1. Verbal Judo | The art of verbal de-escalation

There’s no getting around it, upset and agitated patients are a part of the job in emergency and acute care medicine. Having a consistent approach to navigating these interactions can not only keep you and your patient safer but also make work more enjoyable. We discuss: managing your own emotions, how to absorb the tension in the room, specific scripting for different levels of tumult and disturbance, and the power of the cheeseburger.

A proviso to all of this is that your top priority is to keep yourself and your team safe. Do not put yourself at risk. That doesn’t always mean physical escalation (though sometimes it does), it can simply mean removing yourself from the physical space of the escalating situation. 

Guest Bios:

Jose Pacheco, RN, known affectionately to his co-workers as ‘The Drunk Whisperer’, has a specific sequence to this approach, which he’s going to walk us through, step by step. The good news is that verbal de-escalation is a tool that can be learned by almost anyone. To that end, we’re also joined by Dan McCollum, emergency physician at Augusta University, to talk about conflict resolution that evolved from the martial arts principal of using your opponent’s energy to resolve conflict, rather than simply butting heads. The name for this method? Verbal Judo.

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We discuss:

Jose Pacheco’s tactics to de-escalate and defuse agitated patients in the emergency department [03:13];

• “They’re cornered, they’re uncomfortable, they’re cold, they’re out of control. I’ve never met anybody who doesn’t like to be in control of any situation.”
• He tries to level the playing field. “I’m not better than you. You’re not better than me.”
• If possible, he speaks in almost a whisper
• (more on this below, at the end of the shownotes)

Dan McCollum’s de-escalation sequence based on needs of the situation [09:30];

• Based on the military Defense Condition (DEFCON) designations. 
• It can be hard to predict if things will shift so always be ready to escalate. 
• DEFCON 5 is easygoing but still in a state of readiness. It’s really all about having that empathy, preserving the relationship, and just checking in, making sure things are okay.
  • Turkey sandwich is a frequently deployed DEFCON 5 tool
• DEFCON 4 is where Verbal Judo starts to show up.
  • “If you continue that behavior, things will get worse. How is it that we can work together to avoid that situation? Because neither of us want that.”
• DEFCON 3 about to blow but still keeping it together. Dan commonly uses oral benzodiazepines here so he’s not wrestling with people and using needles.
• DEFCON 2 is when the IM meds come into play. Safely put them in isolation and let them cool off. 
• DEFCON 1 is the out of control, violent, and agitated patient such as with PCP intoxication.

The unifying principle of verbal judo: Empathy absorbs tension [15:50];

• When you feel repulsion toward the person (and you are in a professional capacity), use that as a trigger to first acknowledge the feeling and then ask yourself what’s next.
• “Okay, I’m feeling this strong negative emotion. This is the time when I need to be empathetic with this person and ask, “Where are they coming from? What do they need?”

Present the professional image [22:50];

• Hi, I’m Doctor… or whatever you need to say to present a professional presence.
• Be courteous and begin the engagement without hostility or judgment 

The Universal Upset Patient Protocol [24:20];

• Created by Dike Drummond. Link to the original write up
  • Step 1, acknowledge the vibe and name the emotion, “You look really upset.” It doesn’t even matter if you get it right. The key here is to acknowledge that something is afoot. 
  • Step 2, open the door for them to speak and let them know you’re listening, “Tell me about it.” The key here is to listen.
  • Step 3, it’s OK to apologize and have/show compassion. “I’m so sorry that you’re feeling this way. I’m so sorry this is happening to you.”
  • Step 4, what’s their need (beyond unloading the upset). You don’t have to comply with the ask, but let them say it. “What would you like me to do to help you?”
  • Step 5, pause, give it some thought and offer to help (it doesn’t have to be giving what they asked for, it’s OK to set boundaries), “Here’s what I’m willing to do going forward. Here’s what I suggest, here’s a plan I recommend.”
  • Step 6. Thank them for telling you this so that you can both understand each other. 
• GFOP and patient experience expert Justin Bright has a unique twist on this:
  • For step 4, he asks, “What would you like to see happen today?” or “What do you think needs to happen today” 
  • For step 5, he finds that the above phrasing is too confrontational. He prefers closing the loop by saying “Here’s what I have heard you say.  Am I correct?”  He then follows with, “Based on what you’ve told me, here is what I think we need to do today to help you.”

“We treat people as ladies and gentlemen not because they are, but because we are.” [35:50];

You can’t control how an upset person is going to respond to conflict, you can only control how you respond. [36:40];

Seeing a situation from the other person’s eyes. [37:50];

Sword of Insertion technique aka How to politely interrupt [38:20];

•  “Let me be sure I heard what you said…” and then paraphrase when you think you’ve heard. You might not get it perfectly right, that’s OK.
• It allows you to get your foot into the conversation (which can continue interminably in a vitriolic screed if not interrupted.)
• Allows you to interrupt in such a way that is well intended and can’t be misinterpreted as anything other than trying to get to a place of understanding. 

Active listening [40:50];

• Are you fully listening or are you reloading with your next comment?
• Communication is the responsibility of both the sender and the listener.

Jose Pacheco’s tips for interacting with difficult patients in the ED. [42:30];

• Always have an exit path, situational awareness of room/scene safety .
• Approach them with compassion, humility, and respect. 
• “This is somebody who’s got more emotional baggage than you and I could ever imagine, and one of my biggest fallbacks is to say, ‘I am so glad I’m not in your shoes, but what can I do right now to help you?”
• If possible, be at eye level (not always safe to do so).
• “Your palms are up and your palms are open. You’ll bring your hands back into your body and when you want to emphasize a point, you’ll push your arms forward, almost like you’re holding up a tray and your hands were kind of moving in this circular movement.”:
• Bring down the volume 
• “​​If they’re angry, I bring the volume down to where they almost have to bring that volume down as well.  Mind you, outside the room, there’s 30 people all gloved up. Half of ’em are security guards, some have drugs in hand, and they’re getting ready…”
• “If I leave, what’s behind me is what you’re gonna have to deal with. So give me a moment to try to work with you and at least get your basic needs met. Are you hungry?”
• There is a clear plan of what’s going to happen if things escalate.

Non-verbal cues [53:30].