Objectivity and Patient Care

A Guest Post by Sean Fontaine

I love posting articles controversial enough to warrant a disclaimer. Today I have the pleasure of bringing you another post by guest author Sean Fontaine. Sean is a graduate of Regis University and a Firefighter / Paramedic for The South Metro Fire Rescue Authority. He lives in Denver, Colorado with his lovely wife Oz and their two sons Jonas and Axel.

Today, Sean throws down the gauntlet on an issue that must be addressed by every emergency caregiver; the delicate balance between delivering objective, impartial medical care and the urge to interject our emotions into the often emotional drama that is emergency medicine. Can you make real emotional connections in the process of administering medical care, or does the emotional aspect of the job directly impact the effectiveness of your care? Some of us may address this dilemma only in our own private thoughts. Others may wish to publicly declare their position. To that end, here’s Sean…

Let me preface this post with the explanation that this topic comes straight from my discussions with paramedic school students and co-workers and the differing/agreeing viewpoints that resulted from those discussions.  These are my opinions (not Steve’s) and I know full well that there are many of you out there that will disagree and some that will think I’m an insensitive ass. So be it, we’re here to listen to different viewpoints and think through them for ourselves, deciding in the process what our own thoughts truly are on a given subject.

The Argument: Your level of objectivity effects the quality of your patient care.

I contend that when we emotionally care about our patients we become subjective caregivers and as such render subjective care, transitioning to reactive rather than proactive medicine.

This topic has come up with co-workers when discussing my history of sick and dying pediatric patients, traumatic or precipitous delivery OB calls, and violent sexual assault calls over the past 10 years. (In comparison to the rest of my calls.)  In addition, this topic inevitably came up when I spoke with last year’s paramedic school class at a local teaching institution. (I was speaking on the subject of pediatric death and dying, prior to their PALS scenarios.)

During those instances, I stated with no intended malice, that a sick, dying or dead pediatric patient demands the same mental cognizance as a sick, dying or dead adult patient.  As such, I see no reason to change my treatment or mindset because the pediatric patient is viewed as “innocent” or deemed “more worthy” of our efforts by some caregivers who then become emotionally involved with the patient.  All patients are “worthy” of our full and complete efforts and treatment. That’s our job.

Once we take that step and become emotionally involved with our patient, I believe we cease to observe and treat to the fullest extent of our ability. Hence the previous statement regarding the rendering of subjective and reactive medicine, rather than focused, proactive medicine. I believe that we are paid to think through patient’s current signs and symptoms and consider differential diagnoses, treatment options, appropriate destinations and the most appropriate continued course of treatment. Then, through the course of these actions…we care for our patient by acting in their better interest. We act as their “advocate” if you will.

As you can tell by my verbiage the line as I see it is, “Caring for your patient equals proactive/objective care, whereas caring about your patient equals reactive/subjective care.

Don’t think that I don’t appreciate the weight of this argument. I have had numerous sick, dying and dead pediatric patients with a myriad of outcomes, some of these patients have been carried in my arms to the ambulance, as I have likely carried my own children at some point. However, in acting as our patient’s advocate, we need to operate without our emotions. It’s part of the cost of doing business for us as caregivers.  That’s not to say that I don’t think about the potential gravity of the call, I just do it later.

Thinking through the call later is good for multiple reasons, such as addressing learning points, emotionally dealing with the gravity of the call, and ensuring that the crew are dealing with all associated issues in a positive manner. There is an agreement made when choosing this profession and this unspoken agreement is what defines that “mental cognizance” we are asked to bring on each call. This “mental cognizance” doesn’t recognize age, sex, color, religion, level of income, level of education or attitude. Every patient is deserving of our best and most objective efforts. The great part about this agreement though is that it’s nonbinding. We can opt out at any point and move on with our lives.

As I said earlier, I appreciate the weight of this topic. I do not intend to come across as callous in my stated opinion. I also don’t tread through unfamiliar territory. Quite the opposite, this is territory I’m quite familiar with and fully appreciate after some time running these calls. Additionally, I have come to a personal understanding about how to best work through these emotional issues, both during and after the call, to render the best possible objective patient care.

Now it’s your turn:

Thanks Sean. Now I’d love to hear what you think. Can emotions and objectivity be separated during the course of patient care or do they inevitably affect your care? Leave a comment and let us know.

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Comments

  1. “All patients are “worthy” of our full and complete efforts and treatment. That’s our job.”

    I truley believe that is it in a nutshell but I use a different way of explaining it. I’m sure you’ve been asked the “but what if it was your child question?” My answer is, I treat every child as if it were my own but I also treat every elderly patient as if they were my parent or grandparent, and everyone my age as if they were a brother or a sister. To me there is no difference between letting the age of a patient affect your care and letting their social standing affect it. EMS is knowledge and skill provided with effort and compassion and I strive to give 100% of each on every call to every patient.

  2. I have only 2 years experience in EMS and work for a private emergency and non emergency transport company. My observation is that the “caring for” is much easier to do in trauma situations, whereas it is much more difficult to separate that “caring about” when as Steve says we try to treat patients as close as family. I do try to relate and make my patients feel at ease, I think that the level of emotional shutdown really depends on the patient as well.

  3. Sean Fontaine says:

    GA EMT: different life experiences prior to our jobs in EMS coupled w/how we process difficult calls early on dictate how each of us develops our ability to detach from emotionally investing in our patients. That said not everyone achieves the same level of detachment. Over 12 years I’ve come to be able to detach quite easily during a “difficult” call, when reflecting on the call after the fact is when the emotional torrent will happen if it does. However, as my wife has heard before frequent fliers suck. I say this not out of spite, I actually love them because you get to know them, know when they’re full of it, and know when they’re truly sick, unfortunately you also get to really know them which makes it extremely tough to fully detach when something horrible has happened to them. It’s easier to detach w/strangers, this was proven for me two days after I submitted the final for this piece to Steve and then ran a pediatric cardiac arrest two days before christmas.
    On Steve’s point about treating them like family, you can do this w/out becoming emotionally involved. Look at it this way, would you want whoever was attending on your family member to think clearly/concisely, perform a thorough exam, run through appropriate differential diagnosis and diagnostics, think about appropriate destinations w/continuing care in mind if warranted, irregardless of time of day, location, race, gender, level of education? If you answer yes to these questions then you’re treating your patients as if they were your family by performing these things w/each patient. You’re right, you do need to have discourse w/them and gain that all important level of rapport, but as the care giver your job is that of advocate not friend. It’s as a fine a line as caring for not about is at times, just the same that line exists to benefit you both.

  4. Sean, I am firefighter/EMT in Stamford, CT (13 years) and an EMS Instructor (3 years) and despite what I teach, and what I thought I knew, I found myself on the subjective side of the fence a month ago. My father is suffering with cirrhosis and my fear was always getting a call that he was found in his bed, having drown in his own blood. Never did I prepare myself for AMS that accompanies high amonium levels. His wife had called me over to their house just after I was getting off a 24 shift. He was NOT oriented to person, place, time…. not even his DOB…. the only thing he knew, was that he did NOT want to go to the hospital. The last straw was his insistance that the TV remote was something to eat. If this was anyone else in the world, going to the hospital wouldn’t be a debate. This went on for a few hours before my husband (also a firefighter/EMT) called to find out how we were making out at the hospital, was informed that we were still at the house debating the situation. His tone over the phone was an awakening slap across the face…. “Michele, since when do you let an altered person call the shots….. stop acting like his daughter”. That’s all it took for me to look at my dad and say, “That’s it, I Love you….you’re going to the hospital…. You can hate me later”!. I spent hours in the hospital wondering where this lack of judgement came from….. he wasn’t getting better. I always treat my patients with the respect and passion I would my loved ones (knowledge and skills) are always on the front line……. somehow my knowledge fell in the backseat. This experience will be up for discussion in every lecture I do…… and sooo help the student who tries to defend my actions.

  5. Sean Fontaine says:

    Michele,
    I hear you completely I transported my youngest a year and a half ago (13 months @ the time). My wife was changing him and his older brother distracted them both, but unfortunately the 13 month old fell off of a 3 1/2 foot high changing table as he looked and landed on his head on a hardwood floor. He became lethargic, pale, and threw up twice @ rest. So, my wife called and my ambulance rolled out of post headed for my house. He remained pale, lethargic, and threw up two more times @ rest prior to reaching the DECC (DG peds ED) which is just over two miles from our house. I felt as though since he could track me and engage w/me he would be ok, but I still don’t like walking into an ED where I know the staff and say “he’s mine” to the charge nurse.
    Your story about your father brings home how we look past the basic decisions we make everyday for the better interest of our patients (frequent fliers or strangers). When we are dealing w/our family emotions are worked into the interaction because that is how we deal w/one another on daily basis and as such cloud what would normally be clear/objective thoughts. Think about how a simple argument can be so frustrating and hard to shake some times when it is w/a family member versus a casual acquaintance. Like I’ve said in other posts and to numerous students we’re going to make mistakes and how we learn from them, not making them that defines us. Just remember that student defending you has yet to make mistakes in medicine, but may have other experiences in life you could use to relate to them the subtleties of your situation that day.
    How is your father’s current health?

  6. Steve Whitehead says:

    @Steve Good point.

    @GA EMT, I think it’s true that we identify with different patients for different reasons. Just like we identify with some people and not others. We’re obligated to bring a level of caring to every patient, but I won’t by in to the idealistic idea that it’s going to be the same level for everyone.

    @Michele You can forgive yourself for having clouded judgement with your father. We can talk about treating everyone as if they are family, but, at the end of the day, they aren’t family. Try as you can to separate your judgement from your love, you are inseparably connected to your father emotionally. (As it should be.) Love is an emotion, we can’t care for people whom we love without emotion. We can only manage it to the best of our ability.

    @Sean, I’m still not convinced that you can make a clean separation between caring for and caring about people. How we feel doesn’t define itself so easily. These are feelings and feelings are messy. We can suppress them but that doesn’t mean they necessarily go away. They spill over into other areas of our lives in unexpected ways.

    Also, do you feel that strictly adhering to the formality of not caring about your patients will effect your longevity in EMS? Is there a benefit to making genuine human connections with your patients. Is it possible to make real authentic human connections, to care about people and still treat them effectively?

  7. Sean Fontaine says:

    Steve, there’s not a complete and clean separation, we’re humans and we’re messy by nature. What there is, is a constant conditioning against taking personal details to heart and as such investing or caring about the patient during the call. That said little bits leak in and after the fact have the ability to hang around in your brain as you revisit the call mentally. I remember once noticing that a pediatric arrest patient was wearing the same exact diaper that I had just put on my youngest son the night before as I drew up the first round of Epi and as fast as the thought of the diaper flashed across my brain, I pushed it into those deep crevices of the brain where I hide these things until later.
    I can’t speak to the potential health and longevity of my career and how my current personal philosophy will affect it until I’m sitting on the front porch of my beach house in Kauai, retired w/my beautiful wife nearby and a mai tai or cold beer in my hand.
    As for making solid, genuine connections I believe we can do this and hold a professional distance as I described. I also believe that this is something we owe our patients, objective/proactive care. I still believe it’s our job to operate in this manner in so far as we’re able.
    As to how these suppressed emotions play out in our daily lives, I’m well aware of this. There are many things I do and say that are the result of past experience on calls. My first field tube was a 6 YO trauma arrest run over by his parents in their full size pickup, ever since that call I’m vigilant about my children’s whereabouts in parking lots and near traffic to a higher degree than I was prior to that night. It’s one example of how whether we like it or not these experiences always come back to visit us. However, it’s how we deal w/them that separates us after the fact, do we make peace and move forward as best we can and use the experience to grow or do we kick the dog/beat the wife and kids/drink until we black out/etc.
    It’s not perfect, but it’s where I stand and I’m ok w/that, because at the end of the day we each make peace and deal w/these things on our own or it pollutes everything else in our lives. We owe it to our families to deal w/this baggage.
    As a last thought I have this; the thing that has always stayed w/me longer than any other mental reminder from bad pediatric calls are the parents’ screams in horror when by my/our actions (CPR, intubating them, pronouncing them) confirm for them that their child is in fact dead. Mark Glencourse’s final post (A moment frozen on time) on Medic999 states this perfectly, this is a post everyone should read, think about, then read again.

  8. This is such a great, and tough question. I love the gravity that you’ve given it when considering and presenting your point of view.

    I’m solidly in the ‘emotional connection’ camp, though my experience is different than yours. As well, I’m not sure that we would define ‘emotion’ or the thresholds of objective and subjective the same.

    I believe that the best medicine that I’ve ever done didn’t involve a drug or tube. The vast majority of people that I’ve treated were not dying, they’d had issues that were at least as tied into their emotional lives as they were the physical and physiological. I believe that if those issues aren’t considered and at least an attempt made to manage them that complete patient care hasn’t taken place. I’m certainly not saying that they can’t be managed without an emotional connection, only that I don’t think that I’d be able to do so, and it’s my favorite part of medicine.

    In my experience, very often, the most important medicine that a non critical patient needs is to be ‘seen.’ And I don’t know how to give them that experience without truly seeing them, and I don’t know how to truly see them without being emotionally connected to them. I believe that that connection gives them comfort and confidence, and that those things change their physiological presentation for the better.

    As well, I don’t think that it’s an ‘either/or’ proposition. On the critically injured or ill I don’t initially see a human patient, but a broken machine. My little brain starts lining up signs and symptoms, building diagrams about where they come from and how the effected systems work together, etc. Screams or cries or anger don’t really register, not any more than the screech from a failing wheel bearing would..as a sign of something needing to be fixed.

    But once the machine is halfway under control, once I can have confidence that I have the tools and skills necessary to keep it running, then I begin to love the human being. Address their fear, worry for their families. It seems to be a good mix for me, but I truly have no idea if it’s a good fit for others.

    Sorry Brother. I’ve no idea if I’m adding to the conversation or just rambling. I work remote medicine and the isolation can sometimes queer my perspective.

    Thanks for your article, and sharing your point of view.

    Dwayne

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