Everyone warns you that Intern year is hard. It’s a year of little sleep; a rollercoaster of emotions both good and bad. Frustration and guilt in wanting to know everything NOW, because everything you don’t know might be what matters for this patient, this time. And trememndous successes. Some of the things I did this year, I really can’t believe I was able to do. And survive. Mostly, I’ve learned a lot about myself, and have been reminded yet again, that I work with an amazing group of people.
UP – Running a trauma when I thought I could never do it
I have a distinct memory of standing in the Trauma Bay at Norfolk General Hospital, watching the Trauma Team work its perfectly organized chaotic magic. I paid particular attention to the young female physician leading the whole thing – inserting an airway, calling out physical exam findings, doing an eFAST ultrasound to look for bleeding. I remember hoping, wishing I could ever have her confidence and calm demeanor. That thought was followed quickly by being thankful I wasn’t yet in that spotlight myself. I could never do that, right? In September I ran my first Delta Trauma at a Level I Trauma Center, and I survived to do it again.
DOWN – Those 2-week stretches not seeing my husband
I had no idea how much I need my husband to help me feel like a normal, healthy, centered human being. Amir and I had about four 2-week stretches this year where he was on nights and I was on days, or vice versa. One day we were so desperate for a date we coordinated a 20 minute coffee meet-up at the au bon pain in the hospital. Let’s not talk about what the house or laundry pile looked like during those stretches. This is the video we play each other if we ever need a pick-me-up:
UP – Procedures, procedures, procedures
intubations, central lines, suturing, joint reductions, even a c-section… you get the idea. I get to work with my hands a lot.
DOWN – Crying in the ICU
So I’m a crier. Always have been. I have distinct memories of my dad trying to help me with math homework as a kid, me getting frustrated and crying (my stress response), and my dad getting frustrated because I was crying. “What’s crying going to solve?” he used to ask me, which of course, made me cry more.
To be honest, I was expecting to cry multiple times the first few months of residency. I actually made it to late February before it happened. Combine working 12-14 hours a day, 11 days in a row, with little sleep, food, potty break or non-medical human interaction (one of those 2-week stretches) – and now add to that a dozen of the sickest patients in the hospital. I broke down – red face, tears, snot, the whole nine yards. The nice thing about Intern year though is that everyone around you has been there, so I had about 4 senior residents plus 3 PAs sharing their crying stories right along with me to help pick me up. And that’s what you learn to do – pick yourself up, learn and keep going.
UP – Finally learning my way around the hospital (which is actually 4 hospitals)
Anyone who works in an old hospital knows how the building just gets added onto over the years, creating a behemoth maze of windowless hallways and floors that don’t match up. “Take the elevator to the 5th floor of North Hospital, turn left and you’ll be on the 1st floor of Main Hospital.” As if there weren’t enough to learn as an Intern.
DOWN – Cancer. I diagnose a lot of cancer.
I didn’t go into Oncology for a reason. It takes the smartest, strongest, most energized people to be cancer doctors. As an Emergency Physician, I expected to treat people with cancer, but I hadn’t thought of cancer as something I would diagnose. I guess I assumed that people would present to their PCP with concerning symptoms, get an outpatient workup and diagnosis by a specialist. But people do come to the ED for hematuria (blood in the urine), anorexia (lack of appetitie), back pain and weakness. And sometimes at the end of the workup, it’s cancer.
UP – Baby Mint Mochachino for a dying patient
I’ve seen a lot of amazing, caring people do a lot of touching things in the medical setting, but one moment stands out from this year. I had a patient who had chosen to pursue hospice care. He couldn’t stop telling me how beautiful his wife was and how he looked forward to seeing her soon. He had stopped eating and drinking days ago, so when he asked me for a “real coffee,” I was intrigued. He’d requested a cup of coffee from the medical student who poured him a cup of the hospital grade mud available to all employees. His dying wish was to have a real cup of coffee. How reasonable. I went to the ABP counter, told the story to the barista, and she whipped up the only coffee worthy of such a role – a baby mint mochachino, which she made with honor and pride in her work, even adjusting the temperature down to avoid any burned tongues.
So that’s it – Intern year is coming to a close, and July 1 I’ll be a “Senior Resident,” fraught with its own challenges and lessons to be learned.
Time is an interesting thing. Sometimes it feels as if it’s flown by, other times the same memory can seem quite distant – or both. For me, I can’t not write about an experience 10 years ago that’s left a forever imprint on me. And for the record, this was an experience that occurred outside of my EMS or medical duties, when I was spending time with friends in my own home (so it’s not a HIPAA violation). I’m writing about it because I need to, and because I want other people to know that critical incident stress affects everyone.
I had been in EMS right about the worst length of time. Not long enough to have any experience with a gunshot wound, but long enough to know how bad – how ridiculous, how severe and rare this all was. When he told me “5 people were shot point blank in the head. I’m pretty sure they are all dead,” I knew. I had been in EMS long enough to know those people were dead. To know that what was going on in my home was larger than anything Virginia Beach had seen in a long time. There would be tons of cops and SWAT teams and helicopters. I knew the enormity of what was amassing around me. I wanted nothing more than to see a familiar face with more medical experience than me.
First off, let me say that I think about the people hurt and killed in this incident, while no longer daily, I’d still say monthly. Three young individuals at the prime of the lives were killed senselessly. No matter how much time I spend attempting to process this, that fact still perplexes and bewilders me.
I’m deliberately posting the unedited documents I have from the event (my written account of events, transcript of my call to 911) so you can appreciate exactly where my mind was at the time things were going on. I had been an EMT only 5 months, and this was the first gunshot wound I had ever seen.
Account of the Events of the Morning of May 28, 2005
1:00 am – I get home from airport and meet friends out at Luna Sea on 22nd Street
2:00 am – We leave Baja Cantina when it closes
2:10 am – We reach my condo at 315 24th Street. There were four of us present, myself, Jackie Johnson, Kristin Horgardt (male, unsure of spelling) and a friend of a friend, Shane. I got out my keys to open the door for all of us. We were coming in the 24th Street (side with our parking lot) entrance. We noticed that the residents of 110 were awake and partying. It’s normal for them to have their windows and drapes open with only the screen. Their cat usually sits there. Like us, they seemed to have been out at bars and were having a few drinks at their place after everything closed. The music was not tremendously loud. I only noticed male voices. No one was arguing; all seemed to be normal.
2:15 am – Melissa Ozmar, a girlfriend of mine, showed up downstairs for me to buzz her in. She had been out with us earlier, but drove a friend home and then came back. We buzzed her in without issue.
2:25-2:40 am – Melissa and I were out on my balcony that overlooks 24th ½ Street and the 25th Street parking lot watching people get their cars towed. Kris and Shane were in the living room watching a movie on DVD. Melissa and I spoke to a few people from the balcony. The only suspicious people we encountered were two guys that were a part of a group of 8-10 black guys. One of the two men asked us if he could come up and charge his cell phone. We found that odd and dangerous and said no. The other guy broke away from the group (that has been walking west on 24 ½ Street) and headed east back towards us. At the point Shane had come on the balcony, and the guy asked Shane if he knew where he “could get laid.” I jokingly said 17th Street, and the guy continued in that direction, away from his group of friends.
Kris and Shane decide that they are going to walk to the 7-11 on 24th and Pacific to buy cigarettes for Kris and candy for Shane. I asked Shane to pick me up a Payday. I told them to hit the buzzer when they got back and I would let them in.
2:45-2:50 am – After a quick 5-10 min max trip to 7-11, Kris and Shane hit the buzzer on the 24th Street entrance and I let them in. They walked right past Apt. 110 and did not notice anything odd. They sat back down on the couch to finish watching their movie. Melissa and I never saw anyone enter or leave the building through the 24 ½ street entrance. At least one of us was on the porch the entire time. No more than 2-5 minutes later, Kris called to me to tell me someone was knocking on my door. I went to the door and asked who it was. A guy told me he was hurt and needed to call 911. I opened the door and saw a young white male (John from CA) with blood on his hands and face. I told him to come in and sit down, that I was an EMT, and asked Melissa to dial 911 (2:55 am). I grabbed some spare gloves that I had and some clean washcloths. Patient stated that he had been shot. I initially could not find the entry and exit wounds. Melissa was a bit nervous and was not answering the call-takers questions well, so I grabbed the phone and relayed information to 911. I noticed a large amount of blood on the back of the patient’s shirt, so we removed the shirt. I was then able to see an entry would located behind the left ear, closer to the lymph node. I then located an exit would in the hair line, just left of the patients spine. I applied direct pressure while trying to minimize any spinal movement. The angle of the bullet was such that the wound appeared to affect only muscle tissue and not the vertebrae or skull. Patient’s ear was also bleeding. After examination, the bullet had grazed his ear before entering the neck. I then applied a second wash cloth to apply direct pressure to the ear. Patient complained of inability to hear out of left ear. Patient denied ever losing consciousness, denied back pain, shortness of breath or any other injuries.
During the course of treating the patient, he told me a lot of information about the events of the evening and what he saw. He told me he had been in the bathroom and his friends were in the apartment. He said the shooter shot him in the head and ran out of the bathroom. He did not see which way the shooter ran beyond that. He gave a vague description which I relayed to the call-taker: black male, mid twenties, dreadlocks to just above the shoulders. He said he recognized him from earlier in the evening when they were all out. The shooter knew Rachel, brown hair, a girl in their party (one of the people shot in 110). He did not know if tonight was the first time Rachel and the shooter had met or not. There was no argument between them early in the night that he saw. He did say that the shooter seemed attracted/interested in her.
He said that when he came out of the bathroom, he saw his four friends motionless on the ground, they had all been shot in the head. He was pretty sure they were all dead. He said he ran up to the 3rd floor to look for help because he thought it would be safer than going outside and was farthest away from Unit 110. He also remembered that the gun was “squared off” at the end.
3:00-3:05 am – Police arrive and bang on my door. We open it, and they search my apartment for the shooter. A lead officer asked me if I had any medical training, and I let him know I was an EMT with Station 14. I gave him a status update on the patient’s condition, and the SWAT Medic arrived very soon after. The medic quickly assessed the patient and asked me to remove pressure so he could see the wounds. He then called for a c-collar from 1421 to be brought up to us. We applied gauze to the wounds and secured the patient’s neck with the collar. Scene was not safe, so backboarding was not an option. SWAT Medic walked the patient down the stairs and out to the ambulance.
3:10-3:15 am – Medic knocks on door again to verify that patient never lost consciousness. Medic stated that he was now having CNS issues. Medic also asked me not to dispose of any of the towels or gloves used to treat the patient.
I gave a verbal account to two detectives around 7 am and 12 am respectively. The second detective collected the patient’s blood-stained shirt, which had been lying on my kitchen counter. She interviewed Kris and me, and asked that I write an extremely detailed account of the events.
The following is a taped 911 call between Virginia Beach Communications Dispatcher Charles M. Simpson and caller Stephanie Krebs [Louka], which occurred 05/28/05, 02:56 hours reference DR# 2005-031807. Victim JKT can be heard in the background.
CS: Dispatcher Charles M. Simpson, SK: Stephanie Krebs, JK: JKT
CS: Virginia Beach 911, where’s the emergency?
SK: Hi, um, we are – Apparently there’s an individual that’s come upstairs –Hi, my name is Stephanie Krebs. I’m actually an EMT with Virginia Beach Volunteer Rescue Squad.
CS: Where are you at?
SK: Um, I’m at 315 24th Street
CS: And what is wrong there?
SK: Um, I live in apartment 320 on the 3rd floor. Can you get me a towel? Sorry, a guy just came in. He’s telling me that there were four people on the first floor. Um, the man that’s here that I’m treating right now – Now what happened to you? That man treating, that I’m treating right now is bleeding from the back of the neck. Do you know how – what the status of the people on the first floor is?
SK: He said that the people downstairs on the first floor were shot in the head.
CS: Do you know if anyone is alive or, what status is on anything?
SK: Um, did you, did you see the people downstairs? Was anyone alive or…
SK: People were shot in the head. They don’t seem to be moving. The guy up on the third floor here. He’s talking to me. He’s conscious, breathing, um, doesn’t seem to have neck or back pain. Um –
SK: He can’t hear out of his left ear.
SK: No, that’s okay. Did you know the people downstairs?
JT: Well, I just came in from California. They’re my friends from college.
CS: Do you, do you know anything about the status of them?
SK: Um, I, I don’t and obviously _________I’m not gonna go down there. Um, he said he thought they were all shot in the head, four individuals.
CS: Do you know anything about who did it?
SK: Do you know who did it at all?
SK: You just saw the people?
JT: One guy.
SK: It was one guy. Did you, did your friends know them or…
CS: Can you tell me what he looks like, where, where he went?
SK: He thinks it was someone they had met tonight. Was he black, white?
SK: A black guy. Do you know how old?
JT: Maybe mid 20’s.
SK: Mid 20’s. Did he have any tattoos or piercings?
JT: Um, nothing ___________.
SK: Dreads or maybe dreadlocks to about shoulder length.
CS: Uh, ma’am, I can’t hear you.
SK: I’m sorry. Um, the shooter seems to have dreadlocks about shoulder length.
SK: Sure they’re coming right now.
CS: Okay. Anything else about his dress?
SK: What’s that – Do you know what he was wearing?
CS: He’s on the third floor with the caller I’m – Not the – I mean the victim. One of the victims is. The suspect I’m trying to get information on.
SK: Sure. Um, the one __
CS: Ma’am, where did the guy go? Can you tell me that, anything?
SK: Did he – Which direction did he run – Did he run out 24th ½?
JT: I don’t know. I was in the bathroom when ________________.
CS: So he don’t know where he went?
JT: __________shot me___________.
SK: Okay. Where did he shoot you? I think he grazed you. Hang on for a second. Melissa – Hey, buddy, I’m gonna have to cut your shirt off, all right.
CS: All right. Listen, the guy that’s with you, where is he hit at?
SK: Um, I’m – That’s – I’m gonna cut off his shirt right now ‘cause I think it’s – He’s not bleeding too severely. If you can take it off –
CS: Can you tell me from where?
SK: Yeah, I’m looking right now. It’s not visible. He says he got shot, but.
CS: In the torso area, head?
SK: No, no, no, no he has like a small ________ on his lower head.
SK: Actually, I see the entry wound, and he’s very lucky. He got grazed. He has an entry wound.
SK: On his – It’s just below the patient’s left ear, and it’s probably entered and exited only through about one inch of skin.
CS: And you, and the guy has no idea where the guy did the shooting went?
SK: No, he – He was using the restroom.
CS: All right. Does he know why the guy did it?
SK: Where he did it?
CS: Why? Why did the guy shoot them?
SK: Um—Do you know—I know you said you thought you met them earlier in the evening.
SK: Uh huh.
SK: Do you know what it was about?
SK: Uh, apparently one of the women in the –
CS: I’m trying to get information.
SK: Okay. Apparently–________dispatcher—–
CS: Male subject shot just below the ear. He’s on the third floor.
SK: They’re coming in here.
CS: Let me know when police get there.
SK: Okay. Can someone go down to the, um – Well, actually never mind, don’t, don’t, don’t. Don’t go down.
SK: Okay. Can you – Is the door locked?
SK: You locked them, okay? Um, apparently, the, um –We’re not sure of the motive of the shooting, but the assailant was talking to a woman named Rachel earlier who is a brunette, long curly hair. Um, they had met earlier in the evening and didn’t know each other prior.
CS: And the shooting started, uh, while they were talking to her or do you know where Rachel is at?
SK: Uh, we think she might be one of the victims on the first floor. Are you sending, um, Station 14?
CS: Yes ma’am, we got. I don’t know what rescue unit. Just a moment, I’ll check.
SK: Okay. Sorry. I __________. I’m supposed to be on duty tonight. ________ my shift.
CS: Yeah, 14____ should be there.
CS: I imagine they’re all pretty much –
SK: They’re probably –
CS: –downstairs waiting for police to clear them.
SK: Sure. Sure. Um…Actually, there’s – Hey Melissa – Will you __________the cops out there. Yeah, let ‘em know it was 110.
CS: What is 110?
SK: 110 is the apartment number where we believe all the victims are.
CS: What about your apartment number?
SK: I’m in 320.
CS: On the third floor?
SK: Correct. And – Hey, Kris, can you make sure that deadbolt is locked on my front door. We got –Who is it? Lock the door. Okay.
CS: Now, I’m getting a little ____________.
SK: Who are you? 110.
CS: Who are you talking to?
SK: Police are here now.
CS: The officers are there.
SK: Okay, is it okay to hang up with you know?
CS: If you are with the officers, yeah.
SK: We are with officers.
CS: All right. Well, thank you for your help.
End of recording.
I’ve learned a lot from this experience, in no particular order of importance:
After the police leave a crime scene, you are on your own. What they never show you on TV is that after the crime tape is peeled away, the blood and biological hazards are left for the property owner to address. There are private cleaning companies that drop off fliers and business cards at murder scenes. Sort of like ambulance chasers, I suppose. The expense belongs to the property owner. Many insurance policies have exceptions for acts of violence, so owners have to pay out of pocket.
Police carry more than one type of gun. Anyone that knows me knows that I hate guns. I literally cried the first time I saw one at a neighbor’s house in 6th grade. I knew police carried handguns on their hip, but I had no idea they also carry machine gun like rifles. Big guns. Big guns in my house, opening closets, looking in my dryer for hidden threats.
Memory is fallible. As the case went to trial, I was called in by Harvey Bryant and Colin Stolle for witness prep. I would have bet you $10,000 that I had a full, vivid recollection of the events of that night. They felt so vivid in my mind I assumed they had not faded or twisted. To jog my memory, they played the audio of my call to 911 and showed me photos of JKT’s injuries. I was wrong on a few small things, and it will forever make me question witness testimony in court.
Trials and long and exhausting for all involved. Companies are required to allow employees to attend jury duty, but there’s no provision for people who are subpoenaed as a witness. Some companies cover witness testimony if it’s company related, but most do not. Good Samaritans who attempt to intervene can be rewarded with mandatory court appearance, without pay or protection of their jobs. Fortunately I was able to negotiate my contract with Launch Interactive to include paid leave for testimony in the trial. I imagine not everyone is so lucky.
I’m pretty good in an emergency. I know this sounds silly seeing as I’m now an Emergency Medicine Physician, but 10 years ago I was an inexperienced EMS provider that had never really been put to the test under stress. When I listened to the 911 call, I was surprised and a little proud of myself in how clear and calm I seemed. That’s certainly not the way I remember feeling.
Amber Alerts save lives beyond just the kidnapping victim. The way Marcus Garrett was ultimately apprehended was thanks to an Amber Alert. On his way to flee, Garrett scooped up his daughter, activating an Amber Alert across the state. A law enforcement officer, aware of the alert and on the lookout for Garrett’s car, ultimately apprehended him. Who knows how many lives that officer may have saved that day.
“Maximum Security Prison” is no cake walk. After his conviction, Garrett was sentenced to life in prison at Red Onion State Prison in the most western part of Virginia. For years I pictured in my head, Garrett shooting hoops on a basketball court, chatting with fellow inmates at a lunch table, meeting with visitors behind a clear plastic wall. Like on TV. VCU Medical Center, where I work, has a whole secure floor dedicated to inmates. One day I heard a guard mention he worked at Red Onion. Curious as to the actually quality of life there, I asked. Apparently they spend 22 of 24 hours in a day locked in solitary confinement with no windows, no activities, no interaction with others, but LOTS of time to think. Huh.
So how do I feel about everything now? It’s still hard to say. My thoughts are still all over the map.
I do know that I’m glad I opened the door that day. JKT ended up getting married and has since had children. That makes me smile. When I met with Bryant and Stolle, I learned just how close my friends and I came to being victims ourselves. That’s a thought I tuck way way back in my head and prefer to forget whenever possible. And most of all, I still want to know “Why?” Cliche I know, but I really am curious what motivates someone to do such a thing, or allows them to lose control and change the course of history for so many good families. I admit that on many occasions I’ve Googled Garrett, his prison, his status, his contact information. I worry about myself that I’d ever want to reach out to such a creature, even if to gain closure for myself. I’m not sure what I’m looking for, but I’m pretty sure I’ll never find it.
Lastly, I do want to thank John Carey and Norvel Allen for looking out for me after this happened. Since I wasn’t technically on duty for this event, I wasn’t included in the Critical Incident Stress Management debriefings that took place after the shooting. When I drive around Virginia Beach, I can point to a hotel where a woman overdosed on heroin at her best friend’s wedding; the roadway where 3 kids were driving too fast and paid the ultimate price. After 10 years in EMS, nearly every block has a story. I think everyone in public safety does that, 911 dispatchers included. But it’s different when it’s your home. You leave for work and still can’t help but look at the oddly cut out square of carpet that replaced the original bit that was soiled with an 18″ diameter and 2″ tall pool of clotted blood. You come home and retrace those same steps you took that night – passing by that window with celebratory voices, yet now so silent. You get an at least twice-a-day reminder of the horror and violence that entered your home that warm Friday night. It’s never normal, just slightly less obvious. On this 10 year anniversary I hope that the families of all involved find peace and warmth.
I hear my wife started a blog… and in typical Steph fashion, three days later she has hundreds of viewers in 10+ countries?! Well, I can’t let her have all the fun, and its TEAMlouka afterall. So here’s my take on…
5 Things I Learned in EMS I Wish I’d Learned in Medical School
Airway. Breathing. Circulation. Often boiled down to the ever-popular “air goes in and out, blood goes round and round, and any variation of either is bad.” Seems simple enough. You might even think such a simple, crucial concept would be covered on day one of medical school, just like it was in EMT class.
I distinctly remember sitting in the auditorium at EVMS back in August 2010 and thinking to myself, “OK. Let’s do this. Doctor training, go!” The lecture topic? Intro to medical molecular cellular biology, of course! Because when that critical patient rolls in, all attention should be directed towards the golgi apparatus and endoplasmic reticulum first. Funnily enough, I didn’t leave that class feeling any more clever.
Now in all fairness, ABCs were covered in medical school. The problem is that the single most important concept in the assessment of an undifferentiated patient was sandwiched somewhere between memorizing The Krebs Cycle and the chapter on brain eating amoebas.
So out of four long, expensive years, just half a day was smushed in there for a shoddy BLS/CPR course. By that point, most of my compatriots had drunk the Kool-Aid – BLS was a boring day off for some and an unwelcome eviction from the library for others.
The effect? Time after time, I have watched medical students, residents, and even some attendings rack their brains for a diagnosis, visibly straining to remember what medicine or scan should be ordered next, when called to the bedside of someone going downhill. THE PATIENT ISN’T BREATHING. But is it multiple endocrine neoplasia type 1 or 2? THE PATIENT ISN’T BREATHING. Did she say her great-great-grandmother had psoriasis? I DON’T FEEL A PULSE. Did you do a rectal exam? MAYBE WHEN I FINISH THESE CHEST COMPRESSIONS.
(OK all you sticklers for AHA guidelines out there. I know it’s CAB now. But no one says that. It’s ABC. Forever).
2.Acuity is just a number
In every ED there is some kind of triage coding system. Usually it’s a numerical assignment, 1-6 in ours, given to patients when they arrive, which roughly translate as:
“We need a doc in here!”
“Doc, my chest hurts since this morning.”
“Doc, my belly hurts since yesterday.”
“Doc, my toe hurts for the past 18 years.”
“Need a med refill, Doc.”
“He’s dead, Doc.”
We’ll that’s great when it works. But one EMS call in particular taught me to maintain a healthy dose of skepticism with those low acuity patients.
It was early in the morning. My partner and I had just signed on were still fueling up on coffee and pancakes. So when the call crackled over the radio for a priority 3 injury, “patient stubbed his toe,” we understandably finished our coffee and waited for the check. We drove to a house about 10 minutes away in no rush at all. Why the hell would someone call 911 at 6am for a stubbed toe?!
The question was partially answered when we walked into the house to find a pale, diaphoretic man sitting in his kitchen… holding a slightly bruised toe.
Turns out this guy walked outside to pick up his newspaper and collapsed down by the mailbox. He spent half an hour crawling back up the driveway, and at some point along the way managed to stub his big toe, much to his dismay. He also just happened to be having a massive heart attack.
Moral of the story: Lay eyes on the patient, then finish your coffee. Just in case.
3. Where Patients Come From
Well when diabetes and high blood pressure love each other very much…
No, that’s not what I mean. I mean physically, socially, emotionally. You see, most patients arrive to me looking more or less the same – propped up on a stretcher or in a wheelchair, clutching some form of puke receptacle, and flanked by a pair of overworked, underpaid EMTs and/or an overworked, underpaid nurse. They’ve usually been cleaned up a bit to meet some unwritten, undefined minimal standard and bare few traces from whence they came. By the time they get admitted upstairs, patients are in a standardized gown, on a standardized bed, eating a standardized turkey sandwich.
This creates a poorly recognized issue for us as doctors. We fail to see the idiosyncrasies of a patient’s life outside of the hospital and tend to place them into one of three broad categories: homed, homeless, or living in some kind of facility (nursing home, rehab, assisted living, jail – take your pick). Each of these then receives the ultimate American qualifier – insured or uninsured. That assignment basically dictates more about a patient’s care and treatment than their actual medical diagnosis. And it is horribly flawed.
Only through EMS did I have a first hand, and a first nose, perspective of just how different life can be for a fellow human being. I have clambered over mountains of hoarded garbage in what looked like a upper-middle class home from the street, been in nursing homes which would put North Korean labor camps to shame, and even pulled a young woman out of the bottom of a port-a-potty where she spent the night sleeping in a tub of chlorine and human waste. There is a spectrum to everything, and the circumstances of a person’s life leading up to his or her encounter with me can tell me as much or more about their condition, and what I can do about it, than the symptoms they describe.
I distinctly remember a call to assist a man complaining of some ambiguous pain complaint. He had just been discharged from the hospital that morning. But at well over 600lbs, he was entirely unable to care for himself at home. Never before, and never since, have my nostrils known such misery. He couldn’t fill his prescriptions, get a glass of water, or even get out of the bed to use the toilet. He was, literally, a mess.
The medics bringing me patients now have my full attention. I want to know what they know. They also have my respect – I know what their noses have been through.
4.It’s their emergency, not mine.
This one is simple. Every person arriving in the ER is there because they feel that their condition – be it crushing, unbearable chest pain or thirty minutes of life-shattering hiccups – just cannot wait another moment to be addressed. But as a newbie EMT recruit, doing my EVOC and driver training, I was taught, on multiple occasions, a memorable and poignant philosophical lesson:
“Dude. It’s their emergency, not ours. Slow. The Fuck. Down.”
-Socrates, Field Training Officer
Now that might have had something to do with the pedestrians diving into the bushes every time we responded to a call, but it sticks with me. On a busy scene, with lights flashing, sirens of approaching units blaring, family and bystanders screaming in my ear, multiple patients and limited resources, the public looks to the collective “us” that is Police, Fire and EMS to take control of situation. In the ED that role shifts to the doctors.
Approaching even a critically ill patient, with nurses, medics and techs racing around grabbing equipment and medicines, my job is to remain calm, cool and collected. Allowing my own level of anxiety to meet that of my patient won’t get anything done more quickly and certainly won’t hasten the cure.
Unfortunately medical school does a terrible job of teaching this. Learning about the management of truly sick patients takes place more in the classroom than at the bedside. There is infinite time to think, weigh the options, and look up the answers. The student is usually sent to see the less acute patients, or tags along to observe when things get dicey. Then, day one, intern year, with that long white coat tickling the calves of someone who has never ordered morphine or a blood transfusion or called a surgeon in the middle of the night to say I need you down here now, many struggle when it comes to taking a step back. Looking. Listening. Thinking. Acting.
So when grandpa rolls in clutching his chest, don’t be alarmed if I’m not barking out orders like you’ve seen on TV. I’ll be at the bedside, taking his pulse, followed quickly by taking my own.
5.Scene safe, BSI
If you had asked me five years ago for my thoughts about the pervasive mantra of EMT recruits everywhere, “Scene safe, BSI,” my response would have been an incomprehensible tirade of expletive filled muttering. I’ll wear gloves. I get it. STOP MAKING ME SAY IT. Every skills station, every practical exam, every day. As if the mannequin we were pretending to bandage had actually just escaped some Liberian Ebola quarantine zone and standing in the doorway with jazz-hands to show I remembered to put on my imaginary gloves would somehow protect me. F&*%#$#!
For those of you who don’t know, BSI stands for “body substance isolation.” The idiom is a reminder to EMT students to look for potential danger first, to protect themselves and their partner before even attempting to help anyone else, and to wear gloves. One thing is certain – no one gets extra points for getting hurt on scene and doubling the number of patients, and if you get hepatitis, you lose.
While this definitely remains true in the hospital (i.e. Steph’s “nonverbal” psych patient who wasn’t talking because of the razor blade hidden in his mouth), it goes further than that. It’s a reminder to take care of ourselves, and each other, through the emotional and physical demands of our work. Believe it or not, watching people in pain and dying every day can be rather taxing on the psyche.
Medical school spends a lot of time teaching us how to help others through the process of aging, illness and, ultimately, death. We learn every aspect of disease, how various ailments ravage the body, each in their unique way. But little time is spent learning to carry the weight of our responsibility or dealing with the death of a patient.
In that respect, EMS excels. CISM (critical incident stress management) is a program which helps medics through the worst of calls. The team, staffed by members with specialized training, provides everything from one on one counseling to group debriefings. All hospitals should have such a system.
And for God’s sake put some gloves on when you go in the room. C diff is a terrible, terrible thing.
So that’s that. 5 things which make me a better doctor, all learned at the bottom of the medical totem pole. From the basics of taking care of someone else, to the more complicated task of watching out for myself, EMS has played a huge role in my training. Even as a doctor, I continue to learn on every shift, and that is what keeps me coming back for more.
I think that on a whole, people who work in the ED (doctors, nurses, techs alike) really don’t know how much your average EMS provider is trying to do the best job with each call – recognize all concerning exam findings, make smart decisions on treatments, and communicate all of that in a useful way to the ED. Being on both sides, I’ve noticed quite a few ways EDs send mixed messages that can be confusing to even the most seasoned EMS provider.
1. Stroke – time is of the essence
Or is it? At every level in EMS, we’re taught that a stroke is a “load-n-go” patient, that speed of arrival to the ED, potentially to receive tPA, is what counts as there’s a 3-4.5 hour window for the therapy to be administered safely (although more evidence surfaces daily questioning this).
Still, the standard of care is rapid transport, yet how many times have you transported a stroke patient and waited 5, 10, even 30 minutes to get a bed and give turnover? Certainly obvious strokes get alerted and the patient assessed in the desired timeline. But what about those that fall in a gray zone? How does your ED handle these patients? What message does it send to your EMS providers to have them drive lights & sirens (inherently dangerous in itself), only to wait wait wait? Do you want them to start making decisions about patients with a positive Cincinnati Stroke Scale for say, slurred speech, but without hemiparesis? As both an EMS Provider and an ED Doc, I’d rather let the ED make that call.
2. Handwashing is the best prevention
Plenty of studies have proven this. We hear it every year in Blood Borne Pathogens training, and it’s posted all over the hospital. Yet, how many EMS workrooms at the ED have a sink in them, or even close by, to encourage convenient and frequent handwashing? This is a no-brainer. We’re not talking about adding free Red Bull or a Starbucks machine (I’m looking at you VCU), but something to keep everyone safer and healthier.
We are excited to announce the grand opening of the VCU Medical Center EMS Work Room! This new space… https://t.co/2VOke8vKMo
In all seriousness, VCU did do an awesome job with the EMS room (which does have a sink). Now if only I could get access to the Starbucks machine…
3. Removing patients from the backboard
I think this one is about to self-resolve with the trend to move away from spinal immobilization in the field. Flash back to 10 years ago when I was a new EMT-B. Somehow, somewhere in my mind, I got the impression that spinal immobilization was intended to immobilize not just the head and c-spine, but thoracic and lumbar as well. Time after time I would transport a patient fully immobilized, and before I had finished saying “23 year old fema…” someone would be unclicking straps and removing the backboard. This often left me wondering, why I had spent that extra time on scene carefully packing the patient, only to have my handiwork undone? More groans and moans from nurses, “they could have gone to triage if it weren’t for this backboard.” I was following my protocol, wasn’t I? Was I doing the right thing?
We care about cervical spine injuries more than thoracolumbar injuries because they can kill you. The nerves C3, C4 and C5 in your cervical spine compose the phrenic nerve, which innervates and controls your diaphragm, the main muscle of respiration. Damage or sever these, and you stop breathing. Easy way to remember: “C3,4,5 keeps the diaphragm alive!” In reality, the meat of immobilization is in the c-spine immobilization with a c-collar, and the backboard is more of a transport device to pick the patient up and safely transfer them to a stretcher and hospital bed. EMS protocols have lagged behind in philosophy and approach to spinal immobilization in blunt trauma, but with current chatter surrounding its efficacy, I think we’ll finally close the gap.
What mixed messages have you seen where you practice?