Objection, Your Honor!

A few years ago I was training a new hire.  We were sent to a chest pain call where we found the fire department caring for a middle-aged man.  The trainee walked up to him and asked his first question: “Sir, do you have chest pain?”

“Objection!” I said quickly.

“Sustained!” said two firefighters simultaneously.  That’s awesome.  I love good comedy.

They're never unanimous… (Public domain photo)

What was the issue?

The issue, at least the one I want to write about now, is a common error that I see.  Actually, I hear the error.  It is asking leading questions. 

Leading questions, for our purposes, are questions that can be answered either yes or no.  "Do you have chest pain" is answered 'yes' or 'no' (or 'I don’t know', but if they don’t know that is a whole different rant).  There are two problems with leading questions.  First, a leading question doesn’t facilitate a conversation as well as an open-ended question.  Conversation is good for us – it allows us to get more detail, bond with our patients, and allow the chance for information that we didn’t ask for to be volunteered.  Second, like an unwary Jedi, you can unintentionally lead a patient to answer questions the way they think you want them to be answered.  You are leading them to the answer.  It can be due to people attempting to make sure you pay them attention, or people trying to give you the answer they want you to hear.  Whether it is for good or bad reasons, you are essentially leading them to the answer.  Picture where you would end up if each of these questions were answered in the affirmative:

Do you have chest pain?

Does it radiate to your left arm?

Is it causing you shortness of breath?

Are you nauseated?

Does the pain feel like an elephant sitting on your chest?

The way to avoid leading questions is simple.  All you have to do is start each question with one of the six “journalism questions”: Who, What, Where, When, Why, How.

“How does your chest feel?” can’t be answered with a yes or no.  Neither can “How is your breathing? Why did you call 911 today? How is your stomach doing?  What does your chest discomfort feel like?  Where is the discomfort located?  What would you have to do to me to get me to feel the same way?”

If you start each question with who, what, where, when, why, or how you will be ahead of the game.  How many times have you asked a patient, “Do you know your social security number?” and gotten “Yes” as an answer?  Frustrating, isn’t it?  Replace the ‘do’ with a ‘what’: “What is your social security number?”

Good supervisors will use this on you (at least I did).  “The patient said you were a jerk.  Is that true?” is a dumb question – it is begging for a ‘no’ accompanied by a facial expression that appears to be holding up a halo.  “What happened on that call after you arrived on scene?” is a better way for the supe to phrase it because it is open-ended and without prior assumptions.  By the way, avoiding leading questions also works well when dating.  Remember, the journalism questions are conversation starters:

Me: “Do you work near here?”

Hottie: “No.”

[cricket  cricket  cricket  then I run]

There are three main caveats to the No Leading Questions rule.  First, people in extremis who are 1-2 word dyspneic (or aphasic for whatever reason) are not known to be good conversationalists.  You have a limited amount of time to ask 3-5 questions before they get things placed in their mouth (or between their vocal cords).  Don’t be afraid to ask direct leading questions then.  “Are you asthmatic?  Are you getting tired of breathing?  Do you want me to take over that work for you?”

The second caveat comes up when the open-ended question isn’t working.  For example, I have had this conversation seemingly a thousand times:

Me: “What does your chest discomfort feel like?”

Patient: “I don’t know, it just hurts.”

Me: “I understand, but what would you have to do to make me feel the same way?”

Patient: “Are you an idiot?  I told you, it hurts.”

What we have here is failure to communicate.  In this case, I feed the patient the answers that I am looking for, but it is important that I shotgun a lot of choices at them.

Me: “What I mean is, is it sharp, stabbing, aching, cramping, crushing, burning, dull…”

Even if they start to answer, I try to get through all of my choices.  That way I am not leading them to agree with the first option.  A lot of times, a light bulb comes on over their head and they give me an answer.
Patient: “Oh, I see.  Kind of a dull ache.”

The third caveat is when I am trying to specifically rule something important out.  I had a patient a few weeks ago with ST elevation on his ECG, along with bigeminal multiform PVCs.  His ECG from two weeks before had neither of those concerning findings.  After getting “Fine” in response to several variations to the “how is your chest” question, I really wanted to make sure that we were speaking the same language.  I wanted to know if his chest hurt at all.  At that point, since I gave it a couple of open-ended tries, I asked flat out if his chest felt completely normal.  But I phrased it as: “Let me make sure I understand, because I can be dumb from time to time.  Correct me if I have it wrong.  What you’re saying is that your chest area feels completely normal.  Nothing weird at all, right?”  He said it did.  Weird.  But it can be important to know that his definition of Fine is the same as my definition of Fine.

The three caveats are rare, so if you keep to the journalism questions for the most part you will be doing fine.  Practice asking your questions that begin with did, is, are, and does by using who, what, where, when, why, or how.  

Who, what, where, when, why, and how are your friends.

A Tale of Two Doctors

Let me tell you about two phone interactions that I recently had with physicians.

The first came when I was working a shift at the airport.  In my EMS system, several paramedics posted throughout the property staff the airport.  They generally cover calls for service alone, either on crew response vehicles (fancy golf carts) for indoor calls or Suburbans for outdoor responses.  There is also an ambulance posted on the airport property for any transports, but city resources rotate through that airport post.  Anyway, I was working on one of the concourses and saw a gentleman that was flying from the east coast to the west coast, with a connection in Denver.  On the first leg of his trip he had a medical problem, so the airline requested that I meet the aircraft when it arrived to check him out.

The specifics aren’t important – suffice it to say that he had vague complaints that meant it would have been the smartest move for him to go to the hospital.  But the man had decision-making capacity and chose not to go to the hospital, even after I explained that his complaints were concerning and leaving the ground again increased the danger to him (you’re not especially close to convenient medical care while in flight, after all).  I contacted my base physician to document the against-medical-advice refusal.

When that was all done, the airline representative told me that she was going to call her physician consult service.  There are two or three companies that airlines can use for medical advice.  If there is a medical emergency in flight, the crew can call these services and get advice as to diverting the flight to the closest airport or to continue to their planned destination.  On the ground, airlines can get advice as to whether it is advisable to let the patient continue to fly.  An unscheduled diversion of a flight costs the airline a boatload of money to make up missed connections, fuel and landing fees, and stuff like that, so if you’re sick the airline doesn’t like to let you fly.  It is called boarding refusal – the airline refuses to let the person board.

In any case, I don’t care who the airline calls.  But to be nice, I said that I would hang out in case they decided to refuse him boarding.  If you get refused, the only way to get on a flight is to get a doctor to sign off on you being okay to fly.  So if the patient was refused boarding, I would use the ambulance to get him to the hospital, get him checked out, and then he could continue his travels.  But I told the airline representative that I couldn’t talk to the medical consultation service.  Of course, it wasn’t 20 seconds before she pressed the phone into my hand and I was talking to a doctor that I didn’t know.

Long story short again, our interaction was not pleasant.  The physician wanted my full verbal report, which is a violation of the patient’s privacy.  We went round and round about whether the patient could give his permission for me to give a report.  I feel like it doesn’t matter if the patient gives permission – the doctor I was talking to isn’t involved in the patient’s care.  He is the airline’s doctor, not the patient’s caregiver.  In addition, the patient isn’t making an informed decision to consent to this privacy violation – it can’t be informed without the patient being told that the likely result is that he won’t be allowed to continue on his journey.  I tried to explain all of that clearly, but the conversation got pretty heated.  The consult doctor would not try to talk to the patient directly.  I got the impression that the phone physician wasn’t hearing my point of view.  He was pretty frustrated with me and ordered me, as a paramedic, to do what he, a physician, was telling me to do.  I declined to cooperate with the phone consult, the patient was refused boarding by the airline, and the ambulance took him to the hospital to make sure it was safe for him to fly.  They actually told the patient that it was my fault and my lack of professional cooperation was causing the refusal to board. 

Contrast that story with a call I ran the very next day.  I was working a street ambulance and responded to an elderly man who definitely needed to go to the hospital.  But the patient did not want help, did not want to see me, and was angry that I was even at his house.  It took me five minutes to even talk my way in.  This call worked out that the patient was pretty sick, with sats in the 80s, tachycardia, a bunch of supraventricular ectopy, and respiratory distress.  He needed an emergency department, probably getting admitted for a hospital stay as well.  He did not want to go, however, and had no qualms about profanely and loudly letting everyone know that.  But once I could get him calmed down, I realized that he wasn’t altered or demented – he was just an angry old man.  He was funny and I liked him – I hope to be an angry old man one day.  Picture Archie Bunker, but louder and angrier.  “I’m not going to any goddam hospital, dammit! And you can’t make me!”  I explained respiratory failure, sudden death, and my other concerns for his condition and he repeated them back to me in his own words.  He understood the dangers and his decision.  He was making the wrong choice, in my opinion, but he is allowed to if he has decision-making capacity.

So I contacted my base hospital to document the against-medical-advice refusal.  In my system, we make base contact to one hospital only.  Only physicians that I take orders from are at the other end of that phone number, called the biophone, no matter where I am transporting to.  Nurses don’t answer the biophone.  This allows the attendings and senior resident physicians to get to know the paramedics.  It is a big responsibility – if I describe an incoming patient to them and arrive with a patient that looks completely different, they will remember that Bill doesn't give accurate verbal reports.  That reputation will follow me.  But if I am known for accurate reports and good decision making skills, that reputation will follow me too.  There is certainly a double-edged sword, but it works to the benefit of good paramedics.

Anyway, I explained the situation to the attending physician – that I had an elderly male who needed the hospital, but he had decision-making capacity, and that he didn’t want to go even after understanding the consequences of that decision.  The doctor asked to speak to the patient on the phone.  Some situations call for this, in that the biophone is a recorded line.  I think he wanted to confirm that the patient was competent to make that decision and save the interaction proving it on tape.  But it did not go well.  The patient got his back up again, angrily and loudly refusing to cooperate with the doctor on the other end of the phone.  When I got back on the line, the attending said, “Bill, based on that interaction, I don’t see how he could be described as competent.  He is going to have to go to the hospital.”  Based on that interaction, I had to agree.

My partner asked for a few police officers to come by to help us with the brawl that was about to ensue.  It was not going to be fun to wrestle a sick elderly man to the ambulance.  I was picturing him worsening, plus he wasn’t exactly one of the weaker elderly patients I’d ever met.  This was fixing to be a headache.  So I spent the time waiting for the police by calming the patient down again and chatting.  Once he was calm, you could see that he had capacity.  This guy wasn’t confused, he was an angry old man.  I think my partner saw the same thing.  She came up to me and said, “Bill, I don’t feel good about this.”

I didn’t either.  This was a clash between the ethical principles of autonomy (patient can decide what happens to them) and beneficence (we’re here to help people).  I was being asked to drag a man out of his home and force care upon him.  If he wasn’t competent to refuse, if he didn’t possess decision-making capacity, it would be okay with me.  But he had capacity and didn’t want anything that was about to happen to him.  I continued chatting with the patient more and he mentioned that he would be okay with going to his doctor at the clinic and his son could drive him there.  But he reiterated that he would not agree to visit a hospital.

I decided to call the biophone back and asked for the attending physician that I had called 10 minutes before.  I explained my point of view: “Dr X, I really don’t feel good about forcing this patient to go to the hospital.  I think he has capacity.  He is just a really angry old guy who isn’t interacting in a productive way.  I wonder if I could talk you into speaking to him again.”

“Well, Bill, I will try.  But I don’t see anything that could happen to change my mind.”  The doctor paused.  “What makes you think he has capacity when I am sure he doesn’t?  I don’t like being on completely different pages here.”

BAM!  This is the phenomenal question that made my heart swell with pride at my EMS agency and system.  Both the doctor and I were uncomfortable about being on different pages.  There was only one patient.  We should be interpreting the situation in similar ways.  One of us was wrong.  I am fully willing to accept that it is probably me, but I love it that a busy attending physician will listen to my point of view and consider it.  If there is other information that I didn’t have, was misinterpreting, or was miscommunicating we will get on the same page.  It is this process that protects us, our patients, and the system as a whole.  It is collaboration, with mutual respect, oriented toward doing the best thing for a patient.  The doctor is accepting my role as a patient advocate and respects the fact that my opinion may be correct.  I flat love it!

In any case, I explained what I was seeing that gave me the belief that the patient was competent to decide.  I explained that the patient came up with the clinic/son driving plan on his own, which to me showed that he understood his need for care and could make rational (if still wrong) decisions to get help.  This time, the physician agreed.  I had convinced him.  He had listened to me with a mind that was open enough for me to change it.  We stayed on scene to help the patient negotiate the appointment process, got someone he liked to stay with him and keep an eye on him, and made sure his ride was all set up for the appointment two hours later. 

It is certainly suboptimal that the patient wasn’t going to the hospital.  But patients are allowed to make bad choices.  I wish he had agreed to the ambulance ride and emergency department visit.  But what I want is immaterial with a competent adult who can choose for himself/herself.

The point of all this rambling is to illustrate how clear phone communication that includes open-mindedness, respect, and collaboration can protect the doctor performing the consult, the paramedics on scene, and especially the patients.  If you don’t work in an EMS system where you are trusted to form accurate decisions, expected to describe a situation completely and accurately, be responsible for backing them up and supporting them, and trusted to advocate for the right thing then you are not working in a good EMS system.  On the biophone, I need to be accurate, correct, and pretty much error free.  But if I am doing that, I am considered to be a professional caregiver who is worthy of respect and consideration.  Awesome.  

Oh, and never get on the phone with the airline consultation service. Nothing productive will come from taking that phone the airline rep is handing you.

Enjoyable Partners

Being a skilled provider or a smart medic doesn’t a good partner make.  So as a follow up to the Skilled-Smart Grid, I wanted to write up a list of attributes that I was looking for in a partner.  They included factors like being nice, being fun, wanting to help people, keeping incident reports to a minimum, and a bunch of other stuff like that.  There were fifteen attributes that I felt made for a good partner.  But the post didn’t read very well and I think the list sucked.  Even though it was way too long*, it wasn’t complete.  So it bothered me.

Until I realized that there are only two factors that make for a good partner: Be a decent, normal human being and understand the Two Rules of EMS.  All of the other factors can be distilled into these two points.

Being a normal human encompasses being a person that your partner wants to sit next to.  Be nice to people.  Explain what you are about to do to a patient before you do it.  Smile.  A good partner isn’t habitually malodorous (understanding that we all have bad days after subpar dietary choices – a point with which I have been known to fail) or cross social boundaries with habitual nose picking.  A decent human doesn’t habitually start fights with patients, bystanders, and other personnel.  Show up to work sober.  Keep your moodiness to a minimum, minimize unproductive bitching, and don’t act like your time is being wasted on every EMS call.  Mostly, I am looking for a generally socially acceptable person.

The Two Rules of EMS, for those who don’t click links and read other articles in the middle of an article, are “Leave people better off” and “Look cool.”  The ability to leave a person better off than when you met them means that you understand that our job is to help people.  This is true whether that person is in cardiac arrest or is lonely.  Set people at ease, relieve their pain, and begin the process of arresting and reversing their disease process. 

This is probably good for a whole post by itself, but I see the two most important questions in EMS as “What is going on?” and “Why are you doing that?”  A trainee gets asked those questions constantly.  A skilled provider asks themselves those questions constantly.  (You can tell a trainee has made progress toward being released from the field training program when they begin to question themselves and give coherent, correct answers.)  By being able to ask yourself those two questions and answer them in a rational and coherent way, you are constantly able to monitor your EMS practice and improve your patient care.  I am looking for a partner with the ability to ask themselves those two questions and answer them in a way that makes sense.

The second rule of EMS, look cool, begins with the fact that I can’t look stupid and cool at the same time.  So a good partner stops me from looking stupid.  If you see me screwing something up, or doing something that makes no sense given the situation as you understand it, tell me.  Do not assume that I am pulling out some next level shit that is beyond your understanding.  If you don’t understand what I’m doing and why I am doing it, I am probably about to look stupid.  Stop me.  This is true for driving as well as for patient care.  The route I take to calls is not magical – if you don’t understand it then I am probably wrong.  In regards to patient care, I work under the same protocols as my partner – there is nothing next level that can be done in an ambulance.  I will do the same for you.  Don’t be afraid to question me and don’t be afraid to be questioned.

That’s it in a nutshell.  I don’t care if a partner doesn’t like the same music that I do, enjoys different food, or much of anything else.  We can negotiate everything else.  Be a normal human, understand that our job is to leave people better off than when we found them, and stop me from looking stupid. 

So contrary to the throw-away line in Turn Signal Idiots when I said that there are four people that I am "comfortable allowing to attend," most of the providers in my agency make for fine partners.  I am really glad that I work in EMS and I am glad to work where I do.

* Still too long, I know.