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Journal of Emergency Medical Services (JEMS), August 1986
Jeff J. Clawson, M.D.

The Hysteria Threshold-Gaining Control of the Emergency Caller

The child in a tantrum, a screaming teenager at a Michael Jackson concert, the ex-spouse in a court custody hearing, and an emergency caller, may all have one thing in common. They're out of control. They're h-s-t-e-ri-c-a-l.

The definition of hysteria is listed as " a state of tension or excitement in which there is temporary loss of control over emotions."

Our day-to-day experience leads us to side-step unpleasantness and avoid confrontations which includes the hysterical. It is a process of natural survival. This tendency also exists at the dispatch level and has been a lifesaver there for decades-unfortunately, only to the dispatcher.

"The caller is too upset (hysterical) to respond accurately," is a common argument. When confronted with a screaming, sobbing, threatening caller, what actually can be done?

In 1976, the Phoenix Fire Department initiated their now renowned program of medical self-help, or pre-arrival instructions, due to a fortunate occurrence in their dispatch center. Some wise soul bothered to make cassette copies of their first recorded successful dispatch interventions and sent them to different agencies along with other requested written information.

After playing the tape over and over, we noticed some consistent occurrences in each of the successful resuscitation cases on the tape. While the caller might have been out-of-control [hysterical] at first, something happened each time that allowed the dispatcher to obtain control of the situation and impact the victim through the caller. The first thing we noticed was ever so simple. The dispatcher didn't hang up the phone!

Normally, a dispatcher will avoid the confrontation with the hysterical caller. "We'll send someone right over," and then hang-up! Review a few dispatch calls where the victim is in dire need of immediate BLS and see what happens.

Next we noticed that the dispatchers in these cases always remained calm but firm. And, faced with an initial disregard to their request to "calm down and listen to me," they repeated the same request in identical phrasing over and over again. But that process might eventually take 15 minutes, one hour or two days. Maybe, but not very often. We discovered that with "repetitive persistence" the EMD can obtain "control" after usually two to three repetitions. At this point the caller gives in and becomes a help rather than a hindrance.

But guess what? Thousands of dispatchers have never gotten past this first request and have gone their entire careers without reaching the level of control just past the "hysteria threshold." Once reached, the caller almost always relinquishes control and becomes not just OK, but begins to follow the dispatcher's instructions closely, often exactly. Quite a difference from the screaming lunatic that greeted you on the line just moments before.

There are four simple rules to follow to get past the "hysteria threshold" through the technique of "repetitive persistence":

    1. You must repeat the described request each time in the same identical way. Do not vary the sentence structure (i.e., "Ma'am, you're going to have to calm down if we're going to help your baby." Repeat.). Variation in the spoken format indicates to the caller's subconscious a weakness in your will, a chink in your verbal armor.
    2. People who are out-of-control want people in control to lead them. It's just that, because they are out-of-control, they never appear that way on the surface. And we fall for it. We agree with, and respond to, their behavior instead of their need.
    3. Be firm and in charge. Be generic. Don't antagonize the caller or they will re-direct their frustration at you, making your argumentative attitude the subject of their displeasure, not the victim's distressing state.
    4. You must believe that the threshold actually exists. And while it may vary between different callers-everyone has one. Mine might be on the next request while yours may be next week. But funny thing-if you don't ask, how will you ever find out?

If we don't start asking the right questions, we'll never get the right answers.