I watched as the lead paramedic changed places with my student and took the jump-seat next to the patient. As he made eye contact, he began to speak softly to the patient—a gentleman in his mid-60's, whose COPD had cranked into high gear just after he woke up that morning. An empty albuterol inhaler lying on the nightstand told a big part of the story. In short, staccato bursts, the patient communicated that he'd used his inhaler five or six times, without relief. The look on his face was a blend of exhaustion and apprehension, along with anticipation, because he knew what was coming. Early on in our patient assessment, he shared that he had been intubated two of the last three times that he had been hospitalized. Good to know information, but not good information.
Over the next minute or so I listened as the medic talked to the patient about how hard he was working to breathe. And how tired he looked. And how our diagnostics indicated that he was not ventilating well on his own, despite the delivery of supplemental high-concentration oxygen. Did he want us to breathe for him? Initially, the NO response came quickly. Behind him, I watched as the student drew up the Versed and succinylcholine as he had been directed to. Again, the medic posed the question, and again, received a NO. With each passing moment, the patient looked increasingly exhausted. For the third time, the medic queried the patient, but this time the nod confirmed a reluctant yes. Reluctant because the patient knew that the day would come when the hospital staff would be unable to wean him off the ventilator.
In a professional, low-pressure, caring fashion, the medic had convinced the patient to agree with the care plan. To put it another way, the medic had sold the medicine, getting the patient to buy in to what really needed to happen. In this case, sooner rather than later.
Not a day passes where we don't find ourselves challenged regarding a multiplicity of patient care choices: Is this ALS or BLS? Is it a transport or no-transport? Should we treat at the scene or en route…the list goes on and on. Every day, you make lots of choices with and on behalf of the patients you care for.
In the world of multiple patient care choices, your main goal should always be to help your patients understand what care is truly best for them given the current circumstances and then make the right decision. Make no mistake, under many circumstances this is often no small challenge. For example, the patient with a history of chronic constipation who hasn't had a bowel movement in three days is just what it is—an ongoing problem. They make an appointment and, over the next day or so, they trundle up to see their primary care physician, and he deals with the problem. Today, your patient has frank blood in his stool (a first-time event). This is not just a new problem, it's a potentially serious, possibly even life-threatening problem as well. Then, you find yourself confronted with the oh-so-common quandary of "Do I really need to go to the hospital with you guys?" The patient is thinking down the line of "it's no big deal," like his ongoing constipation problem. Of course, we recognize that this is one of those really important types of transports, as in "You really need to go to the hospital now!"
Frequently, you find yourself in a situation where the patient agrees that he should go to the hospital, but is noncommittal, i.e., he won't go with you, but he then tells you, "My friend is coming by this afternoon, and I'll just have him run me up to the hospital." That almost always translates into "I'm staying home." If that's not the best solution, you need to revisit the transport decision and get the patient to agree to go with you now.
Another example of a tough sell is getting a patient to buy into spinal immobilization when he doesn't hurt, especially when you suspect that his lack of pain may be the result of alcohol or drug use. Given that almost half of all automobile accidents involve alcohol, the likelihood that you will repeatedly have to convince intoxicated patients to think your way about spinal immobilization is a guarantee, especially if you work a Friday or Saturday 24-hour car. With intoxicated or drug-impaired patients, you will frequently need to be persistent, often bringing them back to focus on the issue at hand; the matter of allowing you to take the necessary steps to protect their spine.
Being able to quickly sell your medicine is a critical skill in prehospital medicine. It is a combination of persistence, logic, salesmanship and often a healthy dose of pleading. Oh, and don't forget sincerity.
Over the course of time, you will find that you often need to tap every communication skill at your disposal to get your patients to buy into your care plan. However, when it's all said and done, your efforts are all worth it if you can consistently get your patients to make the best choices, i.e., agreeing to let you do your job properly and, in turn, providing the best care possible under the circumstances.