The Bite Behind the Bark

      Patrick, a five-year-old boy, had been quietly playing in his family's backyard for about an hour. Every time his mother looked out the window to be sure he was OK, he was busily building roads and caves in his sandbox or imagining exciting adventures with plastic people. It only took her a few minutes to put away the day's laundry upstairs before her next check on Patrick. She never heard her son approach the strange dog, nor did she hear his first screams. By the time she returned to her vantage point, she saw that a dog had her son trapped against a fence with no room for escape and no way to protect himself. Already bitten, his hand was bleeding and his face was filled with fear. When paramedics arrived, they had to deal with an injured child, a frantic parent and a vicious dog.

   Dogs are ubiquitous in our society. Numbering over 50 million, they often share not only our workspaces, but our homes as well.¹ This relationship is usually one that fosters positive emotions and increased mobility and safety for pet owners. However, there are times when human-canine interactions result in less desired outcomes in the form of bites, other injuries and even deaths (see Table 1). During 2007, more than 300,000 dog bite injuries were seen in emergency rooms (an injury rate of 103 per 100,000).² When these occur, it is possible that EMS providers will be called to a scene where they will come face to face with an aggressive dog. This article will discuss aggressive dogs, their behavior and some strategies for dealing with them.

BREEDS AND BITES

   It is not known with certainty how many dogs of each breed exist in the country, so calculating "bite rates" is difficult. The best data available indicates that the breed most likely to kill someone is the pit bull terrier. Other dogs, like the Rottweiler, German shepherd and others, have been known to kill as well. These breeds may be genetically predisposed to be violent, but this predisposition is surely affected by training and health. It is worth noting that some breeds are more popular than others meaning there are more of them to potentially bite someone. The popularity of breeds waxes and wanes over time, and it is probable that the types of dogs that bite most often may change to reflect that flux in popularity (see Table 2).³

WHO IS MOST LIKELY TO BE BITTEN?

   While any dog may bite, the greatest likelihood of a bite occurring is when the animal is poorly socialized, scared, injured or threatened. A poorly socialized dog is one that has received too little positive social contact or one that has been trained (intentionally or not) to be aggressive. The most likely victims of dog bite are children, and it is more likely that a male child will be bitten than a female.²

HISTORY AND BEHAVIOR

   A dog's history and its patterns of behavior can give rescuers a clue as to the animal's likelihood of being dangerous. Below is a list of dogs that are more apt to develop aggressive behaviors:⁴

• Dogs that have been allowed (or taught) to play aggressive games like tug-of-war or fighting
• Dogs that are kept outdoors with inadequate positive socialization
• Dogs that have not been trained to follow commands like "sit," "stay" or "no"
• Dogs that have been allowed to become sexually mature (i.e., not spayed or neutered), especially males or nursing females
• Dogs that have not received adequate veterinary care.

RISKS

   Major risks associated with dog bites include the trauma caused directly by the bites, which can range from mild to horrific to systemic infections. The risk of trauma is strongly related to the aggressiveness of the animal and the animal's size and strength. Smaller dogs generally present a lesser risk for significantly traumatic bites than larger and/or stronger breeds. For example, it is less likely that an adult Chihuahua can deliver a life-threatening bite than a similarly mature German shepherd. Infections from bites can be caused by bacteria and viruses (e.g., rabies) found in the dog's saliva and the environment in which the attack takes place. These infections can be life-threatening, especially if unrecognized and untreated. In the case of rabies, it is recommended that persons at the highest (potential) risk for exposure due to work-related duties (e.g., veterinarians) receive routine prophylactic vaccination. For the general public, including EMS providers, it is more likely that you would only receive prophylaxis after being bitten or otherwise injured by an animal suspected of having the disease. While an index of suspicion can be elevated due to an animal's general health and behavior, a definitive diagnosis of rabies is made upon necropsy of the dog. If exposed, the treatment would include a dose of rabies immunoglobulin and five doses of vaccine over a 28-day period. Unlike previous post-exposure prophylaxes, which were administered into the abdomen, these injections are administered into the victim's arm.¹⁰

STRATEGIES

   If you find yourself in the presence of an aggressive dog, it is safest to avoid a confrontation and allow properly trained and equipped animal control officers to manage the situation. These personnel will bring a host of tools and experience to the scene, increasing the chance of accessing the victim and safe capture of the dog. They are also able to decide whether a safe capture is feasible. Unfortunately, calling upon animal control is not always an option for emergency responders. Therefore, it might be helpful to be aware of some general rules of engagement if an aggressive dog approaches you. Remember, the dog sees you as the one invading its territory. It is up to you to avoid a confrontation with an animal that may simply be protecting its space or its offspring. When finding a potentially aggressive dog on scene:^4,10,11

• Call for help! Have animal control or some other law enforcement presence available. Law enforcement officers can help secure the scene and direct the flow of bystanders out of harm's way. They might be able to trap the animal or at least restrict its access to the victim and EMS personnel. If these safety measures fail, having law enforcement on scene allows the final option of using lethal force upon the dog.
• Do not run! Dogs generally see running as a game, and their part in this game is to bite you. This is part of a dog's genetic heritage and is hardwired into its personality. If a dog approaches to sniff you, stand still with closed hands, this presents less threat and protects your fingers (just in case). If you feel threatened by the dog, slowly back away. Do not turn your back to it.
• Do not scream or make sudden movements (especially toward the dog). Doing so can startle the animal or be perceived as a threat or challenge.
• Do not approach puppies. A nursing female dog may see this as a threat to her offspring and bite you, which is the most effective form of communication available to her.
• Do not approach a dog that is eating. Dogs learn from an early age to protect their food. Responsible pet owners teach their dogs that humans are the "leaders of the pack," but it is possible that the dog on your scene never learned this lesson. If so, it's your fingers that may pay the price.
• Do not wake a dog, particularly an older dog whose dulled senses can't detect someone sneaking up on him. Suddenly awakening the dog may startle him before he realizes there is no real threat.
• Do not forget that an injured or sick dog is very unpredictable! Where a human might yell or curse to express fear and frustration, a dog might growl, snap or bite instead.

   If a dog comes toward you to attack, you should:

• Back away to safety.
• Consider using a chemical agent like a high-quality pepper spray with a sufficiently high percentage of oleoresin capsicum to repel the dog. Contact your local law enforcement agencies to discover what brands they use and recommend.
• Place something between you and the dog, like the bag used to carry medical supplies or a cardiac monitor. If that is not an option, use your arm as a shield, especially if you are wearing protective equipment like turnout gear.
• If you are knocked to the ground, curl into a ball and cover vital areas like your head, face and throat.
• Assure that the animal is captured and secured for rabies testing. This will be done by post-mortem examination of the animal's brain tissue.

PUBLIC EDUCATION

   In addition to teaching the general strategies noted above for emergency responders, dog-bite prevention is an excellent activity for EMS to engage in as part of a public education campaign. Knowing that children are in the highest risk group for dog-bite, focus your efforts upon this population. Children should be taught how to avoid dangerous dog-human interactions. Tips for children include:^4,10,11

• Never approach a dog you don't know.
• Never approach a dog with puppies.
• Never approach an eating dog.
• Never approach an injured or sick dog (be careful even when it is your own pet).
• Never wake a sleeping dog.
• Never engage a dog in rough play.
• Never attempt to separate fighting dogs.

CONCLUSION

   EMS agencies should utilize local specialists in animal behavior to provide training for on-scene management and the specific resources available in their community, such as small-animal veterinarians, animal behaviorists, certified dog trainers and animal-control officers. I encourage responders to discuss their agencies' plans for managing scenes with aggressive dogs before an incident occurs. Preplanning and interagency coordination can save not only rescuers and patients, but dogs as well.

   References

1. American Veterinary Medical Association Task Force on Canine Aggression and Human-Canine Interactions. J Am Vet Med Assoc 218(11):1732–1749, 2001.

2. U. S. Centers for Disease Control (2003). Unintentional Dog Bite Nonfatal Injuries and Rates per 100,000, United States, All Races, Both Sexes, All Ages - Disposition: All Cases. Retrieved from https://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html, February 25, 2009.

3. Sacks J, Sinclair L, Gilchrist J, et al. Breeds of dogs involved in fatal human attacks in the United States between 1979 and 1998. J Am Vet Med Assoc 217(6):836–840, 2000.

4. American Veterinary Medical Association & American Academy of Pediatrics (May 2006). What should you know about dog bite prevention. Retrieved from www.avma.org/animal_health/brochures/dog_bite/dog_bite_brochure.pdf, March 5, 2009.

5. Mulick S. Injured officers kill two dogs. The News Tribune, Tacoma, WA, January 25, 2007. Downloaded from database: Newspaper Source on January 27, 2007.

6. Gilpatrick B, Gilpatrick B. Man's death from attack by dog is investigated: A 56-year-old Southwest Miami-Dade man died when a boxer dog attacked him, marking South Florida's second fatal dog mauling in two weeks. The Miami Herald, August 30, 2006. Downloaded from database: Newspaper Source on January 27, 2007.

7. Sallie J. Autopsy describes wounds sustained in fatal dog attack. Sun-Sentinel, Fort Lauderdale, August 20, 2006. Downloaded from database: Newspaper Source on January 27, 2007.

8. Derbeken J. Mom jailed in pit bulls' fatal mauling of son/She is charged with child endangerment for leaving 12-year-old boy alone with dogs. San Francisco Chronicle, CA, June 24, 2005. Downloaded from database: Newspaper Source on January 27, 2007.

9. Egelko B. State top court to decide on sentence in Knoller case/Justices to decide on reduction of conviction to manslaughter in fatal S.F. dog mauling. San Francisco Chronicle, July 28, 2005. Downloaded from database: Newspaper Source on January 27, 2007.

10 U. S. Centers for Disease Control (2003). Rabies prevention and control. Retrieved from www.cdc.gov/ncidod/dvrd/rabies/Prevention&Control/preventi.htm, January 26, 2007.

11 State Farm Insurance, Insurance Information Institute & American Veterinary Medical Association (2007). Retrieved from www.avma.org/pubhlth/dogbite/dogbitebroc.pdf, January 11, 2006.

   Note: Original data collection for analysis of dog bite comparison was retrieved from webappa.cdc.gov/sasweb/ncipc/.

   Sandy Hunter, PhD, NREMT-P, is a tenured professor with the Emergency Medical Care program at Eastern Kentucky University. In the spirit of full disclosure, he was once a friend to a well-socialized and loyal dog "Mandy," his faithful companion for many years.

Table 1: Dog Attack Scenarios

Tacoma, WA, January 2007

   Police officers were returning from a call when they spotted two pit bulls attacking a third dog. The officers pulled over and tried to stop the attack. Using a Taser on one of the pit bulls seemed to have little or no effect and it attacked the officers, inflicting hand and leg bites. The dog was shot to stop the attack.⁵

South Florida, August 2006

   A 56-year-old man was found dead and the body of a 5-year-old boxer was covered with the man's blood. The man was found in the dog's pen, and there were apparently no witnesses to the attack.⁶

   This was the second fatal attack in the area within two weeks. Earlier, a mother of two was mauled by a 120-pound Presa Canario, which reportedly bit and caused fatal trauma to the victim's throat.⁷

San Francisco, June 2005

   A 12-year-old boy was left alone at home by his mother while she was running errands. The mother said she locked the boy in a basement (with food and video games) to keep him away from her two pit bulls while she was away. Upon returning home, she found her child had gotten out of the basement and was killed by the dogs. He suffered several bites to his face and scalp. The mother said she had been concerned because her male pit bull had been acting aggressively toward the female, which was in heat.⁸

San Francisco, January 2001

   A 33-year-old woman was returning to her apartment with groceries when a neighbor's dogs—a 140-pound male and 100-pound female Presa Canario—attacked her. The woman, who suffered more than 70 puncture wounds, including punctures in her neck, died of her injuries.⁹