Death is too often part of living
Volume 23, No. 3
The topic of death and dying is one that is a common theme in the world of EMS, no matter where you work or which agency you work for. Adult medicine is full of death and dying patients at every turn and while it's our job to fight the Grim Reaper I don't think anyone expects to win all of the time. Patients come and patients go. Some live, but some die. No matter how hard we work or how good a job we do, the best of efforts do not matter. We all know this. When we lose a colleague, it's like losing a member of the family. The "service" (Fire Extinguishment, EMS, and Public Safety, etc.) has always melded a tight bond among its members. It's really just the nature of the beast I suppose. We depend on each other so intensely, both on and often off the job. Losing a member on or off the duty can be heartbreaking.
When "Bobby" had all that belly pain, he always said it was the cook's chili or some other such concoction he had eaten. Even when he was doubled over on the kitchen table at 3 AM, we never thought it was something he "could not handle." It was not till we heard that he was in the hospital and that the surgeons had "opened him, and closed him" that we realized how serious it had been. I vividly remember pulling up in front of the firehouse several shifts later and seeing the purple bunting over the door. My heart sank. I knew he was dead. While 'we' had never been close, the mood amongst the brothers that day was somber at best. No one spoke about it. In fact, no one said very much at all the entire shift. When "Ralph" was last seen, people said that he looked terrible. Yet no one had the presence to say anything to "Ralph." He was after all a consummate professional, a Paramedic with years of experience who knew his medicine as good as anyone. He would know if he was gravely ill or not, right?
The point of both of these cases is that they probably did know something was seriously wrong. Denial is a very powerful emotion and one you will see in your friends, family, co-workers, and of course the patients that you are called to treat. That chest pain must be something 'other' than a heart attack..... "It's the damn pepperoni pizza I had for lunch, or that pastrami sandwich. I know better than to eat that stuff." Patients will often deny there is a problem, but the look on their faces (remember that "look of impending doom" from EMT Basic?) gives them away and tells a different story. DO NOT dismiss this observation nor should you force the patient to confront it head-on. Try a subtle approach to convince the patient that he should get 'checked out' just to be sure. "Let's take a ride over and see the Doctor, if it's nothing, you will be home in time for dinner, what do you think? It's better to be safe than sorry, right?" Plan in advance for resistance from the patient. The point is to never take "No" for the answer as to whether or not they will get assistance. Persistence is the key and you may need to "convince" the patient you are right. Gravely ill patients are often reluctant to face their own potential mortality and being prepared with this knowledge can only improve patient outcome. Your actions are critical in assisting this patient in his time of need.
We have all been taught the "stages" in the Death and Dying lecture. Denial, anger and rage, bargaining and even acceptance are what to expect. Patients may present several of these emotional states, all in one call, and you must be flexible in all your care plans to anticipate these changes. The families and loved ones are also susceptible to the same feelings. A patient with a terminal illness may be very cognizant of his own impending demise and the family will hear nothing of it and refuse to face it or, in many cases, not even discuss it at all. Having arrived at the scene and asked the patient, "How are you feeling?" and getting the response, "Good, I'm dying, but otherwise doing well" gives you real pause in your EMS career. Many times the family is a bigger problem than the patient. The previous scenario had the family yelling, "You are not dying, now stop saying that!" The patient responds, "See, they just won't listen to the doctors." In these types of cases it may be just as important to the patient that you help care for his family as it is to meet his medical needs.
I'm not saying that anything could have been different for "Bobby" or "Ralph." Who knows how advanced their issues had been but sometimes you have to wonder if you had said something, could it have made a difference. When someone looks terrible and we ask how they are and we get the usual "I'm fine, how are you?" should we not press the issue and really inquire? Should I not say, "Wow, are you sure you are ok because you look like crap?" Now of course no one wants to hear that they "look like crap." But even risking the possible, "Oh thanks, you don't look so marvelous either!" I do not want the friend or loved one know my real concern! This simple concern might translate into a trip to the doctor just out of common prudence, especially when the person making the query has some experience in these observations. As the loved one, I may only have felt "fatigue" or felt "overly tired," yet someone had the presence of mind to express real concern about my well-being. I just might listen, especially if my physical state was not really the norm and I was aware of it. This goes for co-workers as well, and supervisory personnel must also push for action in the presence of massive denial. Remember, if they look sick, they probably are and you should never dismiss this gut reaction of yours.
"Ralph" died on March 19th and his memorial service was a week or so later. I could not go because I was in class that day, but I felt the loss of a long time colleague. Even if he was aware of his own possible demise, the loss was huge and he hid it well.
Yes, he was always the consummate professional, right to the end. He taught us a sobering lesson, let's not let his death be in vain.
William R. Kerney, MA, EMTP-A, is a professor of emergency medicine at the College of Southern Nevada.