The difficult patient

Paramedics and doctor outside ambulance

Frank Nagorka, a paramedic attorney from Chicago, and I recently discussed the concept of the “difficult patient” as he was preparing to do a presentation. We came to the mutual conclusion that we need to differentiate between the unpleasant patient and the patient in a difficult situation. We all have enough experience with unpleasant patients that we don’t need to describe them. Frank and I developed the notion that there are no difficult patients. We have patients in difficult situations. Difficult situations are those that create an enhanced risk of physical or psychological harm to patients, bystanders, and healthcare providers. Difficult situations may also increase the risk of medico-legal liability. Keep in mind that we can change a routine situation into a difficult one in which someone is harmed or perceived to be harmed. Whenever anybody is harmed, there are potential financial implications. We are in a “somebody must pay environment”. The resultant claims divert financial resources and manpower from the provision of care. From personal experience, I know that being sued drains you mentally and physically even if you are successful. One methodology to help reduce claims is the use of Crew Resource Management (CRM).

The importance of Crew Resource Management

CRM originated in the airline industry to “optimize performance and outcomes by reducing the effect of human error through the use of all available resources”. CRM requires situational awareness. Situational awareness is knowing what is happening and constantly evaluating it to make decisions, choose actions and predict the effects of actions on achieving goals and objectives. There must be an awareness of the surroundings which determines behaviors. The reality of the situation must be determined. Individual perceptions must be assessed. Good communication among all team members is essential. CRM has three components: software, hardware, and humanware. These parallel the risk management concepts of administrative, engineering, and behavioral controls.

Software in this context includes training manuals, checklists and policies, and procedures. Over the years I have written policies, procedures, and clinical protocols. I perceived and referred to these administrative controls as rules. That was a big mistake. Does labeling something a rule make it attractive or enhance compliance? Not in my experience. It is better to think of software as constructs that aid in decision-making by allowing us to choose predetermined maximally effective behavioral options that minimize the risk of harm. Hardware is composed of tools. Vehicles, computers, medical devices, medications, patient handling equipment are examples of hardware. Humanware consists of people. In our context, people are trying to solve the problems involved with providing safe care and transport to our patients.

Don’t think that CRM is only applicable in “big” situations. CRM is commonly used in planning during tabletop scenarios for civil disorders, terrorist attacks (in all their forms), disasters, multi-casualty events, large-scale events, WMD and the like. CRM should be applied on each and every request for service. How can CRM be applied if it is not considered in advance? We mentioned medico-legal risk. Think about your existing software (administrative controls). Do you have up to date policies developed with the advice of local legal counsel? Do they include consent, special transport situations that require same sex transport with a witness present, child abuse, elder abuse, attempted suicide, sexual assault, intoxicated patients (drugs or alcohol), crime scenes, psychiatric patients, refusals, the treatment of minors, and reporting violence and assault of healthcare providers? Do you have adequate hardware (engineering controls)?  Hardware should be selected systematically with specific goals for its use. The use of any device should be limited to the functionality described by its specifications. That can be as simple as being aware of the weight limit for a stretcher or as complex as being aware of the physiological effects that alter the oxyhemoglobin dissociation curve, which impact the accuracy of pulse oximetry. Humanware (behavioral controls) is the most important part. A well-designed system with state-of-the-art hardware will be ineffective and possibly dangerous if personnel are fatigued, overly stressed or non-compliant.

As an exercise, create scenarios for medical equipment failure (including oxygen delivery devices), infectious diseases (viral and/or bacterial), transporting an 800 pound patient, and obtaining consent to treat an 11 year old crash victim whose parents are not present. Determine what software, hardware and humanware are required? Is anything missing or in need of revision? This can be done by individuals, small informal groups or as an organization-wide activity. Thinking ahead and planning will enable us to safely deal with difficult situations and perhaps prevent them.


  • Lesage P, Dyar T, Evans B, “Crew Resource Management; Principles and Practice”, Sudbury, MA, Jones & Bartlett Publishers, 2011
  • Szczygiel, M (Ed), “EMS Safety”, Burlington, MA, Jones & Bartlett Publishers, 2017
  • Nagorka, FW, “The Difficult Patient PowerPoint”, Frank W. Nagorka, Chicago, IL, 2019

Paramedics and doctor outside ambulance
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