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How To Be Assertive Without Being An Asshole Or A Pushover.

The guards found him hanging in his cell. He had hung himself with a noose made from ripped sheets that were tied together. When the guards cut him down he had probably been dead for at least twenty minutes but they started working him anyway. EMS showed up and reluctantly continued the resuscitation efforts.

Given enough epinephrine almost all recently dead hearts can be made to beat again. In spite of being deprived of oxygen for a surprisingly long time the heart can resume normal functioning after a substantial dose of epinephrine is administered. The brain is much less resilient however; just a few moments without blood flow causes irreversible damage. 

After twenty minutes of CPR and a bunch of drugs he regained a pulse and a blood pressure, his brain was well past the point of any meaningful recovery. The EMS crew was well aware that they were delaying the inevitable, they knew they were simply changing the location of his death from a prison to an ICU. 

The EMS crew transported him to the local level IV Emergency department. The level IV ED does not keep truly sick patients around for long. There are transfer agreements with other larger hospitals. They called me to take this patient from their hospital to the larger hospital three hours away. 

Walking into the ED room, the respiratory therapist gave me a knowing smile, the one that says this is a total shit-show.

“Check this out,” the RT says as he disconnects the vent circuit dumping what looks like cherry 7up out of it into a suction canister.  “That was the third one,” he tells me. As soon as the circuit is reconnected to the patient it immediately begins filling up again. There is no need to listen to lung sounds; you can hear him gurgling from the hall way. Over the past few minutes the patient had developed fulminant negative pressure pulmonary edema (NPPE).

When a patient develops NPPE the human lung can produce a nightmarish amount of fluid; an unstoppable rising tide of pink froth flows from the lungs into the trachea. If not treated quickly, a patient with NPPE will drown on their own secretions as providers look on.

NPPE is often encountered in hangings and strangulation but it can occur in any situation when a patient tries to inhale against a closed or crushed trachea; for example, when an intubated patient’s endotracheal tube becomes obstructed by secretions or because a poorly sedated patient is biting down on the ET tube or even with laryngospasms. As the patient tries to inhale against the airway obstruction they create a tremendous amount of negative pressure in the thoracic cavity- enough to literally suck fluid out of the capillaries and into the alveoli.

NPPE causes a positive feedback death spiral - the airways fills with fluid which reduces the amount of gas exchange, the patient becomes more hypoxic. The increasing hypoxic causes pulmonary vessel shunting, the pulmonary vessel shunting raises the pulmonary capillary pressures, the increasing pulmonary capillary pressure increases edema which worsens the hypoxia until the patient dies. 

Everyone in the ED knows this is an exercise in futility; Mr. Cherry 7up is never going to have any sort of meaningful life again, he was brain dead an hour ago. The best case scenario is that maybe some of his organs can be salvaged for donation. 

Despite being ventilated with 100% oxygen the patient is profoundly hypoxic. The pulse ox reads in the mid 60%’s.The blood pressure is shit at 54/32mmhg. The chest x-ray looks like a blizzard. the vent settings are a  respiratory rate of 12/min, a PEEP of 5cm and an fiO2 of 100% -the standard default vent setting in most small emergency departments. 

I ask if anyone has thought about turning up the PEEP. “We tried that. If we turn up the PEEP the BP drops,” The nurse tells me.  “The doctor wants it at 5cm.” she says and walks out of the room to get the paperwork for the transfer together.  I ask the doctor about starting a vasopressor, mentioning the blood pressure is “a bit soft.” This is a classic example of mitigated speech patterns. In “The ethnic theory of plane crashes” Malcolm Gladwell defines mitigated speech as "Any attempt to downplay or sugarcoat the meaning of what is being said".[1] Gladwell presents a spectrum of communication, on one end is a direct command and the opposite side is the practice of “hinting and hoping.” 54/32 is not a blood pressure that is a bit soft, it is life threatening, it is causing his organs to die. But I am polite and want to play nice. I don’t want to create a scene or conflict. I repeat to no one in particular, “yeah, it is pretty soft…”

The ER doctor seems annoyed at this point. He turns towards me and says “I think you guys should just get on the road,” and then looks back at his computer.

The elements of a call going to shit are all coming together now: a sick patient with multiple complications and comorbidities, goal conflict (balancing BP and oxygenation and trying to not be perceived as a dick), egos and feeling, poor communication, and a perceived time constraint. I know what needs to be done here for the patient, at least to keep him alive for the next three hours but I am not getting the buy-in from the ED staff that I want, no one seems to be picking up on what I am hinting at. 

I feel like I am bugging the doctor as I try to diplomatically explain how we can balance the effects of PEEP with a vasopressor, asking if there is any merit to the idea of both turning up the PEEP and staring levophed, but the doctor is not having it. “Seriously, I think you guys just need to get him to big city hospital. You need to go….Now! Or we can just call a helicopter if you can’t do it,” he says in a way that says this is the end of the conversation. We load up the patient and get underway, my partner and I share a knowing glance that says “god, what an asshole.”

I spend the next few days telling myself that next time I am going to be more assertive and not such a push-over. If you are in medicine long enough you’ll witness people stand by silently as horrific medical mistakes are made because “it’s not my call,” or they don’t want to “step on toes.” People routinely take patients out with the wrong medication or wrong dose infusing or with disastrous ventilator settings. During the debriefing, if there is one at all, they shrug their shoulders and reply, “well, I asked about it.” Asking about something is not the same as being assertive. 

The other side of this equation is being overly assertive, it borders on aggression and it rarely accomplishes much.  It tends to alienate people and make you look like an asshole; it creates drama and turns what should be a patient care focused issue into a pissing contest.  You might win the battle with this approach but you will lose the war on a longer timeline. Actually, if you go up against an ED doctor you probably won’t win the battle either.

It is important to state that nothing works all the time. Sometimes “no” is a complete sentence. You could present the most rational well thought out argument and people will be unwilling to budge. There is also the possibility that you could simply be wrong- always go into these conversations with an open mind and be willing to hear ideas that are opposed to what you believe to be correct. This is not about winning or losing, or who has the best idea or most knowledge; it is about doing what is best for the patient. You need to be willing to listen to the other person when they speak. 

Here is a basic framework that I have stolen from various sources to use when advocating for patients in high stress / high ego situations.  It isn’t something I came up with myself, I am not that smart. Most of it is stolen from crew resource management texts, the bulk of it coming from “Soaring to Success.”[2]

Address a specific person and use their name.Do not use thin air statements about how “someone maybe should consider doing something.” Use a person’s name when you address them.  Just like that ACLS video with the multicultural cast that you watch every two years says, “YOU call the code and grab the cart,” rather than “Someone call the code and grab the cart.” It would be even better if they used a specific name in the scenario when they tell someone to call the code.

State what you are worried about clearly:State the problem very clearly. People are not going to search your speech for innuendos, metaphors or nuance when the shit is hitting the fan. This is not the time for subtlety. Avoid using mitigated speech patterns here and be direct. “Dr XYZ, the patient is profoundly hypotensive, with a MAP of 32mmhg.”  State why you think this is an issue:In this case you want to say, “Dr XYZ, the patient is profoundly hypotensive, with a MAP of 32mmhg. I’m concerned that leaving it there for the next 3 hours on this transfer is too risky and could cause kidney damage.”

State what you would like.  Be assertive here - This is not a question, this is a statement.   Either use “I think we should” or “I would like to” or “I want to.” This is a short sentence. You are going to want to keep talking; you are going to want to soften the delivery by using some type of language or turning it in to a question by adding something to the end of the statement like “if it is okay with you?” Do not do that. “Dr XYZ, the patient is profoundly hypotensive, with a MAP of 32mmhg. I’m concerned that leaving it there for the next 3 hours on this transfer is too risky and could cause kidney damage. I want to hang levophed and get their MAP to at least 65mmhg.”

Then close the deal.Ask “would you agree?” and stop talking. If you really want to go for the bonus points you could ask “do you concur?” You need to ask a question at the end of your statement as it forces them to take action and answer you.  The hard part is after you ask the question you need to stop talking. If you are new to this approach you will want to keep talking, you’ll want to mitigate the speech a bit; you’ll want to add some softening language on the end of this. “…if it pleases the crown.” Don’t do this. Let them think it over; let them have a few seconds to process it. 

 “Dr XYZ, I’m worried about their MAP, it is currently 32mmhg. I’m concerned that leaving it there for the next 3 hours is too risky and could cause kidney damage. I want to hang levophed and get their MAP to at least 65mmhg. Do you agree?” 

The easiest way to remember this is the “3W’s” format that crew resource management embraces.

  • What I see. 

  • What I am concerned about.

  • What I want.

The first two “W’s” are easy to do; it is the third “W” that is the hardest. We are not used to saying what we want directly, especially to a physician or mid-level provider.

Communication is an art; it takes practice and constant work unless you are the small minority that is a gifted communicator. I am not one of those people.

We left the hospital with the patient and we did what was needed; our protocols allow for this. Neither of us were okay with sitting there watching a patient slowly drown over a three hour transport. The PEEP was increased to 20cm of h20 and levophed initiated at 10mcg per minute. The flow of pink froth from the patient began to slow; his blood pressure began to climb. His toes and fingers began to turn from blue to pink. The pulse oximeter began improving, slowly at first, a percentage point here, a percentage point there. Two hours later the patient had a normal blood pressure, no more cherry 7up flowing from his lungs and the spo2 was in the mid 90’s. The procedure was a success but the patient was still going to die. 

In the end we did what was right for the patient but still, I wish I had done better at getting the ED staff on board with my treatment plan. Maybe it is driven by ego, perhaps by a need that I want people to see me as smart and as a good provider, but I wish I had done better at communicating that day. 

Citations. 1. Gladwell, M. (2008). Outliers: The story of success. New York: Little, Brown and Large Print.

2. Much of this part is based on crew resource management and the approach comes from “Soaring to Success” Sculli, G. and Sine, D. (2011). Soaring to success. Danvers, MA: HCPro.

Brian Behn 

Brian Behn is a paramedic supervisor and performs quality assurance at Chaffee County EMS in Colorado. He is currently on the NEMSMA Quality Improvement Committee. He writes about human factors in EMS. This is his first piece for FOAMfrat.

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