Your Captain Speaking: Hard Words, Hard Questions

“Samantha, some jobs are kinda easy; EMS isn’t one of them. There are times when we need to say things that are hard and that includes asking hard questions. It’s easy not to talk about them, but today, we’re going to talk!”

Here’s Several Examples, So Fasten Your Seat Belt

Clinician Safety

First, your own safety. Violence against you as an EMT is totally unacceptable. Having a violent patient in the back of the ambulance with a weapon, in this case, a knife, recently resulted in the stabbing death of a caring, professional, and dedicated paramedic. Impossible to say if this could have been prevented but let’s look at some red flags we and potential corrective action.

Scene safety isn’t a one-time evaluation; you repeat it frequently. The world is dynamic, and things change. Take the moment to review the information you have. At first, the patient, family, or bystanders seem helpful but in fact one or more may be showing signs of aggressive behavior or mental illness. In your “SAMPLE” history, are they forthright, or perhaps evasive, are they treating you with respect? Regardless, treat them with respect; it can de-escalate the conversation.

How do you ask the patient or family member riding in the ambulance if they have any weapons on them? First, the question needs to be asked! It doesn’t need to be totally blunt but needs to be clear: “Before we go to the hospital, do you have anything they might consider a weapon with you such as a knife or a firearm? We can work out a solution here.”

With this language, you’re conveying that you’re doing them a favor to keep them out of unnecessary trouble. Certainly, we’re not so naive to think we might not be deceived or lied to. Any bags, purses, or baggage should be placed in a location out of reach, not on the end of the gurney where it can be quickly retrieved by the patient.

Next, it’s standard EMS protocol to perform a “head to toe” exam, which allows you to perform the medical exam while also checking for any obvious weapons. Perform this prior to loading the patient into the ambulance, if possible. Always use shoulder straps on the gurney. This is obvious for transportation safety but also reducing the mobility of the patient to strike you.

If they seem hesitant about being “strapped down,” I like to explain it as, “Go ahead and raise your arms up while we get the seatbelts on, so we don’t make you feel strapped down.” A lot of times, that eases their minds, and they no longer look at the stretcher straps as restraints, instead they see them as the seatbelts they are.

If I think the patient might be an elopement risk, a loop of tape on the strap buckle will give you an important warning that an escape is subtly in-progress. Patients will try to escape out the same door that they entered. Lock that door so you’re not pushed out while running code 3, and they can’t step out unexpectedly.

Related: When Your Patient Has a Gun

If a patient does start thrashing at you and they’re secure on the gurney, you can slide down the squad bench out of range. Years ago, it was unheard of to use safety belts on the squad bench; be prepared to either unbuckle quickly or be seated at the head of the gurney where it would be difficult for the patient to strike you.

You need to communicate with your partner which course of action needs to be followed: stop, continue, or call for additional support. Do you have a pre-set course of action already discussed and pre-planned with your partner? You should, before the fact, discuss a default plan of action with some possible scenarios. Consider solutions such as pulling over, diversion to a facility that can provide support, mutual aid from another ambulance or police assistance, etc.

Other Hard Words

From time to time, we must identify death on scene according to protocols. This is a critical action and adherence to your protocols is strictly needed. Hard Words: death, died. Not acceptable are phrases such as “Your husband is no longer here, he has passed;” “He’s gone now;” or “She’s in a better place.” Instead, use the word “death,” “dead,” or “died,” then stop talking while it’s mentally processed. In our experience, you will hear, “Are you saying he died?” Answer: “Yes, he’s dead.”

“Are you pregnant, or is there a possibility that you are pregnant?” A hard question, especially when the patient is a teenager, but it needs to be asked as part of the patient's history. This may be asked in a more private moment, away from the teenager’s parent or guardian, but it needs to be asked. “Are you sexually active?” is another hard, direct question, but may be needed at times for the circumstances. You might be uncomfortable asking; the patient might be uncomfortable answering.

Don’t shy away from these hard words, hard questions, and hard topics. They are important and can dictate not only your treatment of the patient, but also your course of action for your safety and theirs.

Dick Blanchet, (Retired) BS, MBA, worked as a Paramedic for Abbott EMS in St. Louis, MO, and Illinois for more than 22 years. He was also a Captain with Atlas Air for 22 years on the Boeing 747 with more than 21,000 flight hours. As a USAF pilot for 22 years, he flew the C-9 Nightingale Aeromedical aircraft. A USAF Academy graduate with a Bachelor of Science degree, his Masters in Business Administration is from Golden Gate University.

Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia (Ill.) EMS, and full time at the St Louis South City Hospital Emergency Department as a Paramedic. Samantha was recognized as a GMR Star of Life.