What Frustrates You in EMS?

What frustrates you about patient care in the EMS practice? What assumptions or conclusions do you find yourself making about some of your patients — but would not admit openly? What other issues, aside from your patients, frustrate you in EMS?

A few months ago, a number of physicians (including myself) were posed similar questions by Reader’s Digest regarding the habits of patients and our individual healthcare systems.

The questions I was asked did not involve issues of Medicare/Medicaid and private insurance companies — which are often sources of major angst for doctors. Rather, they touched on patient characteristics and behaviors that irritate physicians. In retrospect, some might find this line of thinking to be divisive and counter to what we have been taught about valuing our patients — but I disagree.

Most of my encounters with patients and healthcare providers I work with are enjoyable at minimum, and at times, wonderful. My desire to help patients in difficult circumstances was the reason I went into medicine in the first place, and that has not changed.

Over the years, my relationships with my patients have been personally beneficial. And in return, I find patients to be very grateful — at least, in most cases. However, there are some recurring themes regarding human interaction and U.S. healthcare that wear on providers like me.

I indicated to Reader’s Digest that patients should take more responsibility for the factors in their life that they can control, especially those that may directly impact their health. I added that, at some point, it is impossible for health professionals to reverse the damage these patients have caused to themselves.

Patients who choose to damage their bodies, and then demand that the health system fix them, are a significant source of frustration for me. I believe that each person is responsible for their body, while acknowledging that there are clearly circumstances that develop beyond our control, resulting in disease or injury. However, disease or injury is often a direct result of really bad choices made by the body’s owner, ranging from dumb acute decisions to the outcome of long-term decisions. The usual suspects include smoking, obesity and substance abuse.

Alcohol and/or other drug addiction can be devastating for patients, bystanders and loved ones. In Colorado, over 40 percent of fatal car crashes are directly connected to alcohol consumption. Nationally, the Center for Disease Control has estimated the cost of healthcare provision for alcohol related diseases, complications and trauma to be over 170 billion dollars annually. Drug abuse (excluding alcohol) costs another 110 billion dollars annually.

Despite our perceived advancement as a society, some things really never change. Substance abuse/addiction has been present for centuries, and will continue to be in the future. In addition to booze, we are seeing a major upswing in the abuse of prescription drugs — primarily opiates and benzodiazepines. And prescription drug abusers are often not just the patient for whom the original prescription was written; they are teenagers who get into a parent's or relative's pills on a continual basis.

Some might argue that addiction is never the fault of the patient, that they are merely victims of other causes and pressures. To some degree, early in the addiction, I might agree. But at some point, after either refusing therapy or multiple failures in rehabilitation, it is the patient’s responsibility to overcome addiction. And that’s when I feel my empathy for the patient slipping away.

Some of us have a hard time assigning responsibility for our own actions. I recall a case in which a young, upper middle class mother was driving around town one afternoon with four small children in her car. She caused a moderate two of the children were transported by ambulance. Fortunately, all were stable and did not require hospitalization, but it was clear to me that the woman had alcohol on her breath. The odor was overlooked by the investigating police officer on scene for whatever reason.

When I contacted the officer from the ED and advised him of this, he seemed very surprised and eventually showed up at the ED. The patient’s blood alcohol was .320. Even after the patient received a citation and reviewed the laboratory test, both she and her husband — a well known businessman — denied the fact that the patient was intoxicated or at risk of injuring herself and others.

I remember another patient who had repeated hospital admissions for alcohol related medical complications. On each admission, he was strongly urged to seek in-patient rehabilitation, but refused. When I took care of him on his final ED visit, he had an upper gastrointestinal bleed that could not be stopped and ultimately died. While it was a miserable end for the patient, I really felt sorry for his wife and family. I thought about the pain they had endured over the years, as he continued to drink and repeatedly failed to ask for help.

Obesity is another important issue that has had a significant impact on the medical profession. Most of us, including myself, fight waistline expansion every day, with varying levels of success. However, despite a clear relationship between obesity and a number of diseases -- as well as repeated education -- some patients continue to consume large quantities of high-calorie foods with no real effort to lose weight.

I have tried to modify my practice in the ED to not overlook the obese patient’s healthcare risks — which other physicians sometimes choose to ignore. As a result, I ask patients for their estimates of height and weight and note that on the chart. In general, I will counsel patients if I think that weight loss is necessary, and certainly if it may be related to the chief complaint.

Most patients accept this or at least tolerate my advice. However, one patient complained to the hospital administration that it was not only intrusive and rude for a physician to ask her weight in the ED, but also that it had no bearing on why she presented. Nevertheless, I still persist (perhaps more cautiously) in providing weight loss suggestions to obese patients.

Another common factor with a myriad of adverse health effects -- smoking -- requires no additional comment. But being in emergency medicine and EMS, we seem to associate with a disproportionate percentage of patients who are smokers. It never ceases to amaze me that some of my emergency patients can’t seem to afford even the lowest cost prescriptions (except maybe narcotic pain medications or benzodiazepines), yet are able to always have a pack of cigarettes and a cell phone on hand.

These are just a few examples of frustrations with patient care and the practice of emergency medicine. With all that I’ve disclosed, some might wonder if I am just burnt out. Perhaps readers may conclude that I ought to retire. While I must admit that is a tempting thought sometimes, my passion for the work continues.

Every job has its irritations, frustrations and problems. The practice of emergency medicine and EMS is no different. What has changed for me over the years is that I am now giving myself permission to question why some things are the way they are. Now I not only look at emergency medical care from a different perspective, I also look at how healthcare in general, is delivered in this country. The basic reasons why I went into medicine remain; I enjoy helping people when they may need it the most.

I would like to hear from you about what you find frustrating in your EMS practices, and also what keeps you motivated. The questions that I responded to from Reader's Digest limited the discussion to patient behaviors. But, for our purposes, I would like to open up the discussion beyond patient characteristics, to include the EMS practice in general. I look forward to your responses.

Author’s note: I think one caveat needs to be applied to all comments left below: It is one thing to just complain and point out problems; it’s another to offer solutions. So, for all responders, please try to include potential answers, if they exist, to the issues you raise.


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