You’re not in Kansas anymore…


In the past couple of months I have been in a discussion on 2 instances where EMS providers wound up in the news for actions (or rather inactions) that were clearly the result of fear for their personal safety. In both instances, the providers took the very posture they were taught in school, “If the scene is not safe, you don’t go into it.”

Of course after each incident, all the brilliant minds on the internet got into mob justice mode and started screaming these providers be jailed, fired, and all other manner of punishment for their doing exactly what they were instructed to do. 1 is facing criminal charges.

In my not always humble opinion, ok…In my rarely humble opinion, we should expect much more of this and there by the grace of god go you.

But in one of the discussions on the matter, an obviously experienced provider and I were basically reflecting on our experiences working in “the ‘hood” and survival skills we learned there. The consensus was many providers who find themselves working in dangerous neighborhoods are actually unaware and unprepared for working with an entirely different culture of people.

Because of the same cretins on the internet, let me just get something straight right now… Color is 1. Not a distinction of race. All humans on this planet meet the scientific requirements to be considered Homo Sapien Sapien.(AKA modern humans).   2. The differences in our behaviors are cultural.

The purpose of culture is to identify members of a group for the security and distribution of home range resources and reproductive rights. While it is possible for one culture to antagonize another, it is not possible for different colors of people to antagonize each other based on which species they belong to.

But now that we got that out of the way, let’s imagine for a moment?

If you went to a different country, where people looked different, had different values, spoke a different language, and were complimented or insulted by different forms of speech or gestures than you, would you be a little nervous? Perhaps you would be outright terrified or any level in between?

If you have lived in your home for any length of time, you are probably rather comfortable there; perhaps comfortable with your whole neighborhood. It is your world; it is familiar and puts you at ease. Your neighbors are probably just like you. You are not afraid of the dark in your home. You may not be afraid to walk outside at night. For the most part you can anticipate and predict what events will occur. It feels “safe.”

Depending on what source in anthropology you want to cite, the USA is made up of at least 6 and depending on how “culture” and “subculture” is defined, probably many more. In a country of 330,000,000 people, with such an enormous landmass, it should not come as a shock to anyone that not everyone is like they are. Compare the USA with Europe. In roughly ½ the area of the USA, there are approximately 50 different countries, speaking 24 official languages and a few unofficial languages and immigrant communities from outside the continent speaking their native dialects.

The differences of these cultures and languages in Europe are responsible for some of the greatest wars and man-made calamities the Earth has ever known. An area ½ the size of the USA! Let that sink in for a minute…

So, when you go to a different neighborhood or community in the USA, it is very possible your experience can be like being in another country. Whether you are from a middle class suburb going to a poor inner-city neighborhood, a liberal Yankee from New York City visiting Southern Louisiana, or a Mid-Westerner visiting California, you are for all intents and purposes, going to what is a completely different culture than your own. The language may even be different! The people might be a different color. They may be complimented or insulted by different gestures. Think of it like going to a different country.

You can expect to be afraid. You can expect to not be able to anticipate or predict what will happen. You may feel threatened by “normal” behaviors of the natives which in your culture are not common or acceptable. Your fear is physiologic. It is natural.

Understanding your feelings and physiologic responses to this noxious stimuli can help you manage your actions when interacting with people from a different culture. In order to reduce your anxieties, to be able to comfortably interact and feel at ease, you must learn the culture (and language) of the people you are interacting with.

Quick history and culture lesson, originally the Northwest Territory, which encompassed a multitude of modern states, including Ohio was huge. Have a look…


Now when this large territory was divided, whoever drew the lines certainly didn’t draw the lines based on culture or language. Modern Ohio has 3 distinct cultures. The Northeast is similar in culture to the East Coast and most of its people do not identify as being part of “The Midwest US.” The Northwest culture is almost indistinguishable from the people and culture of Michigan. Then there is Southern Ohio…or as it is sometimes called “West Virginia Annex.” For all intents and purposes, they speak a different language.

Let me give you an example. Some years ago I really wanted to impress a girl from Southern Ohio. I am from Northeast Ohio.  She actually agreed to go to lunch with me. Think about this… We are from the same State. We supposedly both speak English. We are the same color. We worked in the same industry. This should have had all the makings of a great date. The first thing we tried to do was order something to drink. She asked for a soda. I asked for a coke. When the waitress brought the drinks, I had a caramel flavored cola product from the Coca Cola Company. She had a glass of ice cream with carbonated water and chocolate syrup.

There is a catchy little poem somebody once made up. “You’ve done it I exclaimed with a scream and a taunt; it’s just what I asked for, but it’s not what I want.”

She was not happy with her order. She wanted the same thing I had ordered. This caused stress to both the waitress and me; the waitress because she had to make this right and me because my good date was not starting off as I had anticipated. Fortunately, we both had a good laugh over Ohio being 3 different countries.

But the difference doesn’t have to be 4 hours across the state. Some 15 miles, not 20 minutes’ drive, from my childhood home is according to one source, the second most dangerous neighborhood in the USA. It boasts that your chances of being a victim of violent crime are 1 in 6. It is certainly not the predominantly middle class suburb with a population that 90% identify as “white” I was from.

Until a certain point in my career, that is what I knew, middle and upper class suburbs. The “emergencies” and “illnesses” people suffered from in those places were for the most part the problems of a wealthy society (power outages, broken pipes, the occasional fire which destroyed insured possessions, heart attacks, strokes, the occasional serious car accident, etc.). Myself and many of the people who lived in those suburbs knew of what we called “the bad part of town” was.  Aka lower middleclass and “poor” people. This is where you could find drugs, petty thefts, and other “undesirables” with the occasional fight broken up by the police in minutes.

But in my quest to be a top quality provider I knew I had to go where the action was. When the opportunity came up I signed up to work (and volunteer extra shifts just for experience) without hesitation or doubt in the second most dangerous place in the country. If I had the opportunity to sign up for number 1, I would have. It just wasn’t conveniently 20 minutes from home.

I went from the pristine fire stations and trucks cleaner than your dinner plates, of the suburbs to a red brick building that looked like it had never been cleaned in history. The only “windows” were glass block at nearly the height of the roof (for safety). The door was heavy steel, and looked more like a bank vault. The parking lot a chain linked fence topped with cyclone wire. I was looking for action, and I had come to the right place. Surprisingly, there were no calls…until the sun went down… After hearing a few gunshots sitting in the station, I expected to be dispatched to a gunshot victim. Those calls never came. I didn’t even hear sirens indicated the police were on their way. Then it happened! Respond to just a cross street for “a man trapped in a car on fire.” Score!!! A few blocks away, in a street I would describe as an alley, unworthy of a name, much less a major cross street, was a burning car, people were shouting “there was a man in the trunk.” Without hesitation some firefighters started putting water on the fire. I was not really helping, more observing, as the crew I was with opened the trunk, and pulled out a conscious man who was suffering from burns (that’s when I actually got involved hands on). It was evident from their efficiency and skill, the guys I was with had done this before. This was the start of what would be a busy night. It was what I always dreamed of.

The next morning I was tired, dirty, and really just wanted to go home and sleep… For at least 20 hours. But just before the relief came, the doorbell rang. After the many security devices were disabled and unlocked, the lady, barely standing, said “I just overdosed on crack…” She said it matter-of-factly. As if she was explaining the sky is blue or the grass is green. If ever there was a stereotypical street-walking prostitute outfit, she was wearing it. (I had never knowingly seen a prostitute in my life before at the time.) We dragged her by the arms to the tailboard of the truck and sat her down. I was going to start an IV, and she had the absolutely perfect vein in her right arm. After swabbing the area with alcohol (we didn’t have chlorhexidine at the time), I gripped her arm tightly, and had an 18g needle almost touching her skin. She turned her head towards me and said with the voice of a mother, “Oh honey, don’t use that vein, I save that one for when I score morphine…”

I was dumbstruck. Never in my prior years working in the suburbs had I seen or even heard of such a sight. Without missing a beat a fireman I admire and respect to this day blurted out “Do I tell you how to smoke crack? No! Don’t tell him how to do his job…” Well, as if her statement wasn’t enough, I was in total mental meltdown. I could not believe he just said that to a patient! I couldn’t move. I couldn’t speak. He took the needle from me and started the IV. After we took her to the hospital, he was laughing at me. He rhetorically asked: “Don’t talk like that in the burbs do you?” I was not upset or concerned about his “professionalism” I just laughed, smiled, and he could plainly see I was going to like it here, and he added “I am sure the mayor will be right down to this neighborhood to yell at me.” That was the first of many great days, and many lessons learned. Including how to understand and adapt to a completely different culture; with people who were nothing like me, in a world with realities and challenges I could not have ever imagined.

In my next job, I made working in the worst neighborhood in the outfit at the time a condition of my employment. The human resource guy looked at me like I had just said something he never heard anyone say before. “Done and done. “ So I went to see the place. It didn’t look so different than from where I had just been. Then I met the people I would be working with… They were the same, highly capable; highly experienced. They worked and understood a world many will never see or imagine, but you certainly wouldn’t want them to be on your company’s recruiting poster.  When one of the trade magazines was doing an exclusive on the company, we laughed that they would never come and ride in our neighborhood and the corporate guys would never let them interview us. We were not disappointed in our predictions…

I applied for different jobs after these 2 incidents, and finally ended up at a hospital in such a ‘hood. Doing what I love to do, where I like to do it, with the people just like me. Some would say “crazy”, some will say “tainted”, but their ability, compassion, and intelligence irrefutable. They have stood in the eye of the storm in hell, have been measured, and are found without equal on this Earth.

Then I found myself in Europe… I was warned not to go to the “bad” neighborhoods. So I waited until dark and went right to them… “Bad neighborhoods”…  Yea… In every sense of the appraisal of middle- class suburbanites. I haven’t seen a ‘hood anywhere in Europe from Kyiv to Bucharest, to France, I would call “bad,” which is probably why they get so worked up when somebody gets gunned down in their streets. I feel useless and wasted if I don’t get to be there for that 3 or more times a day. As some of my previous posts indicated, I also don’t look so good on the check-box paperwork here. They cannot imagine what my experience is. They have no point of reference. People have even been amazed by “my ability” in places like Afghanistan. It is no different…It’s what I am. It’s what I do.

But for all my reminiscing and lamenting, back to culture… I was taught how to work in “bad places” by people who had done it for years before me. I have come to know the culture of the poor and undesirable all over the world. I have seen and touched their world. I am not afraid of them. I am just, perhaps more, comfortable in their world as I am in mine. My pilgrimage in medicine has made me experienced in going places I have never been, to try to help people who are not like me, in environments dangerous and unknown, people who speak in languages I will never speak or understand. I understand that I must help them from their perspective of help.

You cannot learn these skills without being taught. You cannot be good at them without practicing them. Even then, sometimes people are hurt, killed, and have many close calls. Working effectively and being comfortable in them cannot be taught by people who have not experienced it. Your safety depends on understanding their culture; on working with them. Knowing the signs of danger vs. signs of respect vs. normal behavior. You will not make yourself safer negatively judging them or complicating their life constantly making them the target of the respective criminal justice system. These people fear the police. They are punished disproportionately, for nothing more serious than trying to survive and cope in their world. A terrible world that is merciless and unforgiving.

You cannot “help” these people unless you can walk among them, understand them. The scene will never be safe. Not going into it means not helping. No EMS education I have seen anywhere in the world teaches students how to work and be safe in these environments. If they talk about culture at all, it is basically lip service. The “safety” training is laughable and totally impractical. When people look to you for help and you choose not to help, even if it is because you are not capable or prepared to, because you were never taught or mentored in the knowledge or skills needed, they see you as abandoning them in their time of need. Of not living up to the position of admiration and respect society gives you. It looks really bad on the 6pm news.

But for other providers, who are no more educated, skilled, or experienced to call for blood from the safety of behind their keyboard, forget professionalism, it is outright betrayal. Then everyone stands around wondering what they could do to prevent the next provider from abusing drugs or alcohol to cope. They wonder why their colleagues do not reach out to them before committing suicide. They are second guessing from a position of hindsight and safety. To the ones who have learned to work in these harsh environments, before you judge, do you teach? Do you mentor? Do you remember what it was like to not know and be scared?

Your patients may not be like you.  You are there to help, not judge or make things worse. If you do not have the knowledge and skills you need to work in different cultures, seek them out. I promise you that you didn’t learn anywhere near enough in school to actually do what is being asked of you. Especially if your teacher has never done it and is just parroting what they were told or read on their instructor notes on a commercial PowerPoint.

You must learn to identify and to be comfortable in different cultures and customs, with people who effectively live in a different world and reality than you do. They speak a different language. They are not like you. But they are still people asking for your help. They still look up to you and think you have no fear, can do anything, and are larger than life. Don’t disappoint.


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