Burnout (with footnotes)

 I wrote this a couple months ago when I was feeling really burned out.  The burnout passed, as I knew it would, and I am back to myself, so I can post it now. (1)

I have been responding to 911 calls for twenty-six years, 21 as a full time paramedic with a busy urban commercial service (2). I have had periods of burnout, more when I first began than in my later years. Once you get used to the business, the stress and emotions of the job are easier to handle; they become almost routine. Lately, however, I confess, I have felt burnout creeping back up on me. It is less a burnout from the emotions of the job and more a larger existential tiredness.

I can identify a number of causes:

Our call volume is as high as it has ever been or perhaps a better way to put it is the ratio of calls to the number of available units is as high as it has ever been. (1/2) Most days I am cranking from the moment I sign on at 5:30 A.M. to the inevitable late call I get twelve hours later as I am trying to get back to the office for crew change.  Oddly, it is so busy that on days it is slow, I feel even worse, like the day suddenly becomes long and unbearable. (3)

We employ system status management which means no lounging on the couch watching HBO movie reruns or working out in a service exercise room. I am fifty-seven years old, six eight, two hundred twenty-five pounds, and I sit scrunched in the shotgun seat of the ambulance, posted on a street corner or driving from one post to another to another in city traffic. I don’t know what my lumbar spine looks like, but I am sure on x-ray, it is not pretty.(4)

My regularly assigned partner was reassigned to work in the office, handing out equipment and doing other odd jobs so we have worked together maybe only six or seven times since the last bid shift about three years ago. For awhile I was able to get an old partner and a great friend assigned to work with me on two of my three days, but he got hurt last spring and has been out ever since. They pulled him out of the car one day when we were precepting a new medic and put him with a new hire because we were short cars. He tore his arm up on a carry down when the chair went out of balance.  (5) I am hanging on, hoping he will be back in another month or two.

In the meantime I have had partner du jour, which means I have worked with just about every per diem and new hire in the company. Let me emphasize partner du jour, not partner du month or du week. Every day I come in I have a new partner, and they are predominately new hires, of which it seems we have an unending supply. Awhile back I worked two weeks in a row each day with a person I had never laid eyes on before.  Six new hires, of which probably only three are still working for us, and in two years, only one will likely be left

I have met some really nice people, and the new hires have ranged from excellent experienced EMTs to zero experience (6), and for the most part they are all strong enough to lift. I try to be nice to everyone remembering what it was like so many years ago when I was new, but I confess, the endless procession of new EMTs has worn me down. I don’t say much now. I try to be polite. It is hard for me to generate the energy at 5:30 in the morning to be much more than monosyllabic. (7)

Every day is like the movie Groundhog Day (8). I give the same directions I gave the day before, the same explanations. Go north on Prospect, take a right on Asylum, left on Scarborough, right on Albany, go way down to Garden, take a left there. Go to Capen take a right, Barber is your second left. Pull back on the stair chair tracks, make certain they are locked. No, we don’t have to patch in to Hartford. Area 10 is downtown. Put the stretcher back in the ambulance before you do anything else. (I have on several occasions found my partner in the driver’s seat with an empty back compartment and the stretcher back in the ED foyer.) (9) Make certain you put both a sheet and a bath blanket on the stretcher. Don’t tape the drip sets to the IV bags. (10) Did you resupply my in-bag after the last call? Never mind, I’ll do it.

I feel like an old grump. Maybe if I had the same new person everyday, it would be different. I would be more invested. One of the new hires was telling me she was talking to another new hire about how the older employees here were mean to the new hires. One new hire said to the other that she had brought that up with one of the older medics who said I have been here twenty years. I have seen hundreds and hundreds of new hires, most of whom don’t last six months, many less than that. You will go on to other things and you will talk about the time you worked Hartford EMS, and I am still going to be here, working with yet another new person.

On TV when they do shows about ambulances, there is always one new guy -- and only one new guy. Here it seems we have twenty new guys every three months. (11)

I am an old grump. I am sorry. I just can’t wait for my old partner to come back to work. When we work together it is just like hanging out. We do calls automatically. I know his moves, he knows mine. Our carry downs and patient transfers are smooth. We have a running banter all day that keeps our spirits up. (12)

Dispatch. I have only had a few times in my career where I felt in sync with dispatch. That was many years ago when I worked at night and we had only a few cars on. Our dispatchers were housed at the same base. We saw them at the start of the shift and at the end of the shift. We all went out drinking together on off nights. (13) Now there are so many cars on, and the dispatchers work in another city, and it all seems impersonal. A car is a car, a call is a call, and an address is an address. A computer could do it. A computer in fact does suggest to the dispatchers which car to send. I go to the EDP (Emotionally Disturbed Person), while BLS goes to the weak. I sit on scene for an hour waiting for the eight year old’s mother to come to the school, while the BLS car goes lights and sirens to the hospital with no medic available. Don’t even get me started on transfers.(14)

I don’t meant to smash on dispatch. I guess when dispatch does their job well, we don’t notice. We only notice when they make little sense. That said, I would not want to be a dispatcher. It does seem like a thankless job. Or rather they get thanks for different things than we do. Their job is to clear the screen -- that is what they are rated on, and where they get their kudos. Sometimes it just makes me feel like I am a mole in Whack-a-Mole. An ambulance pops up available, the dispatcher whacks it with a hammer (the next waiting call).

The corporation. I have been late four times in twenty-one years. Twice my alarm didn’t go off. Once I got messed up by the time change. And once my car broke down. Four times in twenty years. That is worth repeating. (I used to go years not only not being late, but never taking a scheduled day off.) The alarm not going off the second time happened back in November. I punched in at 5:42. I was still on the road in my ambulance doing a call by 6:00. A month later after a long shift, I was called into the supervisor’s office and handed an envelope, which contained a Verbal Reprimand for being late that one time. I had to sign the reprimand to acknowledge I had received it. I was told it shouldn’t be taken as a reflection on my work ethic, it was simply computer generated. Still…

I get off late every damn shift.(15) I bust it out there. I take care good care of my patients. I bang out my run forms, clear the hospital as soon as I can, because I know 911 calls are holding. Few can keep up with my pace. And yet I was looking at a piece of paper that said Reprimand on it. Some hardworking employees get these and say, “Yeah, whatever.” I wish that had been my reaction. I took it personally.

Computer-generated? A person gave it to me, and that person, who I like, and who was required to give it to me by his bosses, was an extension of every boss in the company leading up to the very top.

I am just Meat in the Seat. That’s me. At least that is how I perceived I was viewed by the corporation as I stood there with the Reprimand in my hand.

A while back, the Medical Director for the corporation, who I think is a great and well meaning guy, sent out a truly heartfelt video talking about employee’s mental health and how we all have to look out for each other. He was concerned because there had been a rash of suicides in EMS nationwide. I was touched by his concern, but his concerns do not match the day to day realities of the working life. (16)

I am glad I have other things in my world that I care about (17), but I can see how if EMS was all you had, if this was your identity, despair could grab a hold.

I have been here long enough to have seen a lot of medics walk off the job after many years -- some no longer able to do the job mentally, others no longer able to do it physically. I see others in the waning days of their careers as their ability to do the job dwindles. I have had partners who I used to sit in the front seat of the ambulance with going to calls, now laying on the stretcher in back , with me sitting on the bench, taking them to the hospital because they are old and sick and broken, dying. The sadness comes from the fact that in the end the company did not miss them. Another body was plugged in and the world went on. (18)

Years ago, there was someone from the corporation looking at how much money some of our medics were making due to overtime. I was at the top of the list. Six figures.  A friend of mine who was in the meeting said the suit exclaimed that no medic should be making that much money. He said it in a way to suggest I hadn’t earned it.(19)

I like to use the expression that as long as the check is good at the bank, I have no real complaint. And that is true. I work the hours. They pay me a union bargained rate, and I work as part of my own free will.

Thurgood Marshall, the first black Supreme Court Justice, used to wait tables at a white-only country club while he was in law school. A white acquaintance of his was dining there and witnessed Marshall being repeatedly called a derogatory word by a dining member. (20) The acquaintance asked Marshall how he could tolerate it. Marshall said something like, “He can call me whatever he wants as long he gives me twenty dollars (his usual tip). The day he calls me that word and doesn’t give me twenty dollars, I’m going to punch him in the nose.”

Territory: In the 20 plus years I’ve been a paramedic, our 911 service area has dwindled. Some of the areas we used to respond in, today other services handle the calls. In a matter of months one of the towns we have always served will start their own paramedic service. We’ll still do the transports. But before where I ran the call, now I will sit silently in back and defer to someone else, someone who has yet to work a day as a paramedic on their own (they are still being precepted by another service).  They will ride in on the call as if I am not even there. My run form will read -- see theirs. (21)

There are cycles to EMS as there are cycles to life. Lately, the calls have been mundane. I like to say I learn something new everyday in EMS, but the truth sometimes is you can go weeks without learning anything and without seeing anything new. The other day I did seven EDPs , not a one of them was very interesting and not a one of them made me smile, laugh, cry or experience any emotion other than annoyance.  A 12 year old threatens to punch his teacher.  A 70 year old does crack, stays up all night and says something rude to a woman in the lobby of his elderly apartment. All he wants to do is go back to his room and sleep, but instead he gets papered, and we have to take him in. A 66 year old woman who’s nurse says she needs a psych eval walks around the house packing up what she is going to take to the hospital, including a Christmas gift still in the box of a bathrobe, slippers and lotions. A 15 year old runaway returns home after being away for a week and the family insists she be evaluated at the ED despite a lack of complaint. An 8 year knocks papers off his teacher’s desk. A 17 year old with an anxiety history has a coughing fit and hyperventilates in between screaming. A 40 year old homeless man with two hospital bracelets on his wrist wants to go back to the hospital because he says he still wants to kill himself. I don’t say anything. I just nod and say, “What hospital can we take you to?”

If I were king for a day, I would pass a ruling that all crazy or misbehaving patients stay in their homes, and all crazy and misbehaving patients out on the street would be made to go back into their homes, and not come out for 24 hours. I would have one day a year where people were not allowed to call EMS unless they were truly dying. I would make it stop raining.

Not that I have only done EDPs and BLS calls, I have done my share of traumas and strokes and chest pains, but they have all been by rote, which I guess is a good thing. I have my routine down so pat in my muscle memory that no matter my mood or spirit, the work gets done. Have chest pain? You get a 12-lead and ASA. Possible stroke? Cincinnati scale, last known well time, blood sugar, stroke alert. Hit by a car on your bike and have a broken leg? Clothes get cut off, cervical collar, IV, pain meds, trauma patch.

The hospitals are changing also. Their turnover rivals ours. Everyday I see nurses I have never seen before. The other day I watched a twenty something nurse yell at a patient as if she were a fifty year old battleax yelling at a patient. Go work on a floor if you are going to have an attitude like that, I wanted to say to her. (22)

I stopped yelling at patients years ago. Sick or not sick, it is so much easier to be nice.

So why am I still here besides the paycheck? Because I know it will not last. It may be next week or tomorrow, or better yet the next call, when I feel it all again.

In the meantime, I do have a few moments that keep me going. Those are the moments when it is me and the patient. When I treat them as a fellow human -- they appreciate it because that treatment is not an everyday thing with some people. I have not burned out at that level. That interaction is what keeps me going, it is what keeps most of us who have been doing this a long time going. (23)

***

(1/2) On slow days it is common practice to take cars off the road, thus the remaining cars suddenly get much busier with fewer other cars available to handle any slack.

(1)  This was probably the most burned out I felt since the early burnout most every EMS professional encounters and passes through if they are to continue in this field as their profession.  I think sometimes the most burned out people are at the one year mark (depending on their service conditions and volume) and they mostly leave the field.  They may wonder what the point is, and seeing none, go find something else to do.  Those who stay either see the point, or lack alternatives.  Those without alternatives are the ones we should be most worried about.

(2)  For about ten years or so, my regular assignment was on a suburban volunteer ambulance of moderate call volume,who I was contracted to work for, but as I did 40 hours a week for them in three days (2-12s and 1-16), I regularly worked twenty plus hours overtime in the city over the other four days with some time off, so other than the first three years of my EMS coordinator job when I only worked the suburban shift, I have always considered myself a city medic.  My suburban shift ended about four years ago.  The city shift, which I love, is still much more likely to produce burnout as it lacks the couch, TV, ability to sleep, cook a meal and ride a bicycle in between calls.  In the city shift there is little escape from the constant presence of dispatch, held calls, sirens and nonemergency emergencies, which is not to say there is not bullshit (abuse of the 911 system) everywhere -- it is just a matter of degree.

(3) People can get used to any conditions.  Change, the unexpected, produces stress.  I would rather be getting slammed, than have to sit and wonder why I am not getting slammed, expecting it at any moment, but not getting it.

(4)  To properly stretch out and remain in the ambulance, I have to either go in the back and sleep, which is not permitted, or roll down the window, open the door, and stick my legs out the window, resting on the open window, which is not professional, requiring us to find an out of sight location, where provided there are no drones flying above us,we can truly relax.  Years ago when I worked at night, my partner and I used to take turns sleeping in the back. I could sleep soundly, and yet always hear my number being called, which was important as most of my partners would fall fast and profoundly asleep sitting in the front as most worked prodigious overtime as I did.  A problem with attempting this now is while I am assigned to one car, I often am put in another due to the car being down for service or the night crew still being on a call, and they need to get us on the road.  The older I am the more I think I am in my regular car and not in the different numbered replacement car.  I am constantly telling the various dispatchers we have to talk to (company, police, and CMED) the number  of the car I was in the day before.

(5)  Working with an unfamiliar partner, I think is the most likely way to get hurt on the job, particularly when moving a patient. There was a story about this I read recently, but am unable to find, which basically showed worker injury decreased as their time with a partner increased. A new partner can move suddenly and unexpectedly in ways you cannot anticipate, and you have to try to suddenly compensate.  The result can be injury as it was for my regular partner the day they put him with a new guy.

(6) The company seems to be trying to figure out who the best new hires are.  When they hire experienced EMTs in large quantities, these tend to be younger people who may be less mature, less likely to show up reliably.  When they go the other direction and hire older non-experienced people, many of these non-experienced people, while being reliable are apt to say, once they see what EMS is really all about, this work is not for me.

(7)  A friend of mine many years ago said what they liked about me was when they were with me, they felt like they didn't have to talk.  Talking wasn't required.  When you work with a regular partner-- a good one, after awhile talking is not required.  We have some older medics who have regular partners and who may not say a word all day to them, and it is fine.  I worked one day with a new person who ended every statement with a question mark -- almost demanding an answer.  Example ( The weather is great today, huh?  This implies I am supposed to say, "Yes, the weather is great today."  If I don't answer I am rude.  "Huh?"  "Yes, the weather is great today."  "Don't you like when it is sunny, huh?"  "Yes, I like it when it is sunny."  Another new person asked me questions all day long.  Do I have any hobbies?  What is my favorite movie? Do I have plans later?  Once I stop answering or answer in only grunts, stop asking.  Some people have no awareness.  These are also dangerous people to work with.  If they can't figure out I don't feel like talking, how are they going to figure out what their patient's next move is going to be?  To patient: "The weather is good today, huh?"  Patient punches them.

(8) Ground Hog Day is of course the Bill Murray movie where he wakes up and every day is the same.  Eventually he learns to take advantage of it, but then it leads him to despair.  The difference between his Groundhog Day and mine is my situation is the same every day, but the people I deal with are different.

(9) This, of course, can happen to anyone.  See The Stretcher.  But once it has happened once, it should never happen again.

(10) I think more medics than not like their IV bags taped to the drip sets.  I don't. I hate ripping the two apart.  I would rather reach for the IV bag and reach for the drip set unencumbered.  For the same reason, I hate it when all the IVs of different sizes are rubber-banded together.  At least leave the 20s loose.  Unless the patient needs fluid, I usually always just reach for a 20.  Don't make me futz with a rubber band.

(11) Imagine a scene where the movie producer says to the scriptwriter.  "We don't need twenty new guys!  I don't care if twenty new guys is more authentic!  We don't have screen time to introduce all twenty plus I am not paying screen actors wage for 20 new guys!  I just want one, give me one new guy!

(12)  We tell people we are brothers -- same mom, different fathers.  Our Mom was in the circus, his Dad was the midget, mine the lion tamer.  He tells them my job was to wash the giraffes (because of my height), I tell them the only reason I work with him is a bar room promise I made to our Mom before she took off.  "I can't stand your brother anymore.  Promise me, you'll look after him."  "Okay, Mom, I promise."  Humor goes along way, even if you are funny only to yourselves.

(13) Ah!  Those were the days! We thought they'd never end.  Mary Hopkins.

(14)  This has gotten a bit better.  For awhile, a couple years back, they were in all cases sending the closest car to the transfer, instead of the closest BLS car.  I may go a week now without doing a transfer, but every now and then I might be banged with three in a day.  In this job you can go from being under a car, trying to extricate a bloodied and injured patient as the crowd screams at you to sitting in a doctor's office waiting room reading Better Homes and Gardens waiting for the receptionist to call your patient's name.

(15)  This week I actually got off five minutes early one day!  The other two I had late calls.

(16)  Many corporations have people who work at cross purposes.  They employ the slave driver with the whip and the nurse to apply salve to the wounds.  I wonder if the slave driver and the nurse complain to their spouses about the other, or perhaps they go out for beers together after work and toast each other.

(17)  My family, my writing, swimming as fast as I can, the Boston Red Sox (The Boston Celtics and New England Patriots to a lesser extent), my friends, Vietnamese ba minh sandwiches, the works of Homer, going to Jamaica, world peace.

(18) One day we are six feet tall and bullet-proof, the next we are alone in a nursing home.  The Circle of Life.

(19) I have this first hand.  Years ago I heard a third hand story where a top executive of an ambulance corporation when told a medic was having trouble paying his mortgage, said the company shouldn't be paying their medics enough for them to have mortgages.

(20) The N word.

(21) Our state has a different EMS system in each town.  It leads to a tremendous waste of resources.  In one town you and your partner are the only people responding, in the next, you are on scene with ten other responders (four  of them medics, three EMTs, and six first responders)  (ambulance, fly car, fire engine, police car)-- all for someone with a rash on their groin.  169 towns, 169 EMS systems, all in a state smaller than some counties in other states.  One town I know of has fire independent fire departments within it's borders.  Crazy.

(22) She, I trust, will in fact do this.  She will succumb to the first phase of burnout that weeds out many who don't belong.

(23)  And it will keep us going.  In the words of the preacher on the Gospel radio station "Thank you Jesus, Thank you Lord." (24)

(24) I have to end on a footnote of a footnote.  This line is from the Rolling Stones classic "The Girl with Faraway Eyes."

***

Two final notes:

1. EMS is still the best job in the world.
2. I still love and treasure my job.(25)

(25)  My old partner is coming back to work with me.  At long last!  See you next week, Jerry!  If you can get you tired old butt out of bed and be there at 5:30, old man!

American Pain

Two tattooed muscle head dudes in their twenties, one a convicted felon, who used to work construction as well as sell steroids, started a small business in which they hired a doctor to write prescriptions for pain medicine to most anyone who came through the clinic's doors during business hours. The doctors got $75 a prescription, and were encouraged to see as many patients as possible, and $1000 a week for the use of their DEA MD number to order the pills. In no time, the clinic's waiting room and parking lot was overflowing. Within two years the Florida business, officially named "American Pain," was bringing in $40 million a year, 1000 other pain clinics had opened in the state and places like Kentucky and West Virginia* as well as other Eastern states were besieged by a public health and crime crisis of addicted citizens bent on their next fix. Two years after its doors opened American Pain, as the largest pill mill in Florida, was shut down by the DEA and the young entrepreneurs were on their way to jail, along with a few of their doctors, who were charged with the deaths of patients who overdosed.

*Kentucky and West Virginia had already tightened down on opiate prescriptions so their citizens headed south in van loads to go to Florida where there were basically no restrictions.

American Pain is a fascinating read, but oddly at the end, I felt myself somewhat rooting for the tattooed young men and a couple of the doctors, despite their actions, to get leniency. I am more of system responsibility guy than an individual responsibility guy. I hold individuals highly responsible, but I also think systems should be held to an even higher standard. What rankled me in the end was like the financial crisis and housing collapse, none of the powerful people who made it happen and who richly profited (billions) from it, ended up going to jail, and it was the common man who suffered. The system let these knuckleheads run their business, complete with highway billboards advertising their wares, in plain sight because they were really no laws against what they were doing.

There was little state regulation of pain clinics and the clinic's doctors were following the "pain is what the patient says it is" mantra. The clinic tried to comply with laws in their own shady way, requiring MRIs (they made money on referrals) and urine tests(clean urine was evidently so available you could buy it at areas flea markets), and occasionally refusing to prescribe to clients who showed up under the influence.

In the pill mill crisis, the real bad guys were the pharmaceutical companies who made billions on a drug OxyContin that they knew was addictive and knew was easily abused, and who hid that fact from doctors as they launched an aggressive marketing campaign to promote the drug, and surprisingly the DEA, who on one hand was trying to stop over prescribing and street diversions, but on the other was approving the manufacture of larger and larger quantities of OxyContin at the manufacture's request. Can you say political influence? The book points out that earlier national epidemics involving the misuse of Quaaludes and amphetamines had ended largely because the DEA had cut supply. In the OxyContin epidemic, the DEA did the exact opposite, helping the pharmaceutical company, Purdue Pharma, flood the markets with a killer drug.

What was most amazing to me is all of this was allowed to happen in 2009-2010, despite the publication of the 2003 expose Pain Killer by New York Times writer, Barry Meier, who laid out almost the same scenario of drug company promotion, widespread prescription writing, addiction and crime, with the DEA largely going along for the ride by upping the drug limits.

The sad twist to the tale of Purdue Pharma's billions, and the pill mill business owners and their doctors who wrote prescriptions for what they convinced themselves was legal, but perhaps morally unethical profit, is the crackdown on pain management through prescription opiates has both launched an unprecedented heroin epidemic (shut off from pills junkies have turned to cheaper and more available heroin) and made proper pain management through responsible physicians harder to get for people in legitimate pain. 

EMS Opioids and Chronic Pain (2)

 I wrote recently about my new found concern about giving opiates to patients with chronic pain.

Opiates for Chronic Pain

Subsequently as a member of our regional medical advisory committee, I submitted the following draft proposal:

Paramedic Chronic Pain Management Guidelines (Draft)

Providing opiates to certain patients with chronic pain conditions may not always be in the best interests of the patient and has the potential to cause them harm.

Paramedics may consider deferring opiate pain management for patients with chronic pain if they have any of the following high risk flags:

Poly-Hospital, frequent EMS calls for same condition, allergies to analgesics and other relevant non-opioids, transfer request to distant hospital, history of substance abuse.

Paramedics should still document patient’s pain and institute other pain management techniques such as positioning, distraction therapy and guided imagery.

Paramedics should continue to treat acute pain and cancer pain aggressively. They also have the option to treat breakthrough chronic pain, after considering the possible risk to the patient.

***
I added the following note to the committee

Currently we provide pain relief to any patient with acute or chronic pain of 4 or greater. I have advocated for this in the past believing there was no harm to the patient. If, however, as some in the medical community believe, there is harm in providing opiates to certain patients in chronic pain, I thought we should address the issue. I have attached slides from a presentation on the issue by Dr. Rueben Strayer, along with his risk stratification strategies that I have adopted for EMS. While his lecture is directed to the ED, it has some ramifications for EMS.

I am no great rush to approve this document. I submit it as a unit of discussion, and would look for the guidance of the doctors on whether or not such a guideline is of merit.

***

I had second thoughts almost immediately after submitting it. My second thoughts were that because our pain management is so inadequate currently (multiple QA cases of patients with severe pain not getting medicated and general overall low rate of pain management), my proposal might give some paramedics an excuse not to medicate deserving patients.

When we talked over the proposal at the committee, a few others seconded that concern. I did not aggressively push it, and was satisfied that we agreed to look at how other systems addressed the issue of chronic pain.

***

Since I raised my concern, I have encountered a number of chronic pain patients in severe pain, and when dealing with these people face to face, I have found it difficult to not offer pain medicine. I give it, their pain is relived -- at least temporarily, and they thank me for treating them kindly.

I hope I am doing right by them.