It is in top of the 5th inning. The pitcher has been doing very well, but has just taken a ball off the elbow that was hit sharply by the batter.
The coaches and trainers are out talking to him, and as we watch, it is clear he wants to stay in the game.
However, the coach (like the Chief) wins the argument, and after a lengthy conversation the pitcher walks off towards the locker room for further evaluation. He receives a standing ovation as he leaves.
A cyclist is doing a long charity bike ride. She has been training for it for 10 months and has looked forward to the ride. However, 5 miles from the end of the two-day, 150-mile ride, she falls and strikes her head.
She was wearing a helmet, but was dazed and continues to be dizzy. She clearly needs to be evaluated at a hospital, but wants to continue to ride, and is quite upset. The EMTs taking care of her keep telling her, "It will be OK."
How they relate to rehab How in the world do these anecdotes relate to fire rehab? Quite a bit if you think about it. Evaluation of a firefighter's injury is important. But often equally important is how we communicate with the firefighter.
Many of us have strong personalities and this becomes even more evident when we communicate with others with a strong personality.
The above two scenarios represent two different ways of communicating with an individual who is no longer able to do what they want to do. I believe often we in EMS do not always put ourselves in the position the ill or injured firefighter is in.
I have found this to be the case even more so in rural areas that do not get many fires. Firefighters do not want buildings to catch on fire, but may feel that if they do, "let me be there."
In EMS, we like to treat sick patients. For most of us (I hope) it is the reason we get into the business — the challenge of a critical patient.
We get so many baloney calls, that we may look forward to the ability to use our skills to make a difference.
Firefighters are no different. They will drill and train so that when the "big one" happens, they can use their skills to make a difference. In some areas, these "big ones" are few and far between.
Biggest fire of year Imagine the case where 20 minutes into the biggest fire of the year, a firefighter rolls his ankle. Or suffers a laceration to the hand.
We in EMS see these injuries all the time, and consider them fairly minor. For us, we may shrug and say "you have to go to the hospital" thinking it is not a big deal.
But to this firefighter, who sees his or her crew working to make a difference, this is a major blow. The firefighter may want to refuse and prefer the ankle or laceration is just wrapped up.
This is the opportunity for EMS to communicate better. What can we say to help the injured firefighter make the right decision?
Well, we could say the Chief says he has to go. While the Chief may have a significant amount of influence over his or her department, the firefighter still has rights and is permitted to refuse care and transport.
Now they may not allow this individual to work again until they are evaluated, but they still cannot force transport.
I have found the best way to convince any patient to make the right decision is to eliminate the drama and make a reasonable argument.
In the emergency department we experience this all the time. Patients don't want to wait for a test or to be admitted to the hospital.
Increases our liability If we let every one of these patients walk out, it increases our liability and more importantly does not allow proper care to be given to the patient. We have to try and help the patient understand the risk of the decision they are making.
For the firefighter with the ankle sprain, the conversation might go as such: "Look, your injury, if we permitted you to go back into the fire building, would put other firefighters at risk — you would not be able to help them or a victim out of the building if necessary.
"I can't make you go to the hospital, but if you go and get evaluated and treated now, you will be more likely to be able to return to duty to fight another day.
"The hospital may not be able to help you get back to fight this fire, but they can make sure you are ready for the next one."
Corny? Maybe. But I often see the person come to an understanding in front of my eyes. Their shoulders sag and they are resigned to getting checked out and treated — the right decision.
Ride I covered The second scenario listed above happened on a ride I was covering. Most of the time, I stay in the background and let the EMTs and medics do their job. It is an excellent opportunity to observe my staff in action.
However, after the EMT said, "It will be OK" for the second or third time, I stepped in: "No, it is not OK. It sucks. I know it sucks for you more than I can imagine — you just rode 145 miles and wanted to finish.
"But you are so dizzy you can't even stand. Do you really think it would be safe for you to get back on your bike? Would it be safe for you or others around you?" She went to the hospital.
What we need a little in these situations is empathy — the ability to understand what the other individual is feeling and thinking. Understanding where they are coming from and the concerns they have, and then addressing them.
This is not necessarily "touchy-feely. Patting the patient's hand, saying it will be OK is touchy-feely.
What I am describing is a no-nonsense straight-up assessment of their condition and the ramifications of their decision. They might still make the wrong decision, but it is our job to do our best to make sure they understand and make a calm, informed decision.
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About the author
The Rehab Zone. Kenneth G. Lavelle, MD, FACEP, FF/NREMT-P, is Clinical Instructor of Emergency Medicine at Jefferson Medical College, Philadelphia, and Attending Physician at CapitalHealth, Trenton, N.J. He was previously an attending physician at Albert Einstein Medical Center, and previously spent 14 years working as a firefighter and EMS provider.
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