A letter I received from a reader recently has gotten me just as mad as he is, even more so maybe. This letter came in from someone who identifies himself as a paramedic but asks that I protect his identity and location completely. I will do so, only identifying that the letter comes from someone who works out west, somewhere between the Mississippi and Montana but not east as Maine or as far south as Amarillo.
So He comes from somewhere in the US, not the east coast, and not Hawaii. Heís a paramedic and heís male. Thatís all Iíll say. Iím going to work the things he wrote me in his letter with my thoughts and feelings on what he wrote and the situation he wrote about. Iíll rewrite the letter keeping the point of it intact. Iím fairly sure that youíll be just as angered as I. (Note Ė This is LONG but itís good. It will probably tick you off too, enjoy)
So the other day, I made a decision. I was transferring a patient from a small ER to a larger hospital a short distance away for an inpatient admission from the emergency room. This patient happens to be one of our regulars, and Iíve come to know him pretty well in the course of taking care of him over the time that Iíve worked here. Heís legitimately sick, and certainly has been dealt a poor hand by life. His list of ailments would confound a gerontologist but prove terribly daunting for her team of doctors taking care of him as a young adult. He has been in and out of hospitals since his adolescence and through his contact with medical care has contracted MRSA, one of the scourges of the contemporary age.
Normally, taking care of this patient is a pleasure for me as he is always a good conversation and my familiarity with his conditions has given me a comfort level while in his presence. However, something troubled me with this trip.
This time the patient was being transferred to a room number that I recognized as being on the Mother/Baby unit at the receiving facility. I knew that their policies would never allow an adult colonized with MRSA to lie in the same bed normally occupied by mothers and babies in their most tender first moments. The risk of cross-contamination and infection is too great to allow such a thing and a newborn infected with MRSA may not fare well. Transferring him into that bed put mommies and babies at risk, and I recognized the danger.
Hereís the rub though, the nurses in the small ER had arranged the transfer with the nurses at the receiving facility. They were all hospital folk, and had more experience in the hospital than I do. They arranged it, and if I had voiced my objections I would have been perceived as a troublemaker and as the bad guy. I knew what I was doing was unsafe for every patient currently on the mother-baby unit of that hospital and could pose a risk to every baby born there in the future. Sure MRSA isnít the end of the world, but why increase the risk to a newborn?
I think that weíve all been there, and youíre right. MRSA isnít the end of the world these days. Pretty much everybody has it, and itís nearly impossible to eradicate from the healthcare environment. If youíve read my stuff on limiting the spread of nosocomial, or ďHealthcare Acquired InfectionsĒ (HCIs) youíll know that I try to keep my personal paramedic practice clean and to limit my own risk of spreading the disease between my patients as much as possible. With that said, buddy, Iíve been there. Iíve been in the position many times where I saw something improperÖ something that could potentially hurt someone, and have known that if I were the one to speak up, I would be the one considered to be the agitator. I would be the ďUppityĒ paramedic causing problemsÖ itís a tough call.
The letter continues:
I ended up holding my tongue and not speaking up. I knew that I wouldnít be viewed favorably if I had said anything and I didnít want to create problems with the receiving facility. Honestly, Iíve spoken up on some bigger issues in the past and I decided to pick my battles on this oneÖ I didnít need them mad at me for yet another issue that they thought to be trivial and I wasnít in the mood for trouble. I put the patient on my cot and gave him excellent interfacility care and a comfortable ride to the receiving hospital. Then, I wheeled him right up to the mother/baby unit and put him in his bed in the birthing suite. I didnít like itÖ and the nurses who worked the unit seemed to be a little spooked by the complexity of the patientís multiple conditions. I explained it to them in detail because of my long-time relationship as an acute caregiver to the patient. Then, when they seemed satisfied with the report, I left the room. My partner and I began heading down the hallway towards the elevator when we were met by the House Nursing Supervisor who stopped us and asked us ďDid you know we canít have him on this unit? Heís got MRSA! We canít have him up here!Ē
I said ďIím really sorry about that, but this is where everybody told us to take him.Ē
She left to go into the room, presumably to arrange transfer of the patient to another unit that would pose less of a risk for cross-contaminating the most vulnerable of patient populations. I think that it was a good idea for her to do that. I still canít believe that there was a breakdown in communications, forethought, or whatever on the part of all of those other professional medical people that would cause this inappropriate room assignment and an additional risk, albeit a small one, to mommies and babies.
Sure, itís not the end of the world. I know that. However it was still inappropriate and should have been caught by someone. Iím just as guilty as everyone else because I didnít speak up, or even ask anyone a simple question. (Insert Melodrama here) if just one baby gets infected with MRSA and has a poor outcome or even dies, am I partly responsible for that? (End Melodrama)
Well, I feel your pain. You probably arenít a baby-killer just yet, although youíre right to think that there is a chance. Hospitals have infection control procedures for a reason and HAIs are the 4th leading cause of death in the United States. So itís an issue. It could have been a simple oversight on the part of the small ER who didnít work for the receiving facility, but the receiving facility should have known to follow their own polices. They could be less at fault here if the small ER didnít inform them of the MRSA, which in turn is possible for them to have forgotten. Thereís a lot of wrong here. Yes itís a small issueÖ but what if the disease were, say, ebola or something. What if this were something that would immediately cause people a lot of harm? Chances are that someone would have caught itÖ but what again if that person were you, should you speak up?
This wasnít the only case that the letter refers to and let me read this part of the letter to you as well. Letís see if you can see how these two incidents tie in together:
This case got me thinking about another case where I spoke up on behalf of what I thought to be right and have been raked over the coals for doing so. I was dispatched to a private emergency call in another ambulance serviceís jurisdiction to take a patient from his home to the med/surg unit of a hospital that we only occasionally transport to. It was a non-emergency request through a home healthcare agency and the patient had originally been transported back to his home via our service. In fact, we were talking with the crew who had taken her to her home originally when we got the call. They said that just a few days prior when they transported him, he was a remarkably pleasant patient and that they enjoyed taking care of him. They wanted us to say hello for them.
We drove the 25 or so minutes out to the patientís house in an affluent part of the county and when we arrived on scene we were met by a male who identified himself as the patientís son. He looked positively spooked and told us that the patient had been having a fit of rage for the last 24 hours or so. He said that he was paranoid, combative, and was convinced that his family was trying to kill him. He wished us luck and told us that this was going to be a tough one for us. Compounding all of this was the fact that the patient was up some steep multi-level stairs and down a tight hallway. We were going to have to use our stairchair to get her out. They also informed us a bit on the patientís condition, which was basically intractable cancer and palliative care with a valid DNR order in place.
Iíve been in plenty of these situations before over the years, and my thought is that it is better for a patient to be mad at me if they are to be mad at anyone, lest they spend their last days on Earth mad at their loved ones. Iím a professional. I can take it. I informed the family members down in the foyer that I would play the role of the ďbad guyĒ so that they could be the good guys in the situation and that I would be the one that the patient should be mad at, not them. They seemed to be relieved and agreed to this before we made patient contact. We climbed the stairs together and entered the room.
The patient was loud and was yelling at an obviously frazzled home healthcare provider who was trying to get him calmed down. As soon as he saw us walk into the room in our uniforms he said ďOh my God! Youíre here! Take me to the hospital! These people are trying to kill me!Ē and began to cry. He was definitely paranoid and most definitely very agitated. I walked over to him, introduced myself, and told him that we were taking him to the hospital so they could take care of him. He immediately calmed down and tried to climb out of bed to go with us. He was still relatively healthy in the early stages of his hospice care and could almost get out of bed on his own. I asked him to wait a bit so I could take a look at him before he got up.
This is where the situation starts to go South. You see, I am a paramedic and not an ambulance driver. My job is to provide excellent healthcare to the best of my ability and scope of practice and not to just give a ride to the hospital. I assess every patient and treat them as they need me to. Thatís what I did here. I found him to have tachypnea, a very low pulse-ox, and to be markedly tachycardic above 160. This was a sick man, and an unstable patient. My professional judgment was that this patient was wholly inappropriate for an unmonitored bed in a regular Med/Surg unit. Sure, the patient has a DNR, but DNR has never stood for ďDo Not TreatĒ and this nice man needed immediate treatment to calm his symptoms and ease her suffering. My guess is that his agitation was being caused by his hypoxia and tachycardia, which was also being compounded by the fact that she was suffocating to death.
I let my partner know that I wanted to get the patient into the ambulance so I could correct his hypoxia and take a look at his EKG tracing. I opened up the stairchair to get it ready for him and handed our standard paperwork to the family for them to fill out the demographic information and sign the proper forms for us. Then my partner and I lifted the patient to the stairchair, wrapped him up in a blanket, strapped him in, and began wheeling her out of the room to the staircase. As we did so, I mentioned to the family that the hospital may wish to hold the patient in the emergency room for clearance before admitting him to the floor as his condition may warrant that.
Thatís when everybody started yelling at me.
Nobody in that room wanted the patient to be taken to the ER. They were adamantly against it and were immediately mad at me for even suggesting that he might be taken there. They were pissed. A lot of statements berating me, my professionalism, my care, and even my integrity were thrown at me in a very short amount of time. As someone who understands the grieving process that a family experiences in a time like this, I understand when they need to lash out and as a professional Iíve already mentioned that ďI can take itĒ. A lot of what I thought to be calm, compassionate, and professional talk peppered with a lot of ďSirsĒ and ďMaíamsĒ came out of me as I struggled to carry the patient through the narrow, twisty hallway. The patient sensed the discord that was taking place and got immediately mad at me for angering his family. I had said that I would be the bad guy, and now I was. They were all hopping mad at me.
My partner and I got the patient down the stairs and out of range of the family only to have the patient balk at letting us lift him to the cot. He imagined that the papers I had given to the family were some important and shady legal documents that he absolutely needed to have in his possession before we took him away in the ambulance. Finally, seeing no way that I could convince him otherwise, I went back up into the family room to get the papers while my partner waited downstairs. I was again met by the anger of the family. I honestly, truly tried to explain to them that the patient was unstable with something that we could maybe fix in the short term that would make him much more comfortable in his last days, that I understood that he didnít want any heroic measures, and that I was at the mercy of my medical control physician who controlled such things. They were still angry at me but agreed to handle it at the hospital. Heck, even the home healthcare provider laid into me on this oneÖ like it was my fault that he didnít understand the difference between a stable and an unstable patient. Isnít it his job to provide palliative care and to keep the patient as comfortable as possible? Isnít it his job to know that treatable suffering should be avoided and to know that hypoxia causes agitation? Isnít it his job to work with the entire spectrum of the healthcare team to provide the absolute best patient care in any circumstance?
Oh buddy, Iíve been there. I know that these situations are just plain hard for any provider to manage when you add in the dynamics of a hostile family taking out their justifiable grief on you, the healthcare provider; Iíve been there when people interpret ďDo Not ResuscitateĒ orders as ďLet the patient suffer and die quickly from treatable conditionsĒ orders; and Iíve certainly been there when Iíve been considered an ďAmbulance MonkeyĒ who should just ďShut up and do what youíre told!!!!Ē. However, letís continue with our colleagueís letter.
After I escaped the family and got back downstairs, my obviously frazzled partner had gotten the patient onto the cot with the aid of some of his friends that had stopped by and calmed him down. We buckled the safety belts and beat feet right out to the truck. I hopped in the back with the patient and my partner got up front to just leave the angry scene as quickly as we could. Luckily, the patient was amenable to letting me treat him and I placed him on oxygen via Nasal cannula, on an EKG which showed Sinus-Tachycardia, and he even allowed me to place an IV. He appeared to be dehydrated and I checked his blood sugar for a precaution just to be sure he wasnít hypoglycemic. He calmed down markedly with the oxygen and the fluids. His vital signs came back into more normal ranges and while he still wasnít out of the woods as far as his acute symptoms were concerned, he was a bit more comfortable and stable with the care.
For a few minutes, that is. He fixated back on the paperwork that I supposedly had given to his family and even though I gave him copies of the standard forms for him to peruse, he was convinced that I was doing something nefarious. He started to become agitated again and tried to rip his IV out. I stopped him and he grabbed my hands to restrain ME from stopping him. Owch. I figured that him holding my wrists was better than his ripping out his own IV and I let him continue. I was able to get my cell phone out and dialed up the receiving hospital to give a report. I thought that I painted a calm, cool, and detailed picture for them and suggested that I would stop in the ER for them to take a quick look at before going up to the floor, since at their small community hospital they bring every patient in right past the ER nursesí station. As they answered me incredulously, the patient dug is fingernails into my wrists. I thought I maintained composure over the phoneÖ but when I said”good luckĒ to them they must have gotten mad at me. They said that they would meet me upon my arrival, which took about another ten minutes for me to arrive there to do so.
After taking the patient out of the ambulance he was very much relieved to be back in the hospital. I explained the situation to the ER nurses and the ER physician, including the patientís condition and the family dynamics involved. They assessed the patient and paged the admitting physicianÖ who stated that he didnít know that the patient was unstable and refused the admission to Med/Surg pending clearance in the ER. The ER staff wasnít too happy about having an additional patient to attend to, and I could only imagine how mad the family was going to be.
So let me get this straight. The ER being mad about taking a patient who could have been a direct admit and would have been otherwise none of their concern is a familiar theme for me. While I donít agree with it, I know how they can be sometimes and honestly I can see how their constant condition of being overworked and underappreciated can color their attitudes. I get that. What I donít get is what the family and the ďHome HealthcareĒ person had against the patient being cleared in the ER. Youíre right that paramedics, EMTs, and EMS personnel are not simply ďRides to the hospitalĒ and must use their professional judgment with every patient. You have to do an assessment, you have to provide an appropriate treatment, and you have to advocate on behalf of the patientÖ even when nobody wants you to. Itís your license and your career. Doing the best by every patient isnít always easyÖ but it is always the right thing to do. However, donít finish this letter because I can see where this is going.. donít tell me what happened next.. Just donít tell me that THIS happened.
A few days later I was called into my bossís office. He was livid to say the least. Apparently I got a formal complaint from the family, from the hospital, and from the home healthcare organization. I was the bad guy here everyone thought, and because of it we had lost the transport contract with the home healthcare organization, lost the contract with the hospital, and ticked off the family big time. My name was mud and my butt was in a sling. Apparently I was rude, I had acted against the wishes of the family, and I had interfered with the orders of two separate physicians. They accused me of ďNot thinking about the companyĒ and told me that if they had to lay off staff because of the drop in call volume that it would be my fault when they got laid off. They mentioned firing meÖ but what saved me was my impeccable record, the fact that my partner who happened to be a supervisor of a lower certification level had filed a commendation in my file for the way that I handled itÖ and the fact that as far as patient care was concernedÖ I was right. It was clearly acting in the best interest of patient care and the recording of my radio report that they played for me showed that I was trying to be politeÖ except for the ďgood luckĒ partÖ they were mad at that. I explained to them about the fingernails and the fact that I had been extremely polite to everyone concerned in the trying circumstances. I ended up not having any negative sanctioningÖ but they were still madÖ and the former contracts still arenít calling. I may have irreparably damaged my service by doing what I thought was the right thing to do.
ManÖ that just sucks. It seems to me that you were caught up in a situation where you couldnít win. Yes, you did the right thing by the patient and if everything you say is true, I commend you on your patient advocacyÖ but your boss is right, if the contracts donít call and send their business elsewhere, it hurts the companyís bottom line. Thatís a reality in for-profit, not-for-profit, and in all ambulance services that depend on transport revenue. I would say that if the relationship you had with the contracts was that tenuous to begin with that you arenít the root causeÖ but perhaps the situation was the last straw. I would ask what the home healthcare person was doing while you were taking the brunt of her inaction to correct the patientís immediate suffering or to communicate to the physician the seriousness of the patientís conditionÖ but my guess is that she was of the opinion that the patient was ďJust a DNRĒ.
And this is the part of the letter that really gets me:
The part of these situations that really gets me? The time that I stood up for the best patient care I got raked over the coalsÖ the time I potentially killed babies? Nothing.
There is so much at play here that transcends the experiences of the person that wrote the letter that I donít know how to address it without turning what has become a very long article into a chapter of a book. The way I see it, this is a breakdown on so many levels. However what slaps me in the face is the fact that apparently nobody in those situations respected your professional judgment. You were seen exactly as you put it, as little more than an ďambulance monkeyĒ who they thought was supposed to do exactly as you were told. While the first case was a mild example, you did what you were told to do and the hospital caught the mistake after possibly no damage had been done. While you could have voiced objections, youíre very much right that you would have been seen as the troublemaker and would have been told to mind your own business. I canít even imagine that you would have been vindicated when the nursing supervisor caught the errorÖ although that may be because your letter has left me with an aura of generalized cynicism. Sure, the potential existed to cross contaminate a neonatal unit with MRSA due to a medical error; you knew about it and did nothing due to internal politics. Thatís badÖ but understandable because Iíve been there.
The second case is worse. What do people expect when they call an ambulance? Do they expect you to just throw the patient on the cot and take them to the hospital as they told you to without giving an assessment, using professional judgment, or doing anything the way youíre supposed to? What about when you stood up, and you were punished for being an ďuppityĒ paramedic?
Iím so mad I canít see straight. I gotta take a break in writing thisÖ.
What we need as a profession is to be out there earning our professional respect. Obviously nobody you were dealing with had any respect for EMS and you and your service have paid the price for it because apparently they hold all the cards.
What this harkens me back to is the representations of the ďAmbulance driversĒ Iíve seen on every TV show or movie Iíve ever seen. Theyíre portrayed as bumbling idiots who run real fast, take orders from the shows main characters eagerly, and then scream off into the night doing exactly what theyíre told to by whomever they just met that seems to be in charge. Look at how the paramedics are portrayed in ER as intense, harried people that are just waiting to tell the doctors ďI canít do that, Iím just a bambilance driverĒ and canít seem to treat even the simplest of conditions. Iím actually pretty sure that is what some medics do in order to avoid confrontation, they do exactly what theyíre told and figure that the consequences are someone elseís problem. In fact, that may work out well for them as they never make waves and never get into trouble that way.
I tell my students that Iíve been doing this for more than ten years, and in this job when youíve been doing it for as long as I have, working around a bunch of type ďAĒ personalities whose jobs depend upon them being ďrightĒ the first time every time, that if a person hasnít ticked some people off they must be doing it wrong. I believe it. Anyone who advocates tirelessly for the best interest of their patients is going to tick some people off sometimesÖ It offends the most tired and or laziest among us when they are involuntarily compelled to do the right thing sometimes less they end up looking foolish.
I donít have an answer for you, anonymous paramedicÖ just keep doing right by every patient. And be sure to BE NICE. Thatís all I got. Well, that and push for professionalism and education. Push public education and perhaps set up a meeting with the people involved. Continue being the most professional and caring paramedic you can be. †You may not fix it fast, but collectively we all can make a difference.
We have to.