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Patient Care

Death Wish

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You’re transferring a 30-year-old woman who tried to end her life by choking down the contents of a bottle of Tylenol. Her destination is another ED about 20 miles away.

The lady on your cot has been lavaged. She has an NG tube and an IV, and she’s on O2. She’s docile and timid, and she turns her head away from you. She emigrated from the Ukraine less than a year ago, and judging from her command of English she’s probably smarter than either of us. She’s shivering, so you adjust the thermostat and grab an extra blanket. But as you unfold it to cover her, she recoils and cringes in response to your touch.

You’ve seen plenty of suicidal patients in your career, but nothing in your educational background addressed them specifically. In fact, some of them, after attempts that were obviously ineffectual, seemed like nuisances. But you don’t want to see anybody suffer, and you’re wishing you could mitigate this lady’s fear.

Q. We all develop a repertoire of small talk–polite chatter that doesn’t matter, so to speak, for simple transports like this one. But this lady’s the ice queen. What do you say to somebody like her?

A. Great caregivers use a technique you could call transposition of feeling, by which you imagine yourself in somebody else’s situation and use that as a platform for your care. It’s easy, if you realize everybody you meet in the back of your ambulance is having the worst day of their life. If you allow them to, they remind you how lucky you are and how special your life is. I think that’s one of the gifts EMS gives back to us, shift after shift and year after year. There’s not a lot of money in this business, but it does enrich you, if you allow that to happen.

Q. Sounds wonderful. But what does that have to do with conversation, especially with somebody like this?

A. Well, think about this lady. Try to develop a sense of her situation. She comes from one of the most ancient civilizations on earth. Ukrainians domesticated the horse as early as 5,000 years B.C. Since then, her part of the world has been plagued by wars and dominated by outside cultures. What was it that led her to be here now, on your cot, 6,000 miles away from her home and family? And what did she have to endure in order to get here? Considering her present circumstances, it must have been tough.

Q. OK, so what does that have to do with casual conversation? Especially considering the fact this lady is terrified of us?

A. It gives you the perspective you need as a professional caregiver. There’s a big difference between western and eastern medicine. Western medicine is based on the presumption that patients are impotent, inconsequential idiots, and their doctors are omnipotent. Eastern medicine, which is much more ancient, is based on the premise that every patient has the capacity to heal him/herself, and a few gifted people called caregivers have the power to facilitate that healing. You’ve studied human physiology. Does the body have the capacity to heal itself? Of course it does.

As practitioners of western medicine, our approach to behavioral emergencies is dominated by a powerful pharmaceutical industry. It’s focused on the profitable sale of drugs, not the problems of people in crisis. A basic repertoire is a good tool for stable patients, but this woman is not stable. She’s mired in the crisis of her life. This is not the time for rehearsed, detached, immaterial conversation about the weather. You’re probably the only caregiver who will spend a full half-hour with her today. Tell her, for whatever it’s worth, that her life matters. And ask her please, don’t just throw it away. She may not say a word. But if she does, you may hear the secret whispered again: You’re so lucky.

Q. That sounds kind of personal, even intrusive. We’re medics, not psychotherapists.

A. Actually, for half an hour, appropriately and privately, you can be as much or as little as you want to be. It’s personal, yes. But this lady’s not a box of rocks; she’s somebody’s daughter. And what’s intrusive about extending a human touch to someone who’s clearly reaching out for that very thing?

Earlier today, she was ready to die without it.

Thom Dick has been involved in EMS for 40 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS World Magazine’s editorial advisory board. E-mail boxcar_414@yahoo.com.

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