren’t even asked to fight death at all. Their more daily opponent is not trauma or cardiac arrest, but vomiting, back pain, mental illness, substance abuse and age. Instead of the Reaper they fight overburdened health care systems, and are rewarded not with medals and plaques and televised reunion picnics, but with their own back aches, bills and fear of growing insignificance.
I contend that to last as a paramedic you need to ditch your ego all together. You still need to take control of a scene and act decisively, but the manner in which you do so is different. You act not for yourself, but for the patient. You no longer need every eye on you, you don’t have to boast of the two lines running wide open, the digital intubation, or the number of times you shocked the patient and how you got all the way down the algorithm to bretiylium. You can still have tales of how you challenged death, but the tales that mean more to you now are how you calmed down the anxious patient, brought pain relief to the hurting, and held the hand of the lonely and said something to make them smile and feel cared about. You are as nice to the dialysis patient as you were to the bleeding girl entrapped in the car; you are as thorough with the cancer patient as you were with the man having the massive MI. You learn their names and you tell them yours.
No one makes the transition all the way or all the time. There are days when I am boastful, days when I am resentful, days when I let my frustrations flow, when I ignore my patient and mail in my performance – doing nothing more than taking them to the hospital and getting their billing information. But there are enough days now, when even if I don’t feel my medicine is challenged, when I lack the great dramatic story to tell that I still get satisfaction from simple human contact. That is why I am still out on these streets twelve full-time and mega-overtime years later.
I write all of this as a preface to tell you about my latest trip to the Dominican Republic as part of a surgical mission. This is the second year I have gone, and each time I have had much anxiety about what I would be asked to do. The first year was harder in that it was the unknown. I was the lone paramedic on a team of over thirty doctors, nurse anesthetists, and registered nurses. There was one EMT beside me. I did not want to be the one given the mop, even if it meant I could hand it to my EMT assistant and tell her to mop under my supervision. I wanted my profession and myself to be respected.
The first year with seven surgeons and four operating tables, we turned out to be very busy. I found many opportunities to get involved. Before the week was out my initial assignment of “We want you as a helper in the OR, but don’t touch the instruments, we don’t want anyone to get hurt,” turned into a valued role in the caring for patients both pre- and post-operatively, using all of my EMT skills from IV insertion to assessment and medicine administration as an equal to the nurses.
This year, due to the larger number of nurses and only two surgeons (one a resident) meaning fewer patients, I felt the same anxiety. Who’s going to get the mop? My anxiety was made worse when on arrival we found they had added numerous college student helpers and two more translators. I might not even get the mop nor be needed to translate? I might not have a purpose.
I was first assigned to triage new patients. But then on the first full day when the Spanish interpreter for pre-op fell sick, I was reassigned, spared to my way of thinking, and I spent a useful morning speaking Spanish and putting in IVs.
The next day when the other translator recovered I was back out in triage working with a nurse who not only knew more about assessing hernias than I did, but who was Cuban born and spoke flawless Spanish. Fortunately, we got along well, and developed a system where I met the patient’s on the benches in the hallway, got their names, dates of birth, addresses, and took their vitals and weighed and measured them before sending them into the room for her to obtain the full medical history. We were an awesome team.
But as the week went on and triage dwindled, my assignment was to the post-op area. There during the previous year, at times, I had handled the entire room on my own, at others with one or two other nurses. Now had to share with six other nurses and far fewer patients. My Spanish was often needed – at least until the Cuban nurse entered the room, when the other nurses no longer asked for me to translate or give discharge instructions. Often in fact I had to call the Cuban nurse to assist me in translating, which of course was all for the best for the patient.
One particularly slow early afternoon I was asked if I wanted to go back on the bus for lunch and I responded, sure I had nothing to do. I thought about my comment that afternoon when I returned to work, well-fed. Nothing to do. I was in a room with five patients and their families and while at times there were anywhere from one to six nurses in the room, some who wandered in an out, checking vitals or if meds were needed, I started to keep my eyes open. I saw one nurse in particular, who did more than just check vitals and give post op meds. She had an eye for the patient’s comfort. Let’s get this one off the hot paper sheets they came wrapped in from the OR, or let’s sit him up, he looks uncomfortable. It was the eye for the little detail.
Thom Dick, in his great book, People Care: Career Friendly Practices For Professional Care-Givers writes:
"People don't remember much about our medicine. But they do remember how we make them feel."
I have found that to be true. I started looking for the little thing -- getting a patient or a family member a cup of water, talking to them instead of sitting on an empty bed, making them more comfortable. The head nurse had me take care of two patients directly and I made certain I knew everything about them so when the doctors came by to check, I was not just reading what was written in the notes. I knew the patient and about their lives.
Most of the patients I had met while doing triage. I came to understand that I was, in a small but important way, the face of the project for many of them. I was the maitre d’, the man who had walked them into the door and promised access to the experts. I saw if I was not the one translating their discharge instructions (I sought out the Cuban nurse to make certain they understood everything,) I made certain I was there to say goodbye to them. I did fewer procedures this time* and gave less medicine, but I felt immensely valuable not so much to the team, but to the patients.
At the end of the week when we met as a group to talk about our experiences of the week, I said something similar to the above – how I learned there is never nothing to do. That is what I hope I have brought back to the United States with me. When what I need to do is done – my assessment, the IVs, the monitor, the 02, the medicine are done, I need to see what else there is do because there is always something else to do – talking to the patient, making them more comfortable, making them feel that they are not alone, that someone – that a paramedic – that all paramedics care about them. Each and every one of us is the face of our profession. We are the maitre d', as well as the chef and the dishwashers). Our job is to give our patients the best most painless experience possible during a difficult time.
***
I would like to talk about just one patient I had this week – an eighty year old gardener who had a had a hernia since childhood, a hernia so big you could see it through his clothes like he had shoved a football into his pants. He came in the middle of the week after the head surgeon had already said no more patients – we are booked full. We were just writing people passes for the next mission that was to come to a neighboring area in September. But we had the man with the hernia wait until the doctor was out of surgery. When the doctor saw him, he said, as he did of other people, "We have to add this man to the list." And we did.
I sat with the old man the in the post-op room. He had no family of his own. The woman who he gardened for came and sat with him. She told me how she had watched him all these years and how he had struggled with the hernia, what a miracle it was to see him now. He was discharged the next morning, but he didn’t want to leave, he kept shaking all of our hands. I’d catch him over and over looking down at his waist where the hernia used to be, then looking up at us and smiling. When we said goodbye, we embraced like old friends. He knew my name and I knew his.
Going on a medical mission to the Dominican is a great place to check your ego, to replenish the things that can make you a better medic and a better person. I know in the coming year, I will often fail to live up to the standards I would like to uphold, but I know I will still be out here trying.
For information on the organization and a trip calendar of future trips, go to:
Medical Ministry International
For my daily account of the trip go to:
Paramedic Journal: A Year on the Streets
*I did get to insert an LMA in the OR thanks to one of the nurse anesthetist swho showed how it was done (We may be getting them on our trucks soon) and also scrubbed in on a thyroid removal where the surgeon let me palpate the crico-thyroid membrane and the trachea after the incisions had been made and the neck opened up (Not a lot of room to put an airway through).
