Early in my career, much of my research centered around determinants of survival from out of hospital cardiac arrest. Coming from a background in geographical and spatial epidemiology, it was axiomatic that location of facilities was very important, or even crucial. I was interested in taking the most extreme case: did the location of paramedic vehicles (ALS units) matter to outcome? If Mr. Smith went into cardiac arrest on a Thursday night, was his chance of surviving dependent on where he lived, and where the ALS unit was at the time of his collapse?
The details of the studies are not as germane to my story here as are a few images, and a nightmare, and the consequences. My data showed that when restricting the analysis to VF, that yes, location and response times were huge determinants of survival. And there was an image. I have never been an academic who could sit in an office with a computer and numbers, content with being removed from the world. Fo 2 years, I rode the paramedic units in Seattle whenever I had the chance, going to bad motor vehicle accidents in pouring rain at midnight, or a shooting downtown at 3 am, or, in this case, a cardiac arrest in a modest home in a remote part of the city, though still in the city, a little before midnight on a rainy Thursday evening. All that we knew was that a man in h is 70s had collapsed, and we knew the address. Later, we learned from the first arriving unit was that he had no pulse, and that there was ongoing CPR. We arrived on the scene after a travel time of about 10 minutes. I carried some equipment. An elderly gentleman was on the floor of a living room, and a woman whom I took to be his wife was sobbing uncontrollably in the next room. Nobody was with her; all were engaged in trying to resuscitate her husband. Defibrillator, cardiac meds, intubation, and other measures all failed to resuscitate this gentleman. Fortunately, a daughter arrived before we went back into service, and the bereaved widow had somebody to be with. This was not the first time by a long shot that I saw somebody die. Death was a simple process, a nonevent to my eye. And we left.
Partly, and maybe largely, because of my work, there was a redistribution of ALS units within the city. The argument was made that the units should be located where the need was greatest, so that the greatest number of critical cases could be served. Put another way, this was the argument of the greatest good for the greatest number–the classic utilitarian argument. Shortly after I learned of this reconfiguration, the haunting image of this man’s death reappeared at odd times. I didn’t quite understand why. It was even in a few dreams. And then I realized that he had lived in one of the areas that had experienced *decreased* accessibility because of the utilitarian argument. That area of the city, effectively, was experiencing a decreased chance of survival from cardiac arrest. And I was terrified: the juxtaposition of his death, and the grieving wife, and my academic papers, and the new fire station more centrally located. I had an anxiety attack. And that night, I had a nightmare. I don’t remember the details, but somebody was accusing me of killing somebody in that neighborhood. I do remember “you’re responsible. You killed him.” I remember the line. And I didn’t know how to handle it. When you move from abstraction in your work to the concrete realities, how can you handle the ethical and moral implications if you’ve seen them at work, and if you’re sensitive? I felt so ill=equipped that I talked it over with some clinical colleagues, and then became fascinated by exactly what I was afraid of: the ethical implications.
Instead of running away from those implications, I applied for a three year fellowship in medical ethics and the ethics of health policy, and that I was awarded. It was exciting. I learned. I was invited to be a founding member of a hospital ethics committee, and I instituted and directed a bedside Ethics Consult Service–something at which I felt that I could make a difference. Those were good times. I think that I did make some differences. Yet even after all that, after all the learning, the image of that death, and the accusation remains. My work was not innocuous. Lives matter. And decades later, I feel very humbled by that.
I have never changed my habit of being out on the scene and in the world when I do my work. I do not and will not want to become detached from the human realities of epidemiology and health policy. I immerse myself in the daily dramas and realities. It’s my own way of reminding myself that I, too, am human, and that people are not statistics.