Foot-in-Mouth-Itis. Stupid Things We Say in EMS

A letter I received from a reader who states that she is a paramedic student has gotten me thinking. Im going to include her letter in this post with her permission, but before I do I would like to speak a little bit about things that we say to patients. EMS and all of emergency medicine tends to be full of emotionally charged situations being handled by emotionally drained people. Sometimes our experience in dealing with situations that lay people find to be traumatic can lend itself to our making comments that we find perfectly acceptable to make at the time we make them, and yet upon reflection seem like the wrong thing to have said. I cant tell you just how many times Ive been in trouble for my mouth. I will say something that I intend to relieve the tension of a situation and to provide comic relief that I think is cute and funny, completely thinking that it is above-board and not-offensive to anyone, and then find out that some wet-blanket took offense.

Honestly, I make it my policy never to make a dirty joke. All of my patient friendly jokes are clean enough to tell to my five-year-old with nary an off-color word or adult reference in sight and sometimes still people look at me like Ive dropped a live weasel in the ball-pit at the McDonalds Play Land. Like some random time ago where a patient who had overdosed, scratched her wrists with a dull knife, and was found trying to hang herself apologized to me during my assessment of her because she hadnt shaved her legs. I said Oh thats quite alright, Maam.. You werent planning on needing them anymore and besides, you shaved your wrists real nice. I believe the question I got from my partner after the call was Does your Brain-Mouth filter even work anymore?! He was laughing as he said it, so obviously it was funny. The patient laughed too.

I have stock comments to the common questions and situations that come up on calls that I trot out when needed to liven up the situation. Some are movie quotes, some are lines that Ive stolen from other providers, and some are straight up from my strange brain. Like when I find someone lying in bed that needs to be lifted over from the bed to the cot with a sheet and a couple of people. Some beds are way too wide for me to work from my feet and its often useful to crawl right in bed alongside the patient to lift them over. I ask them So when was the last time you had a strange man in your bed? The unconscious ones almost always laugh. I have yet to have an older lady blush and be embarrassed and the comments I get back are always entertaining. Also, when Im palpating an area of a patients body to see where theyre hurting such as for an injured extremity or the like, if the patient yelps out in pain when I touch something I excitedly declare Found it!! Its much to their relief to know that I know where it is that they hurt. I also have what I call the Poor Mans X-Ray. If someone thinks that somethings broken on their body, I grab it, give it a good squeeze and a shake, and ask them if it hurts. If they say Yea that hurts its probably not fractured. If they say YEeeeeEEaaargh!!! it probably is.

So, exactly how serious do you think Im being with all of that above there? Heres the test. If you took me serious enough that you want to call my medical director to tell him to pull my license I was joking!! Ha Ha!

I remember probably the worst thing that Ive ever said to a patient ever, and in all seriousness I still feel bad about this comment to this day. Early on in my career I worked as a Security Guard *slash* EMT at a big regional 400 bed hospital/trauma center/psyche center/everything center. Usually I worked alone on weekend nights and it was an absolute zoo. While this was one of the most enjoyable jobs Ive ever held, I was in way over my head for an eighteen year-old country boy working in the big city. One day we had a patient come in who had been witnessed swallowing baggies full of what was presumed to be crack cocaine during a traffic stop. He was belligerent as all heck, swearing at us and trying to swing at the police officers who brought him in, the nurses, and myself. He looked at me and said So what the (colorful word) is going to happen to me now you (something my mother would be unhappy with me if I typed on my blog, or even thought about for that matter) I asked him So, are you a religious man? To which he replied Blankety-Blank No!! You Blankety Blankin Blank blank! I said back to him Well you probably should be, because youll need to be saying some prayers. Then he seized and went into V-Fib. I have no idea if he survived. I honestly feel really, really bad about that. I wish I hadnt have said it.

So when you read this letter, go easy on the paramedic student who sent it in. She seems to feel pretty bad about saying what she said and since Im going easy on her, you probably should too.

Here it is:

I did something colossally stupid today. Something so… irresponsible and cocky that I truly can’t believe I allowed it to happen.

I allowed myself… to assume.

To assume that as a paramedic student I knew enough about a patient’s condition that I could safely make a statement to a family member, when in reality, I should have just kept my mouth shut.

It was careless. It was reckless, and it resulted in a family being given false hope.

He was brought into the ER by two of his daughters for a syncopal episode. He hadn’t been feeling well for a few days, and his daughters had been forcing him to eat. When they found him on the floor next to his bed writhing in pain, they loaded him up and drove him over to the local ER.

His VS upon arrival were… less than ideal. Hypoglycemic, hypothermic, hypotensive. He had the hypo’s covered. His coloring was even less impressive than his vitals. A few amps of D50 and some warm blankets later and we had 2/3′s of the hypo’s resolved. He was no longer altered, he was flirting with the nurses, and the color had improved.

Still, his BP was crap. His tank was dry. He needed fluids, and after his third liter bag, his BP in the 60′s started to creep it’s way towards 70 and 75. I did a happy dance in my head.

Then it happened.

I was removing some of his blankets and replacing them with some that were straight from the warmer when daughter number 3 asked me a question. His blood pressure is still so low, should we be worried? Me. The only one in the room with them that had any medical experience.

Five sets of eyes were on me in an instant.

I finished tucking a piping hot blanket in and casually said something to the effect of, His BP is coming up, he’s just a bit dehydrated. One more bag and I’d be willing to bet that his pressure is better than mine.

Ugh. How could I let myself say something like that?

I didn’t know that he had a fractured hip.
I didn’t know he was in kidney failure.
I didn’t know he had a leaking AAA.

I didn’t know the complete picture, and I should have just kept my mouth shut.

I guess it goes without saying, but his blood pressure never came up. It dropped, and it dropped again, and it dropped again.

The family was informed of the complete picture. A DNR was signed. Hospice was called. He died before he could even make it to the inpatient hospice facility.

A family was given hope, because I gave it to them. And I had no right to do that. Watching them emerge from a family consultation room, one by one with blood shot eyes, holding each other when just two hours earlier they had been laughing and joking with their father…

That was probably the hardest lesson that I’ve learned in school. It’s one I’ll never forget, or forgive myself for.

——————————-

So the student who wrote this letter expects to be flamed for it Im willing to bet that the response will be just the opposite. Weve all been there. Well all be there again.

What about you?

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  • http://twitter.com/insomniacmedic1 InsomniacMedic

    I can almost guarantee that there's not a single person reading this blog who doesn't think “been there, done it, will probably do it again”. It happens to the best of us. Often it's a comment that's misinterpreted, misunderstood, mistaken for something else. Sometimes it'll be a case of the mouth bypassing the brain and just saying what it wants ,like me recently, at the scene of a cardiac arrest saying something about killing two birds with one stone. I was mortified the instant the words came out, and was lucky because none of the family heard me.
    EMS is a never-ending learning curve. Sometimes you learn from others, both their triumphs and mistakes, and sometimes you have to rely on yourself to provide both the teaching and the learning.
    Learn from it, remember it, and chances are you'll never make the same mistake again.
    But don't let it eat you up from the inside. Mistakes are not there to be punished – they're there to teach us how to do things better in future.

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  • http://twitter.com/insomniacmedic1 InsomniacMedic

    I can almost guarantee that there's not a single person reading this blog who doesn't think “been there, done it, will probably do it again”. It happens to the best of us. Often it's a comment that's misinterpreted, misunderstood, mistaken for something else. Sometimes it'll be a case of the mouth bypassing the brain and just saying what it wants ,like me recently, at the scene of a cardiac arrest saying something about killing two birds with one stone. I was mortified the instant the words came out, and was lucky because none of the family heard me.
    EMS is a never-ending learning curve. Sometimes you learn from others, both their triumphs and mistakes, and sometimes you have to rely on yourself to provide both the teaching and the learning.
    Learn from it, remember it, and chances are you'll never make the same mistake again.
    But don't let it eat you up from the inside. Mistakes are not there to be punished – they're there to teach us how to do things better in future.

  • K Jo

    She's right – this was one of the hardest lessons she'll learn, but one of the best. Take heart that I can't think of one provider I've worked with — including myself — that hasn't said something they regret on a scene or to a family.

    InsomniacMedic has it exactly right: remember the lesson learned, forgive yourself (this is the important part!), and keep moving forward.

  • emschick

    We've all said something we regret or didn't mean it to sound the way we did. (Um, actually, I did recently yell “FOUND IT!!” a few weeks ago then went “oh um er um, so on a scale of one to ten…”) The important thing is she learned from it and will do better in the future. We are always learning new tips and tricks, just add it to the file and move on to the next one.

  • PGSilva

    Come on…I'm the only one who's ever busted certain patients chops a little bit? Maybe, a little play on words or the occasional sarcastic/snarky/wise-ass comment. Let's face it, occasionally patients have a little ball bustin' coming.

  • Theresa Jones

    As a result of something I once said in the past, and got ragged for it pretty bad by others on my crew, I am now the strong, silient, polite, smiling type. I keep things very polite, cordial, respectful and the like. I've been there and done that too, like most and it hurt. But now I am just a bit more careful and only say what I have to and smile the rest. Great post and a great reminder to all.

  • Theresa Jones

    As a result of something I once said in the past, and got ragged for it pretty bad by others on my crew, I am now the strong, silient, polite, smiling type. I keep things very polite, cordial, respectful and the like. I've been there and done that too, like most and it hurt. But now I am just a bit more careful and only say what I have to and smile the rest. Great post and a great reminder to all.

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  • http://grumpydispatcher.blogspot.com/ The Grumpy Dispatcher

    No flames for the student. But yeah, get over the guilt. It isn't doing anything at all for those family members, but it might be harming your performance with patients since then and yet to come. Let it go with appreciation for the lesson learned, and move on.

  • http://twitter.com/in_the_city Angelo

    If she feels bad, she's good people. It happens, She didnt fracture that guys hip or make his AAA leak. Feeling bad is a natural human reaction she just need to not take it personally. It happens to all of us. About a year ago i told an entire family(daughter son at least 2 grandkids) that we'd take good care of grandma with a fever. They left the scene before we did. They were all standing in front of the ER when we pulled up and unloaded. I was stradeling the women doing CPR. I never forget the way that they looked at me. But I don't take it personally. And she shouldnt either. At least she took the time to offer comfort to a patients family.

  • http://sevyrr.blogspot.com/ Sevyrr

    One time I was toned out to an unknown medical and not given a short report. When we got on scene there was a bunch of people milling around outside so I smiled my best smile and said “Ok, who's the patient?” I got several very cold looks and someone said in a hiss “She's inside and she cold to the touch.” The patient was a DOA and the people outside were her family that didn't know what to do with themselves now that a family member had died. There was actually a complaint made to my boss for that one. So, take heart, it happens to us all.

  • Capt. Tom

    We never truly know. This student seems to learn her lessons (no matter how hard they might be) well. I don't see that she said anything out of turn. She relayed what she saw as a probability based on what she knew. Had the hospital not done the proper testing by protocol to identify the AAA? The Physician should have had a better handle on this. It's not fair to let a paramedic student carry the burden for a bad miss on the part of the senior medical staff. I lost a co-worker to the same AAA 3 weeks ago. He was under treatment in a facility for almost 24 hours where they focused on his “stomach pains” until the AAA burst. This is not something a medic in an E/R should know. Yes, she feels bad about the comment, but she shouldn't. She was providing care and hope. This is something we all need. This gal sounds like she is going to make a first class medic. Compassion comes first.
    Capt. Tom

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  • BaystateEMT

    We've all been there, especially us new people. I'm a newish EMT-B, I've had my cert for a year and man after I got it, I felt like hot sh*t, I felt like I was king of the world. It took a long time for me to realize that this wasn't the case, I really don't know all that much. Being a paramedic student I bet she felt confident enough to tell the family what she believed. BUT more over I think that she was trying to convince herself that the patient would be okay. We've all had patients and their families that we empathize with, and we want to tell them that it will be alright, and we want to convince ourselves that they'll pull through. But no one knows the outcome, not even the doctors know all the times, sometimes you'll have a stable patient that suddenly crashes for no apparent reason. Always remember your mistakes, but do not regret them, no learning experience should be regretted, use it to better yourself and your skills. Always be compassionate, but never let your emotions or your ego get in the way of your patient care.

  • ukorthotrainee

    I've been over optimistic, I've been under optimistic. Some conversations it seems like the only reason I was opening my mouth was to change feet. It's life as a medic / doctor / nurse and the only way to avoid these situations is not to talk and when your voice is your number one tool for diagnosis and treatment.

    Have a high index of suspicion for a AAA – I've known surgeons miss them.

    All you can do is learn from what you do. Don't beat yourself up – that's what's management's for.

  • ukorthotrainee

    I've been over optimistic, I've been under optimistic. Some conversations it seems like the only reason I was opening my mouth was to change feet. It's life as a medic / doctor / nurse and the only way to avoid these situations is not to talk and when your voice is your number one tool for diagnosis and treatment.

    Have a high index of suspicion for a AAA – I've known surgeons miss them.

    All you can do is learn from what you do. Don't beat yourself up – that's what's management's for.

  • Pmstudent

    Yeah I’m a pm student to and have said way worse. Alnog the lines of “hell I’ll start chest compressions now and when you are done with your stroke scale you can join me.” about a pt in AIVR with a rate of 50 and bp of the same that the doc and rn was sure it was a stroke arrested 8 times in the er and once in cath lab before she bought it. Oh and my first run on my ride time I asked our pt from whales if it was anywhere near dolphins.

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I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.
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  • Comments
    Алексей Рукин
    So You Think You Can EKG?
    78% accuracy... and I'm not even a medical student, only a blog reader...
    2014-07-12 18:12:00
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    You BLS guys have got this, right?
    Sorry for the misspelled words. I typed this message via phone.
    2014-07-04 01:39:00
    EMT Student
    You BLS guys have got this, right?
    As an EMT in training(student), I am more dissapointed in the fact that every EMT or Paramedic I have come in contact with (on clinicals) is a burnout who doesn't want to be in an ambulance at all. These leads me to belive im going to hate my future career due to all the slacking…
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