Violence against EMS personnel is a global concern. Research is desperately needed to determine why the number of incidents is so high and what can be done to better prevent harm to those who risk their lives to help others.
We’ve long known EMS personnel face a risk of occupational fatality similar to those of police and firefighters1 and a risk of nonfatal injury that’s much higher.2,3 A 2013 paper found there’s a fatal assault per year among EMS personnel in the U.S.4 Teams of researchers have recently produced five papers on violence against EMS personnel. Their findings provide valuable insight into the problem and direct us to take further protective actions.
An international survey on violence against EMS personnel had 1,778 EMS respondents from 13 countries; a key finding was that 65% of the respondents had been physically attacked while on duty.5 Those who had been assaulted noted that 90% of their attackers were patients and 5% were patient family members. Alcohol and drugs played a part in many incidents.
From a retrospective analysis of occupational injury data between 2001 and 2014 in Australia, investigators determined the total number of violence-related cases against ambulance personnel increased from 5 to 40 per year; the number of cases of injuries secondary to assault tripled from 10 to 30; and the rate of violence cases by ambulance call volume doubled from 6 to 12.6
Similarly, an analysis of U.S. data found that the perpetrators included patients (77%) and coworkers (8%), and female EMS personnel had a disproportionately greater risk of violence-related injuries. The most common injury type (35%) was sprains, strains, and tears, whereas about 4% of cases resulted in fractures, 13% resulted in surface wounds, and 11.7% were head injuries. An alarming finding was that a third of the cases were classified as intentional.7
Asking the Victims
The international survey took an unorthodox approach when it asked EMS personnel who had been the victims of assault what they thought, in hindsight, could have been done to prevent the incident. Recommendations from the assaulted personnel included:
Specialized training such as for specific populations, de-escalation techniques, and self-defense, as well as training for improved situational awareness;
Equipment such as restraint equipment; and,
Operational and environmental measures, including advance warning systems—for instance, having dispatchers and communications personnel collect and relay more information about potential risks.
The assaulted medics identified persons who could have prevented the violence as police, themselves, other professionals, partners, and dispatchers.8 It was especially insightful that so many assaulted personnel identified themselves as the person who might have prevented the event. Some noted they should have known the perpetrator was potentially dangerous or should not have let themselves be trapped in the situation. These reflections reinforce the importance of scene awareness for EMS personnel.
Risks by Demographic Groups
One significant finding from the review of both the Australian and U.S. injury data was the propensity for female EMS personnel to be assaulted. In Australia 42% of the EMS victims of physical violence were women, while they comprise just 32% of the EMS workforce.6 In the U.S. females were also found to have a higher risk than males7 as well as a higher risk of homicide1 and assault-related injury.4 However, the analysis of data from the international survey found men experienced more assaults than women, and younger workers experienced more assaults than older workers.5
That there are differences by demographic factors reiterates the importance of one of the conclusions from the systematic review of the literature on violence against EMS personnel: “The finding that the risks vary by demographic factors implies that incidents are not random. Thus, they may be predictable, and demographic-specific mitigation strategies may be necessary.”9
These papers have reinforced the need for research to determine effective interventions and best practices. The systematic review concluded there was “a lack of peer-reviewed research of interventions, with the result that current intervention programs have no reliable evidence base.”9 Programs and policies have been put into place to protect EMS personnel, but a rigorous evaluation and reporting of the findings in peer-reviewed journals has not yet followed.
There are a host of potential interventions.10 In the international survey some assaulted respondents noted they would have liked to have had self-defense training before the event.8 A study on air ambulances that examined the use of ketamine as a way to sedate potentially violent patients found it was a safe and effective intervention.11 Authors led by the Allegheny Health Network’s Jonah Thompson described a good tool that could be used not only after violent incidents but also after close calls: They recommend an after-action meeting in which 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.”12
Thousands of EMS agencies around the world have likely tried interventions to reduce risks for their personnel. However, the systematic review found no evidence of the outcomes of those interventions. That leaves each EMS agency to, again and again, reinvent the wheel and try interventions that may already have been tried dozens of times without success. Not only do we not know what works, we do not know if any interventions have actually increased risks instead of reducing them. For example, it seems possible that simply issuing bullet- or stab-proof vests might actually result in more assaults (because wearers take more risks) and cause unintended consequences such as higher rates of hyperthermia for EMS personnel.
In its publication The Public Health Approach to Violence Prevention, the CDC describes a four-step approach to violence prevention: 1) define the problem; 2) identify risks and protective factors; 3) develop and test prevention strategies; and 4) assure widespread adoption (dissemination and implementation).13 The papers described in this article have largely addressed steps 1 and 2. To address the final two steps, we recommend EMS agencies work with university researchers to “quantify agency-level risks and develop, test, and implement interventions in such a way that they can be reliably evaluated and the results published in peer-reviewed journals.”5 Only when results are verified can we begin to build our knowledge and develop a reliable set of best-practice approaches to reducing the risks of violence for EMS personnel.
In the meantime, we all know the aviation profession places a tremendous emphasis on safety. As one example, before each flight a pilot recites what he or she will do if there is an engine failure during takeoff. One way to apply this lesson to EMS would be for partners, at the beginning of their shift, to discuss and agree on a procedure for dealing with a potentially violent or dangerous situation. Since you may not want to alert people on the scene that you’re concerned, work out a code phrase—for instance, “Can you give me a hand getting the blue bag?”
That’s a start, but we need to be doing more to protect our EMS personnel.
1. Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency medical services: A hidden crisis. Ann Emerg Med, 2002; 40(6): 625–32.
2. Maguire BJ, Hunting KL, Guidotti TL, Smith GS. Occupational injuries among emergency medical services personnel. Prehosp Emerg Care, 2005; 9(4): 405–11.
3. Maguire BJ, O’Meara P, Brightwell R, et al. Occupational injury risk among Australian paramedics: An analysis of national data. Med J Aust, 2014; 200(8): 477–80.
4. Maguire BJ, Smith S. Injuries and fatalities among emergency medical technicians and paramedics in the United States. Prehosp Disaster Med, 2013; 28(4): 1–7.
5. Maguire BJ, Browne M, O’Neill BJ, et al. International survey of violence against EMS personnel: Physical violence report. Prehosp Disaster Med, 2018; 33(5): 526–31.
6. Maguire BJ. Violence against ambulance personnel in Australia; a retrospective cohort study of national data from Safe Work Australia. Public Health Research & Practice, 2018; 28(1): e28011805.
7. Maguire BJ, O’Neill BJ. EMS personnel’s risk of violence while serving the community. Am J Public Health, 2017; 107(11): 1,770–5.
8. Maguire BJ, O’Neill BJ, O’Meara P, et al. Preventing EMS workplace violence: A mixed-methods analysis of insights from assaulted medics. Injury, 2018; 49: 1,258–65.
9. Maguire BJ, O’Meara P, O’Neill BJ, Brightwell R. Violence against emergency medical services personnel: A systematic review of the literature. Am J Ind Med, 2017: 1–14.
10. Spelten E, Thomas B, O’Meara P, et al. Organisational interventions for preventing and minimising aggression directed toward healthcare workers by patients and patient advocates. Cochrane Database of Systematic Reviews, 2017 May 18; www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012662/abstract.
11. Gangathimmaiah V, Cong ML, Wilson M, et al. Ketamine sedation for acute behavioural disturbance during aeromedical retrieval. Air Med J, 2017; 36(6): 311–4.
12. Thompson J, Hempfling C, Swayze D. Keeping Community Paramedics Safe. EMS World, 2018 Nov; www.emsworld.com/article/1221621/keeping-community-paramedics-safe.
13. Centers for Disease Control and Prevention. The Public Health Approach to Violence Prevention, www.cdc.gov/violenceprevention/pdf/PH_App_Violence-a.pdf.
Brian J. Maguire, DrPH, MSA, EMT-P, began his career as a New York City paramedic and went on to become a university professor and a Senior Fulbright Scholar. He is an epidemiologist with Leidos in Connecticut and an adjunct professor at Central Queensland University in Australia. He has a doctoral degree in public health from the George Washington University in Washington, D.C. and has written numerous peer-reviewed research articles on EMS safety.
Barbara J. O’Neill, PhD, RN, BSN, PGCertNursEd, has experience and expertise in university-level teaching, research and clinical care. She is an associate clinical professor at the University of Connecticut and an adjunct associate lecturer in the Central Queensland University, School of Nursing, Midwifery, and Social Sciences.
Peter O’Meara, PhD, MPP, BHA, is an adjunct professor at Monash University in Melbourne, Australia. His research has focused on the delivery of ambulance services in rural Australia and the development of paramedic extended scope-of-practice roles.