Remember Their Faces

One of the easiest routes to take when dealing with the incessant 911-caller, often endearingly referred to as our frequent flyers, is to show them to their seat in the ambulance and ignore them thereafter.  Generally, these are the callers that - to many of us - regardless of the hour, it is never the right time for them to call.  Typically, these patients are homeless, under-educated, have poor coping mechanisms, a combination of all three, or more.  And sometimes, they fall under none of those categories.

It is simple to assume that because of their seemingly unfortunate circumstances, they won't complain about your lack of understanding, compassion or clinical intervention, and that no one would care even if they did complain.  But is this what we trained for?  Look, I'm not going to say that I've never been frustrated by those callers.  Perhaps, however, we can take the opportunity, instead of berating them for calling just as we're about to get off shift (because obviously every time they call we're about to get off shift), to speak to them, listen to them and truly make the attempt to empathize with them; to appreciate their story just as you'd want someone to hear yours.

One of the most eye-opening, and to some extent, absurd things I've ever heard was "wow, I can't believe you actually treated that patient," referring to one of our regular clients who I found to have an altered mental status, an irregular heart beat, and hypotension.  This wasn't said to me insultingly as if I had over-treated the patient; rather, it was said in true disbelief because so many paramedics and EMTs would have ignored or completely missed the fact that this familiar face was acting differently than he normally does.  That is, because he's a regular, many would have walked him to the ambulance and potentially not even assessed him, dropped him off in the emergency department waiting room and never recognized that the patient was unstable.  Why? Strictly because he was homeless, an alcoholic and called 911 often.

This presents two stunning issues with the current state of EMS: (1) Many of the newer generation of employees only care about themselves, which unfortunately leads to the second issue, (2) they can't empathize with the patients and therefore do not always provide appropriate patient care.

Just the other day I was reminiscing with a friend of mine about a patient we often saw in the ER where we both previously worked.  We admired his persistence to stay afloat, despite multiple co-morbidities causing him to drown slowly.  We chuckled about the fact that he knew the ER so well that we'd recurrently find him in the staff kitchen area getting snacks and juice.  My friend also recalled that one time when the patient was in the ER she asked him why he was homeless.  He told her that his wife left him, he felt lost, found the bottle and drank himself into homelessness.

His story is not so far from the truth for many of our frequent flyers.  In fact, according to Crane et. al. (2005), homelessness later in life is often a result of relationship breakdown, disputes with neighbors, death of a close family member, loss of accommodations or financial troubles.  In addition, alcoholism and mental illness are common contributing factors (Crane, et. al., 2005).  Furthermore, Mojtabai (2005) explains that while mental illness is not a primary reason for homelessness, it certainly increases vulnerability, which has been noted in research for many years.  And according to HomeAid, a non-profit organization that works to provide housing for homeless individuals, homelessness can be linked not only to the above causes, but to domestic violence, divorce or other family disputes.

So, clearly, many of our homeless patients do not consciously choose to be homeless.  Some do, but many of them do not.  And regardless of socioeconomic status or living arrangements, we have a job to do, and that is to care for our patients fairly and responsibly.  Unfortunately, however, I'd guess that many paramedics and EMTs see the homeless frequent flyer as an inconvenience and not as someone, a person,  they can learn from.  Simply put, they don't inquire as to why the patient is homeless because they don't care. 

As I alluded to above, perhaps this is a result of the newer generation of paramedics and EMTs being born into the "me me me" generation; the offspring of the baby boomer generation, or generation me (Stein, 2013).  That is, the newest group of our EMS providers were brought up to believe that they are IT.  Stein (2013) explains that this group, now in their early 20's are three times more likely to be diagnosed with narcissistic personality disorder compared to the generation now in their 60's or older.  By definition, this generation lacks the ability to empathize with others (PsychCentral, 2014).  Thus, this group of newer EMTs and paramedics lack the ability to care for another individual as is required to be effective EMS providers.

I always tell my coworkers and trainees that we have two primary jobs: patient care and patient advocacy; neither are mutually exclusive of the other.  To provide good patient care, one must be a good patient advocate, and to be a good patient advocate, one must do good patient care.  And to do both well, one needs to listen to their patient and to care about what their patient has to say.  To treat their patient as they'd like to be treated themselves.  Or to treat their patient as they would like their family members or close friends to be treated.

Every time I've asked a patient about their homelessness, the answers vary, but are all, nevertheless, equally tragic.  One patient told me he was homeless because he ran away from his home because he was being sexually assaulted on a regular basis, and not just by his parents; his parents prostituted him to make money.  Another got a divorce, lost his children, home and everything, turned to alcohol and drank himself onto the streets.  Others have cited inability to control mental illness or physical disability.  Again, regardless of their reasons for being homeless, or even the fact that they are homeless, they are people who are in need, and so should be cared for. 

Perhaps one of the greatest struggles we, as paramedics, have is identifying with our patient.  Being able to feel what they feel, think what they think and see what they see is not easy for many of us, especially when the patient is the only representation of such an unfortunate life.  However, homeless people are not the only ones who have been sexually assaulted, involved in domestic violence or diagnosed with a mental illness.  In fact, many of our coworkers, family members and friends have been diagnosed with or qualify for a diagnosis of a mental illness, have been in abusive relationships or have been sexually assaulted.

While you may never know who these people are, or that you even know them, they exist in your world.  They are part of your life.  They are your way to identify with a patient you may otherwise care nothing about.

For a few years before I started working at my current place of employment, I volunteered with an organization dedicated to educating people about mental illness in order to decrease the stigma that surrounds it.  I had the opportunity on a number of occasions to share my story of a life with depression.  I shared my story to empower those incapable of sharing their own and to encourage those too afraid to seek help to reach out and speak to someone about their struggle.  I shared my story to give people a relatable and unsuspecting face of mental illness. 

Now, I share that publicly (again, not for the first time, so no worries about the gasps or jaw drops that may have just happened) to provide my coworkers - those I know and those I don't know, those who work for the same company as I do, and those who I'll never meet because they live elsewhere in the world - a face or representative for the mentally ill patients you encounter, some of them homeless, and many of them not.

Sharing is not for everyone, and I know that, and I don't expect a revolution of paramedics offering their own personal stories to coworkers in order to convince them to treat their homeless or mentally ill patients with respect.  For those who do share, I commend your bravery.  For those who cannot, I understand your struggle and your pain.  I understand your desire to keep your personal life personal and your private experiences private.  There are many reasons to share your story, and many reasons not to.  So, for those who are not comfortable sharing, in this forum, I speak for you. 

I speak for the unimaginable number of individuals who die by suicide each year.  For the multitude of people who are diagnosed with a mental illness each year.  And for the millions who live each day with an undiagnosed mental illness for fear of seeking treatment because of the undeniable stigma that exists.  For those of you who know me, let me be the face you see.  For those who don't know me, let me be the voice you hear.  Although, you really don't need to go too far to find a face; use your own face, your parents' faces, your siblings' faces, your friends' faces.  Or simply, look your patients in the face, speak to them, and remember their faces.

I ask but one thing: recognize that you are not alone in your struggles, and that your patients, too, should not be alone in theirs.  Mental illness does not discriminate against age, gender, race, religion, ethnicity or socioeconomic status, so certainly we, as healthcare providers, shouldn't either.  Regardless of who your patient is, where they come from, or how many times they've called this month, treat them as you would like to be treated.


References:

Crane, M., Byrne, K., Fu, R., Lipmann, B., Mirabelli, F., Rota-Bartelink, A., ... & Warnes, A. M. (2005). The causes of homelessness in later life: findings from a 3-nation study. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 60(3), S152-S159.

HomeAid (n.d.) What is HomeAid?  Retrieved from http://www.homeaid.org/About-Us

Mojtabai, R. (2005). Perceived reasons for loss of housing and continued homelessness among homeless persons with mental illness. Psychiatric Services, 56(2), 172-178.

Staff, PychCentral (n.d.). Narcissistic Personality Disorder. Retrieved from http://psychcentral.com/disorders/narcissistic-personality-disorder-symptoms/

Stein, J. (2013, May 20). Millenials: The me me me generation. TIME.