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Violence Against Responders: Risk Reduction Strategies

It’s an unfortunate truth that EMTs and paramedics are no strangers to abuse while working in the field. Even if you view it as a facet of prehospital care that just comes with the territory, there are ways you can prevent it from happening to you and your partner in the first place and mitigate its impact when it does. Wake County EMS (N.C.) decided it was time to train their EMS personnel in harm reduction after one of their medics was choked by a patient. After a series of town hall meetings took place to discuss the issue of provider safety, the county got down to business.


“‘If it’s predictable, it’s preventable,’” said Joseph Zalkin, BSHS - EMC, Paramedic, quoting public safety risk manager Gordon Graham during the “Violence Against Responders: The North Carolina Portal Project Best Practices” session at the EMS Today Conference and Exposition on Feb. 21 in National Harbor, Md.


Zalkin, former chief of Wake County EMS, discussed a preliminary survey conducted among his personnel after the assault against the medic occurred. The department built a portal for providers to participate in the survey so the administration could determine how often assaults were occurring, if an efficient reporting mechanism was available for personnel, and if there were important trends they needed to be aware of. The survey found that 20% of respondents did not feel safe coming to work.


“We’ve got to come up with proven systems that keep our people whole after the event,” said Zalkin, noting that a support system needed to be offered for providers after verbal or physical attacks. That support system should include legal intervention that allows a provider to be an advocate for themselves and use the law to their advantage in the event they are attacked. Unfortunately, while violence against EMS personnel is clearly a significant issue, it is underreported.


According to Jennifer Wilson, BA, EMT-B, Director of UNC Chapel Hill – EMSPIC, this is due to several key reasons indicated by responders in the Consortium Against Responder Violence – NC survey (CARVNC), a workplace violence reporting tool made in collaboration with the N.C. State Office of EMS. The most common reasons first responders had for not reporting workplace violence included a lack of support from their agency (33%), a lack of support from the legal system (32%), no reporting system existed to turn to (29%), and 23% reported that violence is just part of the job.


The goal of the CARVNC project is to compile data on violence in the field, help initiate follow-up investigations, provide best practices and resources for responders, and offer them a support system. Of the 1,203 respondents that participated, 76% worked in urban areas while 24% worked in rural ones, and 54.78% of them reported encountering violence in the last 24 months. Verbal assault accounted for 29% of violence, physical assault accounted for 9% while 39% of assaults were both verbal and physical (the remaining 23% did not respond). The survey also found that 24% of participants did not feel safe going to work.

Training in Violence Prevention


After the town hall meetings and survey results showed that medics needed training on violence prevention and de-escalation, Wake County decided to use simulation scenarios to conduct a needs assessment.


Donald Garner, Jr. BAS, NRP, Deputy Director of Wake County EMS, said the simulations helped pinpoint where things were going wrong and how they could be improved. First, he said, there was some role confusion. Unlike law enforcement officers, EMS personnel do not have a duty to protect and are not covered by immunity, so if a patient or their loved one tells you to leave their house despite an obvious need for medical attention, you need to leave. This is especially true if the individual is growing agitated. Create the shortest possible physical interaction time, said Garner, because when a scene starts to escalate, it’s time to disengage and escape.


Some of the medics struggled with this concept, especially after hearing a baby crying in the next room during the simulation. However, Garner stressed that this is not considered negligence and abandonment as you are rightfully prioritizing your safety. Wake County EMS ended up re-writing their department policy to clarify that employee safety during a scene is the #1 priority, no matter the circumstances.


Communication was another issue during the simulations, as medics were unsure of how and what to report when calling for help from law enforcement, especially if openly discussing the issue in front of the patient or bystander would compromise their safety. This is why you and your partner need to come up with a code word for “we need to get out,” said Garner. That code will particularly come in handy if one partner notices something is off while the other doesn’t and needs to secretly communicate the need to leave so as not to set off the individual.


Learning to identify threats is another shortfall of some providers, and if you and your partner don’t have a code word and one of you is unaware of the need to escape a scene, it puts both of you at risk. Watch for “pre-incident indicators”—this can involve reading body language cues indicating aggression and other verbal indicators, like cursing. In this scenario, a provider can simply state they will refuse to treat the patient and will leave if the bystander or patient doesn’t cooperate. Garner said you can go so far as to blatantly ask an agitated individual, “Do you intend to harm me?” This will catch them off guard, and if they stumble on their answer, that will serve as a litmus test to tell you if it’s time to leave to protect yourself and your partner.  


Garner discussed several tactics for improving your ability to detect threats and how to safely and successfully navigate them. The OODA Loop (Observe – Orient – Decide – Act) is a situational awareness strategy developed by U.S. Air Force Colonel and military strategist John Boyd. The faster you can successfully work yourself through this cycle, the safer you’ll be. He also explained TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety), a crew approach to decreasing patient deaths in the prehospital environment by improving teamwork and communication skills between health care workers. Dr. George Thompson’s “verbal judo” de-escalation technique is also a handy tool for providers to educate themselves on for diffusing conflict with tactical communication.


For more information on the CARVNC Project, click here.


Valerie Amato is assistant editor of EMS World. Reach her at 

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