Everybody Counts or Nobody Counts
At best, air travel today is a drudgery, but when you fly 50,000 to 100,000 miles a year, as I do, air travel moves beyond drudgery to being nothing short of mind-numbing. Back when there was still some room between rows, I could usually wedge my computer on my tray table and get some work done. Unfortunately, as the airlines moved the seats closer and closer to squeeze in a couple of extra rows on their planes, and in turn squeeze a few more dollars out of each flight, even using a computer became near impossible. For me, the next best choice to getting some work done was to read.
Even as a young child, I was a voracious reader. Now, when I fly coast to coast and back, I get through roughly three novels per round-trip. As you might guess, I read lots of books...LOTS. As a result, when I find an author I like, I read every book they write. One particular favorite is Michael Connelly. As with most good whodunit authors, he has a signature protagonist--homicide detective Harry Bosch. When Connelly introduced this character close to a dozen books ago, there was a notable exchange between Harry and another detective who asked how Harry could continue to work homicide and deal with a steady diet of death and mayhem. Harry explained to his colleague that it was his belief that even the dead have a right to justice. Harry succinctly summed his explanation up with the comment: "Everybody counts or nobody counts."
While this comment was made in a piece of fiction, I have thought many times about the real-life message contained in those five words and how important they are to the EMS profession.
There is no question that nearly every EMS provider has certain types of calls they like, such as critical cardiac cases, obscure medical emergencies, or hot knife-and-gun-club calls. However, the types of calls EMS providers may want to run has little to no bearing on the types of calls they will run. Spin the roulette wheel of dispatch and over time it will stop on any and every type of medical emergency and traumatic event possible.
Where a real problem lies is when an EMS provider decides that certain types of calls are just not worthy of their time or not challenging enough. Instead of treating every patient to the best of their ability, the favorite calls start seeing some patients getting better care, while other patients with those less-than-desirable problems simply become a challenge to do the absolute least amount of medicine possible that will quickly get the patient to the hospital and return to quarters.
For providers with this unfortunate attitude, the errant decision process usually starts upon hearing the patient's chief complaint. Let's say you ask your elderly patient why he called 9-1-1 and his reply is, "I just can't go to the bathroom. In fact, I haven't gone for a week." For most young, healthy EMS providers, constipation isn't a problem. As such, it's easy to see how a misdirected provider might think this is no big deal. Try not having a bowel movement for a week and then let's see how big a deal it really is.
Maybe the call involves a homeless person living under a bridge in a box that once contained an appliance, but is now where he tries to hide from the elements. As this dirty, disheveled man coughs and hacks, he tells you that he's been coughing up nasty green stuff and it's hard to breathe. Does this homeless person in the box get the same care as the patient who lives in a million-dollar waterfront home with the same cough, hack and green sputum?
Or let's say as your partner is checking out the patient's medications, he comes upon a drug that is used to treat some form of mental illness. How often have you seen his eyes roll towards the ceiling? You can almost hear his thoughts: "I can't believe I had to get up in the middle of the night for another crazy." In truth, there isn't much we can do in the prehospital setting to treat a behavioral emergency. What we can do is be kind and professional, keep the patient comfortable and transport him to the appropriate facility where a mental health professional can hopefully provide the care and interventions they need.
In each of the examples above, the patient's complaint was discounted as being less than worthy of the provider's time and talents. In that setting, if the problem isn't worthy of your time and talent, then it's just a short mental jump to start thinking that neither is the person having the problem. Do you see the inherent problem in making one patient and his problem more or less valuable than the next? When we devalue a patient's problem, there is the potential to devalue the patient himself.
In the 33 years I've been privileged to work in the EMS profession, not once was I taught or told that some lives have more or less value than others. Thanks to the quality education and training I received from some great EMS educators, I continue to embrace the belief that when you sew that Star of Life patch onto your uniform, you make a commitment to treat every patient with care and compassion, and to the best of your ability.
While I can't say for sure if any of the folks who shaped my career and practice read Michael Connelly, they still imparted the same philosophy of detective Bosch: Everybody counts or nobody counts.
Until next month...
Dedicated to H.K.
