Cultural Competence in EMS

You and your partner walk onto a scene for a 35-year-old female experiencing moderate abdominal pain. Her husband answers the door and shows you to their living room where she is sitting on the couch. Your male partner begins asking about her symptoms, but she keeps looking to her husband to answer. You and your partner make eye contact, discreetly acknowledging each other’s confusion. 

The patient you’re assessing in this scenario is Muslim, and her reticence is not meant to disregard you—her husband’s communication with a non-relative male on her behalf is the norm in their orthodox faith.

If you’re unfamiliar with the cultural customs of Muslims, or those of other major religions common in your jurisdiction, patient interactions may be perplexing and possibly impede your ability to provide proper care. 

A Common Purpose

Raphael Poch, EMT, is no stranger to caring for culturally diverse patient populations. He’s the international media correspondent for United Hatzalah (meaning rescue in Hebrew), a group of nearly 6,000 volunteers providing free emergency medical services to citizens in Israel, which is separate from Magen David Adom, Israel’s national ambulance service. As one of the volunteers, Poch rides an ambucycle (the organization’s medical response motorcycles designed for rapidly navigating narrow city streets) as both an EMT and a member of the Psychotrauma and Crisis Response Unit, which provides psychological first aid to bystanders, patients and even responders on trauma scenes.

Serving a nation as diverse as Israel’s requires setting aside cultural differences to care for your neighbors. Being the Jewish state, the majority of the demographic in Israel is Jewish, while Muslim Arabs come in as the second most populous, followed by smaller minority populations of the Druze religion, the Bedouin (a type of Islam), and even smaller populations of Christians, and then the Bahá'í. United Hatzalah is comprised of volunteers from all of these groups except for the Bahá'í, and each group reflects that of Israel’s percentage-wise. In a country often scourged with political and religious strife, the goal shared by the volunteers to help others unifies them. Since volunteers typically arrive first on scene before handing off the patients to the ambulance service, they often linger afterwards and befriend each other, building connections with people from other cities of different backgrounds—so much so that Muslim volunteers will invite Jewish colleagues to their weddings and vice versa.

“One of the amazing things about the organization is that because it's volunteer-based, the people have a similar mindset of, ‘We are going to put our own lives on hold in order to save others,’” says Poch. “Regardless of your cultural, religious, or national background, you develop this kinship with other people who have the same ethos.”

This familial bond translates into the volunteers’ patient care. “The patients don't necessarily know the religion or culture of the person responding—they just know someone’s there to help them and that's really what they're looking for,” Poch says.  

That’s not to say the volunteers don’t encounter hostility, Poch says. “There have been terror attacks where the crowds are screaming, ‘Death to the Jews!’ or ‘Death to the Arabs!’ and then a responder who’s a target of that crowd walks in and starts treating people,” says Poch. He described one story of a Muslim volunteer who responded to a hotel bombing where people were yelling ‘Death to Arabs,’ but he just left his ambucycle helmet on so he could safely treat people without being recognized. “There's a little bit of a clash of cultures every now and then, but we do our best to try and do good with that cross-cultural pollination rather than focus on the negative.”

While the United Hatzalah EMT school curriculum does include education on different religious laws so providers can avoid breaking them on scene, Poch says the volunteers are actually each other’s best resources for learning about other cultures. For example, walking into a call for CPR in a Muslim community can be alarming if you don’t know that Muslims will begin mourning before a patient is officially pronounced dead.

Understanding what’s normal and not normal for each community informs EMTs how to act accordingly and respectfully. In consideration of religions that forbid non-relative males from touching women, United Hatzalah developed a women’s unit of providers tasked to respond to communities abiding by that custom. And to accommodate for the wide variety of languages spoken in Israel, the dispatch center will send volunteers who speak the languages of patients to provide better care for them, like English, Russian, and French, to name a few (dispatchers also speak multiple languages).

Poch says while it’d be ideal for all EMS systems to incorporate cultural sensitivity training, not all have the budgeting for it, but he recommends providers take the initiative to educate themselves on the populations specific to their communities. This, he feels, is a core component of United Hatzalah’s mission—harnessing the chutzpah, Hebrew for “audacity,” to implement changes that improve patient care.

“If you see something that you can help change and make better, don't wait for someone else to do it,” Poch says. “Go out and use that chutzpah to get things done to make the difference in your community to save people's lives.” 

Culture Shock

Last April, in Bergen Community College, located in Lyndhurst, N.J., Shafeq Zarif, EMT, sat with several other EMS providers on a cultural diversity panel in front of the school’s Paramedic Science Program class. While most EMS curricula don’t cover cultural sensitivity, Bergen County hardly has a choice in the matter. On Cultural Diversity Day, panel members of varying cultural and religious backgrounds discussed with students best practices for appropriately interacting with patients of the extremely diverse north Jersey region, populated by immigrant groups from Spanish-speaking countries, Eastern Europe, and Asia. 

Raised in New Jersey by his Muslim parents who emigrated from Afghanistan, Zarif was fortunate to grow up comfortably immersed in both Western and Middle Eastern cultures, which would later prove to be advantageous when he entered the world of EMS in one of the most densely populated and diverse areas of New Jersey. Zarif says it’s important to be mindful of how everyone lives by their cultural norms in varying degrees. For those who migrated to the U.S. for better opportunities, the cultural differences of the West can make the transition very difficult. But you can navigate that territory even with those who maintain the most traditional roots.

Handling 9-1-1 calls involving pronouncements or resuscitation is more delicate in non-Western cultures, many of which view death as a highly sacred event, making it a major topic of discussion on Cultural Diversity Day. If a provider isn’t prepared for the extreme emotional behaviors associated with the grieving process of a patient’s family, it can be alarming. Zarif tells students that remaining calm, proceeding with the job, and keeping the family completely informed is the best way to manage these scenes—which is business as usual in EMS, anyway. Zarif says he’s never witnessed anything of the contrary in the field.

Zarif says on more dynamic calls when families are highly stressed, de-escalating the situation can be difficult when a language barrier exists, but Zarif says they simply take their time communicating, or find a neighbor or family member who speaks English. Most of the time, though, someone from their crew or even a police officer speaks the language (when Zarif responds to a predominantly Hispanic neighborhood, he uses the Spanish EMS-speak he’s learned to help with patient assessments). Language aside, the main goal is to care for the patient while keeping the family informed in any capacity possible. 

“The whole family gets involved in the patient's care process,” says Zarif, who provides an example of interacting with ultra-conservative Muslim patients as described in the opening scenario. If there is no female provider on scene to perform a physical assessment on a female patient, he advises checking in with a male relative before doing the assessment. Just communicate with the family to gauge what they’re comfortable with.

“I would interact with the patient to the best of my abilities. If I see a trend where she's deferring everything to her husband because I'm a male, then I’d speak to both of them openly to keep them in the loop,” he says. “The more you include family members, the more comfortable they are.” 

Another religious practice that providers should be cognizant of is fasting. During the month of Ramadan, which rotates annually based on the Islamic lunar calendar, Muslims will fast from sunrise to sunset as an act of practicing patience. During this time, patients might be reluctant to accept any medication on scene as it would break their fast and require them to make up lost days. Accepting transport may be an issue as well if it means they might need medications administered at the ED. Explain to them the importance of getting better now and losing one day of fasting as opposed to losing multiple days by allowing an illness or injury to go without treatment. 

The Golden Rule 

Zarif’s upbringing provided him a unique opportunity to empathize with people from different backgrounds. His perspective is perhaps more openminded than others' simply due to his frequent exposure to people from all walks of life, but his colleagues are eager to learn and quick to ask him questions about their interactions with Muslim patients. Zarif likes to believe that ignorance is oftentimes innocent, bred by a lack of awareness on cultural sensitivity or from growing up in a homogeneous area. 

“People are going to have their prejudices or biases against certain cultures and beliefs for whatever reasons they have, but in EMS you take on the understanding that you’re there to help people at their beck and call,” he says. “If you have a problem with it, maybe you should find something else to do.”

That’s where education needs to come in. Of course, in an ideal world, soft skills and cultural competency would be integrated into EMS curricula across the board. Until then, administration staff should take the lead on implementing training on the demographics specific to their region. 

“It is a very difficult subject to talk about, but training needs to be done,” says Zarif. “Just to expose first responders to the different cultural or religious beliefs so they're more aware, can respond better, and communicate better if they ever interact with those patients.” 

Sidebar: Best Practices for Orthodox Jewish Patients 

• Physical contact between sexes: Men and women not married to each other are forbidden to touch each other except in a life-threatening emergency. If a provider of the same sex is available, let them perform procedures that involve physical contact.
• Privacy issues: Ultra-Orthodox communities are extremely private. Respond without lights and sirens, maintain patient privacy as well as you can, and avoid lingering on scene.
• Shabbat observance: When observing the Sabbath, or Shabbat, and other holidays, Orthodox Jews must abstain from activities such as writing or using electricity or phones. Jewish law exempts these customs in the event of emergencies or even minor injuries, but people are still hesitant to call 9-1-1 and will be less communicative if they do. They may only hint at what they need on scene. Jewish patients observing the Sabbath may be resistant to writing anything, so be sensitive if they do not want to sign a PCR.
• Local rescue organizations: Globally, most Orthodox communities have their own local first-response medical organization, known as Hatzolah, comprised of EMTs or paramedics on call 24/7. They might already be on scene by the time an ambulance or fire service arrives. “It’s important for ambulance teams to know that they exist and that you are all working for the same goal of treating the patient faster,” says Poch.

Valerie Amato, NREMT, is assistant editor of EMS World. Reach her at vamato@emsworld.com.