Beyond the Basics: Scene Safety

CEU Review Form Scene Safety (PDF)Valid until August 4, 2006

Your ambulance is called to a generally quiet part of town for an unknown medical problem. Traffic is light at this time of night. You routinely kill your lights and siren a few blocks from the scene, approach the residence and note that it is unusually dark. You stop and tell your partner, "Something isn't right here." Both of you move away from the sidewalk that leads to the door.

     You radio into dispatch, "Dispatcher, confirm the address for us. This house is dark." The dispatcher confirms you are at the correct address. You hate to waste time if someone is down inside, but something still feels wrong. "Let's get a bit closer...but be careful," your partner suggests.

     She moves to the doorway and stands on the doorknob side. You take the opposite side from the bottom of the porch stairs. Your partner's eyes widen. "Let's get out of here. Now. Call for the PD!" As you quickly but quietly return to the ambulance, she tells you that she overheard a man yelling for someone else to "Shut up!" followed by the sound of breaking glass somewhere inside the house.

     The police respond and secure the scene. Had you not been cautious, you would have ended up in the middle of a domestic disturbance.

     Of all the tasks we perform as part of the patient assessment process, scene safety is arguably the most important. If we become injured during a response, we are unable to participate in patient care, become an additional patient for the EMS system and may suffer from pain, disability and, in extreme cases, death. The concept of safety covers a wide spectrum of pitfalls we occasionally encounter while providing EMS: being injured while lifting and moving patients, motor vehicle collisions, contracting infectious diseases and more. Fortunately, EMS is relatively safe. With only a little extra effort we can all enjoy a life-long, rewarding and safe EMS experience.

Scene Size-Up
     Safety is a component of the scene size-up that continues throughout the call. It is worth taking a moment to detail all of the components of the size-up, since safety is interwoven throughout.

     There are five widely accepted components of the scene size-up: scene safety, body substance isolation determination, mechanism of injury/nature of illness determination, number of patients and resources needed.

• Safety
       This step is the focus of this article. Your personal safety must be assured, as well as the safety of your partner or crew, the patient and bystanders.
• Body substance isolation precautions
       Using the nature of the call, dispatch information and observations as you approach the scene, you will take precautions against exposure to all potentially infectious substances you may encounter.
• Mechanism of injury and nature of illness
       Your initial observations and information you receive as you approach the scene are quite formative. These include the forces involved in trauma, as well as the position of the patient, odors and hygiene for the medical patient.
• Number of patients
       Most calls involve one patient, but occasionally we encounter more. Large-scale, multiple-casualty incidents are obvious and require considerable help. The 2-10-patient MCI, however, often catches us unprepared. We know to call for additional help when there are 50 patients. Even when there are four patients, two of them critical and going to different hospitals, we are faced with a multiple-casualty incident.
• Resources needed
       This may include resources like extrication or air medical evacuation, as well as safety issues such as hazardous materials, downed power lines or a need for the police.

     All of the components of the size-up are, in fact, intertwined and help us remain safe. Many times, your observations (e.g., hazmat scenes or mechanism of injury) have implications for both rescuer safety and patient care.

Violence Prevention
     Violence prevention should be the primary safety goal of anyone responding to a scene.

     Observation is key to avoiding danger before you are forced to deal with it. A concept called situational awareness is important for efficient observation. Situational awareness is focusing your senses at an emergency scene to observe and detect violence before it is too late. Because most calls are uneventful and without danger, it can be difficult to believe that the next call could pose a danger. This results in a casual, nonobservant attitude.

     There are different levels of awareness or observation. If you are responding to a nursing home for a transfer, you probably expect a lower potential for danger than when pulling up in front of a dark residence in a part of town that has a reputation for a higher incidence of violence. The concept of situational awareness acknowledges that violence could be anywhere (nursing home or a bad part of town) but the probability and type of danger found in one area may be greater than another.

     Looking at awareness on a 0-10 scale, 0 is essentially asleep, while 10 is panic, neither of which is appropriate for the field. Responding to any call with an awareness level of about 3 or 4 is appropriate. Remember, you are responding to an emergency, and unpredictable things can happen. As you respond to the call, be alert for signs of danger, including information from your dispatcher that there may be yelling, intoxication or a history of violent calls at the address.

     When you arrive at the scene, your observations will also add to your suspicion of violence. Facts to consider are the location, things you see and hear, and any obvious signs of violence or disturbance. Sometimes, unusual quiet is suspicious in itself.

     If you arrive on a scene and all appears well, you will exit the ambulance, approach the scene and begin patient care. Maintain a sense of awareness even as you care for your patient, since emergency scenes are dynamic.

     If you arrive on the scene and find danger, do not enter. Leave, and request law enforcement to secure the scene.

     There are many gray areas in EMS between the safe and unsafe scenes described in the previous paragraphs. In many cases, you arrive on scene and develop a slight sense (sometimes called a gut feeling) that something is wrong. It isn't anything concrete, but it is a sense you can't ignore. This is the true application of situational awareness. On the imaginary 0-10 scale, raise your awareness level. If you decide to approach the scene-and in many cases, there may be no reason not to do so-raise your awareness level to a 6 or 7. Move slowly and carefully. Watch windows and doors. Have the dispatcher call back to the residence and ask an occupant to come out to meet you when possible.

     When approaching a scene cautiously, use the following tactics:

• Turn off your lights and siren in advance of arrival. This prevents broadcasting your arrival and drawing larger crowds.
• Take a nontraditional approach to the door. Those inside the residence will expect you to take the walkway. Don't.
• Observe and listen carefully for signs of danger as you approach. Look for motion in windows. Listen for signs of fighting (loud voices, items breaking) or intoxicated persons. Note darkness and unusual silence as a concern at a scene where an emergency is allegedly taking place.
• When standing at the doorway, listen before knocking. Stand on the doorknob side of the door (opposite the hinges) when possible. Never stand directly in front of a door.

     Using increased awareness and appropriate approach tactics will result in one of two resolutions: carefully moving toward the scene and discovering it is safe, or identifying a danger early and retreating until law enforcement can secure the scene.

Scene Safety Tactics
     When you identify potential danger, or if you find yourself suddenly in a violent scene, there are tactics that will help you respond appropriately and retreat from the danger.

     When faced with danger or violence, retreat is the first and best choice in almost every situation. The exception to this rule is when you are backed into a corner or otherwise unable to retreat without increasing your risk. How far should you retreat? The general rule is that you should put more than one obstacle between you and the danger. There are two things you can put between you and the danger: objects and distance.

     Distance is good. More distance is better. But distance isn't enough to protect you from gunfire. Putting solid objects between you and the danger offers additional protection. The concept of cover will be discussed below.

     There are many misconceptions about retreat. Retreat is not a sign of weakness. It is not considered abandonment if you retreat from a scene that you can document as dangerous until law enforcement secures it-even when a patient remains at the scene. And there are times, such as when the patient is already packaged or can be quickly moved, that you can take the patient with you when you retreat.

     Cover and concealment are terms used to describe barriers that can be placed between you and a violent person. You have most likely heard of people in dangerous situations being told to "take cover." Simply stated, concealment hides the body from view, while cover hides the body from view and offers protection from bullets.

     Cover is a dynamic process. You won't simply find a position and stay there. In many cases, you will find a position of cover and begin to search for the next position of cover that will take you farther from the danger if necessary.

     Distraction is another tactic used for safety that is often combined with other tactics like retreat. For distraction, equipment and other objects at a scene can be used to slow down an aggressor. A kit thrown at a subject's legs, a stretcher wedged in a doorway or doors slammed closed during retreat can slow the progress of the aggressor and buy you valuable time.

     Don't forget to communicate the dangers you have observed to other incoming units and the police. This will prevent other units in a tiered response from facing the same dangers you did.

Conclusion
     While EMS is generally safe and most calls are uneventful, the dangerous calls often provide subtle clues that the aware provider can identify to avoid danger. The fact that most calls are safe often lulls EMS providers into a false sense of security that the next call will be as safe as the last. Unfortunately, there is no way to guarantee any call is safe or dangerous based on the type of neighborhood or chief complaint.

     EMS providers must maintain a level of awareness on every call. This is called situational awareness and can vary from minimal to intense based on changing facts as a call unfolds. Tactics like retreat, cover and concealment are beneficial when your heightened awareness uncovers danger. Remember: Waiting for danger to surface means you are reacting too late. Awareness and observation-performed on every call, every day-are the keys to being safe in EMS.

CEU Review Form Scene Safety (PDF)Valid until August 4, 2006

Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, Maine, and a faculty member at Southern Maine Community College. He is the author of several EMS textbooks and a nationally recognized lecturer.

Joseph J. Mistovich, MEd, NREMT-P, is a professor and the chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.