Scene safety: EMS students repeat it like a mantra when entering testing stations, but few, if any, are trained to determine whether a scene is actually safe. Even fewer are trained to continually re-evaluate scene safety throughout an incident.
Most EMS providers assume they'll never find themselves in the middle of a violent situation. However, at least three studies over the past decade or so have proven EMS providers are at a greater risk of becoming victims of assault than previously thought. A 1997 study found that 61% of EMS personnel surveyed had been assaulted, and 25% of them were injured as a result. A 1998 study showed that violence preceded 14% of EMS calls and that EMS personnel surveyed were victims of violence during 5% of calls. Moreover, this study confirmed that violence against EMS providers is underreported. And, in 2005, the National Association of Emergency Medical Technicians administered a survey to EMS personnel and found that 52% of respondents had been assaulted by a patient.
Threats to Providers
The threats EMS providers face come in many forms, and some types of calls have a higher likelihood of violence than others.For example, providers often expect vague calls, such as "man down, unknown problem" to be cardiac related, but this is a dangerous assumption. The person may be down due to acts of violence, such as those perpetrated by gunmen during the 1966 Texas Tower shooting and the 2002 Washington, D.C., Beltway attacks.
Today's EMS personnel are increasingly becoming targets of domestic and international terrorism. The 1997 bombing of an abortion clinic in Atlanta included the detonation of a secondary explosive device approximately one hour after the initial blast and was intended to target EMS, fire and law enforcement personnel responding to the initial explosion. And the collapse of the World Trade Center and resulting deaths of EMS, fire and law enforcement personnel represents another example of the need to continually reevaluate a scene. Since 9/11, EMS agencies have received regular warnings of possible terrorist plots to steal EMS uniforms and vehicles in order to infiltrate guarded areas and target critical infrastructure. We must remind ourselves of these real possibilities.
More commonly, patients, bystanders, family members and pets can turn against an EMS crew very quickly. Domestic disputes are some of the most hazardous calls to law enforcement officers and are no safer for EMS. Violence is already common in these cases, in which emotions run high. The actions of those involved, including the victim, are unpredictable. It's not uncommon for a domestic abuse victim to be uncooperative or assault the would-be rescuers when it becomes clear the abuser may go to jail. Similarly, incidents involving suspected child or dependent-adult abuse could also turn violent if the abuser realizes your intention to report your suspicions.
Suicidal patients have often been overlooked as true threats. There's a fine line between a person who's suicidal and one who's homicidal. If a person has decided they want to die, they know there will be no consequences for hurting or killing someone else first. And if they're unable to bring themselves to commit suicide, an attack against you may be used in the hope of provoking someone else, such as a police officer, to kill them. A prior acquaintance or friendship with thesuicidal patient will not protect you.
Treating other assault victims, particularly at bars or special events where large inebriated crowds are present, may also be extremely dangerous. Persons who are intoxicated and/or drugged may interfere and demonstrate highly unpredictable behavior, as do those with psychiatric conditions, hypoglycemia, hypoxia and head injuries. They may behave irrationally and violently without warning and may have diminished response to pain.
The Gift of Fear
The good news is human beings have the innate ability to recognize subtle warnings of danger. Gavin DeBecker, author, trainer and specialist in violence prediction and management, refers to this as the "Gift of Fear." Many victims admit they had an eerie or strange feeling prior to their attack or that their hair was standing up on the back of their neck. According to DeBecker, humans typically ignore that little voice or sixth sense.
Most people continue into a potentially violent situation and later state that the attack came without warning. DeBecker says humans are the only species that will sense potential danger and not run away.The feeling that something isn't rightis a warning. Ignoring your mind and body's natural warning system may deprive you of your only chance to avoid or escape a violent encounter in the field.
Time for Tactics
Survival tactics can be employed before arriving on scene and should continue throughout the duration of the incident. Be familiar with your assigned area and the best choices for ingress and emergency egress from the scene. Take a few extra seconds to check a map if an area is unfamiliar. Consider a stealthy approach, slowing down your rig, shutting off the emergency lighting and sirens, easing off the accelerator and turning out your headlights if traffic conditions permit. Avoid parking directly in front of the call location, and approach cautiously on foot. Take advantage of angles and corners by stopping briefly to scan for possible threats. If the patient is in a vehicle, avoid approaching from the front or back, where sudden movement of the vehicle could injure you.
When you arrive on scene, ask other EMS personnel, dispatchers and law enforcement specific questions related to the patient's history. The single greatest indicator of potential violence is a history of violence.
Do as much patient assessment as possible before approaching or touching the patient. Triangulate your positions so that the patient would have to focus an attack on only one crewmember at a time. Distance and barriers can buy you time to escape or defend yourself against an attack. Keep something between you and the patient, such as a table, sofa or your ambulance cot. Determine the patient's airway, breathing, circulation and mental status as fully aspossible without touching them.
Take note of any panic or anxiety, unusual appearance, agitated or unusual activity, unusual speech patterns, bizarre thought patterns, suicidal or self-destructive behavior, or violent/aggressive behavior. Be alert for sudden changes in the patient's emotional status. If you realize your crew is in danger, leave the scene immediately.
Some patients may demonstrate hostile intent by assuming a bladed "fighting" or "boxer" stance with their strong side foot dropped back. A dropping or shifting of the strong side shoulder may be an early indicator of a punch about to be thrown. Be alert for clenched fists, rolling up of shirt sleeves and resistive muscle tension. If a patient target glances or looks around, this may indicate they're looking for an escape route, potential weapons or the presence of any possible witnesses. And if they look you up and down, they may be trying to size up their opposition.
Sudden movements may be the beginning motion of an attack, and sudden stops in movement may indicate a moment of truth and decision. Subjects who set aside an item of value to them, such as glasses, a hat or a watch, may indicate they don't want to damage the item in the forthcoming fight. Finally, some subjects will actually tell you their intent. Don't discount comments like, "I'm going to kick your butt if you touch me" or "I'm not going back to the psych unit."
Three pieces of equipment are vital to your safety in the field: a portable radio, binoculars and restraints. Your portable radio is your lifeline to the rest of the world. Regardless of the type of call, your radio is often your only means to get the assistance you need, whether it's manpower for lifting, helicopter transport for a critical patient or police backup. Critical updates and information about potential threats may also come across the radio during a call. Take it with you every time you get out of the ambulance.
Binoculars are also important, but are often considered only with regard to hazmat response and ability to read placards at a safe distance. If the call information is vague (e.g., "man down, unknown problem"), consider stopping a short distance away and using your binoculars to examine the scene before entering. If the patient is visible, conduct a remote assessment. Look for obvious signs of life or death. Is the patient moving? Can you see the patient's chest rising and falling or their breath in the cold air? Are there any visible injuries, and are those injuries life threatening? Is there visible bleeding? An absence of bleeding from major external wounds may indicate your patient is already dead. Is this a viable patient who would benefit from a timely rescue? Do you see any indications of hazmat, environmental threats or violence?
Lastly, keep restraints on hand. Store them in a convenient locationƒa place where they're easily reached from the cot and conducive to application by only one or two crewmembers. Practice using them under supervision and with role playerswho are willing to be resistant. It's tough to ask a doctor by radio or telephone for permission to apply restraints when a patient is harming you or themselves. Service protocols should allow for the initial application of restraints without approval by medical control until the scene is safe and medical control can be contacted for permission to continue using them.
You may be left with no choice but to apply some type of force to a patient or other bystander to protect yourself and your fellow crew members or escape. Decisive and powerful moves will be necessary to ensure your rapid escape. Punches, kicks, head butts, bites and strikes with the palms, knees and forearms may have to be performed within close quarters, including the back of the ambulance. In life-threatening situations, it may be reasonable to use strikes to the throat, eye gouges or other tactics likely to cause the assailant severe injuries or even death. If needed, consider weapons of opportunity, such as clipboards, oxygen bottles, IV needles and ink pens.
Ensure you use a level of force that another person under similar circumstances would find reasonable, based on the totality of the circumstances known to you at the moment the force is tobe applied. Force must never be punitive. When the attack stops or the patient is restrained, your force must stop. Failure to stopapplying force when you can no longer justify it could result in criminal charges. Consult an attorney to determine your state'slaws regarding the use of force by EMS personnel.
Also, be aware that once a high-stress situation, such as an assault, begins, a host of physiological changes may occur in the mind and body that will negatively affect your physical capabilities and senses. These effects include tunnel vision and/or hearing; loss of fine motor skills and dexterity; sweating; nausea; submissive behavior; trembling; voiding of the bladder and bowels; and increased heart rate, blood pressure and respirations. The body may temporarily shut down any non-vital functions in order to focus all energy on those systems the body deems essential for survival.
There are several ways to counter these physiological occurrences. Maintain your physical fitness. This will keep your heart rate down in a violent situation and enable your body to withstand a greater amount of stress and injury. Also, imagine dangerous scenarios in your head before they happen to mentally prepare yourself for the steps you would take. Combine this with realistic scenario-based training.
In the event restraints or force become necessary to protect your crew and/or the patient, document what the patient did that necessitated your use of force or restraints and how the patient responded to this. You'll likely have to demonstrate you had legitimate reasons to take these actions. Document any safety reasons for taking incomplete vitals or fleeing the scene. Explain why your actions do not constitute abandonment, remembering to befactual and not opinionated.
Be truthful. Describe the original call information, any patient history you already knew and the scene. Relate the patient's demeanor, actions and statements. Describe the patient's stance, facial expressions and body language in objective terms. Quote the patient exactly instead of simply writing that they threatened or swore at you. Lastly, document and photograph any injuries sustained by all parties involved and what treatment was necessary or provided.
There will always be the potential for violence against EMS providers. In fact, you may have already experienced it. But don't become complacent simply because you've responded to hundreds of calls and nothing like this has ever happened. Decide whether you'll be a victim or if you'll respond with intensity, determination and resolve to protect yourself and escape. Commit yourself to the idea that, if attacked, you won't give up.
Eric Dickinson,EMT-I(85), BS, is a senior police officer with the Vinton (Iowa) Police Department, a part-time EMT with Iowa County EMS and an adjunct instructor at Kirkwood Community College and Hawkeye Community College. He holds instructor certifications in various topics related to EMS response, officer survival and use of force. He has taught Survival Tactics for EMS Providers (STEP) to more than 500 providers. Contact him at firstname.lastname@example.org.
This article originally appeared in the July 2009 issue of JEMS.
For more on survival tactics, read"Training EMS for Violent Encounters" from July JEMS.