This article appeared in the March, 1997 issue of EMS Rescue Technology magazine.

“Efficiency of a Practically flawless kind may be reached in the struggle for bread. But there is something beyond—a higher point, a subtle and unmistakable touch of love and pride beyond mere skill; almost an inspiration which gives to all work that finish that is almost art—which is art.” — Joseph Conrad

Good scene control is an aspect of prehospital care that is difficult to describe in words. When a scene is well-controlled, things get done seemingly by magic. It is far easier to detect poor scene control, because nothing seems to go right. Leadership on a scene may change hands one or more times as waves of increasingly qualified people arrive; along with other tasks, each leader assumes responsibility for scene control. Scene control does not end until after patient hand-off at the emergency department.

Normally, scene control is best done by the person in charge of the patient, because that person most clearly knows what must happen, and in what order. The communication skills and interpersonal flexibility of the scene leader tend to define the degree of scene effectiveness. There are good scenes and rotten scenes, but an unwavering constant of prehospital medicine is that there is always a scene of some type. Your goal is to control it, not let it control you.

This chapter strives to address control of the circumstances that are common to everyday scenes. It does not refer to other elements of control that are related either to unusual circumstances (such as disasters or hazmat incidents) or to medical control (where a system's protocols and medical philosophies are defined by a medical advisory system).

In the final part of the chapter, the concept of scene choreography is discussed. Scene choreography is the ultimate refinement of scene control. The term has been coined to represent the fine art that comes with putting all the elements of streetsense together at once. Scene choreography is like the "caller" at a square dance, who keeps the circles of people moving in intricate patterns until the music stops. From the beginning to the end of an emergency call, an EMS provider who wants the experience to outshine plain mechanics should strive for smooth and timely completion of all tasks. That is the essence of scene choreography.

Scene Control

Scene control is a science. It is the coordination of the unlikely mix of people, their emotional and physical conditions, the physical setting, and all the other aspects of the scene into a coherent plan. In a way, doing scene control is a lot like playing the game of backgammon. It is easy to learn to do, but it is difficult to learn to do well. Done well, it is smooth and scarcely noticeable. Done poorly, it can be a mess.

There is always a scene. Each is unique, and in need of some facilitation by you, the expert. Scene control is an important part of every prehospital situation, even interfacility transfers. As with many other aspects of EMS, the best expertise comes from hands-on experience. Learning to control a scene is the same as anything else: Practice makes (more) perfect. Therefore, this chapter speaks in the sort of generalizations that will provide a solid framework for you to build upon. At first, directing how and when various tasks are done, and by whom, requires conscious thought. Eventually, scene control becomes more innate. You will no longer notice handling details that once required specific concentration.

Personal style accounts for many of the differences in the way scene control is done. Many people are excellent at it. Others are not. Working under somebody with poor scene control capability is a source of real frustration for many prehospital workers.

Some prehospital workers do not have the luxury of much apprenticeship before finding themselves in charge. One brand-new EMT was plunked onto a 9-1-1 response ambulance two days after being hired to her first job in EMS. The more experienced partner (who had to drive) was of some assistance, but for the new EMT, those first few days were full of anxiety, frustration and poor scene control. Preferably, the climb to the honor and responsibility of being the one to control a scene is less abrupt for most people.

Power

Power is a curious thing. Control is power. When you are in control of a prehospital medical scene, you are responsible for the well-being of the patient(s), bystanders and other rescue personnel around you. That can include anything from you, your partner and one patient, to dozens of people.

Sometimes power is diffused, and it is unclear whose orders to follow. This is especially common when law enforcement concerns are not blending with those of the EMS providers. For example, parking at a motor vehicle accident can become an issue. Also, it has happened that EMS providers have been ordered by the people with the guns not to go near the "victim" because the police made a presumption of death—only to discover otherwise later. On the other hand, EMS providers sometimes interfere unnecessarily with
legitimate concerns of the police, such as criminal evidence. Emergency personnel from all agencies need to try to understand the concerns of the others, and establish good working relations and general policies. That way, power struggles will fade away.

EMS providers have power because people want our advice and defer to our judgment. We have a palpable impact on their destiny.' Heady stuff. The next aspect of power, then, is knowing how to employ it well. This means having a realistic, mature view of power. We all have a place in the pecking order. As the saying goes, the boss berates the husband, who berates the wife, who berates the kid, who hits the dog, who goes and bites someone. More graphically, there were two EMTs at the bottom of their pecking order who took their frustrations out on a skid-row drunk. They were the ones who decided to give him a ride he'd never forget, and it killed him.

Misuse of power happens more than it should. Many people bestowed with power have subsequently discovered that they were unprepared to handle it. They went on "power trips." They alienated coworkers and angered the public. Some have nearly destroyed the organizations they were asked to lead. Misuse of power tends to occur when people misunderstand the implications of power-tripping, both on the individuals at a single occurrence and on the overall EMS system. When you are in charge of scene control, you set the example. It is important to use power wisely, responsibly and judiciously. Understand how easily power can turn against you, so you can try to use it well—not let it use you.

EMS is suffused with power in many ways. We use lights and sirens to cut through traffic. We have the implied and express consent of people to tell them what to do during a crisis—whether to go to the hospital or not, how to get there, which hospital can best serve their needs. There are different sources of power, and people in EMS have access to several: (1)

• Expert power. The people who dialed 9-1-1 couldn't manage, so they called in the "experts."

• Informational power. The information we can impart is influential and persuasive. "Your EKG is showing me that a trip to the hospital would be a good decision."

• Legitimate power. The public's trust in EMS is what gives us authority at emergency scenes, and by extension, to do interfacility transfers.

• Sanction power. At times, we have the ability to interfere with someone's ability to pursue their own interests, such as when we transport a suicidal person to the hospital.

• Nuisance power. One strategy for helping some people decide to go to the hospital is to be a gentle nuisance. That patient might say, "0K! I'll go with you! Just stop buggin' me!"

• Reward power. Sometimes, the use of such interpersonal strategies as verbal approval, encouragement and praise give us power to accomplish what others could not. It may mean getting a patient to go to the hospital, or it may mean getting a coworker to feel motivated to keep the ambulance clean.

Each individual has a measure of power in every situation. Every participant has at least some power. If nothing else, we are each empowered to maintain our own self-control.

The Leader

Although we collectively share the responsibility for the outcome of every call, the person in charge, the scene leader, has ultimate authority (and power) at a scene. This person should ideally handle primary patient interaction and care, since the medical needs of the situation should drive the call's overall tone. There are specific attributes common to good leaders, but the hallmark is excellent interpersonal capability. Without this, achieving and maintaining scene control is a real struggle.

The other most influential person is the patient attendant's partner (usually the driver). This person acts as the patient attendant's "stage manager," assuring scene safety on the large scale, gathering peripheral information (such as mechanism of injury reports, medications and patient history from relatives), and checking for follow-through on assigned tasks (such as getting the stretcher positioned, etc.).

Problems of leadership come up for many reasons, and they are often the cause of poor scene control. When there are many other people on a scene besides the patient attendant and driver, the scene control challenges will increase. On some scenes, there may be eight or more people, some in the capacity of "first responder," others in law enforcement or fire suppression, and so on. Many EMS services have three or more people on the ambulance. One thing that must not happen is "control by committee." One, and only one, person should be in charge. When that is the primary patient attendant, medical needs can remain the most influential factor in decision-making. "Just as no teacher can be effective unless he or she has some control over the classroom, no health professional can be effective without some control over the therapeutic situation." (2)

In systems with a high degree of formal rank structure, someone with high rank may be in charge while the EMTs and paramedics try to deliver prehospital care. It can be a problem if someone who does not have the training and experience required to appreciate the practice of prehospital care is trying to direct the show. Things may not go well—and may get downright dangerous. One group of EMTs and paramedics worked in an EMS system where prehospital care was politically controlled by the large volunteer fire department. The commercial ambulance service that employed these EMTs and paramedics was awarded the lucrative city contract. The fire chiefs had old-fashioned ideas about how a medical call should be run, but the paramedics had liberal standing orders. Therefore, on many calls, there was an undercurrent of tension because the fire chiefs preferred the old scoop-and-run method, yet the paramedics had an obligation to provide appropriate care. Sometimes, the only way to "control" the scene was to load the patient quickly, leave, and stop a few blocks away to render care. That was suboptimal, but it was the only way to balance the delivery of necessary prehospital care with the political realities. No contract, no job. Fortunately, this scenario is changing as EMTs and paramedics achieve higher rank in their organizations.

Problems are quick to arise, too, when too many people are vying for the leadership role. There is a control conflict. This tends to occur in areas where ambulance services are in direct competition for patients. On-scene squabbles erupt when one crew wants to do things differently from another crew. Once a system matures, many of these problems iron out. But poor patient care has been the result too often when local EMS politics have prevented appropriate scene control.

Finally, some leaders do not command the respect of those they lead. Either they are just learning to lead and have the excuse of inexperience, or they have been doing it badly for years. Administrators of EMS systems that have leadership troubles need to look objectively at rank dissension and determine if it stems from poor leadership.

Like everything else in streetsense, many of the attributes of leadership can be learned. All rely on superior interpersonal communication skills. Good communication skills are obviously an important quality of an effective leader. Scene control is hard to attain when you cannot explain your needs in a way that gets people moving. Four additional attributes to be discussed here are presence, tact and diplomacy, imparting impressions of both reliability and compassion, and building a good reputation among your EMS colleagues.

Presence

More than anything else, your ability to display scene presence will highlight you as a leader. "Presence" is an elusive quality to describe, but you can tell when someone has it because others always look to that person for direction. Basically, presence is "the ability to project a sense of ease, poise or self-assurance, especially the quality or manner of a person's bearing before an audience." (3) It is different from charisma, because people are either endowed naturally with charisma or not. Presence can be consciously developed if you want to work at it. It takes practice to be poised in the face of chaos, at ease in the face of death and self-assured in the face of complex problems demanding rapid solutions. But it can be done.

Presence is in many respects a loud, nonverbal statement of self-confidence. It includes an erect, shoulders-back, head-up posture and a directness of gaze. It is saying, "I'm here, I'm capable, there's a job to do, and together we can get it done." It has nothing to do with either size or gender. Some very small women have impressive presence, and some very large men lack it completely. It has a great deal to do with the way you carry yourself and the genuine confidence you exude.

It is easy to mistake presence for a style that is actually cocky, aggressive or even belligerent. This is the swaggering, bigger-than-life, "I'm great" mentality—a far different thing than presence. It may seem similar, to a point, but a person with presence has real staying power—intellectually and emotionally—to hold things together when the going gets tough. Obviously, people who have good presence command alot of respect.

When attempting to build an image that projects good presence, remember to use good eye contact. Eyes can send powerful messages (even when you are busy with your voice and hands) that prompts others to calm down, regain self-control, listen to directions and accomplish tasks despite chaos and confusion. They can also be powerful touchstones. For example, imagine that you are in charge. You are kneeling on the floor trying to start an IV when the time comes to ask someone to go for the stretcher. You say, "Could someone please get the stretcher?" without looking up. The job may not get done in time, all because you didn't take a moment to make eye contact with someone, an act which causes others to feel personally responsible for the task.

The nonverbal nature of presence cannot be overstressed. Many forget that there are aspects of vocal dynamics that are, in fact, nonverbal. To project calmness and control with appropriate tone, pitch, rate and volume in your voice helps solidify the impression that you know what you are doing.

Tact and Diplomacy

Of course, it is not only how you say things that matters—it is also what you say. This is where tact and diplomacy enter the picture. Tact: "a keen sense of what to say or do to avoid giving offense; skill in dealing with difficult or delicate situations." Diplomacy: "handling people so there is little or no ill will." (4) These definitions are tailor-made to scene control. We wear many hats in EMS. We are actors, playing roles to suit each occasion. We are detectives, ferreting out the true underlying facts about a call. In scene control, we also have to be diplomats, both to the public and to our partners and coworkers.

Someone who is poised and self-assured can be intimidating to others. Often, carefully chosen words can soften this assertiveness. Someone who barks out orders like a drill sergeant will not get much cooperation. It works better to employ the art of tactful communications and diplomatic maneuvers.

When people do a nice job, remember that a compliment goes a long way—all the way to scenes where you work with those people again. "Please" and "thank you" are great words. Often, the only difference between someone with whom everyone hates to work and someone they would do anything for, is that the latter has a knack for tact and diplomacy.

Reliability

It is important to project an impression of reliability because EMS is a pursuit built largely on trust. If presence is a factor in first impressions, the aspect that carries you along is the faith that people have in your reliability.

There are certain situations that sorely test personal ability. Can you really project steady scene presence when confronted with a man trapped by collapsed girders? The bystanders are hysterical. The nearly amputated leg and pool of blood are gruesome. You need him freed now, but there will be delays. Your medical intervention has to go perfectly if you want to save his life. There's a lot of chaos. Yet you must convey the impression that others can rely on you, even when you may be feeling a little out of control inside.

Imparting the impression of reliability builds trust. To do this, the leader must demonstrate good self-control and clarity of mind. These qualities help set the tone of the call. If the coworkers, the patient and the bystanders think that your plan is unreliable, scene control is destined to fall apart. An easy way to lose clarity is to become "hyper," or inappropriately excited by what is happening. If you become hyper, others will too. The most capable EMS providers actually become slowest and most deliberate in situations where others get the most excited.

Sometimes, as a leader, you will lose some self-control. You might be able to salvage things somewhat by admitting what is happening. For example, a flight nurse who had been on the scene of a plane crash all day finally got back to the hospital. As she rolled a patient through the emergency department doors, her first words were, "I'm a little hyper today, so bear with me." This helped everyone slow down enough to realize that she was not the only one swept up by the mass casualty incident.

A reputation for reliability is also built when you can keep from flying off the handle. There is no excuse for anyone to lose his or her temper at a prehospital scene. Sometimes you may choose to give the impression that you are angry. For example, with an uncooperative patient upon whom a flare of irritation might work, but that is different. Really losing your temper means losing selfcontrol. A true professional is better than that. Avoid at all costs the temptation to vent frustration and anger on a prehospital scene.

Developing your ability to impart compassion also helps build a good reputation for leadership. Compassion can also soften the autocratic, declarative style common to prehospital leadership. Make others sense that, above all, you are concerned about the emergency at hand. On minor cases (where others might be condescending or act irritated), you are the one who can proceed professionally and with compassion. On life-threatening cases, you are the one who can still show compassion for the patient and everyone else involved.

Do not shrink from using compassionate touch as an effective tool. It is another highly effective method of control. Touching is an anchoring act. It helps anchor words and actions so that people around you feel a sense of control. Even while walking onto a scene, as you see things that need to be done, you can squeeze a first responder's elbow as you pass and say something like: "Hi. It looks like we'll be needing our stair chair. Could you get it, please?" Touching is a tremendously powerful tool because others feel your control, as well as hearing and seeing it.

Another good way to "touch" people individually is to use names. Try to get to know the other people in your EMS system. People on EMS squads in small towns and rural areas usually know each other, but in bigger EMS systems, it can be difficult to keep up with the faces, much less the names. You will more readily be acknowledged as a leader, though, when you can arrive on a scene and greet people by name. On chaotic scenes, this also helps you get others' attention when you need it quickly.

Reputation

Some people discover that, because of the professional reputation earned by the company or agency they work for, other EMS organizations readily view anyone wearing that uniform positively. They are willing to give new employees a chance to live up to that agency's reputation. Eventually, though, each EMS provider earns a reputation based solely on his or her individual abilities.

If you are unfortunate enough to have developed a bad reputation, ask yourself, "Why?" Do people think you are unreliable? Tactless? On a power trip? Maybe you get hyper, or are chronically preoccupied with thoughts unrelated to the task at hand. Maybe people think you are apathetic or complacent. Maybe you get distracted too easily. With self-awareness, a bad reputation can be turned around, but expect to give it a lot of time and effort. People in our field do not give second chances very easily.

On the other hand, if you consistently demonstrate the qualities of presence, tact, diplomacy, reliability and compassion, you will earn an excellent reputation among your peers. This makes a scene easier to control—not to mention personally rewarding and fun.

References

1. Conflict Resolution Workshop, Council of Michigan Foundations. November 1995.

2. King M, Novik L, Citrenbaum C. Irresistible Communication: Creative Skills for the Health Professional, p. 15. Philadelphia: W.B. Saunders Co., 1983.

3. The Random House Dictionary of the English Language (unabridged), Second Edition. New York: Random House, Inc., 1987.

4. ibid.