Alert & Oriented

How you are, right now?

When I first started as a volunteer EMT in 2011, one of the least helpful things we learned in training was to evaluate our patient’s mental status by asking, “Do you know who the president is?” 

The very first patient I asked, a sixty-something woman with acute hypertension, said, “You want me to say that asshole’s name?” 

We’re supposed to try to keep patients calm, and I’d failed spectacularly. This woman, her blood pressure now stratospheric, took the opportunity to lecture me for most of the six-minute ride to the hospital. She wanted to explain to me all the things I didn’t know about politics and the world—which, to be fair, is a lot. There wasn’t nearly enough time.

At the emergency department, I helped her scooch from our stretcher over to a hospital bed. I got the nurse’s signature on our ambulance’s digital tablet, then said to the woman, “I hope you feel better soon.” She frowned at me.

“Yeah? Well I hope you feel better soon,” she said, unconvincingly. This is one of my wife’s biggest pet peeves, people saying polite phrases in a grumpy way.

It wasn’t her fault, though. I never asked a patient about the president again. 

I know an EMT who asks the more surreal question, “Is Mickey Mouse a cat or a dog?” It makes me laugh, but it’s not helpful. We’re trying to assess the patient, not catch them out. 

Sure, the answer is a mouse. Sort of. It’s also just overlapping circles in a particular configuration, which is somehow the intellectual property of a corporate entity.

What we really want to know is if the patient is alert and oriented—to person, place, time, and event. Do they know who they are, where they are, roughly what time it is, and what’s going on?

From a relative standpoint, these are easy answers. I’m Rob, and I’m sitting in our living room. It’s early morning. There are high winds whistling around our house, seeping in through the window sashes. The branches outside are waving frantically in a diffuse amber light, and I hear a truck backing up somewhere, beeping away in the distance.

From an ultimate standpoint, though, these questions, like the one about Mickey Mouse, are more complicated. Who am I, really? Where is this place? When is it, right now? And what is it that’s happening? 

I’m reminded of my favorite Zen koan:

Emperor Wu asked the great teacher Bodhidharma,
“What is the first principle of the holy teaching?”
Bodhidharma said, “Vast emptiness, nothing holy.”
“Who are you, standing here in front of me?” asked the Emperor.
“I don’t know,” said Bodhidharma.
The Emperor didn’t understand.

— Blue Cliff Record Case 1, translated by John Tarrant & Joan Sutherland

I like noticing the unanswerability of even basic questions, from a certain standpoint. I find it even more helpful, though, to cultivate a deep unknowing about other people. To approach them as an open question.

Like these high winds, which have been whipping around us for days now, there are understandably so many intense emotions right now. I feel them, too.

So, I’m taking a cue from EMT training. We have two basic principles:

1. Deal with any immediate threats to life first.

2. Remain curious about the person in front of you, assuming nothing.

Assumptions can be deadly in EMS. Someone might appear to be drunk, but it could be hypoglycemia, or stroke, or any number of possibilities. I don’t know. I ask patients questions about their symptoms and history, and look at signs, trying to understand what’s happening. It’s helpful to stay open and curious. Whatever’s true in this moment might be completely different a minute from now, for better or for worse.

I’m trying to bring this to my regular life, too. I’d much rather hear your side of the story than make up my own story about you.

If someone says Mickey Mouse is a cat or a dog, I’ll have some questions, for sure. I’ll feel a strong sense that they’re wrong, or maybe just not a very good listener. But inside or outside the ambulance, there’s a deeper question I’m trying to understand about anyone I meet, which is: What’s it like to be you right now?

I might notice a lightness in that, feeling less certain, more like wide open space, awaiting an answer.

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“There is no knowing for a fact. The only dependable things are humility and looking.”

― Richard Powers, The Overstory