Administration and Leadership, Operations, Resiliency

Detroit Fire Department Addresses Violence Against EMS Providers Following Attack

Issue 8 and Volume 42.

Shortly after midnight on October 20, 2015, Kelly Adams and her partner, Alfredo Rojas, responded to a call for an ankle injury. They drove their rig to a part of the city where many of Detroit’s homeless population dwell and EMS calls are frequent.

Rojas performed an initial assessment on the female patient, while the patient’s companion hovered nearby and answered questions for her.

Rojas attempted to separate the patient from her overbearing companion, enraging the man, who suddenly punched him, then pulled out a box cutter and began attacking him. With only his bare hands to fend off the attack, Rojas received multiple defensive wounds.

Adams quickly grabbed the steel stepstool used to help patients climb into the ambulance and struck the attacker repeatedly. Frightened, the female patient moved away from the scene, as her companion, undeterred even after being struck by the stool, turned and attacked Adams.

“I felt the knife slice through my cheek,” Adams recalled. Rojas began kicking the attacker, ultimately getting him away from his partner. As Rojas radioed for police backup, the microphone difficult to grip with blood-covered hands, the two managed to get into the cab of their rig.

The rest of the incident is preserved in the recording of the harrowing radio call: At 35 seconds, Rojas requests a scout car to be dispatched to their location; grunting and heavy breathing can be heard in the background. At 1 minute 6 seconds, Rojas uses a distress code to notify communications that they have an emergency and at 1 minute 13 seconds he states that both he and his partner are injured. Dispatch says the police have a five-minute estimated time of arrival, and the supervisor on duty will likely take even longer to arrive on scene.

At 1 minute 45 seconds, Rojas states that he and Adams are bleeding badly and are taking themselves to the hospital. At 2 minutes 13 seconds nearby ambulances state that they’re headed to the scene. Adams responds in a firm but remarkably calm voice, “Don’t send anyone over there, that guy is wielding a knife.”

Less than one minute later the medics arrived in the trauma center at Detroit
Receiving Hospital.

After the incident, Detroit Mayor Mike Duggan described the crew’s actions as an “act of heroism.”

Adams said that despite having never received personal safety training, she was just doing what had to be done. But now she worries that other medics faced with a similar situation might panic or freeze up.

Aftermath

Traumatic injuries occur in an instant, but recovery from their psychological effects can last a lifetime.

I visited Rojas and Adams in the hospital that morning, and despite being dazed, their strength and resilience were evident. “My world has just been rocked over sideways,” Adams told me. “Nobody goes to work thinking this is going to happen.”

Both paramedics had lost a lot of blood and their wounds were sutured. The nerves in Adams’ face were severed; one eye wouldn’t close and she couldn’t completely close her mouth. A small weight was placed in her eyelid so she could close it all the way. Her salivary gland duct was damaged.

The entire EMS community has been very supportive of the recovering paramedics. The city insurance case manager has become their advocate and is now a close friend of Adams, accompanying her to every appointment, asking questions and helping to arrange follow-up appointments.

Nearly two years later, Adams continues to see specialists and will soon have more surgery. As a result of the injury, the muscles in her face have become unbalanced and she receives regular Botox injections to relax the other muscles. “I don’t want to look 20 years younger!” she jokes.

Adams has worked in Detroit for most of her adult life. Prior to working in EMS, she worked for child protective services, assisting in transitioning children away from abusive environments. She’s used to difficult situations and isn’t thin-skinned. Her colleagues have always known her to be a tough, confident EMT who’s not afraid go to bat for them.

She remains an employee and hopes to return to work in some capacity soon, but doesn’t think she could get back on an ambulance today.

After initially seeking help from several mental health counselors who couldn’t provide the support she needed, Kelly finally met a psychologist who had experience working with military veterans and now feels she’s coming to terms with the attack.


Kelly Adams on the day of the attack.
Photo courtesy Kelly Adams

The City Responds

When the attack occurred, the city of Detroit was emerging from bankruptcy, and new leadership in the city’s fire department were working on expanding its medical response to include more fire-based first responders. This resulted in a need for
additional training.

The attack on Adams and Rojas was a grim indicator to fire department leadership that we’d entered a new era, where attacks on first responders and prehospital emergency medical providers are distressingly frequent-although many don’t result in injuries as severe as those Kelly suffered-and training on violence against EMS providers is inconsistent in municipalities across the
United States.

According to the Bureau of Labor Statistics, in the healthcare and social assistance industries, an assault is the most common source of nonfatal injury or illness requiring days off work.1

The day of the attack was the first full day of work for Eric Jones, the city’s new executive fire commissioner. A former Detroit police officer and attorney, Jones had experience leading departments in the city, but he had no fire or EMS background.

On the day of the attack, Jones stood at the bedside of the injured medics feeling angry. “[First responders are] working in some dangerous conditions,” he later explained when asked to recall what he was thinking that day. “They’re concerned-police officers are concerned, firefighters are concerned, EMTs are concerned. They’re professionals, but [the men and women of the Detroit Fire Department and Detroit EMS] go into some very dangerous situations … and I’m working aggressively to get them the training and equipment that they need [to protect themselves].”


Kelly Adams after her most recent-and hopefully
final-operation. Photo courtesy Kelly Adams

Training

Situational awareness is a key part of EMS training; however, most personnel haven’t been trained to recognize the cues that precede violence. There’s little or no formal violence prevention or self-defense training for EMS providers. Too often violence is perceived as “part of the job” or something that’s just “expected.”

Within weeks of the attack, the Detroit Fire Department identified a multipronged training strategy. The first phase included training all medical responders in a “verbal judo” de-escalation program used by the Detroit Police Department. By the end of November 2015, all Detroit EMS personnel were trained.

The next step was identifying a comprehensive violence prevention and self-defense course. The Defensive Tactics for Escaping, Mitigating and Surviving (DT4EMS) program was recommended to the department by other agencies that had used it. The goal of the program is to guide culture change and provide practical, hands-on self-defense training for EMS providers.

Kip Teitsort, the founder of DT4EMS, has worked in both law enforcement and EMS, and he’s a passionate advocate for safety. He’s collected the stories of countless responders, including his own experience of having his ambulance hijacked while he was caring for a patient. He continues to improve the DT4EMS training program based on these
real-world experiences.

Teitsort explains that a key part of the success of the program is helping responders to “overcome the culture of
accepting violence.”

He reminds trainees that violence isn’t socially acceptable in public places, and it shouldn’t be acceptable in an EMS rig or in an ED. This is a message engrained more easily in new medics, who haven’t yet developed the “emotional armor” of seasoned medics, who have many barriers to break down before they can be effectively trained.

Impact

Taking advantage of a “train the trainer” component of DT4EMS training allowed for every medic that provides emergency medical support for the city of Detroit, including those with private EMS agencies, to be trained between February and April 2016. Equipment was purchased to support ongoing training and the course was subsequently added to the curriculum taught at the Detroit EMS academy.

The training center now has a cadre of instructors for the program and all new employees receive this instruction. Psychological first aid training is also provided and the department expanded on-call peer counseling services.

Sean Larkins, Detroit EMS superintendent, is impressed with the results of the training. “Our staff learned how to really talk to people,” he said-something that’s not well covered in EMS programs.

Emergency responders in Detroit see horrific crimes and often care for severely injured or neglected humans and animals. These experiences have an undeniable effect on daily life.

Physical well-being is of the utmost importance, and mental health also plays a part. Counseling is an ongoing need, as post-traumatic stress disorder often goes undiagnosed in field emergency workers. It can manifest as anger and is often written off. There’s a need for forums where experienced providers can share both their frustrations and wisdom.

Detroit has begun to identify high-risk locations by coordinating police and fire/EMS data. These are areas of the city where a history of violence demands a tailored response, where EMS providers must often wait for a scene to be fully secured. But even calls that appear generally safe require vigilant providers, as any scene can go bad. To address this, the city has now instituted policies to track police response to medic requests.

In May 2017, the Detroit City Council approved the purchase of body armor for all response personnel. However, additional self-defense strategies are needed when vests fail to protect them; often the only ally during an attack is a partner. It’s imperative to train providers in de-escalation techniques as well as methods for disengaging and escaping safely. Some support the use of other, non-lethal self-defense tools, including energy weapons, collapsible batons and chemical irritants; however, to date there’s no consensus on the efficacy of these tools.

The Outcome

On Oct. 23, 2015, Michael Montgomery was charged with two counts of assault with intent to murder, two counts of assault with intent to do great bodily harm, one count of assault with intent to maim, and one count of resisting and obstructing causing serious injury. Evidence linked Montgomery to older crimes including two counts of first-degree criminal sexual conduct, kidnapping, torture and felony firearm possession. He was also charged with the sexual assault and fatal stabbing of a teenage girl in 2006. Montgomery plead guilty to all the charges and was sentenced to serve 40-80 years in prison.

Adams was often frustrated with the criminal justice process, angry that Montgomery hadn’t been aggressively pursued in the past. Showing me a picture of her bloody face from the night of the attack, she said, “He got all Freddy Krueger with us … but he didn’t win.”

The conclusion of the court case was one small step in the recovery for Adams and Rojas. Their experience had a huge impact on the Detroit Fire Department, which recognized that the approach to protecting EMTs and paramedics must change and continue to evolve.

The problem of violence against EMS providers must remain front and center, and the lessons we learn from violent attacks such as the one experienced by Adams and Rojas can’t be forgotten. This isn’t a problem that Detroit is alone in experiencing. It’s up to all of us to prevent future incidents.

Reference

1. Workplace violence in healthcare: Understanding the challenge. (n.d.). Occupational Safety and Health Administration. Retrieved June 20, 2017, from www.osha.gov/Publications/OSHA3826.pdf.