Introduction

Amid reports of high rates of assault-related injuries among emergency medical services (EMS) personnel, anecdotal evidence suggests that many EMS agencies, and individual EMS professionals, are using, or considering the purchase of, a variety of solutions. The purpose of this article is to describe the evidence and encourage the consideration of options to reduce the risks of assault-related injuries for EMS personnel. This article will quantify the current problem, describe possible interventions and make recommendations that may be helpful for EMS administrators, educators, researchers and personnel.

Scope of the problem

Every year, on average, more than one EMS professional in the U.S. is violently killed on duty.1,2 According to the U.S. Centers for Disease Control and Prevention (CDC), there are 2,000 EMS professionals injured every year in a violence-related incident.3 The rate of violence related injuries with lost work days for EMS personnel is 22 times higher than the national average for all workers.4,5 More than half of assault-related injuries result in lost work time.5 Of growing concern is the finding that female EMS personnel may have a disproportionately greater risk of violence-related injury.6 In Australia, about 10 paramedics a year suffer serious injury secondary to an assault7 and the rate of assaults tripled between 2001 and 2014.8 London paramedics were assaulted 600 times in one year.9 In a survey of EMS personnel in 13 countries, 65% of respondents reported that they had been physically attacked on duty.10 Violence against other health care workers is also a growing concern.11  

National Highway Traffic Safety Administration photo
Two thousand EMS workers a year are hurt in violent incidents on the job, according to the U.S. Centers for Disease Control and Prevention.

Potential interventions

There are a variety of potential interventions that might reduce the risks of assault related injury among EMS personnel. They include: self-defense training, body cameras, weapons (e.g. handguns), ballistic vests, chemical restraints (e.g. antipsychotic and benzodiazepine medications), pepper/capsicum spray, physical restraints (e.g. handcuffs), community education, taser/stun guns, and a variety of other training options such as de-escalation strategies and specific programs such as Escaping Violent Encounters. The one thing that all of these interventions have in common is that none of them have been proven to reduce risks for EMS personnel.12,13

To reemphasize, none of the programs being implemented today to protect EMS personnel are evidence-based. 

Risks associated with interventions

Some managers may think it is better to do something rather than nothing and so just pick an intervention and implement it. The problem is that such a course of action may result in increased risks for the EMS personnel through unintended consequences.

Many of the potential interventions may pose potential risks. For example,

  • Ballistic vests – may increase exposure to dangerous situations because vested EMS personnel may go into a dangerous situation that they would not have entered without the vest. Ballistic vests may also increase the risks for hyperthermia (imagine vested personnel doing CPR, a long stair carry or an extrication on a very hot day)
  • Body cams may likewise provide EMS personnel with a false sense of security leading to an increase in injuries. An unintended consequence may be that patients may be reluctant to confide in their providers when they know the information is recorded
  • Weapons pose a host of potential problems. Kirkwood and Teitsort described many considerations associated with weapons for EMS personnel.14 The issuance of handguns may also increase the risks of suicide, injuries among EMS family members and may lead to increased legal costs for EMS personnel and agencies. Handguns also raise the need for a secure weapons lockbox in the ambulance for when the crew responds to an airport or other secure site.

Recommendations

When we asked 600 paramedics from 13 countries who had been assaulted what they thought, in hindsight, might have prevented their assault we learned that:

  • Not one suggested that having a gun would have prevented their assault
  • Not one suggested that having a ballistic vest would have prevented the assault.

The assaulted medics did note that the following factors might have prevented the incident:

  • better situational awareness on their part
  • better relationships with police (who sometimes arrived late or left the scene too soon) and dispatchers (who could have collected and relayed additional information about the risks on the scene)
  • better access to and knowledge of the use of restraints
  • self-defence and violence prevention/de-escalation training.15

Anecdotal information suggests that many EMS agencies are trying to reduce the risks for their personnel.16 What is needed next is a structured approach that can demonstrate reliable findings and provide evidence of effectiveness. The medications that EMS professionals administer every day in the field are all evidence-based. It is critical that the programs implemented to protect our personnel also be evidence-based.

So how can we develop evidence-based programs to protect EMS personnel? The first step is to follow a strategic approach to developing your intervention. This requires clearly defining the problems you want the intervention to address and then prioritizing the problems based on their importance and the ability to act on them. Then analyze whether and how the intervention in question addresses the priorities. The CDC recommends four steps to violence prevention:

  1. Define the problem
  2. Identify risk and protective factors
  3. Develop and test prevention strategies
  4. Assure widespread adoption.17,18

Steps 1 and 2 have largely been completed. The logical next step is for ambulance agencies to work with university researchers to develop and test prevention strategies in such a way that the interventions can be reliably evaluated to demonstrate any differences in outcomes and, any findings of unintended consequences.

Program development should include a method of rigorous evaluation. Once you are confident the program has the potential to address a problem you have to consider how you will evaluate it. The World Health Organization (WHO), as an example, has created a handbook that provides guidance on how to evaluate programs. “The evaluation is an assessment, as systematic and impartial as possible, of an activity, project, programme, strategy…”19( p. 1). The evaluation focuses on what is expected and what is achieved by the program in question and how it contributes to the organization. WHO has adopted five principles that underscore the evaluation: Impartiality, Independence, Utility, Quality and Transparency.

Impartiality requires that there is an absence of bias in the evaluation process. One way EMS program developers can maintain impartiality in their evaluation is by working with university-based researchers to design and implement potential interventions in such a way that the interventions can be reliably evaluated to demonstrate any differences in outcomes and, any findings of unintended consequences. University-based researchers have the specialized expertise to conduct rigorous evaluations and may also know of, or be able to apply for, grant money that might be available to help support the project. Another benefit to working with university researchers is that they will publish the findings in peer-reviewed journals where EMS personnel around the world can review the findings and consider their next steps based on the evidence. This is how we build evidence-based practices.

These are just two of the many EMS examples of the value of this approach:

  • Some of us remember a time that we routinely used Military Ant-Shock Trousers (MAST) on trauma patients. We could share many stories of dramatic benefits for our patients as their blood pressures went from zero to near normal or how they regained consciousness as we inflated the suit. But, when an impartial, structured study was conducted, it found that patients who had the suit applied had a higher mortality rate than similar patients who did not have the suit applied 20
  • In 2004, two EMS agencies in the U.S. worked with university researchers to determine how their injury rates compared to other professions. This first-ever study of its kind found that EMS was much more dangerous than anyone had previously believed.5

One of the crucial components of this partnership between agencies and trained researchers is that it includes publishing the findings. The outcomes of the programs aimed to protect EMS personnel need to be published so that all EMS agencies can benefit from the lessons learned and not have to, again and again, spend our professional resources reinventing the wheel. As more agencies learn of successful interventions, widespread adoption will be assured. University researchers can also help ensure the program adheres to the WHO principles of independence, utility, quality, and transparency.

Other considerations

It is likely that any successful intervention will have to be multifaceted. As an example, a successful ambulance crash reduction program included multiple simultaneous interventions.21 In the case of violence, a reasonable set of components was described by Cohen as:

  1. strengthening individual knowledge and skills,
  2. promoting community education,
  3. educating providers,
  4. fostering coalitions and networks,
  5. changing organizational practices, and
  6. influencing policy and legislation.22

Following is a list of suggestions on where EMS providers interested in tackling the problem of violence can begin. When considering these options, keep in mind that there are multiple factors that can influence the outcomes and that consideration should be given to taking a multifaceted approach, as previously described. A team might:

  1. Pick a training program. At the moment there is no evidence for or against any program so select or develop a program and offer, for example, self-defense or de-escalation, or Escaping Violent Encounters. Self-defense training has worked for healthcare personnel.23 De-escalation training may be considered.24 Chemical restraints are potential options.25 Ketamine was found to be a safe, effective intervention to reduce patient aggression when used on aeromedical retrieval calls26 and was found to improve patient conditions in prehospital EMS;27,28 however, there is no evidence that it results in decreased risks for EMS personnel, especially when one considers that patients are not the only aggressors. Once you have selected and deployed the program keep track of who trains in what program and when, and then document any changes in the rate of events among those who had the training and those without the training.
  2. Develop a community education program. Many EMS agencies have tried this. There is no shortage of ideas, there has just been no evaluation of outcomes. So, pick or develop an EMS violence prevention community education program, describe it, implement it and keep track of results. The added potential advantage to this option is that it can also be a good opportunity to educate your community about EMS. Related to educating the community is educating potential perpetrators. Gillespie noted that a protective strategy for reducing violence against health care workers was: “instructing perpetrators to stop being violent. 23
  3. Educate EMS providers about their potential risks. This education can also help develop a commitment to the interventions and a better understanding of the shared responsibilities necessary for any successful injury-reduction program.
  4. Foster coalitions and networks with your local police, nursing home staffs, emergency departments and other emergency service organizations. Educate them about the program and ask for their support. Also note that this is another opportunity to educate people about EMS.5
  5. Examine your organization and change any organizational policies that are not supporting efforts to reduce risks for the staff. For example, anecdotal reports indicate that EMS organizations announced that they were implementing interventions to reduce risks, but the actual outcomes were that some staff felt unsupported if they intended to press charges against an attacker. Other staff felt pressured to press charges against people who they did not want to charge, and some staff were told that if they wanted to press charges, they would have to take vacation time to go to court. These factors created barriers to program success.
  6. As a profession, we have much room for improvement in the area of influencing policy and legislation. This issue may be one that EMS agencies will find that politicians are supportive and are interested in being involved. Approach your local elected officials, educate them about violence, and about EMS, and ask for their support. As an example, EMS professionals in Connecticut recently rallied together to encourage legislatures to provide PTSD benefits for EMS and not just for police and firefighters29.

Conclusion

As a profession we must ensure that the same rigour that is used to demonstrate the safety and efficacy of every medication we administer to our patients is used to demonstrate the safety and efficacy of every intervention that we use to protect our EMS personnel.

References

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2.         Maguire BJ, Smith S. Injuries and fatalities among emergency medical technicians and paramedics in the United States. Prehosp and Disaster Med. 2013;28(4):1-7.

3.         U.S. Centers for Disease Control and Prevention. Emergency Medical Services Workers: How Employers Can Prevent Injuries and Exposures. 2017. Available at. https://www.cdc.gov/niosh/docs/2017-194/pdfs/2017-194.pdf?id=10.26616/NIOSHPUB2017194. Accessed 23 Jun 19.

4.         Maguire BJ, Hunting KL, Guidotti TL, Smith GS. The Epidemiology of Occupational Injuries and Illnesses among Emergency Medical Services Personnel. ProQuest; 2004.

5.         Maguire BJ, Hunting KL, Guidotti TL, Smith GS. Occupational injuries among emergency medical services personnel. Prehosp. Emerg. Care. 2005;9(4):405-411.

6.         Maguire BJ, O’Neill BJ. EMS personnel’s risk of violence while serving the community. Am. J. Public Health. 2017;107(11):1770-1775.

7.         Maguire BJ, O’Meara P, Brightwell R, O’Neill BJ, FitzGerald G. Occupational injury risk among Australian paramedics: an analysis of national data. Med. J. Aust. 2014;200(8):477-480.

8.         Maguire BJ. Violence against Ambulance Personnel in Australia; a retrospective cohort study of national data from Safe Work Australia. Public Health Research & Practice. 2018;28(1):e28011805.

9.         Dean L. London ambulance medics assaulted almost 600 times during 2013. International Business Times. 31 March, 2014. Available at: http://www.ibtimes.co.uk/london-ambulance-medics-bitten-spat-hit-fence-post-during-2013-1442652. Accessed 13 April 2014.

10.       Maguire BJ, Browne M, O’Neill BJ, Dealy M, Clare D, O’Meara P. International survey of violence against EMS personnel: physical violence report. Prehosp. Disaster Med. 2018;33(5):526-531.

11.       Spelten E, Thomas B, O’Meara P, Maguire B, Fitzgerald D, Begg S. Organisational interventions for preventing and minimising aggression directed toward healthcare workers by patients and patient advocates. Cochrane Database of Systematic Reviews. 2017;Issue 5:Art. No.: CD012662.

12.       Maguire BJ. Future Directions for EMS and the EMS Agenda for the Future. U.S. Government: NHTSA. 2016. Available at. https://www.regulations.gov/document?D=NHTSA-2016-0035-0015. Accessed 30 June 2016.

13.       Maguire BJ, O’Meara P, O’Neill BJ, Brightwell R. Violence against emergency medical services personnel: A systematic review of the literature. Am. J. Ind. Med. 2017:1-14.

14.       Kirkwood S, Teitsort K. Violence against EMS providers: What can we do about it? EMS World 2012.41. Available at: http://www.emsworld.com/article/10741287/violence-against-ems-providers-what-can-we-do-about-it. Accessed 1 Jul 17.

15.       Maguire BJ, O’Neill BJ, O’Meara P, Browne M, Dealy MT. Preventing EMS Workplace Violence: A mixed-methods analysis of insights from assaulted medics. Injury. 2018;49:1258-1265.

16.       Dunne RB. Detroit Fire Department Addresses Violence Against EMS Providers Following Attack. JEMS. 2017. Available at: https://www.jems.com/articles/print/volume-42/issue-8/features/detroit-fire-department-addresses-violence-against-ems-providers-following-attack.html. Accessed 30 Jun 19.

17.       U.S. Centers for Disease Control and Prevention (CDC). The Public Health Approach to Violence Prevention. 2015. Available at. https://www.cdc.gov/violenceprevention/pdf/PH_App_Violence-a.pdf. Accessed 4 Nov 16.

18.       Mercy JA, Rosenberg ML, Powell KE, Broome CV, Roper WL. Public health policy for preventing violence. Health Aff. (Millwood). 1993;12(4):7-29.

19.       World Health Organization. Evaluation Practice Handbook. 2013. Available at. https://apps.who.int/iris/bitstream/handle/10665/96311/9789241548687_eng.pdf;jsessionid=844E6CF2E1B31353918CAA371EE894DD?sequence=1. Accessed 11 Aug 19.

20.       Mattox KL, Bickell W, Pepe PE, Burch J, Feliciano D. Prospective MAST study in 911 patients. J of trauma. 1989;29(8):1104-1111; discussion 1111-1102.

21.       Maguire BJ, Porco FV. EMS and Vehicle Safety. Emerg. Med. Serv. 1997;26(11):39-43.

22.       Cohen L, Swift S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Inj. Prev. 1999;5(3):203-207.

23.       Gillespie GL, Gates DM, Miller M, Howard PK. Workplace violence in healthcare settings: risk factors and protective strategies. Rehabil. Nurs. 2010;35(5):177-184.

24.       Heightman AJ. Dealing with Psychotic Patients. JEMS. 2019. Aug 7. Available at: https://www.jems.com/articles/2019/08/dealing-with-psychotic-patients.html. Accessed 11 Aug 19.

25.       Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clinics. 2009;27(4):655-667.

26.       Gangathimmaiah V, Cong ML, Wilson M, Hooper K, Perry A, Burman L, Puckeridge N, Maguire BJ. Ketamine sedation for acute behavioural disturbance during aeromedical retrieval. Air Med. J. 2017;36(6):311-314.

27.       Keseg D, Cortez E, Rund D, Caterino J. The use of prehospital ketamine for control of agitation in a metropolitan firefighter-based EMS system. Prehosp. Emerg. Care. 2015;19(1):110-115.

28.       Ho JD, Smith SW, Nystrom PC, Dawes DM, Orozco BS, Cole JB, Heegaard WG. Successful management of excited delirium syndrome with prehospital ketamine: two case examples. Prehosp. Emerg. Care. 2013;17(2):274-279.

29.       Besthoff L. EMS Workers Criticize PTSD Bill, Say They Also Need Help. NBC Connecticut. May 17, 2019. Available at: https://www.nbcconnecticut.com/news/local/EMS-Workers-Criticize-PTSD-Bill-Say-They-Also-Need-Help-510093181.html. Accessed 11 Aug 19.