Safety First or Safety Third: Considering Practitioner Safety in EMS

The photo shows the back of an ambulance.
Photo/National Highway Traffic Safety Administration

“BSI! Scene Safe!” This clarion call signals the start of a paramedic student’s scenario, indicating the first priority of the call: the practitioner’s safety. Having ensured the scene is safe, the paramedic can then approach the patient. This “safe” scene can be as exotic as a collision on a highway or the scene of a vicious assault. As noted in the article, “Safety is Third, Not First, and We All Know It Should Be,” there is very little safety to be found in many of these scenes.1

The paramedic’s job is inherently risky, and it is therefore futile to follow a “safety first”  mentality. Instead, safety should come third, after “getting the job done” and “having fun.” When critically assessing this article and its ideas, however, it becomes clear that they are based on faulty logic. However, the article does raise an important question about the balance between personal safety and the paramedic’s duty to act. It is worth deconstructing these arguments and asking where the line for safety really is.

Paramedics are taught that their role is to respond to the scene and take care of the patient, who is experiencing some form of life-threatening emergency. In EMS culture, paramedics are seen as heroes, standing guard against illness and disease. It is therefore difficult for practitioners to balance the need for their own safety over that of the task they have trained to do.

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It is especially difficult to balance the unknown variable of personal safety against the known variable of the patient’s emergency. One variable must take priority, potentially at the expense of the other. If patient safety is prioritized, should practitioners understand that when they sign up to be paramedics, they are duty-bound to place the patient’s safety above their own? If practitioner safety is prioritized, do we run the risk of failing to provide timely medical assistance?

There is no doubt to the priorities of the “safety third” mindset. To quote the article, “The mission to bring a caller to safety begins with one or more first responders getting in a vehicle and driving, an activity proven to be one of the most dangerous activities in the United States. Were safety actually first, they’d never even take this first step.” Examining this argument further, it is built on a false premise.

The premise is that safety can only be maintained if practitioners are not placed under any risk whatsoever. This is a common logical fallacy known as the “straw man fallacy.” By refuting the related argument that safety can not be guaranteed, the main argument, safety first, is made to seem invalid. To put it another way, the safety third mindset argues that “if safety is not guaranteed throughout the entire call, then either the call is not worth responding to or safety is not worth pursuing.” With that logic, it is clear why safety must come third. This misrepresentation underlies the entire article and limits its overall value in EMS practice.

The article then states that getting the job done is the first priority. Relative safety is a priority, inasmuch as it permits the completion of the job, but it is not the highest sole priority. But what exactly is the job of a paramedic? The job is to respond to emergency calls as they come in, and paramedics regularly attend multiple patients in the same day. In this case, relative safety becomes the priority, as the paramedic crew will not be able to respond to subsequent emergencies if even one member is injured on a call. Further, an ambulance must be taken out of service to respond to each injured crew member, not including another ambulance that will now be required to attend to the original patient.

Research has shown that paramedics take on significant risk and incidences of injury and fatalities on the job are quite high.2 The addition of the coronavirus pandemic has further increased the importance of safety on the job. It is important for each practitioner to be safeguarded from the risk of infection, if only to ensure that there are enough first responders to keep responding to emergencies.

The second priority, having fun, is a sign that the job is indeed safe. The article notes that fun on the job directly translates to job satisfaction, an important factor considering the high rates of job dissatisfaction, unhealthy life decisions, and suicide. I am sure that the article is not trying to imply that a lack of fun on the job is the direct cause of these challenges and tragedies, for that would be as superficial as it is crass. It clearly ignores the other elements of the job that develop satisfaction, such as safe working conditions, reasonable working hours, appropriate compensation, and supportive administrative and operational staff.

Where’s the Line?

Clearly, safety is not something that we can put third, so it is worth looking at in some detail. First, are we training our practitioners about the correct risks? The article correctly notes that we are training practitioners to watch out for major threats such as gunmen while ignoring the molehill in the front yard. Are practitioners aware of the importance of being well-rested prior to commencing a night shift or a 24-hour shift when they may be called out during the middle of the night?

When these risks become significant, are there systems in place to mitigate the danger to the crews and their patients? If a crew has not had a decent night’s sleep and is being sent on a long-distance transfer, is the risk of operating while fatigued noted? Are there steps the crews can take to minimize this risk? Can they alert a supervisor and make alternate arrangements, deferring the transfer until a more appropriate time or tasking a rested crew?

Looking into other articles on scene safety, a number bring up the wisdom of scene safety being an initial step and then maintaining situational awareness in case the situation changes.3 Few discuss the gray area, where there are potentially significant risks on scene that may impede or prevent the call from proceeding. Consider a hockey player who has collapsed in the middle of a skating rink. Is the benefit of immediate CPR and defibrillation balanced out by the risk to the EMS crew slipping and falling on the ice on the way to the patient?

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There are several factors to consider. First, there is a bias towards personal strength and health. The default presumption when assuming a risk is that the situation will turn out fine. The practitioner may think a lift is safe until they throw their back out, or presume that other drivers will yield at the intersection until the ambulance is struck. It is only after a negative outcome develops that the bias is revealed. Assuming repeated risks with positive outcomes further strengthens this bias.

Another factor to consider is that of risk versus uncertainty.4 A risk can be mathematically calculated, such as the outcome of a coin toss, while an uncertainty can not be. In practice, EMS operates almost entirely on uncertainty, complicating hazard assessments and determinations. An accurate assessment can take time and is liable to run into biases of emotion, fatigue, and previous personal experience.

Should Paramedics Put Their Safety First?

Practically, there is a thin line between heroism and recklessness and the ends often end up justifying the means. In the article, a police officer runs through traffic and jumps on vehicles in order to apprehend a suspect. He is hailed as a heroic example of getting the job done because he was successful in this case. The perception of the officer would have changed significantly if he or someone else were injured or killed as a result of that pursuit. Similarly, the paramedic who runs into a burning building is hailed as a hero if they pull someone out but seen as reckless if they collapse within the building and are killed or require rescue. As the International Trauma Life Support textbook notes: “You are there to save lives, not give up your own.”5

A paramedic should put their safety first because they can’t continue caring for future patients if sick or injured. A paramedic who rushes into an unsafe scene and is injured can no longer care for patients and may require assistance of their own, potentially putting other lives at risk. In the case of a pandemic, practitioner safety directly translates to community safety. In the time it takes for the practitioner to show symptoms, they may have interacted with people across the breadth of their service area and potentially spread the illness to those most vulnerable.

In this Medpage Today article, the authors note that the patient is the first priority and that in a pandemic, every environment should be considered unsafe.6 They conclude by stating that “safety may be our third consideration on its own, but during a pandemic, it is intrinsically required to complete our first priority: getting the job done and caring for our patients.” If practitioner safety is intrinsically required in order to get the job done, does that not make safety the first priority to enable practitioners to care for patients?

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