It’s become a mantra: “Is the scene safe? BSI in place?” Once the answer is determined, a course of action follows—either we go about our business with an assumption that we can not be hurt, or we vacate the scene. This is easy to test, and unfortunately, has become embedded in the culture of EMS. It’s also dead wrong—and presents the possibility of paramedics (of any level) getting hurt because they are not sufficiently aware, or sufficiently trained, to deal with the hazards they may encounter.
The truth is that “safety” is not a binary concept. It is neither present nor absent. It is relative, and continually evolves throughout the course of a patient encounter. Paramedics need to be re-trained and re-oriented to stop thinking that a safety evaluation occurs only once at the beginning of the call, and to start seeing safety as something that needs to be continually re-evaluated and addressed. Paramedics also need to be trained to evaluate and address evolving threats, and to implement processes and techniques to mitigate those threats at each level of escalation.
Consider the following scenario: EMS-32 is dispatched to a call for respiratory distress in a private residence. The unit arrives, with no indication of difficulty at the scene (“the scene is safe”). The paramedics begin their routine of the 68-year-old woman – assessment, treatment and decisions about transportation. The patient gets some relief from her albuterol treatment, and a discussion ensues between the patient and the paramedic about whether or not the patient wants to go to the hospital. As often occurs, the conversation becomes a bit animated. Nothing unusual so far, right?
Suddenly, the patient’s son, who was sleeping in a bedroom by the front door (where we entered), awakens, appears in the doorway with a handgun holstered on his hip, and tells the medics, “You stop disrespecting my mother!” What now?
In a heartbeat, the scene has turned from benign to …. what? Is it now dangerous? Maybe. It’s surely a bit more dangerous than it was an instant before. Is it life-threatening? The actions of the paramedics in the next few seconds may make that determination. A proper application of verbal de-escalation techniques may cause the son to close the bedroom door and mind his own business while the medics wrap up their on-scene activities. An improper response may cause the handgun to move from the holster to the hand—worsening the situation.
Change the scenario a bit. The son is loud and threatening, but has no weapon. Or perhaps the weapon is a knife. In either case, he’s standing between us and the door, and the patient still needs care. What do we do? In any of these situations, our training teaches little or nothing about what to do. Even much of what is “discussed” is anecdotal or even just plain dangerous.
Our focus needs to change. Safety needs to be an ongoing concept for paramedics, which is addressed realistically in any scenario. Every paramedic needs to understand that the relative safety of a scene is something that is always changing, that just like the condition of the patient, it must be continually re-assessed and dealt with appropriately.
To accomplish this, some fundamental changes need to occur, both in pre-service education and in daily practice.
First, the concept of “safe” vs. “unsafe” scenes has to be eliminated. All scenes are relatively safe along a continuum ranging from “not very safe” to “quite safe right now.”
Second, paramedics need to develop a new set of competencies involving awareness of scene safety and ability to respond to condition changes at all type of scenes. These competencies should include, as a minimum, the following:
- Understanding the difference between patient and attacker.
- Understanding the limits of the concept of abandonment when applied to a situation where a provider is in danger.
- Understanding that violence is not just “part of the job” and knowing the cultural implications of violence (zero tolerance of violence against paramedics, and zero tolerance of other paramedics teasing or harassing colleagues who have been victims of violence).
- Understanding the mental and psychological issues involved in seeing and dealing with violence.
- Customer service skills such that patients, families and bystanders perceive paramedics as helpful, non-threatening responders.
- Verbal conflict management and de-escalation skills.
- Escaping physical encounters (e.g., blocking, parrying, releasing choke holds and establishing distance).
- Self-defense skills, in case you can’t escape from an aggressor.
- Documentation of encounters involving violence, and preparing for the legal process that will follow an assault on a paramedic.
Along with competencies, we need to have a realistic discussion about the need for personal protective equipment. Some agencies are compelled to issue soft body armor to their personnel, some allow but do not require the wearing of this PPE, and. some feel that this is unnecessary. Medics are concerned about the violence they face on a regular basis, and part of that solution is appropriate protective equipment.
So where do we begin? I think the first starting point is easy; we do away with the “Is the scene safe?” mantra at the beginning of each patient encounter and recognize that scene safety is a relative and fluid concept. Perhaps we should initially decide, “Should we go in?” This would provide for an assessment of the scene based on what we know at the time we approach or arrive on the scene, and recognizes that no scene is completely and forever safe. Once that decision is made, we need to teach paramedics to “keep their head on a swivel”—to maintain situational awareness, to continually re-assess the safety of their environment and to maintain situational awareness throughout any patient encounter. Because a scene that might have seemed safe—or might once have been safe—is likely to change. Our safety depends on our awareness and responses to those changes.
It is unfortunate, but violence against paramedics appears to be on the rise (another possibility is that it has been an ongoing issue, but we are hearing more about it because of improved communication capabilities.) In either case, our community is not well-prepared to avoid, prevent, respond to or survive hostile encounters. Some paramedics, through lucky experience, may have learned these skills in the school of hard knocks – not the best place for development of personal survival skills. We need, as a community, to start to take this issue seriously – demanding coverage of these important topics in pre-service education, in continuing education and in operational support. Let’s get “Scene safe? BSI?” out of our vocabulary and start learning how to keep ourselves safe. Let’s make going home at the end of our shift uninjured a real priority.
Be safe! Train! Keep your head on a swivel – and stay alive!