15 steps for EMS providers to provide compassionate care

EMS Legal Update

Teaching points from the ‘malpractice or murder’ case: Action steps for EMS practitioners

Two Illinois EMTs were charged with first-degree murder and booked into Sangamon County jail on $1 million bond each after a patient in their care died.

Read the details of the case as they were first reported, watch the bodycam footage, and find expert analysis and ongoing updates in our coverage.

In Part 1 of this two-part series, Steve Wirth and Doug Wolfberg discussed 14 action steps for EMS leaders to implement. Here in Part 2, Steve and Doug expand this list of action items to include 15 steps that EMS practitioners in the field should follow to reduce potential harm to a patient and to minimize liability risk. Send your questions about how to implement these action steps to us at [email protected].

By Steve Wirth, Esq.; and Doug Wolfberg, Esq.

You’ve watched the bodycam footage and were outraged. What happened to Earl Moore, Jr., in Springfield, Illinois, can only be described with words like "despicable," "reprehensible," "disgusting," "sickening," – and the list goes on. We have been literally brought into that bedroom and had a front-row seat to this call through the power of technology. We’ve watched the video and shook our heads in near disbelief. And now the key question is this: What are we going to do about it?

EMS practitioners have a legal, moral and ethical obligation to never be in a situation where a patient may die or suffer harm in part because of our own actions or inactions. We all need to work at every level of our respective organizations to prevent this type of tragedy from happening.

As the phrase goes, "Now what?" Let's make this tragedy a call to action to everyone in EMS – regardless of your role – to take concrete steps now to prevent this type of conduct from happening in our own EMS agencies. Here are 15 action steps for EMS practitioners to adopt in their day-to-day work that may help.

After years of experience dealing with difficult people who don't always appreciate what we do, it's easy to become cynical and negative. Resist this temptation! Remind yourself frequently why you got into EMS in the first place – to help others in need and make a difference in their lives; to help your community. EMS is inherently positive work. It's truly meaningful and satisfying. It pays to remember that when we are feeling down.

Read more. Why would you want to be a paramedic? EMS providers share why they recommend the profession

When we put on an EMS uniform, we not only have a legal duty – we also have a moral and ethical responsibility to uphold the standards of care in our profession. Our "duty to act" – the failure of which is one of the elements of negligence – can be summed up simply as a duty to prevent harm and to act for the benefit of others. It's a moral imperative that we all ascribe to when we decided to become an EMS practitioner.

Read more: Duty to act, assess, treat and transport: A legal refresher for EMS providers. Make no mistake, every EMS provider in every state has a duty to perform a full and complete assessment on every living patient

Cameras are everywhere. EMS is under more scrutiny today than ever before and we must always act as if we are being recorded. Always assume that your actions could end up on the national news. Always act in a manner you’d be proud to see displayed on the evening news – or in a courtroom. Without a doubt, the conduct of the EMTs that the prosecutor observed on the videos in the Moore case made his decision to file murder charges much easier.

It is within the power of every individual EMS practitioner to control how they will appear on any video that the public – or a prosecutor – might review. Whether you know a camera is present or not, your conduct is completely within your control. If you always act professionally and with compassion, or at least with basic human decency, you reduce your risks substantially. If a video camera happens to be present, that's what it will capture, and that's what the world will see. It's completely in your control.

You’ve seen the footage – Now what?: Part 1

Action steps for EMS leaders

EMS has the equipment, supplies and technology to aid in our treatment of the patient. But we need to take that equipment off the ambulance and bring it with us into the scene or home and have it near the patient. It's not that difficult!

Much of what we do is preparing for the unexpected. True, many times we won't need to use the equipment. So, what's the worst thing that can happen if you bring in your equipment and don't need it? You need to carry it back out to the truck. No big deal and you get a little exercise at the same time.

But what's the worst thing that can happen if you walk up three flights of steps and find a patient in respiratory distress and chest pain, but you don't have your equipment with you? You may be depriving the patient of the supplemental oxygen the patient needs, or the lifesaving medication, or the defibrillation shock to convert a life-threatening dysrhythmia. That would be tragic and is completely preventable.

When we don't bring your equipment into the scene – it is noticed. The public and family expect to see it. In the Moore case and other similar cases where bad behavior was exhibited by the EMS personnel, failure to bring the tools of our trade with us was a common factor.

With some legitimate exceptions, both crew members should access the patient and assess the situation. It increases your own risk when your partner stays outside, and you approach a scene or enter a residence by yourself. Both crew members should stay together in a single patient situation as a team whenever possible. That ensures there are two sets of qualified eyes on the patient.

Having two crew members with the patient also helps keep us honest and respectful. A partner having a horribly bad day may be more likely to be disrespectful to the patient if their partner is not present. Most importantly, having both crew members engaged with the patient situation can lead to a better patient outcome and reduce the likelihood of medical errors.

Read more: When crew dynamics disrupt patient care. 5 insidious partner issues to avoid so that patients feel safe in our care

How we approach the patient sets the stage as to how the interaction will go. If we tower over the patent and talk to the patient in a rude and dismissive way, the patient will not feel that you are there to help them. Patients will decide in the first 30 seconds of the interaction whether they like you and whether they think you are a competent and caring health care professional.

Making a good "first impression" with the patient is key to the rest of the interaction being a positive experience. Getting down on the patient's level – physically and in how we communicate with the patient – is critical to making that good first impression. Actively listen to what the patient says. A tip of the head, a gentle nod, and an expression of concern, and asking thoughtful and open-ended questions will go a long way to gaining the respect of the patient and in getting the information you need to properly assess and treat the patient.

Read more: Greet the patient. How an EMT or paramedic greets the patient often sets the tone for the entire call.

Contrary to popular belief, being compassionate is not a quality that you must be born with – compassionate behavior can be taught. People who model and practice compassionate behaviors and who are grateful for the opportunity to help others have a more positive outlook on their work and on life in general.

Patients who are treated with compassion are more satisfied with their care and rate their clinicians more highly. Greater patient satisfaction, of course, translates into reduced liability and lowers the risk of lawsuits. Imagine feeling healthier and lowering your legal risks all through simple displays of compassion toward others. EMS providers can become more intentional about studying, learning and practicing compassion, and incorporating it into their provision of care.

Read more: 4 things to explain to patients to increase their comfort and compliance. Put yourself in the patient's position to gain an understanding of how their fear may complicate your interventions

Implicit or unconscious bias resides in everyone. Our prior experiences and the media we consume can lead us all to hold beliefs that are based on generalizations and not individuals. Having these unconscious biases is human; there is no need for guilt, blame or recrimination for having them.

But what is most important is that EMS practitioners become cognizant of their own biases and not let those biases affect the care provided to the patient. Whether it's built-in beliefs about age, race, gender identity, homelessness, appearance, weight, income level or any other characteristic, we can all benefit by remembering that no human is any more or less worthy than any other human of our expert care and compassion.

Joseph Zalkin, Executive Director of Wake County (NC) EMS Foundation, shared this quote with us that sums up the essence of our work: "Your job is not to judge. Your job is not to figure out if someone deserves something. Your job is to lift the fallen, to restore the broken, and to heal the hurting."

Read more: How anchoring can cause medical errors. EMS providers need to understand anchoring, a type of cognitive bias, to prevent errors in prehospital patient assessment and care

Asking the patient: "Can You Walk?" should not be one of the first questions you ask the patient. Yet the female EMT can be seen on the BWC video telling Mr. Moore: "You’re gonna have to walk; we ain't carrying you!" and "If you’re going to go, you need to get up and walk!" This harsh admonishment came after no assessment of Moore's physical condition to determine if he could even reasonably assist in his own movement.

In most situations we have seen where negligence was alleged, the fact that the patient was "walked" is often present. In those cases where the patient was walked to the stretcher or the ambulance, the reason the patient was walked was usually for the convenience of the providers. It was not with the interest of the patient in mind. In other words – they were being lazy.

Listen for more: Falls, drops and lifts. Matt Streger, Brian Hupp and Simon Claridge discuss patient and provider safety devices and protocols

As EMS practitioners, we see patients in their worst possible moments. They may be upset. They may be hurting – both physically and mentally. They may be afraid and feel helpless and hopeless. And often they may take it all out on us – usually not intentionally – by yelling, screaming, spitting, or being disrespectful or abusive toward the very people who come to help them.

It's not easy to be positive in the face of these negative behaviors directed toward us by the patient and others. But we simply cannot let that affect how we treat the patient. We must rise above that. We cannot turn that behavior back on the patient. It does not do us or the patient any good.

EMS practitioners who have "survived" many years of serving patients recognize the tremendous power that that we each have within us to control our attitudes and behaviors. It starts by not letting the negative behaviors of others affect our own behaviors. In other words, don't let the reality of others become our own reality.

We must recognize that our attitude is based on only about 10% of what we actually experience. The attitude we feel and that is reflected in our behaviors is really 90% of how we react to that experience. Think about that. If we react positively – even in the face of negative behaviors exhibited toward us – it not only helps the patient, it improves our own wellbeing. Letting negative behaviors of patients and others "get to us" is a recipe for disaster not just for the patient but for our own long-term mental wellness.

Read more: 4 things to explain to patients to increase their comfort and compliance. Put yourself in the patient's position to gain an understanding of how their fear may complicate your interventions

It's the golden rule that we all must live by – especially when we are in one of the helping professions where treating others with empathy, kindness and compassion is an essential part of the job description. Treat others how you would want to be treated. We literally can improve the lives of our patients in every patient encounter – whether it be using our lifesaving skills or simply holding the hand of an elderly patient or a child who is frightened and upset. Displaying empathy – putting yourself in the patient's shoes – can help ensure that you will treat the patient in a way that your loved ones would expect.

Read more: 6 ways to quickly build patient trust. Gaining patients’ confidence can be achieved by deliberate actions, like connecting with caregivers, as well as small subtleties, like body language and facial expressions

Talk to a coworker, friend, family member or others you trust if you are concerned the stress of the job may impact your performance. Take advantage of the professional services your EMS agency may offer, or through your medical plan. Take care of yourself first – you can't help others if you are not well physically or mentally. Take advantage of resources your employer or agency may offer. If those resources are not offered, discuss it with your agency leadership.

Support each other and look out for each other. Learn how to recognize mental health issues in ourselves and our colleagues. Get involved in a peer support group. Work on developing a healthy lifestyle that includes proper nutrition and exercise. Participate in outside hobbies and other non-EMS activities when you can.

Read more: 5 things EMS providers should know about seeking mental health treatment. Consider the benefits of seeing a mental health professional to help manage EMS acute and chronic stress

As far back as 2002, the National Association of EMS Physicians (NAEMSP) has recognized the importance of having in place a prehospital patient restraint protocol to help ensure the safety of both EMS practitioners and the combative or agitated patient [1].

More recently, NAEMSP emphasized that: "Any physical restraint device used must allow for rapid removal if the patient's airway, breathing or circulation becomes compromised [2]. They also state that "patients must not be restrained … with techniques that compromise the airway or constrict the neck or chest. During transport on a stretcher or other transport device, patients must not be restrained in a prone position."

On the bodycam videos, Moore appeared lethargic with bouts of respiratory distress – not combative or agitated. Yet, he was shoved face down onto the stretcher with straps cinched up tightly. These are actions that violate fundamental standards of care when it comes to positioning and securing the patient for transport.

Yes, patients may need to be restrained either chemically or physically for their own protection and for the protection and safety of others around them – especially when they are agitated, violent, or combative. In some cases, prone positioning may be appropriate, but only when it is clinically indicated and where the patient's airway and vital signs can be closely monitored.

That is why EMS agencies must adopt – and EMS practitioners must always follow – protocols for safely securing and transporting our patients. These protocols should be patient-centered clinical protocols that are overseen and approved by the agency's medical director.

Read more: Prone positioning: Therapy or apathy? If you don't know that prone positioning can cause great bodily harm or death in some patients, you don't belong in EMS

When watching the bodycam video in the Moore case, the police officers at first appear be respectful of Mr. Moore and truly act like they want to help him. Then the female EMS provider enters the room and is rude, disrespectful and abusive to Mr. Moore. Then the officers seem to adopt her attitude and start to do the same.

It's one thing to be complacent and not do our jobs with our best effort. That's bad and can lead to a claim of negligence against the EMS practitioners and their agency. But it is an entirely different thing altogether when we become complicit with the bad behaviors of others, and we then adopt those very behaviors.

As we have seen in recent cases such as the George Floyd case involving the improper conduct of police officers, and the Elijah McClain case involving both the police officers and paramedics, "going along with the show" and not doing anything to stop bad behaviors that could potentially harm another human being can rise to the level of complicity in that behavior – and ultimately a crime.

One of the NAEMT's Principles of Professional Conduct is "to refuse participation in unethical procedures, and assume the responsibility to expose incompetence or unethical conduct of others to the appropriate authority in a proper and professional manner."

We all need to become moral rebels, recognizing that anyone can have a bad day, but that we cannot let that bad day evolve into conduct that could be harmful to others. We need to act. We need to take the steps necessary to stop behaviors exhibited by others that could harm another person. Invoking de-escalation techniques, implementing a process where an EMS practitioner can call a timeout to reassess the situation and reset, or simply pointing out negative behaviors to the person exhibiting them can be effective tools in stopping bad behavior in its tracks.

Read more: Standing up or going along: How the fear of being shunned impacts our choices. Reflecting on why other officers didn't speak up during George Floyd's detainment

Whenever faced with a difficult decision and you are not sure how to act, a good check and balance is to ask yourself this fundamental question: What would another reasonable and prudent EMS practitioner do if they were faced with the same situation I am in now? If what you are about to do – or not do – is not what other EMS practitioners would be doing in this situation, then you are likely an outlier.

That means your behavior is outside the norm and could put you on the road to committing negligence – or worse. In the end, it is all about accountability in healthcare. We must not only be accountable for what we do, but also for what we do not do when we should. Accountable healthcare providers recognize that we are each responsible for our own actions and we must accept responsibility for the good and the bad. We are all human. We all make mistakes. We just need to be certain that the patient benefits from our presence and is not harmed by it.

Read more: EMS: Anyone could do it; not everyone should. "EMS is a privilege that has been entrusted to you for safekeeping"

Stephen R. Wirth, Esq., EMT-P; and Douglas M. Wolfberg, Esq., EMT, founders of the national EMS law firm Page, Wolfberg & Wirth, are among the most well-known and respected EMS attorneys in the United States. Both served as long time EMS practitioners and administrators prior to becoming lawyers. They can be reached at [email protected] and [email protected].

For over 20 years, PWW has been the nation's leading EMS industry law firm. PWW attorneys and consultants have decades of hands-on experience providing EMS, managing ambulance services and advising public, private and non-profit clients across the U.S.

PWW helps EMS agencies with reimbursement, compliance, HR, privacy and business issues, and provides training on documentation, liability, leadership, reimbursement and more. Visit the firm's website at www.pwwemslaw.com.