The Midlife Medic: When `Just Ask` Doesn`t Work

One of the things not frequently taught in prehospital curricula is how to finesse an interview. We cram a ton of clinical knowledge into students' heads and then shove them out into the wild with the universal advice, "If you want to know something, just ask for it, kid." This may work in tabletop scenarios, but not so much with real people on real scenes.

Developing successful interview techniques takes time and practice, and not just by binge-watching Law & Order or A Few Good Men. There are environmental considerations like family, bystanders and setting. Is the patient's mental status altered for medical, traumatic or substance-related reasons? Personal history and cultural considerations may cause a patient to be far more forthcoming with one provider than another over something as simple as gender or age. Interviewing is a fascinating topic that takes way more time and space than we have here, so let's just look at a couple of things that can help you improve your interview game.

There is a general social rule that if you want to avoid the risk of an argument, you avoid talking about politics or religion (although asking someone a political question during a mental competence interview often produces passionate and amusing responses). This is an example of a what. EMS-related whats include complaints, history, medications and events surrounding your interaction, among other things. We know the whats; what we also need to realize is that when and why we ask something may not only radically impact the answer but change the outcome of a call.

When refers to the timing of a question. You need the answer, if you can get it, but the timing may impact just how much of a response you will get from somebody who is already under stress. Perhaps your agency is strict on the collection of insurance information. If that's the first thing you ask for before anyone lays a hand on the patient, it reflects poorly on you and your service. It implies your priority is money. When someone's family member is struggling to breathe, put the clipboard down and intervene first.

If you suspect something isn't quite right—that drugs, alcohol or some other domestic factor may be involved in the call—don't throw it out in your opening line of questions. This is a sure way to put people on the defensive and escalate tension on a scene. I don't care if you're responding for an asthma attack in a meth lab, do not make your first question, "So, do any meth today?" (Actually, don't ask any questions at all—just get out of there before it blows up.) Let them volunteer or draw it out later if it's pertinent. (We'll come back to that last part.)

Being strategic with your timing can help you get a more comprehensive history from reluctant patients. Use some benign questions that are off the topic you want to know about to elicit a sequence of short, positive responses. Slipping in what you really want to know between these positive interactions gives you a greater chance of a legitimate answer. This approach has the added benefit of helping you develop trust and a rapport with the patient, which will help your overall care. Human nature makes people want to give the answer they think you want to hear. Sometimes you have to be a little sneaky to get to core of the problem.

Back to the meth, or drugs in general. Consider the following conversation:

Provider: "Have you taken any drugs?"

Patient: "No."

Provider: "Nothing? Are you sure? We don't care, we're not the cops."

Patient: "No, I don't do drugs."

Provider: "Look, buddy, I don't care what you did. You can tell me. I need you to be honest with me in case I have to give you a medication or something."

Patient: "No! I haven't done anything!"

My point here is not that you shouldn't try to discover what agent is involved with an overdose patient, especially one in distress. You should do whatever you can to find out what's involved, especially if you're treating specifically for it. But please, apply situational awareness to your interview.

How you speak to someone can and will directly impact your safety, so consider your line of questioning. Is it in your purview to begin with? Will the answer change anything in your clinical course? A percentage of those in our care may not be law-abiding citizens, or it could be some illicit activity that got them on our stretcher in the first place.

If you have reason to involve law enforcement, then by all means do so and call them early—but I routinely enter scenes where crews are not only relentlessly questioning patients on details that don't matter but are grossly agitating not only the patient but bystanders as well.

If they are alert and oriented, cooperating with your assessment and care, and are otherwise stable…why do you need to know?

Stay safe out there.

Tracey Loscar, NRP, FP-C, is a battalion chief for Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla, AK. Her adventures started on the East Coast, where she spent the last 27 years serving as a paramedic, educator and supervisor in Newark, NJ.  She is also a member of the EMS World editorial advisory board. Contact her at taloscar@gmail.com or www.taloscar.com.