At least before the COVID-19 lockdown, civil unrest had become a regular factor in a lot of American lives. It’s not just an impression that Americans are angrier, more divided, and taking it more to the streets; in its compendium of U.S. civil unrest events, Wikipedia lists seven incidents in the 1980s, 10 in the 1990s, 15 in the aughts, then 31 from 2010–2019.1
That’s some increase, and it’s not confined to big cities. Among the affected locations in the 2010s were towns like Harrisonburg, Va., and Santa Cruz, Calif. Two of the worst occurrences were in Charlottesville, Va., and Ferguson, Mo. Not all produced large numbers of casualties, but virtually all had (and have) the potential—and all can pose risks to EMS personnel.
To distill lessons and best practices for dealing with these volatile events, EMS World talked to three leaders who have been through them: Andrew Baxter, chief of the Charlottesville Fire Department; leadership consultant Chris Cebollero, who headed St. Louis’ Christian Hospital EMS (CHEMS) during the Ferguson riots; and Rob McDonald, operations manager for AMR in Multnomah County, Ore. Multnomah County includes Portland, where prolonged strife has followed the 2016 election and left- and right-wing protesters frequently square off in dueling, sometimes-violent rallies.
Here are 10 of their key ideas.
1. Talk first
When an event erupts without warning, such as after some police shootings, it can be difficult to pre-map specifics—you have to rely on broad-brush plans and training and work out aspects like staging locations and command details in real time. But when an event is planned, like the 2017 Unite the Right rally that went awry in Charlottesville or some of the Portland protests, it may be possible for public safety, generally led by law enforcement, to communicate with group leaders and get some degree of advance handle.
Portland police have been known to talk extensively with both sides before protests. “It allows incident command to plan ahead,” says McDonald, whose agency typically handles triage and transport at protest scenes. “We’ve gone so far as being able to get estimated numbers of attendance. For the last year or so we’ve had relatively decent notice because of our relationships with our law enforcement partners. They’re quick to reach out to us and the fire agencies to establish a working plan.”
2. It’s hard, but stay unified
Getting everyone on the same page isn’t easy in the heat of events. Don’t wait till things are burning to try. In Charlottesville a KKK rally the month before Unite the Right produced some low-level violence without a single incident action plan or real unified command by responders. As Unite the Right approached, fire leaders saw the potential for a repeat.
“It became clear we were headed for the same thing as far as command and control,” says Baxter. “We also saw the resources being brought to bear on the law enforcement side were extensive. So after a couple of weeks of trying, we finally convinced the Charlottesville police to bring in an incident management team through the Virginia Department of Emergency Management.”
That team arrived three days before the rally and pulled disparate law enforcement operational plans into a single IAP with unified command. That broke down when the event began and law enforcement agencies reverted to their individual plans, but the framework was in place.
In Ferguson they didn’t have that opportunity. After officer Darren Wilson shot teenager Michael Brown in 2014, protesters, police, and press began accumulating, and things hit a flashpoint after a candlelight vigil the next day, with at least 12 businesses vandalized and more than 30 arrested.
CHEMS personnel had staged nearby that night but quickly found themselves in the middle of the conflagration. Trucks being surrounded and blocked had to be quickly relocated.
“The protesters on that scene were very, very angry,” says Cebollero, “and one of the things I had difficulty with was knowing who was in charge. I was trying to look for unified command, for my peers who’d be running this incident. We never had the opportunity to collaborate because there was never a unified command.”
The looting, vandalism, and violent clashes between police and citizens lasted nearly two weeks. “I don’t know that we got a true unified command until about day 14,” Cebollero adds. “There were just too many chiefs and not enough Indians at this event. The county police showed up, the state police showed up, the FBI came—there were more and more people getting involved. And the higher they got, the less they kept the lower people involved in discussions of what was going on.”
3. Protest scenes are dynamic
As CHEMS’ troops had to relocate, so have AMR’s in Portland. Rallies may not stay in their original or permitted areas.
“It’s pretty dynamic—the venues change, the geographic and topographical areas change, so access points and staging areas often evolve,” says McDonald. “It ends up being very much a case-by-case basis. Our common goal is that transport and triage stay in a cold zone, but we’ve seen these events can migrate—on one occasion right into our laps. It went from nobody around us to 300, 400 people angrily shouting at one another all around our ambulance.”
Unite the Right was supposed to begin at noon, but tensions were so inflamed that protesters and counterprotesters gathered early, and brawling commenced even while fire personnel were being briefed. The city, then the governor called emergencies, and state police declared the rally unlawful and cleared the park. Around 1,000 people scattered into downtown. Two hours later and four blocks away came the infamous car ramming attack in which James Fields killed Heather Heyer and injured 19 others.
Things were explosive enough in Charlottesville that day to spook even those with military experience.
“You had multiple armed militia groups from various places on the political spectrum marching around with long guns and Kevlar helmets and ballistic gear,” says Baxter. “You had neo-Nazis and white nationalists marching to and fro. At one point one of my firefighters, a combat veteran, looked at a state trooper guarding the perimeter of our staging area and said, ‘Are we going to be able to hold this?’ The trooper told him, ‘I don’t know. These guys are better armed than we are.’ That firefighter told me he’d been in combat, but he was more concerned about his safety that day in our city than he was when he was deployed. Everyone was armed, and it was such a dynamic situation.”
4. Keep a pulse
Safety is priority No. 1, of course. Keep EMS troops in the cold zone, have casualties brought to them, and stay situationally aware if things evolve.
Charlottesville’s coordinated response defined three operational levels, the last of which was a complete defensive posture for worst-case turns.
“We had three predetermined levels tied directly to the health system’s IAP and operational modes,” says Baxter. “Level 1 was normal operations for both us and the hospital, albeit with a lot of extra resources. Level 2 was a declared MCI, but not particularly because of violent activity. And then Level 3 would be a defensive operation. That declaration triggered preplanned steps, including us pulling all our resources back to a protected staging area and the hospital activating its disaster plan, which calls in extra staff and shuts down the road in front.” That point was reached even before the emergency was declared.
Also with an eye on safety, Multnomah County AMR has provided de-escalation and defensive tactics training to its entire workforce of more than 500 and drafted a policy to allow ballistic vests.
Remember these are stressful and unpredictable situations that can tax responders psychologically as well as expose them physically. In Ferguson Christian’s contingent included many younger providers. There’s a lot going on at these events, but try to monitor field troops’ state of mind.
“At one point I looked at the team, and somebody said to me, ‘I am very uncomfortable here. I am out of my comfort zone, and I don’t know what to do,’” Cebollero says. “I hadn’t been thinking about that. I had to think about my team’s safety and making them feel a bit more comfortable in this very volatile situation.
“There were times when things got iffy—rocks and bottles were thrown at the ambulance, there was one time where a car pulled up next to the ambulance and someone brandished a weapon at our driver. Fortunately nobody was hurt. I think our folks were more hurt mentally than they were physically.”
5. Help everyone help themselves
You shouldn’t need to be told to treat all injured victims professionally, but it can be hard—especially when some of these players really hate the whole authority structure of which EMS is a part.
“It’s a difficult thing when you hear a provider say, ‘I’m not going to treat those people!’” says Cebollero. “We didn’t want to be seen as only there for the police—we’re here for everybody. This isn’t about politics, it’s about our duty to act.”
“I got feedback from some of our firefighters that they had some less-than-positive interactions with the counterprotesters,” says Baxter. “The folks we ended up engaging with were what I guess you’d call street medics, which we learned a bit more about when this all happened. There’s online curricula for people who want to provide medical support to their friends and comrades who are protesting.”
In fact, “street medics” have been a feature of protests in all three cities, and it can be valuable to work with them if they’re willing. In Missouri CHEMS helped protesters set up and stock a basic medical tent. In Charlottesville, after denigrating firefighters, protester teams sought resupply from them. And overall they may relieve a bit of burden on actual EMS personnel.
“On a practical level, we haven’t necessarily been required to render a ton of EMS treatment during these events,” says McDonald. “Their embedded volunteers do some of the irrigation and treatment on the fly in the hot zone, where they’re actually part of the event. They have fanny packs or some other carrying device with bandaging and other treatment equipment. So very often the injured don’t actually get to us but are taken care of by their own.”
6. Mind your identity
Though present to help, not incarcerate, we’ve all felt lumped in with police and that power structure many people distrust. It’s a paradox, as EMS must work closely with law enforcement for the protection of both sides—so how do you distinguish EMS in a way that says “don’t take it out on me”?
Prior to Ferguson Cebollero had been working to spruce up CHEMS’ look, adding button-up shirts and badges and brass. When the riots started, that idea needed reevaluated.
“People were coming out against the police, and we realized the danger, and I told them to take those shirts and badges off,” he says. “There’s no evidence EMS providers who wear uniforms with shirts and badges are equated to police officers, but that changed my opinion. When folks walk in with a blue shirt and gold badge on, who’s to say who they are?
“I’m not advocating we don’t put our people in professional uniforms,” he adds, “but I am saying that in a crisis of civil disobedience, maybe those aren’t the uniforms we should be wearing.”
“We do encounter that distrust in some of those communities,” says McDonald. “It often takes a one-on-one conversation: ‘Hey, I understand I arrived with law enforcement, but I’m not part of law enforcement. I’m here to help you.’ That seems to be the most effective manner to educate folks: real-time one-on-one. But I think there’s also merit to considering a more mediacentric outreach to folks to indicate that EMS is here to help and isn’t an incarcerating body.”
7. Game faces—always
Shortly before Ferguson a CHEMS provider was caught laughing at the scene of a car accident. It made national news and dinged the organization’s professional shine. That provider didn’t intend disrespect or find the accident or injuries funny, but any mirth at a crash scene was seen as inappropriate. That’s the kind of thing you have to worry about when cameras are everywhere and every citizen potentially a journalist.
That was on Cebollero’s mind during the riots. It’s not unusual for humans to react to great stress or tragedy with dark humor, nervous laughter, or an awkward grin. EMS requires suppressing that instinct in public.
“We were in a group, and some of the paramedics were laughing and smiling—it was their defense mechanism,” Cebollero says. “I looked over their shoulders there at the news cameras and told them, ‘We don’t want to smile at this event. We don’t want to laugh. We want to make sure we handle this business as professionally as we can.’”
8. The injury profile
You know most of what to expect here: blunt trauma, contusions, lacerations, chemical exposures. More pepper and bear sprays these days. Not so much gunfire sometimes. Reports of Portland protesters throwing milkshake cups full of fast-setting concrete were dispelled.
Cebollero: “Rocks and bottles were big. A police responder had an ankle broken—I believe somebody threw a cinderblock. We were seeing people beaten up—injuries to the head, face, and torso. There was one guy beaten unconscious, but because he was in the area we considered hot, he lay there for a bit before we could get to him. There were a couple of people shot, but by the time we arrived they disappeared.”
McDonald: “Knock on wood, we haven’t actually had a gunshot. Typically it’s contusions, abrasions, very rarely a puncture. More often than not it’s a lot of irrigation of eyes and faces—folks who have been pepper-sprayed or something. We end up going through all our saline bottles.”
Baxter: “There was fighting but no real dramatic, serious injuries. We had some environmental injuries with law enforcement officers in various levels of protective equipment. There was only one shot fired. But it is remarkable—given the number of people who were heavily armed that day, we were one bad actor away from an absolute massacre.”
9. Keep communicating
These are stressful, fast-moving situations, and leaders may have to make quick decisions. Blow-by-blow updates for the field may not be feasible, but keep it a priority to communicate downward.
“At times it was hard to make decisions and have the workforce understand why,” says Cebollero. “As one example, we had a pregnant woman in imminent delivery, and we weren’t getting force protection at that time. We parked the ambulance about half a mile away, and the EMTs had to walk through some woods to get to her house and then walk her back through the woods to the ambulance. When that call was over, I had one provider livid with me. He said, ‘How can you make a decision like that?’ I told him, ‘The reason I can make a decision like that is so at 7 o’clock tomorrow morning, you go home to your wife and kids. That’s why I made that decision.’”
Kept too much in the dark, people tend to invent their own narratives, which can grow quickly. Even if you lack information, update what you can and be frank about what you can’t.
10. Never waste a good crisis
There’s no substitute for experience, and turmoil can help forge young talent into tomorrow’s leaders. Make the best decisions that you can but allow trusted subordinates to be part of the planning, execution, and after-actions.
“[The Ferguson riots] was something EMS really had never experienced before, unless you were in Los Angeles after the Rodney King verdict,” says Cebollero. “Is this ever going to happen in Ferguson, Mo., again? I can’t answer that question. But I can tell you that we made decisions that would allow people who are still there to be prepared if it ever happens again.”
1. Wikipedia. List of incidents of civil unrest in the United States, https://en.wikipedia.org/wiki/List_of_incidents_of_civil_unrest_in_the_United_States.