saving lives?

[Veneficus]

Perhaps I should get a blog... But who would be able to find it or want to read it?

But in the meanwhile perhaps I can spur some discussion here.

On my medical journey over the last couple of weeks, I have been seeing dead people. As of this writing, only one has decided to stop breathing, but from my first contact, it wasn't a stroke of genious to figure out his race was run before the labs and xray came back.

Though I do admit he "outlived" my estimate by about 12 hours.

At one point in my absence I was told providers started CPR on him. My question was "why?" The answer was a long silence before a senior doc said "that's what we do."

When I first saw the pt, important findings for this discussion; GCS was 1,1,4 (6) He had an accelerated ventriclar rythm with low amplitude qrs, diminished heart tones, a history of lung ca, his right lung was totally occluded, his left diminished, and on dopamine, his BP was 60/40 and he had no known family to even contact. (not that anyone made an effort to find any)

For all intents and purposes, it was over. Even the ICU didn't want him, so he was admitted to a medicine floor.

Several other patients I saw were in a hematology ward. While Heme is supposed to be all blood disorders, the only people there at the moment are Neoplastic patients. It seems that is who are usually there (aka some form of leukemia or lymphoma)

Many will never leave the hospital. The providers and patients try to keep spirits up, but there is a lot of smiling and pretending to not know things in front of them.

I had the opportunity to look over a request to a drug company for free meds that are not demonstrated to work but cost tens of thousands. It is not even palliative care. It is protocol driven medicine. These people actaually have blood work drawn once a day.

Start at point A, decision tree to point B. If not, then decison tree to C.

In all fairness some of these patients actually benefit and will be leaving for productive lives. Some young, some old, but with things left to do.

But what about the ones who will not be returning home?

On most days I just want to tell them to get the hell out of the hospital, spend the remaining time with friends, family, skydiving, or whatever they have the strength left to do. Unfortunately I am not in the position to do that. When I ask the powers that be to they look at me like I am crazy after admitting they have no hope and have never in their collective experience seen these types of patients go home alive. Patients that can still walk and talk today. Who spend hours starring at a TV, hoping to be visited by friends or family, reading, and generally trying to pass time between meals, chemo, and blood and bone draws.

Is it crazy to urge dying people to live rather than sit in a hospital that knows they cannot help and die hoping for a miracle?

(In fairness it is not just this hospital, it plays out everyday in many countries)

This protocol crap really needs to go. It sucks. It makes no sense. It doesn't help. How did this madness ever become standard?

How does this relate to EMS?

It relates to all healthcare everywhere. Whether you are deciding to terminate efforts, not start efforts, or run the dialysis derby on patients being hacked away a limb at a time.

How did we get here? Where did we lose our way? Where are we even trying to go? What is your take on this? Does anyone else even see the madness?

 

[terrible one]

I agree with you. I have no idea how these people (who are at the end of the road) just sit in a hospital and wait to die. I pray to God that myself or family never has to go through that, wether on the sidelines hopelessly watching or the one on the bed hopelessly dying.
I don't know if I could ever work in a hospital and witness that day in and day out. Atleast on an ambulance you only have to play the carrade up until you pull into the ER, con home, diaylsis center, etc...

Good post.

 

[TacoMEDIC]

I've got nothing to contribute to that. I think you covered it very well. I think that at times many of us feel the same way.

Good post

 

[Seaglass]

In my ideal world, doctors would be entirely honest with their patients. That means no sugarcoating, or pretending not to know that their chances are slim. That means telling them that when they check into the hospital for that course of treatment, they're trading a more active and pleasant death for a slow withering that isn't all that likely to cure anything.

Some of them will still grasp at that little chance of beating the disease, and I think they should have that option. Some of them will prefer to go home and die in a nicer manner, and I think that's fine as well.

If they can't speak for themselves, it becomes a lot stickier. I think that assuming they'll all want heroic measures taken is as fair of an assumption as any, though.

 

[Smash]

How did we get here? Where did we lose our way? Where are we even trying to go? What is your take on this? Does anyone else even see the madness?

Our technical ability to "save lives" long ago outstripped our intellectual and ethical ability to recognize that just because we can, doesn't mean we should.

EMS needs to be involved in the discussion around managed end-of-life care but we as an industry seem to find this very unpalatable.

 

[firetender]

Vene,

Excellent post! Request permission to use in my EMS blog

 

[FrostbiteMedic]

I think that a little of our soul goes to each and every one of those patients. Having that dialysis patient that you transport every other day for two years, only to show up to get them one morning and be told by the family that they passed during the night, yeah, that hurts. To say that it is completely possible to do this job without ever getting emotionally attached to someone is to say that this job requires no heart, and I refuse to believe that this is a heartless job.

 

[MrBrown]

*Brown puts down his phytochemical rich cancer defeating immunoboosting salad

Hmmm ..... you are correct good sirs, we have become so technically proficent at whizbang technological medicine I think the moral and ethical implications of what is done have long been tossed by the wayside

By the way, green cures cancer, they just don't want you to know that so its not out yet

 

[Veneficus]

Vene,

Excellent post! Request permission to use in my EMS blog

use it as you see fit

 

[fast65]

I'm not really sure what to say to that, however I did want to say that this is an amazing post and reading it has further inspired me to be the best healthcare provider that I can. Thank you for another piece of inspiration.

 

[firetender]

What are we?

Vene, I know you as an extremely dedicated man who, even while juggling enormous responsibilities and a family AND medical school in a different country still works incredibly hard to share his knowledge and experience with EMTs learning the ropes. I can't thank you enough for your dogged determination to contribute!

I will be expanding on this topic in my blog, but for now, I want to speak directly to you.

Perhaps I should get a blog... But who would be able to find it or want to read it?

EMSBlogs.com Your POV is invaluable! Watch what happens with this!

At one point in my absence I was told providers started CPR on him. My question was "why?" The answer was a long silence before a senior doc said "that's what we do."

That was as honest as he could have been, and accurate as well. I've been grappling, if not struggling with the very same themes, but from a different perspective. You see, most everything I used to save lives in 1980 have been debunked. Today, medics are using stuff in the field expressly because, through guys like me (and the patients I unsuccessfully treated, if not prolonged their agony!), we learned my stuff was no good.

The medics on this site will discover 25 years from now that what they're using today was mostly no good (or going in the wrong direction) as well. This is not a curse, it is scientifically grounded; science is beginning to tell us that aggressively "jump-starting" the body back into life is out and the next direction will be "slowing it down" through hypothermia and suspended animation drugs.

What a miserable situation; I was a vehicle through which not quite completely tested drugs and interventions were delivered to patients who were, essentially, guinea pigs without a right of refusal. This is our reality, Vene; well, not mine anymore, but this is what I was part of and set the scene for your generation to reflect as well!

For all intents and purposes, it was over. Even the ICU didn't want him, so he was admitted to a medicine floor.

In all fairness some of these patients actually benefit and will be leaving for productive lives. Some young, some old, but with things left to do.

But what about the ones who will not be returning home?

They were part of an experiment that, perhaps ten years down the road may help someone like the above return to "productive lives".

YOU are part of an experiment. EVERYONE reading this is part of an experiment and, quite frankly, experimenters with a Lower Case "e". For the most part, you are testers of therapies that may or may not work, but some will.

In order to reconcile my life in EMS, I've had to come to terms with the fact that I was a reflection of mankind's insistence that it can beat death.

Everybody believes that our science can prolong our lives and the way things have evolved is the overall culture of Western humanity, not just U.S. medicine (as reflected in your European training facility) gives us in the profession Carte Blanc to try EVERYTHING AND ANYTHING to keep people alive!

On most days I just want to tell them to get the hell out of the hospital, spend the remaining time with friends, family, skydiving, or whatever they have the strength left to do. Unfortunately I am not in the position to do that. When I ask the powers that be to they look at me like I am crazy after admitting they have no hope and have never in their collective experience seen these types of patients go home alive. Patients that can still walk and talk today. Who spend hours starring at a TV, hoping to be visited by friends or family, reading, and generally trying to pass time between meals, chemo, and blood and bone draws.

Is it crazy to urge dying people to live rather than sit in a hospital that knows they cannot help and die hoping for a miracle?

No, it's not. In fact, it's much more sane than what you're doing and "you're" includes all the aggressive treatment that EMS prides itself on. Many, MANY patients are snapped back into lives that turn into emotional and financial nightmares because we got to them too fast or they got to the hospital too early.

YET, this isn't at all about sanity >>>

(In fairness it is not just this hospital, it plays out everyday in many countries)

This protocol crap really needs to go. It sucks. It makes no sense. It doesn't help. How did this madness ever become standard?

How did we get here? Where did we lose our way? Where are we even trying to go? What is your take on this? Does anyone else even see the madness?

Western culture does not accept the inevitability of death. It is looked at as an "ending". It must be because if all the Christians REALLY believed they were going to Heaven, they wouldn't let their bodies be part of the experiment, they'd just relax, die and go home! (Just an example, folks-- eeeasyy!)

We, as a species, are programmed to fight like hell to stay alive. Period. That's reflected in our patient's willingness and our aggressive interventions.

Ultimately, it's pretty much the flip side of why we keep insisting on bringing NEW people into the world; it's hormonally driven!

Medicine today, like it or not, is geared toward exploiting that survival drive. It's not for gain per se -- though let's face it, it sure makes the drug companies rich in the trying!

Looking at humanity from the moon it boils down to our medicine of today trying as much as it can, as often as it can get away with it, on as many people as possible to EVENTUALLY build a body of knowledge that WILL allow us to beat death.

As long as no one is really acknowledging that "that's what we do" and protests, then the people will WILLINGLY subject themselves to the experiment.

So where does that leave us, my friend?

The most subversive question you or anyone on this site could ask today is "Why?"

Right now, that question could drive you nuts, Vene, so let me try to help with perspective:

Right now, as is true with the medics on this site, your job is not to question so much as to deliver. You are delivering "chances", some very few of which will stick and be applicable to the health and happiness of individuals in the future. In some cases, the chances you deliver may work right now!

For you in particular, Vene, you've opened a Pandora's Box for yourself; but here's what I think.

You are a student directed and guided by a system that is doing things according to today's science. Today's science is impersonal. You are learning to be a Doctor, not a Healer. Healers understand that for many, embracing death is the best healing available.

You are gaining tools now. You are literally overfilling your tool kit so that you will have things to offer to the patients that you will end up treating. You really can't pick and choose your tools today, but you must get familiar with as many as you can.

Perhaps the most important thing you're developing right now, as painful as it feels, is DISCERNMENT. Quite frankly, as long as the people buy in to the system you reflect you're not harming them, you're delivering hope; that's what they want from you; even when there is none. We're programmed to thrive on the illusion we may not die.

(Let me thank you for helping ME to see this!)

Medicine as we are practicing it today is not really ready to hear that its practitioners want to start being with their patients in their life-cycles rather than placing all their efforts on delaying inevitable death. Unfortunately, a huge reason for this is that so many people make a living off of fighting death, let's face it, were we to drop the effort, the economy would collapse worse than GM and the Banks!!

But maybe you are part of a new generation -- all of you -- who are learning that giving patients a chance needs to include taking the time to consider; Is this a chance for life, or a chance for living?

 

[TacoMEDIC]

Wow... Just wow.

Well said :unsure:

 

[FrostbiteMedic]

Wow... Just wow.

Well said :unsure:

Couldn't agree more

 

[46Young]

Great thread! It would seem that many of us share your sentiment, myself included.

 

[Foxbat]

In my ideal world, doctors would be entirely honest with their patients. That means no sugarcoating, or pretending not to know that their chances are slim. That means telling them that when they check into the hospital for that course of treatment, they're trading a more active and pleasant death for a slow withering that isn't all that likely to cure anything.

Nocebo.

Writing from his extensive experience of treating cancer (including more than 1,000 melanoma cases) at Sydney Hospital, Milton (1973) warned of the impact of the delivery of a prognosis, and how many of his patients, upon receiving their prognosis, simply turned their face to the wall and died an extremely premature death: "... there is a small group of patients in whom the realisation of impending death is a blow so terrible that they are quite unable to adjust to it, and they die rapidly before the malignancy seems to have developed enough to cause death. This problem of self-willed death is in some ways analogous to the death produced in primitive peoples by witchcraft (“Pointing the bone”)." (p.1435)

A few decades ago it was a common practice in USSR, and perhaps other countries, not to reveal to patients the seriousness of their condition. For example, cancer patients were often told they had benign tumor, ulcer, etc. (while being treated for cancer) because fear and hopelessness had a bad effect on outcome.

 

[Bosco578]

Very profound. A truly great post against the tsunami of endless generic stuff........mine included. Your spirit is strong.

 

[firetender]

Nocebo.



A few decades ago it was a common practice in USSR, and perhaps other countries, not to reveal to patients the seriousness of their condition. For example, cancer patients were often told they had benign tumor, ulcer, etc. (while being treated for cancer) because fear and hopelessness had a bad effect on outcome.

As an extension of this, in a clinical study of the effects of prayer on the prayed for (noted in Dr. Sanjay Gupta's book "Cheating Death") the patients who knew they were being prayed for did worse!

 

[JJR512]

How does this relate to EMS?

I don't think it does at all. Last time I checked, EMS stood for Emergency Medical Services. In general, this is out-of-hospital emergency care, and usually specifically, pre-hospital emergency care.

What you're talking about is in-hospital care. There are doctors, nurses, and other healthcare professionals to think about and take care of patient care once the incident report is signed in the emergency department. That's where the care, and the decision making thereto, ends on the part of EMS.

I recently started another thread here asking if anyone has ever gone to a funeral for a patient for whom they provided EMS but died, and the consensus there so far seems to be No, not unless the provider knew the patient personally. To paraphrase one person replying to that thread, "[Our] job is done once [we] get back in [our] truck and head to the next [patient]."

EMS needs to be involved in the discussion around managed end-of-life care but we as an industry seem to find this very unpalatable.

It's not part of our industry. Our industry is keeping people alive long enough to get them to a hospital where someone else can figure out what to do with them. If possible, we can do certain things to make it easier for the next set of care providers. But again, once that incident report is signed and care is transferred, that's the end of it.

If anyone wants to take part in what happens after care is transferred, hey, I'm all for it. Be my guest by all means. Go to medical school or nursing school, then get a job in the emergency department, or deeper in the hospital. Then post-EMS care can be your problem.

Don't get me wrong, now. I'm not saying that what happens to patients after EMS transfers care is great and perfect. I'm not saying there's no room for improvement. All I'm saying is it's beyond the scope of what EMS is.

 

[SanDiegoEmt7]

I don't think it does at all. Last time I checked, EMS stood for Emergency Medical Services. In general, this is out-of-hospital emergency care, and usually specifically, pre-hospital emergency care.

What you're talking about is in-hospital care. There are doctors, nurses, and other healthcare professionals to think about and take care of patient care once the incident report is signed in the emergency department. That's where the care, and the decision making thereto, ends on the part of EMS.

I recently started another thread here asking if anyone has ever gone to a funeral for a patient for whom they provided EMS but died, and the consensus there so far seems to be No, not unless the provider knew the patient personally. To paraphrase one person replying to that thread, "[Our] job is done once [we] get back in [our] truck and head to the next [patient]."


It's not part of our industry. Our industry is keeping people alive long enough to get them to a hospital where someone else can figure out what to do with them. If possible, we can do certain things to make it easier for the next set of care providers. But again, once that incident report is signed and care is transferred, that's the end of it.

If anyone wants to take part in what happens after care is transferred, hey, I'm all for it. Be my guest by all means. Go to medical school or nursing school, then get a job in the emergency department, or deeper in the hospital. Then post-EMS care can be your problem.

Don't get me wrong, now. I'm not saying that what happens to patients after EMS transfers care is great and perfect. I'm not saying there's no room for improvement. All I'm saying is it's beyond the scope of what EMS is.

I can't believe you missed the point of what he is saying here. His post is 100% related to EMS.

He is talking about modern medicine's desire to treat every patient by what the big book of medicine says, when half the time there's no benefit and it only has a negative impact on the patients' lives. This is true in EMS as well. I ran a call for a patient that had been in a coma for 40 years, on a ventilator, called out because she coded (she's a full code) managed to get her back on the way to the hospital, she was release back to her SNF 5 days later. What's the point of that?

Just because we treat patients should we go to their funeral? No. What that has to do in a discussion of the validity of our dependence on protocol driven patient treatment, is beyond me.

The last part of your statement is exactly why the advancement of EMS is so damn hard. The lack of desire to be part of the entire healthcare team. Do you think the emergency department says to the ICU/med surg floor "My job is EMS, I don't care what happens to the patients after they are out of my department, they're only here for a little bit, I treat them off my protocols, and they are all yours"?

 

[JJR512]

I can't believe you missed the point of what he is saying here. His post is 100% related to EMS.

No.

At one point, the OP is talking about telling patients in the hospital to get out of the hospital and go live what little lives they have left. I'm all for that, but that's not EMS. Once they get admitted—once an EMS provider gets the patient to the hospital—we have no business telling them it's now time to leave where we just brought them.

EMTs and Paramedics aren't doctors. It's not up to us to decide if the patient is best-served by being left at home or getting taken to the hospital. Our job is to get them to the hospital where someone else can figure that out.

If the patient doesn't want to go, they should refuse to go. If they're not capable of competently refusing, then...well...that's a problem, sure. That's a specific problem that does affect and involve EMS, and that's one I'm all for trying to figure out how to fix, sure.

He is talking about modern medicine's desire to treat every patient by what the big book of medicine says, when half the time there's no benefit and it only has a negative impact on the patients' lives. This is true in EMS as well. I ran a call for a patient that had been in a coma for 40 years, on a ventilator, called out because she coded (she's a full code) managed to get her back on the way to the hospital, she was release back to her SNF 5 days later. What's the point of that?

Again, it's not for an EMS provider to say what's the point of that. Well, we're perfectly able to say what we personally think about it. What I mean is it's not our decision to make. We're not doctors. We can't decide on the spot that there's no point trying to save this patient, I mean we certainly can't act on any such decision (and believe me, I agree with you, I'd be thinking the exact same thing myself if I was in that position).

Just because we treat patients should we go to their funeral? No. What that has to do in a discussion of the validity of our dependence on protocol driven patient treatment, is beyond me.

Now who if failing to comprehend what someone wrote?

In this thread, I never said anything about going to a patient's funeral. I only mentioned that thread to tell you where I was quoting from.

The last part of your statement is exactly why the advancement of EMS is so damn hard. The lack of desire to be part of the entire healthcare team. Do you think the emergency department says to the ICU/med surg floor "My job is EMS, I don't care what happens to the patients after they are out of my department, they're only here for a little bit, I treat them off my protocols, and they are all yours"?

I have no idea what an ED doc says to an ICU doc when care is transferred. I'm sure some, maybe many, do a follow-up check on their former patients later on. I know I've seen that happen in some of the hospital reality shows on the Discovery Health channel.

And I'll admit I'm often curious to know what happens to patients after they leave my care. Sure I wonder. But am I ever going to go find out what hospital room a patient has been admitted to so that I can go tell them they should get out of the hospital and enjoy what's left of their life? No. That's not for me to do, and it's not for me to decide. I don't know what's really going on with the patient, and even if I read the patient's entire chart I still wouldn't really know because I don't have years of medical school, internship, residency, etc. to interpret that chart and make that kind of decision.

So if you want to do something about protocols and cookie-cutter EMS, be my guest. Let me know if there's anything I can do to help. But again, once we transfer care, leave the doctoring to the doctors is how I feel.