It’s a sweltering, sticky summer night with humidity so high every breath you take feels laborious and heavy. Your uniform clings to your body like a suffocatingly moist second skin. The only cup of coffee you were able to obtain spilled all over you just fifteen minutes into your shift, eight hours ago. You haven’t even had time to think about another cup of coffee, let alone food. Finally you crawl back into your ambulance to hopefully finish a few of the charts you are behind on. As if on cue, the radio crackles and you punch your clipboard as you hear your unit number called, yet again. This time your assignment is for “the twenty year old female with a toothache and possible syncope.” The patient is on the fourth floor of an extremely nasty apartment building. Instinctively, you reach down to your pocket just to make sure that you have your trusty flashlight, because this particular building has scarce to no lighting. As you pull up to the scene, the new song you have been raving about all night to your partner drifts out of the speakers mockingly. You sardonically chuckle to yourself thinking “REALLY!” After hauling all of your equipment up the four unlit, urine-drenched, seemingly never ending, flight of stairs, you rap on the door. Of course it takes five or six hard knocks before someone finally hollers “Who is it?” Your partner holds up their hand to stop you right before the words “the Tooth Fairy, who do think?” slip out and responds “the ambulance.” You take a deep breath and feel the flush creep away from your face. This is the very moment when what you say, the tone and inflection of your voice, your appearance, and body language form the first impression of you for the patient or their family member.
We are all human, and it is perfectly normal to be tired and frustrated. There are times when life and all of its accompanying stressors seem to form large concrete barriers, and cause us to lose sight of why it is that we do what we do. We can all be guilty of forgetting the real reason we got into EMS in the first place – which, by the way, is to help people! Despite being hypo-caffeinated, over tired, and hungry, it is important to remember that for better or for worse, you are the professional in this situation. Your attitude and the way you present yourself ultimately affects the patient, your safety, and dictates the flow of the assignment.
The “first impression” that is formed by the patient (or the patient’s family) strongly impacts how they are going to act towards you and your partner as their pre-hospital care providers. I am by no means delusional, neither; am I advocating for you to be poised and ready to enter a situation hugging patients, their families, kissing babies, and drying crying eyes. That is not what we are called to do as pre-hospital care providers, nor is it a reasonable expectation of our patients that we provide such a service. Yet, what is a reasonable expectation on the part of all past, present, and future patients is professionalism. We must strive to remain professional at all times. Be both conscious and contentious of what you say, and how you say it. It is not only the words you use that the patient hears, but also the inflection, and the tone of your voice. Your appearance and body language will also give away what you are thinking and how you feel about the situation. Is your shirt tucked in? Are you obviously wearing your coffee on the front of your shirt? Are your hands in your pockets? Should you be slouching over or holding up the walls by leaning on them? Did you make eye contact with the patient or are you scrubbing the dirt off the floor with your eyes? It is important to be mindful of these things and not put the patient or their family on the defensive, before you even get in the door. Putting the patient or their family in a defensive mode is not only counterproductive but dangerous. It can make you appear as if you do not care about the patient or their situation. Being uninterested or confrontational is different than being calm, yet confident and assertive as called for to manage or control the scene. Self-assuredness is acceptable; being unapproachable and unwilling to listen is not. What you say, and how you appear can even inadvertently make you seem as if you are a poor pre-hospital care provider.
There are a lot of “unknowns” and variables when initially entering a scene or assignment. In most instances we are not familiar with the house or scene we are walking into. We do not know where any guns, knives or other potential weapons may be hidden. Although it should be part of your initial scene assessment prior to any patient contact, you may not know all the means of ingress or egress. We do not know the mental state of the bystanders or the patient. We also do not know why EMS was really called to respond.
The anxiety level on the scene of an assignment is usually elevated. When people call 911, their degree of control over a situation changes, the knowledge that they are no longer in control and have therefore called someone else to assume control over the situation can be a point of relief or a point of added stress for the patient and/or family members. As EMS providers the first words that come out of our mouths should be direct, to the point and respectful. Our focus is to quickly discover exactly who the patient is, where they are, and why the ambulance was called, all the while, assessing whether or not we are walking into to a violent or volatile scene.
“Yo, what’s going on?” is not the best approach even if you are in an urban area, where this type of language is common place and acceptable. Instead, try to incorporate more courteous and professional “opening questions” such as “Hi, are we here for you sir/ ma’am? Did you call the ambulance today, and if so, what can we do for you?” These questions show respect, attempt to identify the patient or patients and can clue us into what may possibly be waiting in the next room. If the first person you make contact with believes you are truly there to help, you may find that you have at least one ally if the patient proves to be uncooperative, combative or “difficult”. If you have unintentionally offended or upset this person of “first contact”, they will be less inclined to help you. This person may even stand in the way of patient care both literally and figuratively.
Upon approaching the patient try making eye contact with them, while simultaneously introducing yourself. Nobody likes to be touched uninvited, especially by a stranger in uniform. Your apparel or your presence in an official capacity can be intimidating. The patient may not have given permission for the ambulance to have been called to care for them, and EMS might have been activated by family, friends, a concerned third party, or law enforcement. To the patient you may simply be an unexpected or uninvited guest. Ask the patient what, if anything, is ailing them, and why someone has called for the ambulance (if the patient did not call for themselves.) If you take the initiative and demonstrate respect by asking the patient first it lets your patient know that you care about them despite the possibility that your presence was requested against his or her wishes. It is imperative that we somehow communicate to our patients that we do care what they have to say, how they feel and about their general well-being. Don’t make yourself or your partner the enemy by ignoring the patients concerns.
When the bystanders try and intervene respectfully let them know that the patient’s ability to answers question appropriately for themselves is part of your assessment. Bystanders can provide you with crucial information that the patient is unable or unwilling to communicate during assessment. You can always try and gather this information as well as other background and demographic information from the bystander on scene after you speak with the patient. Sometimes this additional information is best exchanged between bystander and provider out of ear shot from the patient.
As often occurs when speaking to patients, EMS providers are able to make some sort of basic interpersonal connection. It is this simple connection that lets the patient know that they can trust you as a provider. Your presence should be a calming one. If the patient is loud, hysterical or agitated try to coax them into speaking quietly. Explain to the patient that you are there to help them but that you cannot understand them and therefore help them if they are yelling at you. There are also physiological changes that occur when a patient is upset, angry, or anxious. These states will raise a patient’s blood pressure and heart rate and have the potential to exacerbate a patient’s current conditions or symptoms. Even if it seems that all you have done was calm the patient’s anxiety or fear you have ultimately helped the patient on many levels.
When patients trust that you are competent and have their best interests in mind, they are much more likely to comply with any patient care–related requests that you may have. The more cooperative and collaborative the effort between the patient and the provider, the more synchronized and seamless patient assessment, patient treatment, and patient transport can be. Simple actions such as a patient calmly allowing you to assess their wounds, the establishment of IV access, or even assisting the patient in walking to the ambulance when medically appropriate, are all examples of tasks that are better accomplished with patient trust and cooperation.
A patient’s perception of you as their health care provider will unequivocally determine the level of care they allow you to provide for them. Subsequently, a patient’s family’s perception of you will also determine just how much they are going to interfere – or help – with the care you provide. Your job will be easier, safer, and your patient care improved, if you remember to check your attitude at the door.