Columns, Operations

Situational Awareness Advice for EMS Providers

Issue 4 and Volume 42.

When I played football, we had a tough drill called “Bull in the Middle,” which was used to teach us what one coach called “rapid recognition and defensive aggression.”

When it was your turn to be the bull in the middle, you laid flat on your back while 12 other players yelled and chopped their feet in place, ready to attack you when the coach pointed at them.

The bull’s job was to quickly get to their feet and into a contact (i.e., defensive) stance as rapidly as possible to take on the charging offensive players one-by-one as they attacked. You stayed in the middle until you had taken on all the aggressors and hadn’t been taken down by at least five of them in a row.

Because we had to stay focused on those in the circle, we couldn’t see who the coach was sending in at rapid-fire succession.

It forced us to develop an awareness-“eyes in the back of our heads,” as our coach said it, and it taught us to take on a threat directly, stay low and focused and then look for other attackers and threats.

The first time I took my turn in the middle, I got the snot beat out of me. However, once I experienced the stress, pain and, more importantly, the requirements of the drill, I learned to excel at it.

I learned to be hyperaware of my surroundings, constantly looking out for attackers and prepared to engage them and fend them off. I got up off the ground as soon as I could, ready to take on the next attacker.

By the time I was a junior, my upperclassmen teammates and I couldn’t wait for the drill to be sprung on us in preseason training camp. It wasn’t because we were masochists but rather because we were educated, experienced and aware players who wanted to show our stuff, never get blindsided or knocked down, and always come out the victor.

The second reason we loved this tough drill was that we wanted to indoctrinate the new rookies on our team so they would also be winners when confronted by opposing forces.

What I Learned

The bull in the middle drill taught me a lot about adversity, education, resilience and, most importantly, to always be aware of my surroundings-things I’ve used many times in my education and career, particularly as they related to EMS operations.

During SCUBA rescue training, I was being tested on an underwater corner-to-corner pool exercise where I had to start without equipment on and swim the four corners, first putting on my flippers to speed up my swim, then donning my SCUBA to breathe, then putting on and clearing my mask of water so I could see better, and then swim at full speed to the fourth and final corner.

I had to do this all in five minutes or I wouldn’t pass. All was going well during the exercise, until I left the third corner and started fast kicks to finish in time. That’s when my right flipper came off.

I thought, “screw it, I don’t need two flippers to finish,” so I started toward the final corner without it. I got to within 10 strokes of the finish when suddenly, one of my instructors grabbed me from behind and signaled for me to return and put my missing flipper back on before I could finish.

I don’t know where I got the fortitude to return, put it on and finish the drill in time, but I did. I will always remember my instructor yelling at me, “You can never panic underwater, abandon your equipment or your partner, or you will die!”

Soon after completing the SCUBA training, I got cocky and went on a body recovery mission in a river that ran between Easton, Pa., and Phillipsburg, N.J. It was my first experience in dark, fast-moving water. I back flipped off the boat and immediately found myself being swept away in the rapid current. I suddenly realized that I had no control over myself, and I couldn’t stop being pulled downstream and I soon began bumping into underwater objects like trees and tires.

I thought, “Oh sh#t, I’m not prepared for this! If my regulator gets pulled off me or caught in debris, I’ll die!”

That’s when experienced diver Frank Turney-you remember names forever when someone saves your life-saw I was in trouble, grabbed me and handed me a cinderblock he found on the bottom of the debris to hold. It was enough extra weight to slow me down and we proceeded to look for the body, releasing objects and then grabbing onto others to stay in control-and alive.

What You Should Know

Just as I benefited from my bull in the middle experience, I also want to present a few areas where you, as the EMS bull in the middle, should be alert and prepared to take appropriate actions. I want you to pass this along to your partners, friends and colleagues so they don’t get knocked down, injured or harmed (physically or emotionally), or perhaps even killed.

Stay educated and put on your game face: Stay current on clinical issues as well as infectious diseases or trends, such as a violence against police officers or riots occurring in or near your service area. Know that an increase in overdoses can mean an increase in violence against responders.

Your brain must be engaged before you can engage your assessment, equipment or defensive skills. Be an educated, experienced and aware provider, and never get blindsided.

Think before you act, especially when using your cellphone. Statements you make, or photos you take and send, can hurt you and cost your job. The burden is on you to ask yourself, “Should I be doing, saying or sending this,” whenever you have your cellphone while on duty.

Check and double check your equipment: A dead suction unit or cardiac monitor can result in the unnecessary death of a patient. Enough said.

Focus 100% on the road and cross traffic at all times: Drivers should drive, with hands free of microphones or smartphones and firmly on the wheel, not turning on equipment or touching computer screens. These should be the responsibility of the person riding shotgun.

Your partner should also be watching for, and calling out, traffic hazards and cross traffic entering an intersection.

My father taught several driving tips that helped me avoid serious accidents. To buy a few seconds of extra time when someone blows a red light or enters your lane, he advised me to straddle the center line or stay in the far left lane whenever possible.

When on a highway, however, particularly at night when drunk drivers are on the road, you should avoid driving in the far left lane. Impaired drivers who try to avoid detection by traveling in what they think is the far right lane often get confused and drive onto exit ramps instead of entrance ramps, and they end up driving the wrong way in the high-speed far left lane.

Keep your situational awareness switch on, and watch your back and your partner’s back at all times: There are people who can or will purposefully or unintentionally attack you when you least expect it.

I’m not just talking about terrorists or others who want to lash out against us. I’m also talking about people or patients who are hopped up on drugs, intoxicated, mentally challenged, suffering from and triggered by post-traumatic stress, or who have sustained a traumatic brain injury.

Remember these people aren’t in their right mind, and they don’t care that you’re an EMS provider. They will just as quickly attack, stab or shoot you as they might a police officer. Don’t think that the words embroidered on your jacket or your patch, badge or Star of Life emblem will help or save you.

You should learn recognition skills and defensive tactics that most regular EMS classes don’t teach you. For every door you enter, look for another escape route if the reverse of your entry can’t be used to quickly escape. Firefighters are taught to plan for an escape route when in a structure in case it’s needed during firefighting operations. That often means simply turning around and following the hose line being advanced up a stairway or through smoky rooms because it leads back to the entryway and a safe space.

But that doesn’t always work, particularly when there’s a collapse or flashover that cuts off the reverse path. Always be thinking of alternative exits as you proceed through a house.

In EMS, when entering a bar to attend to a fight victim, or in a home where there’s domestic violence involved, you should also plan an escape route in case a situation develops or escalates.

Always be prepared to use a piece of equipment as a barrier, distractor or defensive (or, as a last resort, offensive) weapon if your life depends on it. You can buy a lot of time by throwing a stretcher or stair chair in the path of an aggressor! You can also use it as a defensive weapon by launching it into the legs or knees of an attacker. Oxygen tanks, clipboards, suction units, monitors and flashlights can also be used as weapons when necessary.

I teach defensive tactics using kubatons-multifunction, pen-size items that you can get online that are made out of steel and function as a regular pen, penlight, glass breaker and, if necessary, a defensive weapon. They look harmless, but when applied against one of many pressure points on the body, you can stop aggressors in their tracks or painfully force them to release a grip they have on you. They’re legal to carry in most states but must be checked in baggage when you fly.

I also believe that each person on a response crew should have access to a portable radio to alert crewmembers or the communications center when danger is present or assistance is needed. Cellphones don’t cut the mustard when seconds count.

Do a stress check before you leave work: Try your best to leave as much of your job stress at work: Taking it home can exacerbate it and result in personal or spouse, friend or partner problems.

If you go home and have problems sleeping, thinking or interacting with those around you, talk to friends, co-workers and loved ones to try to relieve some of the stress before you boil over. If this doesn’t work, seek help through your employee assistance program. There’s no shame in feeling or reporting stress; it’s a normal part of our job.


This isn’t a complete list of the mindset responders should have or the many hazards they should be aware of and prepared to fend off when they’re the bull in the middle. But, it’s a start, and there are likely countless others that you can think of that can help you stay safe and alive.