by Charly Miller, EMT-P

This page was originally published in's November/December, 1998 issue.

Just like almost everything else in medicine (or life), patient communication begins with the "ABC"s.

Do infants communicate? Of course they do! They smile, grimace, yawn, laugh, gurgle, hoot, and (most effectively) they communicate by crying and screaming. These infant methods of communication are the direct result of basic and first-learned responses to their immediate, personal, perceptions (beliefs) about their internal and external environment. A comfortable infant communicates with comfortable activity and noises. An uncomfortable infant communicates with uncomfortable activity and noises. Guess what? These are the first forms of communication that we learn, and the last forms of communication that we lose if we are lucky enough to die of "old age." No matter what age we are, however, when surprised we always essentially respond to the stimuli of our environment in the same manner that we did as an infant! In an emergency, this basic communication response reflex is acutely enhanced.


AFFECT pertains to facial expression. Our mood and internal monologue is reflected in our facial expressions - whether we wish it to be, or not. Since emergency patients are in an altered state of awareness, they are acutely sensitive to this form of communication. If emergency responders are tense, nervous, frightened, or otherwise uncomfortable with a situation, patients recognize the facial expressions that accompany these distressing emotions. When approached by an emergency responder, the patient's first awareness is of the responder's facial expression or "affect." If the responder is worried or concerned or fearful of the patient's situation, the responder's affect communicates these emotions to the patient, effecting the patient in a negative manner. Believe it or not, a smile - even just a small one - is the best affect to use when approaching any emergency patient! But, to be able to wear a smile, emergency responders must maintain a calm, confident, self-assured internal mood and monologue to effectively project these qualities to their patients. This ability takes practice, and is the result of things we will discuss in more depth in a later installment.

BODY LANGUAGE pertains to Postures, Actions, and Rates of Activity exhibited by emergency responders. Anxiety, fear, nervousness, or tension cause our postures, actions, and rates of activity to become more rapid, more agitated, and significantly uncoordinated. This type of activity sends strongly negative messages to patients, and results in strongly negative patient responses. In order to act with body language that communicates calmness and self-confidence, in order to positively effect emergency patients with our body language, emergency care providers must be acutely aware of their physical activity. We must approach the patient calmly, slowly, and with confidence. We must "get down to" the patient's physical level and physically communicate our eagerness and ability to positively help them in their emergency.

CALMNESS pertains to all the above - Affect, Body Language, Rates of Activity, Tones and Rate of Speech - and ties the communication ABCs together. Provider anxiousness, fear, nervousness, or tension is communicated to patients in multiple ways. This sort of communication causes increased patient anxiousness, fear, nervousness, tension, and increases the patient's pain! Provider calmness, however, promotes increased patient calmness, decreased patient stress, decreased patient pain, and increases the patient's ability to cooperate. Calmness also increases the patient's positive response to treatment.

The basic rule of promoting calmness at the scene of any emergency is to GO SLOW! Approach the patient in a slow and controlled, confident manner, smiling as you approach. Act in a slow, controlled, and confident manner in everything that you do. Take command of the scene and slow down the activity of all those involved with the patient's emergency. By promoting a sense of calmness within yourself and the scene, you greatly improve the patient's prognosis.

THAT, in a truly, tiny nutshell, is a basic description of the "ABC"s of communication.

Now! A frequent initial student-response to my description of the ABCs of patient communication is: "OH, COME ON, CHARLY!! Emergency care providers don't have the time to be calm, confident, and relaxed! We need to move! We have only a fraction of the 'Golden Hour.' When patients are seriously injured, we don't have time to pay attention to Affect, Body Language, and Calmness!"

My argument with this frequent response begins with the following fact: Critical patients requiring rapid treatment and transport represent less than 10 percent of all patients seen by emergency care providers operating in any city, or during any career. The vast majority of all emergency patients are those with minor-to-moderate cuts, bruises, earaches, falls, sore throats, seizures, and the like. Thus, for the majority of our patients, we have plenty of time to utilize the ABCs of communication. And since appropriate utilization of the ABCs of communication improves patient prognosis, we have a great responsibility to learn and consciously use these positive communication techniques.

The expectation that emergency 911 calls are all life-saving and super-excitement situations is what I call the "William Schatner's 911 MYTH!" Educators are currently acting to finally dispel this myth, and train EMTs to understand that it just don't happen that way! We don't spend every shift "saving lives" and running exciting, Hollywood-program-generating calls. William Schatner's Hollywood agents would consider the majority of our patients completely uninteresting.

Additionally; WHAT emergency patients have the most profoundly altered states of awareness? WHAT patients have the greatest need for appropriate communication ABCs?! The patients with the greatest need for smiling, calm, confident, and relaxed care providers are the patients who are the most gravely injured! The patients who require rapid care and transport are the patients who have the most profoundly altered states of awareness - and are also the most susceptible to communication-suggestion of either a negative or positive nature. If the positive ABCs of patient communication are ignored, the patients with the greatest need for effective emergency care will be negatively affected by their poorly-communicating emergency care providers.

And finally; by "taking the time" to practice good communication ABCs, we increase our ability to provide the best possible care for these most critical patients. When we "take the time" to thoroughly assess the patient's physical condition, we are less likely to "miss" any critical patient care need. When we "take the time" to perform critical care procedures with more control, we don't require multiple attempts to achieve critical care procedure success. And, lastly, by "taking the time" to go slowly and act in a confident and controlled manner, we vastly improve the patient's positive response to everything we do. Thus, by "taking the time" to practice good communication ABCs, we end up saving time in the long run.

In the next installment of THE FOUNDATION OF PATIENT COMMUNICATION, we'll discuss How to Accomplish the "ABC"s of Patient Communication:

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