Tuesday, January 2, 2007

Crazy

Not exactly known --by myself at least-- for his deep insight into the incintricities of culture and social interaction, I was surprised the other night when I heard Dave Chapelle say something extremely profound about what the EMS community refers to as an "EDP," the Emotionally Distressed Person. He was more talking about himself, I guess, but the logic translates. "The worst thing you can call someone is crazy," he says. "It's dismissive." Chapelle goes on to describe how we use this word --crazy-- not just in a derogatory manner, but also to separate ourselves from the behavior. The crazy person, the EDP, is bizarre and wild-- a scary vision if we were to think that this person was ever normal, ever like us. Instead we differentiate. That person is crazy. Of a different class, a different background. He is not like me.

An old woman kicked me out of her home yesterday. She dialed 911 because she was having chest pain and shortness of breath, a pair of complaints that both demands the attention of health care providers, and rolls off the tongue of practiced, chronic EDPs. People like this know the game, they've learned the magic words. Chest pain. Shortness of breath. Head, neck, or back pain. They are all used, chronically, by legitimate patients and attention seekers alike. We would be remiss to ignore the complaint but, seeing the woman and upon examination, the truth of the matter is clear to even the most green of EMTs. This woman is full of shit.

I introduce myself politely and ask her what can I do for her. She looks me up and down slowly, her eyes peering out above a non-rebreather mask. They narrow as she begins to laugh at my question. Not a mirthful laugh, no, a laugh of foul distain. Without a word she says to me "you? What could you possibly do for me?"

Already having made a decision that this patient was an EDP, my clinical interest - and with it my patience for this woman - goes down the drain. I ask her what is so funny. "You," she says. "You are funny." I'm pissed off. Who does this woman think she is? She calls us for help, and when we get here she finds breath despite her "difficulty breathing" to mock me? I grip my stethoscope harder in my hand, but manage to keep my mouth shut. A jabbing remark slams into the back of my teeth as I keep it in. No, be professional.

I try to start my assessment, but as I reach to listen to her lungs she recoils. She shrieks, screaming "What the hell is that smell?? What cologne are you wearing? Oh my god I cant be around that smell!" I try to calm her down, soothe her into letting me listen "just quickly," but she wont relent. Her cries get louder and louder, as she carries on about how cologne gives her seizures. I can look it up in a book, she says. She has a condition. I take a step away from her, and start to explain that I am not even wearing cologne, but it is no use. She is inconsolable, and begins to cry. "Get the fuck out of my house," she says- her finger pointed to the door. "Get the hell out of here or I am going to call the police!" The police officer standing in the other corner of the room lets out a snicker, which she either doesn’t hear or ignores.

My preceptor nods to me and I go. Screw it, I think to myself. She's full of shit anyways. Crazy.

I stand outside the house with some other police officers and the firefighters who responded. They all joke and make fun of me, and I laugh back. "You smell like a French whore house," they say, "my eyes are watering!" One of them falls to the ground and pretends to have a seizure. Breathless with laughter we call the woman nuts. "What a freakin wacko."

It it is comforting to convince myself that I am not like that woman, that she is different from me in some profound way. She is crazy, I am not. My abiliy to differentiate has become almost automatic. As soon it was obvious to me that this woman was a difficult emotional case, I began to take steps back. I had left her room long before she asked me to.

As easy and helpful sometimes as it may be to separate ourselves from patients like this, I have been finding that medicine --good medicine-- asks us rather to integrate with our patients. The adept clinician establishes a professional relationship that serves both as an emotional backdrop and as a functional tool. I have witnessed this as an EMT, riding with proficient paramedics. Tones of voice drop into practiced words as smooth as silk. Empathy becomes an underlying tone to otherwise indifferent clinical procedures. I have heard medics bring up the topic of imminent needles so expertly that I myself wouldn’t mind getting stuck. All the while, the patient begins to open up. Harsh complaints and antagonistic laughter turn into a story, a history that the provider then translates and condenses, refining from narrative into chief complaint, past medical history, and an exhaustion of pertinent negatives. Often times, I have been able to do nothing but sit back and marvel.

Dealing with these people, these EDPs, requires a lot of experience, patience, and --perhaps most importantly-- empathy. The clinicians that I have seen that do this well do so not simply because this is a practiced routine, but because they truly do care. Empathy is fuel for patience, the reason for excellence.

My natural reaction, I admit, is often to retract from these people and protect myself. I dont doubt that this is the natural reaction that most people would have. Still, in full conscious knowledge of a better way, I wonder how to draw the line. How do I let myself care just enough, so that I can get the job done without sticking my neck out too far?

I hope that for now, it is enough that I simply care enough to care.

5 comments:

PC said...

This is a great blog -- for the writing, the stories and the insight. I hope you keep it up beyond your ride time.

Best of luck,

Peter Canning

Eric said...

Excellent writing! As Peter said, you have great insight. Best of luck with your blog and your career.
Eric Augustus
http://emshaiku.blog-city.com

Anonymous said...

I like to think of psych calls as trauma calls. You can't fix the patient. You won't have an opportunity to make any meaningful changes for them, but you have a pretty impressive opportunity to really make things worse. It's pretty obvious in trauma when there are iatrogenic injuries, but for psych patients, the iatrogenic injuries are invisible, borne by the patient.

It lies with you to avoid harming the patient through word or action. Patients with mental health problems are among the most misunderstood and most mistreated patients in EMS. Calling a person "crazy" is no different than calling a victim of sexual assault a whore.

EMS providers are quick to forget that mental health issues have a real biological basis within the brain. Just as Addison's disease and hypothyroidism relate to insufficient hormones, things like borderline personality disorder and schizophrenia relate to structural deficiencies of the brain and problems with neurotransmitters.

But I can't offer dialectial behavior therapy for borderline, nor can I offer provide antipsychotics for schizophrenia. They're hard to treat. One thing I have is two ears to listen, and a voice that can provide some empathy. This goes a long ways.

EMS isn't the only medical arm that is guilty here. Much of emergency medicine is equally implicit in this lack of care. Nurses and ED docs are just as big of offenders as anyone else.

It's hard. These patients are mean, grumpy, spiteful, and difficult. They demand more patience with less thanks than about anyone else. Often, they're mandated to treatment. They display irrational self-injurious behaviors time and time again. We know them on a first name basis. They call use complaining of "chest pain" because those are the words that unlock a 24 hour visit to the hospital to be doted upon.

Their pain doesn't bleed. The cuts don't heal with sutures. But they hurt just like everyone else.

Sean said...

You make an excellent observation, Foster. It's always difficult to deal with, well, difficult patients. We have a class in it during second year where we actual go interview psych patients. It is extremely tough...and very draining. Some people are naturally better at it than others, but no one I've seen is "good" right from the start. It's something that takes practice. You'll get the hang of it, and I don't think it sounds like you did too badly.

Anonymous said...

God Bless you anonymous, God Bless any of you who try.