True Emergencies

   There's a scene in the film A Few Good Men where Lt. Kaffee, played by Tom Cruise, asks Jack Nicholson's character, Col. Jessep, whether a Marine under Jessep's command was in "grave danger." Nicholson's droll "Is there another kind?" is one of Hollywood's most memorable lines.

   I never considered "grave danger" overkill until I saw A Few Good Men, but "true emergency" sounded redundant the first time I heard it--in medic school, when an instructor used that term to characterize a prolapsed uterus (a uterus having an out-of-body experience). "Just-plain-emergency" suits that condition well enough, I thought. Besides, we'd need another layer of protocols if we were to classify emergencies as "true," "extreme," "unprecedented in the annals of time," etc. Then we'd have to balance all that hyperbole with "partial" or "pseudo" emergencies. (Could that lead to first-trimester "para-pregnancies?")

   Not all calls are emergencies, but I think patients consider all of their emergencies true emergencies. Our EMS training and experience shield us from most of the psychological trauma, but also desensitize us to victims' acute anxiety and discomfort. Our arrival on scene is the first in a series of unintentional medical indignities that violate patients' social boundaries and exacerbate their feelings of vulnerability. Ambulances and ERs, designed for efficiency rather than reassurance, can be harsh, inflexible environments unless healthcare providers show we share ownership of customers' crises.

   Last spring I answered a call I thought was an emergency: a 28-year-old soldier with severe back pain from a prior blast injury in Iraq. His wife told me he was much more uncomfortable than usual. I found him trying to stand mid-spasm, using the two-thirds of his spine still working. He wasn't doing well. He had an almost-full bottle of hydrocodone that had been as effective as breath mints managing pain. Although he didn't request medication, I figured transport would be somewhere between unbearable and intolerable without analgesia. I called medical control for permission to administer morphine, our only painkiller. My request was denied because "This isn't an emergency."

   I suppose that depended on perspective. The dispatcher must have considered my call an emergency, because he contacted me on a frequency reserved for emergency traffic, and requested I respond immediately, instead of whenever I wanted to. PD and security were already on scene with their game faces; they certainly looked like they were answering an emergency (I get paid to be observant). The patient's wife had a worried look that said, "Gee, honey, the only other time I've found you doubled over, making noises like a crow caught by a hyena, was the first time your backbone tried rerouting itself through your navel." Yes, I believe she was thinking "emergency," too.

   My dictionary says an emergency is "an unlooked for or sudden occurrence, often dangerous." According to that definition, my patient was having an emergency--not because he had a new or dangerous condition, but because his pain level was suddenly much higher than it had been. The lesson, I think, is that patients should play the lead in determining their own emergencies--particularly in the field, where they can't promptly access definitive care for a second opinion.

   Is it my emergency if it's my patient's emergency? I don't see how I could separate the two. "Adopting" an emergency doesn't mean internalizing the victim's distress; it means managing the crisis as conscientiously as we can. We're supposed to be better at that than the average citizen. Most times we have the means and opportunity to limit the damage.

   If my patient had been transported to a hospital, he probably would have been given an analgesic strong enough to at least diminish his pain. Perhaps I didn't do a good enough job of selling that option. I think the medical control physician and I focused too much on the length of time since the original injury, and not enough on the immediacy of the victim's discomfort. Absent empathy and flexibility, the system failed the patient; he wasn't taken seriously.

   Calls considered frivolous generate lots of chatter in EMS circles. Providers become frustrated when patients demand ambulances for emergencies that don't meet caregivers' criteria. Some of our conclusions are hasty, but a conventional view of social responsibility does prescribe optimization of limited resources--ambulances, for example--to benefit the neediest. The problem is that neither dispatchers nor EMS providers have enough training to reliably diagnose many life-threatening conditions. The ubiquitous "sick" call could be anything.

   Do most EMS patrons consider the common good before dialing 9-1-1? I doubt it. I think our customers want to know they can summon an ambulance whenever they wish, and are willing to pay for that privilege, either directly or through insurance. Is there a collective burden? Certainly. We hope to address it with public education that discourages parochialism and promotes rational management of mission-critical assets. Government and industry leaders still struggle with that imperative. Meanwhile, our duty to act doesn't include an escape clause for inconvenience. Those of us in the field might as well focus on patient advocacy instead of on society's shortcomings, and treat every 9-1-1 call as a true emergency.

   Is there another kind?

   Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World's editorial advisory board. E-mail mgr22@prodigy.net.