medical coding training at home.
For those of us who work in Emergency Medicine and in Emergency Medical Services (EMS) it is a given that we are able to face any and all situations in an objective manner so we can go on automatic, carry on our duties and not be inhibited by emotions that could cloud our judgment. The knowledge and skills we bring to our jobs each day must be able to rise uninhibited to the surface so that in times of life and death crises our performance is optimal. Any ER physician will tell you that the ability to remain somewhat detached and objective is a fundamental prerequisite for ultimately doing what is in the best interests of the patient.
Of course, it is desirable that healthcare workers see their patients as persons, not merely as cases and it is true that compassion and caring are valued qualities that do much to augment the technical and pharmacological tools in the emergency medicine field. But when a life is threatened and seconds count, the thing that gets me through, that allows me to save a life, is the ability to see the situation as a "case" and know what I have to do.
What if the patient is family? Fortunately I have not yet been in a situation where I have had to resuscitate a critical or dying patient who was someone I loved. I am hoping that I never will be called upon for such a challenge but that if ever I find myself in that dreaded situation I will be able to "work the case" as I would any other. Not to be able to do so could very well mean certain death for the patient.
Yesterday, at 8:00 on a holiday morning, EMS radioed that they were bringing to us a "code". The word code, in medical parlance is used both as a noun, e.g. "We have a code." and as a verb, e.g. "That patient is going to code." and basically describes a situation in which a person's breathing and/or heart function have ceased. It also describes the entire process of trying to revive the victim, as in, "We coded that guy." There are set protocols, i.e. guidelines, for managing a code and most of the time it turns out to be a fairly straightforward scenario. It is a little bit like riding a bike in that once you have done it a few times it is relatively easy and you are able to do everything you need to do without really thinking too much about it.
Our "code" turned out to be a 61 year-old man who had become extremely short of breath at home and had subsequently suffered a cardiac arrest (his heart stopped beating) while EMS personnel were moving him from the house to the ambulance. The paramedics both happened to be women and were definitely not the athletic type. There were no first responders (firefighters who sometimes get to the scene of a 911 call ahead of the paramedics and initiate basic life support efforts) present to help with lifting. The patient had insisted on walking to the ambulance rather than being taken out of his home on a stretcher so he was now on the ground. The man's 28-year old son did all he could, including CPR, to assist the paramedics. By the time the patient came to us he had been asystolic (i.e. without a heartbeat or any signs on the monitor of cardiac electrical activity) for approximately thirty minutes, in spite of EMS skillfully doing everything expected in such situations.
For us it was an easy code. Downtime thirty minutes, no response to advanced cardiac life support (ACLS) protocols in the field, no signs of life in the ER. The man was dead on arrival (DOA). A quick minute to assess the situation and I pronounced him dead and then thanked the paramedics for their efforts. Now I faced the hard part, telling the wife and son that this man they loved could not be resuscitated and had died. Of all the unpleasant tasks required of an ER physician this definitely is, for me, the most worst.
The wife and son listened intently while I gently told them that all efforts by EMS had not revived their loved one and that he was dead on arrival in the ER. One of the interesting things about the case is that this man had metastatic cancer and had already lived longer than his family had expected. You might wonder, as we did, why a known terminally ill patient would be a code in the first place. Though the family well knew that he was dying they had not been able to muster the courage beforehand to discuss with him the wisdom of having a "do not resuscitate" (DNR) form signed.
In Florida, as in most places, when 911 is dialed and EMS arrives on the scene, even though the paramedics may be told of a patient's terminal status, in the absence of a signed DNR document or the patient's actual verbalization of a wish for no heroic measures, they are expected to do everything possible to keep the patient alive. It is not determined on a case-by-case basis, should they or shouldn't they. The expectation is that they will and so they do. When you call for an ambulance it is assumed that you want everything done.
The family, accompanied by their pastor, graciously accepted our invitation to spend some time with the man's body, to say their good-byes. They appeared grateful for the efforts of EMS and the wife made it a point to personally thank the paramedics before they left the ER. Then the son took me aside and privately expressed some concerns.
He told me that he believed the two female medics should have had someone else available to help with the lifting. He felt that they were not strong enough to be able to handle such cases, as two males would likely have been. He had a valid point. As he gave an account of his concerns, using medical terminology, I suspected that he had had experience in medical matters. He informed me that indeed he had been a combat medic in the US army in Bosnia and in Panama.
Then suddenly his eyes filled with tears and he said that today when he had started doing CPR his father's eyes had met his and he saw that they were filled with fear. His resolve to do what he had been trained to do and to assist in the resuscitation process was shaken to the core and now he was wondering if he had done the chest compressions too hard or not hard enough. He was basically asking himself if perhaps his failure to do something right had contributed to his father's death. He, who had competently handled unimaginably horrific situations on the battlefield in foreign lands now had to come to terms with the realization that he could not save his own father, and he was beating himself up over it.
My job now was to reassure and try to convince this son that if his father's heart had stopped beating in the ER the outcome would have been the same, that it had been his father's time to die and that no one could have done any better than he had. I desperately wanted the young man to hear and to believe my words, for the loss of a loved one, especially a parent, is painful enough without guilt layered on top of all the other emotions. This clearly was a caring, loving son, a good man who should not spend the rest of his life doubting his own abilities because he found himself in a no-win situation with his own father.
I think he heard me. I think he believed me. Only time will tell
medical coding training at home.