Dealing With @$$HOLES & The Upset Patient Protocol (From ICON2020)


Dealing with @$$#oles:

Welcome to a game changer in my practice.

I’ve been away for a while, working my tail off in the ED and with flying on the helicopter, so please forgive me for being away for so long & not having posted sooner.  As, Tyler said “I’m an OG of FOAMfratt”, so this will always be my home, but this girl gets around and when new friends ask me to help them out, that’s what I do.  Plus, I love sharing what I’ve learned throughout this whirl wind of an awesome career.   

Recently, I was asked to give a presentation of my choosing on a new platform and I was thinking about things that have truly changed my practice over the past few years.  More than any procedure or chest decompression talk, cric talk, or amputation skill, the thing that has changed my practice the most has been learning to communicate with patients and what I call “Dealing with @$$holes!”  

And no, patients are not assholes, but sometimes when someone is mad or upset it sure can feel that way. 

Anyone who knows me personally, knows that I lack a filter and my nickname in residency was #nofilter. I blame the puertorican genes, but hey, that’s just me. I tend to be shy at first yet you’ll find out that I don’t sugar coat things, I have no poker face, and I can be super blunt. 

I had a colleague of mine recently retire from the ED and I told him that I would try to use a little more sugar than salt, as he did, with all of his patients. He told me to never let go of my salt and vinegar because hearing me say it, “like everyone was thinking”, was refreshing and made our shifts more fun. He said I used it appropriately and that patient’s loved me because I truly did care and it showed in my work despite my blunt demeanor. I’ll miss “Big Daddy B” and in his honor I still try to be a little sweeter.

Especially now, in the era of COVID19, I feel as though more of my patients and their families have been disappointed or upset because of either fear, anxiety, lack of understanding, failed expectations, and the new cognitive burden of dealing with the stressors of a pandemic and all that comes along with that.

In the past, I absolutely hated when I was told that one of my patients or their family members was upset/angry and wanted to “talk to the doctor”. I dreaded these interactions because they felt uncomfortable and I was not the type of person who did well with confrontation. I would avoid this at all costs and try to have my nurses or my partner try and defuse the situation. Luckily for me, a few years ago I stumbled upon a new podcast called ERCAST with host Dr. Rob Orman, who introduced me to the upset patient protocol and came up with a way to manage these interactions, meet a patient’s concern, and come out better on the other side. 

Please feel free to check out his HIPPO ERCAST podcast which explains this protocol well (see link below). This protocol was developed by Dr. Dike Drummund from the Happy MD and his website has videos, as well as an in depth explanation of the upset patient protocol. This was not my idea, but man, has it been a game changer.  Dr. Drummund says that this will work on about 85% of upset patients and I actually think the percentage might be higher. 

This protocol goes over phrases to use when dealing with upset patients.

There will be a quick vodcast of this which will be placed on this site soon.

Here are the steps of the protocol below & the phrases you will need to commit to memory.

It all starts with acknowledging that your patient (or their family member) is upset. Then the protocol goes into allowing them to tell you their concerns and having you both come up with a plan within the boundaries of good medicine. These phrases open the doors of communication and will really help foster that patient-clinician relationship leading to shared decision making and a better understanding of each other. None of us want to be the reason our patient is having a bad day, they are already here, worried, anxious, and sick, so let’s put ourselves in their shoes and show them some empathy. After all, that’s why most of us got into healthcare. To help people, right?

In the vodcast I will go over these in a little more detail yet here are the steps.

Commit these phrases to memory:

“Wow, you look really upset.”

“Tell me all about it.”     “Got it.”

“I’m sorry that this is happening to you.”

“What would you like me to do to help you?”

“Here’s what I’d like us to do next.”

“Does that sound FAIR?” (this step was added by me)

Thank you so much for sharing your feelings with me.”

As with anything in healthcare, you will need to practice this until you feel comfortable utilizing it in everyday interactions and it comes out naturally. Practice this in simulations like you would any other scenario.

I actually look forward to these initially-uncomfortable interactions because I know that it will open a door of communication with my patients and clear up any misconceptions.

I truly do not want any of my patients to have a bad experience in the ED because of me or because of my staff and with using this protocol they will see that I truly do care and that I am here to help.  

As Teddy Roosevelt said, “People don’t care how much you know, until they know how much you care.”

@$$hole Sending-Providers, Consultants, or other Clinicians:

If there is an issue with another colleague or a referring doc/provider/clinician, a good method to use is “graded assertiveness” with the CUSS model. I don’t know who the originator of this one was, but if you google it, it’s everywhere.  

CUSS stands for concern, uncomfortable, safety, and stop.

These are phrases you can use if you feel another provider or clinician is about to do something unsafe or something that you don’t feel is in the best interest of the patient. 

You can say these phrases:

“I am concerned that XXX”

“I’m uncomfortable with XXX.”

“I think this might be a safety issue regarding XXX.”

“Please STOP.”

Examples would be “I am concerned that transporting this hypotensive patient on propofol will lead to further hypotension and end organ dysfunction.  I am uncomfortable with transporting them with this as their form of sedation or transporting them with propofol and no plan for pressor support.  I’m thinking it might be a safety issue to transport this hypotensive patient before they are stabilized as we don’t carry pressors on our truck or don’t have a protocol, orders, or pressors available for this patient.  Please STOP and consider an alternate for this patient.

In aviation I know that if I say “STOP” my pilot will stop his decent or ascent, maintain his altitude and look for hazards, my nurse will stop administration of a medication or rolling the cot, and my RT will stop bagging because this is our biggest safety word.  Nothing trumps STOP and if you hear it, you STOP.  It means danger is coming unless we stop now and all things must halt. Our lives as well as our patients’ lives are at risk.  

Even now, when I am in the hospital if I have someone say they are concerned about an issue, it’s basically trigger word tand red flag that’s warns me to reconsider what I’m doing and slow down.

What about when everyone is an @$$hole?

Now, all that being said, sometimes I’m having a bad day and sometimes, everyone I run into seems to be an @$$hole.  My garage door is stuck, I can’t find my badge to get in, my dog ate my presentation, she won’t go find a spot fast enough, I got cut off in traffic, the person in front of me didn’t hold the door, there’s pee on the toilet seat I just sat on, my partner left crumbs on their keyboard and gave me a crappy signout, there’s blood on the monitor cables, my radio is dead, the bags weren’t stocked right, and I just walked into staff telling me to run in another direction because today is a crap-show.  When I notice that these things are piling up and the day is already ALL going downhill, I try and check myself.  

If you start off the day and you run into an @$$hole, then you ran into an @$$hole… and that sucks.  But if you start off the day and everyone you run into is an @$$hole and all @$$hole things are happening to you, then just maybe, you are the @$$hole.

I try to make sure I’ve been fed and watered and that my head is in the game… after all, I chose to be in the ED or on the scene in the helicopter today, not the other way around.  I’m here to help and I do care.

We all can have bad days, but let’s look out for each other and not be the @$$hole.

I hope this helps.

Love you ALL! 

Feel free to email questions to This email address is being protected from spambots. You need JavaScript enabled to view it.

Dike Drummond–The Happy MD creator of this protocol can be accessed at www.thehappymd.com

Hippo EM – “ERCAST” podcast w Rob Orman was where I 1st heard about this method

Podcast from sept/oct 2016, “Airways, Strokes, & the upset patient protocol” can be found at https://www.hippoed.com/em/ercast/browse

PS.  None of the opinions from this posting represent either of my employers and are from me alone





Anchoring Heuristics

A few years ago I decided to go back to college to obtain my bachelors degree in psychology. I am often asked why I chose this field of study. "Do you plan on becoming a shrink?"

The answer is.. probably not.

Yet, the study of psychology has helped me tremendously when meditating on certain behaviors and decisions in medicine. 

Medical errors are commonly portrayed as individualistic faults that manifest from either a lack of training or diligence. Application and understanding of cognitive psychology can partially explain the reason smart people make simple mistakes.

If this stuff interests you, I encourage you to check out a 2005 article published in Annals of Internal Medicine titled “ The cognitive psychology of missed diagnosis.” In this paper Donald Redelmeier unpacks the logistics and heuristics of clinical decision making. Contrasting cognitive psychology with other psychological paradigms (e.g. humanistic and psychoanalysis) can provide further insight into clinical error. 

When a computer has multiple tabs or programs running at once, there can be a frustrating lag that occurs. Cognitive psychology and anecdotal experience support the fact that the human brain experiences a similar processing lag when choices or stimuli accumulate.

In order to increase cognitive bandwidth, clinicians will develop mental shortcuts known as heuristics. Heuristics are decisions based on familiar patterns we have experienced. Humans repeating actions and mentally recording the effect, was noted by Swiss developmental psychologist Jean Piaget, as “circular reactions."

Illustration by Hugo Lin. © Verywell, 2018.

When studying infants, Piaget noted mental shortcuts that were formed when the infant experienced the cause and effect of actions. When this theory of mental shortcuts is applied to medicine, it allows rapid life-saving interventions to be performed with incredible pace.

Let's try one out! How fast does a differential come to mind when you look at the picture below?

You likely did not hesitate to analyze the complaint/story and patient demographics to produce a suspision of an acute myocardial infarction. Your brain has created shortcuts based on previous experiences or experience of others. Let's try another one!

Don't feel bad if drug use was your first thought! Your brain has seen enough of these that it has attempted to create a mental shortcut. This is called recognition primed decision making (Klein, 1998). While it works a lot of the time, it is not flawless. 

Occasionally clinicians can fall victim to anchoring heuristics and diagnostic momentum. Perhaps a humanistic approach to psychology could explain why this occurs. 

Abraham Maslow, an American psychologist in the 1900’s commonly known for his theory of self-actualization, postulated that humans have specific needs that must be fulfilled before they can reach self-actualization.

For example, consider an EMS provider who is having personal health issues. Pre-existing experience and heuristics may lag in processing information even when providing routine care. Anchoring on a specific diagnosis and tunnel vision is a hallmark symptom of decision fatigue and accumulative stress.

In aviation it’s commonly taught that human error is a symptom of a deeper systemic flaw. Rather than blaming the individual, diligence should be made to evaluate why the error occurred.

Maslow reminds us that sometimes the system issue is internal and/or individualized to basic needs. However, even if all essential needs are satisfied, specific presentations or sensatory stimulation may exacerbate emotion from repressed experiences or memories (Wortham, 2017) . This type of error is harder to detect from pure external observation.

An unconscious emotion manifested by repressed experiences is best described through psychoanalysis, a theory proposed by neurologist, Sigmund Freud (Goodwin, 2015). Freudian resistance was a term developed to describe an individual who avoids specific topics (consciously or unconsciously) due to previous experiences. When contrasted with an EMS provider or healthcare worker - one may defer a specific skill or medication based off poor anecdotal experience.

Surfacing  and vocalizing memories that connect a frightening experience to trepidation was suggested by Freud to be the first step in eliminating repressed emotion. But getting individuals comfortable enough to accurately reflect on an emotionally pivoting experience is cumbersome (Wortham, 2017). 

Sharing vantage-points with various psychological paradigms and theorems allows for an objective and holistic understanding of human factors that lead to predicatble error. By emphasizing that clinical error is typically a symptom of systemic flaw, cognitive dissonance may subside and allow honest reporting of mistakes.

If you have interest in learning more about the online university I decided to go with and pursuing a degree in Psychology, please reach out. This email address is being protected from spambots. You need JavaScript enabled to view it..


Goodwin, C. J. (2015). A history of modern psychology (5th ed.). Hoboken, NJ: Wiley.

Klein, G. A. (1998). Sources of power: How people make decisions. Cambridge, Mass: MIT Press.

Redelmeier, D. A. (2005). The Cognitive Psychology of Missed Diagnoses. Annals of Internal Medicine, 142(2), 115. doi:10.7326/0003-4819-142-2-200501180-00010 

Wortham, S. (2017). Resistance and Psychoanalysis : Impossible Divisions. Edinburgh University Press



© 2021 FOAMfrat LLC. All Rights Reserved.


FlightBridgeED Logo

Your personal access to all things FlightBridgeED

Don't have an account yet? Register Now!

Sign in to your account