Tune in to the Event Horizon

     Emergency scenes are unique events-places where multiple variables come together to produce the distinct environments in which the EMS team provides patient care. Even going to the same location for the same patient with their usual complaint will never be exactly the same as other calls you've run there previously. Maybe your patient is sicker this time, or maybe there's an ornery old family pet that doesn't appreciate your intrusion. Weapons, people, dogs, inclement weather, drugs and alcohol represent but a few of the variables that can make your life difficult.

     In the airline industry, pilots use the artificial horizon in their aircraft to keep themselves oriented as they fly. Similarly, if you monitor what I call an event horizon as you work your way through challenging calls, you will be more oriented, with an increased awareness of what's going on around you, helping keep you safe and focused. This month in BTB, we look at four sentinel events to watch for as you monitor that wide-screen panorama of the emergency scene. Each represents a red flag that the scene is beginning to destabilize, signaling you to take some decisive action. With tact and a professional demeanor, you can use what are often called "verbal judo" skills to defuse and regain control of the situation. In other cases, your most appropriate action is to retreat to the safety of your rig. In a worst-case scenario, you may need to leave the scene.

     Whatever the case, let's look at how to recognize these four sentinel events and discuss some strategies for their successful management.

1. The volume, speed or intensity of conversation increases.
     Discussions as to whether the patient should be transported, and if so, to which hospital, occur frequently-sometimes many times during a shift. Often, these conversations involve the patient and a loved one or friend or two who are at odds as to how things should proceed. One of the first warning signs to be alert for is a progressive rise in the volume of a conversation. As the decibels increase, the speed of the exchange often quickens as well, as each party tries to make their point of view the only point of view. In addition, expect to see the intensity of the exchange heat up as well.

     This trifecta of conversational events represents a simple equation: When emotions increase, judgments decrease, and the likelihood that someone will do something stupid, often involving violence, increases markedly.

     When you note any of these signs, make immediate attempts to defuse the situation. Identify the most agitated person and attempt to calm them first. While you're doing that, another member of the EMS team should request law enforcement.

2. A person or persons become increasingly animated.
     As people get increasingly worked up, especially when they think their suggestions are being ignored or discounted, they often become very animated. Flailing arms, pointing fingers for emphasis, or even just rapid body movements all signal loss of emotional control. At this point, you must either defuse the situation immediately or make plans to leave. It's essential to recognize the deterioration of scene stability and decide quickly. If law enforcement hasn't been requested already (a large "oops"), do it now.

3. Threats begin to surface.
     Frequently, these threats will involve punitive legal action, and given the litigious nature of our society, this should be no surprise. In any case, when a person's frustration level finally gets to a certain point, a common last-ditch effort to sway another's opinion or decision comes when they throw the lawyer card: "If my mom dies because you took her to the wrong hospital, I'm gonna sue your sorry [butts] off." These threats can take a much more dangerous turn when a member or members of the team are threatened with bodily harm. Take all threats seriously; at the very least, retreat to the relative safety of the rig and consider leaving for a safer staging area.

     The decision of whether to take the patient with you as you exit the scene is a difficult one. You have to calculate how much time it will take to secure the patient vs. what could happen during that time. You must also consider whether the simple act of removing the patient will itself produce a violent response.

4. An angry person abruptly leaves the room.
     This can be one of the most dangerous occurrences to come over the event horizon, if for no other reason than someone has finally reached the "out of control" point. Extreme possibilities must be immediately considered. The person may simply have stepped out or gone to cool down. The other end of the spectrum is where that person leaves to get a weapon, with plans for an immediate return to right whatever wrong they perceive. If possible, have an EMS team member follow the person out of the room to monitor their actions and continue attempts to calm them. If you're just now deciding to get law enforcement on scene, you have made an error with potentially lethal repercussions.

Conclusion
     While some level of instability is expected at all emergency scenes, each of the above events represent a distinct level of destabilization. As you provide patient care, maintaining an awareness of your work environment is an absolute must, but understand that the real challenge is that you must still execute your plan and provide quality patient care. Stay alert and react quickly and decisively should any of these sentinel events come into view on your event horizon.

     Until next month...

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.