Dialing it Down a Notch

Bringing order to chaos. It’s hard to suggest a more important skill for an EMT.

Emergencies are chaotic. Heck, even non-emergent “emergencies” are chaotic. The nature of working in the field is that most situations are uncontrolled. Part of our job is to bring some order to it all, sort the raw junk into categories, discard most of the detritus, and loosely mold the whole ball of wax into something the emergency department can recognize. Call us chaos translators. This is important stuff; it’s why the House of God declared, “At a cardiac arrest, the first procedure is to take your own pulse”; and it’s why we walk rather than run, and talk rather than shout.

The thing is, it’s not just those of us on the provider side that need this. Oftentimes patients need it too. Imagine: every other day of your life, you’re walking around without acute distress, in control of your situation and knowing what to expect. Today, something you didn’t anticipate and can’t understand has ambushed you — a broken leg, a stabbing chest pain — and you don’t know how to handle that. So you called 911 to make some sense of it all.

Most ailments are side effects of other problems: the fear of going mad, the anxiety of being so alone among so many, the shortness of breath that always occurs after glimpsing your own death. Calling 911 is a fast and free way to be shown an order in the world much stronger than your own disorder. Within minutes, someone will show up at your door and ask you if you need help, someone who has witnessed so many worse cases than your own and will gladly tell you this. When your angst pail is full, he’ll try and empty it. (Bringing Out the Dead)

With some patients, this is more true than with others. With some patients, there may be little to no underlying complaint; there is mainly just panic, a crashing wave of anxiety, a psychological anaphylactic reaction to a world that is suddenly too much for them. Particularly in those cases, but to a certain extent with everybody, bringing that patient to a place of calm may be exactly what they need. I have transported patients to the hospital who clearly and unequivocally were merely hoping to go somewhere that things made sense.

The burned-out medic likes to park himself behind the stretcher, zip his lip, and allow things to burn out on their own. This may sound merciless, but there is a certain wisdom to it.

We are very good in this business at escalating the level of alarm. Eight minutes after you hang up the phone, suddenly sirens are echoing down your street, heavy boots are echoing in your hall, and five burly men are crowding into your bathroom. We have wires, we have tubes, we have many, many questions. What a mess. So sometimes, once we’ve finished ratcheting everything up, it behooves us to pause, step back, and make a conscious effort to turn down the volume.

Take the stimuli of the environment, of the situation, and dial it way back. One of our best tools is to simply get the patient away from the scene — the heart of the chaos — and into the back of the ambulance, where we’re in control. It’s quiet, it’s comfortable, and there is less to look at. Move slowly, consider dimming the lights, and whenever possible avoid transporting with lights and sirens. Demonstrate calm, relaxed confidence, as if there’s truly nothing to be excited about. Some patients with drug reactions, or some developmental or psychological disorders (such as autism spectrum), may be absolutely unmanageable unless you can reduce their level of stimulation. Just put a proverbial pillow over their senses.

If you’re stuck on scene, try to filter out the environment a little. If bystanders or other responders (such as fire and police) are milling around, either clear out unnecessary personnel or at least ask them to leave the room for a bit. Make sure only one person is asking questions, and explain everything you do before you do it.

There’s a human connection here, and if you can master it, you can create an eye of calm even as sheet metal is being ripped apart around you. Look directly into your patient’s eyes, and speak to them calmly, quietly, and directly. Take their hand. Use their name, and make sure they know yours. Narrate what’s going on as it occurs, describe what they can expect next, and try to anticipate their emotional responses (surprise, fear, confusion). If they start to lose their anchor, bring them back; their world for now should consist only of themselves and you. To achieve this you need to be capable of creating a real connection; it is their focus on you that will help them to block out everything else. Done correctly, they may not want you to leave their side once you arrive at the hospital; you’re their lifeline, and it may feel like you’re abandoning them. Try to convince them that the worst is over, and they’ve arrived somewhere that’s safe, structured, and prepared to make things right. They’ve “made it.”

Applying these ideas isn’t always simple, and learning to recognize how much each patient needs the volume turned down requires experience. But just remember that no matter who they are, no matter what their complaint, most people didn’t call 911 because they wanted things more chaotic. Try to be a carrier of calm.


  1. Great post!
    I have often told people that all the hustle and bustle of responders and the things they need to do don’t mean that things are terrible, we just want to help make things better as soon as we can. I try to arrange things so that whoever is ripping open packages and setting up O2 and whatever are not in the direct field of view of the patient.
    I’ve done a fair amount of “look at me, breathe with me” sorts of things to narrow focus and slow things down.
    At a recent MVA, with a patient who was near panic, I purposely slowed down my speech and narrated not only what we were doing for the patient, but made sure they knew that the people in the other car were being well taken care of.
    I had an emergency of my own not too long ago that reminded me how easily the scene can feel chaotic and out of control and scary, simply because of all the fuss it creates, so I’m somewhat more sensitive to it than I was before that experience.

  2. Scene Management, aka making order out of chaos, is a skill that takes literally years to develop. That’s why I have a hard time getting so many EMS personnel saying go straight to paramedic and don’t sweat the smal stuff by spending time as an EMT first.

    It ain’t small stuff. You’re better off sweating it while you do not have the distraction of all the bells and whistles.

  3. When I was in medic school, I used to ask a lot of questions. One in particular I asked of every medic that I looked up to. “What is the one thing that makes a good medic?” Almost every one of them answered “scene management”. Excellent post.

  4. I was on my first clinical ride a long for EMT-B and we went on an unresponsive pt. It was the first call of the day and my first real experience in a professional EMS setting. When we arrived and entered the room, the pt literally took his last breath and went into cardiac arrest. He was a big person in a small room. He had coffee ground emesis coming out of his mouth and nose. I was on suction and was making sure to get all of this stuff sucked up and out of the way. It was even getting into his eyes, his lifeless eyes. I had to stifle my gag reflex more than once during this time. I was concentrating on all of this…mess and chaos and I was getting lost in it all. The next thing I know everything just seems to slow down to a smooth professional rhythm. The medic I was assigned to was talking to everyone with a calm voice, doing things in a smooth efficient manner and even using “pleases and thank yous”. It was amazing the effect this had on everyone in the room, EMS and family alike. I know the medic realized there was almost no chance to get ROSC on the pt, but he worked it like it should have been.
    Since then I have become a paramedic myself. I don’t have the time and experience under my belt like he does, so I strive every shift to emulate that medics behavior on scene.


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