A Letter to Myself (and I didn't know it)

Social media in my circles is abuzz by shares of a LinkedIn article by Oleg Vishnepolsky discussing leadership and what it means to be a leader.  The cover of the article displays a Simon Sinek quote: "Leadership is not being in charge, it is about taking care of people in your charge."  The headline, another quote, "Great leaders don't set out to be a leader.  They set out to make the difference.  It is never about the role - always about the goal" (Lisa Haisha).  Vishnepolsky (2019) writes that "strong leaders measure success by the difference they made in other people's lives."

The concept of leadership has recently been weighing on me; the goal, not the role.  Every day I think to myself: Am I cut out for this? Am I effective? Am I what’s right for my organization? Am I what’s right for the people we serve (the internal customer)? Am I doing it right? And the most important question: How can I do better?

Every single day, I look for opportunities to learn and grow.  Every single day I look for ways I can be better for my organization and our workforce.  Every. Single. Day.  Leadership is not just about leading people.  It’s not just about getting the job done and making sure others do, too.  It is so much bigger than that.  So much bigger than me.  Leaders have the capacity to build their workforce into a beautiful architectural phenomenon or the potential to demolish it like a wrecking ball clinging to the lifting hook of a crane aimed right at them, ready to wreak havoc.  As leaders our responsibility is to build and beautify.  Our responsibility is to sustain and grow our workforce, to help mold them into future leaders.  To support them and guide them.  They are our legacy and our succession plan.  If we destroy them, we have no future and neither does EMS.

In my pursuit to answer the questions I ask myself daily, I have dedicated several hours to researching different leadership and followership styles, how to relate to people of various backgrounds and generations, how to speak to people, public speaking, business development, recruitment, retention, human resources practice, mental health in EMS and so much more.  I learned a lot, but the greatest lessons I learned only validated the results of my own introspection and clarified my beliefs about leadership.  After searching and reading for days, I realized I didn’t really have to look too far to find exactly what I needed.  In my phone I found a note consisting of a list of qualities I sought in a leader that I gave my old partner when she promoted to supervisor.  I was still a street medic but knew exactly my expectations of an EMS leader.  I read this letter to myself the other night to see if a younger, ambulance-riding me could provide insight or advice to the manager me about how to be a great leader for a great generation of EMTs and paramedics.

I wrote the list in 2015.  Now a manager, I was humbled reading the list knowing that I haven't lost sight today of what it meant to me back then to be a leader.  You see, when I accepted my first management position in EMS, I swore I would be the manager I always wanted to have.  It hasn’t been easy at all.  It has been filled with an almost never-ending emotional roller coaster ride (and no, still not afraid to admit it).  But I’m trying.  It's important to note that the managers I had happen also to be the reason I am where I am today as their legacy, so I must pay homage to them.  EMS was built on their backs; from their blood, sweat and tears.  Without them, I wouldn't have so many fantastic leadership styles from which I can draw upon – both positive and negative – to execute my leadership responsibilities effectively.

I wrote:

• Lead as you'd want to be led
• Get out of the office and see your employees working; help them...even if I don't see you on my calls, I will hear you on the radio busting your ass the way I am
• Run calls solo when we're at level zero - show crews you are part of the team
• Go to the hospital, sign PCRs for people waiting for extended periods of time or when several crews are delayed at one hospital, especially when at low levels or level zero
• Be held to the same standard as everyone else - protocol/clinical knowledge, uniform, language, behavior
• Know your employees - go through the staff list and note who you would absolutely want to be taking care of you or your loved ones.  Go through the staff list and note who you absolutely wouldn't want to take care of you or your loved ones.  For those you aren't sure about, run some calls with them and decide.  For those you don't want there [helping you or your family]...what is your reason with an example...then fix it either by remediation, training or coaching.  Continue to build your workforce.  Coach those who need coaching, cheer for those who need cheering.  Sit down with those who need a sit-down.  Know your employees.  Know their stories.  We all have stories.  Learn what makes them tick.  Learn what makes them who they are.  Learn them.  Know them.
• When a problem is reported to you, don't just pawn it off on the next person...make the problem stop there...be the solution, don't perpetuate the problem by ignoring it.
• Acknowledge good work from good employees who set the standard and go above and beyond, not just the ones who don't, but occasionally perform well.  Coach those employees, show them, lead them by example so they will become the employees who set the standard and go above and beyond.
• Make your presence known not just when someone messes up, but when they do good work, too.  It is much easier to respect a leader who reprimands you when you do bad if they are also a leader who says "good job" or "thank you" when they do good.  It shows you're fair.
• Show your employees you care, not just before survey time!
• SET THE STANDARD, don't be lazy.  Show your face...lead by example
• Spend a day (or more) in your employees' shoes.
• Remember, everyone is your favorite.  Everyone needs a mentor (even you).  Remember we are dealing with people, not numbers, not robots, not machines.  People.

The questions I have, though, can’t be answered strictly from some list I gave to my former partner.  I needed to understand why it was I felt that way, and why today I still feel that way.  Why only a few short years ago, was the culture of EMS such that I had different expectations of my leaders than they had of theirs.  I guess the question I have is: What makes me tick?  What makes me who I am as a leader?  Well, I’m a Millennial (as much as I hate to admit that), so I started my introspective journey there.

In an International Journal of Human Resources Studies article, Chou (2012) discusses the various leadership styles that have been studied throughout history, the various followership styles studied throughout history, and then links them to today’s culture in which Millennials nearly dominate the workforce and play a crucial role in the development and future of the workplace.  Chou (2012) extrapolates from previous research how Millennials function both in the roles of leadership and followership.

He suggests that Millennials are more likely to function as participative leaders because Millennials prefer to lead by encouraging collaborative discussion, to ask for input on substantial decisions, and to promote open dialogue regardless of rank (Chou, 2012).  Essentially, participative leaders engage their employees to improve outcomes, encourage involvement and ensure a team-based approach to meeting goals.  As for Millennial’s followership style, Chou (2012) indicates that Millennials likely fall into the exemplary category because they are innovative, independent thinkers who desire open and continuous communication with their leadership and aren’t afraid to ask questions or challenge authority.

As the culture in today’s world evolves and as societal expectations change with the growing number of Millennials in the workplace, so too, the EMS workplace needs to evolve.  And there we have it.  EMS is a culture rich in the belief of “suck it up, buttercup” and “do as I say because I’m the [insert title or rank here]”.  But today's frontline staff have been raised to question – to ask why, to propose their own, researched solutions to problems, to be a part of the team and the discussion.  We, I should say, were raised to want to collaborate, to have strong opinions, to question authority when appropriate – and not to be afraid to have or ask questions.  We are also documented as the most educated generation thus far, and we expect to be recognized for the dedication we have in our academic and intellectual growth.  So too, we seek acceptance by our leadership for the theoretical approach we take in our efforts to enhance EMS.  No, we may not have 20 years of riding an ambulance to shape our views, but we have 20 years of school to guide our analytical thought processes.  As Brack and Kelly (2012) point out, we did not have to walk to the library, browse through index cards and search shelves upon shelves to learn what we know; rather, we gathered the information with a few taps on our touchscreen phones, read the material on a bathroom break and collated in our minds several theories and approaches to whatever it is we seek to change.

All that to say: Millennials want to be engaged.  They need to be engaged.  They thrive on engagement.  But if we don’t engage them, or we fail in our efforts to engage them, where does that leave us?  Well, as noted above, if we as leaders fail to engage those who desire to be engaged, it doesn’t take a rocket scientist to guess that they (we) will become disengaged.  We will feel dejected and become disenchanted with our organization and the meaningful work we seek.  And if we become disenchanted, what does that do for the future of EMS as the generation gap continues to grow between today’s leaders and tomorrow’s?

Even worse, however, if we reject the efforts of our Millennial workforce to enrich EMS, we will push them away – both physically and emotionally – and our existence will suffer.  Our productivity will suffer.  Our workforce, already 10 times more likely than the national average to contemplate suicide and 13 times more likely than the national average to die by suicide, will be placed at even greater risk and will suffer (Abbot, Barber and Burke, 2015).  And not because they are weak, lack resourcefulness or resilience, but because WE took from them the resources, resilience and strength they brought with them.  We neglected to use what they brought to the table.  We shut them down.  We failed to tap the talent that exists in our younger team members.  They will disengage.  They will leave us.  They will leave EMS.  And with them, our future will disappear.  The next generation of EMS leadership: gone.  Gone.  Just like that. 

And then what? And then we’ve destroyed our own legacy by being too bull-headed to listen to the youth.  Frankly, I think Whitney Houston said it best in her 1985 award-winning remake of The Greatest Love of All: “I believe the children are our future. Teach them well and let them lead the way.”  The youth of EMS are our future, they desire to be heard and taught.  And if we do that, if we let them be our future, they will lead the way.

So, what does it mean to be a leader in EMS today – the goal and the role?  It means we lead by example.  We give our troops what they need.  We communicate openly, honestly and frequently with them.  We motivate them.  We guide them.  We help them grow and develop them into leaders.  We collaborate with them and respect their thoughts, feelings and opinions.  We swallow our pride and realize our feelings are not theirs nor their problem.  We treat them with humanity and compassion.  We help our people.  We support them.  We inspire them.  We engage them.  We make a difference in their lives.  We care about them.  Vishnepolsky (2019) writes “If we don’t care about people, we don’t deserve to be leaders.”  And at the end of the day, our job is to recognize that our workforce is comprised of our people; that’s right, people.  Not numbers, not metrics.  People.  People who will break if we are not careful and release the wrecking ball atop the crane.  Or people we can build into a beautiful, futuristic architectural EMS structure.

Citations:

Abbott, C., Barber, E., & Burke, B. (2015). What's Killing Our Medics? (Ambulance Service Manager Program) https://static1.squarespace.com/static/555d1154e4b09b430c18fd39/t/5599d2b2e4b0c805c287aa3a/1436144306212/What%27s+Killing+Our+Medics+Final.pdf. Accessed on 11/27/2019.

Brack, J., & Kelly, K. (2012). Maximizing millennials in the workplace. UNC executive development, 22(1), 2-14.

Chou, S. Y. (2012). Millennials in the workplace: A conceptual analysis of millennials' leadership and followership styles. International Journal of Human Resource Studies, 2(2).

Vishnepolsky, O. (2019). Untitled (LinkedIn). https://www.linkedin.com/pulse/kindness-best-strategy-life-business-oleg-vishnepolsky.  Accessed 11/22/2019.

Life Matters...Even in Death

A moment of silence.

Taking a moment in the hustle and bustle of emergency medicine is a rarity. As medical providers, we often get caught up in the rigmarole of a fast-paced emergency department, or in my case, the fast pace of a high-volume, high-acuity, inner-city 911 ambulance service. 

But sometimes, taking that extra moment can change the way we and those with whom we interact view the world.

"Is he gonna make it? Is he gonna make it?" I recall a sobbing wife shouting at me as I stood in the poorly lit living room of a quaint blue house in East Atlanta holding a bag of saline behind the paramedic leading a team of rescuers. I was witnessing my first cardiac arrest as a student on an ambulance my first summer in EMS. At the conclusion of the resuscitation attempt, we walked out the front door and through a vibrant green lawn sprinkled with red and yellow flowers, carrying our used equipment to the ambulance. I sat quietly in the back of the ambulance while the paramedic finished his paperwork. 

We left a forty-five year-old male on the floor of his living room and a widow kneeling in her kitchen, grieving the sudden loss of her best friend, soul mate and husband. The paramedic turned to me and asked if I had any questions. "We just leave him there," I said, "and continue on with our day?"

That summer, as a recent high school graduate I saw more death than my immature mind could comprehend. I was a member of a unique summer internship program at the level one trauma center in Atlanta, GA, shadowing physicians in the emergency department. At that time in my life, the exciting cases were generally the ones in which a life was lost: someone had to be shot to death or succumbing to a massive heart attack or chronic illness.

The following academic year, I studied abroad in Israel and had the opportunity to volunteer as an EMT for the Country's national ambulance service. I was awe-struck after my first failed resuscitation as my fellow rescuers paused before cleaning up to say a Jewish prayer for the deceased elderly woman laying lifeless on the cold tile floor of her narrow upstairs apartment. Because there were so many experienced rescuers on scene, I stood in the hallway and observed.

Back in Atlanta the next summer, I worked in a different emergency department where I'd finally get to participate as a medical provider in the "cool" cases. I remember the first time a patient report for a cardiac arrest was called in. I was so nervous because I had never performed CPR on a real person. When the paramedics arrived and the patient was transferred to the hospital bed, I was the first to do chest compressions. 

After doing continuous compressions for some time, my vision became blurry and my field of sight zoomed out as if I was adjusting the telescope of my brain. When the patient expired the staff exited the room one-by-one, tossing their sweaty gloves in the trash can, taking not even one second to think about what had just transpired, moving on with their other tasks. My focus returned, and I couldn't help but wonder why or how we do what we do.

Years later I became a paramedic and then a field training officer. I had become the medic who asked students if they had any questions, who continued my day after watching someone die, who could socialize and even laugh with my coworkers despite bearing witness to the tragedies that people - not patients, but people - face.

Even though I always felt strongly that a healthcare provider should explicitly show reverence to human life, it wasn't until recently that my behavior reflected this in death, as well.

Let me explain. 

I arrived at our local public academic hospital with a forty-year-old female who was found in cardiac arrest. While performing our duties on scene, my team and I were able get a brief return of spontaneous circulation. During transport to the emergency department, however, the patient became pulseless again. After a few rounds of CPR and advanced life support interventions in the emergency department, the resident physician pronounced the patient dead. He then asked for a moment of silence to show respect to the patient.

I asked the attending physician if this was a new practice, as I had never before seen such an expression at this hospital. He replied that one of the most compassionate physicians on staff instituted this practice a few years ago and has inspired all of the residents to do the same.

Later, I corresponded with that physician to let her know how far-reaching her impact was. I told her that I would begin to encourage other prehospital providers to take a moment of silence should resuscitation efforts be terminated on scene prior to transport.

She wrote back "It has and continues to be a humbling experience to remember life."

My first opportunity to perform this ritual in real-time was as a fill-in supervisor at the EMS agency for whom I work. I responded with an ambulance crew to a 911 call at a nursing facility to find a young man in his twenties in cardiac arrest. I treated him a weeks earlier when his tracheostomy stoma became clogged and required aggressive suctioning to maintain his airway. His unfortunate predicament was a result of injuries he sustained in a motor vehicle accident months prior and the numerous brain and orthopedic surgeries he underwent in the aftermath.

When our efforts became futile, I asked everyone to pause before cleaning up. I asked that we observe a moment of silence to remember this man's life, to respect his life, and mourn his death. I was met with a few looks of surprise as this practice was not only new to me, but apparently no one else, not the nurses, firefighters, police officer nor other paramedics had ever seen. When we left the patient's room, the entire team seemed touched.

Since then, myself and my team have observed a moment of silence at the conclusion of every resuscitation event terminated without transport. We've been told that we actually seem to care.  I've been told by family members of the deceased, bystanders and other healthcare providers that this expression, this extra moment spent on scene in peace and calm, is an honest communication that human life matters.  Even in the hustle and bustle, we stopped.  We took a moment.  We thought.  We mourned.  Together, we sung a symphony of silence in honor and memory of a person who lost their life, sending them off with dignity and respect after an otherwise dehumanizing presentation.

As I've written previously, whether on the job or not, I value human life. I work diligently to treat each and every patient with whom I interact as I would like to be treated myself; as if they were my own family, friend, or friend's family. I treat each patient knowing that they are someone's someone: mothers, fathers and children to someone; brothers and sisters to someone else.

That day, we took a moment to remember the life of someone’s someone. I saw just how important it is for us - all healthcare providers - to remember life, for life is what we are assigned to preserve and protect; to heal and comfort. It was and will continue to be a humbling experience to remember life. Even in death.

Fixing the Unfixable: The Absurd Hero

Not too long ago I came across a quote by an unknown author that struck me as a rather important life lesson, and especially pertinent to the work we do as pre-hospital medical providers: “Sometimes the most broken people try to fix others because they cannot fix [themselves]”.  It took a little bit of time for me to truly appreciate this quote because, naturally, like many others, I’m often in denial of that within myself in need of fixing.  But after absorbing the words I saw on the screen in front of me, I realized that everyone is in need of fixing, to some degree. 

No one is perfect.  No one is unbroken.  Everyone has a past that has left them with a scar or two, physical or emotional.  Everyone has a present that is, in some fashion, etching scars into their skin.  Nevertheless, it is those scars that led us to where we are now.  It is our past that has brought us to our present where trying to fix others is our passion.  It is those scars that attracted us to a profession in which we can help prevent, treat or heal others’ scars.  It is those scars that brought us into the business of helping people, of healing people, of fixing people.  It is those scars that drive us to continue to do what we do.  And, as with many in the medical field, I too have an undeniable, unrelenting, nagging desire to fix people and things. 

Aside from our superficial, yet deeply personal motivation for pursuing a career in EMS, why do we have this urge to fix others?  At what cost?  And who are we really trying to fix?

According to Messina (2008) this need to fix is a “compulsively driven behavior to rescue or help another person, place or thing to be the way you believe it ‘should be’”; or our “inability to accept people, places or things the way they are and the chronic attempt at changing them even if they are unchangeable”.

By this, I don’t mean that we live our everyday lives working toward the goal of making people become what we want them to be, or how we feel they need to be; rather, I mean we have taken on the responsibility, the job, of doing what we can, of doing the right thing, in order to save people from their ailments, self-inflicted or otherwise.  In doing so, we interact with others in such a way to gain insight into their behaviors.  We utilize the attribution theory, to some extent, to assign certain behaviors to either dispositional or situational causes.  In other words, we make a judgment: is this person the way he or she is because of an internal desire, thought or personal motive, or are their actions a result of their situation and surrounding environment, such as socioeconomic status, upbringing, or home life?

We’ve all had those patients who, no matter how much effort we put forth to fix their COPD exacerbations, we see them again the next week for the same thing.  This time, however, they know the protocol almost better than we do, and definitely better than any of our trainees.  They tell us what to do, how to treat them, and what course of action they know will work best for them.  No matter how hard we try to fix them, though, we can’t.  We can educate them, but they still won’t take their medications as prescribed.  We can administer albuterol, steroids, magnesium and continuous positive airway pressure in the acute setting to help them breathe again, but the hypoxia and feeling of impending doom doesn’t persuade them to be compliant with their medications in healthy times.  We can fight for their life, and they still won’t fight for their own life.

Likewise, we’ve all had that friend or family member whose life means more to us than anything else.  We will fight for them, for their success, for their happiness, and for their friendship.  But no matter how much effort we use to help them fix their own issues, they still fumble just a week, a month, or a year later and need our help again.  Or we have that friend we wish we could help, but he or she won’t allow it. 

Similarly, we have all been that friend or family member in need of fixing and have either allowed it, fallen again and needed the support once more, or we have been that friend who refused to allow someone to make an impact on our life due to stubbornness or simply denial, trapping us into a lifetime of enduring turmoil.

This brings to mind the Greek Mythology story of Sisyphus.  Sisyphus was a king who conducted himself in a less than favorable manner.  As a result, he was punished by having to roll a boulder up a mountain forever.  As soon as he’d near the top of the mountain, the boulder would slip down the hill, and his task would begin again from the base of the mountain.  Thus, he was fated to eternal struggle; to what has become known as a Sisyphean task: one that appears never-ending and represents perpetual torment.

In his essay, The Myth of Sisyphus, Albert Camus recognizes that Sisyphus is considered the absurd hero of the story because he persistently started his punishment from the beginning each time the boulder rolled to the bottom.  But Camus (1955) suggests that instead of viewing Sisyphus as a miserable mortal who would forever participate in his routine in sadness, he should be viewed as happily undertaking the mundane, everyday life allotted to him.  And that is what makes him a hero.  That is, instead of giving up, Sisyphus remains steadfast and inclined to complete his interminable task that has become his life’s challenge, or his challenging life.

On a personal level, like many others, I am in need of fixing.  I do what I can to fix myself, but sometimes I fail.  I can try, but often, I don’t succeed.  I'm human; by definition, I’m not perfect.  And so, over the last year I’ve taken on an incredible challenge: transition into a person I’d want to associate with and revert back to the person I truly am.  I have not only bettered myself physically, becoming a healthier and more active person, but also have made strides toward bettering myself emotionally and mentally.  Now, don’t get me wrong, it hasn’t been an easy road and I’ve hit multiple speed bumps on the way: socially, emotionally and physically; nonetheless, the journey I set out to trek seems worthwhile, despite the trials and despite the grief it has caused.

Elizabeth Kubler-Ross (1969) describes the grieving process in five stages: denial, anger, bargaining, depression and acceptance.  Kubler-Ross (1969) notes that these stages do not have to occur in the above order, nor do they have to occur at all.  The author also explains that each stage is not bound to a specific timeframe.  While these stages are generally relevant to loss by way of death, I’d like to attempt to use them in analyzing the following situation, starting with what I wrote above: that like many others, I was initially in denial of that within myself in need of fixing.

As a generally calculated individual, I have been surprised by the things with which I’ve been confronted that I didn’t, and probably couldn’t have planned for during my personal evolution.  For starters, emotionally, I have allowed barriers once erect to fall to the ground.  As I’ve shed weight in the form of fat, I too have shed weight in the form of emotions.  In fact, as difficult as it is to admit, for the first time in a very long time I can honestly say I feel again, both positive and negative emotions; I can truly empathize and sympathize with and for others.  I can genuinely smile, laugh and cry again, all of which I’ve done in the past year.

I learned this through various experiences, including thoughtful introspection and interpersonal interactions. When I first started exercising and working toward bettering myself, I received a lot of flak from the people I once considered close to me.  I was told by many that I became a bad friend as I ditched them for the gym and my trainer, one of my closest friends.  Many things from my past resurfaced, both internally and externally, which taught me that no matter how difficult a physical feat getting healthier can be, the social and emotional aspects of getting in shape, too, are difficult.  Alas, the depression kicked in.

I’m not really sure why my physical transition became a threat to anyone else, or how any person, whether a friend or an acquaintance could possibly see a downside to my becoming healthier.  Despite opposition, I continue to grow.  In spite of what people think and say about me in my pursuit of happiness, I continue to try to better myself; to fix myself.  Despite some of the immaturity, bullying and down-right viciousness, I’ve continued to try to put a smile on my face, keep it moving, and persevere.  In the face of struggle, I’ve chosen to proceed in happiness rather than in sadness, even though there was, and still is, a lot of sadness and hurt.

What this has uncovered, at least from my somewhat belittled perspective and perhaps for many of you, is something that I believe has afflicted our profession for some time; a pandemic issue that we are all aware of, but somehow haven’t taken a stand against.  Something that, conceivably, if unfixed, can ruin our profession, or at least prevent it from progressing to the greatness it deserves: dirty politics. 

In a profession that theoretically attracts individuals who are innately good, who try their best to help people they’ve likely never met or whom they might never meet again, it is, instead, one littered with individuals who, while potentially excellent practitioners of pre-hospital medicine, lack the interpersonal skills and emotional intelligence quotient to recognize that we are not here only to help fix our patients, but also to help fix ourselves and our colleagues.  We are here to fix each other, our team. 

In an age where mental health issues and emotional well-being are common conversation topics, less stigmatized than even five years ago, where multiple organizations and movements exist to promote personal health, mental and physical, for pre-hospital providers and other public safety workers, it is unfortunate that in many cases, we ignore the needs of our co-workers.  And for what?  Personal gain? Status?  Ego?  Reputation?  I'm still not quite sure.  The way I see it, the stronger our workforce, the better care we, as a cohesive group, can provide for the people we serve.  The more mentally and physically healthy our workforce, the more meaningful our service becomes, to us, our peers in the medical field, and most importantly, our patients and their families.

Linking this to a relatively current incident, there have been a set of viral images floating around the internet that depict a pre-hospital provider giving the middle finger in front of dying patients.  Much of the commentary surrounding this circumstance relates to how awful an individual she is.  Many people have nothing but harmful things to say about her.  However, one of my respectable and noble bosses very astutely pointed out that instead of berating this provider for her actions, why hasn’t anyone stepped up to ask her what’s wrong?  Why have many assumed she is an evil person, and that’s why she did what she did?  Why are we perpetuating the evil by portraying her as evil?  Don’t get me wrong, I do not, in any way, condone her actions; however, we as a group of pre-hospital providers, all too familiar with the effects of burnout, should, instead of pointing the finger at her for doing something terrible, ask her why she did it?  Why don’t we ask her what bothered her so much that she felt she had to do that?  Or simply ask her if everything is okay?

So in this era of understanding, why is it that we allow the bullies and the childish gossip-mongers to continue to do what they do?  Why do we allow such behaviors and verbal or emotional assaults to continue to bring down our own?  To bring down OUR workforce?  In a profession that is supposed to attract innately good individuals, why have we allowed our profession to be consumed by some who are incapable of expressing that innate gift of kindness and caring?  Why have we allowed our profession to be consumed by some who are not just incapable of fixing and of being fixed, but who alternatively cause damage and create the very scars that brought us into this line of work?  And then there was anger…

And what have we become?  Who have we become?  How have we been changed?

Messina (2008) explains that when we become overwhelmed by our compulsive desire to fix others, we subsequently become incapable of emotional detachment; thus, we will be unable to walk away from someone we know needs help, our help, or anyone else’s help.  Furthermore, we will lose sight of our own needs, our own wants, our own desires; our self-identified physical and emotional characteristics in need of fixing.

But how do we walk away?  Or how can we walk away?  As part of my challenge over the last several months, I’ve decided to rid my life of toxicity and toxic people.  I’ve cut off ties that I previously couldn’t fathom severing.  I’ve removed certain people from my phone, stopped saying hello to them and even do what I can to avoid them altogether.  Now, I’m not preaching that avoidance is the key to being successful in such a mission; on the other hand, when communication is unproductive or impossible, and all avenues to decrease hostility or toxicity have proven fallible, distance is what I’ve found to be effective.  And yes, I’m happier as a result, even though it took some time before I could accept that fate. 

Messina (2008) adds that in our fight for someone else, in our pursuit for their happiness, we allow them to become dependent on us, incapable of fixing or even making the attempt to fix their own wounds.  And then we continue to fight for something or someone that we cannot control, who we cannot change.  We begin to fight a losing battle against our self, and only our self because no one else is fighting.  We begin to bargain.

And so, I offer a different set of questions related to Sisyphus’s heroism:

Why did he not walk away from the challenge?  How could he not recognize that his task was endless and that his efforts would be fruitless?  Perhaps Sisyphus is stubborn, or in denial.  Perhaps he was fueled by his anger with the gods and the underworld or by the fact that his task could never be completed.  Perhaps Sisyphus didn’t want to be a quitter; he bargained for a better outcome.  Or perhaps Sisyphus just accepted his depressing fate and continued to push forward, despite opposition, or in spite of opposition. 

Still I have a hard time believing that anyone, including Sisyphus, can truly be happy without attempting to alter the mundane, to affect change, to create their own happiness.  And not through acceptance of the routine, but by crafting a routine, a life that is fulfilling; a clever method of pushing the rock over the mountain top.  I have a hard time with accepting a task as inflexible, unchangeable, or futile.  I have a hard time accepting that some are capable of accepting as final that which they know they can change and that which they know if changed would create a world of happiness.  I have a hard time giving up, unless I’ve tried everything in my power to make a seemingly losing battle meaningful, until I’ve exhausted all options, or until I can prove to myself, without a shadow of doubt, that my continued effort would be wasteful.

A lot has happened over the last year and it affected me in ways I never could have imagined.  I lost friends who I thought were close friends but turned out to be less than acquaintances.  I lost a lot in investments I made and continuously bought into over the last several years.  And despite my overwhelming desire to fix messed up relationships and situations, I’ve decided that in this specific situation, with these specific relationships, I needed to give up.  Instead of persevering as Sisyphus and accepting a losing fight, I chose to continue my walk up the mountain, leaving the boulder at the bottom where gravity dictates it should stay.  I’ve accepted that which I cannot fix.

And I’m not accepting it in a way that makes me a quitter; I’m doing it in a way that proves I’m a winner because I tried.  I did everything I possibly could and realized there was nothing more I could do to fix this except move onward toward affecting change on a global level by taking a stand against bullying, trash-talking, pitting people against others, back-stabbing and ultimately damaging individuals who we are supposed to help, fix and heal.

Messina (2008) concludes that we must learn to “accept the belief that others must accept personal responsibility for their own lives and actions.”  Not everyone has to be Sisyphus, forced to fight for an unattainable goal.  In fact, we shouldn’t want to be the absurd hero.  We should want to be the hero who refuses to accept the status quo and takes a stand against that which can be changed.  And we should want to be the hero who can happily accept that some people or situations are unchangeable.  That at some point, our efforts become futile, rigor mortis sets in, we can no longer try to fix the unfixable, and we must subsequently let the boulder roll to the bottom of the hill so we can keep moving forward a few pounds lighter.

"God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference." -Reinhold Niebuhr

References:

Camus, A. (1955). The myth of Sisyphus, and other essays. Vintage.

Kubler-Ross, E. (1969). On death and dying. New York, NY: Macmillan.

Messina, J. (2008, December 22). Overcoming the need to fix. Retrieved January 26, 2015, from http://www.livestrong.com/article/14696-overcoming-the-need-to-fix/ 

The Worst Thing I've Ever Seen

"What's the worst thing you've ever seen?"

This undoubtedly tops the list of FAQ's to all paramedics, EMTs, and probably everyone in public safety.  Needless to say, all of us have our go-to story that isn't quite the worst thing we've ever seen, but will nevertheless satiate the inquirer's insatiable appetite for drama.  Although everyone enjoys the graphic, traumatic tale that many of us could relay to our listeners, I think the most profound response that I've ever heard to that question was from a paramedic who used to work at my service, Ramon Henderson.

When I asked him this question, I was a rookie; still very, very green.  I had no clue what was in store for me.  All I wanted was to hear the war stories.  I wanted the sultry details of every bad call.  But his response left me speechless and dumbfounded, and admittedly, at that time I didn't quite understand how to digest what he had just said.

His go-to story was simple.  In fact, it wasn't a story at all.  It painted a picture for any person seeking a word thrill, without the gory, blood-and-guts-type details that most want.  Instead, it painted a different style of a grim story.  It conveyed a message to all those searching for excitement through others' tragedy and despair that the exciting moments, the desirable moments of our job, aren't those represented by the collateral damage of a human life.  Those certainly aren't the moments we want to remember in a positive light, not to mention share.

His answer with some of my own extrapolation: The sheer poverty that exists in our city.  The poverty that prevents those who need to care for themselves and their family from truly being able to care for themselves and their family.  The child abuse and child neglect.  Children unable to reach their innate potential due to extenuating environmental circumstance.  Children unable to meet their potential due to lack of parental guidance, concern or attention.  Children unable to achieve their potential because their parents lack the resources - financial, social, and otherwise - to provide for them.  Or children incapable seeing their potential and of surmounting the preconceived set of rules that govern their life and abilities to develop and then conquer their goals.  Hungry children.  Fearful children.  Children who don't know where their next meal will come from, when it will come, or if it will come.  The blatant maltreatment of and disregard for human life.  The human trafficking.  The drug abuse and dependence.  The elder abuse.  The sexual abuse.  Abuse of disabled.  Abuse of Veterans.  Lack of education, both in school and at home.  The substandard, overcrowded, often lacking water and power housing arrangements.  Or no housing arrangements; homelessness.

Worse, however, is our interpretation of those issues.  Our frequent or occasional denial in the face of reality.  Our society's refusal to acknowledge the existence of these conditions and those that cause these conditions.  Our desire to maintain a photo shopped world sans the violence and death that occur in their reality, but only in our local news, the TV shows we watch, and while we're on the clock.  The us versus them mentality.  The approach from an often (more) privileged and myopic perspective.  And the stance we take from afar with a certain blindness to the inequalities that exist in this world, natural or environmental.

We all have our stories that will forever scar our hearts and leave long-lasting images in our eyes and brains; the stories that create audible tension in our minds and palpable tension in every room we enter (or maybe that's also in our minds as a result of our experiences). But sometimes, despite overwhelming negativity in our daily work lives, some positive light can shine through.  And, in fact, as a general optimist, I try to see or create the positive in the face of all the negativity.

For example, recently I experienced two fairly juxtaposed situations that have definitely left a mark on me.  The first is probably, to date, one of the saddest, yet touching moments of my career.

I was posted at a gas station across from a skating rink.  My partner and I walked into the gas station to buy a few snacks and some drinks.  As we exited, we were met by an 11 year old child who appeared to be upset, but we didn't really think anything of it.  We continued walking toward our ambulance and the child called out "Excuse me, do you have a phone I can borrow?"  My gut instinct is always to say no.  In fact, I even considered using my standard line "we're not allowed to give money or let people use our phones because we're on camera".  I guess after working in EMS for some time I am always suspicious when someone asks to use my phone (especially after someone tried making an international call at one of our northern posts).  But something about this situation felt different, so I turned around and asked the child who he needed to call.  He said his mother.

So naturally, I asked the kid for his mother's phone number, put my phone on speaker and made the call for him.  He told his mother that he needed her to pick him up because the "guys" wouldn't pay for him and he has no way home.  His mother, screaming at him through the phone, asked him where he was, who's phone he was using, why he wasn't skating, etc.  She told him she was out and couldn't pick him up and he'd have to find another way home.  I interjected and explained that I was a paramedic and would see to it that her child would get home safely.  The kid looked devastated and embarrassed.

I asked the kid where he lived and he told me.  I can't really go into the part of the story about how I was able to get permission to "figure out a way" for the child to get home, but what I can write is that at some point during that process, my partner pointed out to me that he thought the kid didn't have money to skate, not to get home as I had thought.  We went back to the gas station and withdrew money from the ATM.  It required no further thought.  It's what needed to be done.  After all, skating only cost five dollars, so what the hell.  We gave him $5 for skating and $5 for food/snacks/drinks and watched him overcome with relief, joyfully walk back to the skating rink where he'd presumably join his friends and have the fun night he planned on having.

Whether anyone else in my situation would have done that or not is irrelevant.  What is relevant, however, is the fact that this child was upset.  The child was nearly in tears when he asked us for a phone to call his mother.  The child felt abandoned by his friends, and now by his mother.  This child still had the innocence in his eyes we often don't see in our line of work.  He still had a kindness and respect that we generally aren't afforded.  He had something different.  He hadn't yet been affected by the gangs that patrol his neighborhood, the violence that he regularly hears in his back yard, the limitations society has placed on him.  He hadn't been scarred by his version of normal.  He was a child.  A child that no one (until now) would know.  A child that, unless something unusual, or spectacular occurs, may succumb to his surroundings and lose his sense of self and his dreams.  Or the potential to form an alternate future for himself, rather than the one he has been taught to believe exists.  A child incapable seeing his potential and of surmounting the preconceived set of rules that govern his life and ability to develop and then conquer his goals.  Maybe that's who this child was, or maybe not.  But at that moment, that was the child I saw and that was the child I felt was different; a child I felt needed someone, anyone, to stand up for him and show him that the world is not always a terrible place.

The second situation is almost the opposite.  My partner and I were called to the home of a young child who recently had a catheterization to repair a hole in the septum between his atria and was now complaining of dizziness and left arm pain.  Of course, on the way to the call, I went over the list of cardiac medications we carry and their pediatric dosages in my head and out loud with my partner, as I think anyone would (or at least should).  When we arrived on the scene, we were greeted by a very worried mother holding her young child.  En route to the hospital, I could see the worry on the mother's face and we started talking.  The child, by the way, was stable and considerably stoic.

The mother explained to me that she noticed her son wasn't as playful as her other kids were when they were his age, but thought nothing of it.  She said the doctors discovered the hole in his heart because she wanted to take her son to get his teeth cleaned, but because of his age, the dentist required a physical.  The pediatrician who performed the physical noticed some abnormal heart tones and referred the child to a cardiologist.  At the cardiologist, multiple tests were conducted and it was determined that the child's lack of energy was likely a result of a congenital atrial septal defect that would need to be repaired.

I spent the majority of the transport monitoring the child while quelling the mother's fears to the best of my ability.  One thing we don't spend enough time on in paramedic school is the interpretation of pediatric 12-leads.  I pulled out my smart phone and started researching after explaining this fact to the mother.  I assured her, that regardless of my ability to interpret the 12-lead, I would be able to care for her child as he needed.  I also transmitted the 12-lead to one of our local adult emergency departments and spoke with the doctor over the phone who confirmed my interpretation as unremarkable.  After discussing the situation further with the mother, I called the pediatric receiving facility to which we were transporting and consulted with the pediatrician over the phone to again confirm that nothing acute was apparent on the 12-lead.

The mother explained to me that she had never had paramedics seem so invested in her child's health or her own well-being as a mother.  She told me that given her limited education and financial resources, there are some times that she is incapable of providing for her children, but that she does everything in her power to do so and to raise them right.  Regardless of her best efforts, her child will forever have a cardiac history.  He will forever have this history.

Both children in the above examples will forever have the situations in which they were brought up, but what they do with those experiences, those limitations, with the blessings and the curses, is what will define them and what will make their lives seem limitless.  They will not be defined by their past social or medical histories.  They will not be forgotten.

When people ask me what the worst thing I've ever seen is, their faces, among the many other children I see on a regular basis will populate in my mind.  What I will think about are the conditions that produce the sick children we see and society's sightless view of them, both their present state and their presumed future.  I will internalize their plight.  I will sympathize with their suffering.  I will convey to whomever will listen that the worst things we see are not the colossal car accidents or the mangled limbs they produce; they are not the people shot or stabbed; they are not the strange anatomy through which we were able to pass an endotracheal tube; they are not the cool and unusual cardiac rhythms; they are not the tragedies of others' stories.  Rather, they are our own tragedies and lack of awareness.

The worst thing I've ever seen is the unfairness in this world that cascades to produce further disparity affecting the lives of children, their social and psychological development into adolescence and adulthood, their futures and ours.

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.

 

I have been changed...

As I've mentioned in previous posts, often I have been asked why I chose to become a paramedic; why I remain a paramedic.  The answer I frequently provide, jokingly, of course, is because I am selfishly selfless.  The looks I get after giving that answer are generally perplexed.  So, let me explain.  I enjoy helping people.  I feel it is my calling to render aid to those in need.  Thus, when helping someone else, I get the warm and fuzzies; I am selfishly helping others.  However, how selfish is it really?

According to a Psychological Reports article from 1996 by Francine Grevin, paramedics show the highest rate of burnout among all other healthcare professionals due to "dealing with life and death emergencies in hazardous environments and chronic exposure to human tragedy" to name a few.  That is, we see graphic things in austere environments.  Grevin (1996) comments that such astonishingly high rates of stress lead to burnout, drug and alcohol abuse, and work-related and family problems.  Furthermore, Drewitz-Chesney (2012) explains that paramedics experience higher rates of PTSD than police officers and firefighters for the same factors listed above, which can be severely detrimental to personal and family lives.

So, I ask again, how selfish is it really of those of us who chose to become paramedics because we get a good feeling from helping others?

My co-workers and mentors in EMS always told me that EMS changes people, but, naively, I chose to ignore what they had to say and pretend that I was invincible and couldn't be changed.  My mind, and thus behavior, could not be altered by the effects of EMS. 

But I find myself wondering how invincible I truly am, or was.  I have seen, over the years, friends get married and get divorced and get married again and get divorced again.  I have seen relationships blossom and relationships die.  I've seen the spark of happiness in a new employee's eyes and the look of horror and defeat in their eyes just years, or even months later.  But I have also seen marriages and relationships flourish in EMS for whatever reasons; maybe strong coping skills, resilience or a sense of coherence (a view of the world that recognizes the meaning and predictability of it), as Streb, Haller and Michael (2014) suggest.

My parents recently asked me if I actually have feelings, if I have the capacity to love another human being, trust another human being.  And honestly, that got me thinking.  Do I think I have that capacity, of course.  I have grown to truly love many of the people I work with, if for no other reason because of the common bonds we share, because of the tragic images that will forever remain stained in our brains.  For the sounds of gunfire that will forever ring in our ears.  And for the stench of a dead body that will forever remain in our nares.  We share that.  We get that.  Not many other people can understand what we understand.

I've recently found myself at events with friends of mine from my pre-EMS life.  They do and forever will have a special place in my heart.  But every time I see them, I find myself thinking about how much THEY have changed.  How little we have in common because they're all different.  Although, I can't help but think that maybe they're all the same, and I have changed.

For example, the things we used to discuss no longer interest me.  It's no longer intriguing to hear about so-and-so and whatever mishap has happened in their life.  It no longer piques my interest to hear about so-and-so and their 60-, 80-, or 100-thousand-dollar-a-year job.  Or about their children who are constantly misbehaving, or their children who are perfect angels.  It no longer makes me smile when they talk about how inexpensive their ridiculously priced haircut or shirt or suit or shoes cost.  All I hear in my head is how petty the discussions have become. 

Why should I care that you are cooking a 10-course meal for people who just moved into the neighborhood when I have to walk into homes in the middle of the night and see malnourished children who have never, and likely will never experience a 10-course meal?  Why should I care that your pool man or housekeeper didn't show up today, even though they were supposed to, when I see people who are the pool man and the housekeeper both for their family and yours?  Why should I care that your kid can read at 1 year old when I see 50 year olds who never had the luxury of attending school, and still have no idea how to read?  Why should I care about your debate between this name brand pair of shoes and that name brand pair of shoes when I have patients who couldn't dream of such shoes or having a debate about such shoes?  Or where you're going to eat for dinner tonight when I see people who don't even have enough money to put food on their own table, in their stomachs and their childrens' stomachs, not to mention eat off the dollar menu at McDonalds??

Do I feel this way because I have changed or do I feel this way because they have changed?  If it's me, is this a good change or a bad change?  Is it bad that the conversations and people who used to interest me rarely do so now?  Is it a problem that with whoever one of us has changed, a distance has grown between us?  I can't answer that question for myself or anyone else.  What I can say is that things that once were run-of-the-mill, important, life-altering questions and decisions no longer seem to be; in fact, many seem unimportant and petty.

This previous line of questioning brings to mind a song from the epic Broadway play Wicked: "For Good".  A line from the song "Because I knew you...I have been changed for good".  I think of my career in EMS in a similar way; however, to define the word good appropriately in context, I have to figure out if EMS has changed me for the better, or forever; both of which sufficient definitions for the word good.

I know that over the years in which I have been in EMS, the way I view the world has changed.  The things that used to have meaning, don't necessarily carry the same weight as they used to.  The people and interpersonal relationships I've known no longer have the same significance.  The context of the world has changed in my mind.  Certain things, materials, individuals and experiences don't have the same relevance as they once did.  However, the world is still a meaningful place for me.  So, have I changed for the better, have I changed forever, or both? 

I'd venture to say that to those who once knew me, my world, my attitude and my ability to express and receive emotion, I have changed...not for the better.  But does that make me a worse person?  No, it makes me a person more familiar with what may or may not be as important in MY world as it may or may not be in someone else's world.  It makes me an individual who recognizes that the world and the environments in which we live are ever-evolving, dynamic and, to some degree, predictable.  It makes me a person who is more aware, both of my self and my surroundings.

But, again, to those who once knew me, it makes me appear more distant, withdrawn and, perhaps, less compassionate.  The truth is, externally, I may not convey compassion, I may not be the model of kindness and caring, but I am compassionate and I do care and I am kind.  I just express my sense of caring in a less exaggerated fashion to things, material and individuals who aren't experiencing true tragedy or dilemma.  I don't appear compassionate to those suffering from a bump in the road versus a life-changing, sentinel event.  That, however, does not mean I don't care; it just means my view of what is important has changed.

So, relating back to relationships outside of my EMS family, I can understand why people say I have changed, because I have.  But, because they don't know what I do, how I do it, or even the circumstances under which I do it, they don't get it.  And they never will. 

To reference my last post regarding burnout, which is very much related to this post, paramedics and EMTs might find it easier to confide in and express emotion to others who have experienced the same or similar incidents as they have, that's just human nature.  Is it something to become offended by?  No.  It is just a reality that those who aren't in the EMS family must learn to understand and accept.  It is also why having people with whom you can relate is so important for those of us in EMS, because most of the time, we won't find it at home.  And at home, our behavior, emotions (or lack thereof), and point-of-view may not be favorable, even if we can no longer control it or provide reasonable explanations for it. 

But there is a reason.  In fact, there are as many reasons as there have been patients under our care.  Every patient has a story, and every story affects the story of my life, of our lives, of any EMS provider's life.  Those stories have changed us for good.  Those stories make all of us question whether or not we pursued a career in EMS for selfishly selfless reasons, or for selflessly selfless reasons.  While we may gain a stronger sense of self throughout our careers, to others who knew us before, we appear to lose some of ourselves.  Maybe we do lose some of ourselves, but that which we lose, we gain in other areas of our lives and we do become better people forever, potentially just more difficult to understand.


Citations:

Drewitz-Chesney, C. (2012). Posttraumatic stress disorder among paramedics: exploring a new solution with occupational health nurses using the Ottawa Charter as a framework. Workplace health & safety, 60(6), 257-263.

Grevin, F. (1996). Posttraumatic stress disorder, ego defense mechanisms, and empathy among urban paramedics. Psychological reports, 79(2), 483-495.

Streb, M., Häller, P., & Michael, T. (2014). PTSD in paramedics: Resilience and sense of coherence. Behavioural and cognitive psychotherapy, 42(4), 452-463.

Burnout...The Other Silent Killer

Burnout is a terrible thing that we all learn about in paramedic school.  It's usually discussed in the first couple of chapters of the paramedic book, but never again, really.  Burnout sucks.  When you get to the point that showing up at work makes you cringe and you start developing creative excuses for calling out or going home early, you're getting there.  When you lose focus and forget about why we do what we do, and allow that to change the way you do things, speak to people and think, you've probably gotten there.

Recently, I hit what others have told me was my "first burnout".  A burnout that, thankfully, is easy to overcome.  I've been asked by other paramedics, many of them newer than me, how I stay focused, appear calm, and always try to do what is best for my patients...basically, how am I not burned out.  My answer is usually that appearances are deceiving.  I've learned over the year to develop the paramedic version of a poker face.  That is, I don't show my emotion.  I don't allow my patients, their family members or my crew to see the stress in my head.  I keep it in my head.

As to how I strive to deliver par or above par patient care, the answer is simple.  Our patients, whether homeless, smelly, mean, nice, poor, wealthy, or what have you, are someone's family member.  They are a brother, sister, father, mother, aunt, uncle, cousin to someone.  They are someone to someone.  And we have been put on this earth, for at least this moment, to care for them.  So how do I stay focused, appear calm and attempt to do what is best for my patient?  I put myself in their shoes, or, better yet, I put a friend, or my parents, siblings, cousins, family members, in their shoes and remember that I have to respect my patients the exact same way I'd expect...and demand...a paramedic treat my family member.

But, I also explain that it is our responsibility to do what is best of the patient because that is our job.  We were not hired, nor did we attend school and ultimately get licensed to practice as paramedics and EMTs to sit on our asses and do nothing while our patients writhe in pain, wretch from nausea, cry due to depression, clutch their chests because of chest pain, or struggle to breath as a result of COPD; we got hired to act upon our callings to save lives and treat people in their time of need.  We come to work every day (for many of us, just three days a week...THREE out of seven), to be compassionate, to speak to our patients, to listen to our patients when they speak to us, and to treat our patients when they need us.

The practice of medicine is taking an interesting turn.  We've seen medicine all over the place (especially in the United States) move away from patient-focused medicine to finance-focused medicine.  Medicine has shifted away from a practice to a field in which we can be sued for making human errors.  From a field where good judgment, clinical gut, hands-on-diagnostics to a field where every test must be employed to cover ourselves from legal liability.  Ultimately, however, medicine is still and always will be about the patient.  If we fail to focus on our patients, on what they tell us, on their signs and symptoms, the minutia we find, what they feel like, sound like, smell like or look like, we will fail at providing patient-focused medicine. 

Again, we went to school to learn how to interact with other humans, to be humans who are capable of helping other humans when the need arises.  We went to school to do this, so, why not do this?  Why not give it your all, for three days a week?  Why become bothered and frustrated when someone makes you have a bad day.  For all intents and purposes, they called 911, so by definition, they're having a bad day!  That's why they made your day worse; why they're being rude or short with you.  They're sick!

So how do I try to continue to treat patients to the best of my ability even if I don't feel like it?  Because not feeling like it is not a legitimate excuse; it is an excuse that simply represents laziness, the inability to convey compassion.