Point Counter-Point on EMS Scene Staging and Actions at High Hazard Incidents

Point Counter-Point on EMS Scene Staging and Actions

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Introduction by A.J. Heightman, JEMS Editor-in-Chief

A recent Blog post on FireEngineering.com by Mike McEvoy, EMS Editor for Fire Engineering and a member of the JEMS Editorial Board, fired up some readers, authors and educators who wanted to weigh in on the current practices of EMS and fire responders at hazardous or suspicious, potentially hazardous scenes.

“EMS Wake-Up Call” blog post by Mike McEvoy

Mike McEvoy, PhD, NRP, RN, CCRN, is the EMS coordinator for Saratoga County, New York, and the EMS editor for Fire Engineering. He is a nurse clinician in the cardiac surgical ICU at Albany Medical Center, where he also chairs the resuscitation committee and teaches critical care courses. He is the chief medical officer and a paramedic/firefighter for the West Crescent Fire Department and a member of the JEMS Editorial Board.
 The mother of a 13-year-old girl gave me a wake-up call several weeks ago.  After her daughter overdosed on heroin, her husband rushed home from work following a panic-stricken call.  On the way, he passed an ambulance idling on a roadway several blocks from their home.  That same ambulance later arrived to provide care but only after law enforcement appeared on scene.  I knew exactly what the ambulance was doing–staging until the scene was safe.  Trying to explain this protocol to the mother of a child who nearly died as a result was difficult.  She posed a question, “While my daughter lay in her bed dying, your paramedics and firefighters were hiding.  So I’d like to know: Is your priority to provide emergency medical services to the people of this community or to stand by, watching out for yourselves while people die?” I have thought long and hard about that phone call.
EMTs learn about scene safety from the very beginnings of their training.  The concept is drilled on and tested, often becoming a chant uttered at the start of every practical skills evaluation.
Law enforcement learned a game-changing lesson 17 years ago in Columbine, Colorado: If you don’t enter the scene immediately and take action, more people will die.  Their time-honored “Surround the building, set up a perimeter, and contain the damage” tactic went by the wayside.
Since then, countless lives have been saved in active shooter and other hostile events.  EMS may well be 17 years behind the police.
Truth be told, no scene is safe.  Any emergency responder with a little field experience can recall a response where a seemingly benign scene turned violent.  Law enforcement doesn’t describe scenes as “safe” but rather “secure,” implying that they have some perceived degree of control over the perimeter.
To believe that a scene is safe merely because law enforcement is present is delusional.  The fact of the matter is that public safety and emergency response are inherently risky and sometimes dangerous.  Nothing is this business is predictable.
Law enforcement officers know that their response to an active shooter will require them to immediately enter the premises and, at great personal risk, locate and stop the killer.  Firefighters expect that they will need to charge into a burning building, also at great personal risk, to locate and extinguish the fire.
EMS providers expect someone else to eliminate any potential risk or danger before they consider it safe to provide lifesaving care. The first priority of EMS providers is not, as my wake-up caller said, to save lives but to protect ourselves–even if it costs someone else’s life.  I’m not sure that priority can be sustained in today’s society.  Truthfully, it seems horribly and terribly outdated.
The practice of staging EMS resources for every unresponsive patient where drugs or alcohol are involved, every suicidal threat, every elderly nursing home patient who assaults a staff member, every psychiatric-related call, and every response where law enforcement is dispatched needs to stop. Refusing to enter an active shooter or hostile event scene with a police escort to render immediate care to dying victims also needs to end.
This paradigm shift will not be easy and cannot happen overnight.  It will take time, money, equipment, and training.
I’m not sure how EMS became so risk adverse.  Forty years ago when I started working in the streets, we didn’t wait for the police.  We stood to the side of the doors we knocked on, parked next door to suspicious scenes, never turned our backs on a patient, and paid a lot of attention to situational awareness.  When things looked bad, we left the scene, often with the patient in tow.
Over the years, EMS has drifted far apart from our public safety brothers and sisters in our ability and willingness to acknowledge, recognize, and effectively manage the risks we all face.  As a consequence, the public is beginning to question our ability to do our jobs.
Situational awareness needs to be resuscitated in EMS.  Our providers need training in recognizing and diffusing hostile events, minimizing risks, and preventing injuries when violence erupts.
Every EMS responder should be equipped with an active shooter response kit including ballistic protective equipment (BPE) such as a level III steel-plated vests and IIIA helmets.
Crews should train and practice with local law enforcement in the Rescue Task Force Concept, Tactical Emergency Casualty Care (TECC), implementation of Casualty Collection Points (CCPs), and common operating language and radio frequencies.
All of this takes time, but it can and must be done.
When people are dying, they call us for help and expect us to respond.  Hiding around the corner is no longer acceptable to the public we are sworn to protect.  I know I have a lot of work to do at home.
Mike McEvoy, EMS Editor – Fire Engineering & JEMS Editorial Board Member
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Counter-Point

Balancing Personal Safety and Patient Care

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By Robin Davis
Robin Davis is a retired police officer and flight medic, now Deputy Chief of Operations and Nationally-registered paramedic with the Sterling (VA) Rescue Squad. He has extensive experience in designing and delivering personal safety awareness and fear management solutions for diverse clients. With foundational leadership and safety development experience amassed during his nearly 30 years as a police officer and paramedic. He is known for dramatically changing the way EMS providers respond to a crisis.
Over the last few years, there has been a strong push for active shooter training, ballistic vests and rescue task force teams, with the idea of getting the medic to the patient’s side as soon as possible. We all agree rapid assessment, treatment and transport is what saves lives in trauma, but are we going too far? 
I’ve recently read several articles, including Mike McEvoy’s recent blog, about the need for EMS to abandon the practice of staging, with some going so far as to say we should not consider our own lives in the safety equation.
The tragic shootings in Orlando really brought this discussion to the forefront of our collective consciousness. “Why?”, the world asks, “Did EMS stage for such a long time?” I don’t know that answer, I wasn’t there. Law enforcement probably had a very good  reason to hold EMS back, including industry practice and policy.
I’ve heard people say that police and firefighters go into dangerous situations to save lives while paramedics and EMT’s “hide around the corner.” It’s as if EMS workers are being called cowards.
But, if you dig a bit deeper I think you’ll find a critical difference in our police and firefighter partners … a means to defend and protect themselves.
A firefighter, entering an IDLH environment is fully protected and armed with a charged fire hose and offensive/defensive entry tools. Their breathing air supply is pure. Their outfit will shield them from the flames and, if the fire blasts into the room, they are armed with a means to protect and defend themselves.
Likewise, if a police officer is doing a building search, he or she is protected by a ballistic vest and a host of weapons to address nearly any threat.
But, what does an EMT or paramedic have? A cardiac monitor, kit, stethoscope and an oxygen bottle? The answer is, NOTHING that offers a similar level of protection or defensive capability!
Have some agencies gone overboard on staging? Perhaps. Should we stage on the overdose or a domestic violence call with reported injuries? The shooting? The answer is a very solid “it depends.”
The accidental overdose of a prescribed medication may not be a reason to delay entry. EMT’s and paramedics the world over are being assaulted, attacked and murdered as they go about their daily business of protecting others. It is unreasonable to suggest they not consider their own safety as they complete their scene size up.
Would we tell the firefighter to rush into a burning building alone, in street clothes with no hoseline? Or the police officer to go to the gunfight in a t-shirt and armed only with a ball point pen? Absolutely not.
So, why are we criticizing EMS personnel for staging? In many cases, staging is the only means of protection afforded to the EMS crew before they enter their own IDLH environment … which may be a darkened nightclub, a living room, an accident scene or the ever popular “man down, unknown cause”?
The question that has yet to be answered is, “where is the data?” How many victim lives are lost as a direct result of EMS crews staging for law enforcement? I haven’t seen a study on that topic and perhaps, it’s time someone undertake such a research project before we suggest that EMS not consider their own safety.
This discussion is certainly going to go on for some time and we do need to find a way to balance the needs of personal safety against the risks of going into hostile environments entirely unprotected.
We are not John Wayne, nor are we cowards. Personal safety and exceptional pre-hospital care are not mutually exclusive.

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An International Perspective from Sweden

“Colleagues pinned down, we are under attack!”

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By Henrik Johansson
Henrik Johansson is a Senior Fellow with The Ambulance Association Ambulansforbundet, the union open for all types of ambulance staff in Sweden. The Ambulance Association is an independent non-political union that unites about 4000 people in Swedish ambulance services that are employed by county councils, municipalities and private contractors.
This headline “Colleagues pinned down, we are under attack!”, could have been retrieved from a war film showing a soldier shouting out a distress call on his radio. But, it is not.
Threats, violence and attacks on individuals who have by their profession as ambulance personnel and dedicated to the emergency sector chosen to help other people is a blow against our democracy and the principals that should imprint a constitutional state. Ambulance staff have been assaulted, threatened to life and shot at with firearms.
The headline I present is not a quoted distress call taken from a war film, it is, in fact, retrieved directly from reality; a reality that is so intimidating to some people that they deny the likewise.
Just a couple of hours ago, two of our Swedish ambulance colleagues where fighting for their lives, attacked by the person they were sent to help; a person who was everything but a patient, a person who assaulted a mother and a father, a sister and a brother, and our colleagues who have chosen to wear The “Star of Life”.
In Sweden, violence against ambulance personnel is becoming a more frequent occurrence:
  • A few weeks ago, an ambulance colleague received a hard blow to the face; the colleague coming home to his family with a well swollen and bloodshot eye. His children started to cry and wondered what had happened.
  • Two months ago, two ambulance colleagues where dispatched to rescue a person. In the dispatch information following they read only that it was a “fracture”. Once on scene, the patient was found to have a gunshot wound and were told by threatening bystanders that they were not to snitch about it because, if they did tell, they would be “dealt with”! As a result of this, several of my colleagues do not wear nameplates any more.
  • Several months ago, ambulance colleagues received threats and were assaulted when they were dispatched to an address that was well known by the police as a particularly hostile address. The incident was the last straw for one of the responders who left the service.
  • Eighteen months ago, another ambulance colleague had their life threatened and was forced into a car followed by a nightmare journey with reiterated death threats. That ambulance colleague still has nightmares regarding the incident and also continuous trouble working night shifts.
  • Two years ago, two ambulance colleagues where threatened with a knife by a notorious violator. He repeatedly tried to slash/stab them without success. However, the two involved responsers are still undergoing psychotherapy once a week.
  • Three years ago, an ambulance colleague was helping multiple gunshot-wounded patients and was threatened by several assailants while caring for the victims. They made it clear to him that they had weapons and would not hesitate to use them if needed. That collegue is now taking medication for insomnia, has a high alcohol consumption and is suffering of intermittent nightmares.
We do understand but we don’t want to understand.
How often do we hear or say, “what is it with people”, especially when we read about a violent act against personnel in the emergency sector. Reports are more frequently appearing on social media and in news links.
We express that we don’t understand, but it is my belief that this reaction utterly an expression of evasion. It is not that we don’t understand, we don’t want to understand.
We understand that there are people who want to hurt us, and that they are prepared to do so. The frequent drizzle of news broadcasts featuring the price set by the lack of values, unfortunately, over time, becomes a normalisation.
To deny the growth of collateral communities, gang structure and heavy crime rate benefits no one.
Mention things by their actual names
Those who chose to believe that recurring shootings and violent riots don’t concern or impact decent citizens or responders are simply ignoring the facts. It is brutally misleading to describe violent riots as “disorder, disturbance or social commotion”.
It is alarming that community resources who are dispatched to help others are being met with a rage that implicates danger of life for as well as emergency personnel and residents. Throwing stones, firebombs and the use of weapons doesn’t create a forum intended for dialog.
Many in EMS are being provoked by the normalisation and the re-written conversions about the severity of the recurring violence, especially when politicians speak of the high cost of preventing interventions, such as a campaign to educate people not to attack or violate rescue personnel who are being sent to help them.
To tell you the truth the throwing of stones and the use of weapons doesn’t create a forum intended for dialog.
Here is how one ambulance colleague commented on the rising violence
“Within the ambulance service, we now handle trauma that use to be [primarily in] the military medics domain. I have lost count of all gunshot wounded patients I have treated”
 It is natural and human to feel anxiety regarding this destructive progress. We are more vulnerable than ever. Legislators must address the judicial system, the emergency service and the healthcare to meet the increasing rate of excessive violence.
We must revise of our (Swedish) laws is needed allowing for identification and warning of responders about well-known addresses of potential risk, providing civil servant protection and reinforcing security. This must come from community and national authorities rather than from solitary trade associations, trade unions and political parties.
After a “Round table” meeting with the minister of home affairs which I attended in early February of 2016, there is nothing to report, only silence reigns.
The actors who want to make this issue to a oratorical and pointless battle of words must let reality in. The security regarding emergency personnel must have a new place on the political agenda.
Legislators must realize that silence and fear often goes hand in hand. It’s about time to speak loud and clear about how vulnerable the Swedish ambulance staff, fire fighters and police officers are.
We experienced this again yesterday when the alarm sounded: “Colleagues pinned down, we are under attack!”
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Additional Follow-up Comments by Mike McEvoy

I will assert once again that the job of EMS is to stop the dying in active shooter events, not stop the killing.  Once the police do their job of stopping the killing, then EMS needs to move in and stop the dying.
Therein is our modern day problem: we don’t communicate well enough to pull this off (leaving people to die from delays in care) or we don’t have the resources needed to do our job (i.e., bullet-proof PPE, tactical medicine training and proper equipment, training drills with law enforcement).
Until EMS steps up the call of their communities and gains the skills and desire to respond to volatile social situations, the equipment and training needed to work collaborative with law enforcement in responding to active shooter and hostile events, civilians are going to continue to die needlessly.
I see no need to risk the lives of EMS providers or increase the risks they currently face every day.  I do object to risking the lives of civilians because EMS is ill informed, poorly equipped, not willing or not able to respond to life threatening emergencies.  There is no excuse for not responding to 9-1-1 calls.
We must assure that every responder is appropriately equipped and trained to answer any call they receive.  Delays in care due to lack of appropriate protective equipment, insufficient training in scene and crisis management, or unwillingness to respond are not acceptable to society and should not be acceptable to any EMS administrator, board member or chief.
The number one job of EMS it to stop the dying.  Any delay in responding is unacceptable to the patients we serve.  EMS providers must be trained, equipped and prepared to answer the call of the public without delay.
Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator – Saratoga County, New York EMS Editor – Fire Engineering magazine Chief Medical Officer – West Crescent Fire Department EMS Section Board Member – International Association of Fire Chiefs Chair – Resuscitation Committee – Albany Medical Center Hospital
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Concluding Comments by JEMS Editor-in-Chief, A.J. Heightman

This is a spirited but timely discussion of how the job, and life, of EMS and fire responders has changed.
After the Baltimore riots last year, I did a ride-along in West Baltimore to see the damage caused by the rioters and hear what was occurring in the aftermath.

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Baltimore City Fire Department (BCFD) EMS responders I spoke to told me they had never felt threatened in their jobs until last year’s riots after which the community suddenly changed their attitude about EMS, lumping them in with the police officers that they felt they could no longer trust.
I witnessed this first-hand on a response to a pedestrian stuck by auto during a rainstorm. We arrived and found a 30-year-old African American woman with minor injuries, sitting on a curb. She, and her friend were both inebriated.
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The friend was screaming and carrying on and would not allow the EMS crew to assess the patient. So, a very polite African American police sergeant stepped in and asked her to stand back and allow the paramedics to do their job. When she refused, he politely repeated his request.
The women, after the second polite request, jumped back in a huff and threw her hands up, shouting, “I get it, Hands Up – Don’t Shoot!”
The officer, as surprised as we were, said in reply: “Ma’am, I am one of you [African American]. I have been a Baltimore police officer in this district for 20 years. Please do not do that to me.” That was what I call, a statement of the times, with all responders lumped together as untrustworthy.
Later that evening, the crew told me that they BCFD had a crew assaulted at a wedding reception by bystanders soon after the riots, upset that they were delaying care on scene. The crew said their personnel had never felt the need to have ballistic vests in the past, but many were now changing their position.
That’s because the times, and attitudes are unfortunately changing. Just as our enemies in wars no longer respect the Red Cross on the helmets of military medics and, in fact, try to kill them to ensure that care capability is taken away from our injured on the battlefield, EMS providers are no longer safe from harm.

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I will summarize my opinion in a few bullet points:
  • While noble, the Hartford Consensus documents, written at the request of the Obama administration, is just the tip of the iceberg. To combat and prepare for violence, particularly violence directed toward emergency responders, we need funding to properly train and equip all urban and rural, paid and volunteer EMS responders, not just police, to use wound clot dressings, tourniquets and occlusive chest seals for stabbing, gunshot and IED victims.
  • We also need funding for ballistic vests and inexpensive body cameras for agencies that want them. The public films what they want to film and release with their cell phone cameras, but we do not have complete assessment and care footage at violent encounters to protect us in the event of false accusations of delays in care or inadequate care.
  • We also need funding to train all responders to safely de-escalate, perform defensive tactics to protect ourselves, or retreat when we are threatened or attacked.
  • I am lukewarm about requiring all EMS/fire personnel to participate in “warm zone” advancement at hostile or active shooter incidents because not all responders will feel comfortable doing so, particularly because the officers surrounding them in a diamond pattern are armed and they are not. Responders, game to “go in” when hazards like knives, guns and IEDs are potentially involved, should be identified, trained and properly equipped.
  • Most importantly, law enforcement officials must involve EMS/fire agencies more closely in their plans and training, rather than view us at pawns that should just stage with limited knowledge of the tactics or command decisions being implement.
Have an opinion? Let us hear from you because you are the agents of change that must push elected officials and legislators to but their money where they mouths (or documents) are.
 

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