Every month there seems to be another EMS provider assaulted or even killed in the line of duty. Why? Is it because there are more violent and unstable situations? Or are we simply unaware and leaving ourselves vulnerable?
The answer lies with each EMS provider:
- Do you routinely perform weapons searches (pat-downs) on all your patients?
- Do you ask your patients if there's anything in their possession that may harm them or you?
- Have you ever transported a patient's belongings in a bag without knowing the exact contents?
- Have you ever encountered a situation on a call that caused you to feel uncomfortable regarding your personal safety? Was law enforcement present?
- Have you ever been involved in a close call?
If you answered yes to any of these questions, then it's safe to say your scene choreography may have left you unaware of an unsafe situation, and therefore vulnerable.
What is scene safety? Are EMS providers taking appropriate precautions and fully aware of potential hazards on every scene? Any scene has a potential for violence, and many have not-so-obvious indicators of danger. Just as we proceed as if all our patients have bloodborne pathogens, we should respect all patients as having the ability to become violent, cause an unsafe situation or intentionally injure someone.
Personal safety should be your primary concern on every call, regardless of the call's acuity. Our goals on every call are patient compliance and scene control, both of which directly affect safety. Safety awareness is something that should be applied to every aspect of each call, from dispatch through completion. In this article we will focus on applying safety awareness to every patient approach and assessment.
TACTICAL APPROACH, ASSESSMENT
A tactical patient approach and assessment includes self-awareness, situational awareness, patient awareness and environmental awareness. It requires being assertive, as appropriate, and helps you develop the ability to protect yourself and others. It necessitates appropriate verbal engagement (see the book Verbal Judo by George Thompson and Jerry Jenkins) and simple physical strategies to survive. It demands a position of superiority at all times. It's about looking, sounding and acting like a professional.
There are four main components to total safety awareness:
- Self-awareness is being cognizant of your own actions (posture, stance, hand position and gestures) and communication (tone, dialect, speed and demeanor). Learn to be conscious of items on your person that may be used as weapons, either against you or by you. Know your vulnerabilities, strengths and weaknesses, and what can potentially set you off.
- Patient awareness is respecting that a patient possesses the ability to harm you, and may have a weapon until proven otherwise. This includes rapid evaluation of the patient's actions and communications.
- Situational awareness is awareness of the circumstances around the EMS encounter. What are the patient's thoughts, perceptions and beliefs?
- Environmental awareness includes the conditions of the scene. What parties are in attendance, both visibly and out of sight? What is within the patient's reaching distance, and what are the potential risks and hazards?
APPROACHING THE PATIENT
The manner in which you approach the patient is a critical step in ensuring safety and allowing for a productive interview. First, the patient's location can give them a psychological advantage. If a patient presents in their residence, outside or inside, it's their domain—you cross a boundary into it. People have different beliefs, rules and manners that guide their actions within their property and personal space.
In crossing these invisible boundaries of social space to perform our jobs, we risk triggering attacks. Even without a word or with the slightest gesture, violence may erupt. Our patients' posture should dictate our body, hand and foot position. Remember, we're trying to subtly yet effectively place ourselves in a position of superiority. As we approach, we visualize the patient for any signs of medical distress and simultaneously scan for indicators of potential violence.
It's rare for a violent person to attack randomly; instead they act with precise and well-planned intentions. Victim selection generally is driven by ability, opportunity and intent. They are not selecting a victim to fight, but rather a victim they feel they can easily overwhelm. With that considered, we must approach with an air of confidence. As we approach, we too are being assessed, even if the person is not of a violent nature.
A rule of thumb is to utilize 45-degree angles when approaching patients. This way, you present them with the fewest possible vital targets, and make their potential angles of attack more difficult. It also maximizes your view of their extremities, thus increasing your reaction time. Your body should be erect, with hands displayed above the waist in a passive yet effective manner. Your arms should be bent with palms facing out, or one hand placed to the chin and the elbow resting in the palm of the other hand (Figure 1). Both of these positions allow for a quick and effective response against several angles or types of attack.
Establish eye contact promptly and directly to display confidence, but not prolonged as if to challenge. Your demeanor should be calm and caring, assuring the patient you're there to help. Identify yourself by first name and title ("My name is Roger, and I'm a paramedic"), then follow with a neutral opening question ("How may I be of assistance?"). Try to avoid "why" questions, which tend to put people on the defensive.
As you establish physical contact, rapidly survey the patient's immediate surroundings and move your hands to a position of comfort and control (Figure 2). Place your left hand on the patient's near shoulder and your right hand on their wrist, with the fingers curled under to locate the radial pulse. The thumb of your right hand should remain adducted to your hand, not curled on the opposing side of the wrist, in order to maneuver to a point of control. This hand placement allows for a rapid assessment of airway, breathing and circulation, while also providing a passive guarding position for self-protection or physical control.
If the patient is supine or seated, the hand position remains the same, but the kneeling position is used by placing your feet at a 45-degree angle toward the patient (Figure 1). As you kneel, bringing the interview to eye level, the right foot pivots, pointing toward the patient. This positioning of your hands, feet and body lets you easily maneuver to one of three options if a patient becomes violent:
- Separate and escape—Use your hands to push down and away on the patient, thus loading their weight on their near arm and leg, while you stand and propel yourself back away. This will slow the patient who attempts to move, and immediately create distance between you and them, while keeping you in a position to defend yourself.
- Sustained control—Using various methods of joint locks and manipulation gives you sustained control over the patient, and positions them for restraints. This option is effective for the patient who requires transport but is physically resisting.
- Personal self-protection—Using body and hand maneuvers, you will be able to protect yourself against an attack, and finish with a defined objective, namely incapacitation. Your goal might also be separate and escape or sustained control.
If the interview requires a standing position, the hand and body position remain unchanged, and the feet remain at a 45-degree angle without pivoting the rear foot (Figures 2, 3). The dynamics of the safety position for superiority remain unchanged, but the standing position gives you a strong base to perform various maneuvers. A standing position is definitely required for the interview of a standing patient, but may also be the wiser choice with a patient who is seated or lying on an elevated surface like a bed or exam table.
The patient who presents lying prone requires a slight modification of the kneeling stance. This is accomplished by lifting the right knee off the floor and angling it over the edge of the patient's closest presenting flank (Figure 4). This allows for control of the patient who might attempt to roll or stand against your wishes. With the knee placed as noted, you will be able to shift your weight onto that knee, resting it on the small of the patient's back or lower abdomen, pinning them to the ground. It also disrupts their breathing and works to short-circuit their thoughts. If they are forced to choose between breathing and attacking, breathing will take precedence.
Another key point is to always visualize the patient's hands, especially when rolling a prone patient. Roll prone patients toward yourself, not away—that makes it difficult for the patient to maneuver for a strike, grab or thrust.
MEDICAL AND THREAT ASSESSMENTS
While performing a rapid medical assessment, you are also performing a rapid threat assessment, working verbally to encourage a neutral interaction and applying body language that says "I'm here to help."
Understanding the AOI principles also helps prevent the interaction from becoming violent:
- Ability—Does this person have the physical prowess or strength in numbers (allies) to hurt me, or immediate access to a weapon? My rule of thumb is to believe so until proven otherwise.
- Opportunity—Opportunity is only present if you allow it—are you viewed as easy prey? Violence will not evolve if a would-be attacker considers their opportunity to be questionable. Shut the door to violence with a strong presence visually, vocally and strategically.
- Intent—Does a violent attack make sense to them? What is their mental state? If they view you as a difficult attack, chances are it will not happen. Their intent is to overwhelm you with violence, not fight to achieve their objective.
If the interview suggests imminent violence, you have no choice but to alter your essence in order to survive. Verbal threats are frequently just bluster, and if the immediate threat of violence is not present, extreme reactions on your part aren't justified. But statements of intentions to harm, maim or kill justify self-defense.
How do you distinguish between empty threats and those signaling real violence? By conducting a rapid threat assessment and listening to your gut instinct. Some situations present with clues. When doing a threat assessment, try to observe eye movement, posture and motor activity. These are reliable predictors of violence (see Rapid Threat Assessment).
Anger, intimidation and hostility by themselves are not reasons to use physical self-defense. Intimidation is usually for the psychological gain of the aggressor, as in social status or respect. Demonstrating anger and hostility can be normal reactions to the unfairness and harsh realities of life. It's important to take these situations professionally, not personally. If a patient is angry and just needs to vent, let them. But physical attacks, or some threats of them (for instance, by patients with known histories of violence), are just cause for using reasonable force in self-defense.
Some situations present with uncontrolled variables that may increase the risk for violence, like cultural incongruities or a language barrier. It's stressful enough having a loved one severely ill or injured, let alone not being able to communicate with the care provider. Other factors that may lower the threshold for violence include disrespect (real or perceived), medication changes, gang activity, involuntary transport, hunger, loss of employment, lack of privacy, police presence, drug or alcohol abuse, and numerous medical causes. Some notable characteristics of unstable behavior include confused or altered mental status, alcohol or drug dependence, anger, frustration, psychological and personality disorders, history of violent activity, financial instability, male gender, homelessness, poor empathy or insight, and unemployment.
Rapid Threat Assessment
The following may predict violence from a patient:
- Eye movement—Rapid eye movements, piercing stare, "clearance" glance (the assailant will glance around as if to check for witnesses);
- Speech—Threatening, belligerent, mumbling, nonarticulate;
- Posture—Clenched fists, crossed arms, hands on hips, definitive shifts in posture (the assailant will subtly adjust his posture and/or retrieve a weapon prior to attacking);
- Personal ability/presence of a weapon—Assumed until proven otherwise;
- Motor activity—Fidgeting, pointing or rapidly alternating moves, grooming-type gestures (e.g., wiping face/nose, slicking hair back, rubbing the back of the neck, etc.).
- Gut feeling—When it talks, listen!
Anticipate the unexpected. While most EMS encounters don't result in acts of violence, one study found the rate to be 8.5%.1
Our line of work requires us to deal with people, and our "people" skills—our abilities to communicate and calm and de-escalate—is what will truly save our lives. Verbal skills will be our first line of defense, and physical self-defense our last, but they both need to be honed in order to honor our other personal statement: "Everyone goes home safe, always."
1. Grange JT, Corbett SW. Violence against EMS personnel. Preh Emerg Care 6(2):186–90, Apr–Jun 2002.
Roger Olson, BA, NREMT-P, is a paramedic with Platte Valley EMS in Brighton, CO. He is a black belt who trains in Kenpo, Kali/Escrima, Brazilian Jui Jitsu and other eclectic methods of self defense at the International Black Belt Academy in Greeley, CO. Reach him at firstname.lastname@example.org.