It’s pretty well established that violence against EMS personnel is a real and pervasive problem.1 It’s reasonably well documented in the U.S., and it has become almost a recreational activity for certain individuals in the United Kingdom.2–4 Reviewing the literature, it looks like violence against EMS providers can be expected to occur on perhaps one of every 20 calls, on the average, with wide variations giving the differing natures of the communities served by EMS agencies in the U.S.
Violence comes from various sources and in various forms: EMS providers shot in the chest walking up to the front door of a house call; EMTs attacked by friends and family who don’t think that they’re “moving quickly enough;” paramedics injured when they’re grabbed, kicked or head-butted—sometimes by patients who are violent for clinical reasons (e.g., hypoxia, hypoglycemia, intoxicants or head injury) or who are violent simply because they’re difficult people.
Much is written about EMS becoming more “evidence based,” and our more progressive EMS agencies are seen to be making strong efforts to practice evidence-based medicine. Yet, both our EMS educational institutions and our EMS provider agencies seem to be willing to turn a blind eye to the strong evidence showing that EMS personnel are likely to encounter a “recognized hazard” that’s “likely to cause death or serious physical harm.”5
Brian Maguire, MSA, DrPH, is a well-known EMS scholar who has devoted a lot of energy to this topic. He’s currently on the faculty of Charles Sturt University in Australia. Maguire reported that EMS personnel are seven times more likely to be killed by workplace violence than other healthcare professionals and 22 times more likely experience injury from assault than the population at large.6
My interest in this topic, which has ebbed and flowed over the years, was heightened recently when I learned that a female EMT in a neighboring county had been assaulted by another female on a scene—a relative of the patient who had been involved in an motor vehicle collision. While trying to free herself, she was further assaulted by a male relative, who attempted to choke her out. At the end of the call, the perpetrators went to jail, but the EMT went to the hospital, with bruises, strains and a possibly dislocated shoulder. A couple colleagues of mine, adjoining EMS chiefs (one the chief of the involved agency), got together to talk about how we could better prepare our workforces for the inevitability of unanticipated violence.
Employers generally have a duty to provide their employees with a safe workplace, particularly for cases in which hazards are known and can be controlled through education, engineering and enforcement. Although not universally and directly applicable, the OSHA “general duty clause” sets forth this duty in general terms: Each employer shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.5
That doesn’t seem to be happening too much that I can see. It seems like our employers turn a blind eye. Employee associations are not making much of a fuss about this issue. Our OSHA inspectors aren’t sufficiently savvy about our workplace, and that apathy and ignorance reign. Our employees, given the chance, make it worse. One EMS agency I know serves a community known for having “violence issues.” It spends a lot of money outfitting all EMS personnel with ballistic body armor. Yet, the use of that body armor is optional. So every employee’s $700 ballistic vest spends its life … in the employee’s equipment bag, rarely being removed or worn. The law enforcement community knows that you can’t “predict” from dispatch information when you might be likely to encounter violence.
Then there’s the educational approach, as set forth in the National EMS Education Standards and supporting documents. Our federal guidance suggests that violence is something that can be avoided simply by not entering particular calls. I scanned the National EMS Education Standards and the supporting “instructional guidelines: A search for “violence” and “assault” yielded the following wisdom: EMTs should not enter a scene or approach a patient if the threat of violence exits.1,7
That’s it! So somehow, guidance not provided, we’re supposed to predict whether a threat of violence exists and then not enter the scene. Hello, sports fans. The potential for violence exists on almost every call, and you can’t tell until you’re into the call which calls are more likely to have violence erupt than others. And there’s nothing—repeat, nothing—about what to do once bad things start to happen. Hmm …. does this suggest that those who wrote these documents work exclusively in peaceful suburbs? Or is this another one of those “difficult to teach using a powerpoint lecture” subjects, such as ambulance driving, that was conveniently left out of the preservice educational programs?
OK, we know there’s a problem. What can we do about it? Is this just another one of those issues that will die on the vine of apathy in the EMS community or not be heard through the whining about lack of funding to do things that need to be done?
One guy who’s doing something about this issue is a gentleman named Kip Tietsort, a paramedic-turned-police-officer-turned-educator out of Norwood, Mo. Tietsort runs an organization called DT4EMS (Defensive Tactics for EMS). He’s developed a variety of training programs, the most recent of which is EVE (escaping violent encounters) for fire and EMS personnel.
Since starting his training effort in 1997, in partnership with an EMS medical director, Tietsort has trained hundreds of EMSers in personal defense and has trained instructors who are now embedded in dozens of EMS educational institutions and EMS agencies. The course includes not only physical skills but also the whole continuum, from mental preparation and situational awareness, through the violent encounter, to proper documentation of the event and managing the possible aftermath (the media and the courtroom). The course is oriented toward the “average EMSer” who doesn’t want to become a martial artist but who does wants to be safer on the street, at the scene and in the ambulance.
Another impending entry into the area of “violence continuing education” is Calibre Press. For 25 years Calibre Press has been known for its excellent street survival seminars for law enforcement officers. It has recently joined forces with well-known EMS educator (and martial artist) Mike Taigman to develop a “Street Survival for EMS” program. Knowing the players, I expect it should be relevant and of high quality.
So what should the EMS community do about this? I would submit that every EMS preservice education program should include additional components:
1. A course in managing verbal confrontation, such as the well-known “Verbal Judo Healthcare” course developed by George Thompson, PhD.
2. A general physical fitness course equivalent to three credit hours per semester of instruction (three credits during an EMT course, 12 credits during a four-semester paramedic program) based on the Cooper Institute standards for cardiovascular fitness. At the very least, the EMS provider would then be able to run away from a threat.
3. At least 40 hours of instruction involving violence awareness, escaping violent encounters, releases from grips and choke holds, avoiding knife attacks, subduing and restraining violent patients and application of clinically appropriate restraints. This course should involve force-on-force simulation, using the “FIST suit” or the “Red Man Suit” and other appropriate training devices to familiarize students with the stresses that occur during person-to-person conflict.
Before credentialing, every state (and the National Registry) should require every employee to pass a valid, job-relevant physical abilities test. When we move away from the current isolated, static skills testing stations to scenario-based testing, the scenarios should include actual safety issues—not just the “scene safe, BSI” nonsense that passes for scene safety in today’s teaching and testing environments.
Employers should provide employees with at least 16 hours of continuing education per two-year credentialing period with subject matter taken from the third item in the list above. They should require every employee to pass such a test every two years.
So have I lost my mind? The data suggest that we need this knowledge, these skills, these abilities. Is it too difficult or too inconvenient to apply evidence-based to our own safety? What do you think? Is a little bit of safety worth the investment?
I surely hope that you think so.