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Mindful Practice

The best that I could be

Pavlik, Daniel MSPAS, PA-C

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Journal of the American Academy of Physician Assistants: February 2018 - Volume 31 - Issue 2 - p 1-2
doi: 10.1097/01.JAA.0000529777.77435.dd
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12:04 A.M.

A 56-year-old man who had a heroin overdose is brought to the ED by emergency medical services. The man received naloxone in the field and is now awake, alert, and oriented. During the initial evaluation, he proclaims that he does not use drugs. The nurse and I roll our eyes; I examine him, and she takes his vital signs. He has no obvious signs of trauma, and his heart and lungs are clear. Eventually he clarifies his statement, saying that he does not “shoot” drugs intravenously. He admits that he was with a friend that night and he snorted something he thought was “speed” or methamphetamine. The next thing he remembered was awakening in the ambulance. I explain in layman's terms that the half-life of the antidote, naloxone, is shorter than that of the heroin he took. I also explain that he could develop noncardiogenic pulmonary edema and for these reasons I must keep him in the ED for observation for a few hours.

3:51 A.M.

A car pulls up to the front of the ED driven by a man who is known as a “frequent flyer” in this department. He is upset, and as he runs in, tells the security desk personnel, “she's overdosing.” I run out to the car with a technician and a nurse, and we pull a 29-year-old woman, also a “frequent flyer,” out of the back of his car. She is cold, limp, and foaming at the mouth. He states that he was driving through the neighborhood and saw her on the ground. It is the dead of winter and he does not know how long she was down. She is pulseless and cyanotic. Resuscitation is initiated but she has passed; the ED attending physician calls the code.

As a PA in emergency medicine, you can easily become judgmental and jaded when you see such things regularly. When tearing through patients during a shift, you tend to view them as their pathology rather than as people. An outsider looking in might just as easily judge those of us who work in the ED as callous. But working in the ED is truly being in the trenches of medicine. We see violence and drug abuse, we see noncompliance and malingering, we get admonished for wait times, and sometimes we endure threats of violence to ourselves. More than ever, and especially during this current opioid epidemic, I often feel abused by the patients I serve. It is difficult not to grow cynical.

At times I find myself caught up in it, insulating myself from feeling. I struggle with this internal battle constantly. Years ago, a mentor of mine told me that it is better to feel and be taken for granted and even taken advantage of than not to care. I believe you must try to see the humanity and the soul of each patient, to remember that just like you, they have family, friends, hopes, and dreams. When you accomplish this in a patient encounter, the judgment is replaced by understanding. During my drive in to each ED shift, I say a prayer asking that I may be the best that I can be every minute of that day and that shift; as smart, compassionate, caring, and positive as I can be. Although I do not always accomplish this, it is my goal.

4:35 A.M.

The attending physician speaks to the coroner after the 29-year-old woman is pronounced dead. A police officer who originally brought the 56-year-old man to the ED gets on the phone with the coroner and states that there is no suspicion of foul play in the woman's death. He goes on to say that he had seen her twice earlier that night and she was “high as a kite,” and that one of those times was when he picked up another overdose patient currently in the same ED. After he gets off the phone, he tells me that she had been with the 56-year-old patient when he overdosed; she called 911 and saved his life. I am immediately struck by the irony of the situation, the fragility of life and the renewed significance of each human interaction. A 56-year-old man is awake and ready for discharge, while the 29-year-old woman who saved his life is dead from the same drug overdose 15 ft across the ED. He has family at the bedside. In the moment, it is obvious from the looks on their faces that they are experiencing concern, anger, but most of all, judgment. I examine him again; I smile at him and tell him that he is very lucky to be alive. He has no idea of the added significance and poignancy of this reevaluation. More than at any point in the entire ED visit, I understand that he must see care when he looks back at me rather than judgment. I am positive that I was not the best that I could be every minute of that shift, but at that moment I like to think that I was.

The situation comes full circle when it comes to judgment. How would I have felt about the woman who died had she come into the ED awake in an ambulance after naloxone? Perhaps that night she was the best that she could have been. I don't know her story or why she turned to heroin, and at this point it is irrelevant. I look at the man and realize that whether she was a heroin addict or not, he was alive because of her. For at least that moment, she was the best that she could be.

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