Saturday, January 1, 2011

The Big Picture

“Holy bat guano it's cold!” Sarah shivered at me as we literally ran from the hospital doors to our waiting rig. Jeff, my paramedic student, more slid than ran, grabbing the tailboard on his way by to stop his perilous slide on the evening ice. It was two weeks before Christmas and our area was hit with record lows, spreading ice everywhere. Thankfully it was too cold to snow. The rig was a little warmer and once we got it fired up, I asked Jeff the usual round of student questions about the last call. How do you think it went? Was there anything you missed? Anything you would do different? Why this medicine instead of that one? Do you think the chest pain was cardiac or maybe something different and why?
Jeff was good. He had been with us for over a month now and had a good solid foundation and excellent treatment modalities and he could multitask and think on his feet. The only concern I had was that we had yet to have a truly critical medical or trauma. Someone may be excellent at everything else but if they did not possess the ability to keep their head in a critical situation they might as well start looking for another career. I had been working with him on “the big picture.” The most common area that needs work on EMTs that have recently gone to medic school, is the ability to stand back and take in the whole patient and the whole scene. We teach that it is NOT the medic's job to be taking vitals. That it is not the medic's job to perform BLS interventions. Not even the medic's job to hook up the heart monitor. That's what our excellent EMTs are for. They are competent and know their job, so stand back put your hands in your pockets and ask questions and take everything in. There might be some small piece of the puzzle you uncover by doing so that will make a difference in what is done for the patient. A difference that might save their life.
Before we pulled out onto the deserted street in front of the hospital the tones alerted. Car verses pedestrian a short two miles away. Sarah flipped the overheads and I called in route. I asked Jeff what he knew about that area and what we might expect. He was right on. Forty-five miles per hour and no shoulder. The recipe for nastiness. I could see the adrenaline pumping through his shaky limbs as he described the possible injuries and safety concerns this scene would likely have.
We arrived on scene shortly to find a large, adult male sitting in the road unable to talk. There was blood on his face and he was drenched in sweat. There was several concerned bystander looking almost as dazed as the patient but they had done well by blocking traffic and shutting down the road. The truck parked in front of the patient was a very large dodge diesel with a distinctly man-shaped imprint in the grill.
Jeff got out, looked around, taking in the scene and headed straight over to the patient. Then I heard him gasp. I peeked around his shoulder, curious. The patient's right leg was sticking out at an odd angle, his pants were ripped and I could see pieces of his shattered femur laying on the road next to him. Oddly enough there was very little blood. Poor Jeff's eyes were big enough around I thought they might fall out of the sockets.
Sarah, in her usual form of excellent wisdom already had the bed and backboard coming with bystanders and was setting up our IV supplies.
Jeff kind of froze for a second. The longest second I have experienced in a while. I asked him, “What do you need?”
“Uh, dressings! Lot's of dressings, oh a splint!” Came his reply.
People were watching so I whispered, “Jeff, big picture, man, big picture!”
Then it clicked, he saw the profuse sweating despite the single digit temperature. He saw the dazed, non verbal condition of the patient. He saw the imprint in the grill.
“Oh crap! Get him on the board we need to go now!”
Jeff was amazing on that call. He properly medicated and carried out the rapid sequence intubation. He called early for a helicopter to our trauma center. He had a couple large bore IVs. I mean he did awesome. All in the two miles it took to get to the hospital with the landing pad. I gave him high marks. He went on to work for a life flight company taking calls like that all the time. All he had needed was someone to kick him a little and remind him, “Big picture, man, big picture!”
I tell this story story not because medic's out there need to be reminded of this. I tell this story because it can be applied to our daily lives, and even when not making life and death decisions on an ambulance, not seeing the big picture can be fatal.
I used to work a side job doing construction. One of my coworkers was this guy named Steve. I did not like him. Not even a little. He was rude, treated people badly and expended more energy avoiding work then it would have taken to just do it in the first place. We all know the type. We have all worked with someone like him before.
Over the course of six months though Steve got worse and worse. More mean tempered and even cussed out coworkers and customers. I mentioned this to my boss, asking why he didn't fire him. My boss was a wise man. He told me he didn't hire Steve because we needed his help. He had hired Steve because Steve needed ours. My boss was a man that could see the big picture, though at the time I thought it was the stupidest thing I had ever heard.
Things got worse and worse. Steve showed up late, frequently fell asleep on a job, and continually made mistakes I had to fix. My boss was always talking to him just out of my earshot, but he never looked angry at Steve. I would have canned his butt.
That fateful Friday we had been working on a big roofing job. There were only three of us there. My boss, Steve and I. We were working fast and hard and didn't have time for anything else and Steve was in rarer form then ever. He kept riding me and making backhanded comments at me. Critiquing my work, that was better then his, and cussing at me. About the time I had reached my boiling point I was on my way down a ladder with some tools and Steve was supposed to be holding it for me. The ladder started to slide sideways and I dumped the tools to save myself. Falling in a heap with the ladder. Luckily it was not far to the ground and I had only bruises to show for my acrobatics. Bruises and broken tools. I was livid. Steaming. I ran around the corner and found Steve sitting on the truck tailboard drinking a soda. It was too much. I let go. I yelled, I berated, I cussed, I was righteous with deserved anger. Steve just sat there looking at the ground, not saying anything. My boss just watched from the roof without expression.
The next morning, at my medic job, I was feeling a little better. A little sore but my ire had fled and I thought probably I should tell Steve I was sorry for yelling at him, even though he deserved it. Then the tones went off for the first call of the day. Possible suicide. I grimaced. I hate suicides. Weird though the address sounded familiar.
We got on scene and that's when I figured it out. It was Steve's house. I blanched, my stomach sick, suddenly full of dread. I had dropped him off here last night after work. No, please no!
I had never been in Steve's house but I was shocked by it's condition. It wasn't dirty, it was empty. There was a card table in the kitchen and one lawn chair. A cooler but no fridge. Nothing in the living room and his bed was a small mattress on the floor with one threadbare blanket. There was a note written and pinned to the wall, it was from his wife.

“I'm taking the kid's to my parent's. Don't even think about coming around until you get yourself straightened out. Lisa”

It was dated over a year ago.

The volunteers ushered me out to the garage in silence. There was Steve. My heart cried out. He had been hanging there since last night. Probably right after I dropped him off. Cold, rigored, lividity. He was long gone. I couldn't speak, shame filling my soul. Finally I understood my bosses words. “We don't need him. He needs us.” Such a simple phrase with so much meaning. With all my training in depression and psychiatric disorders, I failed to see. With all my experience in dealing with people with exactly his problems, I did not notice. With the critical indecent stress classes and debriefings I had been to, I missed this one. Heck, I have even written presentations outlining the signs of stress and mental illness to teach to our EMTs. I had gotten so wrapped up in my own irritation at his behavior. I had judged him without knowing him. I failed to step back and look at the big picture and ask myself what is really going on here. I didn't kill him. I know that, but I may have helped him on that path. If only I had taken my own advice to my paramedic student. Why was he acting like a bear just out of hibernation. I wished I'd asked myself that. I don't know that I would have made any difference in the outcome. There were a lot of factors that played into his decision to end his life I am sure. But it wouldn't have hurt to have seen the signs and tried. Now when someone exhibits less the tasteful behavior I stand back. I look at the whole scene, so to speak. I ask myself why, maybe even ask them why. Steve taught me an invaluable lesson and I will never forget him.
“Big picture, man, big picture!”


Life is amazing. I continue to be floored by the way people's lives intersect and have incredible impact on each other. How the events of a day sometimes unwittingly bring us into contact with others, sometimes hours later. How our decisions, meant to effect only ourselves, produce undeniable changes or surprises in ways that we could never predict or expect. Like ripples in a pond that change the course of other waves and ripples, we tread through our lives, the repercussions spreading into the world around us. I challenge you to pay attention to how what you do has an effect on other people. It can be downright intriguing to study this phenomena, sometimes the twists are better then any drama on television.

To drive this point home I would like you to meet Dave. Please understand I have never met the man. I only saw him once, on the side of the road, sitting in his car. I don't even know if his name was Dave, he just kind of looked like a Dave. But you could tell the kind of man he is. He was efficient and obviously a man that took great stock in his routine and doing the same thing, the same way everyday. He believed that if something worked so well it should be done that way everyday. If it's not broke, don't fix it.

0553 hours. The tones go off for County Medic to go on a diabetic male way up in north county. Altered mental status, blood sugar is 34. My partner Steve and I drag ourselves from bed groaning, get dressed and stumble out into the rising sun to fire up the ol' beast and head north with lights and sirens running. Bleary-eyed, bad breathed and craving coffee we start our trip staring sullenly at the road, unknowing that this call was going to change an unwitting bystander's day completely.

0600 hours. Dave's alarm goes off, slowing increasing the volume of his country music station to a decibel that brings him to consciousness. His eyes pop open and he smiles to himself. He can feel the morning sun through his window and hear the birds chirping. Perfect morning. He can hear the last few gurgles of his preset coffee pot finishing up, just waiting for him to come in and pour a cup. Life is good.

0618 hours. We arrive on scene, a little more awake. The county volunteers meet me at the ambulance to give me a short report and vitals. We get inside, the patient is minimally responsive, covered in sweat and pale. Heart rate in the 130s, blood pressure is good but the glucometer reads 28. Steve and I now end up in a wrestling match with this big sweaty patient but finally get our IV and start some IV dextrose 50%. The patient starts to blink and look around in surprise at all these people standing over his bed.

0630 hours. Dave has already had his two cups of morning java, taken a shower(putting his towel in the laundry basket, he's not the kind to leave a mess), and starting on a breakfast of eggs, bacon and toast. After all, breakfast IS the most important meal of the day. After eating and looking out his big picture window to watch deer cavort in his field, he carefully cleans his dishes and put the salt and pepper away, leaving his kitchen clean for his evening meal. It's exactly the same as yesterday, and probably the same as tomorrow. There's just no reason to change anything. He lets a very small belch of satisfaction and heads for his car keys and morning paper and that last cup of coffee.

0647 hours. After feeding the patient a peanut butter and jelly sandwich to get some carbs on board and talking to the emergency room physician we leave the patient's house. Leaving him and his family instructions to follow up with his primary care doctor and to eat frequently through the day to help level off his fluctuating sugars. We are now fully awake and really starting to anticipate hitting the mocha stand when we get to the city for shift change over. We are talking about the calls we ran last night, or maybe about our wives, I don't really remember. Just that we were talking amicably as we traveled down the canal on that beautiful sunny morning.

0655 hours. Dave reaches the end of his driveway at exactly the same time he does every morning. He turns off his car and rolls down the window to listen to the birds, open his paper and takes a long pull of the last cup of morning coffee, full and steaming in his hand. His buddy will be there in moments to pick him up for their carpool to work. He sees that his neighbor's cows across the highway seem to be doing well this morning. He does not see the big ambulance coming down the highway however.

0657 hours. Steve sees the cows. I think it is important here to explain that most EMS workers LOVE their PA system. Not many will mention this and some may even feign indifference, but having the opportunity to pick up that microphone and raise our voice several hundred decibels to project out the front of the ambulance is extremely satisfying. So like I said, Steve sees the cows and suddenly becomes very animated, eyes wide with excitement jumping up in down in the passenger seat.

“Oooo, cows! Cows! Give me the PA! Quick!” I hand it to him. Steve does not see Dave on the opposite side of the road sipping his coffee and contentedly reading his paper, window down.

Steve raises the mic to his lips, the volume cranked and lets loose his best Brahma Bull moo at sound levels that would give a Blue Angel a run for it's money. The cows jump and stare with alarm at this giant white and blue bull that moves 55 miles per hour. Steve giggles and claps with glee, like a little kid.

That's when I notice Dave. For the first and last time in my life. He appeared to be seizing inside the front seat of his car. His newspaper is in shambles. There's coffee across the windshield and dripping from the ceiling. He may have wet himself, though I couldn't be sure from the drivers seat of the ambulance. And that quick he was gone. We were past him and down the road. We never got any complaints at the office which leads me to believe he never did know what it was that disrupted his morning in such a dramatic fashion. That or he was just too good of a guy to fault a couple of immature paramedics. Steve never even saw him. Never realized that the events that started in motion early that morning made an unbelievable difference in another person's day, completely by accident. I told Steve about Dave and he just looked at me, I don't think he ever believed me. I hope Dave's doing all right.

I've always wondered if he changed his morning routine at all, to protect himself from high-speed mooing ambulances.