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4 ways to bring order to a chaotic scene

Approaching every scene with calmness, compassion, command presence and code choreography leads to better patient care


"Thank you."

Two words, spoken too rarely, that makes all the difference in the world for an EMT.

Said with sincerity, it makes up for months of drudgery, long distance transfers, system abuse, hours posting on street corners, and a thousand other tedious realities of EMS.

In this case, those words were spoken to me by a mother of a 4-month-old infant who had just died. I still don’t know why the child died, only that it had been chronically ill with respiratory issues. The cigarette stench that clung to every surface in her home undoubtedly exacerbated those issues.

The apartment was small and dirty, in a housing development where white EMTs are met with the same barely veiled hostility and distrust normally reserved for the local cops.

I doubt whether the care and discharge instructions provided by the child’s pediatrician and the local emergency department were ever followed up on or continued at home. I do know that the mother had drug abuse issues of her own. It wasn’t the first time I had been in that apartment.

We couldn’t have been more different: a young, uneducated, black unwed mother with a drug abuse history, and a white paramedic with a beer belly and a Southern drawl.

Walking clichés, both of us.

Yet none of that mattered when her baby’s life was in danger. She had called for help, and I was the one who showed up. All the ingredients were there for conflict, but because I refused to follow the recipe, so did she.

In my last column, I spoke of the need to put compassion before protocols. Most of the people who commented understood my point.

But a number of people in the various social media sites fixated on the one example where I allowed the mother of an infant to accompany her child in the back of my rig while I performed CPR. The objections were predictable.

  • We don’t have enough room.
  • I’m trying to save a life here. I don’t have the time to calm a distraught parent.
  • Parents should never witness CPR on their child. It’s cruel.
  • Sure, like I’m gonna let a hysterical mother in the back of my rig while I’m trying to work. Not gonna happen.

Most of these objections are based upon two fallacies: that resuscitations are inherently chaotic, and that family cannot handle witnessing such chaos.

Neither of these things is true.

In the case I mentioned, chaos and parental conflict weren’t elements of the call because of the skills I try to bring to every scene: calmness, compassion, command presence, and code choreography.

Calmness

Unlike most EMTs of my generation and earlier, my role models were not Johnny Gageand Roy DeSoto. I looked up to Hawkeye Pierce from M*A*S*H. Hawkeye faced every situation with humor and insouciance.

Watching him, you got the impression that no situation was beyond his capability to handle, yet no amount of wisecracking made you think he was unconcerned about his patient’s welfare.

Hawkeye knew what many people don’t: medicine is far too important to take seriously.

Humor defuses tension, and keeps everyone else on the team loose and relaxed. Relaxed caregivers make fewer mistakes, and focus better on the quality of their care, rather than just the speed at which it was provided.

Compassion

There’s an old saying in medicine that goes, "People don’t care how much you know until they know how much you care."

It’s a cliché, but all clichés contain a fundamental truth. Families and patients are largely ignorant of the medical knowledge and skill you possess.

What they notice, and remember long afterward, is the kindness and compassion you display. A blanket and a little hand-holding mean more to them than the fact that you can extract blood from a rock or fall down a flight of stairs and intubate five people on the way down.

That compassion is why many an old country doctor was able to commit acts of medical malpractice long after the science of medicine had passed them by, simply because his patients knew that old Doc Johnson genuinely cared about his patients.

The lesson there is that competence is not an adequate substitute for compassion. You need them both.           

Never, ever fall prey to the notion that you don’t have time to be compassionate. It never takes any longer to do your job with compassion, no matter how bad the call.

Command Presence

Once upon a time, many years ago, I had to transport my boss from the local hospital to a chest pain center 40 miles away. When I arrived at the ED, she was being stubborn and difficult with the staff, and refusing to let them treat her.

Her husband — my other boss — was there, as was the ED physician, who happened to be our service’s medical director, and the nursing staff. All of them were friends, and all of them were unsuccessfully pleading with her to accept treatment.

I watched the scene for a few seconds, and then quietly said, “Excuse me.” Every one stopped what they were doing, and stared at me. I made eye contact with my boss, held it, and gently said, “Liz, get on the bed and stop arguing. Give the man your arm and let him start an IV. And do it right now.”

She did.

Twenty minutes later, as I adjusted her nitroglycerin infusion, I asked her, “You sign my paychecks. Why did you obey me and not everyone else?”

She looked surprised, then thoughtful, and then shrugged her shoulders. “It didn’t occur to me not to,” she answered. “You’ve got a quality.”

I’m not sure command presence can be taught. But what I do know is, it has nothing to do with barking orders, or shouting or hurrying.

The times I have seen it in others, it was best described as quiet leadership: thoughtful, unhurried, matter-of-fact. You got the sense that the person in command was a step ahead of everyone else, and was patiently waiting for the rest of the team to catch up.

New EMTs working with me for the first time invariably remark on how rarely I transport with lights and siren, or how they did not appreciate how sick our patient truly was. And the answer I always give them is that the better I do my job, the less dramatic it is.

Planning, thinking, and staying ahead of the treatment curve may not make for a Hollywood-worthy medical drama, but it makes for great patient care.

The attitude you want to project is, "The emergency ended when I arrived on scene."

That doesn’t mean you don’t move with a sense of urgency or that you never feel stress. It simply means that the person in charge should always be the island of calm everyone looks to for guidance.

If that person on scene is not always you, change what you’re doing because it isn’t working.

Code Choreography

If there is one thing I have learned in leading several hundred real resuscitations and several thousand mock ones in teaching ACLS classes, it’s that the smoothness of the code has little to do with the individual skill of the team members.

Resuscitation is a complex ballet of interventions, and the key to making sure all the dancers aren’t stumbling over one another is effective communication. It’s the team leader’s job to know what the dance steps are, and to make sure that all the dancers have their movements synchronized.

I call it "being the stand-back, big-picture, non-interventional paramedic."

It takes open communication and a great deal of practice to do that, but you need not be working a code or even a simulation on a manikin to get that practice.

Game plan with your partner en route to the call. Work out imaginary scenarios in between calls. Critique your performance after calls.

Let mental preparation between you and your partner fill in the gaps between physical activity.

Because I work with a lot of brand new EMTs, I’m frequently required to work a resuscitation before we’ve had the opportunity to do that mental preparation. On the way to the call, they’ll ask nervously, "Sooo … what do you want me to do?"

I always answer, "I want you to slow down, because when you hurry you make mistakes. I want you to do CPR. You have the most important job in a code. Don’t interrupt compressions unless I say, and everything else I need to do, I’ll work around you."

On those instances when we’re second-in, I tell my partner to plug themselves into the BLS side. Ask the EMT what still needs to be done, and do it. Then get prepared to switch out compressor roles.  

I’ll plug myself in on the ALS side. Sometimes, the lead medic doesn’t know how to be that stand-back, big-picture, non-interventional paramedic, and I assume that role.

But rarely is it ever chaotic and disorganized, and as a result I have no problems allowing family members to witness it, and those families draw strength and calmness from the professionalism of the rescuers on scene.

Remember that calmness, compassion, command presence and code choreography are the tools you need to bring order to chaos. With those in your toolbox, you’ll be surprised how easy it is to be kind while providing excellent patient care.

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