Being invited into someone’s home is an act of trust, one prehospital care professionals participate in thousands of times during their careers. For a community paramedic (CP), that initial trust turns into an ongoing relationship: Our patients share not only immediate medical concerns with us, but a wide range of challenges and stressors. Helping them navigate these barriers is what we do, but it comes with risks.
Melissa, a full-time CP with the Allegheny Health Network in Pittsburgh, arrived at her patient’s home for a scheduled and confirmed follow-up visit. They had been working together for several weeks on fairly sensitive issues that had led to recent 9-1-1 calls and emergency department visits. They were working to find physician support to reduce the man’s dependence on high daily doses of opioid medications to control his chronic pain and better manage his new insulin pump. The patient lost both legs in a work-related incident nearly a decade prior and relies on adaptive technologies to maintain his home. In addition to his physical ailments, he was concluding a very contentious divorce that also caused significant financial concerns.
From the moment he answered the door on their follow-up visit, it was clear to Melissa that her patient was agitated. While none of his frustration appeared directed at her, he was furious with the judge responsible for his alimony agreement. Within minutes of her arriving, he said he intended to take his guns to the courthouse and shoot everyone if the ruling was not changed.
Melissa subtly maintained a physical route of escape from the house and attempted to redirect the conversation while simultaneously deescalating his anger. The patient abruptly wheeled out of the room, returned brandishing a pistol, and removed the magazine to show her the hollow-point ammunition he intended to use. He described his plan to execute “the mass shooting to top them all.”
Maintaining a professional composure, Melissa expressed that she understood his current frustrations were overriding his health concerns but was unable to assist with these legal issues. She departed quickly, assuring him she would check in with him in a few days. After leaving she contacted the authorities to relay what she'd witnessed.
Why CP Safety Is Different
Traditional EMS providers are often called to uncontrolled and unpredictable environments. From their earliest training students are taught to assess and address potential dangers. “Is the scene safe?” is often the first phrase uttered during our training and testing stations.
Even after that initial contact, smart students and seasoned providers know they need to keep their eyes open for changes that may become dangerous. If the environment becomes too hazardous, the providers can quickly remove themselves and their patients to the relative security of their ambulance, where at least they can exit the scene quickly. Extracting themselves from the environment often immediately reduces the threat and minimizes the risk to the team on what will likely be their only interaction with this patient in that setting.
Scene safety considerations differ between community paramedics and traditional EMS providers from the point at which the patient enters the system. A call to 9-1-1 leaves traditional EMS personnel no opportunity to decide whether the patient’s current location is the safest place for them to meet. Community paramedics, on the other hand, will have repeated visits with the patient and thus more potential exposure to dangers in their environments, but also more opportunities to plan and reduce any risks involved in conducting those contacts.
Since Melissa’s interaction was one of the first times a CP in the Pittsburgh region encountered such a serious threat, the manager of the AHN program reached out to the other CP programs in the region to conduct a joint after-action review (AAR) in an effort to share the lessons learned from this experience and discuss best practices moving forward.
The combined teams worked through a “sustain and improve” list, a format common in AAR processes in the U.S. military. Unlike a critique, this format is not focused on dissecting the event itself for failure points. Instead the goal is to use a chronological review by participants as a basis for identifying areas where current doctrine, training, SOPs, and workflows were effective and should be reinforced, and areas where current approaches did not or would not have worked.
The following were determined to be practices that contributed to the safe exit of the CP from the hostile encounter.
1) Motivational interviewing—Melissa’s skill in motivational interviewing (MI) contributed to the rapport that already existed and her understanding of the range of challenges her patient was experiencing. Her MI skills also likely prevented his rage from escalating toward her. The patient appeared to treat Melissa as a confidant and ally, possibly because at the time of crisis she already knew much of his background and had used MI techniques prior to this visit to express empathy and support. Had she approached the conversation as an outsider or followed a traditional medical or task-oriented line of questioning, it’s likely his attitude toward her would have been different and potentially more dangerous. Similarly, her use of reflections, affirmations, and summaries likely helped deescalate his frustration while she was present. Thanks to the rapport she developed and her use of MI skills during the crisis, he did not perceive her to be a part or cause of his problems.
2) Identify and maintain an escape route—Drawing on her experience as a traditional paramedic, Melissa had identified an escape route when she first encountered the patient. Thanks to her previous training, Melissa began planning her exit as the interaction deteriorated. She was able to blend her traditional street smarts with motivational interviewing skills to verbally deescalate the patient and quickly and safely depart the scene.
3) Two-person teams for initial visits—While single CPs are common for follow-up visits, most of the CP teams present at the AAR already used two CPs for the initial assessment of new patients. This precaution was reemphasized during the AAR as an important risk-mitigation tool. The goal of the initial visit is not only to develop a therapeutic rapport with the patient but to assess the patient and their physical and social environments for potential threats to providers during subsequent visits. Melissa and her partner determined it was likely safe to conduct follow-up visits with this patient individually, which is why she was alone during this incident. The teams still felt follow-up visits could be done safely with one CP but emphasized awareness of how quickly the risk can change even with patients you’ve previously vetted.
4) “Previsit” the patient—Unlike traditional EMS responses, which are unscheduled and emergent, CPs often can research the patient before their first interaction. Mapping and satellite imagery can help the CP identify potential threats in the neighborhood and familiarize the CP with landmarks to find the patient as well as map out the closest escape route. Prior 9-1-1 record searches can give the CP a more complete picture of previous public-safety interactions. Simple web searches and open-source criminal records databases can reveal potentially dangerous criminal activity and/or interactions with the criminal justice system. Medical and discharge records are helpful in helping the patient manage their health, but criminal-record and Google searches can help the CP better manage their personal safety. When CPs visit patients on a scheduled basis, they should use all the tools available to mitigate risk. Many teams, including those in Melissa’s program, have these tools available.
The following areas were identified as opportunities to change current practice to increase the safety of the CP during home visits.
1) Determine if a home visit is necessary—Face-to-face visits with patients help build rapport, especially during the first interaction. Subsequent home visits are often necessary to help complete forms or conduct other follow-up interventions that require the CP to be physically present. However, rather than defaulting to the belief that all patient contacts should be face to face, the CP should determine if the home visit could be effectively replaced with a phone call. If the patient’s home environment or neighborhood is unsafe but a face-to-face meeting is required, plan to meet at a safer venue where the interaction can occur.
2) Know crisis resources in the area—At the time her incident occurred, Melissa’s CP team did not have a well-rehearsed mental health crisis plan for the county where the patient lived. Since it occurred in a rural county, crisis resources were not as robust as those available in the urban county more familiar to the team. The process of initiating an involuntary mental health assessment order and obtaining law enforcement support can vary quite a bit from county to county, and it is important that CP teams are well versed with the emergency response capabilities for each county’s crisis-response teams.
3) Conduct and document the “previsit” assessments more consistently and update the information on a regular basis—While there is a wealth of information potentially available on patients before we visit them, the process of assessing potential hazards and documenting them for others was not done consistently by many teams. The group felt research prior to the first visit was essential but that they should periodically repeat the search to identify recent or previously undisclosed safety threats.
4) Obtain safety-related information from the referring facility on your intake forms—At times other home-care providers had interacted with the patient, only to discharge him from their care for safety concerns. The CP program should request access to these records as part of the integrated care team relationship with home health and other agencies involved.
5) Build relationships with local law enforcement—Law enforcement databases may be more detailed and/or accessible through different search parameters than what's available to the general public. Developing a trusted relationship with the agency may provide access to those data. For CP patients with a violent crime history, collaboration with the police while scheduling the time and/or venue of the visit may reduce police response times if the situation deteriorates. Regardless of potential collaboration opportunities, these discussions are best explored before a crisis occurs.
The combined group also explored using risk assessment matrices and tools used by comparable professions but were unable to identify any that seemed appropriate for CP use.
Changes in Policy and Practice
Once the AAR was finished, another CP team in Pittsburgh, the CONNECT community paramedic team, revisited the discussion and tried to determine how to implement many of the best practices discussed during the meeting. In addition to changing the documentation practices to more consistently and reliably note the results of previsit searches, the team also recommended the following changes:
Use of a personnel tracker and alarm system to track CPs while at work;
Develop a set check-in time at which the CPs will be contacted if they haven't made contact with the office while on calls;
Develop a “safe word” cue that will discreetly let your partner know you no longer feel safe in the environment. The CONNECT team decided to use “Kai is calling” while looking at their cell phone in memory of the late CP pioneer Kai Hjermstad;
Collect individual employee emergency action plans and contact information should their team need to make emergency notifications;
Develop a protocol for what types of information will prompt patient visits to be scheduled in a public venue rather than at home.
A Worthwhile Discussion
Melissa was able to exit her situation unharmed, and the patient was subsequently held for psychiatric evaluation, potentially saving dozens of lives. The AHN CP team is to be commended for spearheading such a worthwhile discussion on CP safety practices with all the local teams rather than keeping the incident to themselves. Those operating CP programs should consider implementing safety practices that take into consideration the unique risks of CP visits and research local resources that can be used to mitigate potential threats.
Jonah Thompson, CP-C, NREMT-P, is operations manager for the Allegheny Health Network community paramedic program.
Christie Hempfling, BS, EMT, is community health team manager for the CONNECT community paramedic program and Emed Health program at the Center for Emergency Medicine of Western Pennsylvania, and team manager for the Allegheny County PORT (Post-Overdose Response Team). She is an adjunct faculty member in the MIH class at the University of Pittsburgh.
Dan Swayze, DrPH, MBA, MEMS, is vice president and COO of the Center for Emergency Medicine of Western Pennsylvania Inc., and a member of the EMS World editorial advisory board.