Cultural Awareness and EMS

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Cultural Awareness and EMS

• Glenn H. Luedtke, NREMT/P
• Director, Sussex County Emergency Medical
  Services
• Adjunct Assistant Professor
• Emergency Health Program
• The George Washington University School of
  Medicine and Health Sciences

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Objectives

• Increase awareness of changing demographics in
  our communities
• Understand our own cultural identities
• Understand health traditions that vary from
  Western methodologies
• Respect religious laws honored by patients
• Develop new skills to assist in communicating
  with patients from other cultures
• Ensure all patients are treated with dignity and
  respect

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Special Thanks

• Linda Honeycutt
• Executive Editor, Elsevier Publishers
• Past President, NAEMSE

• Beth Adams
• Quality Manager, Fairfax County Fire and Rescue
  Department
• Faculty, GWU Health Sciences Program

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United States has always beena country of
immigration
give me your tired, your poor, your huddled
masses yearning to breathe free
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Immigration Law Milestones

• Naturalization Act of 1790
• 1820 1st immigration records law
• Chinese Exclusion Act of 1882
• 1924 national origins quotas
• 1960 hemisphere limits
• Title VI/Civil Rights Act of 1964
• 2001 National Standards for CLAS in Health Care
  

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Cultural Competence

• "Cultural and linguistic competence is a set of
  congruent behaviors, attitudes policies that
  come together in a system, agency, or among
  professionals that enable effective work in
  cross-cultural situations."
• 2001 National Standards for Cultural and
  Linguistically Appropriate Services in Health
  Care Act

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CLAS Standards 3 Themes

• Culturally competent care
• Language access services
• Organizational support for competence

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Organizational dimensions
external dimensions
External dimensions
Internal dimensions

• Layers
• of
• Diversity

Personality
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4 Layers of Diversity

• Personality
• Internal Dimensions
• Age
• Sex
• Ethnicity
• Physical Ability
• External Dimensions
• Life Experiences Choices
• Organizational/Vocational Dimensions
• EMS is a Culture

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Diversity in the US

• 106 ethnic groups
• Minorities majority population in 6 of 8
  largest US metro areas
• 20 of MDs in US are foreign trained

• Largest Arab-American population outside Middle
  East Dearborn, MI
• Largest minority population in US Detroit, MI
  (80)

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Pop Quiz

• What is the most popular condiment in the U.S.?
• Ketchup
• Mustard
• Mayonnaise
• Salsa
• Answer D

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Diversity in EMS

• According to self reports to NREMT in 2001.
• Ethnicity
• 83 majority 14 minority 3 other
• 23.37 respondents did not specify
• Gender
• 69 male 31 female
• 0.03 respondents did not specify
• 133, 526 (Hunter, 2002)

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How have we adapted?
Assimilation
Amalgamation
Anglo-Saxon Racialism
Cultural pluralism
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Adapting To New Cultures

• Assimilation
• Americanization
• Conformity

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Adapting to New Cultures

• Amalgamation
• Melting Pot
• Blending best of old and new

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Adapting To New Cultures

• Anglo-Saxon Racialism
• American WASP

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Adapting To New Cultures

• Cultural Pluralism
• Strength in variety

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Ways Cultures Differ
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Cultural Awareness

• Culture is not overt
• We are all ethnocentric
• We observe, interpret, then act based on our own
  cultural programming
• We may not know when we are offending others
• Awareness and knowledge increase our choices
• Understanding ones own culture is a first step

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AGE
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The Culture of Age

• The Greatest generation
• The Baby Boomers
• The Me generation
• Generation X
• Generation Next

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The Greatest Generation

• Lived through the Great Depression
• Value stability, loyalty to employer
• Stick with relationships no matter what
• Dont take risks
• Fear for their future
• Health insurance
• Continuance of promised pensions
• Being put away in a nursing home
• Wanted something better for their children

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The Baby Boomers

• Increased value for education
• Witnessed greatest strides in technical
  achievement
• Loyalty to employers
• Trusted government in youth, later more
  suspicious
• Vietnam war a major part of their experience

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The Me Generation

• Were young during Vietnam War, but remember it
• Distrustful towards government
• Personal agenda supercedes employer loyalty
• Employers less loyal to employees?
• Value home and family, but more likely to abandon
  a relationship that isnt working
• Not as volunteer oriented as their predecessors

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Generation X

• Until recently, war has not been a part of their
  lives
• The first technology oriented generation
• Job is a means to an end, not an end itself
• More loyal to relationships than Me generation

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Generation NextTodays Teens Tomorrows
Providers!

• 58 have visited or lived in a foreign country
• 57 have a friend who is openly gay
• 48 have known someone who is in a gang
• 21 have a friend who was killed or injured by
  gun violence
• 19 have been the victim of a crime or violence
• Source Washington Post Magazine, Kaiser Family
  Foundation, Harvard University poll, 570
  respondents, published 10/23/05

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Generation NextTodays Teens Tomorrows
Employees!

• 57 think there will be another terrorist attack
  like 9/11
• 54 think this country is headed in the wrong
  direction
• 54 think our countrys best years lie ahead
• Its a confusing time, rather than bad or good.
  Im stuck in the middle of so many things
  college things, the war, the economy, other
  things that are going on.

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Generations and EMS

• Greatest and Boomer now reliant on Me and
  X for emergency care
• Boomers as administrators
• Boomers and Me experienced the AIDS epidemic
• Me and X as supervisors and experienced
  providers
• X and Next as new generation of providers

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SEX
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Sex and EMS

• Fire Service and Volunteer EMS were traditionally
  male-dominated
• Although women often ran calls during daytime
  while men worked
• Fire/ EMS tradition re homosexuality
  transgender generally mirrored societal view of
  the times
• Often slower than society at large to change
  views
• Changes over last 20 years have resulted in more
  women in leadership command positions

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Gay and Transgender Issues

• Alternative lifestyles more common
• More gay people out of the closet
• Legalization of same sex marriage
• Increased efficacy of transgender surgery
• Accepted by some
• Resistance by others

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ETHNICITY
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Ethnicity CharacteristicsMainstream American

• Individualism
• Independence/freedom
• Competition/achievement
• Materialism
• Technology dependant
• Instant time/actions
• Youth/beauty
• Equal sex rights

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Ethnicity CharacteristicsMainstream American

• Leisure time highly valued
• Reliant on scientific facts/numbers
• Less respect for authority/elder
• Generosity in crisis
• Self esteem issues during illness or recuperation
• Believe there is cause and cure for any ailment
• Expect health care professionals to fix the
  problem

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African-American

• Not all African-Americans are black
• Not all Blacks are African-American
• Extended family networks
• Religion valued
• Interdependence
• Daily survival
• Technology valued
• Folk foods
• Folk healing modalities
• Matriarchal family structure common

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African-American

• Music is central
• Inquiry re personal info may be seen as offensive
• 1 in 400 suffer from Sickle Cell Anemia
• High Blood and Low Blood
• Common diseases
• Hypertension
• Diabetes
• High cholesterol
• CAD

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Mexican-American

• Extended family values
• Interdependence with kin
• Patriarchal
• Exact time less valued
• High respect for authority, elders
• Religion valued
• Same-sex medical staff preferred
• Native foods for well-being
• Very ill/dying pt may wish to say last words to
  each family member

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Asian-American

• Tradition highly valued
• Family/extended family extremely important
• Patriarchal/elder obligations respect
• Group compliance, not self-care
• Holistic approach to medicine
• Harmony and balance
• Medical interventions may interfere with ones
  spirit
• Religious spiritual values
• Folk care practices
• Non-aggressive, non-confrontational

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Asian-American

• Eye contact a sign of disrespect
• Touching stranger considered rude, intrusive
• Same-sex touch preferred
• Area of body below waist almost never exposed
• NEVER touch the head
• Feet should not be pointed at another person
• Soles of feet should not face another person
• Smile nod not understanding, or not wishing
  to disagree with authority to their face

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Asian-American

• Snickering embarrassment confusion
• Silence strong disagreement
• Yes may mean I hear you, not I agree
• Do NOT like to say no
• Blood is the source of life (Chinese, Vietnamese)
• May expect to receive medication
• Name is private prefer to be addressed by
  profession
• teacher
• mother

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Native American

• Harmony between land, people, environment
• Reciprocity with Mother Earth
• Spiritual inspiration/guidance
• Folk healers/medicine men
• Do not heal aid in journey
• Cultural rituals taboos (cleansing)
• Authority of tribal elders
• Pride in cultural heritage nations
• Respect and value for children

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Native American

• No direct eye contact
• Silence valued
• Offended if rushed, interrupted, not listened to
• May be viewed as non-compliant, stubborn by
  Westerners
• Note-taking may be considered rude
• High incidence of disease
• Diabetes
• Gallstones
• Ischemic heart disease
• Rheumatic conditions
• Arthritis
• Alcoholism

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Arab-American

• Christians Muslims
• Male-dominated often demanding
• Head of family given medical info, determines
  disposition
• Male responsible for sexual purity of female
• Sexual discussions not tolerated
• Extended family
• Passivity in presence of authority figure
• Look down on female medical personnel
• Illness is Gods will
• Evil Eye
• Food deprivation or bad news illness

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Arab-American

• Right hand only offered for dx/tx
• Left hand used for cleaning, going to bathroom
• Male-female eye contact sexual invitation
• Time is servant not master
• Mourning may be emotional
• Shoes may be left _at_ door of home
• Complimenting womans beauty offensive
• Avoid admiring object in home
• May feel obligated to make it a gift
• Rejection of gift is a tremendous insult

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Pacific Islanders

• Extended family, interdependent
• Spiritual bond between family and nature
• Living family members may interact w/deceased
• May be inappropriately viewed as bizarre
• Herbal remedies may be used
• Avoid conflict, social disruption
• Heirarchical system
• Females defer to males
• Young defer to old
• Medical decisions made by eldest male or church
  leader
• Sitting while talking w/pt, family a sign of
  respect

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RELIGION
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Religion

• Christian Science
• Blood blood products not ordinarily used
• No medical surgeries generally practiced
• Church of Jesus Christ of Latter Day Saints
  (Mormon)
• 24-hour fast required once a month
• Sacred undergarment (do not touch, remove or cut
  without explaining need)

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(No Transcript)
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Religion

• Hinduism
• Shoes never worn indoors (_at_ home)
• Shoes never pointed at elders
• Jehovahs Witnesses
• Blood blood products forbidden
• Medications acceptable if not derived from blood
  products

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Religion

• Judaism
• No pork or shellfish (includes pork-based
  insulin)
• Sabbath Festival Days, Orthodox Jews may not
• Work
• Fill out paperwork
• Turn electricity on or off
• Answer a phone
• Travel, except on foot (unless life or death
  emergency)
• Opposite sex touching should be avoided with
  Orthodox Jews

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Religion

• Islam
• Pork alcohol prohibited
• Includes pork-based insulin
• Alcohol wipes may be unacceptable
• Opposite-sex touching should be avoided
• Deceased persons body turned to face east
• Allow only Muslims to touch body
• Ramadan (9th month of lunar calendar)
• Month of fasting from sunrise to sunset

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Religion

• No medical restrictions for EMS for
• Bahai
• Buddhist
• Roman Catholic
• Seventh Day Adventist
• Unitarian/Universalist

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Other Cultural Concerns

• Homeopathic remedies
• Dermabrasion
• Acupuncture
• Coining
• Cupping
• Herbal remedies
• What was done before you arrived?

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Coining
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Cupping
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Other Cultural Concerns

• Cleanliness
• More valued where water is plentiful
• Body odor as sign of being alive
• Layer of dirt layer of protection
• Personal space
• Mainstream American arms length
• Middle Eastern, Latin American close enough to
  feel breath
• Modesty
• Opposite gender touching
• Disrobing

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Other Cultural Concerns

• Gestures
• OK sign obscene in S. America, Mediterranean
• Smile
• Korea stupidity
• Middle East sexual come-on
• Come here gesture w/index finger used in Asia
  ONLY to call animals
• Thumbs Up sign FU sign in Middle East

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Other Cultural Concerns

• Pain
• Stoic cultures (true feelings never revealed)
• Emotional cultures (free expression of feelings)
• Language
• English very difficult to learn
• Non-English Speaking feel they are assumed to be
  less intelligent, less competent
• Children as interpreters
• Confidentiality?
• Role within the family
• ATT Language Line

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Other Cultural Concerns

• Time
• Agricultural groups have no need to keep time
• No word for time in many Native American
  languages
• Orientation may be difficult for peds, elders,
  homeless
• Relationships
• Family a necessary part of healing in many
  cultures
• Show respect by addressing family (eldest first)
• Death Dying
• Family may be expected to make decisions for
  gravely ill patients
• Some pts not told they have terminal illness

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What Can We Do?

• Awareness of our attitudes
• Awareness of attitudes of others on the scene
• Educational support for competence

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Beth Adams Rules

• Every person deserves to be treated with respect,
  and as an individual.
• In truly life-threatening situations, most
  rules are ignored, but asking first will offend
  no one.

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LEARN to Communicate

• Listen
• empathy understanding to the patients problem
• Explain
• your perception of the problem
• Acknowledge
• and discuss differences and similarities
• Recommend
• course of action/treatment
• Negotiate
• agreement (go to ED or stay home)

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Communication Tips

• Start with a formal tone
• Introduce yourself by full name title
• Address other person by name title
• Mr., Mrs., Ms., Dr., etc.
• Avoid yes-no questions- give choices
• Watch body language (yours theirs)
• Smile, laughter may indicate confusion,
  embarrassment

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Communication Tips

• Avoid use of idioms
• Cold feet may be perceived as circulation
  problem
• Fanny means Vagina to Australians South
  Africans
• Rubber is an eraser in most places
• Plusses and Minuses of using children as
  interpreters

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Conclusion

• You cannot be expected to remember all of the
  unique elements of every culture
• In life threatening situations, many rules are
  exempt
• Asking before assuming will offend no one
• Above all, treat everyone with respect

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gluedtke_at_sussexcountyde.gov
Thank You!