Managing Public Expectations

Fourteen years ago my field training officer told me, “EMS is like no other business.” Many of us find truth in that statement. I think he was simultaneously right and wrong. Being “like no other” can be a place to hide under a blanket of profound avoidance. Over the years EMS agencies have fought to overcome internal attitudes on safety, management, and professionalism that found solace beneath this binky. 

When it comes to dealing with public expectations, explaining that you’re unique can set your agency apart from the pack. It can also fall on deaf ears in the dire moments of an emergency when a person’s common sense processing fails. What are some of the public expectation variables that make a field provider’s communication more challenging? An EMS administrator receiving a complaint over the phone?

How would you handle this situation?

Once upon a time two paramedics were dispatched for a woman with abdominal pain at a suburban grocery store. We’ll call them Stan and Gabe. They parked in front of the store and retrieved their patient on a stretcher. Inside the back of the ambulance, Gabe performed numerous exhaustive yet highly appropriate assessments and developed a working diagnosis of FART syndrome. This gassy lass fit the “stay and play” assessment model, with a window cracked open, of course. Suddenly they noticed a man’s face peering through the back window of the box. The man quickly ducked out of sight and then reappeared with a frantic rapping on the side door. Gabe opened the door, and a man in a milkman’s delivery uniform presented himself, looking like the patient’s frightened spouse. Gabe calmly introduced himself, and the milkman said, “What’s going on in here?" Gabe said, “She has some pain in her belly, and we’re doing some tests.” The patient turned to look at the milkman and glared. Gabe, accurately sensing discord, asked, “Do you know this man?” She replied, “I’ve never seen him before.”

Lacking his partner’s patience, Stan stepped out of the side door and closed it behind him. Stan asked the milkman if he knew the patient, to which he replied, “No!” The milkman insisted, “You need to go…Take her to the hospital!…I don’t understand why you’re waiting here!”  Sensing the pending apoplexy, Stan told the man that though they appreciated his concern, they were paramedics doing their jobs. Stan asked him not to interfere further, and the milkman departed in a huff.

After the call Stan and Gabe wondered what possessed the milkman to interfere. They had initially given the man the benefit of the doubt based on his level of concern. Both the milkman and the patient had a plausibly similar ethnicity. They both spoke with foreign accents not typical in their area. Of course they could be related, right? Apparently, not so much.

Later that shift Stan and Gabe told the story to their supervisor, who was less amused than angered. The supervisor contacted the local dairy’s apologetic manager and, per EMS lore, said the following: “I don’t tell your guys how to stack milk! So don’t tell my guys how to run EMS calls!” That’s the kind of story that’s funny enough to make the milk you just drank rocket out your nose! It also raises the question, what was the steamed milkman thinking, and could the situation have been handled differently? The first part of considering how the other side got to their conclusion is to step into their shoes. 

Navigating Diversity

The differences in care capabilities close to home are generally well-understood by EMS providers. As soon as we leave our county, region, or state, we’re often surprised by the variety of organizations that supposedly do the same job we do. We also know  this leaves most of the public confounded by the role of EMS. When you visit other places, do you know what to expect from the EMS providers? Is there an EMS provider? Stan and Gabe will never know where their interloper hailed from for certain. West Africa, the West Bank, and even West Texas have dramatically different dynamics than Central Texas. 

If the lactose loiterer emigrated from the West African nation of Ghana, his expectations might be driven by the sheer oddity of seeing a patient in an ambulance at a grocery store. Perhaps he’d never seen an ambulance in person. In 2014 Ghana’s nascent National Ambulance Service call volume was more than 80% interfacility transfers, followed closely by “roadside” events. Ghana had 199 ambulances (not all functional), about one for every 130,000 people. In 2010 the U.S. had an estimated one EMS vehicle per 3,800! Maybe this contributed to a milkman’s froth of confusion.^1,2

Did the milkmeister hail from the West Bank? We’ve all seen videos of ambulances barely stopping as less-injured folks fling more injured folks into the box, sirens wailing away. Even if the guns are silent, the political complexity of the never-ending Israeli-Palestinian conflict compounds EMS challenges. Israel’s national EMS service, Magen David Adom (MDA), the Palestinian Red Crescent, and United Hatzalah (a volunteer service) are all potential lifesavers in the hotly disputed West Bank. After many years of declining funding for MDA services in the West Bank, the Israeli government recently decided to fund them fully for 2019. Now, in addition to an Arab-Israeli conflict, there’s an Israeli EMS conflict. The MDA and United Hatzalah are suing each other over the ability to respond, dispatching, and more. Ay caramba! Udder confusion for our man of milk.^3,4

Was our ice cream cowboy from the West Texas county of Hudspeth? His EMS services would cover 4,572 square miles. That’s an area larger than Delaware and Rhode Island combined! Unlike those wee states, Hudspeth County has 0.76 persons per square mile. There’s no 3/4ths folks out there. No zombie apocalypse! Just 3,476 whole folks being served by three mostly volunteer EMS agencies. According to the Texas Health and Human Services Commission, there are five currently licensed “in-service” EMS provider vehicles countywide.⁵ If you’re a ways from one of the county’s three small towns, your ice cream might get soft before the ambulance arrives.

Were Stan, Gabe, and their manager wrong? Not necessarily. They did the best with the information they had at the time. They put the well-being of their patient and personal safety at the forefront. Perhaps a nonmoving ambulance brought the milkman to a boil, thinking someone was dying inside as Stan and Gabe looked on. Only one thing is certain: As long as EMS at every geographic level remains diverse, we will be seriously challenged to educate the public and satisfy their expectations. 

Engaging the Public

Being EMS folks, many of us enjoy a serious challenge. So what can we do to bring expectations into the realm of reality? First, every EMS provider from the loneliest prairie to the densest city should consider themselves a small fish in a big ocean. This ocean containing the EMS genus teems with a seemingly endless variety of species. Medics who are learned in cultural and EMS diversity will be better prepared to patiently and respectfully inform the public.

Next, let’s not forget that only a small percentage of your local public will experience EMS during an emergency. That leaves a gap that can only be filled by working to engage the public at every other opportunity. Social media should be part of your recipe, but it cannot supplant live interaction. The most important person in your organization for spreading the word about what you do has a title like “outreach coordinator.” In an all-volunteer department, that person might be you. Teaching compression-only CPR, Stop the Bleed, and child safety can potentially double or triple your face-to-face public contact in a way that is much more meaningful than social media.

Finally, we should look both regionally and nationally at what EMS does so, when appropriate, we can educate the public on the few simple points that make us all the same.

References

1. Zakariah A, Stewart BT, Boateng F, Achena C, Tansley G, Mock,C. The Birth and Growth of the National Ambulance Service in Ghana, hwww.ncbi.nlm.nih.gov/pmc/articles/PMC5558015/

2. National Highway Traffic Safety Administration. EMS System Demographics. 2011 National EMS Assessment Research Note. Washington, D.C.: National Highway Traffic Safety Administration, 2014.

3. Government Announces It Will Fully Fund MDA Services In The West Bank. Jerusalem Post, 2019 Mar 29; https://www.jpost.com/Israel-News/Government-announces-it-will-fully-fund-MDA-services-in-the-West-Bank-585123

4. Staff AS. United Hatzalah Slams MDA Following Lawsuit. 2019 Mar 25; www.israelnationalnews.com/News/News.aspx/260859

5. Texas Department of State Health Services. Texas Population, 2010 (Historical Race Ethnicity Categories), www.dshs.texas.gov/chs/popdat/st2010.shtm

Capt. Dan Cohen is a provider of clinical education for Williamson County EMS in central Texas.