Why do we ignore mental illness?

A colleague from the Internet recently posted this on social media; in reading it I felt that they had very eloquently stated some of the same ideas that had been rolling around in my head.  "A" (they asked to remain anonymous) graciously gave me permission to repost their thoughts.

"We had one of our medics commit suicide Wednesday.

While enjoying my dinner of chocolate pudding cups and beer (don't judge me), I started to get a bit philosophical (and tipsy).

The idea that EMS eats our young has come up a bazillion times before; But what if we're not eating our young, what if we're killing them? As healthcare professionals we should know that mental health problems are more common that most people realize, and that millions of people with a mental health disorder function in society every day with no one knowing the wiser.

How many of those people are our co-workers?

I can't remember how many times I've heard co-workers b**** about all the psych patients they had that day, or how stupid/worthless/horrible "those patients" are, or laugh at self harm or a failed suicide attempt. It is a never ending stream of putrid hate that spills out of their mouths where psych patients are concerned. The overwhelming vibe is that they aren't real patients. They don't have real problems. They just need to suck it up and get over it.

What kind of effect is that having on those among us who are in a bad place? We talk about having a "work family" and the "brotherhood", but when s*** gets real and someone is struggling, are they going to remember all those rants about psych patients or are they going to remember that bond?

People keep arguing that talking like that is just blowing off steam, and is part of the job, and whatever other BS they can come up with to justify their abysmal behavior.

F***. That. Why do we tolerate that kind of behavior?"

I think that "A" hits the nail on the head; we get so caught up in the flashy parts of our job; the cardiac arrests, STEMIs and multisystem trauma patients, that we can forget the much more common patients that we see.

Our system of education doesn't exactly help...my paramedic training spent two whole semesters on medical emergencies, and exactly 16 hours on behavioral emergencies.  Many times, our education in behavioral emergencies is heavily focused on "scene safety" and patient restraint; how many of us have had education on how to speak to a delusional patient properly?  Who wrote that chapter in the textbook anyway?  The quality of education has significant implications down the road...

One of my first partners committed suicide.  At the time, I didn't think much about it; I went to the memorial service and muttered the appropriate condolences.  Then I went back to work with a new partner and promptly forgot about Bekka.  Since then, I'd taken care of many, many psych patients; every now and then I would remember, almost as an afterthought, that they shared a common affliction with Bekka (as if "mental illness" truly describes the spectrum of problems these patients face), but it would take almost a decade for the realities of mental illness to really sink in.

About a decade after I started in this field, I wound up with a live-in girlfriend and her daughter from a previous marriage; our relationship seemed good enough, but gradually the bad days began to outnumber the good ones.  She went to her doctor, got a referral, and told me one day that she had been diagnosed with a mental illness.  I was supportive and understanding; after all, I was a medical professional, right?  I knew how this stuff worked.

Wrong.

Our relationship grew strained; fights, days when she could barely drag herself out of bed, followed by days when I'd come home to a 5-course meal because she got bored.  There were trips to therapy that I never got a chance to go to, which became a point of contention for me; why was I excluded from this secret side of her?  There were days when the slightest whimper from her daughter would trigger a full-scale meltdown; I would scoop up her daughter and take her away to "let Mommy rest" for a few hours.  Her migraines grew daily, and I would get concerned about the amount of medicines she was taking; we would fight.  Eventually, we broke up; suddenly, while I was away working.  I was hurt, pissed off, and confused.

If mental illness affected my life to that degree, I can only imagine what it was like for her.

Those two experiences dramatically changed the way that I approach the "cuckoo for Cocoa Puffs" patient; sadly, it took real, prolonged, and painful experiences for me to learn how mental illness affects people and the ones close to them.  And it makes me wonder...why can't we EMS educators find ways to pass those lessons on to students?  We have fantastic, high-fidelity simulation mannequins that can automatically adjust 40-some odd different hemodynamic parameters; why can't we reach out and find a way to relate to our students the effect of mental illness on people?

I'm sure we can find a way, in time, to effectively educate our young to be sensitive to the mental wellness of our patients....but how do we teach people to be attentive to themselves?  One of my favorite quotes about EMTs and paramedics is that we "know just enough medicine to be dangerous to ourselves"; we will self-diagnose and refuse care until we absolutely have to.  But mental illness, depression, etc. isn't something we can ignore until it becomes unbearable and just go get a Z-pack; when it becomes unbearable, we eat a gun in the car.  Or realize that an 18-pack of beer is only enough for one day off-shift.  Or get served divorce papers.

We need to get in touch with ourselves as providers and know that it's not being weak of "pussing out" (the favorite phrase at my workplace).  We need to demand that our employers take our mental health as seriously as they do back injuries.  And we need to starting nurturing our young, instead of eating them; set them up for success and healthy longevity instead of substance abuse, relationship problems, and depression/suicide.

After so many years, I think I finally understand where Bekka was coming from.  And I'm slightly ashamed that it took me so long.

I'm sorry, Bekka.

Why Should A Study Mean The Same Thing to Everyone?

While staying current in EMS/medical research today (OK, I admit it....I was on Facebook), I came across a blogpost by Brooks Walsh, who has a great blog (if you've not seen it, go look at it and subscribe!);

http://millhillavecommand.blogspot.com/2014/03/we-had-lucas-save-no-you-didnt.html

In it, he looks at the LUCAS device, a mechanical CPR device that's gotten a lot of media attention in both local news and trade magazines like JEMS.  He then provides info and commentary on a study published in JAMA last year, which evaluated the LUCAS against well-trained human CPR providers and found that there was no clinical benefit to using a LUCAS versus human hands.  Here's the abstract in PubMed; you can find some tables from the article in the blogpost above.

http://www.ncbi.nlm.nih.gov/pubmed/24240611

I mostly agree with the conclusions and statements that Dr. Walsh made, particularly his stressing that humans, not technology or advanced treatments, make the difference in cardiac arrest.  And I love that several of my Facebook friends were sharing the post and the article so that more EMS providers can become aware of relevant EMS research.

However, I wanted to add a note of caution; your mileage may vary.

Any piece of equipment or medication that an EMS service deploys should be looked at critically periodically; and literature reviews are an important part of that process.  If a device or medication can't be proven to benefit patients in meaningful ways, then it's time to take a hard look at whether or not it's worth spending additional money on it.  However, the results of a study often mean different things to different people; the LINC trial is a great example of that, I think.  Consider the viewpoints of two EMS managers evaluating whether or not to buy the LUCAS for their service:

System A is a large, urban or suburban system with 10-20 units on the road normally, strategically deployed around the service area.  They work closely with a paid fire department that automatically responds to cardiac arrest calls.  On average, there are between 6-10 medical providers who are dispatched to a cardiac arrest call, and transport times to the hospital are normally 5-10 minutes.  Is it worth spending a couple hundred thousand dollars to place a LUCAS on every transporting unit?  Probably not!

System B is a small, rural EMS service with 2-3 units in service at a central EMS station.  Both 24-hour ambulances will typically respond to a cardiac arrest call (assuming the 2nd truck isn't already on a call), but the local fire departments are 100% volunteer, and medical training isn't required to be a member.  On average, there are 2-4 medical providers who are dispatched to a cardiac arrest, and transport times to the local hospital are 30-45 minutes.  Is it worth spending a few thousand dollars to place a LUCAS device in the station so an ambulance crew or volunteer firefighter can grab the LUCAS device if a cardiac arrest call comes in?  I think it does!

I guess my point is this....good-quality research is absolutely essential in providing quality medical care.  However, there are other system-specific considerations like cost, logistics, training, etc. that necessarily play a role in what therapies you stock on your ambulance.  Evaluating the results of evidence should always be done with these other factors in mind.  In the case of the LUCAS, for my EMS service (service B), "just as good" as human hands is as beneficial as "better" than human hands.  At my former service (service A), we would have either not purchased the LUCAS or auctioned off the units we'd already purchased.

With everything that gets studied in medicine--your mileage may vary.