The wizened creature sits on the stool in the restaurant. He watches us come in with sharp eyes buried in sunken, yellowed features. His layers of clothes, representing probably most of what he owns, hang off skeletal limbs. Conversely his belly is huge—evidence of an organ system decimated by a life of poor choices. As he makes his way to his feet, his pants sag as if trying to escape. He is weak, he is broken, he is dying.
He is a pain in the ass.
“Frank” (name and locations changed or made composite for privacy) is not a newcomer to the 9-1-1 system. Since his first brutal bout with liver failure a few months ago, he has evolved into one of our “high-utilization users” (“frequent flyers,” if you prefer). Today he is having a heart attack, last night it was GI bleeding, and yesterday, at another food establishment, it was a cardiac arrest that coincided with the arrival of his bill.
Frank represents a unique problem in this vast area with rural populations. He has a home and some family but lives almost two hours by ground away from the hospital. His cycles of calls represent two different logistical issues. When he is calling from where he lives, we need to mobilize our rural responses to address it, and if he needs to be transported, we lose those resources for that entire area for as much as six hours.
Once at the ER (the only one we have), he often refuses treatments or gets released in short order—with no means to travel back north. This puts him in the populated center, where he may call 2–3 times in 24 hours from various locations.
Because of his history and complaints, he is always coded high-priority, eating more resources. None of this includes the times when he gets feisty and makes physical threats when he calls, requiring us to involve law enforcement and stage before approaching.
Every one of you reading this knows some version of Frank.
Walking in, I recognized him immediately. He was agitated, his voice raised and his hands fluttering excitedly as he rambled on with the bewildered teenage staff. I sighed, already irritated—with this contact I would lose one of my precious few trucks for an hour, and there was nothing I could do about it.
I’m telling you about Frank because of the crew’s response to him and the insight it gave me into how it is we navigate these complicated nonemergencies and keep hold of our compassion.
They pushed through the door, gear on the stretcher. They had already guessed who it was but did not treat the response any differently than the dozen that came before it. They approached him with smiles, greeting him professionally and listening seriously as he recanted the exact same story he had told them just two days ago.
Frank visibly calmed as they asked him their demographic and assessment questions, taking notes as if they didn’t know the answers by heart. He became jovial, exchanging jokes with the crew and treating them like old friends. One held up his pants as they assisted him onto the stretcher. They wheeled him out with little fanfare, and it was over.
By the time the crew was leaving, the mood was completely different. The staff relaxed, the noise levels were normal, and people were smiling, waving, and saying thank you. We had treated him like a person, and that telegraphed itself to the room. Frank waved back regally as he was wheeled out the door.
This is not a discussion about abuse of services. Our current situation is what it is, and for the next hour my crew would function within the rules as they are now—not as we would prefer them to be. You cannot change the system in the moment.
High utilization and societal resource failures are not fixable in that one hour where you’re faced with their effects. You can, however, change your perspective of it and your approach.
How you enter a scene sends a very clear message. Experts say you have four seconds (or less) to decide what that message is going to be.
Entering that scene visibly annoyed, scowling, perhaps without anything more than a clipboard and an attitude, sends a message that devalues that patient and can lead even you to inherently discredit his complaints or possible medical issues. Your telegraph reads “bullshit.”
Coming in with a professional appearance, courtesy, and a willingness to help validates the public’s trust and reinforces their confidence in you as a resource. Everyone in that room is looking to you for guidance. Your telegraph reads, “No judgment, how can we help?”
Four seconds; four ways to make meaningful contact. What is your message going to say?
Author’s note: Frank has since passed. We wish peace to him and his family. We hope they know he was cared for—even when it was only for an hour at a time.
Tracey Loscar, BA, NRP, FP-C, is a battalion chief for Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla, Alaska. Her adventures started on the East Coast, where she spent 27 years serving as a paramedic, educator, and supervisor in Newark, N.J. She is a member of the EMS World editorial advisory board.