Making friends with the ghosts

Realizing that no matter how skilled my hands or knowledgeable my head, what matters most to my patients is my heart

I killed the first critical patient I had as a paramedic.

I had graduated paramedic school only a couple months before, flush with all the cockiness and arrogance one often sees in new medics. I was ready to go save some lives and stamp out disease, show everyone what a stud paramedic I was, if only some unlucky person would have the common courtesy to drop dead in front of me.

I got my chance, but it didn't play out the way I way I envisioned it in my hero fantasies. EMS has a way of humbling even the most arrogant medics. The problem is, we're usually just the bit players in the drama that humbles us, and the patient is the one who suffers. My demotion from paragod to mere human cost a 25-year-old kid his life.

It wasn't anything I did, really, just things I wasn't capable of doing. I was too tired, too cocky, too sure that a simple interfacility transfer was beneath my talents as a medic. I took a transfer that I shouldn't have, too proud to ask for help, too dismissive of the ED nurses to request that they do more to stabilize the patient before transfer.

I distinctly remember thinking as the nurse gave me report, "Whatever. Let's just get him out of this Band-Aid station before they kill him."

Forty-five minutes later, we backed into the ambulance bay at the receiving hospital, me with his blood on my uniform shirt and pants, all the way up my arms … even blood on my face and in my hair. Even worse, the patient's aunt had ridden in with us, with a front row seat to my total meltdown as a paramedic and the death of her nephew.

Afterward, she hugged me and thanked me for everything I did.

Shame will never burn you so hot as when a family member thanks you for failing their loved one.

I had nightmares about that kid for years. I remember his name, his face, his date of birth. There were times I searched for his obituary online, wondering what it would say.

I found it, and read it more than once, and each new time I read it, I half-dreaded that it would say what I already knew: "Died with paramedic assistance."

It took a good five years before my knowledge and skills caught up with my ego, and that night did more to spur my growth as a man, and an EMS provider, than any single event before or since. And as I grew, I slowly came to realize that no matter how skilled my hands or knowledgeable my head, what mattered most to my patients was my heart.

Heck, a woman thanked me for killing her nephew, because she could see that it bothered me. She could see that I cared.

Adding headstones is part of caring
I've come to believe that every good medic (and by "good," I mean "conscientious," not "skilled") carries around their own little mental graveyard, filled with the headstones of people they think they've failed. It's not the death or the horrible physical trauma that EMTs see that haunt our dreams, it's the calls where we blame ourselves for a bad outcome.

When you fail to resuscitate the 80-year-old with a heart attack, it's easy to rationalize, and put it behind you. You remind yourself that you're skilled, and you run a smooth code, and that some people's bodies are just too broken to save, and you restock your truck and move on to the next call.

But when the patient is a 25-year-old kid, and you didn't run the call so smoothly, it's harder to rationalize, and another headstone gets added to the graveyard. You can either try ignoring the faces behind those headstones or you let them drive you out of EMS. And even if you leave, you still carry the graveyard around with you, damaged by what you've experienced.

Or, you can make friends with the ghosts.

My nightmares stopped soon after I wrote about that call. It was as frightening a thing as I could remember, knowing that a total stranger could pick my book off the shelf at Barnes and Noble and know that I had screwed up.

And then people started emailing me, saying, "Thank you for writing that. We've screwed up, too."

I won't say that the nightmares stopped right then, but they occurred less frequently, and they didn't seem so frightening. And eventually, they stopped altogether.

Developing emotional resilience
It doesn't mean you don't feel any more — you can't be a good caregiver without care — it just means you learn to do something constructive with the pain. Ultimately, hardening yourself to emotional trauma has the same effect as hardening anything else: it just makes you brittle.

More than anything else, what has helped me to develop emotional resilience is a sense of perspective about what I do, and who I am as a provider. That perspective allowed me to stop defining myself as a lifesaver, and start viewing myself as a caregiver.

If we're honest about it, saving lives is pretty rare in our profession. Making people a little better, yes that's more common.

But really, truly being the difference between life and death, using skills that only a health care provider knows, comes around but very rarely. And even then, it's mainly a matter of luck and timing.

Even our code saves are largely due to prompt CPR and defibrillation — both layperson interventions. When your self-image is as a heroic lifesaver, failing in that endeavor comes hard. Even worse is the other 99 percent of EMS calls, where we don't even get to try. 

But we get to care for people every day, on every single call. Often in the constant grind of post changes and psych calls and the non-critical, routine bread-and-butter runs of EMS, we tend to forget that.

But caring is important, and no one finds it more welcome than our patients. They'll appreciate it even more than your mad paramedic skills.

That's why last week, when we were called to the scene of a toddler accidentally backed over by a truck, I was able to bounce back. We were 25 minutes out, and they were already doing CPR when they called 911. I knew we weren't going to save him.

I also knew that a lot of people were going to be beating themselves up because we didn't. My partner. The dispatcher who took the call. The sheriff's deputies. The child's entire family, most especially the parent driving the truck.

Kids don't survive trauma like that, and most often trying to save the child only means you run an unacceptable risk of adding a flight medic, ambulance crew or deputy to the death toll.

So I got on the phone with the medical control physician, ran my thoughts by him — before I got to the scene, because that's not a conversation to have in front of family — and got his approval to terminate resuscitation efforts if the child's injuries were not survivable.

And when I saw that resuscitation was not possible, I quietly told the deputies they could stop and thanked them for everything they had done. They knew the child wasn't coming back. They just needed to hear it from somebody official, someone with more training than themselves.

And then I braced myself to tell the family, knowing that their world was already wrecked, but that if I handled it right, that at least I wouldn't make it worse, and that I wouldn't prolong their grief.

And I quite possibly might ease the process, just a little bit. That's something I'm really good at, and experience has taught me that such things are often the most important acts of life support we do.

So I told them, and I held the mother and grandmother as they cried, and I cried a little myself, and I wasn't ashamed about it. And then I made sure that the deputies, trying manfully not to cry and failing at it, knew — again — that they had done everything right, and that such injuries are simply not survivable, because not knowing is what gnaws at you the most.

Don't be afraid to share your pain
When Acadian's crisis counselor called me later that afternoon, I thanked her for her concern, and assured her I'd be okay, but I'd appreciate her checking on my partner and those sheriff's deputies. And then I went home, cried in my girlfriend's arms and went to bed.

And I went back to work the next shift, without another headstone in the graveyard, because I knew I had done the only things that could be done, and done them well. And I knew that the tears I shed were simply a part of healing.

You'd do well to approach bad calls in the same way; do your best, and don't be afraid to share your pain with those you love when your best simply isn't good enough.

That's the easiest way to make friends with the ghosts.

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