Your Captain Speaking: Scene Safe or Scene Secure?

“Samantha, there’s an important difference between a scene being safe and being secure that all of us in EMS need to know.”

“Dick, every time I’ve gotten tested in a classroom scenario, I’ve always parroted the phrase Is the scene safe? But maybe I don’t understand the question I’m asking? Break this down, as this is pretty much the first step in every call we’ve ever been on.”

In EMS, we’ve gotten so used to this phrase we might have blown right by the real meaning and what we should be considering.

The question of scene safety is not a one-time evaluation that’s good for the duration of the call. Things can change rapidly. Sometimes one particular area will get better while other areas deteriorate. Scene safety is no different.

Three Levels of Safety

In a recent article, the NIH stated that EMS providers should evaluate every scene on three different levels, and the first level must be met before moving on to the second or third.¹ Furthermore, when entering a scene, responders are taught to follow a specific order of priority:

Personal safety. You should reasonably expect to not suffer a physical injury in the short term, but neither should you suffer a longer-term illness from exposure to toxins in the environment (viruses, chemicals, bacteria, etc.) Immediate physical injury to the EMT can come from a number of sources and you need to be creative to recognize them. Bystanders can be helpful or hurtful on a scene. We are all clear-eyed about how an uninjured person at a domestic violence scene can suddenly cause havoc, but we expect that less on other calls. The world is not predictable but we should reasonably expect an outcome based on our observations and what information we have gathered.

Safety of partners or colleagues. After you have evaluated the scene from your own perspective it needs to be checked with respect to the other responders currently present or those who will be needed. What are their abilities, experience, and perhaps weaknesses? How additional responders should approach the scene could be a critical factor. Do we need a lift assist? Back injuries in EMS are common yet we too often are shy to ask for an assist. At a roadside scene, responding vehicles sometimes inadvertently channel first responders into lanes of traffic as they work the crash. NIH overlooked mentioning the safety of bystanders as a factor in the second step, and only indirectly considered them. Crowd control requirements can be critical and can prevent you from getting to the patient, including bystanders blocking you from patient care. There may be dangers to bystanders they do not envision. You may be able to delegate to another agency or you may have to do it yourself.

Care of the patient. First, do no harm is part of the Hippocratic Oath. I can’t think of a case where dropping a patient will make things better. Sure, it hurts to have an IV started or a wound bandaged—that’s not what we’re talking about here. There’s a decision to be made when running lights and siren to or from a scene. This is an increased risk vs. reward judgement.

In our experience, there’s a palpable difference between a 9-1-1 call made by the patient vs. one by another person. If made by the patient, it’s a tangible sign they are requesting help. If the call was made by a bystander, family member or other acquaintance, there’s a good chance the patient wants nothing to do with EMS. Attempting to deliver care to a patient who doesn’t want it can be unsafe for everyone involved—both physically and legally.

Safe vs. Secure

You are not allowed to skip any of these three steps and progress to the next. According to the NIH, “Any threat to one prevents moving forward to the next.”¹ This means that safety is a continuum from personal safety to the safety of the other first responders. Only then do you move forward to care of the patient. You move up the scale from one to another, but likewise you may need to move back.

There are no guarantees in EMS. The best we can do is evaluate the situation as most likely to be safe at that moment. Scenes change for better or worse. Sometimes the answer to patient care is to move them to a higher level of care. If asked What did you do for the patient on that call? the best thing might be that you moved them to a higher level of care.

What’s the difference between safe and secure? Have you or your service decided which you are willing to respond to? If police or fire can get EMS to the patient without unreasonable risk to EMS, they consider the scene safe, even though there is still a potential physical confrontation or active fire somewhere else. You could consider a scene secure if all reasonable factors are under control.

Back to the Basics

Let’s use the example of an active shooter at a school. (You could also imagine a mass demonstration.) Back to the basics. One of first things we ask is, Is the scene safe? We’ve covered the three steps and we can’t skip any of them. We should be doing this on every call.

We can’t be sure before we arrive that a scene is safe or secure, even if police are on scene. You might need to ask whether the scene is secure or merely safe. Be prepared for change—many of us have been on scene where a domestic episode escalates from verbal to physical right before our eyes.

It’s standard practice for EMS responding to an active shooter situation to post some distance from the scene until police declare it secure. Is this what we should be doing? After the Columbine school shooting, police procedure changed from “surround the location and wait for SWAT” to enter-and-advance as soon as there are two or more officers on scene. The reason for this is to deny mobility to the shooter(s) and, if possible, engage. The officers can also provide critical intelligence to the commander but their objective is not to stop and treat victims. As it turns out, people who are trying to provide both security and medical aid do poorly at both. I have seen this both in the military and civilian worlds.

In many municipalities, EMS is often expected to follow police into active shooter scenes if they are with two or more officers. In this instance, the scene is considered safe but not secure. It’s an important distinction for your own procedures and responsibilities. When the event is over, will you be criticized publicly, and perhaps legally, if you did or not enter a scene considered safe but not yet secure?

Much of this comes down to training and procedures. Did your employer—municipality, volunteer, or private service—provide specific training on what you should do? Secondarily, are these actions supported by written and approved procedures?

Now is the time to ask, in advance, what is expected of you and what you're willing to do. Clearly, not every situation or potential circumstance can be anticipated and prepared for. But it is a good discussion to have with your partner as a start.

Think of yourself, your partner, and other responders as well as your patient when you ask that ubiquitous question: Is the scene safe?

1. EMS Scene Safety. Taylor A. Klein; Prasanna Tadi., NIH, National Library of Medicine, National Center for Biotechnology Information, May 8, 2022. Accessed via https://www.ncbi.nlm.nih.gov/books/NBK557615/

Dick Blanchet, BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Missouri and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years. He is a graduate of the US Air Force Academy with an MBA from Golden Gate University.

Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia EMS in Illinois, and a full-time paramedic at the St. Louis South City Hospital emergency department. She was recently recognized as a GMR Star of Life.