Threat Mitigation Strategies for Emergency Medical Services

By Sgt. Rino Belcamino

In recent years, there has been an ever-increasing frequency of violent attacks against members of emergency medical services (EMS). Although members respond to dispatched calls or attend the emergency department, they face many unknown threats and dangers.

EMS members must take a holistic approach to their safety and embrace true de-escalation, situational awareness and threat mitigation. Mitigating violence starts with an assessment of all intelligence associated with an interaction.¹ Although operational dispatch and tasking do an excellent job of attaining details, the on-scene environmental assessment needs to be enhanced. Individual members need to develop the ability to conduct a personal threat assessment beyond the scope of their traditional medical training.

Thinking outside the box is crucial when dealing with the possibilities of on-the-job dangers. The common questions may be: What are the apparent dangers associated with the call? Do you have an appropriate ingress route? Do you have an emergency egress route (foot/vehicle)? Do you have the individual skills, abilities, perception and experience to garner your safety?

When dealing with subjects/patients, EMS personnel may not consider an attack’s speed or violence.

There are usually four factors associated with an attack or ambush:

1) The element of surprise

2) Concealment of the assailant’s intentions/weapons

3) Suddenness of the attack

4) Lack of provocation.

Most attacks are spontaneous or opportunistic, with a smaller percentage being premeditated. Situational awareness barriers may affect EMS interaction with the people they serve. These may be apathy, complacency, denial, excessive pride, underestimating the subject’s skills and abilities, overestimating your skills/abilities or tunnel vision compassion.

A barrier to traditional de-escalation techniques may be the reality of persons suffering from contaminated thought. This is a condition of thinking in which a person has lost the ability (either temporarily or chronically) to clearly, logically, and/or rationally understand their environment. The brain`s homeostasis has been affected by mental illness and or drugs, high emotion, anger, sadness, depression, environmental toxins and intellectual disability. Traditional crisis intervention and de-escalation strategies may not affect the behaviors exhibited. These actions may be considered a medical emergency and may require advanced medical intervention to make a difference.²

Whether dealing with a person with contaminated thought (mental health/head injury, etc.) or a generally hostile element, the ability to read and react to body language will assist in de-escalation techniques when combined with appropriate communication skills. It is essential to understand that while EMS members use this to appraise the situation, the patient or subject conducts a similar assessment.

When dealing with patients with mental health issues, the primary emotion is fear. If an EMS member displays body language contrary to verbal communication, this could affect the behavior and reaction response, resulting in lost trust and negative rapport building. However, it is paramount to understand that some mental health subjects with predisposing factors for violence do not always respond positively to de-escalation attempts, and sometimes, they display violence that is instantaneous, extreme and intense. Coercive measures may not work in these circumstances.³

We are always trying to hardwire and plan our actions. Mental rehearsal is important before incident/patient interaction so one can perform under stress. EMS personnel under traditional stressors have been able to adapt their thought and decision-making effectively with traditional EMS training.

A problem presents itself when the stress inducement is in the form of directed violence or an attack toward them personally. Training and rehearsing to recognize pre-contact cues will allow appropriate responses when time compression affects reaction and response.

An assessment must consider the thoughts, emotions, and behavior being presented by the patient or subject, as well as volatility risk and the volatility type.

The categories are:

• Thought (contaminated or clear)
• Emotion (high or low)
• Behavior (compliant / non-compliant)
• Volatility risk (high, moderate, low)
• Volatility type (primal/cognitive).

When a person’s action behavior is volatile and contaminated, their base thinking may revert to the realm of a primal survival mode. This will have a subject reaction fall back to basic human instinct. In shear self defense, a fight or flight type posture is exhibited. They believe they are in a life-and-death situation and will do anything to survive.⁴

It is important to focus on all the non-verbal signs that may present themselves. Deliberate contact physiology and subconscious signals will provide time in the decision-making cycle to deal with the presented danger. Humans will always present nonverbal expressions even when making deliberate attempts to mask intentions.⁵

Here are some basic signs to recognize that may aid in risk mitigation.

• Scanning – Attention is drawn to the surrounding area rather than the person asking questions. The head is moving, and the eyes are searching. Reasons may vary from escape to attack to weapon selection.
• Target Glance – An apparent preoccupation with a part of the body or a tool as an improvised weapon. May focus on the nose, throat, and eyes (strike points). May focus on hips / upper leg, looking for a possible takedown.
• Clenching – Indicates physical stress and perhaps readiness for attack. It involves the fingers, muscles, and teeth. Pre-attack tension may cause the jaw muscles to bulge and/or facial muscles to contract. The subject may be hiding their hands or constantly fidgeting.
• Eye Blinks – The average person in a non-arousal mode will blink approximately 20x / min. Under stress, there can be two responses (rapid/slow). A rapid response could show 40-60x / min, with a slow response being 2-4x / min. Each sequence could signify an adrenaline dump or a possible focused preparation (fight or flight).
• Pugilistic – Stance develops a combative, typical fighting or modified stance. This may be an obvious precursor to attack. When a subject is attempting to hide their intentions, it may simply present as a shifting of body weight.
• Flanking – While dealing with one party at a scene, a second party starts to move to the rear or side to garner a position of advantage.
• Crossing Arms – Many believe this to be a psychological blocking barrier presentation. This may be true if the hands are tucked in the arm pits. If the hands sit on top of the arms, this could be a preparatory phase so that there are closer to a striking mode or a defensive posture. This could be a sign of a pre-emptive attack.
• Hesitation in response – Humans are not good at divided tasks. Hesitation may suggest contemplation of an attack, measuring odds of success, measuring target suitability, or pondering consequences. Repetitive questions may also be used to garner time for planning or to be used as a ruse.
• Bobbing / Rocking – An increase in adrenaline and oxygen uptake in the system will have the body attempting to get rid of this excess. The subject may not even recognize they are presenting this. They may also lower their center of gravity in preparation (athletic movement).
• Blading the Body – Preparation for an athletic encounter. Could signify prefight or attack. The body`s natural stance to protect its core and central nervous system.
• Dissociation – Subject attempts to avoid attention from first responder. May avoid eye contact, present a submissive posture, or may attempt to exaggerate normalcy.
• Dissipatory Actions – Physical movements associated to the body’s parasympathetic nervous system. During stress the body is trying to dissipate the hormonal dump. The subject may subconsciously rub hands, constant touching hair / face, fidgeting, yawning (fake or real), rocking, stretching.⁶

Another area that may be overlooked by EMS personnel in their safety “toolkit” may be the recognition of possible hidden weapons or contraband on a patient or subject. This recognition will assist in decision-making and may contribute to action strategies for disengagement or exodus.

Some of these characteristics may be:

• Sagging Jacket – May signify something of substance/weight in one of the pockets.
• Obvious Outline – A weapon outline or package of contraband.
• Hand Position – Palm of the hand facing rearward. It could indicate something in their hands.
• Jacket Displacement – Jacket or hoodie on weapon carry side hanging down further than other side. Jacket pendulum swing.
• Asymmetrical Gait – Leg movement on side of weapon may be hindered. Typical stride may be shorter to compensate.
• Clipped Arm Swing – Forearm close to the body (guarding position).
• Quick Adjustments – Constantly checking. Security check/tap (printing) of item. More evident running or going up stairs.
• Bracing – Holding clothing or item under clothing so as not to drop or reveal.
• Layered Clothing – Multiple layers may conceal hidden weapons. Dressed inappropriately for weather or conditions.

The information presented is not intended to take the place of traditional de-escalation strategies delivered to EMS. This information is a supplement and holistic approach to individual safety, awareness, and threat mitigation. The information will provide the EMS professional with additional skills and abilities to provide client services in every day, challenging encounters. 

Sgt. Rino Belcamino is a 28-year veteran of the Thunder Bay Police Service in Ontario, Canada. He spent 20 years as the tactical commander of the hostage rescue/SWAT team, as well as being the chief instructor. He is a master use of force instructor, a master Taser instructor, and a firearms instructor, as well as a subject matter expert in hostile events, anti-terrorism, and operational and emergency planning. Currently, he is the NCO of the Training and Special Operations section.

References

1. Mullins W. “Advanced Communication Techniques for Hostage Negotiators.” Journal of Police Crisis Negotiations; 2:1, 63-81; 2002.

2. Montemayor C. “Homeostatic Consciousness: A New Approach to an Old Problem?”. Psychology Today; May11, 2021.

3. Ewington, J. (2016). Best Practices for Reducing the Use of Coercive Measures. In: Völlm, B., Nedopil, N. (eds) The Use of Coercive Measures in Forensic Psychiatric Care. Springer, Cham. https://doi.org/10.1007/978-3-319-26748-7_16

4. Meloy J, Hoffman J, Guldimann A, James D. “The Role of Warning Behaviours in Threat Assessment: An Exploration and Suggestion Typology.” Behavioral Science and Law. DOI 10.1002/bsi.999; 2011.

5. Westland G. “Verbal and Non-Verbal Communication in Psychotherapy.” American Psychological Association. 2015.

6. Navarro J. “The Dictionary of Body Language: A Field Guide to Human Behavior.” William Morrow Paperbacks. 2018.