Heroism is the Same, but Loss and Coping are Different Over Time
A Personal Reflection after the 2016 International Roundtable on Community Paramedicine
Complex and complicated as it is being a technology provider to the Fire and Emergency Medical Services industry, when you work among — and for — heroes, it’s easy to find inspiration. It can be less-easy to elicit quotes that describe the daily life and feeling of being That Guy (or Gal) when your heroes prefer to do their duties in the background, as sentinel fixtures of patriotic pride, bravery and security who act almost anonymously (except when deploying lights and sirens). These professionals are subject to the command structure of their military pedigree, deferential to superior officers…and even to civilians whose spot-lit faces are often painted, and tainted, with political colors. Mayors, governors, even CEOs.
But quotes flowed freely at the 2016 International Roundtable on Community Paramedicine, a collective of Big Thinkers on the goals of readmission avoidance, proactive care, and post-discharge follow-up that was held this year in Saskatoon, Saskatchewan (Canada). Indeed, to the journalistically inclined — which this author will forever be, having started my career a report-editor — the words were stolid and sure, heartfelt but urgent. Some were optimistic, as when Allina Health president Brian LaCroix told me that because Community Paramedicine is an emerging discipline, its culture of support among service members and managers is new, too. Therefore, Brian said, “we have a chance to build it right.” Other anecdotes squeezed our tear ducts: Pat Songer, EMS Rescue Director at Nevada’s Humboldt General Hospital, offered a face-slap look at the suicide epidemic among EMS personnel — even the strongest and most experienced, like Capt. Monique Rose, whose confessional was powerful enough to stop everyone from checking email and fretting about flight times. Such jumbled emotions: joy to know that one’s “product” is a life empowered to live another day, and a spike of sadness when the mission and vocation fails. Because sometimes it does.
I feel at times like a professional masochist. My dream is to be President of the United States. My first love is the media (magazines in particular) — an industry that breaks hearts daily and twice on Sunday. My proudest credential is having served in the White House, where eight months to deploy innovation that had been stalled for two years was considered lightning speed and agility. My current occupation calls for pulling the American EMS industry up a mountain called modern technology. Even by entrepreneurial standards, one might say I have chosen challenging routes.
Yet the theme underlying each link in my career chain is one that I feel is noble: to speak for those without a voice. For the gumshoe writers who live on pennies in New York and Boston, chasing leads and bleeding ink so that someday they might see their names in print, speaking truth to stupid. For the gay, lesbian, bisexual and transgender community that has suffered so long and so unjustly at the hands of a conservative majority, bearing the savagery of families ripped apart in the name of archaic ideology. Along the way I have been called upon to speak for the disabled community — of which I am a part, as a man with Tourette’s Syndrome — because Dad bestowed on me the power to bend language to my will. I hope to pay this gift forward to my son, Hunter.
Yet my present work is nearest, dearest, and by measures more important, because it involves our deepest instinct as rational animals: to thwart death. On days when work becomes a grind — I find our business fascinating, so only a minority of my days grind — I remember that on December 27, 2006, William and Elizabeth Witt, father and sister of my business partner Christian Witt, were killed in a collision with a semi near the Four Corners of New Mexico. For so long I asked myself, as CEO of a team that makes technologies to “connect the dots” in prehospital care: “What if the crews had been better able to communicate what they saw to the hospital that cared for these two beloved patients?” During ICRP 2016, however, my question evolved: for the first time, perhaps, I found myself wondering how the Responders reacted when they arrived on-scene, and what they felt afterward. Surely they did all that they could to save William and Elizabeth, but I’d never really thought about the tragedy from their vantage point before. How did the Responders cope? Could they empathize with the grief that Chris, his brother Bill, and their mother Pam internalized…which Chris later used as fuel to build innovations dedicated to his family’s memory?
The catalyst of my entrée into the EMS business could not have been more different from Chris’s, yet I heard my own thoughts in Captain Rose’s question: Had I known what I was getting into, would I have taken a different path? Would having been “better prepared” made a difference? On September 11, 2001, my country was crying, so I joined the United States Army Reserve. This may sound like an act of patriotism — and it was — but you don’t know the half of it: Department of Defense policy excludes individuals with tic disorders (including Tourette’s syndrome by name) from service in the American military. I find such a policy disheartening, offensive prima facie, and too categorical to be rational. Nevertheless, my personal experience cannot call it “wrong”:
In 2001, I fought for a medical waiver to enlist but I never finished Basic Combat Training (BCT) because, around week six at Fort Leonard Wood, we had been running in the woods with bayonets on rifles. I already owned the fastest run time in my platoon; I was in the best shape of my life; I easily compensated for shoulder tics when learning to fire an M16. Yet during this day’s run in the woods, my eyes began twitching in a manner reminiscent of nystagmus — a tic that persists to this day and that becomes more pronounced when I’m tired. Exhaustion is a permanent fact of BCT, and as I learned from Chief Songer, it is a part of daily EMS work as well. (Some 72% of EMS professionals are beset by the insomnia and nightmares that are among the hallmarks of post-traumatic stress, yet they fail to realize that sleep deprivation is not only an effect of PTSD but also an exacerbating cause. Drug-induced sleep does not recuperate the brain; in a past part of my career I developed a model for modulating and desensitizing the nightmare itself. To finish this work and prove the model is among my chief next-career-step ambitions.) I instantly foresaw an accident that I could not suffer: if my eyes twitched and I tripped, I might have knifed a buddy in the neck.
By the end of the afternoon, despite feeling that I had let my country down, I sought a transfer out. Since June 2002, I have worked daily to serve in other ways, including researching, developing, and creating jobs with a mission to end the pain that we needlessly, and shamefully, inflict on our veterans.
Shortly after returning from BCT, I watched Stanley Kubrick’s “Full Metal Jacket” for the first time. It felt…familiar. Some might take issue with any comparison between the indoctrination of U.S. soldiers and Marines, but I finally understood what the drill sergeants meant when they called me “Gomer Pile.” (Hint: It wasn’t a compliment.)
Would having known to keep my mouth shut; that I might come home early; that Mom would stay up late — and refuse to eat — because she was worried that her baby might get sent to Afghanistan; that our military takes wonderful care of enlistees that serve as a way to earn opportunities and train, but those with a higher degree and leadership aspirations may fare better in the officer corps…would knowing any of this have made a difference to my choice? Was my attempt to enlist, and all that followed, inevitable no matter the precipitating call-to-action? Would Capt. Monique Rose, who stepped before a camera to admit persistent sadness, have abandoned her passion or resolve if she had known what to expect? The answer is no: She thickened her skin like leather and steel with all she’s seen, done, loved, and lost. We should drape her in medals.
But she doesn’t likely need them. I have not yet met Captain Rose but she speaks clearly and with resonant voice for those who suffer silently. Given the widely lamented stigma associated with confessing to such fundamentally human needs, she is not stepping forward as a matter of ego. Rather, she is doing so because she can, just as I can testify for those who are chronically underestimated due to a body or mind that is “disabled” by an inconsequential measure. Don’t we all have some cross to bear? I say that we do, so we should celebrate the power of individuals, and brotherhoods, to spin so-called “imperfections” into the basis for what Rabbi David Wolpe, a friend and one of America’s leading clerics, once described to me as “a special kind of empathy.”
Until one realizes that everyone who gets into the EMS industry has a story — or as a homeless man named Stanley once told me, “Everyone has a life” — it’s hard to fathom what could convince an otherwise happy person to risk life and limb in the name of altruism and far too little cash. Firefighters get to face The Beast, and the dangers of policing come with a dose of adrenaline. EMS carries a unique burden of sanctity, and no religion has ever suggested that walking the path of saintliness is fun. EMS is the institutional practice of saving those who can’t save themselves.
In 1912, Émile Durkheim — heralded by the academy as the “father of sociology” — described a theory called “The sacred and the profane” in his book The Elementary Forms of Religious Life. His reflection on the totems, rituals, people and places that embody human values noted a critical characteristic of the religious: separation. All that is holy is rarely part of daily life, except during designated “sacred spaces” like prayer time in one’s home, church, synagogue, temple, or mosque; saying grace before a meal; or setting aside time to mediate and remember. The holy is aspirational and it informs our moral compass, so we put it on a pedestal and make turn it into our Polaris. We cannot let it become common and mundane, or forget what makes it special.
This is the reason that I avoid telling the story of Chris’s family more frequently than is absolutely necessary to offer context for our dogged corporate persistence: his family’s tragedy is a potent fuel but it nevertheless was born in loss. I have zero doubt that Chris would give up his role as an industry-leading technologist for a chance to return to the Day Before. Yet the exquisite pain of consigning ourselves to doing all that we can also reminds us that we are still here — and in the name of those who stand next to us on the phalanx line, we must continue to do all we can to keep on keeping on. We will again see those who we miss. Someday….but not yet. Not yet.
At the same time, you and I are but animals — flesh and bone that break as much as we bond. This reality leads us to the next critical point that Brian LaCroix made at IRCP 2016, one that will haunt me for the foreseeable future as my company continues to lead the emergence of data solutions for Community Paramedicine and Mobile Integrated Health: The common thread of Community Paramedicine — in its myriad forms nationwide — is longitudinal care. Care over time.
The practice of Community Paramedicine may have more in common with home health than with emergency services. Unlike incident-specific interventions, Community Paramedics will get to know their patients. They won’t save lives instantly; weeks, months, even years will pass. Their charges will evolve from mere patients to friends and more. (Newfound family?) Brian noted that Community Paramedics will watch — not just see, but watch — people that they have come to know suffer and die. They need to be ready for that. Hearts will break on both sides of the relationship. Deaths will be gradual, agonizing, and Community Paramedics full of love and honor will ask why they didn’t do enough. In most cases, they will have, and they will now be emotionally invested. As someone at IRCP noted, EMS teams often don’t return to their stations, seeking closure and commiseration and primally screaming while debriefing with sisters and brothers in service. EMS professionals return to a post on the side of the road somewhere, thoughts stewing. Possibly with an equally shell-shocked partner. Does misery love company or does silence make things worse?
One can train an EMS professional to dissociate. But do agencies want to wrest away their crews’ humanity in the interest of faux objectivity? Can someone truly objective and unemotional be an effective caregiver — or is the ability to detach from a neighbor’s suffering the sign of a sociopath? The FBI and DEA don’t trust candidates who have never done any drugs to be convincing while swimming in crime-infested waters. Should EMS agencies want to hire someone who does not, and maybe cannot, feel another’s pain?
I am not a medic — I am a technologist, a strategist, and an entrepreneur — but I experienced the feeling of shell-shock in New York City a few years ago. During a ride-along with a Transcare EMS crew (the now defunct company was my company’s partner-client, having deployed our software across Pennsylvania), a call came in for an elderly patient who had choked on his dinner. The crew was confident that by the time they reached the scene, in the high East 70s not far from Lennox Hill Hospital, the danger would have passed and the call would have been a dud. When they arrived at the patient’s apartment building, another rig was parked in front. Now they really thought that the trip would be wasted, but still they went upstairs fully geared up (with me in tow).
When we arrived at the apartment, nothing was as expected, and I still marvel — years later — at the speed with which the crew leapt into action, like a blur missing only a cape. The elderly man had indeed choked on a piece of chicken, but it was a three-inch piece and so completely blocked his airway. He went hypoxic, his brain starved of oxygen, and his eyes bugged out of his skull like Arnold Schwarzenegger in that horrible Martian scene from the original “Total Recall.” He fell over, hit his head on the corner of the table, and now was face-up on the floor, eyes open, bleeding from above his eyes, not breathing. His wife was freaking out, distraught and crying like she might never see her best friend again. Their daughter had been elsewhere but apparently her mother called, and now she appeared in the doorway, freaking out like she also might not see her father again. I was standing to the side, watching, trying to remain out of the way and learn how to make patient charting software that would never get in the way of such obviously more important work.
Then the crew brought him back! They brought him back! The man’s heart had stopped but now it was at 16…now 24…now 60 beats per minute. But they brought him back! He was looking around, terrified of course but conscious and breathing. I heard one of the medics tell the daughter, “He’s going to be fine. You can meet us at Lennox Hill in a few minutes.” The crew wheeled him to the ambulance; I rode in the next truck, less than two minutes to the hospital. They then wheeled him through the sliding door into the emergency department, and I followed. He coded immediately as we crossed the threshold into the Lennox Hill emergency department. I was told that the man likely had a heart attack when he realized what was happening to him. I can still see the chest compressions, years later, his ribs obviously obliterated because chests just aren’t supposed to move that way. All the way down, full depth. All the way up. The fellow never woke up. His wife and daughter had not yet arrived. We had driven fewer than two minutes.
I have seen some tragic accidents in my life: when I was a kid, an elderly neighbor dislodged the emergency brake on his car, which then slid backward in the driveway, knocked him over and ran across his chest. So it wasn’t the death in New York that bothered me — people die. What bothered me was that the man’s daughter and wife thought he would be fine; they never said goodbye because they didn’t think they had to. I was just riding along. I didn’t touch the patient. I didn’t bring him back and think he would be OK. Still, to call me “shell-shocked” is insufficient; few words can describe the feeling of not wanting to talk for days. Yet when I told Transcare’s managers what happened, they laughed. Not maliciously, because they understood what I was feeling; rather it had become routine to them. Remember the scene in the film “Goodfellas,” when Ray Liotta’s character gets arrested for the first time but refuses to snitch on his gang? The gang celebrates his trip through the fire. Transcare’s managers reacted similarly to my experience.
I…I…I…was speechless. Somewhere in me, I understood the camaraderie. It was the military all over again: sometimes in a foxhole you laugh at the morbidity around you, because if you don’t, so much death will make you shrivel. Losing your death virginity is a rite of passage in a profession where death happens daily. You learn to be a bit calloused so you can bear without tearing. But we cannot forget that someone’s father, brother, mother, sister won’t be going home.
Maybe we’re supposed to cry and shrivel, at least momentarily. If we sequester and store pain because exorcising our demons is too difficult, doesn’t it accumulate to toxic levels and seep into our non-work hours? It was confusing — almost scary — to think that anyone could have been okay with knowing that a father and husband was dead. That it was nothin’ but a thang, an inevitable reality of the job. I know now that the team in New York was deflecting, shielding itself emotionally.
Multiply what I felt by every shift, of every day, of every month, of every year. From what I have learned at IRCP 2016 and other conversations, with my Boston University degree in “Psychology, Religion, and Conflict Negotiations,” I’ve had more training in how to cope than most medics. Yet I have encountered only one apt analogy in the years since school — and it, too, came from ICRP 2016: Darryl Cleveland, a 32-plus year veteran of EMS and the American military, who is now an educator at Truckee Meadows Community College in Northern California, described the psychology of EMS professionals like the tragic chimera of a nested doll and Pandora’s Box. Memory after memory had been locked in ever-smaller compartments. Only after retirement did Darryl let himself peek at the ghouls in the box. Doing so, he said, was a first step toward healing.
by Jonathon S. Feit, MBA, MA
Co-Founder & Chief Executive
Beyond Lucid Technologies, Inc.