EMS Violence

1. EMS Violence Nothing is a routine call anymore Timothy S. Arnett BS, NREMT-P

2. Objectives • Identify some of the reasons behind why violence occurs against EMS workers • Describe ways to identify potentially violent situations before they occur • Identify calls for service that have a potential for violence • Describe ways to approach and appropriately respond to these calls • Define situational awareness and how to use it

3. Introduction • Background • How does this relate to trauma? • Can you learn everything in an hour? • Where do we go from here?

4. Background A simple internet search using parameters ‘violent incident emergency response’ will find results ranging from a one person attack on an individual responder to massive and widespread rioting in which entire agencies came under attack.

5. Where do we start? In 2004, under the leadership of Executive Director Ronald J. Siarnicki, the NFFF expanded its mission to include the prevention of fire fighter injuries and deaths. In 2007 a summit was held to better define the Life Safety Initiative and a white paper was created that developed 9 specific recommendations to support the initiative.

6. 2007 Firefighter Life Safety Initiative 12 White Paper Recommendations 1. Improved Dynamic Risk Management for incidents involving violence. 2. Initiate and/or improve communications and relationships with law enforcement responders in your jurisdiction. 3. Define the role of dispatchers in reducing hazards to firefighters. 4. Prohibit single resource (individual) response to incidents of violence. 5. Require all Law Enforcement responders that may respond to a violent incident in your community to use an Incident Management System (IMS). 6. Fire department personnel should communicate, face to face, with the law enforcement component on scene. 7. Recommit personnel and equipment and leave if violence commences or recurs during fire department operations. 8. Obtain stakeholder understanding and buy-in of response and deployment policies including non-response and non-engagement at incidents of violence. 9. Fire Departments should strive to ensure their duty uniforms are not similar to, or could be mistaken for, those of law enforcement personnel. *NFFF Fire Fighter Life Safety Initiative 12 Final Report

7. True or False?? • The Emergency Run Today Poses One Of The Greatest Hazards in Emergency Medical Services Today.  In fact Emergency Medical Service Personnel are more likely to be killed, injured and disabled during the course of an Emergency Run, than contracting AIDS during direct patient care. True!!!

8. Does this really happen? Paramedic Shot On February 23, 2004,  A female Paramedic was shot by a sniper, according to Metropolitan Ambulance Services Trust, spokesman Eric Dooley. The paramedic's name has not been released, but Dooley stated she has been with MAST for more than 15 years.  Her injuries were classified as serious, but she was reported to be in stable condition after undergoing surgery at a hospital. The paramedic was with police, fire and other ambulance personnel who came under gun fire, striking the paramedic after  they arrived to fight the blaze, said Capt. Ron Fletcher, a spokesman for the Kansas City Police Department. Only the paramedic, a 15-year veteran of the Metropolitan Ambulance Service Trust was shot. Paramedic Killed On a Friday afternoon, the 13th of February 2004, Lt. Brenda Cowan, a 12 year veteran of the Division of Fire & Emergency Services, was slain on duty. Lt. Cowan was hit by gunfire while responding to an emergency medical assistance call on Adams Lane in rural Fayette County. Lt. Cowan's promotion was just celebrated at the Fire Training Center Tuesday, the 10th of February 2004. This was her first duty day following the promotion ceremony

9. Does Every incident fall into this category? • Unknown Emergency • Sick person in a vehicle • Injured Person – Something isn’t right • Person Down • Attempted Suicide • Assault • The list goes on and on

10. Where do these incidents happen? EVERYWHERE

11. This doesn’t happen in my little town!! • http://www.wistv.com/story/5224559/elderly-man-charged-in-shooting-of-north-carolina-paramedic • Small town • Seemingly routine call • Elderly male in a vehicle • Wife wants help taking care of him • What went wrong?

12. Elderly Man Shoots Paramedic • What information did the caller give the dispatch center? • Did the dispatch center relay the information? • What was the neighborhood like? • How did you approach the scene? • Lights and sirens? • With police?

13. It’s a Cardiac arrest….. • http://www.starnewsonline.com/article/20130812/ARTICLES/130819953 • Large City • Again seemingly routine call • What things about this cardiac arrest should make you think? • Where was the offender when the care was taking place?

14. It’s a cardiac Arrest….. • What are the policies and procedures for your department? • Police dispatched on cardiac arrests? • How many personnel are required for a high priority call? • Do you think you or your crew have the situational awareness to see this brewing?

15. Staging Many EMS Agencies have established “staging” policies. Which in essence, when an Ambulance is dispatched to a violent-crime scene involving any form of assault need to stage away from the incident until the police have secured the scene.  Remember the difference between “police being on the scene” and “securing the scene” are two different things. It is possible to have the police on the scene and the situation is still volatile.  Remember thata secure scene means the assailant is gone or has been arrested and Law Enforcement gives the okay to enter the perimeter.

16. Situational Awareness • http://www.cnn.com/video/data/2.0/video/politics/2013/04/11/savidge-ga-firemen-hostage-standoff.cnn.html • What is it? • Where do I get some? • What do I do with it once I have it? • Is there such a thing as too much situational awareness?

17. Lt. Brenda CowanLexington, Ky. FD/ 2004 On the afternoon of February 13, 2004, a Lexington Fire Department unit was dispatched to a report of a woman down on the ground that may have been shot. The apparatus was parked away from the scene and crew members, under Lieutenant Cowan’s supervision, approached the shooting victim on foot. At the same time that the fire department had been dispatched to the medical aid call, police units were dispatched to the same address for a possible shooting. As Lieutenant Cowan and her crew bent over to assess the condition of the victim, gunshots were fired. These bullets struck Lieutenant Cowan and another firefighter. At almost the same time, a police officer arrived at the scene and attempted to use his police vehicle as a shield to protect the firefighters from further harm. Shots continued to be fired at the firefighters and other emergency responders. A police tactical team removed Lieutenant Cowan approximately forty minutes after the shooting began. *NFFF Fire Fighter Life Safety Initiative Final Report

18. Special Considerations • CRIME SCENE WARNINGS • FIGHTING OR LOUD VOICES • WEAPONS VISIBLE • SIGNS OF ALCOHOL/DRUG USE • UNUSUAL SILENCE • KNOWLEDGE OF PRIOR VIOLENCE

19. Consider This…. ONE DANGER THAT IS PRESENT AT MANY SCENES IS THE FAMILY DOG. EVEN ONES THAT LOOK HARMLESS COULD ATTACK IF THEY FEEL THREATENED. BE CAREFUL.

20. Unknown emergency • What am I talking about here? • Dispatched for an unknown emergency behind your local convenience store on Christmas. • No additional information • It’s 2 o’clock in the morning • Weather is clear but cold (28 degrees)

21. Scene Approach and assessment • Store is closed and there are no cars in the lot. • Lighting is not good especially around back • You can drive all the way around the building. • Do you? • What lights if any do you have on? • The caller has left (cell phone hero) • What’s the status of police?

22. Scene Approach and assessment When you drive around back with all your scene lights on and no emergency lights you see a seemingly well dressed man sitting against the wall of the store looking down with a bottle in his hand. • Position the vehicle so the most amount of light is shining on the subject. • Talk to the subject as you approach • Make sure you can see his hands and what items he may have with him i.e. bags • As you assess the subject physically also check for weapons or others items that may hurt you or your team

23. During arrival at night, keep cab lights off to minimize the chance of being an easy target. Note the difference from outside when the cab lights are on (photo A) and when they are off (photo B). *USFA EMS Safety Information

24. During first contact, be extremely cautious. Note in photo A how the EMS provider has his weight back, and is prepared to push away if the patient comes up quickly. His partner is also watching for suspicious behavior. In photo B, he would have a much more difficult time backing off quickly and safely. Remain especially observant until both hands have been checked for weapons. *USFA EMS Safety Information

25. Standing with the feet side-by-side and with hands in pockets (photo A) or with arms tightly folded (photo B) is dangerous. It would probable take too much time to position hands to deflect an attack, and it is nearly impossible to back off quickly without one foot forward. These postures may also indicate a lack of compassion on your part. *USFA EMS Safety Information

26. An open stance can pacify a situation. Note the open hands (which are nonetheless positioned to defect a blow!) and the softening angles of having one hip and shoulder back and the head tilted. *USFA EMS Safety Information

27. Sick person in a vehicle • We have all run these calls. • Dispatched for a sick person in a vehicle in a parking lot. • No additional information from dispatch • Friday at 11pm down the street from the station • Weather is clear and warm

28. Sick person in a vehicle As you approach you notice the vehicle is running, the drivers door is open and there is a male sitting in the drivers seat. What do you do now???

29. Scene Approach and assessment • Pull behind the vehicle in a defensive position with the unit. • Traffic stop style - Placing the bulk of the engine between you and the vehicle • Make sure that you are creating a safe area around the vehicle from traffic • Call the license plate of the vehicle into dispatch • Call for additional resources if you can’t create that safety zone • Attempt to make contact with the subject with your loudspeaker

30. In some situations, such as drivers who are slumped over the wheel, • Approaching from behind is prudent until the circumstances are clear. • Create a “corridor” that will protect the approaching EMS personnel from other traffic by positioning the EMS vehicle as shown *USFA EMS Safety Information

31. Scene Approach and Assessment • Approach the vehicle on the passenger side first. • This causes confusion on the part of the subject if they are expecting you to approach. • While you are walking up to the vehicle make sure you are looking inside the vehicle. • Looking for other people as well as weapons, chemicals, drugs or other items that pose a threat to your team. • Make sure as you make contact with the subject you can see his hands and anything around the subject. • Identify yourself (EMT, Paramedic, FF, etc.)

32. Scene approach and assessment • When it’s safe to do so make sure the vehicle is in park and the ignition turned off. • If it is safe and the patient is able to do so have them walk back to your unit with you. • They are safer, better controlled and in an unfamiliar place when they are in the back of your unit. • While they are walking with you or you are moving them to the stretcher make sure you are checking for weapons and such in their pockets, waistband, side. Everywhere!

33. Ok…So we have covered the obvious. We know that stuff. • http://www.cnn.com/2012/12/24/us/new-york-firefighters-shooting/ Do you think they thought they would be shot when they jumped on the fire truck and headed for the dwelling fire?

34. Scene Approach and assessment • Cover and Concealment • The consistent use of cover or concealment opportunities is an important prehospital tactic. They may be the best chance for survival in situations that are impossible to judge ahead of time. (Remember, law enforcement should precede EMS personnel to scenes known to be dangerous.) *USFA EMS Safety Information

35. Cover • An object large enough to hide behind and strong enough to stop a bullet. Good examples include a solid tree or telephone pole, brick or stone walls, steel garbage dumpsters (the fuller the better). The door of the EMS unit or a wooden fence may both seem substantial but usually cannot stop a bullet, so they cannot be considered adequate cover. Remember, the best cover in situations that appear hostile is to stay in a safe location out of the way while law enforcement personnel secure the scene. *USFA EMS Safety Information

36. Concealment • A place that will hide a person from view, but which may not be capable of stopping a bullet. The door of the EMS unit and the wooden fence previously mentioned would be suitable for concealment. A large bush, or even shadows, are also appropriate. It is important to be sure that the structure is reliably concealing; for example, would the hiding spot be illuminated by the headlights of an approaching vehicle? *USFA EMS Safety Information

37. Always be aware that when entering the kill zone whether a hazard exists or not may not be known until it’s too late.

38. Never knock while standing in front of the door (photo A). Stand well to the side, either separately, as shown in photo B or on the same side (photo C) to minimize the chance of injury in the event of an attack.

39. Are you ready to respond to a violent incident? These nine questions can help you prepare for your response to a violent incident.

40. 1. Do you use risk/benefit for every call? “With incidents where there is a threat of, or actual violence, it must be remembered that a judgment is required to ensure that risks to personnel are not out of proportion to the benefits to be gained from achieving a given task” (Labor Research Department, 2005). Risk Management is not new to the fire service. The balance of perhaps limited potential benefit in light of substantial risk should be foremost in every responder’s mind.

41. 2. Do you have an effective relationship (both at the ‘boss’ level and ‘street’ level) with the law enforcement agencies in your community? As noted by the Columbine Review Commission (2001), familiarity of personnel and roles prior to an incident through training and planning exercises provides for better communication and operation during the event. Fire Department personnel should have access to, and use, law enforcement intelligence information in order to preplan response to incidents. This may include information regarding domestic terrorism, gang violence, known or suspected drug factories and/or houses

42. 3. How good is the information you get from your Dispatcher? Response to an incident of violence carries significant uncertainties. The ability of the dispatch staff to reduce the uncertainty while increasing the level of information provided is critical. It is also helpful for responders to have the ability to communicate on a specific, shared, common, radio frequency to remove the potential for message corruption as it is passed through another person. Dispatch staff should critically and carefully monitor the operations radio channel of personnel responding to and operating at incidents of violence and perform Personnel Accountability Report (PAR) checks on a prescribed interval.

43. 4. Do you allow members to ‘first respond’ directly to the scene? Many jurisdictions have response and deployment plans that include the dispatch of individual first responders and/or a single person in a response vehicle. This should be prohibited or at least limited to the extent possible. The ability of a single person to react to an act of violence is limited. It may not even be possible to retreat. Responding and deploying in a group provides added protection, awareness, and visibility.

44. 5. Does your law enforcement agency use an incident management system? Each agency should strive to ensure that the IMS used in that community is applied as uniformly as possible. Fire departments should take a leadership role in assisting their law enforcement compatriots, particularly at the street or service delivery level, to understand and apply the IMS.

45. 6. When responding to a potential violent incident, do you seek out a law enforcement officer when you arrive? Fire department personnel should communicate, face to face, directly with the law enforcement component on scene. Direct face-to-face communication, with clear understanding of the hazards, risks associated, potential outcomes, and planned actions on the part of each agency should precede any fire department response into a hazard area.

46. 7. Have you told your fire officers/personnel that it is OK to leave the scene if things go ugly? If fire department operations have commenced and violence erupts, fire service personnel should consider leaving the scene until the law enforcement component has stabilized the situation.

47. 8. Is there a point where we don’t respond or limit our response to violent incidents? Fire department personnel may not respond into a hazard area due to the potential for additional violence or because the situation is not yet under control. Some responders and organizations fear their community will view this in a negative light. A 2005 Labor Research Department report stated ‘the key issue here is the extent to which fire crews can make decisions when dealing with an incident and with the confidence that they will be backed up by senior management if criticized by the local community or in the press for leaving a fire to burn or holding back from attending (responding to) an incident.” It is imperative for the department leadership to establish relationships with key stakeholders in the community to ensure they understand and support the response protocol.

48. 9. What does your uniform look like? Uniform insignia, style, and color should be of sufficient difference that fire department personnel would not be mistaken for police officers.

49. Preliminary Checklist when confronted with a violent incident 1. If your initial size-up assesses a threat of confrontation, wait for police assistance. Do not insert yourself into the situation. 2. If you find yourself in a confrontation where you can remove yourself to wait for police assistance, do it. 3. If you find yourself in a confrontation that you cannot remove yourself from: a) If confronted with non-lethal force (no weapons are involved), defend yourself and attempt to control the situation using non-lethal force. b) If confronted with lethal force, use whatever means is necessary to eliminate the threat or get out of the way. At times, this could mean not doing anything at all that might provoke the attacker. This would be an appropriate course of action when a gun is pointed at you. *NFFF Fire Fighter Life Safety Initiative Final Report

50. References • Federal Emergency Management Agency, United States Fire Administration (1994) EMS Safety, Techniques and Applications. FEMA Publication No. FA-144. U.S. Government Printing Office. • The National Fallen Firefighters Foundation Firefighter Life Safety Initiative 12 Final Report. (2013) National Protocols for response to violent incidents should be developed and championed. • Skip Kirkwood, MS, JD, EMT-P, EFO, CMO, Kip Teitsort. (2012) Violence Against EMS Providers: What can we do about it? EMS World. HTTP://Violence Against EMS - EMSWorld_com.htm • http://www.fireengineering.com/articles/print/volume-165/issue-9/departments/fire-service_ems/responding-to-scenes-of-violence.html • http://www.cnn.com/2013/04/10/us/georgia-firefighters-hostage/ • http://www.cnn.com/2012/12/24/us/new-york-firefighters-shooting/ • http://www.emsworld.com/article/10320697/safe-response-to-incidents-of-violence • http://www.wistv.com/story/5224559/elderly-man-charged-in-shooting-of-north-carolina-paramedic • http://event.clirems.org/Portals/4/Violence%20Reports/2013/EVENT%20Provider%20Violence%20Summary%203Q2013.pdf • http://event.clirems.org/Provider-Violence-Event