BY BARRY S. DASKAL
Envision the following scenario: Fire/rescue is dispatched to a report of a 35-year-old female who is “not feeling well.” As the two EMS providers approach, they are met at the door by a uniformed police officer who tells them he found the patient “slumped forward into her food” at her desk when he arrived. Coworkers say she is a diabetic.
Once inside, the two responders observe an approximately 35-year-old female sitting at a desk with the remnants of a grilled chicken salad in front of her and her drink knocked over onto the floor. She is leaning her forehead heavily into her right hand. A few seconds later, her head bobs down and then back up; she makes eye contact with the EMS crew but fails to show any appreciable acknowledgment of the rescuers.
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The lead firefighter steps toward the patient, kneels to reach her eye level, and places his clipboard on the floor. He begins to introduce himself and reaches for his stethoscope. The patient’s head again bobs down and back up and, as the medic raises his stethoscope, the patient jerks up suddenly with a look of fear in her eyes, grabs a knife sitting in her salad bowl, and thrusts it toward the EMS provider’s face. He falls backward and screams as the other students in the room gasp. It wasn’t a real knife; it was a rubber replica. The scene wasn’t an office building but the local EMS academy.
The students’ reactions were what I anticipated. The students began defending themselves, saying things like “I’m in a classroom; I wasn’t expecting that” and “That doesn’t happen around here; it’s not the city.” And, yes, the ever-popular response: “Police were on-scene; they should have prevented that.”
It’s not entirely the students’ fault. From their first EMS class, they are taught about BSI (hand, eye, and respiratory protection) and scene safety, which they typically practice by walking into a scene wiggling their gloved fingers in the air to show BSI and saying, “Scene safety.” At this point, I take out an Internet news clipping dated April 24, 2008, describing a patient with diabetes who assaulted police and paramedics responding to assist him during a hypoglycemic emergency. The patient was restrained and subsequently charged with a crime; the county judge dismissed all charges.1 The only difference between the above classroom scenario and the actual news event was that a knife was used instead of a closed fist.
WHAT IS SCENE SAFETY?
In the fire/rescue-EMS profession, our safety is frequently at risk in ways we fail to perceive. When fighting fire, the enemy is dangerous and unpredictable; but for the most part, we have a good idea of what we might be facing.
Firefighters are trained to think of scene size-up from the time they receive the alarm until scene arrival. When the tones go off and the address is announced, we automatically picture so many things: the neighborhood, traffic conditions, the types of structures in the area, whether there is high fire activity in the area, and whether you anticipate forcible entry problems or excessive life hazards. We use a standard memory-recall technique such as COAL WAS WEALTH or BELOW to form our mental picture. For EMS, a great device to use is ENAMES, coined by JoAnn Berven, an EMS instructor in California.2 (See “Size-Up Acronyms,” left.)
On EMS alarms, there is one additional potential danger to deal with, and it can be just as unpredictable as fire. It’s called the “human element.” You may think some of the points mentioned in this article are overkill or farfetched. I am not saying that you should treat every patient as a potential criminal. What I am saying is that you should think about what “could happen” on any “routine” response. This article focuses on the first “E” in ENAMES, the environment and its dangers. Many of the tactics discussed are from law enforcement training.
ASSAULTS ON EMS PROVIDERS
Assaults on EMS providers are nothing new. However, scene safety and hazard awareness are being more thoroughly emphasized as EMS providers now are gathering and sharing more data on the dangers encountered in the field through podcasts and Internet Web sites. In fact, one interesting Web site, EMSnetwork.org, has a section entitled, “Bodily Assault Log,” which provides links to current news reports of EMS workers who have been injured as a result of violence.
Note: As with all EMS responses, make sure you are guided by your local protocols.
GENERAL APPROACH
Fire/EMS personnel should use tactics similar to those used by police. As you approach a residence, don’t walk or stand in front of windows or doorways. Knock on the door, and stand to the side (photo 1). Announce yourself as, “Fire Rescue,” “Ambulance,” “Paramedics,” or “Emergency Medical Service.” Don’t use the phrase “EMS”not every civilian knows what EMS means.
 (1) Photos by author. |
Environmental concerns include lighting and ventilation. Immediately light up a dark environment. Before stepping into a room any farther than necessary, find a light switch. Your and your crew’s safety must always be the number-one concern. From a patient-care standpoint, it is very difficult to perform a patient assessment in darkness.
The single most important thing to remember when approaching a patient is that if you cannot see his hands, back away and do not enter. Even if a patient appears to be unconscious or down with a serious injury, if you cannot see his hands, do not approach (photo 2).
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No matter how sharp your observational skills may be, you may be risking becoming engaged in a hand-to-hand struggle with a patient who was “playing possum” and hiding a weapon beneath him. This is especially true at scenes where obvious or potential violence occurred. Think of the patient as a possible “secondary device” at a terrorist incident.
Most of us have been in freezing-cold homes or apartments in the dead of winter. Often, you’re responding to a patient suffering from an upper respiratory infection and the only heat in the room is provided by a gas stove or kerosene heater. In addition to BSI and getting oxygen on your patient, you need to open a window for ventilation and your safety (respiratory in this case).
CROWDS AND BYSTANDERS
A recent news story out of Glasgow, Scotland, UK, tells of a paramedic who arrived on the scene of a stabbing before the police arrived. With the scene still unstable and the perpetrators’ whereabouts unknown, the paramedic was forced to stand by a short distance away in her vehicle and watch the patient die.3 I would never second-guess EMS providers for doing what they felt had to be done to ensure their safety. This medic chose not to take the “hero” route and put her life at risk. She likely saved not only herself but also other first responders who would have had to retrieve her as a victim. Nowhere in the job description of a police officer, a firefighter, or an EMS provider does it require getting hurt or knowingly compromising personal safety. This EMS provider followed the first rule of EMS: Your safety comes first.
When arriving at a scene where there is a large crowd, do a “windshield assessment.” Often, the true nature of the call is not clear from dispatch information. You need to exercise extra caution any time you are potentially outnumbered. If you encounter a large group at the scene, call for more resources, especially law enforcement. Even though the crowd may seem to be orderly, that can change in a split second. Public events, particularly where alcohol is being consumed (and even family gatherings), are notorious for sudden and potentially violent “crowd shifts.”
Law enforcement officers (LEOs) are trained to have adequate resources on-scene before dealing with disorderly or large-crowd situations. If you have to go into a bad situation, always coordinate with on-scene law enforcement to make sure you have somebody watching your back. Usually, the LEOs form a wedge (V-shaped pattern) around the patient and EMS providers. If possible, have one member of your crew watch the crowd for any hostile movements. If law enforcement determines the situation warrants rapid extrication from the area, quickly evacuate the patient to a safe environment (usually the back of an ambulance). Law enforcement can employ specific tactics to retrieve a victim in a hostile environment while a crowd is being dispersed.
Any time you step onto someone else’s property or into their home, you face potential safety threats. A well-meaning family member or neighbor may not approve of some aspect of your patient care, be it your demeanor or their perception of the patient care. In California, a “nosy neighbor” asked the firefighter treating a patient what was wrong with the patient. The firefighter told him he was prohibited from disclosing any information to him because of patient privacy laws. The individual came out of his apartment and assaulted the firefighter.4 Most fire-based EMS agencies send a minimum number of personnel (usually two or more members) on a fire apparatus or an ambulance. Safety is everyone’s responsibility; however; one member of the crew must remain continuously alert, specifically to environmental safety hazards. This is generally accomplished by the company officer or another individual who is responsible for taking the patient’s “pedigree information” and medical history from family or bystanders.
POLICE
Many providers fall into a false sense of security when law enforcement arrives or is already on-scene. Sometimes, this can be the complete opposite. At times, the introduction of LEOs to a residence where they are unexpected (“I called for an ambulance, not the police”) can create difficulties, especially with substance abuse patients. At times LEOs may have to take a patient into custody. In one such incident, a police officer arriving at a routine medical call for a patient with difficulty breathing walked by the living room couch and observed a firearm lying in plain view (the EMS team failed to notice it on the way into the residence).
Emotionally disturbed patients (EDPs) and others with altered mental status need law enforcement intervention. LEOs are trained so that their key strategy when dealing with an emotionally disturbed person is to isolate and contain the individual. At that point, a more thorough evaluation of the situation can be made in a more controlled manner and additional law enforcement resources can be requested. At some point, the individual must be taken into custody for his safety and that of those administering medical care. Fire/EMS personnel often become the “calming influence” on these patients, especially after law enforcement has restrained and searched them. For this reason among others, it is very important that only the police restrain the patient (if possible). Again, just because law enforcement is on-scene addressing the immediate problem, it doesn’t ensure your safety. In December 2007, a police officer in Portland, Oregon, accidentally shocked a paramedic with a TASER while attempting to restrain a patient.5
You can care for individuals in law enforcement custody, although it is more challenging. Restrained patients still require patient care. Never transport a restrained patient, regardless of the reason for which he is restrained, with the restraints in front of him. When the hands are in the front, the patient can easily use them as a weapon. If for some reason the hands cannot be rear-restrainedi.e., shoulder injurythen restrain each arm separately to the stretcher or backboard. (photo 3). Close coordination between EMS providers and LEOs is imperative. Many jurisdictions do not allow “patients” to be transported in handcuffs. To the LEO, his priority is his “prisoner,” not your patient. Cravats can often be used efficiently as well, but, again, follow your local protocols and interagency agreements. The time to plan for these events is before they happen.
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One of the most versatile items available is known as the collapsible folding or “roll-up” stretcher. It allows you to wrap the patient up, virtually as if in a body bag or a cocoon, using the straps and restraints without jeopardizing the patient’s airway. Never place a patient in this stretcher in the prone position. If any ventilation issues need to be addressed, “log-roll” the patient to his side (left lateral recumbent position) to correct the problem and then return him to the face-up position.
For patients with spinal injuries, the long board is always the primary option. The main drawback is that the patient’s restrained hands are being crushed by the body weight against the hard surface (long board). Try to have the LEO restrain each of the patient’s hands separately to the long board. One last-resort technique involves using the “scoop” or “orthopedic” stretcher. It provides a minimal degree of spinal support while allowing room for the restraints to rest under the patient’s body. Then place the patient inside the Reeves “cocoon,” taking time to pad the voids underneath the scoop stretcher so the patient is essentially on a cushion and not resting with his hands being crushed by his body weight. Again, this is for extreme circumstances only; be guided by your local protocols.
ANIMALS
Look for any signs of dogs or any other animals. Heed all “Beware of Dog” signs. Be alert for other features as you approach a residence, such as chains, tie downs, or stakes. In certain areas, particularly high-crime locations, look closely for tires, tug toys, or tree limbs. They are often used to train dogs for aggressive behavior. Don’t rely on hearing barking; many dogs have had their vocal cords surgically removed to facilitate a “surprise” attack. Conversely, don’t allow yourself to be surprised by fluffy, puffy little dogs. They may be cute and small, but they can be a nuisance, if not a danger. Exercise special care with assistance canines. Although they are trained to have a calm demeanor, they may be as fiercely protective of their master as any other dog.
The best approach is to have family, friends, or bystanders remove the animal from the environment into a room with a lockable door or a fenced-in rear yard rescuers will not have to transverse. In any event, don’t hesitate to call for police emergency service teams or the local animal control agency.
Other creatures can pose a threat to rescuer safety. Pests such as deer ticks, snakes, and spiders, which can be found in an austere environment, are concerns. Recently in Long Island, New York, rescuers responding to a civilian with chest pains arrived to find the patient with highly contagious bird mites. The patient was removed from the house in a Tyvek® suit and transported to the hospital; he was in isolation at the time this article was written.6
UNSTABLE VEHICLES AND EXTRICATION
These issues have been addressed in numerous other articles. Some things to remember are to properly position your apparatus and to mark your work area with flares or other devices such as “light sticks” if a fuel spill or similar hazard is present. Coordinate lane closures and safety zones with law enforcement at the scene. Dedicate one rescuer to continuously monitor for traffic hazards.
One point that needs to be emphasized is training, especially that between fire/rescue personnel and solely EMS providers. There is a huge difference between extrication and extraction/disentanglement, and rescuers must understand the other’s role. EMS providers should always wear full protective equipment; they face as many hazards inside the vehicle while caring for the patient as the patient. They should also be trained in the use of basic extrication tools. At a serious motor vehicle collision, an EMS provider may not be able to exit the vehicle so someone else can jump in. It may be easier to have the EMS provider make a few quick cuts. The main concern associated with EMS providers’ doing extrication is taking the caregivers’ attention away from the patient. As much as you want to be the one with the tools in hand (akin to being the nozzleman at a job), remember that it is a team effort and you must fill your role as a patient care provider and step aside to make sure the overall goal is accomplished.
HAZARDOUS/TECHNICAL RESCUE ENVIRONMENTS
Fire/rescue personnel may, again, find themselves in the position of having to stand by for further resources prior to assisting a patient in plain view. This is common at the site of an electrocution, a trench collapse, and other construction-related incidents. These situations have a fairly high potential for rescuer injury. Unless you are properly trained and have the right equipment and adequate resources on hand, do not enter the scene. The best care you can provide is psychological first aid or emotional support while awaiting further emergency personnel.
PROTECTING YOURSELF
Safety always starts with your equipment. Make sure you are wearing all your issued safety equipment, firefighting turnouts, EMS gear, and your everyday BSI. If your department issues you a bullet-resistant vest, wear it. If you are routinely stationed to stand by on the street in your ambulance, keep your gear on at all times. Don’t leave it in the rig between the seats or in a compartment so you can put it on just for the “hot calls.” When responding from your station, put it on before getting on the rig. You may not have the time to do it later.
Proper safety tactics for fire/EMS personnel primarily involve two important skill sets: observation and body positioning.
On entering the area, expand your “doorway survey” to include not only your patient but also the surrounding area in a more in-depth fashion. How does the patient appearnot just from a medical standpoint? What is around the patient? Is there anything in the patient’s immediate area that can be used against you? Where are family members and other bystanders? What is their demeanor?
Patients are most commonly encountered in living rooms, bedrooms, and seated at the kitchen table. Attempt to position yourself with easy access to an exit. Attempt to keep all family members in front of you. At a minimum, be certain you have room to retreat backward a step or two unimpeded. Move any potential weapons out of reachanything from the obvious (kitchen knives, beer bottles, hypodermic needles, and fireplace tools) to things you wouldn’t imagine (flower vases, umbrellas, canes, a sculpture such as a porcelain dolphin during a fight over a turkey leg on Thanksgiving). All can become a weapon. Before you laugh, I’ve seen each one of those things used against a victim (initiating the emergency call) or for striking a police officer or an EMS provider. When interviewing your patient, you can subtly slide these items away by maintaining eye contact with the patient and engaging him with your initial assessment and OPQRST-SAMPLE questions. When you move to perform an assessment step, such as taking a blood pressure, do not stand directly in front of the patient. Stay off center and slightly to the side. If you wear an equipment belt, position the hip with your equipment away from the patient. A pen, forceps, or clamps thrust into your thigh will definitely leave a mark.
If the patient is standing indoors, outdoors, or in a large open environment, you and your partner should use triangulation. Position yourselves at 45-degree angles to the patient (a “V” formation). Assume what is referred to as an “interview stance” (photo 4). This is slightly blading your body on an angle to your patient with your strong leg back. The interview stance is similar to a boxer’s stance but not as pronounced. Keep your hands at mid-chest level with your fingertips touching in front of you to defend against any strikes. Holding your clipboard in one hand in toward your body is a great technique and also very subtle.
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Keep a physical barrier between you and the patient. Position yourself behind an item of furniture, a park bench, or another type of protection the situation provides. Maintain a zone of safety. In an open area, place your trauma bag or other item on the floor between you and the patient. This creates an obstruction should the patient attempt to make an aggressive move toward you. Law enforcement studies have shown that an aggressive individual can cover up to 21 feet in three seconds or less.7 All our dealings with patients tend to be within one to six feet, distances at which the patient can reach out and grab us in a split second. That is why your initial scene assessment and general impression of your patient are so important.
If the patient is suffering a psychiatric emergency or is combative for any reason, immediately retreat and call law enforcement for assistance. If you can verbally engage your patient from a safe distance, position yourselves at 45-degree angle to the patient. (If you have a crew of more than two, form a semicircle around the patient.) Only one rescuer should initiate a dialog with the patient, offering reassuring statements as necessary. The remainder of the crew should be dedicated to watching for overt or subtle changes in behavior, speech, or body positioning.
Like any other area in the fire service, EMS responses require many of the same skill sets and cautions. Your size-up starts from the time of the alarm and continues until the time you depart the scene. Be alert for any patient encounter that just “doesn’t feel right.” Not everyone we go to help wants to be helped. Some may even have ill intent toward their rescuers. Keep any potential problems or threatsman, animal, environmental and hazardous areasin front of you. You can perfect your response, observation, and safety skills through training before the call comes in and by practicing them on every alarm.
Endnotes
1. “Judge clears diabetic in assault,” The Times Leader, Wilkes Barre, Pa., April 24, 2008. Article ID: 12066438859CCC50.
2. Prziborowski, Steve, “Tips for Scene Size-up and Safety,” http://emberly.fireengineering.com /display_article/282311/25/none/none/Depar/.
3. Telegraph.co.uk, April 26, 2008.
4. http://www.emsnetwork.org/artman2/publish/article_28961.shtml/.
5. Fox News 12, Portland Oregon. http://www.kptv.com/news/14880610/detail.html/.
6. Sophia Chang and Joseph Mallia, NY Newsday, June 6, 2008.
7. “Surviving edged weapons,” Dennis Anderson, director, Calibre press.
BARRY S. DASKAL is a police officer/aircraft rescue firefighter with the Port Authority of New York and New Jersey Police Department at John F. Kennedy International Airport in NYC. He is also a certified EMT-critical care and clinical lab instructor at the Nassau County (NY) EMS Academy and a member of the Wantagh (NY) Fire Department in Nassau County. He previously served as a police officer with the NYC Police Department and as a supervising fire alarm dispatcher with the FDNY. He has been a volunteer firefighter since 1990 and has served as a captain and training officer. He hosts the “Average Joe Firefighter “ podcast at www.FireEngineering.com.
