The Importance of Professionalism in EMS

Late in 2017 a video surfaced on the Internet and quickly went viral. Its premise was simple: A group of Indiana University police academy recruits were brought outside by their instructors, made to stand at attention, and then endured an arduous torture. 

Instructors approached each cadet from behind while wielding a squeaky rubber chicken. They held the plastic poultry close to each cadet’s ear or face and, without any dialogue, squeezed the toy. A comical “cluck” emanated from the chicken. Some cadets stood stone-faced and did not flinch. Others broke into laughter and were compelled to do push-ups. The video is hysterical. There was, however, a far more serious point to it.

The Internet boasts no shortage of cell-phone videos of encounters with police. Some individuals even deliberately harass and annoy officers, baiting them to behave poorly while being recorded. Most law enforcement leaders understand a positive public image is essential not only to the success of police work but to the very lives of those on patrol.

Negative video encounters, even when embellished or edited, can strain relations between police and the public. While having a rubber chicken thrust into one’s face is not inherently dangerous, an officer’s inability to maintain their emotional composure during a tense situation certainly is, and this is the real crux of the Indiana video. 

EMS has long been protected from the same level of scrutiny police officers face. People are generally happy when we show up. Like our friends in the fire service, we’re the “good guys.” Yet social media and the ubiquity of video cameras have begun to put us in the crosshairs.

In decades past our worst and dimmest could hide in anonymity, collecting customer complaints and having closed-door meetings with management. This has irrevocably changed. Every action how has thousands of potential witnesses. Our encounters with patients and families are forever preserved in MP4 snippets. We’re just as likely to be baited as police and just as likely to injure our professional image. 

We have reached a point where it is no longer good enough to have sound skills and strong medical knowledge. Professionalism is now a requisite attribute in EMS.

Fatal Consequences

The story of Paul Tarashuk is a tragic tale. A diagnosed schizophrenic, Tarashuk was traveling through South Carolina in September 2018 when he experienced a mental health crisis. He was found running along Interstate 95, naked and acting erratically. Someone called 9-1-1, and an ambulance crew arrived to evaluate him. 

The evaluation, captured on a deputy’s body cam, shows a paramedic and two other providers attempting to get Tarashuk’s name.¹ Tarashuk never speaks a word in the video, and as the EMS crew’s frustration grows, they lose their focus on medical care and begin berating him for not cooperating. One provider inserts an ammonia capsule into Tarashuk’s nostril in a seemingly punitive act. Tarashuk does not respond to the ammonia or any of the providers’ questions. Still the crew fails to appreciate the very obvious alteration of his mental status. They eventually ask him if he wants to go to the hospital. He shakes his head, and with that the crew releases Tarashuk to the deputy. The deputy is subsequently seen on security footage dropping Tarashuk off at a closed gas station several miles from the original call. Tarashuk later wanders back into traffic and is killed when struck by a vehicle. 

The entire incident was a miscarriage of medical care, but the most pressing issue was not that EMS misapprehended Tarashuk’s lack of mental competence. It’s that several emergency responders treated this man as if he were unworthy of their concern. In the court of public opinion, EMS as an industry could not have possibly looked worse. It is conceivable the providers in this case were suffering from compassion fatigue or some other type of cumulative stress, but that does not excuse the behavior, nor does it repair the broken bonds of trust between EMS and the community.

Errors of the Heart

Paramedic Bryan Brauner, CEO of Twin City Ambulance Corp. in New York, speaks to all incoming employees about culture, professionalism, and compassion. “We can deal with errors of the mind,” he tells them, defining those as mistakes made due to a lack of knowledge or a true oversight. The unacceptable errors are those he calls “errors of the heart”—mistakes made when a provider puts his or her own comfort or self-interest above the needs of patients and the mission of the agency. 

Errors of the heart kill our public image. They indirectly killed Paul Tarashuk. Errors of the heart are often unforgivable because they are generally a reflection of provider’s character, rather than competence. Failures of competence can be addressed with training. Failures of character are far more malignant; indeed, an individual of questionable character may not even perceive his own shortcomings, which makes the path toward resolution a tangled and narrow one. What is the prescription for selfishness? What is the cure for indifference? For a lack of integrity?

Social Contract and Morality

In a 2004 article, “Professionalism and Medicine’s Social Contract With Society,” Sylvia and Richard Cruess outline the nature of medicine’s relationship with the community at large.² As practitioners we expect trust, status, and autonomy from the public. In return the public’s expectations include our competence, altruism, and integrity. On every call the EMS provider faces the decision of whether to honor or breach the social contract. As an industry we must expect our practitioners to deliver competent, compassionate medical care. Any deviation from this represents an opportunity to lose face with the people we expect to trust us—and pay us. 

In seeking professionalism from medical staff, Thomas S. Huddle, MD, PhD, says we are really seeking morality, which he defines as a blend of conscientiousness, altruism, and compassion.³ Interestingly, Huddle suggests the scenarios in which morality is most at play are the situations where the right thing to do is very obvious. “The bread and butter of morality in medicine is not in the ‘hard cases,’ where the right way forward is difficult to see,” he wrote. “It is in acting rightly when the right path is clear before us but other pressing needs and desires pull us away from that path in the midst of day-to-day medical routine.”

In short an EMS provider displays morality simply by doing what is incontestably right. The Tarashuk case demonstrates this poignantly. The right thing to do was evident even to the layperson. Transport for evaluation was very clearly indicated. 

Solving the Problem

Like proficiency in IV access or endotracheal intubation, professionalism needs to be developed. Many people learn professionalism from their mentors, but training and education can promote the attribute as well. In exposing students to scenarios that call for moral and ethical decisions, we can teach critical analysis of behavior. A thorough treatment of professionalism and ethics should be provided in EMS education, even at the EMT-Basic level. 

Self-policing is another way for EMS to improve its image. One cannot underestimate the power of being called out by a peer. Disappointing a manager or supervisor is not the same as disappointing the people you sit next to for 12 or more hours a day. Official discipline usually falls far short of interpersonal relationships when it comes to changing behavior. 

Finally, EMS leadership bears the responsibility of establishing a Just Culture atmosphere that focuses more on education and mentorship than discipline. Leaders must also develop the ability to recognize and address providers who struggle with professionalism. Administrators can coach employees by helping them align their expectations with the realities of the job, helping them find resources to deal with personal and emotional difficulties, or ultimately by steering them toward a line of work better suited for them. 

At the end of the day, the development and maintenance of professionalism is a team effort and should be treated as an essential part of EMS. We must maintain our good standing with our patients and partners if we desire to improve our stature. The rubber chickens are not going away. 

References

1. YouTube. BODY CAMS Neglect of EMT’S and POLICE death of mentally Ill man Orangeburg, SC!! Paul Tarashuk, www.youtube.com/watch?v=AzgfusrUB5w.

2. Cruess SR, Cruess RL. Professionalism and Medicine’s Social Contract with Society. Virtual Mentor, 2004; 6(4).

3. Huddle TS. Teaching Professionalism: Is Medical Morality a Competency? Acad Med, 2005 Oct; 80(10).

Sean P. Hulsman, MEd, EMT-P,  is a paramedic and EMS educator with more than 25 years of service. He currently serves as director of education at Twin City Ambulance in Western New York.