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Gorilla in the Mist (2008)

By: Steve Urszenyi, A-EMCA, ACP

It’s 3 a.m. and you’ve been called to a residence for an 83-year-old woman who got out of bed to use the washroom. In doing so she tripped over a pile of laundry that was laying in the middle of her bedroom in her less-than-tidy little apartment over the Three Sheets Laundromat. Her 61-year-old daughter meets you and tells you that “Mum hasn’t been doing so well for the past few months, ever since getting out of the rehab hospital following her hip replacement.” She further tells you that she wouldn’t have called you, “but since I’m scheduled for my own knee replacement surgery next Thursday, I had no way of getting her back to bed myself.” You assess the older woman and determine she’s not injured. Thank goodness for that—another courtesy call. You suspect there are other issues, but they are none of your concern, since they seem to be more psychosocial in nature and you’re no social worker. Besides, no transport means no offload delay, and with any luck it’ll be back to the station for a little shut eye. You have performed all relevant assessments, including a capacity assessment to ensure that the patient is capable of making decisions regarding her own care, and you are confident that she is sound in mind and body before obtaining a signature and cancelling off the call.

When you get back down to the truck, you find your partner already fast asleep in the driver’s seat waiting for you. As you finish writing up your report to the sounds of Nickelback on the radio and your partner’s sleep apnea beside you, you wonder if there was something more you could have done. You glance up through the steamy windshield, the haloes of light made by the headlights of one or two approaching cars appear like iridescent donuts in the condensed breath vapour haze cast by your partner’s nocturnal respiratory pattern. You turn up the defroster fan and it all becomes clear, not just your view through the windshield, but all of it. The proverbial big picture smacks you in the face like your snow- board the last time you tried the terrain park. There is more you can do. But there are just so many obstacles preventing you from doing so.

The realization that hit our medic on this fictional call is one that any medic who has been around for a while has surely learned. It’s easy to think that we operate in a vacuum, that as paramedics we are independent operators. And to a certain extent that is true. We practice our profession with a good deal of autonomy. We may feel like we are being told what to do all the time, but the reality is that once you get dispatched to a call, the rest is up to you and your partner. As long as you perform within your scope of prac- tice according to a predefined, but some- what flexible, set of medical directives, and you do so with a professional demeanour, you are on your own. In fact, few professions in health care or in any other field can say they operate with so much independence, making life and death decisions often several times daily, with little or no direct supervision or oversight. So, it runs contrary to our nature to try to involve others, to bring in outsiders. But, in circumstances such as these, is that not exactly what is needed? Maybe not to address the immediate needs of this patient, but to ensure her longer-term health and wellness?

In communities and in larger hospitals, staff operate in a multidisciplinary approach to patient care. That is, the needs of the patient are assessed in a team atmosphere, with various specialties recommending treatment plans to assist the patient through their immediate and long- term requirements. This approach has more recently come to be known as interprofessional collaboration; a more accurate descriptor that addresses the role of the various team members involved in the patient’s care.

The idea seems intuitive. Few patients, especially within our aging or marginalized communities, present to ER with just one problem that needs “fixing.” Even a seemingly obvious medical complaint, such as a hip fracture or a heart attack, does not stand in isolation, but rather, like an iceberg, is only the part we see, the rest being obfuscated by layers upon layers of other problems, ailments or limitations. By bringing in the geriatric social worker, the occupational therapist, the nurse manager, the primary care physician, the system advocates on behalf of the patient and increases the chances of that patient doing better at home, with a proper needs assessment having been performed and the services of the community coming to bear for that patient’s benefit. But where do paramedics fit into this interprofessional collaborative model? We are most often the first con- tact point for so many of these patients. We have access to their homes (by way of the originating 911 call) and get a look at their living conditions. We are the first to get a glimpse of their psychosocial status, their economic status. Often the problem is not that we fail to recognize obvious problems in their living circumstances, but that we have no immediate access to mechanisms to ad- dress these problems.

Thankfully, the professional colleges of many of the health care disciplines have begun to recognize the need for in- creasing interprofessional education opportunities, to the point where these efforts are driving various multidisciplinary conference sessions and making their way into the curricula within the education of caregivers right at the outset. Paramedics, some of whom lack their own professional college, are somewhat behind in these efforts, when by pure situational geography they should be at the forefront. To address this apparent deficiency (or sometimes serendipitously in spite of it), some EMS agencies have launched community medicine programs that attempt to bridge these gaps. But too often this is happening in only the biggest services and a universal approach does not appear imminently forthcoming. In the absence of such programs, para- medics need to do what they can to bring awareness to their managers and to in- volve other community groups in an at- tempt to expose the gorilla in the mist. Paramedics need to ensure that information is communicated to triage staff at the receiving hospital, if they feel their patients might benefit from a team approach, by making sure that their observations form part of the triage record. Just as we paint a picture in trauma by using key words and phrases like “unbelted driver of compact car in moderate speed, single-vehicle versus guard rail incident with substantial passenger compartment intrusion by lamp post following roll-over and impact on driver’s door,” so too should we consider saying something like “sole occupant of apartment that is unkempt and buggy with inadequate food in refrigerator and newspapers dating back to the sixties piled throughout the corridors, tripped over kitty litter box when wheel fell off his walker.”

As is so often the case in EMS, we frequently see the cause and effect relationships between our patient’s circumstances and their presenting problems, but are unable to address them due to so many re- strictions on our time and resources. With an eye to understanding the genuine push towards an interprofessional approach to health care, we should soon be able to make greater inroads at improving our response to the needs of our communities and positioning ourselves rightfully within this professional framework of caregivers. This will not only benefit our patients, but will also contribute to the advancement and increased positive perception of our profession.


About The Author (at the time of original publishing)

Steve Urszenyi is an Advanced Care Paramedic with Toronto EMS, where he has worked since 1983. He is also a tactical paramedic with the Ontario Provincial Police.

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