Difficult Situations and How to Talk Your Way Out of Them

     In EMT and paramedic school we learned how to save lives. We learned the signs and symptoms of diseases and how to treat the sick and injured. What we didn't learn was how to handle difficult situations.

     We know how to treat the overdose patient, but we didn't learn what to say to her on the way to the hospital as she tearfully looks for comfort. We didn't learn that saying the right thing to a hostile patient could prevent you from having to wrestle him to the ground. We got our first jobs and found ourselves on the front lines, center stage in the middle of someone's living room. We were in the midst of their crisis, and expected to resolve situations we'd never been in or dreamed of.

     They taught us what to do, but not what to say. Yet it's these skills that make or break you as a caregiver. What they should have told us is that patients, in general, need two things from us: respect and understanding. This is especially true for patients in crisis. Here are three patient scenarios and how to come out a winner.

THE PATIENT WHO REFUSES TO GO
     You're called to the local Red Lobster for a 75-year-old man who has had a syncopal episode. You find him sitting on the floor, leaning against the wall. He has a military tattoo on his deltoid and casts a furtive glance your way when you walk in. When you get to him, the fire medic says, "He's not going anywhere, but we told him you had to take a look at him first." When you approach him, he says, "I'm fine. Everyone is just overreacting. I'm not going anywhere."

What are his issues?
     Since he's in a public place, embarrassment could be a major player in him wanting to rush through the interview. And being forced by his family to stay and wait for you may have agitated him even more. He's the man of the house and not used to being told what to do by anyone, let alone his family. He may also be in denial about a declining state of health.

What to do
     Acknowledge that he doesn't want to be transported. Tell him in simple terms what you think could be wrong and what could happen if he doesn't go. Offer solutions, and involve family only if they're helpful in getting the patient to go. If this doesn't work, bring out the big guns.

     Sit down next to him. Sit there, looking straight ahead or wherever he is looking, and let him get used to you being in his space. As you look over at him, you are now eye to eye, as would be a friend. Here's what to say: "I know you don't want to go anywhere. But I just want to say one thing:-If you were my grandfather, you would be in that ambulance right now, and we would go get you checked out. There's no way I would let you take a chance with something this big." After you let this sink in, add: "And you and I both know your family is going to worry about you all night and bug you until you go. Why don't we just go get this checked out? If there's nothing wrong, you can hopefully be back at home in a few hours."

What not to do
     Don't talk down to him or call him endearing names like "Grandpa." This will only cause him to tune you out, and he may even get up and walk off. Don't forecast doom-and-gloom scenarios of his impending death if you leave. This will invalidate any progress you may have made.

WALKING WOUNDED MCI PATIENT
     You respond to a middle-aged female who was involved in a five-car pileup on the highway. As you exit the ambulance, you see five other patients who appear to be critical lying in the roadway. When you approach the scene, she walks over to you from her mildly damaged BMW, holding her arm. She's wearing a fur coat and high heels, and lifts up her sunglasses to look you in the eye. "You need to help me right now," she says in a demanding tone. "Don't you know who I am?"

What are her issues?
     You have to make a few assumptions based on this patient's behavior and how she presents herself to you. What she's showing you is that she's upset, maybe even angry. But that's probably a cover for the real emotion she's feeling-fear. More important, she probably feels out of control. Since she's probably almost always in control, she may not respond well to a situation where she isn't calling the shots. She's used to a lot of attention, and when she doesn't get it, she acts out.

What to do
     Acknowledge her feelings. Explain to her what's happening. Tell her what to expect, and then redirect her energy. Here's an example of what to say: "I know you're hurting, but there are some critically injured patients over there who could die if I don't get to them right away. As soon as I get them stabilized, I'll come back over, and we'll get you taken care of. In the meantime, you can help me get back to you faster if you could…" Insert a task here-e.g., hold c-spine, or watch those kids and make sure they don't run in the roadway.

     What not to do: It may be tempting to blow her off. It may feel good, in the moment, to set her straight. Unfortunately, it increases the chance of her retaliating with a lawsuit.

DEATH NOTIFICATION
     You respond to the home of a six-month-old female. Baby went down for a nap at 1500, and when her parents went to wake her up, she was unresponsive. As you approach, it's an obvious pronouncement.

What to do
     Sit the parents down in an area away from the baby. Remember that the parents will not only remember what you say, but how you say it. Use good, direct eye contact and touch a hand or shoulder if it's OK. One example of what to say is, "I'm sorry, Mr. and Mrs. Jones, but [insert baby's name here] is dead."

     Allow a time of silence for them to reflect and absorb what you've said, and be ready for emotional explosions. Then follow up with things that will aid them in starting the healing process. And before you leave, help them make phone calls to summon their support group.

Things that are good to say
     "What you're feeling is normal."

     "Things will never be the same, but they will get better, and you will feel better." Things not to say

"You can have another one."
     "It is best if you just stay busy."

     "I know how you feel." (Even if you've lost a child, there's no way you can know how they feel. Everyone responds differently.)

     Make sure not to leave until additional reinforcements are on scene.

     By treating these patients like the people they are, instead of the problems they have, you will avoid making a bad situation worse.

Bibliography
Reilly L. How to Outnegotiate Anyone (Even a Car Dealer!). Holbrook, MA: Adams Media, 1993.
Soreff S, Cadigan RT. EMS Street Strategies. Philadelphia, PA: F.A. Davis Co., 1992.
"How to Talk to Families" by Karen Long. Presented at the Totally Trauma by the Sea Conference, October 25, 2002.

Jennifer Leigh Carlquist has worked as a paramedic and EMS instructor in California.