Monday, January 29, 2007


I took care of a man today who, according to the convenience store owners where he was found, "went totally crazy." When we got there he was on the floor, writhing like a fish out of water as eleven police officers stood over him catching their breath. He was handcuffed and lying face down, screaming as he struggled against his bounds. He covered his posterior with his hand, madly swatting away some invisible insult. "He's raping me," the man screamed. "Why are you letting him do this to me?"

When we flipped him over and onto the stretcher he hardly seemed to notice. His face ran with tears, his mouth wide open in anguished cry. Every once in a while he would catch my eye and plead with me that I make "this guy" stop. I tried to ask him what happened, what was going on. Looking into his eyes I tried to offer him a way out, a softness beyond the hell that he endured. He looked right through me. His reality was too much for him to bear, too potent to ignore.

I did my best to perform an assessment. He had a strong, regular radial pulse at about 134, his skin hot and diaphoretic. His lung sounds seemed to be clear between screams. I did a rapid trauma assessment and found nothing. PEARRL. Unable to obtain a medical history, meds, or allergies. I wasn't even sure I had his first name right. I tried to give some nasal cannula oxygen, but the man kept shaking his head whenever I got close, screaming with rapidly depleting energy and fighting the best he could. I resigned myself to simply trying to calm him down, which didnt work either.

Patients like this are not uncommon in the city. They get into the back of the ambulances - willing or, sometimes, unwilling - and refuse to budge. We do routine assessments, going through the motions to be thorough, knowing all the while that we cant really touch these people. The barriers are too high, the insults are too deep. They look at us with the eyes of experience, tired of the same questions. Most have done this before and seen failure, their pockets filled with medications and crisis intervention business cards. Again we both try.

Its easy to burn out on these patients. Perceived futility is an especially hot ember. I'm not sure how long-term, adept clinicians handle this. Do they relax in the system, mindlessly going through the motions in efforts to provide for these patients another halfway opportunity? ...Or are they convinced of the value of these interventions, actually believing that people this far gone can truly be helped?

Which method is the best for the patient? Which is more healthy for the provider?

On our way to the hospital I sat in the airway seat, behind the patient. I didnt want him to look at me, ask me for help I couldnt give. I spoke to him from out of his view. "Calm down buddy. Try to relax. We're taking you to the hospital, we'll get you some help."


Chris said...

Reading back through your blog, I've noticed a few references to PEARRL. I've heard PEARL (Pupils Equal and Responsive to Light), but wondered what the extra R referred to?

fiznat said...

Hey Chris,

The extra "R" is for "Round." Pupils are Equal and Round, Reactive to Light. ;)

Chris said...

Thank you fiznat, much obliged