The information gained while interviewing patients and bystanders is of the highest value, yet very little time is spent training in this area. As ED personnel do not have the benefit of seeing the patient prior to arrival at the hospital, it falls on the shoulders of prehospital providers to obtain any necessary firsthand information from the field. In cases where a patient's mental status deteriorates, EMTs may be the only medical providers in a position to gain valuable information from the patient. While experienced EMTs know what questions to ask, many providers could benefit from learning how to more effectively communicate with those they serve. The following 10 tips can be incorporated by providers with any level of experience on almost any run.
1. Establish rapport
In a typical healthcare situation, a patient interacts with a doctor or nurse in a controlled setting with office staff they have known for years. Patients share private information with them based on trust that has developed over time and understanding that these individuals have their best interest in mind. In the prehospital environment, patients are expected to entrust their physical well-being and private medical information to those they have never met before, and to do so merely seconds into the patient-provider relationship. While it is sometimes important to gain information very quickly, in many cases you can spend a minute or two getting to know your patient and the situation. Rapport is most easily established by providers who are confident and professional, and who take the time to communicate with their patients.1
2. Respect patient privacy
When it does come time for those more difficult questions, patient privacy must be considered. If others can hear, it is often unwise to ask very private or touchy questions if an honest answer is the goal. Failure to respect the patient's privacy in this way also demonstrates to patients that they may not be able to trust you or your judgment. Before asking about things like the possibility of pregnancy, potential substance use, or psychiatric conditions, it is worth considering the environment and the patient. These questions can often be addressed in the privacy of the ambulance rather than a home crowded with family or in the patient's workplace.
3. Recognize face value
Paying attention to patients' facial expressions may give clues regarding things they are not saying, as well as alert you to pain and severity of pain. Facial expressions may also allow you to see to what degree you are connecting with your patients.2
Your own facial expressions also matter. When in conversation with others, people have a tendency to watch facial expressions.2 Consider whether your facial expressions show concern for your patients. Did you give a comforting smile? Do your eyes convey interest in what your patient is saying, or do they wander? Facial expressions that show interest are linked to reported better rapport.3
4. Move to the patient's field of vision
When possible, approach a patient from a direction where he will be able to easily see you. For those with limited mobility, make sure to position yourself in a way that is comfortable for the patient to communicate with you. For example, if your patient is a wheelchair user, standing directly in front of him and perhaps crouching will make it easier for him to communicate with you. Some individuals with hearing impairments will understand you more easily if you position yourself so they can see your mouth as you speak. Looking down directs your voice away from the patient and may be perceived as a lack of attention to what the patient is saying.
5. Consider how you look
Truly good communicators say as much with their physical presence as with actual speech. It is easier to gain more information if the way you present yourself invites the patient to communicate with you. Crossing your arms, impatiently tapping your foot, or not directly facing the patient may convey that you are not particularly interested in the patient or what he has to say. The counseling field uses the acronym SOLER as a reminder to sit squarely, have an open posture, lean forward, make eye contact and relax.2 While prehospital providers do not have the same luxuries of time, the basics remain the same. Whenever possible, it helps to face patients, make eye contact when speaking with them, and show interest in them and their presenting problem. There is evidence that people are more satisfied with healthcare providers who have these strong, positive nonverbal communication skills in both medical and psychiatric situations.4
6. Ask open-ended questions
You risk missing out on potentially valuable information if you only ask questions that require a yes or no answer. For example, asking an elderly male patient if he is having any pain may get a "No" answer, causing you to miss the description of an odd feeling in his chest that has been coming and going since about noon. Instead, consider something that will force the patient to describe what is going on: "What happened today that caused you to call 9-1-1?" Sometimes the best "questions" are in fact not questions at all. It can be helpful to use statements that accomplish a similar objective, such as, "Tell me how you're feeling right now," or, "Talk to me about the surgery you had last week."
7. One thing at a time
Remember that while you do this every day, your patients do not. As an experienced prehospital provider, you may be thinking five steps ahead, but make sure you ask your questions one at a time. If you string together all of your thoughts into one big question, or ask question after question with just seconds in between, you will likely get answers to only some of what you truly need to know.
8. Leave the medical terminology alone
When conducting your interview, you and your patient will be best served by using common English. Save the medical terminology for the doctor at the receiving hospital. Using words your patient is not familiar with will only hamper your communication and confuse the patient. Some patients may be too embarrassed to ask for an explanation when they do not understand, and you may fail to get important information.
While this sounds rather elementary, actually listening to your patient's responses to questions is essential. Too often, we are busy thinking ahead to the next step and our next question rather than paying attention to what the patient is telling us. You will know what to ask next based on experience, so focus on what the patient is saying now.
10. Culture matters
If you live in an area where a culture different from your own is prevalent, make it your business to learn about it. Knowing the culture, particularly social customs, will allow you to connect with your patients and their families, and will assist you in quickly gaining the trust you need.
Many of you will find the above suggestions easy to incorporate. EMS and other healthcare providers are often naturally good communicators who are already doing many of these things on a routine basis. While not all of these suggestions are possible or realistic for every aspect of every call, many of them can be used without adding any significant time to the run or delaying important care. Combining already highly skilled emergency care with better empathetic communication can make for even better outcomes and more satisfied patients.
1. Belcher M, Jones LK. Graduate nurses' experiences of developing trust in the nurse-patient relationship. Contemporary Nurse 31(2):142-152, 2009.
2. Murphy BC, Dillon C. Interviewing in a Multicultural World, Third Edition. Belmont, CA: Brooks/Cole, Cengage Learning, 2008.
3. Sharpley CF, Jeffrey AM, McMah T. Counsellor facial expression and client-perceived rapport. Counselling Psychology Quarterly 19(4):343-356, 2006.
4. Griffith CH, Wilson JF, Langer S, Haist SA. House staff nonverbal communication skills and standardized patient satisfaction. J Gen Intern Med 18(3):170-174, 2003.
Matthew Putts, BA, EMT-B, is first lieutenant of EMS for the Cedar Knolls (NJ) Fire Department and an associate EMT with the Morristown (NJ) Ambulance Squad. He is currently pursuing an MS in rehabilitation counseling and can be contacted at email@example.com.