Your crew is dispatched to a seemingly benign medical emergency call outside of a homeless shelter for a third-party call of a “man down.” You and your crew advise dispatch that you are on scene investigating. Numerous homeless people are standing in a circle around what appears to be a man lying in the grass. You get a sick feeling in your stomach, your breathing picks up, and you feel a jolt of energy that you realize is an adrenaline dump.
Why did this happen? Are you in danger based on the facts so far? Did your brain compute something that you are not fully aware of yet?
On your approach, you and your crew receive some hostile looks from a few homeless bystanders. There is a man, barely audible, cursing under his breath as you walk to the man in need.
You ask the group to disperse; some people move, others do not. One man says that the patient is his brother. Another asks, “What took you so long to get here?” You respond that the city is busy now, and your crew is coming from three districts over. He states, “You took your time because you don’t give a damn about the homeless.” You tell him that this is not the case. You ask for everyone to back up again. A few more people back up, but three men remain standing around the patient.
You begin to check the patient’s status. Is the person “alert and oriented to person, place, time, and situation” (A & O × 4)? The man smells of ethyl alcohol and marijuana. You get no response, so you attempt a sternal rub and he moves slightly in response.
You ask the men standing around if the patient has been using drugs or drinking. The three men become enraged immediately and start to threaten you and your crew. One man looks at a crew member and states, “What are you freakin’ looking at? I freakin’ hate you! You are worse than the police!” The man who claims to be his brother asks, “Are you freakin’ idiots going to do something or just stand there?” You contact dispatch to send the police. This enrages the men even more, and they start to verbally hurl more distasteful and obscene expletives at you and your crew.
Another crew member pulls out an ammonia snap and places it under the patient’s nose; he wakes up immediately and looks at that crew member. He reaches for his pocket and pulls a knife as the others start to kick you and your crew members.
A fight is on now, and you begin to defend yourselves. The police are more than three minutes out, and you hit the emergency button on your radio to have dispatch send more resources and personnel. Luckily, no one is stabbed. You ended up wrestling the knife from the drunken man.
Once the police arrive, all three men are handcuffed and placed under arrest. You and your crew visit the local emergency room for cuts, abrasions, and bruises; no serious injuries are found.
Your supervisor asks how this happened, and you begin to explain the situation. Your supervisor asks the following questions: Did you follow the department’s policies and procedures? Shouldn’t you have asked for the police immediately after being dispatched? Even though you tried to render patient care, was that the correct choice given the circumstances? While defending yourselves, you knocked out a homeless man, and he is suing the department. Could this have been avoided? What else could you have done?
As you and your crew approached, could you have recognized signs and cues in the men’s behavior that would have alerted you that they were dangerous? Do we, as fire/medics and emergency medical technicians, get focus-locked with patient care?
RELATED FIREFIGHTER TRAINING
Violent Scene Response for Fire and EMS Agencies
Scene Safety: Violence Against Firefighters
We do get tunnel vision even though we know that scene safety is paramount. The scene safety training we receive in the fire academy and paramedic school is not enough. At times, because of cognitive dissonance, we become complacent and deny that we are in a dangerous situation. This is where the prefrontal cortex, the brain’s executive thought center, is not in agreement with the primitive part of the brain—mainly the limbic system.
The limbic system picks up on danger cues because it is the area of the brain responsible for our personal survival (i.e., “fight or flight”). This area of the brain has been a part of our primitive biology since humans started inhabiting the earth. The executive part of the brain will dismiss cues and patterns of danger by denying the current situation. Cognitive dissonance means that there are two competing thought processes; one will be suppressed so as not to disrupt what the prefrontal cortex believes is “logical.” This dissonance has led to numerous assaults and some deaths in the fire/emergency medical service (EMS) community. Fire/EMS personnel need another intangible tool to “train the brain” to stay safe. We must recognize the prethreat behaviors to avoid and mitigate a situation before it spirals out of control, upgrade our brain software to achieve cognitive dominance, and lead to better situational awareness.
Human Terrain Mapping and Behavior Pattern Recognition
Military and police personnel have used human terrain mapping and behavior pattern recognition (HTMBPR) to keep themselves safe as they perform their duties. The Six Layer Concept (SLC) of human behavior pattern recognition and environmental understanding is articulated through the layers of HTMBPR: heuristics, proxemics, geographics, atmospherics, biometrics, and kinesics. Fire departments also must keep fire/EMS personnel safe in the field. Prehospital and hospital personnel are assaulted and attacked more than any other profession. The HTMBPR program can keep firefighters/EMTs safe by mitigating risks. This vital-to-understand concept provides us with the correct analytical lens to assess a situation. Looking through the proper lens is the first step. Learning the various signs of danger enables us to make the correct decision and to act on it to ensure a positive and safe outcome. Critical thinking and decision making must also align with our department policies and procedures. We must be able to articulate our decisions and actions to the top brass, the community, our families, and even a court of law. Our problem solving and subsequent decisions must make sense. So, where did all of this originate?
The SLC was developed by the consulting company SLC Squared and is supported and backed by neuroscience, psychology, sociology, criminology, physiology, biometrics, kinesics, and geographical profiling. The military, special forces, law enforcement, and undercover operatives use this training to operate safely in the field, and it is applicable to the fire/EMS community. It is used during calls to keep crews safe. SLC is practical, has depth, and allows for growth and change in our profession. Human behavior is dynamic yet constant; it evolves over time. Even though humans may behave differently based on personality, genetics, and environment, all human behavior has a baseline that can be studied, documented, and observed.
Heuristics are shortcuts used in our decision making. Firefighters, paramedics, and the police use mental shortcuts instantaneously every day when facing situations. They accumulate as the first responder gains experience. Our heuristics are an accumulation of the other five layers in the SLC. The mind will construct a mental schematic or a mental “file folder” where prior experiences and decisions are placed for future reference. We will pull from this file folder and apply successful past problem-solving tactics to a current situation to draw a conclusion and speed up the decision-making process. Beware not to fall into cognitive bias traps—e.g., the confirmation bias—in which we look for patterns and cues that support our preconceived notion of a situation. People who fall into this trap attempt to keep their hypothesis by finding evidence in support of it. This evidence is usually faulty and may not fully support the supposition. This flawed decision making is an example of a bad heuristic and could have devastating effects. Attempting to disprove a hypothesis is how we make concrete theories and scientific discoveries. When we can no longer disprove a hypothesis with evidence, this standing hypothesis has a very high probability of being the answer to the problem.
Proxemics comprises the interpretation of spatial relationships according to cultural norms, tactical considerations, and psychosocial factors. These relationships are the level of proximity a person or a group of people place between themselves and others or objects. Two people walking close to each other reveals a message to outsiders. We intuitively read others’ proxemics naturally, usually without much thought. What does it mean if these same people were seen in the same setting two weeks later, significantly farther apart and not even talking? What is the anomaly? You process more of the larger picture, and you notice a large police presence today in the area. Do they not want to be seen together? Why? Or is it just a personal thing between the two being observed? You also notice that one of them has bruises, and you remember that he was taken to the hospital by another crew last week. You were also informed that he is a drug dealer and a user. What could be going on now?
Geographics provides an understanding of physical geography by analyzing the behavioral interaction of the humans who inhabit it (human terrain). Geographics works in concert with proxemics and atmospherics to provide information on the relationship between people and their surroundings, which determines the significance of social interactions relative to their motivations.
Atmospherics is the interpretation of the environment based on seemingly intangible observations—the sights, the sounds, the tastes, the smells, the mood, or the “feel” of a person, place, or situation. Tangible atmospherics observations include the presence or absence of trash, rubble, graffiti, tattoos, clothing, ambient sounds, people, animals, and traffic. Understand that the six layers are not an A-to-Z checklist or order. Anomalies may present themselves from any layer at any time. Concerning atmospherics, an “atmospheric shift” may be the only observable preevent indicator that you get, so trust your gut!
Biometrics are observable physiological cues that humans give off or convey in response to stress or stimuli. We have no control over our biometrics; they are innate, instinctive, and autonomic. Histamines, catecholamines, adrenaline, and other hormones are released into the system when external stimuli elicit responses such as fear, embarrassment, love, joy, anxiety, and so on. Once these chemicals are released, uncontrollable reactions like pupil dilation, reddening skin, sweating, or heavy breathing occur. Note that not all people will manifest biometric cues the same way, so establishing the baseline and being alert to the clustering of cues are musts. Understanding the baseline is analogous to the pain scale used in the medical field. We use this ordinal scale by gathering data to gauge a patient’s pain level. We ask patients to rate their pain on a scale of 0-10, with 0 representing no pain and 10 indicating the worst pain. The parallel is that ordinal scales are as subjective as a person’s baseline. A 5 on a pain scale for patient A may be a 1 or 2 for patient B, even if the injuries are the same. Subjectivity is very difficult to measure and is relative to the person. The key with baseline is reading an individual’s behavior as unique for that person. Once biometric cues are noticed, these become that particular person’s “signature.” These signatures can be read subsequently and used in further interactions.
Kinesics is simply the way people express themselves through body language and paralanguage. Reading body language is the interpretation of body movements, gestures, facial expressions, and so forth. The body language can be read and compared against the person’s “baseline” demeanor; this is where to look for anomalies and clusters of three or more aberrant behaviors. Studies have revealed that people interpret approximately 65 percent of human behavior and communication through body language. Sometimes, what people say does not match their physical cues. Saying “no” but nodding one’s head “yes” is just one example of words not matching body language.
Another critical facet of kinesics is paralanguage, or the tone of voice, its pitch, and the emphasis placed on specific words in a sentence; these subtle nuances affect the meaning of what is being said. In the following sentence, “I didn’t say he stole it,” the sentence’s meaning changes if a single word in it is specifically emphasized. Within kinesics, these same nuances in a kinesic gesture or cue totally change the meaning of what is said. Not everyone presents the same type of body language or paralanguage. However, you must consider the totality of the behavior relative to the context of the current situation. Has the body language changed based on a tough question? What does this mean? Has the tone of voice changed throughout the conversation? Are certain words being emphasized?
To clarify the sentence example above, consider the following. Emphasizing “I” implies that “I” didn’t say he stole the item in question; someone else said it. Emphasizing “say” implies that I didn’t “say” he stole it, but I imply that the person in question did steal it. Emphasizing ”he” implies that I didn’t say that “he” stole it; someone else stole it. This is how paralanguage is used; it may be used to deceive or to express truth. Context and body language will assist in accurately interpreting the behavior and situation. Understanding the meaning behind what is stated in communication can give the firefighter/EMT cues to the person’s true intentions, the ability to “read” the person, and the context of the situation at hand. Furthermore, it heightens our level of situational awareness, leading to better scene safety.
Staying Safe
Fire/EMS personnel must stay safe in today’s world. We must keep ourselves and our crews safe while serving the community. Since we are within very close proximity to patients, suspects, families, and victims, we have a greater risk of being assaulted and attacked. Learning how to Observe danger, Orient the mind, Decide the best course of action, and Act competently (the OODA loop) within set policies and procedures allows us to provide excellent patient care, fight fires, and initiate rescues while staying safe. Safety is the number one priority because if we are injured, then the victim’s level of care is nonexistent.
Tactical Patience
Moreover, applying a level of “tactical patience” will mitigate our risk factors, too, but allowing the situation to unfold may not always be the best course of action. First responders will usually require approximately 60 to 80 percent of a situation’s facts before making a reliable and accurate decision. Slowing the situation down with tactical patience may make the difference between life and death for the victim and safety for the first responder. If possible, take time to gather all the facts before hastily making life-changing decisions. Be observant and maintain a good level of situational awareness and a high index of suspicion for danger. Understanding human behavior is the key to remaining safe in this ever-changing society.
Jarred R. Alden is a lieutenant, paramedic, and operations officer for the Akron (OH) Fire Department. He has 17 years of experience as a firefighter and 15 years as a paramedic. Alden has a master of arts degree in applied behavioral sciences from Wright State University in Dayton, Ohio, and a baccalaureate degree in sociology/criminology from Urbana University in Ohio. He served as an instructor in sociology at the University of Akron for six years.
Jay Seese is a co-founder of slcsquared.com and has 20 years of experience in law enforcement, working in corrections, patrol, and counter-narcotics, with 14 years in undercover/plainclothes operations. He served five years with the U.S. Army with the military police and in two combat tours.
Lynn Westover is the co-founder of slcsquared.com and has 20 years of experience in intelligence and counterterrorism, with 12 years in U.S. Marine Corps Special Operations and in five combat tours.
