Violence Against EMS Providers: What Can We Do About It?

Violence is a complex issue, and responding to it in ways that are appropriate, effective and acceptable (socially, morally and legally), especially for helpers and healers, is even more complex. It becomes especially challenging when decisions involve business or governmental entities, where issues of employer involvement and liability come into play.

The question raised by some colleagues about arming EMS practitioners is a deep one. We admit up front that we think firearms are not the solution to our very complex problem—few of EMS’ violent encounters involve such application of deadly force that the use of deadly force would be justified in response. But the discussion is a symptom, indeed a significant one, that something is wrong. Our brothers and sisters in the field are afraid (not the cowardly afraid, but the thoughtful, mature state of mind that recognizes that violence is a possibility for which they are not adequately prepared), but talking about being afraid of violent encounters is not “cool”—so discussion instead leaps to an easy-to-grasp, dramatic and controversial “big” solution that raises more questions than it answers.

At the same time, at the organizational level (public and private), in educational institutions and in state EMS offices, this topic is rarely discussed. Managers and executives don’t see the problem because violent encounters are mostly not reported. For a number of reasons, EMS seems to have developed its own “don’t ask, don’t tell” culture—bosses don’t ask, and medics don’t tell. Educators give the topic short shrift because it is poorly addressed (if at all) in textbooks and teaching resources, and most educators are neither well informed nor equipped to address it. Regulators, not seeing a problem either, have bigger matters to contend with.

So what’s the deal? Violent encounters are of concern to medics in the field, but not the structures that support them? Why not?

The Problem

Violence against EMS practitioners takes many forms. Most acts of violence are less than deadly. The risk of non-fatal assault resulting in lost work time among EMS workers is 0.6 cases per 100 workers a year; the national average is about 1.8 per 10,000 workers. Thus the relative risk of non-fatal assault for EMS workers is roughly 30 times higher than the national average. Over a five-year period during which 91 line-of-duty fatalities were identified, 10 (9%) were violence-related.¹ The relative risk of fatal assaults for EMS workers is about three times higher than the national average.

The National Association of Emergency Medical Technicians (NAEMT) found four in five medics have experienced some form of injury as a result of the job. The majority, 52%, claimed to have been injured by assault. More than 20% ranked personal safety as a primary concern.² Yet this issue is not widely discussed and not considered a priority by EMS executives, researchers, educators or practitioners. This attitude lies in stark contrast to those of our law enforcement and fire suppression colleagues, whose culture, training, equipment selection and daily activities focus first on survival. “Everybody goes home intact at the end of the shift” is deeply ingrained in the culture of the police and fire communities.

A majority (54%) of respondents to a recent survey of rural EMS practitioners reported they had not received any employer-sponsored training on dealing with potentially violent situations, although 25% said they had been physically assaulted while performing their duties.³ A study in Australia found that rural ambulance officers reported nearly twice the instances of violent encounters as their urban counterparts.⁴ Recent articles, papers and programs in Canada,⁵ the United Kingdom,⁶ France⁷ and Australia⁸ address this issue in a variety of ways and demonstrate that it’s a universal phenomenon.

It is believed, though it has not been studied, that not reporting violence against EMS is widespread throughout the United States. Many of us accept it as “just part of the job.” Yet when providers fail to report assaults to anyone, including law enforcement and supervisors, administrators remain unaware of them.

As a result of this apathy or embarrassment, violence against EMS providers seems to have not achieved prominence as an issue. If there are not “numbers” and sentinel events, other issues may squeeze violence out of discussions that lead to widespread change. There may also be a bit of hoping for the best, or believing that violence will only impact others. Accordingly, quality training on this issue is the exception, rather than the rule.

No other profession accepts being the victim of assault as a legitimate function of the job. Law enforcement officers, among those most assaulted in the professional realm, respond with a zero-tolerance policy—nobody assaults a cop and moves on without consequences. Why doesn’t EMS?

Institutional Culture and Training

Our institutional and cultural approaches seem to be formed at an early stage of EMS training, where considerations of safety are superficial, represented by a single check-box that asks “Is the scene safe?” at the beginning of practical skills stations, followed by “I have my gloves on” or some other singular approach to body substance isolation. Candidates are never presented with unsafe scenes, and the use of actual protective devices is rarely a part of the evolution.

The oft-quoted maxim “Train as you fight and fight as you train” is as relevant to EMS as it is to the athletic field or battlefield. When placed under stress, we will revert to our training for tools to solve the problem. That is good, as long as our training is correct (i.e., has taught us to do the right things) and sufficient (i.e., we’ve had enough of it so the desired actions are almost unconscious in nature). If our training teaches us to do the wrong things, we will do things that aggravate the situation, not improve it. If our training is insufficient and our responses not second nature, our responses will not be effective. If we don’t have training, there are two possibilities: We will freeze (and get hurt), or we will pick the wrong tool to solve the problem.

The overly simplistic approach of EMS to the possibility of violence is carried further by those who say, “I don’t belong on violent scenes—I’ll just stage until law enforcement arrives.” That thought pattern is a good one, as far as it goes. Medics should not enter unsafe scenes and should, in fact, wait for law enforcement to stabilize them if there is violence in progress. Yet a quick look at the cases in the sidebar reveals other possibilities. First, an EMT may enter a scene not known to be violent without the presence of police (as we do on the vast majority of calls), and for some reason the scene turns violent. Second, a medic could get seriously hurt as the result of a violent encounter that did not occur on a dispatched incident. Injury through these scenarios is probably far more likely than through “known violence in progress” types of calls.

Consideration of the Issue

In the EMS community, we have a history of jumping from problems to solutions as quickly as possible, without always considering all the evidence. It is possible this approach has helped prevent the issue of violence against practitioners from getting the attention it deserves. Complex non-clinical issues in EMS often require a complex balancing of concerns and interests among labor, management and the educational process. Buy-in from leaders, field personnel and educators is necessary for these problems to be addressed. An irresponsible approach by one group can cause other groups to withdraw from the problem-solving process, eliminating the possibility of resolution.

Too many discussions of EMS violence lead right to discussions of whether EMS personnel should carry firearms on duty. In addition to being ill-considered, this discussion is offputting to managers and educators—managers because they don’t see the problem and don’t realize its magnitude, never mind the risk management concerns, and educators because they can’t visualize how to incorporate something so complex and radical into the existing EMS educational system.

Our approach to the issue of violence should be similar to our approach to other issues: We should conduct research so that we thoroughly understand the problem, develop a body of knowledge and then develop evidence-based solutions. We face the ever-present problem of lack of a central reporting repository, but that obstacle can surely be overcome.

Legal Environment and Issues

EMS practitioners are mostly not sworn law enforcement officers (LEOs). When confronted with violence, we have no legal duty to confront and control offenders or place or keep them in custody. As non-LEOs, our approach to violence should be limited to preventing violent encounters if possible and escaping them once they escalate.

There is a misguided notion in some parts of the EMS community that practitioners who evacuate unsafe scenes or allow “patients” to escape may somehow be committing the tort of abandonment. Not so! Abandonment is generally defined as the termination of the provider-patient relationship by the provider, without the consent of the patient. The patient who attacks, or threatens to attack, an EMS provider has functionally granted his or her consent to termination of the provider-patient relationship.

The use of force by persons who are not LEOs is subject to limitations. Generally, a private citizen can use reasonable physical (less than deadly) force to defend against an attacker using physical force. Physical force is force not likely to result in death or serious injury (generally, an attack with empty hands). Physical force must be reasonable (as determined by a jury) and the minimum necessary to stop an attack. Deadly force (likely to produce death or serious bodily injury) can be used only when the user reasonably believes the attacker is about to use deadly force against the user or another person.

Under no circumstances is a private person justified in using physical force or deadly force if he or she provokes a fight, starts a fight or continues a fight when the circumstances do not justify the use of force. This may seem obvious, but in discussions of violent encounters in EMS, it appears that many arise when the practitioner goes too far in trying to force their services upon an unwilling person, or treats a patient in a manner that is perceived as disrespectful or lacking in compassion by the patient, family members or other bystanders.

The Firearms Question

There have been many animated discussions about whether EMS personnel should be permitted to carry firearms for personal defense while on duty. This is a very complex issue—and one which requires different pathways depending on the state, the nature of the employer and a variety of other factors. The right to keep and bear arms is not an unlimited right, and the right to use those arms is even more complex.

Many states have “shall issue” concealed-carry laws that allow private citizens not explicitly disqualified (for example, convicted felons) to easily obtain concealed-carry permits. However, these permits are subject to a variety of limitations. For example, a particular state may not allow a CCW holder to carry his firearm into a school, bar, post office or other particular locations. Since we can’t have EMS personnel breaking laws while on duty, what has to happen? Do they take the time to remove and secure their weapon before going into the scene? Do we then require that every ambulance have a gun safe? Much of this sounds like stuff that would impair the prompt delivery of care and distract the EMS crew from the business at hand.

Deadly force is only one option on what law enforcement describes as a “continuum of force” that escalates against threats. Law enforcement officers are trained in the full spectrum of response to threats of all types, ranging from passive resistance to deadly threats. This spectrum includes:

• Presence (of an authority figure)

• Verbal commands

• Soft physical force (restraints, joint locks, etc.)

• Hard physical force (punches, kicks, throws and takedowns)

• Impact and chemical weapons

• Electronic immobilization devices

• Lethal or potentially lethal force.

Before an organization takes a position on allowing on-duty carry of firearms, it needs to consider all aspects of responses to violent encounters, including the entire force continuum, and the training issues associated with each step. The organization, as the employer (whether personnel are volunteer or not), is legally responsible for the actions of its employees and must make sure they:

1. Develop the necessary skills to deal with likely threats (a great investment in training);

2. Maintain those skills at a level of proficiency (periodic retraining and requalification); and

3. Use those skills in accordance with established policies.

How often would lethal force be justified? Not very. One researcher found that of all the assaults against EMS personnel in the United States, approximately one per year is lethal.¹ Most issues of violence against EMS personnel do not involve deadly force, and it is not reasonable, in the eyes of the law, to use deadly force in response to a non-deadly threat. Where does that leave the EMT or paramedic carrying a firearm who is confronted by a non-deadly threat? This decision tree is very complex and doesn’t lend itself to analysis in the heat of a violent encounter.

Most assaults on EMS practitioners involve unarmed attacks (punches, kicks, grabs, etc.). Most law enforcement trainers will tell you that drawing a firearm in the midst of a grappling-type attack is a poor idea. Historical data indicate that many police officers shot by criminals have been shot with their own weapons, which were taken away and used against them. LEOs rarely find themselves “locked in” with individuals who may assault them—weapons are removed before entering jails or prisoner transport vehicles. EMS personnel in moving ambulances would face extreme difficulty if any “patient” became aware of their weapon and tried to take it from them.

Few EMS agencies have comprehensive, policy-based approaches to issues of violence against staff. These programs should include a statement of policy, training and tools to implement the policy.

Training EMS

EMS agencies seem to shy away from training their personnel to deal with violent encounters. Some providers and administrators may erroneously perceive defensive training as a form of offensive conduct or fighting. Some fear that if an EMS agency trains its staff in techniques for dealing with violence, the staff my try out their new skills in a manner that could bring harm to the agency. Regardless of its reasons for not providing training for its staff, it would be difficult for an agency to defend the actions of an employee who used inappropriate and excessive force when the agency had not supplied them with training or an appropriate alternative. Not training field personnel in appropriate response can have devastating consequences.⁹

Some agencies, with good intentions, have introduced training delivered by law enforcement “defensive tactics” instructors to their personnel. These courses are often well received by field EMS providers. However, there is an issue with law enforcement defensive tactics—most of them are not defensive at all! All law enforcement combat activities have a single endpoint in mind: control and custody of the opponent. Thus law enforcement defensive tactics instruction may, if not carefully adapted, lead an EMS provider deeper in to a violent encounter, rather than helping put distance between the attacker and the EMSer. These programs also often fail to differentiate between medical restraint and self-defense, and between uncooperative patients whose actions are medically induced (hypoxia, hypoglycemia, etc.) and those engaging in purposeful violence.

Another dangerous path lies in “self-defense” courses offered by local martial arts studios. Individuals teaching these programs likely have no experience in the healthcare environment or with the unique needs of EMS practitioners. Moreover, most martial arts training involves some competition, which means teaching participants to “win,” not to escape. Escape should always be the goal of the assaulted EMS practitioner.

One author (Teitsort) has been involved in teaching EMS-specific techniques—and, more important, tactics for avoiding and escaping violent encounters—for more than 14 years, training hundreds of students. Many students have now become certified instructors, teaching escape from violent encounters across the nation. His programs, known as Defensive Tactics for EMS (DT4EMS) and recently retitled Escaping Violent Encounters for EMS and Fire (EVE4EMS/Fire), bring practical skills for defusing, avoiding and escaping purposeful violence while appropriately managing medical patients demonstrating physical manifestations. These courses, usually involving two days of instruction, are widely acclaimed by participants.

One surprising revelation after EVE4EMS courses: The students uniformly ask for more training, while managers of their organizations too often ask, “Isn’t there a way that you can get this down to 4 or 8 hours?”

The EVE program provides training in four areas:

Train the mind of the practitioner—EMS practitioners need to understand that it’s not just part of the job to be assaulted. EMS agencies, in this same vein, need to learn that employees being assaulted is not acceptable, and that every violent encounter needs to be dealt with appropriately. Practitioners need to understand and believe that it is acceptable for them to defend themselves when attacked, and that there is an appropriate way to deal with noncooperative patients that is different from defending against and escaping from attack.

Train for the street—EMS practitioners need to learn and maintain proficiency in a small number of easy-to-learn, easy-to-maintain physical skills that facilitate escape from violent encounters. Maintaining proficiency is a major issue, because like most psychomotor skills, defensive skills are lost if not practiced or used. All but the smallest law enforcement agencies have in-house instructors who periodically refresh members on these skills; EMS agencies should develop and maintain these important capabilities.

Train for the media—We have learned that every action we take may appear on video, and that almost everyone carries some sort of video camera everywhere they go. EMS practitioners forced to defend themselves need to know how to present themselves in a manner that demonstrates a lack of aggression, and have at their disposal techniques to make it clear that they are the victims, attempting to escape harm. Whoever views that video needs to clearly understand that the EMS practitioner was trying to avoid, not engage in, a fight.

Train for the courtroom—The aftermath of any violent encounter involves other people and other agencies. Proper documentation of an event, using the correct terminology of the law of self-defense, and correct interaction with law enforcement and judicial officers will assure that this stage of the encounter winds up favorably to the medic.

The Organization’s Responsibilities

Just as EMS practitioners need training in escaping violent encounters, EMS supervisors and managers need training in properly managing issues of violence against employees. Such an effort has been underway in the hospital community for several years, under the leadership of the Emergency Nurses Association.¹⁰ The American College of Emergency Physicians also has a policy statement recognizing that EMS personnel should be protected against violence on the job.¹¹ The National EMS Management Association recently undertook a violence initiative intended to bring education and management tools to EMS agencies. Agencies should have policies, procedures and practices that facilitate effective response when employees are assaulted.

Employees should know their EMS organization will support them. This means the agency should have a policy of zero tolerance of violence against employees, and encourage reporting of violent encounters and the prosecution of anyone who attacks a practitioner doing his or her duty. EMS executives should work with police chiefs, sheriffs, state police superintendents, prosecutors and others to develop climates in which assaults on medics are met with the same force of response as assaults on law enforcement officers.

Organizations should have practices and procedures that don’t impede the reporting and prosecution of violent incidents. If, through paperwork, investigations or other mechanisms, a medic who is assaulted is discouraged from reporting it, then the effort to deal with this important issue will fail. Don’t make reporting violence more bother than it is worth!

Classroom discussions reveal that one of the major reasons EMS practitioners tolerate violence against them is organizational cultures that mock them (particularly senior personnel) if they make a fuss about being assaulted. Do LEOs mock other cops who are assaulted? No, they help “cuff and stuff” attackers and take them to jail. Do firefighters mock other firefighters who fall through floors or get hurt fighting fires? Nope—they rescue them and use the lessons learned to improve safety at the next fire. EMS folks need to support and help our brothers and sisters who are assaulted on duty—and assist the perpetrators in receiving their just rewards via the criminal justice system.

Conclusion

The issue of violence against EMS providers is significant, and responding to it is complex. The U.S. EMS community has been remiss in not giving this issue the attention it deserves.

It is time for our national EMS leadership to acknowledge this issue and put it in its place on the menu of issues we must address. It is time for our EMS educators to build responder safety into every day and every module of preservice instruction, creating a safety mind-set like those of our law enforcement and firefighting colleagues.

It is time for employers to support their employees with policies that encourage safe behavior and discourage violence against staffs, and provide their medics with the equipment and ongoing training to stay safe when they encounter violence.

And it is time for every EMS practitioner to step up, be mindful of the hazards in the workplace, and faithfully make use of the tools and training provided to them. We pay lip service to the idea that our employees are our most important assets. It’s time to start safeguarding them the way valuable assets deserve to be safeguarded.

References

1. Maguire BJ, Hunting KL, et al. Occupational fatalities in emergency medical services: a hidden crisis. Ann Emerg Med 2002; 40: 625–32.

2. NAEMT. Experiences With Emergency Medical Services Survey, 2005.

3. Carlson GP. Hostile Workplace: Violence Directed Toward Rural Emergency Medical Services (EMS) Personnel. University of Wisconsin master’s thesis, 2007, www2.uwstout.edu/content/lib/thesis/2007/2007carlsong.pdf.

4. Mayhew C, Chappell D. Ambulance officers: the impact of exposure to occupational violence on mental and physical health. University of Wollongong Research Online, https://ro.uow.edu.au/cgi/viewcontent.cgi?article=1077&context=lawpapers.

5. CBC News. Paramedics Reporting High Levels of Abuse, www.cbc.ca/news/health/story/2011/12/29/paramedics-abuse-report.html.

6. U.K. Department of Health. NHS Zero Tolerance Zone Campaign: Tackling Violence in Primary Care, Ambulance, Mental Health, and Community Settings, www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_4002920.

7. Duchateau FX, Bajolet-Laplante MF, et al. Exposure of French emergency medical personnel to violence. Ann Fr Anesth Reanim 2002 Dec; 21(10): 775–8.

8. Koritsas S, Boyle M, Coles J. Factors associated with workplace violence in paramedics. Preh Dis Med 2009; 24(5): 417–21.

9. Firegeezer. Denver Paramedic Sentenced to 12 Years for Assaulting Patient, https://firegeezer.com/2009/11/14/denver-paramedic-sentence-to-12-years-for-assaulting-patient/.

10. Emergency Nurses Association. ENA Toolkit: Workplace Violence, Step One: Understanding the Issue, www.ena.org/IENR/ViolenceToolkit/Documents/toolkitpg4.htm.

11. American College of Emergency Physicians. Protection From Physical Violence in the Emergency Department Environment, www.acep.org/Clinical---Practice-Management/Protection-from-Physical-Violence-in-the-Emergency-Department-Environment/.

Kip Teitsort, EMT-P, is the founder of EVE4EMS/Fire, which teaches providers to escape violent encounters. He is a veteran paramedic and police officer experienced as an EMS educator and a certified law enforcement defensive tactics instructor.

Skip Kirkwood, MS, JD, EMT-P, EFO, CMO, is chief of the Wake County (NC) EMS Division, president-elect of the National EMS Management Association and an editorial advisory board member for EMS World.