EMS Revisited: Professional Etiquette

This article first appeared in the April 2004 issue of EMS World Magazine and is reprinted here as part of our EMS Revisited series.

Probably not much in medicine is sillier than an 18-year-old high school graduate completing an EMT class with an 80-hour certificate and suddenly being instructed to “act like a professional.”

How we relate to a boss, colleague, medical director, patient’s physician, ED nurse, a crowd, a patient’s family members and (oh, yeah) a patient is crucial, even on our very first day as EMTs. It determines not only our effectiveness as communicators and caregivers, but also our safety and continued employment. Certain behaviors at public scenes or in the privacy of someone’s home are so significant, they can get us killed. Yet, they have been omitted from our training.

Professional etiquette is more than just making nice. It’s how you show your respect for people. And to show it, you have to mean it. As an EMT, you will meet plenty of people who are smart enough or sensitive enough to know when you’re faking.

Respect for people comes easiest when you naturally like them. But more than that, you need to understand a little bit about their responsibilities and what makes them tick in order to get a feel for what they expect from you.

The scope of professional etiquette warrants more than a single journal article, but the following should serve to outline its basic elements.

Etiquette Toward Other Medical Professionals
Since its inception, probably no area of EMS has been as fraught with on-scene and in-hospital misunderstandings as the interface between EMTs and other medical professionals. Things are better now than they once were, but EMTs still don’t learn much about their medical colleagues except by experience. Let’s review.

Physicians make medicine happen. When a physician identifies himself as a patient’s personal physician, and the patient agrees that’s his doc, the physician’s word is law, figuratively and literally. If you’re absolutely convinced the patient’s physician is wrong about something, your best recourse is to involve your designated medical control physician and get the two docs to talk to one another. Otherwise, don’t ever get between a physician who is assuming responsibility for a patient and a patient who really needs care.

Nurses, especially critical care nurses, deserve similar respect. They tend to be overworked, underpaid, over-responsible, and much better educated about medicine than their field counterparts. At the same time, show respect to all caregivers, including those who work in subacute settings like hospices and nursing homes. They all do jobs that require their own kinds of competencies, which we do not necessarily possess.
CNAs—certified nursing assistants—are some of the hardest-working, least appreciated people in medicine. In most states, they receive about the same amount of training as an EMT, but receive less pay and terrible benefits. A typical CNA working in a nursing home might be responsible for 10 or more patients per eight- or 10-hour shift.

During that period, the CNA would likely be responsible for bathing (sometimes more than once), feeding (three times), skin care, dental care, change of linen (sometimes more than once), administering medications (sometimes more than once), exercise, social interaction, janitorial duties and all related charting of care for each patient. Due to financial difficulties in many nursing homes, CNAs routinely shoulder at least some nursing responsibilities. As a result, they are often the most knowledgeable resources concerning patients. If the patients are poor or have no relatives, they often come into facilities without personal essentials like robes, slippers, hairbrushes or toothbrushes. It is not uncommon for CNAs to provide these things out of their own meager wages. They deserve both personal and professional respect from EMS crews.

Etiquette Toward First Responders
When it seems appropriate to ask a first responder crew to do something (like placing someone in c-spine), it is usually considered appropriate to address the engine company’s ranking officer, unless you are closely acquainted with the department and crew. In that case, you can communicate much more informally.

Depending on local procedures, the type of call and staffing, it’s a good idea to take your normal complement of carry-in gear, O₂ and the ambulance cot with you. Otherwise, you communicate to the engine company that you’re presuming they will do it for you. That’s an insult.

When time and circumstances permit, question others about their observations and opinions. It shows respect and communicates unmistakably that you view them—and yourself—as professionals.

Thank people when they do something that makes your job easier, even if it’s their job anyway. And when somebody thanks you for something, let them know how welcome they are (Don’t just say “No problem!”).

Before you call a code, ask if anyone else has any suggestions. If they don’t, call the code, but be aware of where the family is situated first.
When you finish a response, ask other team members what you could have done better.

Develop a practice of announcing major intersections over common frequencies during your emergency responses to advise other responders of your location.

Etiquette Toward Other Drivers
Watch your speed and your general driving behaviors; they communicate to the public something about your regard for their safety. Remember, you’re driving a four-sided billboard, and everything you do says something about you, your colleagues and your agency.

Never insist on right of way when breaking traffic. If other drivers seem bewildered, shut down the siren and use the PA system to instruct them politely: “Ladies and gentlemen, please pull to the right and stop. Thank you.” Never berate another driver publicly, even one who infuriates you. Remember, it’s not the other drivers who are expected to be the professionals. We are.

Not responding to your polite instructions is one of the effects of “fight-or-flight” syndrome. Consider that other drivers may be scared to death. Shut down your lights and siren altogether until you determine what they are going to do. If you overwhelm them, their response may accidentally kill someone. Maybe you.

On-Scene Etiquette
Remember that every response is a public performance. Be conscious of your demeanor and appearance on scenes, whether private or public, especially in the presence of people with serious or fatal injuries. It can look bad to the uninformed public, and especially to family members after what they consider a cataclysmic event, to see emergency crews smiling or laughing at the scene. Make no mistake—no explanation or apology will ever repair this kind of indiscretion.

Bystanders may not be EMS professionals, but they understand the importance of courtesy (“Ladies and gentlemen, would you mind stepping back, etc…”) and recognize its absence. Be especially cautious of your behavior in front of large gatherings. Even usually civilized people can exhibit ugly behavior in a mob.

Listen to people when they talk to you, especially if they’re trying to answer your questions.

Do your best to insulate patients and their families from public view, using any means that seems appropriate.

No matter how rushed you are, remember that you’re no more important than anyone else. Be polite to everyone you encounter on scene, including janitors, food servers and candy-stripers. They all work hard for little or no money, and receive little of the respect they deserve every day.

Anytime you terminate a resuscitation effort, no matter how appropriately or under what circumstances, immediately redirect your attention to the needs of surviving family members or acquaintances. Do not abandon the survivors without giving your best effort to counsel and comfort.

Learn the differences between jails and prisons. Jails are usually municipal facilities that incarcerate misdemeanor-class offenders. Prisons are usually higher-security state or federal facilities used to detain felony-class offenders. Both are dangerous places, especially if you engage in judgmental behavior. Try to remain objective as long as you are dealing with a prisoner, whether inside or outside a detainment facility.

Patients in medical restraints warrant the same treatment you give prisoners. Avoid stepping outside the role of caregiver, at all costs. Remain nonjudgmental. No matter what the patient says or does, refrain from engaging or “punishing” them in any way. These behaviors can cloud your thinking and rob your self-control.

In-Station Etiquette
We all live according to schedules of one kind or another. Find whatever form of scheduling device works for you (calendar, electronic device, computer, etc.) and use it.

Be on time for duty. Better yet, be early. There’s nothing worse than handling a call after your off-time because an oncoming crew is late. You feel disrespected, and so do others. Routinely missing meetings or showing up late is rude and communicates your lack of respect for the people who get there on time.

Leaving a crew with dirty or improperly stocked equipment is also an insult. You don’t like it if they do that to you, so don’t do it to them.

Your uniform communicates who you are and what people should know about your profession. Appearing in public with a scruffy uniform, unshined leather and poor grooming reflects badly on your colleagues. Look like a professional and make them look good too.

When someone leaves a message, try to return the call as soon as possible. If it is a request for information that will take some time to gather, contact them to let them know you will be gathering it, then get back to them with the information. If you want to be treated as a professional, don’t develop a reputation for not returning phone calls. It’s universally perceived as a form of disrespect.

Etiquette Toward Patients
Patients always have the right to know what we know or don’t know. They have the right to know what’s being done to them, and the right to consent to or refuse care without coercion through intimidation, subterfuge or outright dishonesty. A great standard practice, better than explaining everything before you do it, is to ask permission. Otherwise, explanations are little more than threats.

When you do explain a procedure, include family members who are present. Remember that family members are likely to be experts on the patient’s medical history, medications and allergies, and they are likely to have a vital interest in the patient’s well-being. Don’t make the mistake of excluding them, unless the patient wants it that way.

Patients have the right to everything we would expect if we were in their position, including comfort, warmth, and physical and informational privacy.

Patients have the right to be accompanied by any one of their choosing, or to be protected from anyone they do not want present at any time they specify. Consider including family members whenever the situation does not clearly interfere with your practical ability to provide care with appropriate dignity and privacy for the patient.

Patients have the right to know the names and medical qualifications (including details of licensure, education and experience) of every caregiver. Wear nametags anytime you are involved in patient care.

Patients and their family members have the right to know how to express unhappiness with your service, but never solicit their appreciation, praise or thanks in any way.

Patients have a right to know the cost of their care and all consequences of their care-related decisions and requests. If you don’t have that information, refer their request to someone who has accurate answers.

Patients have a right to know when their requests for medical advice may be limited by the medical qualifications of their caregivers. A good way to respond when a patient asks for your advice is to say something like, “You should get your medical advice from a doctor, not an (EMT, paramedic, etc.). But if you were my mom, this is what I would tell you…”

Patients should rarely need to be patient, except when our response to a request is limited by the level of our medical qualifications or our physical ability to comply with their wishes.

Patients have the right to our best efforts to physically protect them from the effects of weather. That includes not only temperature control, but also the use of a physical barrier to protect their face from exposure to direct sunlight, wind and precipitation in any form. If any crewmember on a call is wearing a jacket, there should be a second blanket on the cot. Both blankets should be deployed as a matter of course on behalf of every patient who does not spontaneously decline. You could call that the two-blanket rule.

Every patient has the right to a pillow. They may not be able to calculate dopamine drips, but they understand and expect ordinary amenities. When we ignore the importance of such things, we look like amateurs.

Etiquette Toward the Elderly
There are some specific behaviors that many elderly patients find irritating. Even if they don’t say so, the elderly really hate it when you:

Talk about them in their presence as though they weren’t there. You probably wouldn’t be too crazy about that yourself, but it’s more of an insult when somebody is 50 years wiser than you are and you treat them like an idiot.

Shout at them as though they’re deaf. So far, there is no evidence to suggest that a disproportionate number of elderly people have hearing deficits.

Treat them like children. A person who has raised children and grandchildren doesn’t like being treated like a child (or being referred to by garbage labels like “honey,” “dear” or “pal”) by someone who’s one-third their age. Instead, address them as Sir or Ma’am.

Ask them a question, then interrupt before they can answer. That’s downright rude, unless the patient’s physical status is extremely acute and you follow it with an apology or an explanation. Nothing else ever excuses you from being rude to a patient.

Ignore them when they try to tell you something. That’s not just rude, it’s also dumb. Hippocrates said, “Doctor, listen to your patient, and he will tell you what is wrong with him.” Wise physicians have followed that advice for more than 3,000 years.

Etiquette Toward Officials
Public officials or officials of allied emergency services should be addressed by their title and last name, unless they indicate a preference otherwise, such as Chief White, Officer Krupke or Councilman Varga. A mayor is usually addressed as Your Honor; so is a judge.

Members of the clergy warrant our respect. Most clergy are professionals who respect your on-scene responsibilities as much as you do. More than that, nothing is more important to some people in crisis than their faith.

When you encounter a clergy member, try to elicit their identity and affiliation, and refer to them by the appropriate title of address. For instance, address a priest or nun as Father or Sister; a protestant minister as Reverend. A bishop of any denomination is addressed as Your Eminence, unless they indicate another preference. A rabbi should be addressed as Rabbi. Ask representatives of other religions how they would like to be addressed, unless a crew is familiar with the specific protocols that pertain to a given individual.

When called to a place of worship, be aware that the patient is the center of attention for the entire congregation. Protect their modesty and remove them from the environment as soon as possible.

School officials deserve special respect, because they bear the ultimate responsibility for the welfare of their students. Do everything you can to avoid challenging their authority in front of pupils.

It is never inappropriate to ask dignitaries how they would like to be addressed. In routine conversation, it’s okay to address people you don’t know as Sir or Ma’am until you learn their name and title.

Domestic Etiquette
Next to a patient, no one possesses as much vital knowledge, has as much authority or warrants as much respect in a domestic setting as the patient’s spouse. Listen to what the spouse has to say, keep him/her informed and consider the spouse’s input. On the other hand, if a patient is competent to make his own decisions and the spouse doesn’t agree with those decisions, reject the spouse’s input as politely as you can. If you aren’t careful, you can provoke both of them to take sides against you. In that event, you will have no influence as a caregiver.

Acknowledge the relationships between parents and children, and always show parents respect while in the presence of their kids.

Consider that some ethnic groups assign special respect to certain family members; however, you can offend more people by making assumptions than by simply being unfamiliar with their customs. It’s better to concentrate on treating all people with respect than to concern yourself with cultural generalities.

If it seems appropriate, welcome family members who represent themselves as medical professionals to accompany a patient to the hospital and to participate in treatment (depending on the circumstances). Many family members expect varying degrees of leadership from their medically trained relatives, and may forever remember their degree of involvement in the care of a loved one.

It’s almost always appropriate to allow a family member to hug or kiss a patient prior to transport. Consider the possibility that this may be the last time they see one another alive, and, if the circumstances allow it, offer them the opportunity.

Be turf conscious. When you are in someone’s home, do not exhibit carelessness or disregard for their personal property, and never express ridicule toward the home of someone who has invited you there.

On the subject of turf, we should mention bars. Bars are dangerous places. Drunk or not, expect every patron to behave as though they’re on their own turf. Chances are, most of them will be much more familiar with the bar than you are. Fortunately, every bar is equipped with a barkeeper. They know how to control their establishment and can be expected to know their regular customers. Ask the barkeeper to turn off the music, turn up the lights and stand behind you to keep an eye on the crowd while you get your patient out, pronto.

It is essential to protect the modesty of patients and their families in any setting—not only in the public eye, but also when you are working within sight of family members. Remember that a patient’s bedroom is his/her most private place, and being invited there, especially in the middle of the night, is a distinct honor.

Etiquette at Death Scenes
Nothing is as frightening for a new EMT, or as challenging for any EMT, as breaking the news of the death of a patient to family members. Having someone you love suddenly taken from your life is a horrifying, disorienting experience, and the words and actions of caregivers can have a profound and lasting impact on survivors.
When it becomes necessary to pronounce death or decline to resuscitate, it is essential to handle the deceased gently and with a subdued demeanor. This is especially important when family members are present, but it applies at all times, considering that family members may appear on scene at any time under such circumstances.

The techniques for facilitating bereavement are as varied as the circumstances that surround it, and they warrant formal training. Basically, death may have been anticipated for some time, or it can occur without warning. Clues include the appearance of the body and the family’s demeanor. A family who is expecting death might appear quiet and resigned, although they may be weeping when you arrive. A family who was not expecting death may not be aware it has occurred when you arrive. Assess the family’s awareness level as you assess the patient. The history of the event can be helpful, such as learning about a terminal disorder prior to a survivor’s initial discovery that the patient is unresponsive.

If it appears that the patient died during sleep, tell the survivors this was a painless way to die. Ask how long the survivors have known the deceased, and encourage them to talk about their mutual relationships. If the relationships have been happy ones, remind them that they can still treasure their memories. Depending on the family’s spiritual beliefs, they may derive great comfort from the notion that their relationship with the deceased does not have to end.

In the case of unanticipated death, direct your first efforts at resuscitation. When it becomes evident that you will not be successful, designate one or more communicators from the crew to sit down with the family. Start by asking when the patient last talked to them, how he or she was feeling at the time, and if there have been any warning signs of serious disease. These questions give you a chance to see how the survivors will react, and also give you an opportunity to break the news of their loved one’s death.

If appropriate, tell the family you did everything possible to resuscitate, but that your efforts were unsuccessful. Consider showing the family the obvious signs of death. In that case, make it clear that there was nothing they could have done to prevent the death.

Finally, let the survivors know what to expect next: the arrival of law enforcement, a few questions, and some further instructions about the next few steps.

Following the call, send a sympathy card. Don’t include your return address or your agency’s name—that construes self-aggrandizement. Instead, write something like, “We’re sorry you have to feel so bad, and sorry we couldn’t have helped you more.” Then sign it simply, “Your friends, the paramedics” (or “…the EMTs”).

Conclusion
Professionalism mandates competence. More than that, it means we can prove we’re competent. If we drove nails for a living, we could be competent all by ourselves. Instead, we belong to the most important service industry in the world, whose challenges are routinely impossible. But no matter how good we are at what we do, our safety and effectiveness depend on professional etiquette—our ability to consistently interact in a positive way with other people, especially knowing that many of those people are in crisis and having the worst day of their lives. Maybe it’s time we started teaching one another how to do that. And maybe this small article will serve as a beginning.

Thom Dick has been involved in EMS for 40 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of the EMS World editorial advisory board. E-mail boxcar_414@yahoo.com.