Cases With a Twist: When a Call Turns Violent

Editor’s note: Cases are obfuscated and amalgamated to protect patient privacy and provider anonymity. While staying as true as possible to the actual event, creative license is used to better explain the lesson(s) in the case.

Woman tries to stab Pennsylvania medic in the chest; two Detroit paramedics stabbed and slashed in the face; EMTs shot at, ambulance stolen in Alabama; chief calls stabbings “near-death experience.”

All of these headlines have one thing in common— they all happened in 2015, along with many similar events.

Violence against police receives a lot of media attention. What about violence against EMS providers? The public often does not view EMS as a target for violence, and event reporting and tracking is sporadic at best.

In this article we review a recent attack and outline strategies to mitigate our risk of becoming victims of violence.

Case Presentation

On Wednesday, November 25, 2015, at 10:38 p.m., an EMS crew responded to a domestic violence call. On scene they began treating their patient when a woman holding a knife lunged at the EMS crew yelling, “I’m going to kill you.” She stabbed one of the crew members in the chest and slashed at his abdomen.

The second crew member had the presence of mind to reach for the orange trouble button on his radio. He pressed it, tripping the radio’s silent alarm and transmitting a state of emergency to their dispatcher.

Fortunately the EMT who was attacked was wearing a protective body armor vest, which is still relatively uncommon in EMS. The vest blocked the knife, and the responder did not sustain any injuries from the initial stabbing attempt.

Unfortunately accidental trips of the orange button are common in that system, so dispatchers are forced to check on the crew before sending help. You can imagine the look of dismay on the crew and assailant’s face when the radio chirped: “Ambulance 10, reset your trouble button, we are getting a false alarm up here.”

The assailant, upon hearing the dispatcher’s radio reply, became angry and struck the face of the crew member holding the radio. The radio flew out of the hands of the crew member and a struggle for survival in close quarters ensued. The lack of a follow-up reply after two more unanswered radio transmissions did eventually prompt the dispatcher to send additional help. It is lucky neither crew member sustained career- or life-ending injuries.

The Facts

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. This means 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. The relative risk of fatal assaults for EMS workers is about three times higher than the national average.

From the first day of EMT school, we focus on “gloves on, scene safe.” While it’s great that this is at the top of our skills evaluations, it is often a check-mark that is quickly and definitively answered by the evaluator saying, “it’s safe,” and that mind-set then never changes.

In our opening scenario, it appeared exactly that way on arrival and the responders believed the scene was safe. Unfortunately, scene safety is never static or clear cut. The level of risk always varies as a call naturally evolves. In this case, the violent action was rapid and lethal.

Hindsight is 20/20 and the facts from this case—along with multiple other incidences of violence against our colleagues—may lead many of us to blame the crew for letting their guard down, or a complacent dispatcher for not reacting immediately to the call for help. But in a culture of safety, a root cause analysis would set up processes with multiple redundancies that account for human errors and ensure a systematic response focused on safety. In this case, waiting for or arriving with police to a high-risk event (domestic dispute call), wearing body armor, and maintaining radio systems and protocols so help can be summoned quickly are all key processes.

Current Trends

The increase in attacks on EMS providers is causing some systems to evaluate their preparedness.

Cleveland EMS cited national trends as its reason for mandating the use of bullet-proof vests by anyone responding to any emergency call. The use of vests is not entirely new to Cleveland EMS; they have had a policy in place since 1990 that required the use of these vests in “high-risk” responses. While not all services can afford vests, a thorough risk assessment should be undertaken to determine strategies necessary for ensuring personnel safety.

Another example of protective strategies comes from New York City, where officials established the “Assaults Against Paramedics and EMTs” initiative. In this initiative, legislators and city administration have established more stringent processes for prosecuting those who attack EMS personnel.

Additional strategies that mitigate the risk of violence to EMS providers include:

• Concurrent dispatching of police in all high-risk calls (e.g., suicide, homicide, domestic violence, intoxication, psychiatric illness).
• Staging at a remote location for high-risk calls until police have secured the scene.
• Uniforms that clearly identify EMS as separate from law enforcement.
• Continuous education in the use of de-escalation strategies.
• Continuous education in the use of physical restraints if necessary (and how to determine when necessary).
• Establishing a different set of triage and treatment priorities if the EMS service supports law enforcement or responds to tactical operations.
• Advanced tactical training and defensive skills for close combat encounters.

CRM Tips

• Identify the improbable or unpredictable: In EMS we are constantly considering the worst-case scenario. Scene evaluation should ask that same question. In this case, responding to a domestic dispute should create more intentional situational awareness.
• Post-event review: In a rapid “hot-wash” or more extensive analysis it is crucial we evaluate our performance on difficult cases. Discussing facts and identifying—in a non-blaming, non-judgmental way—different outcomes and processes that worked and those that did not will help prevent the same scenario from occurring again.

Report Events

Please help us identify errors and near-miss events that affect the safety of EMS providers and patients. Report events anonymously at www.emseventreport.com.

E.V.E.N.T. is an anonymous tool designed to improve the safety, quality and consistent delivery of EMS. The data collected will be used to develop policies, procedures and training programs.

Bibliography

Blair BL, Jensen JL, Tavares W, Drennan IR, Saleem H, BSc, PCP, Dainty KN, Munro G. Paramedic Self-reported Exposure to Violence in the Emergency Medical Services (EMS) Workplace: A Mixed-methods Cross-sectional Survey. Prehospital Emergency Care, 2014, 18:4, 489–494.

Corbett SW, Grange JT, Thomas TL. Exposure of prehospital care providers to violence. Prehospital Emergency Care, 1998, 2:2, 127–131.

Fox News. Cleveland EMS crews ordered to wear bulletproof vests at all times.

Heiskell LE, Carmona RH. Tactical emergency medical services: An emerging subspecialty of emergency medicine. Annals of Emergency Medicine, 1994;23:778–85.

Kirkwood S, Teitsort K. Violence Against EMS Providers: What Can We Do About It? EMS World, August, 2012.

Koritsas S, Boyle M, Coles J. Factors associated with workplace violence in paramedics. Prehospital Disaster Medicine, 2009, 24(5): 417–21.

Maguire B, Hunting K, et al. Occupational fatalities in emergency medical services: a hidden crisis. Annals of Emergency Medicine, 2002, 40: 625–32.

PennLive News. Harrisburg woman wanted for trying to kill paramedic, domestic assault.

David Page, MS, NRP, is director of the Prehospital Care Research Forum at UCLA. He is a senior lecturer and PhD candidate at Monash University. He has over 30 years of experience in EMS and continues to be active as a field paramedic for Allina Health EMS in the Minneapolis/St. Paul area.

Will Krost, MBA, NRP, is a fourth-year medical student and a faculty member at the George Washington University School of Medicine and Health Sciences in the Departments of Clinical Research and Leadership and Health Sciences. He has over 23 years of experience in EMS operations, critical care transport and hospital administration.