The Illussion of Control

Part two of a two part series on scene presence. Part one is here.

While we’re talking about scene presence, I think it’s important to bring this one up. I’ve hesitated to talk about the illusion of control on the blog even though it’s a learning point that I invariably discuss with new students on the rig in the first one or two shifts. The illusion of control is deeply applicable to learning scene presence, but, quite frankly, it contradicts something I’ve preached here on The Spot for some time.

It contradicts my advice to always be authentic. When it comes to authenticity, the illusion of control is the exception to the rule. I suspect that some of my regular readers may have take issue with that. It’s OK, I’m a big boy. I can handle it.

In the world of scene management and scene control, the illusion of control is a metaphor for how we should respond when things don’t go the way we planned.

There is an awkward and embarrassing moment that we all have to deal with while running calls. It helps to think it over before it happens. If you’ve been in EMS for any length of time, it’s already happened to you. So let’s talk about it now. How do you react when you make a mistake during a call? What do you do when things don’t go as planned? How do you respond when you make an outright flub, guffaw or blatant error right there for everyone to see?

My answer, “The illusion of control.” Allow me to explain.

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Get Anyone to Go With You to The Hospital

I’m going to share with you a very powerful technique to convince just about anyone to go with you to the hospital, and I’m going to ask a favor of you. Please only use this technique in the patient’s best interest. This isn’t a technique to drag out when your service pressures you to increase transports or you’re not in the mood to call in for a proper refusal. This is a technique for when you really honestly believe that the patient needs to go, but they refuse.    -Steve

It’s an interesting contradiction in prehospital medicine. The people who don’t really need an ambulance insist on transport and the really sick folks refuse to go. Sometimes the people we could really help dig in their heals and just refuse to go. It’s frustrating. It can be maddening. And occasionally it means that we have to pull out our paper work and sign a potentially really sick patient out against medical advice. (AMA)

In these moments we implore the patient to reconsider, hand over the paperwork for signing and then we say something about calling us back if things change. Now let me give you one more technique to try before you pack up and walk away.

This is a simple, three-part technique. 

Step One: Establish a rapport with the patient. Hopefully you’ve been working on this from your first contact. Fair warning, don’t try to skip over this step. If you haven’t established a rapport with the patient this just isn’t going to work. The patient needs to trust you and be willing to consider what you say.

If you’re developing your patient rapport skills I recommend reviewing Connections, Patient Rapport Land Mines and You Can’t Give Away What You Don’t Have. You may even want to stop by Patient’s Define Their Emergencies.

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How To Make Sure Your Hand-off Reoprt Gets Heard

“But … It Was In My Hand-off Report“

Every EMS responder who delivers patients to the emergency room has experienced the frustration of feeling like the ED staff didn’t really get the whole picture. You came in, you told the story and you said your goodbyes, but somewhere along the way it felt like there was a disconnect.

Now, some excellent research out of Harvard tells us exactly how much of the EMS hand-off report is really making it into the patients chart and being used in the clinical decision making and care of the patient. I’m sure the study findings are going to have a bit of a “duh” effect on responders who give routine hand-off reports to ER staff, but it is nice to feel that your impressions have been validated by some objective measure.

Researchers decided on 16 prehospital data points that were considered to be significant in effecting patient outcomes in level one trauma activations. Then they had a panel of trauma physicians watch videos of the EMT-to-trauma-team hand-off reports and checked off when the data points were actually communicated in the verbal hand-off report. Next they checked the patients medical record to see how many of these data points had been recorded in the patients chart.

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Patient Rapport Land Mines

Patient rapport is something we can easily overlook in our quest for better medicine. Our book never touched on it. It was barely mentioned in class. It doesn’t make its way to the EMS conference circuit very often – outside of a few exceptional lectures by Thom Dick. So how important could it possibly be to good patient care?

Patient rapport is one of those foundational skills in EMS. When we improve this one skill, it supports everything else we do. You’ve heard me talk about ways to break through the initial patient / caregiver barrier and develop rapport in the past. Now let me talk about the other side of the coin.

Let’s discuss the things that we do that break down rapport or prevent it from ever forming. It’s much easier to break down rapport than to build it up. Here are some of the landmines that can break a good rapport into bits. We’ve all stepped on these a few times in the past and, unfortunately we’ll probably do it again. The best thing we can do is recognize these awful habits for what they are and try to avoid them at all costs.

Here are my top six patient rapport killers:

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The Oklahoma State Trooper vs EMS Mess

This has gone on long enough and gotten big enough that I feel compelled to say something about it. By now I’m sure you’ve seen and heard all about the Oklahoma State Trooper / EMS roadside circus.

First we had the cell phone video of an upset family member recording an odd looking scuffle between an Oklahoma State Trooper and an ambulance crew on the side of the road. It starts with a narrative by the family member and ends with the ambulance dude in a disturbing looking choke hold.

Then the driver of the ambulance went public and started giving news interviews, stating he was compelled to do so by the statements of the trooper in his report. Somehow he felt that the media spotlight would be the best place to get this off his chest. He was followed by his partner, calling for the officers badge on The Early Show.

The OSP finally released the dash cam video showing an ambulance yielding appropriately to the officer and never taking the aggressive swing at the trooper as initially reported. Then the biggest clown of all chimed in when the OSP lawyer held a press conference to say that everything we saw on the tape was normal and appropriate except for the gross negligence of the ambulance crew failing to yield for a full 24 seconds. What?

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Connections

Sure you communicate with your patient, but do you make connections? The difference may sound like semantics … but it’s not. The difference is extraordinary.

Do you remember James Burke? He was the plucky, dry humored narrator of the 1970s BBC TV series “Connections”.  James would begin each episode with some historical event like the invention of the catapult and show how it was related to the way we make billiard balls or some other impossible sounding connection. His message was simple and profound. The big idea was that we are interconnected in ways that are complex and impossible to predict. Reality doesn’t flow forward in a perfect linear timeline.  An intricate web of human connections drive history and innovation forward.

Without one minor connection another crucial event becomes impossible. Alter one seemingly insignificant event and you change the course of history.

There is something vital in the way we are interconnected. When we connect, we change each other in ways that we can’t predict. If we simply communicate with our patients and coworkers but never reach out across that gap and connect with them, our work can become dull and routine. On the other side of the gap the patient / caregiver / human relationship is far more fulfilling.

If that sounds worthwhile, let me give you a few tips for making conscious connections with your patient.

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5 Big Trauma Scene Mistakes You Can Avoid

We all have our good calls and our bad calls. Don’t we? Sometimes things just flow. Sometimes the patient, the bystanders, the crew members, everyone just clicks. And it’s beautiful. It’s like that perfect drive off the tee box that keeps you coming back for another round. The three point jumper that makes you wonder if you should have tried to play college ball.

Unfortunately (perhaps) it is the rare scene that runs flawlessly. More often than not we look back on our calls and think about the things we could have, and should have done better. Of course, that’s how it should be. Without those moments we don’t grow or become better. Some EMT’s carry the philosophy that we should emerge from our field instruction with flawless medicine. Nothing could be further from the truth.

Here is my list of six common trauma scene mistakes I have encountered frequently in my career. I am guilty of doing all of these, some with painful frequency. In those moments of personal scene review, I rank these as my top six, “I wish we had done that differently.” items.

#1 Failing to manage the scene.

We learn a lot about patient care in school. Unfortunately our education regarding management of the scene may be limited to being taught to blindly recite the words, “Scene safe, BSI” as we enter our skills stations. Scene management can be hard. Especially management of big scenes with multiple priorities like calling for more resources, assessing hazards, protecting bystanders, interacting with family and friends of the injured and triaging multiple patients.

On these scenes, patient care suddenly becomes a warm comforting blanket. Caring for one patient seems so much more manageable. Patient care priorities like holding c-spine and doing an assessment call to us like a sirens song. Don’t do it! It seems obvious but, when it’s your job to manage the scene, manage the scene.

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