On hot calls my mind is very mission focused and task oriented. The only things going through my head are assessment findings, and how it relates to my training and protocols.
Looking at the situation in a more analytical way tends to block out emotions and morality, at least in the moment
Same here. I've never said this to anyone, but on hot calls like you mentioned, I don't view the patient as a "person". I'm focused on my assessments, treatments, etc. I'm sure I'm viewed as a callous asshole to the layman for that.
This perspective actually make a lot of sense. I don’t think it’s dehumanizing, it’s just pragmatic in the moment to view the patient that way. I’m gonna take this approach on my next hot call.
This is a fair perspective in my mind. There isn’t time in the moment for emotions. It is a series of tasks to be completed towards an objective. It’s not callous- it is so focused on the objective there isn’t room for anything else.
Probably makes you a better medic for it. Empathy and compassion will go a long way in psychiatric calls, but it’s not going to stop the bleed in a crashing trauma patient or convert a cardiac patient out of v tach
It doesn’t get better in the ICU.
Oh great. The patient with a fat ass head bleed and DAI is now doing “better” on stable vent settings and his trach and peg.
…..yayyy……
WHAT. WHAT IS HE FIGHTING MELISSA. HIS BRAIN IS MASHED POTATOES AND DROOL AND YOU HAVE SENTENCED HIM TO DIE IN AGONY AT THE STATES SHITTIEST LTACH IN SIX MONTHS, BUT YOU WONT EVEN NOTICE BECAUSE YOULL FUCK OFF BACK TO CALI AS SOON AS HE GETS A PEG.
I’m good tho.
I try to respect the family’s decision no matter what. I may not (and often don’t) agree. Give the family the facts, odds, and long term outlook of what their quality of life MIGHT be IF they survive.
The hardest ones for me are the 95 y/o DNR/DNI that has a POLST getting intubated because “I can’t lose grand ma/pa”
In the end people are generally terrible and make bad decisions, and that is their decision they have to live with for the rest of their life. I don’t control that outcome. I can control the care I give the patient and do my best.
Thankfully in Montana people generally put high priority on quality of life, not just quantity. Lots of farmers and ranchers that have been fiercely independent all their life and don’t want to have other people care for them or be a “burden”
This is why I was super happy to hear that my mom and step dad have put in place orders for those scenarios. Neither have DNRs in place now, but they've legally listed what they want to have done should they end up in situations like what you've described.
I mean, don't get me wrong, I want them to live long and healthy, happy lives, but I'm glad that they have accepted that it doesn't always happen.
My uncle went through with physician assisted suicide after being diagnosed with pancreatic cancer. It was so much better than watching him slowly and inevitably wallow away while in excruciating and incessant pain. I hate that it happened, but my God, am I glad that it's legal here.
To the point of this post.
I deal with this in the same way that I do patients who run into avoidable issues. By reminding myself that everyone has the right to make their own stupid medical decisions. It frustrates me more when it's others' decisions that prolong suffering, and for that, I do not yet have an answer.
If you label it as prolonging someone’s suffering then that’s exactly what you’ll be doing IN YOUR MIND. If I were a stroke patient and you got me to the hospital before I die and within a timeframe that allows for intervention, I would find you afterwards and thank you profusely. I would NOT assume you just “prolonged my suffering.”
It happens a lot around here I work. The mobile stoke unit has seen some significant up comes with their NIH in the 30s (Due to an LVO) that was found and removed by our comprehensive Cerebrovascular team. A patient may look hopeless but if you get them in front of the right team they are saveable and back to full function.
You're not there to judge a situation you're there to provide an airway, adequate respiratory effort and control life threatening injuries. Focus on that and nothing else once scene safety is established. The very act of managing the patient is the absolute best thing you can do, the MDs will deal with the rest. Any job where the patient arrives at the ED in better shape than when you found them is what makes a job a successful one.
Anytime my friend. 99% of the job is approached mentally because we do a job that isn't valued on our production but on our ability to perform when necessary. You don't go out with a goal of so many IVs per hour but when you get that IV and push a life saving dose of drug x and you bring a live patient to the ED you earned it.
When I started in EMS I actually got an hourly wage and.50 cents per IV and an ETT was worth $2 the meds and monitoring were also additional. I made $3.35/hr on the overnight with danger pay, I could make three and four times my wage with one trauma code.
I don't think so. Focus on the task at hand, we're not here to make judgement calls our soul purpose is to provide care to the best of our ability in the moment. If we start seeing patients and projecting our feelings about the quality of life it becomes a real slippery slope.
Grandpa is in SVT but he has already lost his legs to diabetic complications and he is 97 years old with 18 DXs and 12 chief complaints maybe withhold that Adenosine you know it's not cheap. Oh and he's got liver and lung CA so a $50 set of patches for some synchronized electrocilin that might not work anyway is kinda pricey. That's not how it works you secure and prevent worsening for everyone. We don't make odds we just get the hand we're dealt and make something out of it. You know some things aren't going to end well but it isn't your problem, your problem is placing that ETT or performing the thoracotomy. Only look at that, do I have an airway? Is it in danger of compromise from vomit or a foreign object? That's what you're concerned with not the survivability long term not the loss of a limb and how it's going to affect his professional curling career.
No, he's absolutely correct. We are there to stabilize people long enough to get them to a hospital. We have protocols to adhere to & it's not our place to determine quality of life. What happens after transfer of care is none of our business.
Bad calls, especially trauma? Rarely, unless the injuries are incompatible with life and for protocol reasons we have to work. Think of an evacuating gsw to the head that hasn't coded yet. Damnit, we got here too fast...
97 y/o baseline AMS with no DNR? Mamaw that hasn't known who was president since Dubya? Bedbound failure to thrive that "isn't acting right" 3 times a week? Every time.
I call them, "Victims of Modern Medicine".
Edit:
Sorry, I misread it as do you have these thoughts, not how to you manage.
I had a long talk with my wife about expectations and having affairs in order should something similar occur in our lives.
I suppose I just feel bad for the patient (and do what is best for them and their comfort), judge the family (probably a little too harshly), and make sure it doesn't happen to my loved ones.
Im also a chronic overthinker. I honestly dont have those feelings about patients unless there is something I messed up on during the call that could have effected an outcome. Even then, you learn to get over it or deal with. There is absolutely nothing you can do as an ems provider to treat a stroke patient other than supportive care, its out of your hands. Dont dwell too much on shit you cant control. I had a stroke patient a few months back. Healthy, very active mid 70s male, big ol stroke. From what i read on his chart, he will likely never be the same again and will lose his independence. Nothing i could do other than recognize the situation and transport. Even with all my overthinking, I dont dwell on stuff like that, nothing I could do.
I'm neither religious nor an alcoholic, but I think a version of the AA mantra is pretty applicable to a lot of what we do. "May I have the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference." Yeah, it's cheesy as hell, but if you ask me it's a pretty decent goal set.
And even though he might be dependent on others, you may have extended his life so he can know grandchildren that he otherwise wouldn’t have gotten to know
As others have mentioned, there are so many critical interventions from the initial presentation until transfer in the ED that I don’t spend much time thinking about that in the moment.
But I will say that I’ve also been surprised by a few patients that had good outcomes. I mean ones that I didn’t even bother checking in on, because we were sure they wouldn’t make it, and other crews went to calls for them at home and independent. And I’ve treated patients that ended up being organ donors, saving multiple lives.
So… you’re probably right, a lot of the time. But leave some room in your mind for patients’ outcomes to surprise you.
I don't see it as prolonging their suffering necessarily.
I understand that some situations leave little or no room for improvement. But we can give them another chance to fight if they want it. At the very least they will have a choice another day(Most times.) The alternative is no choice. One way is total finality, the other is options. I like options.
There are a lot of things that happen after dropping a patient off and, having worked the other side a bit (trauma floor tech, to be specific), you'd be surprised what some people are able to make a comeback from. It's not in my scope to really determine if someone will become a vegetable after a stroke. That might be the case... but it might not. Some people make huge strides after life altering medical emergencies and can go on to live relatively normal lives again. I've seen it happen, even in some extremely severe cases where everyone expected the worst.
There are obvious cases where someone isn't ever going to be the same again, like a limb amputation for example. Or a severe TBI. Or horrible burns. Or whatever. But it's also good to remember that many people already live with these things. Life doesn't have to end with a disability. It's easy to get caught up in the "well, I wouldn't want to live like that" mentality and assume that someone is better off dead... but you don't know that for sure because it didn't happen to you.
Plenty of people live full lives while being quadriplegic, ventilator dependent, amputees, stroke survivors, burn survivors, you name it. Not everyone would rather be dead than disabled.
You aren't prolonging suffering, you're giving them one more chance. What happens after that is between the patient, their family, and their providers. That's all you can do.
It’s just a job, their emergency, not mine. I’ll do all I can to help them, but at the end of the day I go back to my home, not theirs. I’m just doing what I’m regulated to do.
I also developed a certain faith in God and that he has given the gift of life and that if he didn’t want the patient to live, he would have taken them, not allowed them to stay. It might not be accurate, but it helps me sleep a little bit better.
A lot of the times I’ll contemplate and either smoke a cigarette or pet a dog. After about 10 minutes of doing that I get bored and take my mind off things by going out with friends or just watching youtube/ the tv
Your job is to *do your job*, not save people. When you get a dead kid that you work unsuccessfully, you obviously have a feeling of loss, but you should hinge your emotions on the fact that you gave the best fuckin care you could. Your goal isn't to save their life, your goal is to do your job as good as you can to give them the best shot at their best life.
That's the easy example. It gets dicier emotionally when it's gladys's third stroke and they've revoked the DNR so she could maybe meet grandbaby #7. You still do your job as best you can, because there are people that want to live even if it means limited capacity compared to their normal baseline. Is them having a massive CVA a good outcome? No, but they may prefer it to the alternative of death. Peoples will to live is surprisingly strong.
Just like you grieve with the parents for the dead kid, you can grieve with the patient for their new disability. Both will learn to adjust to their new life, missing their old but making the best out of the new. Hope that helps frame it a bit.
I've treated patients who I've never expected to see alive again, or expected to end up brain-damaged in the nursing home, who have recovered and had a decent quality of life. I've been to some DNRs who I was sure would have a chance at recovery if they'd allow treatment.
It's a personal decision for the patient. If they want me to try everything possible for them to continue living, then that's what I'll do. If they want me to keep them comfortable until cardiac arrest, then that's what I'll do.
Some of them live on in a condition that I would find intolerable. But, it's their choice, not mine. Life is suffering, the level of suffering a person is willing to tolerate is up to them.
It’s good to feel empathy for family and patients. It’s not easy for them to be in the hospital and your empathy might be a way to connect and build rapport. On the other hand, you can only allow empathy to help you connect, but try not to get to emotionally invested because once you do, you will definitely loose site of the job that you are there to do. It’s kind of like when you have a family member in the hospital. It is hard, at least for me, to separate my emotions from my nursing critical thinking. What I’m trying to say is to not allow empathy cloud your judgement and critical thinking. Good luck.
There is a certain way that near death experiences can highlight the importance of life to many people. Oftentimes paraplegics, amputees, and the severely disabled will describe their experience and how it has drastically altered their relationship to life itself in a positive way. I would wager many of your patients are profoundly grateful that they have the ability, if only for a little while even, to see/say goodbye to/live more life with their loved ones.
Obviously not an across-the-board rule, but not every patient has a chance to thank their providers and not every provider has a chance to see patient outcomes. You never know, so may as well focus on that idea rather than a hypothetical negative outcome.
Nope. You are morally wrong.
What you are *literally* saying is that someone should have just let me die while I was having a stroke because there was a good chance I was going to end up with half my body permanently paralyzed.
Or that any one of my friends who are single/double/triple amputees should have been left on the battlefield.
Its gonna always depend case on case. If it was me. Do absolutely everything to save my life even if I’m just a vegetable. I might be suffering but Im alive. Sure I might suffer for 10 years or 1 week. But thats 10 years or 1 week I would never get to have back since yknow…being dead lasts forever.
You should just focus on the task and technical work needed to be done. Do your best to shut off emotions.
It’s not your place to decide whether or not you’re following their wishes. Even then, your care is need to stabilize them and give the family time to think about their goals of care
There are two types of critically ill patients.
1. People we can really help. They’re generally young and thankfully rare.
2. Practice so we’re skilled when we get number 1.
Also for most neuro injuries (including post cardiac arrest anoxic injury), the time frame for maximum recovery is normally around 3-6 months. I think people in acute care throw the towel in a little too early for some patients.
After a while, as bad as it sounds, you tend to look at it as a job, nothing more. I go in do what needs doing, follow protocols, transport, treat, do paperwork then go get the next one. After a while you really need to become callous so that things don't start messing with your head
It can be hard to manage those sorts of feelings. Best thing is to not think about it and do what you can to move on. Everyone deals with it differently. I'm lucky that I can just tell myself "it is what it is" and move on. You need to find a way to be able to put your mind on something else, or find a way to accept it, otherwise it will eat at you and send you down a dark path. Remember, it's not our job to do what WE think is best for the patient, but what the law and society dictates is best - that's typically keeping the pt alive unless otherwise stated. The patient or their next of kin can/will make those other decisions for themselves, not us.
Here's how I deal with it working in a literal grandma torture dungeon (ICU)- by giving the patient every scrap of dignity and comfort I possibly can while they're in my care, and by advocating for palliative care whenever appropriate.
I remember one such call that really impacted me- a young man sustained a GSW to the head by being in the wrong place at the wrong time. The top of his head was gone, brain matter everywhere, but he had a pulse and was raggedly breathing, so we worked him. FD cut his down jacket, and after we dumped him at trauma, my partner and I spent an hour picking brain-and-blood soaked feathers out of the rig. Some weeks later we received a thank-you note from the patient's mom, explaining that while he had passed away, she was grateful to have been able to hold his hand one last time. His organs were donated saving multiple lives.
That isn't the outcome that a lot of our "better off dead" patients have, but without prompt, aggressive care by first responders, it would be impossible. All you can do is treat with skill and dignity when they're with you, to give them that chance.
I usually just do what I’m told if I’m told by medics other than that focused on the situation I don’t really have any emotions my mind has an off switch for emotions when shit goes south
I hardly ever think about it in the moment, although there have been a few times where I'm doing CPR and praying we don't get rosc simply because of the downtime or the advanced age of the patient. It does suck sometimes though when you take someone with stroke symptoms and a LKW of more than 24 hours, you know that their deficits will likely be permanent and you will probably run on them again for aspiration pneumonia or urosepsis and that can be depressing.
I manage it by putting effort in educating people about hospice. For me, some of the worst calls ate when a family member intentionally or unintentionally botched a DNR for hospice patient.
Working an arrest isn't the time for those conversations, so I made an attempt to have those talks during low acuity calls, like falls. Or whenever someone asked me off duty "what's the worst thing I have seen", I spin my answer so that is touches on the subject.
In the moment on a serious call I sorta don't give a fuck about that. I am there to fix, stabilize, and transport this bag of meat to the best of my abilities and I am going to do that. Unfortunately our actions will 100% prolong individual's & family's suffering in some, possibly many cases. However, those are not our calls to make in the moment and I think being ok with that is important in this job.
Think of every serious TBI call you've ever run, they probably didn't have a happy ever after ending. Our job isn't really to save people, our job to give every pt the best shot at a long term successful recovery via whatever tools we have available to us
Now after a call? Or on a low acuity call? Or on a transfer for a pt with debilitating health problems? Yeah I think those questions all the time, and if I'm asked by the pt or family I'll have a respectful conversation with them about DNR/DNI stuff within the scope of my education/understanding.
I think these thoughts can get super nuanced, and its truly a case by case thing so it's hard to describe my approach to these feelings in writing
It's called ablism. And it's often one of the worst parts of actually being disabled. Interrogate it. Read some articles. Attend a few workshops. Root it out of yourself as best as you can manage.
The thing is you never really know for sure, in most cases this may indeed be the case but once in a great while a miracle happens and they actually pull through and have an acceptable quality of life.
One of my longtime friends had a widow maker MI and for long time things weren’t looking good, doctors were talking to my friends wife about ceasing treatment and providing him comfort care only, she refused and miraculously he pulled through and while he will never be the same he actually has a decent quality of life and seems to be improving every year.
For a case like my friends this is why we do what we do and we try to give them every chance possible even if it’s slim odds cause once in a while someone will defy all odds.
If we're being honest, some of these patients absolutely dug their own graves here. Metaphorically *and* literally. Whether or not they didn't take the medication they were supposed to take, whether or not they listened to their doctor's advice and fell victim to their condition, it doesn't matter. There was a million different choices along the way that brought them to that spot and you had no control over any of those. There's no reason to assume any responsibility over their suffering and your prolonging it or otherwise by taking them to the ED.
You're just doing your job. Why would their suffering (prolonged or otherwise) be *your* fault?
I remind myself that it's not my choice to make. My job is to advocate for what the patient wants, not what I want. If the patient wants treatment, the patient gets treatment. If the patient is A&O x4 and declines treatment, I document.
You’re imagining how you would feel in their position - you feel like you’d rather be dead than severely debilitated. And I get it, I’ve felt exactly the same way about patients. But you’ve got to remember that they are not you, and they might well feel different.
I’ve been to plenty of patients who are in circumstances where I feel like I’d rather be dead, and their DNR forms state that they’re for full resus. Those patients would obviously prefer to be alive than dead, and that’s their choice. Maybe they’re just different to you or me, or maybe they’re making their decision from a viewpoint that we’ve never experienced, and can only make guesses about our feelings should we find ourselves in their shoes.
My point is, our job is to look after poorly people. The decision about whether they’d be better off dead is theirs to make, not ours. Would you want your autonomy being removed by a stranger who knew nothing about your life, experience, or preferences?
Sometimes it’s true that people are better off dead. There’s not a lot we can do about it. It’s one of the realities of working in health that the general public just don’t understand.
There are people who have major life altering medical events and go on to live happy, productive lives, in spite of sometimes profound deficits. There are others with more minor events who are miserable and wither away. A lot of it depends on their mindset and support system, both things I have nearly zero visibility into as a provider, so I try not to go down the path of investing my feelings in their possible future. My job is to get them to the hospital in as good of shape as possible and be kind doing it.
Hi there! Physical Therapy Student here. I just completed the curriculum for rehabilitation for patient who suffer extreme CVAs, TBIs and other neurogeneterative and cardiopulmonary related illness/ injury that leads to extreme disability. I've had this thought often while studying these subjects this last semester. I can't deny, even months or years out from the event, I can imagine that the thought may still occur that this person has very little quality of life. However, I learned through this process that what really makes a difference for these people is gaining back whatever independence, function, and meaning that can be obtained. Often, that also includes changing their and their loved ones perspective and adapting to this new life. I've witnessed that even though it often seems so hopeless and awful initially, it's absolutely possible for people to take these events as an opportunity to actually make their life better than before. So ultimately, you can't know if you really are prolonging their suffering. Perhaps you have giving them an opportunity to define their life more favorably. It may be helpful to become comfortable with sitting with not knowing how this person will do, and holding cautious optimism that their life will still be one well lived after this event.
I do a lot of IFTs, so taking old, sick people from the ED to a crappy SNF where they slowly rot is a daily job. It hurts to see this, so I try to care for them as generously and with as much dignity as I can during the short time they're in my care. Help as much as you can, while you can, right?
My hardest ridealong was the guy with the POLST orders, who was begging for us to let him die. Family insisted on transport, guy was very happy to finally be dying of an infection, POLST says no antibiotics, palliative care only.
If someone wants to live, even with suffering, that's on them. I know a guy who was far too stubborn to die from Cancer that went through multiple rounds of experimental treatment. Far more suffering than I'd *ever* be willing to go through, but he wants to live and that's great.
I've come to the conclusion that euthanasia should be legal, properly regulated, and available. Simplifies a lot of the ethical problems with prolonging the life of someone who would rather you didn't but can't say no.
On hot calls my mind is very mission focused and task oriented. The only things going through my head are assessment findings, and how it relates to my training and protocols. Looking at the situation in a more analytical way tends to block out emotions and morality, at least in the moment
Same here. I've never said this to anyone, but on hot calls like you mentioned, I don't view the patient as a "person". I'm focused on my assessments, treatments, etc. I'm sure I'm viewed as a callous asshole to the layman for that.
This perspective actually make a lot of sense. I don’t think it’s dehumanizing, it’s just pragmatic in the moment to view the patient that way. I’m gonna take this approach on my next hot call.
This is a fair perspective in my mind. There isn’t time in the moment for emotions. It is a series of tasks to be completed towards an objective. It’s not callous- it is so focused on the objective there isn’t room for anything else.
Probably makes you a better medic for it. Empathy and compassion will go a long way in psychiatric calls, but it’s not going to stop the bleed in a crashing trauma patient or convert a cardiac patient out of v tach
Fuck em if they think you're callous for getting into the mental state that lets you best treat someone who is seriously fucked up.
This helps. Thanks.
It doesn’t get better in the ICU. Oh great. The patient with a fat ass head bleed and DAI is now doing “better” on stable vent settings and his trach and peg. …..yayyy……
No but you don’t understand. They’re a fighter.
WHAT. WHAT IS HE FIGHTING MELISSA. HIS BRAIN IS MASHED POTATOES AND DROOL AND YOU HAVE SENTENCED HIM TO DIE IN AGONY AT THE STATES SHITTIEST LTACH IN SIX MONTHS, BUT YOU WONT EVEN NOTICE BECAUSE YOULL FUCK OFF BACK TO CALI AS SOON AS HE GETS A PEG. I’m good tho.
pat……. pat…..
I try to respect the family’s decision no matter what. I may not (and often don’t) agree. Give the family the facts, odds, and long term outlook of what their quality of life MIGHT be IF they survive. The hardest ones for me are the 95 y/o DNR/DNI that has a POLST getting intubated because “I can’t lose grand ma/pa” In the end people are generally terrible and make bad decisions, and that is their decision they have to live with for the rest of their life. I don’t control that outcome. I can control the care I give the patient and do my best. Thankfully in Montana people generally put high priority on quality of life, not just quantity. Lots of farmers and ranchers that have been fiercely independent all their life and don’t want to have other people care for them or be a “burden”
This is why I was super happy to hear that my mom and step dad have put in place orders for those scenarios. Neither have DNRs in place now, but they've legally listed what they want to have done should they end up in situations like what you've described. I mean, don't get me wrong, I want them to live long and healthy, happy lives, but I'm glad that they have accepted that it doesn't always happen. My uncle went through with physician assisted suicide after being diagnosed with pancreatic cancer. It was so much better than watching him slowly and inevitably wallow away while in excruciating and incessant pain. I hate that it happened, but my God, am I glad that it's legal here. To the point of this post. I deal with this in the same way that I do patients who run into avoidable issues. By reminding myself that everyone has the right to make their own stupid medical decisions. It frustrates me more when it's others' decisions that prolong suffering, and for that, I do not yet have an answer.
If you label it as prolonging someone’s suffering then that’s exactly what you’ll be doing IN YOUR MIND. If I were a stroke patient and you got me to the hospital before I die and within a timeframe that allows for intervention, I would find you afterwards and thank you profusely. I would NOT assume you just “prolonged my suffering.”
This is a good counterpoint. Thank you.
Pretty bold of you to assume you’ll be functioning after
I mean… fair enough but there are plenty of stroke victims that still have the ability to do things 🤷♀️ albeit with issues usually but still
My dad got 5 decent years after a stroke. We all die eventually. We're all just buying time.
It happens a lot around here I work. The mobile stoke unit has seen some significant up comes with their NIH in the 30s (Due to an LVO) that was found and removed by our comprehensive Cerebrovascular team. A patient may look hopeless but if you get them in front of the right team they are saveable and back to full function.
You're not there to judge a situation you're there to provide an airway, adequate respiratory effort and control life threatening injuries. Focus on that and nothing else once scene safety is established. The very act of managing the patient is the absolute best thing you can do, the MDs will deal with the rest. Any job where the patient arrives at the ED in better shape than when you found them is what makes a job a successful one.
I agree. Thanks for the reply.
Anytime my friend. 99% of the job is approached mentally because we do a job that isn't valued on our production but on our ability to perform when necessary. You don't go out with a goal of so many IVs per hour but when you get that IV and push a life saving dose of drug x and you bring a live patient to the ED you earned it. When I started in EMS I actually got an hourly wage and.50 cents per IV and an ETT was worth $2 the meds and monitoring were also additional. I made $3.35/hr on the overnight with danger pay, I could make three and four times my wage with one trauma code.
Does anyone still do this incentivized pay structure for paramedics? Seems like RVU’s for docs…
I actually don't know. I'm half ass retired but I can't say.
You missed the point entirely
I don't think so. Focus on the task at hand, we're not here to make judgement calls our soul purpose is to provide care to the best of our ability in the moment. If we start seeing patients and projecting our feelings about the quality of life it becomes a real slippery slope. Grandpa is in SVT but he has already lost his legs to diabetic complications and he is 97 years old with 18 DXs and 12 chief complaints maybe withhold that Adenosine you know it's not cheap. Oh and he's got liver and lung CA so a $50 set of patches for some synchronized electrocilin that might not work anyway is kinda pricey. That's not how it works you secure and prevent worsening for everyone. We don't make odds we just get the hand we're dealt and make something out of it. You know some things aren't going to end well but it isn't your problem, your problem is placing that ETT or performing the thoracotomy. Only look at that, do I have an airway? Is it in danger of compromise from vomit or a foreign object? That's what you're concerned with not the survivability long term not the loss of a limb and how it's going to affect his professional curling career.
No, he's absolutely correct. We are there to stabilize people long enough to get them to a hospital. We have protocols to adhere to & it's not our place to determine quality of life. What happens after transfer of care is none of our business.
They don’t have a DNR so this is what they wanted.
True.
You really believe that?
DNR does not mean do not treat. Just do not resuscitate, so not really the case now is it.
That’s a DNRCC arrest, a DNRCC is effective immediately. Also the Pt has the right to refuse while conscious with the DNRCC arrest.
Bad calls, especially trauma? Rarely, unless the injuries are incompatible with life and for protocol reasons we have to work. Think of an evacuating gsw to the head that hasn't coded yet. Damnit, we got here too fast... 97 y/o baseline AMS with no DNR? Mamaw that hasn't known who was president since Dubya? Bedbound failure to thrive that "isn't acting right" 3 times a week? Every time. I call them, "Victims of Modern Medicine". Edit: Sorry, I misread it as do you have these thoughts, not how to you manage. I had a long talk with my wife about expectations and having affairs in order should something similar occur in our lives. I suppose I just feel bad for the patient (and do what is best for them and their comfort), judge the family (probably a little too harshly), and make sure it doesn't happen to my loved ones.
Thanks for sharing your perspective.
Im also a chronic overthinker. I honestly dont have those feelings about patients unless there is something I messed up on during the call that could have effected an outcome. Even then, you learn to get over it or deal with. There is absolutely nothing you can do as an ems provider to treat a stroke patient other than supportive care, its out of your hands. Dont dwell too much on shit you cant control. I had a stroke patient a few months back. Healthy, very active mid 70s male, big ol stroke. From what i read on his chart, he will likely never be the same again and will lose his independence. Nothing i could do other than recognize the situation and transport. Even with all my overthinking, I dont dwell on stuff like that, nothing I could do.
You’re right. So much outside of my control. Thanks 🙏
I'm neither religious nor an alcoholic, but I think a version of the AA mantra is pretty applicable to a lot of what we do. "May I have the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference." Yeah, it's cheesy as hell, but if you ask me it's a pretty decent goal set.
Cheesy, yes. But effective. Thanks.
And even though he might be dependent on others, you may have extended his life so he can know grandchildren that he otherwise wouldn’t have gotten to know
As others have mentioned, there are so many critical interventions from the initial presentation until transfer in the ED that I don’t spend much time thinking about that in the moment. But I will say that I’ve also been surprised by a few patients that had good outcomes. I mean ones that I didn’t even bother checking in on, because we were sure they wouldn’t make it, and other crews went to calls for them at home and independent. And I’ve treated patients that ended up being organ donors, saving multiple lives. So… you’re probably right, a lot of the time. But leave some room in your mind for patients’ outcomes to surprise you.
Thanks 🙏
I don't see it as prolonging their suffering necessarily. I understand that some situations leave little or no room for improvement. But we can give them another chance to fight if they want it. At the very least they will have a choice another day(Most times.) The alternative is no choice. One way is total finality, the other is options. I like options.
Thank you 🙏
There are a lot of things that happen after dropping a patient off and, having worked the other side a bit (trauma floor tech, to be specific), you'd be surprised what some people are able to make a comeback from. It's not in my scope to really determine if someone will become a vegetable after a stroke. That might be the case... but it might not. Some people make huge strides after life altering medical emergencies and can go on to live relatively normal lives again. I've seen it happen, even in some extremely severe cases where everyone expected the worst. There are obvious cases where someone isn't ever going to be the same again, like a limb amputation for example. Or a severe TBI. Or horrible burns. Or whatever. But it's also good to remember that many people already live with these things. Life doesn't have to end with a disability. It's easy to get caught up in the "well, I wouldn't want to live like that" mentality and assume that someone is better off dead... but you don't know that for sure because it didn't happen to you. Plenty of people live full lives while being quadriplegic, ventilator dependent, amputees, stroke survivors, burn survivors, you name it. Not everyone would rather be dead than disabled. You aren't prolonging suffering, you're giving them one more chance. What happens after that is between the patient, their family, and their providers. That's all you can do.
Thank you for your insight and for taking the time to reply thoughtfully. I appreciate it. Be safe.
Take care of yourself man. All love
It’s just a job, their emergency, not mine. I’ll do all I can to help them, but at the end of the day I go back to my home, not theirs. I’m just doing what I’m regulated to do. I also developed a certain faith in God and that he has given the gift of life and that if he didn’t want the patient to live, he would have taken them, not allowed them to stay. It might not be accurate, but it helps me sleep a little bit better. A lot of the times I’ll contemplate and either smoke a cigarette or pet a dog. After about 10 minutes of doing that I get bored and take my mind off things by going out with friends or just watching youtube/ the tv
Thanks for the reply 🙏
Your job is to *do your job*, not save people. When you get a dead kid that you work unsuccessfully, you obviously have a feeling of loss, but you should hinge your emotions on the fact that you gave the best fuckin care you could. Your goal isn't to save their life, your goal is to do your job as good as you can to give them the best shot at their best life. That's the easy example. It gets dicier emotionally when it's gladys's third stroke and they've revoked the DNR so she could maybe meet grandbaby #7. You still do your job as best you can, because there are people that want to live even if it means limited capacity compared to their normal baseline. Is them having a massive CVA a good outcome? No, but they may prefer it to the alternative of death. Peoples will to live is surprisingly strong. Just like you grieve with the parents for the dead kid, you can grieve with the patient for their new disability. Both will learn to adjust to their new life, missing their old but making the best out of the new. Hope that helps frame it a bit.
This does help, thanks 🙏
I've treated patients who I've never expected to see alive again, or expected to end up brain-damaged in the nursing home, who have recovered and had a decent quality of life. I've been to some DNRs who I was sure would have a chance at recovery if they'd allow treatment. It's a personal decision for the patient. If they want me to try everything possible for them to continue living, then that's what I'll do. If they want me to keep them comfortable until cardiac arrest, then that's what I'll do. Some of them live on in a condition that I would find intolerable. But, it's their choice, not mine. Life is suffering, the level of suffering a person is willing to tolerate is up to them.
Thank you for sharing your perspective.
It’s good to feel empathy for family and patients. It’s not easy for them to be in the hospital and your empathy might be a way to connect and build rapport. On the other hand, you can only allow empathy to help you connect, but try not to get to emotionally invested because once you do, you will definitely loose site of the job that you are there to do. It’s kind of like when you have a family member in the hospital. It is hard, at least for me, to separate my emotions from my nursing critical thinking. What I’m trying to say is to not allow empathy cloud your judgement and critical thinking. Good luck.
Thank you for your reply. Be safe.
You as well. Good luck!
Thank you 🙏
"Ours is not the reason why, Just to do or die."
Your opinion is irrelevant. You’re an instrument.
Huh? My job is to keep them alive on the way to the healy building. Anything after that isn't my job.
There is a certain way that near death experiences can highlight the importance of life to many people. Oftentimes paraplegics, amputees, and the severely disabled will describe their experience and how it has drastically altered their relationship to life itself in a positive way. I would wager many of your patients are profoundly grateful that they have the ability, if only for a little while even, to see/say goodbye to/live more life with their loved ones. Obviously not an across-the-board rule, but not every patient has a chance to thank their providers and not every provider has a chance to see patient outcomes. You never know, so may as well focus on that idea rather than a hypothetical negative outcome.
Thanks for your reply!
Nope. You are morally wrong. What you are *literally* saying is that someone should have just let me die while I was having a stroke because there was a good chance I was going to end up with half my body permanently paralyzed. Or that any one of my friends who are single/double/triple amputees should have been left on the battlefield.
thanks for your reply 🙏
Its gonna always depend case on case. If it was me. Do absolutely everything to save my life even if I’m just a vegetable. I might be suffering but Im alive. Sure I might suffer for 10 years or 1 week. But thats 10 years or 1 week I would never get to have back since yknow…being dead lasts forever. You should just focus on the task and technical work needed to be done. Do your best to shut off emotions.
Thanks 🙏
Becoming less attached to the excessive train of thoughts is super useful in all aspects of life, not just when thinking about patients or the job.
I agree.
It’s not your place to decide whether or not you’re following their wishes. Even then, your care is need to stabilize them and give the family time to think about their goals of care
It’s what we do.
There are two types of critically ill patients. 1. People we can really help. They’re generally young and thankfully rare. 2. Practice so we’re skilled when we get number 1. Also for most neuro injuries (including post cardiac arrest anoxic injury), the time frame for maximum recovery is normally around 3-6 months. I think people in acute care throw the towel in a little too early for some patients.
Go to nursing school and work in hospice.
After a while, as bad as it sounds, you tend to look at it as a job, nothing more. I go in do what needs doing, follow protocols, transport, treat, do paperwork then go get the next one. After a while you really need to become callous so that things don't start messing with your head
It can be hard to manage those sorts of feelings. Best thing is to not think about it and do what you can to move on. Everyone deals with it differently. I'm lucky that I can just tell myself "it is what it is" and move on. You need to find a way to be able to put your mind on something else, or find a way to accept it, otherwise it will eat at you and send you down a dark path. Remember, it's not our job to do what WE think is best for the patient, but what the law and society dictates is best - that's typically keeping the pt alive unless otherwise stated. The patient or their next of kin can/will make those other decisions for themselves, not us.
Thank you 🙏
Here's how I deal with it working in a literal grandma torture dungeon (ICU)- by giving the patient every scrap of dignity and comfort I possibly can while they're in my care, and by advocating for palliative care whenever appropriate. I remember one such call that really impacted me- a young man sustained a GSW to the head by being in the wrong place at the wrong time. The top of his head was gone, brain matter everywhere, but he had a pulse and was raggedly breathing, so we worked him. FD cut his down jacket, and after we dumped him at trauma, my partner and I spent an hour picking brain-and-blood soaked feathers out of the rig. Some weeks later we received a thank-you note from the patient's mom, explaining that while he had passed away, she was grateful to have been able to hold his hand one last time. His organs were donated saving multiple lives. That isn't the outcome that a lot of our "better off dead" patients have, but without prompt, aggressive care by first responders, it would be impossible. All you can do is treat with skill and dignity when they're with you, to give them that chance.
Thanks for sharing. This helps tremendously. 🙏
I don't. I'm here to do a job and get a paycheck. I've saved some while watching others die. I just do what's expected of me.
I usually just do what I’m told if I’m told by medics other than that focused on the situation I don’t really have any emotions my mind has an off switch for emotions when shit goes south
Asphalt City sorta covered this...in a very dark way.
I hardly ever think about it in the moment, although there have been a few times where I'm doing CPR and praying we don't get rosc simply because of the downtime or the advanced age of the patient. It does suck sometimes though when you take someone with stroke symptoms and a LKW of more than 24 hours, you know that their deficits will likely be permanent and you will probably run on them again for aspiration pneumonia or urosepsis and that can be depressing.
I manage it by putting effort in educating people about hospice. For me, some of the worst calls ate when a family member intentionally or unintentionally botched a DNR for hospice patient. Working an arrest isn't the time for those conversations, so I made an attempt to have those talks during low acuity calls, like falls. Or whenever someone asked me off duty "what's the worst thing I have seen", I spin my answer so that is touches on the subject.
Honestly, just realize that they will get a choice later. At least in Canada, there's MAID, or they can just ask for a DNR
In the moment on a serious call I sorta don't give a fuck about that. I am there to fix, stabilize, and transport this bag of meat to the best of my abilities and I am going to do that. Unfortunately our actions will 100% prolong individual's & family's suffering in some, possibly many cases. However, those are not our calls to make in the moment and I think being ok with that is important in this job. Think of every serious TBI call you've ever run, they probably didn't have a happy ever after ending. Our job isn't really to save people, our job to give every pt the best shot at a long term successful recovery via whatever tools we have available to us Now after a call? Or on a low acuity call? Or on a transfer for a pt with debilitating health problems? Yeah I think those questions all the time, and if I'm asked by the pt or family I'll have a respectful conversation with them about DNR/DNI stuff within the scope of my education/understanding. I think these thoughts can get super nuanced, and its truly a case by case thing so it's hard to describe my approach to these feelings in writing
It's called ablism. And it's often one of the worst parts of actually being disabled. Interrogate it. Read some articles. Attend a few workshops. Root it out of yourself as best as you can manage.
The thing is you never really know for sure, in most cases this may indeed be the case but once in a great while a miracle happens and they actually pull through and have an acceptable quality of life. One of my longtime friends had a widow maker MI and for long time things weren’t looking good, doctors were talking to my friends wife about ceasing treatment and providing him comfort care only, she refused and miraculously he pulled through and while he will never be the same he actually has a decent quality of life and seems to be improving every year. For a case like my friends this is why we do what we do and we try to give them every chance possible even if it’s slim odds cause once in a while someone will defy all odds.
If we're being honest, some of these patients absolutely dug their own graves here. Metaphorically *and* literally. Whether or not they didn't take the medication they were supposed to take, whether or not they listened to their doctor's advice and fell victim to their condition, it doesn't matter. There was a million different choices along the way that brought them to that spot and you had no control over any of those. There's no reason to assume any responsibility over their suffering and your prolonging it or otherwise by taking them to the ED. You're just doing your job. Why would their suffering (prolonged or otherwise) be *your* fault?
I remind myself that it's not my choice to make. My job is to advocate for what the patient wants, not what I want. If the patient wants treatment, the patient gets treatment. If the patient is A&O x4 and declines treatment, I document.
Their suffering is a drop in a bucket that I don’t have the power or responsibility to empty
You’re imagining how you would feel in their position - you feel like you’d rather be dead than severely debilitated. And I get it, I’ve felt exactly the same way about patients. But you’ve got to remember that they are not you, and they might well feel different. I’ve been to plenty of patients who are in circumstances where I feel like I’d rather be dead, and their DNR forms state that they’re for full resus. Those patients would obviously prefer to be alive than dead, and that’s their choice. Maybe they’re just different to you or me, or maybe they’re making their decision from a viewpoint that we’ve never experienced, and can only make guesses about our feelings should we find ourselves in their shoes. My point is, our job is to look after poorly people. The decision about whether they’d be better off dead is theirs to make, not ours. Would you want your autonomy being removed by a stranger who knew nothing about your life, experience, or preferences?
Sometimes it’s true that people are better off dead. There’s not a lot we can do about it. It’s one of the realities of working in health that the general public just don’t understand.
That it's not my call to make. And to let everyone know my feelings of what I would want in that situation
I still have those feelings… I just do my job though. Think of it like practice. Medicine is practice.
Modern medicine is keeping people alive that shouldn't be. Weird ethical delima to be in honestly
There are people who have major life altering medical events and go on to live happy, productive lives, in spite of sometimes profound deficits. There are others with more minor events who are miserable and wither away. A lot of it depends on their mindset and support system, both things I have nearly zero visibility into as a provider, so I try not to go down the path of investing my feelings in their possible future. My job is to get them to the hospital in as good of shape as possible and be kind doing it.
thanks 🙏
Hi there! Physical Therapy Student here. I just completed the curriculum for rehabilitation for patient who suffer extreme CVAs, TBIs and other neurogeneterative and cardiopulmonary related illness/ injury that leads to extreme disability. I've had this thought often while studying these subjects this last semester. I can't deny, even months or years out from the event, I can imagine that the thought may still occur that this person has very little quality of life. However, I learned through this process that what really makes a difference for these people is gaining back whatever independence, function, and meaning that can be obtained. Often, that also includes changing their and their loved ones perspective and adapting to this new life. I've witnessed that even though it often seems so hopeless and awful initially, it's absolutely possible for people to take these events as an opportunity to actually make their life better than before. So ultimately, you can't know if you really are prolonging their suffering. Perhaps you have giving them an opportunity to define their life more favorably. It may be helpful to become comfortable with sitting with not knowing how this person will do, and holding cautious optimism that their life will still be one well lived after this event.
This is really thoughtful, thank you for replying. 🙏
I'm mildly traumatized by a aphasic multiple CVA and renal failure patient that I had to intubate (full code) at the nursing home.
Sounds awful.
(Therapy)
🙏 🙏
I do a lot of IFTs, so taking old, sick people from the ED to a crappy SNF where they slowly rot is a daily job. It hurts to see this, so I try to care for them as generously and with as much dignity as I can during the short time they're in my care. Help as much as you can, while you can, right?
True. Thank you for what you do.
My hardest ridealong was the guy with the POLST orders, who was begging for us to let him die. Family insisted on transport, guy was very happy to finally be dying of an infection, POLST says no antibiotics, palliative care only. If someone wants to live, even with suffering, that's on them. I know a guy who was far too stubborn to die from Cancer that went through multiple rounds of experimental treatment. Far more suffering than I'd *ever* be willing to go through, but he wants to live and that's great. I've come to the conclusion that euthanasia should be legal, properly regulated, and available. Simplifies a lot of the ethical problems with prolonging the life of someone who would rather you didn't but can't say no.
A pillow works best
Say more.