Monday, February 11, 2008

Weighty Decisions

In light of the great expanse of that which I do not know, it is often hard to justify following through with any method of treatment at all.

When faced with a complex patient who is in the least sense stable, who could stand the ride to the hospital in relative good health without printing flat lines, more and more it seems that the answer for the questioning paramedic should be to do nothing. Old wisdom says that it is better to spend time with the non-invasive, with the safe and comfortable until more skilled hands take charge of the real decisions. The fancy drugs? Leave them. The risky procedure? It can wait.

See, in the loosest sense we are technically allowed to perform a large list of interventions. Our drug bags are fairly extensive, stocked with fairly complex and fancy solutions about which we understand only a small portion. We are granted surgical procedures which many of us - even the brave with many years of experience - have never or only once attempted. We are able to stop and start heart rhythms in the right patient on our whims, and every paramedic knows: the decisions are not always obvious.

That was the attraction, though. Murky gray patients in discomfort or teetering on the edge of something worse, supine on my stretcher and I, a paramedic, with the ability to do something about it. Yes I can intubate a patient in cardiac arrest, push epinephrine through their flattened veins and heroically demand all to stand clear while the electricity flows... but what I really wanted, what I really looked forward to was to take a patient who was almost worse. ...A patient that I could see circling the drain and then - by the strength of my notice and power of my appointed abilities - reverse the course. Epinephrine for a bad allergic reaction. Magnesium Sulfate for severe asthma. A dysrhythmic for a tachycardia. These are the interventions that make the differences, that require knowledge and skill and ability and all of those things attribuited to the provider who is truly good at what he does.

These are weighty decisions, though, and there is a reason why they are made only by the experienced and able. It is too easy to swing wide, to notice what there is not and power-over in an unnecessarily aggressive treatment. Equally there remains potential to undertreat, exaggerate permissiveness to an unhealthy degree. In these cases especially, as much as there is the capability to reverse sickness, used incorrectly these treatments have a special potency to accelerate certain doom. Here lies at once the ability to do immediate good, living right alongside - as neighbors - a potential to cause disastrous harm. It is a delicate and discerning touch that knows the difference between too much and too little, a rare mind that weighs the evidence in proper perspective and always hits center with each decision.

From the view of this still-new paramedic, it seems increasingly clear that given all that there is, it is best to remain conservative. ...Even if it is not what I think is best for the patient, recent experiences are teaching that it is better to hang back for a few minutes; observe instead of reaching for the boxes and bags. Retrospect teaches that it is far easier to justify an omission than an act, simpler to explain the why-not than the why.

Nagging, though, is the patient. Better for him or better for me? Even in full awareness of my ignorance compared to the depth of medical knowledge, in plain view of my inexperience and lack of education: the supine patient will ask for help.

1 comment:

Bobby, not my liver said...

{Retrospect teaches that it is far easier to justify an omission than an act, simpler to explain the why-not than the why.} ^This is what I was thinking as I read along. How do you explain if you have "leaned forward", and the out come is not good, as opposed to living with guilt or "what if's" for holding back...