Hidden traumas

Whenever I bring up my EMS involvement in casual conversation, the questions I get are usually influenced by a high-adrenaline public perception of the field: “What’s the worst thing you’ve seen?” “Have you ever seen somebody get shot?” “Have you ever done CPR?” While we’ve all had our fair share of harrowing experiences in the field, the call-to-call reality is considerably less dramatic -- though that’s not to say it doesn’t hold its own excitement. Truth be told, sometimes the most critical patients are the easiest to manage. After all, pre-hospital care boils down to some simple concepts – to quote an instructor of mine, “air goes in and out, blood goes round and round, any variation on this is a bad thing.” Sometimes, it actually is that easy. Patient not breathing? Breathe for the patient. Massive extremity arterial bleed? Tourniquet it and forget it. See? Emergency medicine’s not that hard.

At other times, you have to do some detective work to figure out exactly what is going on. If your patient is talking, then the majority of your sleuthing is usually a matter of asking the right questions. But what about the other case? Calls involving patients who can’t communicate with you, for whatever reason, will have you relying on all of your senses (well, hopefully not taste) to piece together the puzzle. You’d be surprised at how little our sophisticated diagnostic equipment can contribute to our knowledge of the patient’s condition in some cases. After all, a $30,000 cardiac monitor will tell you if your patient is having a heart attack, but it won’t tell you anything about his lifestyle, habits, or daily routine. Recently, I was acutely reminded of this need for observation in reconstructing the bigger picture.

I had just gotten in from Jersey at the end of winter break, and I was working my first shift after three weeks of holiday festivities and blissful abandon. My partner had told me that he was looking forward to a busy night. Drawing on the sardonic superstition ubiquitous among EMS folk, he concluded that a week’s worth of slow shifts portended the collapse of western civilization at some point during our 12 hours working together. While our district did not descend into anarchy during the night, we stayed busy enough, bringing multiple critical patients into the trauma bays at the ER. One of them, in particular, ended up sticking with me for a while.

The story begins as they always do – a disembodied, emotionless voice blaring from the radio, rattling off a dispatch for our unit. “Overdose,” it drones, instructing us to respond to a residential address for a 17-year-old unresponsive female. Jump cut to an upper-middle-class living room, where our patient lies motionless in the embrace of an armchair, her mother frantically telling us about the two bottles of pills she washed down with alcohol. Calm and collected, we work efficiently, protecting her airway, obtaining vital signs, and moving to transport quickly. Her best chance of survival comes with intubation, dialysis, and antidote administration, none of which we can effectively provide on-scene.

As we navigate the pockmarked city roads at breakneck pace, my partner and I look to set up IV lines in accordance with another pithy instructor mantra - “the solution to pollution is dilution.” As we expose her arms, though, scars of intricate shapes and ranging sizes stare back at us, telling a story of deep-seated, severe pain that compelled this young woman to take to her body with blades. It isn’t until we turn our patient over to the emergency physicians that the final piece of the puzzle slips into place—while preparing to monitor urine output, the nurses discover that our patient is biologically male. And so this story ends in a trauma bay, with me watching her intubation in muted horror, silently terrified at how my patient’s protracted pain had culminated in this moment.

I never did find out what became of my patient that night. The unfortunate reality of the job is that our war stories don’t always have an ending, and when they do, it’s rarely a happy one. But we still tell them. Someone has to speak for those who can’t, or won’t. At the end of the day, it’s not all about keeping air and blood moving through their respective cycles – you have to be an advocate for your patients. I’ve never particularly understood why extending basic civil rights to the LGBT community is controversial – in many ways, the systematic denial of these rights is the adult equivalent of the high school stigmatization that likely helped drive my patient to her breaking point. Nobody should face this sort of unwarranted hardship as a result of their gender identity or sexual orientation, yet there are people all around us who must deal with it daily and bury deep the scars of social prejudice. So go out and effect change in society – you never know who amongst your friends and family hides traumas behind a gilded facade.

Jay Srinivasan, Trinity ’14, is a Duke pre-med. This column is the second installment in a semester-long series of weekly columns written on the pre-med experience at Duke, as well as the diverse ways students can pursue and engage with the field of medicine.