For pre-hospital providers, violent patients may be part of the job, but understanding the cumulative effects of traumatic stress is essential to a thriving workforce.
“Officer needs help. Officer down.”
These kinds of calls heard over the radio send chills down the spines of first responders and the public way too often. And now the calls are changing, and hitting even closer to home.
“Paramedic needs help.” “Medic down.” We stop in our tracks, hoping that our brothers and sisters in trucks are okay, willing things to change.
Paramedics have met with physical violence in Dallas, San Diego, Detroit, Minneapolis, Florida and elsewhere. And it’s not limited to the United States – violence against prehospital workers has cropped up in other nations, from Crimea to Australia to England.
Why is this happening? What are we missing? How do we stop it?
The Provider’s Perspective
From the provider side, it has routinely been communicated to pre-hospital providers that taking abuse and being assaulted are “part of the job.” Yes, you’re going to take swings, be called names, and have patients that fight with you. Just deal with it. Studies indicate that abuse and assaults of prehospital providers that go unreported and unenforced are increasing stress levels not only at work, but also at home. One study out of Great Britain is showing a 15% increase in sick calls from their EMS providers due to stress and anxiety from work . Speaking as a provider on the front lines, we don’t need a study to know that this is true. Walk into any quarters at any ambulance service and ask how they view these hot topics. And bring a notebook. You’re going to get an earful.
A foundational problem is that violence has been accepted as par for the course. The more that these assaults on prehospital providers are seen as the “norm,” the quicker the provider is going to burn out, be less engaged with their patients, and their company. They dread going to work, getting ready for work. They dread their days off because the countdown starts to when they have to go back to work. Burnout, PTSD, alcoholism, drug use…you lose excellent providers to demons that could have been controlled, but weren’t.
Assault can be prompted by any number of issues, but more often than not it involves some sort of intoxicant. The increasing availability and presence of stronger opioids (carfentanil), as well as the synthetics (K2, bath salts, and hallucinogenics) have only made the rates of violent patient encounters rise. Alcohol is no stranger to any of us, and should not be ruled out as a troublesome contributor. Bystanders and family members on scene may escalate the situation or the patient into a state that prehospital providers aren’t trained to deal with on their own, or at all. The key is picking up on small indicators and heading off a problem before it starts.
It is common practice for EMS to request the assistance of law enforcement when responding to potentially dangerous calls as well as calling for immediate help when there is an unanticipated threat that develops during the call. Even so, EMS is still often handed the patient back because of fears from law enforcement that patient may become medically unstable or unmanageable. When such situations occur and the patient has been restrained by police, there are usually rules for the officer to ride in with the crews, but this is only feasible when police staffing allows. The EMS provider then is doing the double duty of providing care but also acutely aware of the personal danger, mitigated but not relieved by law enforcement.
A Lack of Training
On an ongoing basis, pre-hospital providers are offered training for airway management, cardiac arrests, and respiratory issues. That said, training on restraint systems, crew safety, and self-defense are glossed over, or not addressed at all. In a recent study, 75% of providers reported that safety is rarely discussed at their company, although to what extent and depth was not revealed . The same number also reported they had been assaulted by a patient within the last year and that personal safety training was not offered by their organizations . Wake County EMS (North Carolina) and Hennepin County EMS (Minnesota) have developed simulations and scenarios for their providers to work through regarding their safety, but they are relatively new and still in development. Crews are asking for more.
Personal protective equipment has been a hot topic nationwide with regards to EMS. Multiple agencies are providing ballistic vests to providers in order to protect from punches and kicks, as well as the rogue bullet. Some areas are looking into allowing their providers to conceal and carry firearms on duty. Others are looking into tasers, handcuffs, zip ties, self defense classes. Many states have been changing laws so any assault towards prehospital providers is now a felony and a hate crime – a step in the right direction. For a long time, the topic of provider safety beyond “BSI, is my scene safe?” has been uncomfortable, and not addressed. This isn’t a new problem; it’s just increasing. We all thought, “it won’t happen to EMS, we’re the good guys!” But it’s here and it’s not going away. Providers have noticed it and are taking action themselves. We’re taking it upon ourselves to protect each other: we’re investing in ballistic vests if our organizations aren’t willing to provide them for us, we’re discussing what we’re comfortable with on scene and when we bail, we’re willing to break protocol to make sure we go home to our families at the end of shift – because there is no protocol for when you’re assaulted by a patient. How do we change this and how do we protect our providers?
National guidelines and training for prehospital providers may be the best option and forward the career, in general. Training in situational awareness, verbal de-escalation, and self-defensive moves with minimal injury to patient and provider are a few suggestions from providers across the country. Knowing where to sit or stand in an ambulance and where to enter the ambulance when your partner is in trouble in back are also key components that should be addressed. Radio traffic protocols when hailing dispatch for help, steps for administration to take when an event occurs and how to follow up with providers were also suggested. Many providers are asking for the establishment of a national reporting system for assaults that occur towards prehospital providers that is monitored. There are a few anonymous national reporting systems but nothing that is tied to any official prehospital provider association. The mantra we all learned in school regarding patient care of “if you didn’t write it down, it didn’t happen” also applies to our safety. If an assault occurs and isn’t reported and investigated, it’s as good as enforcing the idea that this is “just part of the job.”
The EMS Medical Director’s Perspective
As EMS has evolved since its first inception, we have increasingly asked our providers to do more medical interventions and become true “physician extenders.” While we have given them the tools and training to do these things, we as medical directors have unfortunately not kept pace with the safety and violence issues that now affect our providers on a daily basis. We now have come to understand that PTSD is not necessarily “incident” related, but can well be cumulative in nature, and that these stressors will affect the well-being and performance of our providers. In addition, there remains a substantial dearth of reporting mechanisms and support services for the providers who have suffered these incidents. The concept that the provider should just “forget about it” and move on to the next call doesn’t work, and breeds problems further down the line. Providers who are concerned for their safety are distracted providers and will not be able to provide their best level of care. In addition, they will be more susceptible to health issues, depression and the use of other substances (alcohol, stimulants, and sleeping aids) to self-treat their symptoms. We have all seen good, experienced providers who have “burned out” and can longer perform their jobs, or in some cases even taken their lives. As our providers stay in their profession longer, they will gain valuable experience, but they will also be more at risk for these conditions.
While EMS acquires more equipment and tools for providers to do the tasks we ask of them, we must not lose sight of the fact that our providers are our most important assets. The critical thinking and skills that they bring to a scene are the deciding factors in patients having good outcomes and getting the care they need.
As EMS medical directors, we ask our providers to exercise critical thinking and perform difficult tasks on a daily basis. In order for them to succeed, they not only have to have the right skills and tools, but they must have the necessary psychological and emotional resiliency. The need for further reporting, research and action on these issues is past due, and the longer it is neglected, the greater the problem will become. As EMS medical directors, we need to look at our own practices and services to give our providers the support and training they need to continue to perform well and be well.
Key Takeaways for EMS Medical Directors
- There is accumulating evidence both in the US and abroad that violence toward pre-hospital providers is increasing.
- Pre-hospital providers routinely view violent behavior as “part of their jobs”, and it is affecting not only their job performance, but also their home life, relations with their coworkers and longevity in their careers.
- There is a clear indication that further training and resources are needed to deal with this increasing problem.
- The increasing variety and use of intoxicants is playing a significant role in this problem.
- The option for LE agency co-response in these situations is becoming increasingly more unfeasible.
- We need to establish guidelines for training pre-hospital staff in situational awareness, verbal de-escalation (verbal Judo) and personal protection when dealing with a violent patient.
- We need guidelines for the acceptable use and types of physical restraints, chemical restraints and protective equipment for pre-hospital personnel.
- Encourage readily available debriefing resources to provide staff with relatively rapid help for dealing with these incidents and the accompanying stress.
- Johnson, B. G., Conterato, M. R., Trembley, A., & Lyng, J. (2017). A SURVEY OF THE PERC EPTIONS OF VIOLENCE AND SA FETY AMONG EMS PREHO SPITAL PROVIDERS [Abstract]. Prehospital Emergency Care, 20(1).
Photos by Paul Newson // Top of screen photo of EMS Chief James Goetz of Fort Meade, Maryland.