by Charly Miller, EMT-P

This page was originally published in's May, 1999 issue.

In addition to making patients Hypersuggestible To All Perceived Stimuli,
Emergency Crisis brutally rips away a patient's Sense of Self-Control.

Normal people don't experience emergencies every day. No matter how often they watch "emergency" TV shows, they don't know what to do. They feel "out of control." Indeed, if they had control over their "world" - as they usually do - would they be having an emergency? No, of course not!

It's difficult to help emergency care providers (both pre- and in-hospital providers) understand how truly brutal and devastating it is for someone to feel that he's lost control of his world. After all, you're reading this in a climate-controlled environment, so you're warm and comfy. You're happily in control of your world right now.

But, what if? What if, right now - while reading this sentence - you suddenly lost control of your bladder - peed yourself, soaking your clothing and the chair you're sitting on?! And, what if someone was there to watch you do it?! How would you feel about that

Experiencing a loss of control over your life is devastatingly brutal to anyone's psyche, in any situation. It's especially detrimental to people experiencing an emergency. As long as a patient perceives a "loss of control" he'll suffer:

To arrest and repair these negative effects, we must speak and act in specific ways that help restore a patient's sense of control.

In Parts 5 and 6 of "The Foundation of Patient Communication" we discussed some very simple things that begin to restore a patient sense of control: personal introductions, patient name use, etc. Now, lets discuss the more complex - and even more successful - ways of restoring our patient's sense of control.

Two of the best ways to help any patient regain a sense of control are to:

Giving patients "choices" or asking "permission" to do things rapidly begins to restore a sense of control, decreases anxiety and pain, improves physiological condition, enhances their response to treatment, and even improves their overall prognosis!

But do we give a patient the choice about spinal immobilization? Do we ask their permission to start an IV when one's needed? Patients have a right to refuse such things. In the US, competent adult patients have the legal right to refuse any examination or treatment.

If the patient responds, "No! I don't want to be laid down on that hard, cold board," it would create an enormous problem! There is a risk to giving a patient choices, or asking for permission. That's why offering choices and gaining permission is more complicated than simply introducing yourself or learning what name your patient prefers.

The Three Divine Secrets to restoring a patient's sense of control with choices or by asking permission:

  1. Only give a patient a Choice when you Don't Care what she/he might answer!
  2. Never ask Permission to do something that Must be done.
  3. When Choice or Permission is not an option:

When the mechanism of injury indicates that a patient should be spinally immobilized, I care about that, and it must be done. So, instead of asking permission or offering a choice, I'll act to restore the patient's sense of control by positively explaining why I'm spinally immobilizing her - and finding something else to offer as a choice:

Do I care how many blankets the patient uses? Nope - not as long as there isn't a heat injury involved, and I've got more blankets! So, that's a safe choice to offer.

Do I care how many places I put pads to help my patient feel more comfortable? Nope - not as long as they don't interfere with in-line immobilization! It's a safe choice to offer.

Do I care where the patient holds her/his hands? Nope - a safe choice to offer!

Do I care which arm the patient's IV is put in? Not usually, just as long as they get one when they need one. If I subsequently discover their initial choice has no apparent sites for an IV:

What about a patient who doesn't require spinal immobilization?

Do I care whether the patient sits up or lies flat? Nope - as long as the patient's blood pressure is over 100 systolic. If it's below that, however, I do care!

There are many things that you cannot give an emergency patient a choice about. Yes, patients have a "right" to refuse treatment. But as professional emergency caregivers, we have the responsibility of providing the best possible treatment - even when that treatment is unpleasant. To do that, we must avoid offering choices or asking permission when the patient's refusal or wrong choice might interfere with appropriate emergency care. Instead, we should explain the needed care and perform it, while simultaneously directing our patient's attention to the options that are available!

Find things to give the patient a choice about!

Throughout any kind of emergency call there are many, seemingly "little" things that we can give patients a choice about. Remember that these choices only seem "little" to us! To the patient, exercising any choice is an opportunity to get one step closer to a restored sense of control. The more choices we offer, the more often we seek the patient's permission, the better our patient will feel.

If you remember and practice the Three Divine Secrets to restoring a patient's sense of control with Choices or by asking Permission, you can't go wrong.

  1. Only give a patient a Choice when you Don't Care what she/he might answer!
  2. Never ask Permission to do something that Must be done.
  3. When Choice or Permission is not an option:

In the next Foundation of Patient Communication installment, we'll discuss how offering choices and asking permission can actually assist in diagnosis and care decisions!

If you wish to, Email's Editor with your feedback:
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"Feedback About The Foundation of Patient Communication - Part 8"

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