Ethics in Transport

My patient was an elderly man in his late seventies, let’s say seventy-eight. He only spoke Spanish, but I knew enough to get by, so I introduced myself and began asking my assessment questions. He was alert and oriented times one (A+Ox1): he knew his name, but nothing else about where/when/why he existed at the present moment.

But he knew he was in pain. A pressure ulcer on his left hip caused him to cry out with any movement. “Maria linda!… Dios por favor!” You didn’t need to know Spanish to understand.

I told him we were here to take him to his doctor’s appointment. The appointment was with a wound care specialist twenty or so minutes away. My partner got vitals while I grabbed his chart and tracked down his nurse for release signatures. As I walked down the hall, I looked at his list of medical diagnoses and confirmed my guess: late stage dementia.

When we lifted him over from his bed to the gurney, his pain got unavoidably worse. Every bump on the ride to the wound care clinic came with a sharp cry. I tried to make him as comfortable as possible, but nothing really helped. My patient’s problem was bigger than my powers; his ulcer likely came from weeks of lying in the same position in bed at a skilled nursing facility (SNF), cared for by overworked nurses aids who hadn’t the time or energy to turn him every two hours.

At the clinic, the doctor was backed up with patients, so we waited in the hallway for an hour, listening to our friend whimper on the gurney. When our turn finally came, we wheeled him next to the exam table and prepared to slide him over. Luckily, the doctor decided he could do his examination right on the gurney, so we helped him turn our patient on his side and hold him in position. As the doctor unwrapped the bandages, the smell of decay filled the room. The wound was deep, and the nurse cursed the patient’s caretakers as she wiped excrement out from inside it. Our patient’s whimpers rose to yelps.

The doctor measured the wounds size, took pictures, picked at some of the dead flesh, then re-bandaged it while muttering about the need to schedule surgery later next week. Another round of movement and pain for our patient. We got our paperwork in order, left the wound care clinic and returned him to his bed at the nursing facility without incident.

For many of us working in medical transport, this is a pretty common call: A+Ox1 patient needs wound care for a pressure ulcer. But for some reason this one in particular left an impression on me. Maybe it was the patient’s obvious pain, or the cracks in our health system that caused it, or the man’s lack of authority over how he’d spend his last months – at that stage of dementia, your life is no longer in your hands. Whatever it was, I left the call feeling like this wasn’t what I signed up for. When I decided to become an EMT, I did so because I wanted to tangibly help others. But with that patient, I felt like I was only contributing to and prolonging his pain. What was most frustrating was that every caregiver at every stage of the process, from SNF to transport to wound care specialist, was simply doing their job: fighting for life. But at least in this case, I wondered whether prolonging life was actually in my patient’s best interest.

It’s easy to use our job titles – EMT, nurse, doctor – as de facto proof that we’re “doing good.” But even if our intentions come from the right place, sometimes they don’t add up to an outcome that’s morally defensible. I still don’t know if for that patient on that day, I was an instrument of care or an instrument of torture.

As our aging population expands, it’s important to recognize how our healthcare system promotes or prevents death with dignity. When companies profit from every drug prescribed, every patient transported, every wound excavated, our good intentions can end up prolonging suffering instead of alleviating it.

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