Therapeutic

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3
Therapeutic Communications
2
Standard

• Assessment

3
Competency

• Integrate scene and patient assessment findings
  with knowledge of epidemiology and
  pathophysiology to form a field impression.
• This includes developing a list of differential
  diagnoses through clinical reasoning to modify
  the assessment and formulate a treatment plan.

4
Introduction

• As a paramedic, you must use every strategy to
  make sure you understand your patients and they
  understand you.
• Word choice, tone of voice, facial expressions,
  body language.
• Adjust your communication style to fit each new
  situation.

5
Introduction

• Sincere desire to be part of helping profession
  understanding of human strengths and weaknesses
  empathy.
• Communication sender, message, receiver,
  feedback.
• Sender encodes, creates message.
• Receiver decodes, interprets message.
• Feedback response to message.

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Introduction

• Failure to Communicate
• Prejudice, or lack of empathy.
• Lack of privacy.
• External distractions.
• Internal distractions.
• Patience and flexibility hallmarks of good
  communicator.

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Building Trust and Rapport

• When trust established, rapport follows.
• Establish positive rapport quickly.
• Ask patients the right questions.
• Respond with empathy.
• With good rapport, people you are serving will
  follow your lead.
• Effective communication begins and ends with
  trust and rapport.

8
Building Trust and Rapport

• Present yourself as caring, compassionate,
  competent, confident health care professional.
• Dress and grooming important.
• Voice, body language, gestures, eye contact
  communicate you care about patient's problems.
• Be aware of your patient's comfort.

9
Building Trust and Rapport

• If patient in obvious distress, try to alleviate
  his pain or discomfort while you interview him.
• Introduce yourself.
• Use patient's name.
• Modulate your voice.

10
Building Trust and Rapport

• Use professional but compassionate tone of voice.
  
• Explain what you are doing, and why.
• Keep a kind, calm facial expression.
• Use the appropriate style of communication.

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Introduce yourself and use an appropriate
compassionate touch to show your concern and
support.
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Effective Communication Techniques

• General Guidelines
• Patients' response to questioning
• Pour out information easily.
• Reveal some things conceal others.
• Resist, hiding information.
• Be consistently professional, nonjudgmental,
  willing to talk about any concern.

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Effective Communication Techniques

• Nonverbal Communication
• Gestures, mannerisms, postures person uses to
  communicate with others.
• Distance socially acceptable distance between
  strangers is 4 to 12 feet.
• Relative level remaining at eye level indicates
  equality.

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Interpersonal Zones
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Effective Communication Techniques

• Nonverbal Communication
• Dropping below eye level helpful when patient
  elderly adult or child.
• Open stance arms extended, open hands, relaxed
  large muscles, nodding head.
• Closed stance arms flexed, or arms crossed
  tightly over chest.

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Getting down to a patient's level can help
improve communications on a pediatric call.
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Effective Communication Techniques

• Nonverbal Communication
• While interviewing patient, use eye contact as
  much as possible.
• Look at patient frequently.
• Eye contact one way to send message to patient.
• Nothing builds trust and rapport, or calms
  patients, faster than the power of touch.

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Effective Interviewing Techniques

• Identify patient's chief complaint, learn
  circumstances that caused emergency, determine
  patient's condition.
• Ask questions, observe patient, listen
  effectively, use appropriate language.
• Gather information that is accurate, complete,
  relevant to emergency.

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Effective Interviewing Techniques

• Let patient state chief complaint in his own
  words.
• Chief complaint should drive all other questions
  to be asked.
• Continue to ask open-ended questions.
• Use direct questions when necessary.
• Do not ask leading questions.

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Effective Interviewing Techniques

• Ask only one question at a time allow patient to
  complete his answers.
• Listen to patient's complete response before
  asking next question.
• Use language patient can understand.
• Do not allow interruptions, if possible.

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Effective Interviewing Techniques

• Active Listening
• Listen closely to what patients tell you.
• Do not develop tunnel vision from dispatch
  information.
• Begin assessment without any preconceived
  notions.
• Watch for subtle clues patient may not be telling
  truth.

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Effective Interviewing Techniques

• Listening is an active skill, not a passive one.
• Requires your complete attention.
• Focus on the messenger.
• Watch for clues to important signs, symptoms,
  emotions.
• Modify questions to follow clues.
• Provide feedback to confirm you have understood
  message correctly.

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Effective Interviewing Techniques

• Feedback Techniques
• Silence
• Reflection
• Facilitation
• Empathy
• Clarification
• Confrontation

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Effective Interviewing Techniques

• Feedback Techniques (cont'd)
• Interpretation
• Asking about feelings
• Explanation
• Summarization

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Effective Interviewing Techniques

• Common Errors
• Providing false assurances.
• Giving advice.
• Abusing authority.
• Using avoidance language.
• Distancing.
• Using professional jargon.
• Talking too much interrupting.
• Using why questions.

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Effective Interviewing Techniques

• Observing Your Patient
• Observe patient during interview.
• Note appearance, level of consciousness, body
  movements.
• Be aware of defense mechanisms.
• If indication patient's hostile behavior may
  threaten your safety or crew, maintain distance
  and exit path.

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Effective Interviewing Techniques

• Using Appropriate Language
• Most patients will not understand medical terms.
• Use appropriate level of questions do not appear
  condescending.
• Barriers to communication cultural and language
  differences, deafness, speech impediments,
  blindness.

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Special Needs and Challenges

• Start interview in usual manner.
• Develop rapport by reviewing reason dispatch gave
  for call.
• Attempt to ask open-ended questions.
• If unsuccessful, try direct questions.

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Special Needs and Challenges

• Provide positive feedback.
• Be sure the patient understands questions.
• Rule out language barriers, hearing difficulties,
  pathology.

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Special Needs and Challenges

• Children
• Effective communication with pediatric patients
  depends on their age.

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Childhood Development by Age
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Childhood Development by Age
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Special Needs and Challenges

• Children
• Start by talking to caregivers.
• Gradually approach patient.
• Get down to child's eye level.

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Special Needs and Challenges

• Children
• Introduce yourself use child's name often be
  careful not to clam up.
• Tell child everything what you are looking at
  and why it is important.
• Most important, you must build trust.
• Giving child stuffed toy may be helpful.
• Use straightforward language.

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Special Needs and Challenges

• Children
• More matter-of-fact and informative you can be,
  the better.
• Use lots of eye contact compassionate touch.
• Ask child for feedback frequently.
• Be aware young children very literal word choice
  important.
• Build trust and rapport with parents.

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Use a small toy to help calm a child.
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Special Needs and Challenges

• Elderly Patients
• Be respectful use formal means of address.
• Speak slowly and clearly.
• Interviews might take longer.
• Use compassionate touch.
• Give elderly patient choices whenever possible.
• Take along their living assists.

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Special Needs and Challenges

• Patients with Sensory Impairment
• Blind present special problems.
• Identify yourself immediately.
• Nonverbal communications useless in these cases.
• Voice and touch only effective tools.
• Ask hearing-impaired and deaf patients preferred
  method of communication lip reading, signing,
  writing.

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Special Needs and Challenges

• Angry, Hostile, Uncooperative Patients
• Understand anger is a natural part of grieving
  process may be venting their frustration.
• Try to accept their feelings without getting
  defensive or angry in return.
• Be nonthreatening avoid confrontation.

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Special Needs and Challenges

• Angry, Hostile, Uncooperative Patients
• Set limits and establish boundaries.
• Document unusual situations.
• If blatantly hostile, or your safety is
  jeopardized, stay far enough away.
• Monitor patient closely.
• Be sure you have clear path to exit.
• Do not hesitate to call law enforcement.

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Special Needs and Challenges

• Sensitive Topics
• Sexual activities, death and dying, physical
  deformities, bodily functions, domestic violence.
• Make the unfamiliar familiar it will seem less
  imposing.
• To earn patient's trust, try to make him or her
  feel problem is not uncommon.

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Special Needs and Challenges

• Sensitive Topics
• Sexual history taken later during history it can
  be part of present illness or past history,
  depending on chief complaint.
• Remain calm, objective, nonjudgmental, regardless
  of how patient answers.

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Special Needs and Challenges

• Silence
• If patient suddenly becomes silent, try to
  determine why, what is happening, what you should
  do about it.
• Stay calm observe patient's nonverbal clues.

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Special Needs and Challenges

• Overly Talkative Patients
• Accept less comprehensive history.
• Briefly give patient free rein.
• Focus on important areas.
• Ask closed-ended questions.
• Interrupt frequently summarize what he says.
• Try not to become impatient.

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Special Needs and Challenges

• Patients with Multiple Symptoms
• Challenge is to discover chief complaint.
• Sort through multitude of information quickly
  recognize patterns that lead to correct field
  diagnosis.
• Anxious Patients
• Anxiety natural reaction to stress.
• Encourage patient to speak freely about the signs
  of anxiety.

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Special Needs and Challenges

• Patients Needing Reassurance
• Do not be overly reassuring or prematurely
  reassure anxious patient.
• Intoxicated Patients
• Irrational, disrupt your control of scene, rarely
  allow you to examine them.
• Make sure your environment safe.
• Avoid challenging body language or remarks.

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Special Needs and Challenges

• Crying Patients
• Crying form of venting clue to patient's
  emotions.
• Accept it as natural release do not try to
  suppress it.
• Depressed Patients
• Depression potentially lethal recognize its
  signs and evaluate its severity.
• Ask about suicide risk.

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Special Needs and Challenges

• Confusing Behaviors or Histories
• You may encounter patient whose story you just
  cannot follow.
• In these cases, problem cannot be diagnosed in
  field.
• If patient's behavior seems distant, aloof,
  inappropriate, or even bizarre, suspect mental
  illness.

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Special Needs and Challenges

• Confusing Behaviors or Histories
• Delirium and dementia disorders relating to
  cognitive function.
• Delirium common in acutely ill or intoxicated
  patient.
• Dementia occurs frequently in elderly.
• Often cannot provide clear, accurate histories.

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Special Needs and Challenges

• Patients with Limited Intelligence
• Do not assume patient will not be able to provide
  accurate information concerning medical status.
• Try to evaluate patient's education and mental
  abilities.
• If you suspect severe mental retardation, obtain
  history from family or friends.

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Special Needs and Challenges

• Talking with Families or Friends
• Patients who cannot give useful information find
  third party who can.
• Patient confidentiality priority.

52
Transferring Patient Care

• When you arrive at scene, EMS-trained first
  responders may already be there.
• Before they transfer patient care to you, listen
  to their report carefully.
• Integrate information they give you into
  questions you ask patient.
• Interact with emergency colleagues with respect
  and dignity.

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Summary

• Quickly and effectively gather information about
  patient.
• Remember your body language, tone of voice,
  facial expressions, how you position yourself to
  patient.
• Develop situational communication templates that
  you can draw on as scenarios unfold.

54
Summary

• Situations that require assertiveness or calm,
  empathetic compassion call for two different
  communication styles.
• You will need sensitivity to recognize and
  respond to signs of suffering to create ideal,
  individualized process of communication.
• Show compassion and empathy demonstrate
  expertise necessary.