By STEVEN C. HAMILTON
Scenario: You respond to a residence for a reported suicide attempt with no information other than the individual had lacerated his wrists. When your department arrives on scene, do you and your personnel attempt to make contact with the occupant and render aid or stage your apparatus away from the scene, awaiting arrival of law enforcement officers to deem the scene safe? Can this scene be hazardous? Are there indications from dispatch that this is a scene of violence? What if the response had nothing to do with a suicide but rather it was a call for a victim of an assault outside of an apartment complex? Is that a scene of violence? Fire and emergency medical services (EMS) respond to scenes of violence every day, and the consequences of not being prepared can be significant.
Ask any firefighter whether he would conduct a primary search of a building with fire blowing out of every window and a partially collapsed roof. The answer should be “Absolutely not!” Fire departments train personnel to recognize hazards and make informed decisions on the proper approaches to mitigation.
In March 2006, former Peoria (AZ) Fire Department Fire Inspector Howard M. Munding produced a thesis titled “Violence Against Firefighter: Angels of Mercy Under Attack.”1 In the thesis, he quotes the stunning statistic that an estimated 700,000 assaults occur on paramedics and emergency medical technicians (EMTs) annually. Additionally, according to a 2008 National Fire Protection Association (NFPA) Firefighter Fatality Report,2 32 firefighters died from assaults while on duty in the report’s 32-year history. At the end of 2010, that number grew to 34,3 or one firefighter per year. After comprehensive research, I found no known National Institute for Occupational Safety and Health (NIOSH) report or postincident investigation detailing a firefighter line-of-duty death from scenes of violence comparable to the reports generated from the loss of a firefighter in a structure fire. Why? Are there no lessons to be learned that should be published for the entire fire service to digest?
According to Audrey Reichard of the Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH, the Highway Traffic Safety Administration, the Office of Emergency Medical Services, and NIOSH are collaborating to collect detailed data on nonfatal injuries to EMS workers. These data capture injuries from all causes, including those related to violence. The project aims to collect important details related to the injury event and surrounding circumstances. It is the first step in the right direction of recognizing the true threats to personal safety from violence.4
In July 2008, Firefighter/Paramedic Ryan Hummert of the Maplewood (MO) Fire Department was shot and killed at the scene of a vehicle fire by a sniper who laid in wait for responders to arrive. Hummert’s death was unavoidable, owing to the inability to predict an ambush. However, there are incidents of violence that can be avoided.
Look at the average fully equipped firefighting ensemble. Notice that a firefighter is provided with the proper personal protective equipment (PPE) to face the hazards he may encounter during any given shift. Now, pay close attention to the average uniformed law enforcement officer. He is outfitted with a bulletproof vest, a gun, pepper spray, a stun gun, a baton, and handcuffs. This equipment is used to combat any hazards or threats during a tour of duty. Do you notice a vast difference between the two?
In my department, on occasion, the engine company has had to chase a patrolman or two out of a building during a smoke investigation because they did not have the proper PPE to protect them from the hazards they may have encountered. The common response is, “What were they thinking? Were the cops going to order the fire to go out under the threat of arrest?” Who chases us out of an incident scene when the occupant becomes or was violent? When the warning signs of violence are not recognized and the scene becomes hostile, firefighters and EMS personnel are now in danger; the reactions result in “too little, too late.” Personnel are at risk of injury or death when the situation may have been avoidable. And yes, law enforcement has a similar thought process. “What were those firefighters thinking? Were they going to ‘extinguish’ the guy with the gun?”
WHAT IS A SCENE OF VIOLENCE?
Any incident that resulted in the actual or attempted willful harm of oneself or another is a scene of violence; this includes suicide attempts. Just because an individual has decided to leave this world by his own hand does not mean that he will harm only himself when encountered by emergency workers, loved ones, and bystanders. The aforementioned incident involving Hummert is an example. The sniper planned to commit suicide from the beginning, and he wanted to take people with him. Most individuals who decide to commit suicide do so with a well-thought-out plan of action. As this plan begins to unfold, any deviation can result in the individual becoming violent. You, as the emergency responder, represent that deviation. You are there to counteract the results of his actions. The interventions administered may create frustration on the part of the patient, a frustration that could be directed toward you.
A form of suicide gaining immense popularity is “suicide by cop.” An individual will present a credible life threat to a law enforcement officer in the hope that the officer will kill the individual in self-defense. In some cases, the act is well-thought-out by the individual; in other cases, the suicidal person resorts to this tactic as a last resort, which is more commonly brought on from a deviation from the original suicidal action. That deviation occurs as initial responders arrive and disrupt the individual’s actions.
Domestic violence incidents pose a significant threat to responders. All of us have responded to some sort of domestic incident. They are the most dangerous incidents that fire service personnel can encounter because of the manner in which the incidents are reported. Responders can be called to homes for fall victims, lacerations, difficulty breathing, or a number of other categories that are later identified as domestic violence. This type of response also has the most potential for becoming violent again. In some cases, the victim is not the person who reported the incident; the call could have come from a neighbor or loved one. These situations demand that you pay particular attention to the “victim’s” body language and actions. Use caution, and remember that the victim can become the aggressor. Domestic violence scenes are unpredictable and extremely dangerous. Personnel must consider every single person in the environment as a threat, regardless of gender, family status, or age. Responders must never put someone from the environment between themselves and their exit.
Other scenes of violence are “no brainers” based on the dispatch information. Emotionally disturbed patients and victims of gunshot wounds, stabbings, and assaults will immediately send up red flags. Most of these incidents result in a tiered response, determined by dispatch and departmental procedures. Stage away from the scene, await law enforcement, and do not proceed until the scene is rendered safe.
RESPONSE CONSIDERATIONS
There should be little doubt that responding to the no-brainer incidents poses a real threat. Following are some precautions that you should consider and put into practice. First, turn off your lights and sirens as you get near the scene. Many departments use nonemergency mode response to calls where units will stage. The Austin (TX) Fire Department has a procedure for responding to such scenes.5 Its policy requires the responding apparatus to proceed in a nonemergent mode to the designated staging area and await instructions.
Communications with dispatch are equally important for safety. The statement “law enforcement on the scene” does not denote that the scene is secure. Ensure that responding units specifically ask if the scene has been secured. Doing so may prompt the dispatcher to ask the question to the officers on scene if it is not readily known. In the law enforcement community, the saying “the scene is secure” can simply mean that a perimeter has been established, access and egress are being denied, and potential evidence is being preserved. Unfortunately, that does not mean that the scene is safe by fire and EMS standards.
As a reserve deputy, I once responded to a 911 hang-up call. When we arrived, it was apparent that a man in his 60s was experiencing a medical problem. As an EMT, I recognized the signs of a diabetic problem. I obtained a quick history from the man’s wife and asked him some questions to establish his mental status. He had been drinking earlier and, by his wife’s accounts, more than he should have. My partner radioed for an ambulance, and we awaited its arrival. The gentleman was not excited about our presence; he asked us to leave a few times, but there were no outward signs of aggression.
Once the responders arrived and began assessing the patient, one of the paramedics called my partner over to the couch to retrieve the rifle that had been under some blankets on the floor. I had a heart-stopping moment of pause. I did what I had criticized law enforcement personnel for doing to me in the past. The lesson learned is that each career field is trained to look for signs that prompt action. We did not uncover or attempt to manipulate the patient in any way, so the weapon was overlooked. Had the patient become aggressive or had his glucose levels dropped low enough for him to become extremely confused, an incident could have occurred. The actions of the paramedic and his thoroughness protected us all.
Span of control and crew continuity are especially paramount; do not use four firefighters when one or two will do. When you flood a scene with more personnel than is necessary, it increases anxiety in patients and bystanders. Depending on the scene, excessive personnel can contaminate crime scene evidence. Use the resources you need to deliver the patient care required; stage or release everyone else.
Additionally, many jurisdictions have a common problem with firefighters being confused with law enforcement officers. In many states, fire department vehicles and law enforcement vehicles are equipped with similarly colored emergency lighting. Citizens can confuse who is who, especially at night. With the exception of a gun belt, many officers and firefighters wear distinctly similar duty uniforms. How discernable are the two while being observed through the peephole of an apartment door? Again, when you consider the hours of darkness and some poor hallway lighting, ascertaining who is who during a medical emergency can be difficult. Some aggressors attack the first-arriving unit regardless of occupation or duty.
On September 2, 2009, Las Vegas (NV) Fire Department (LVFD) engine companies responded to a house fire and, on arrival, came under shotgun fire by an unknown gunman. Personnel immediately left the area and notified law enforcement. The ensuing gun battle resulted in the death of the gunman and the wounding of a patrol officer. No firefighters were injured. Reports later indicated that the suspected assailant was distraught over his unemployment and previous criminal past. Although not confirmed, this incident has all the elements of suicide by cop. The unfortunate fact remains that the structure fire brought LVFD personnel to a scene where they were immediately targeted by a gunman.
SITUATIONAL AWARENESS
Situational awareness can be defined as understanding your environment and the influences affecting it now and in the future. As firefighters, we maintain situational awareness at structure fires by conducting a good thorough size-up that begins with the dispatch information and continues until you leave the scene; this applies to EMS incidents as well. Pay particular attention to what bystanders and family members are doing. Do not focus all your attention on the patient. Read the environment. Personnel must ensure that they observe the entire scene as opposed to going straight to the patient. Tunnel vision may cause responders to miss critical information about the scene.
On July 22, 2008, an anonymous story posted on FirefighterCloseCalls.com entitled “Another Crew Attacked on EMS Call”6 discusses a rescue unit and ambulance dispatched to a residence for a female patient with respiratory difficulty. On arrival, units were met by a male individual smelling of alcohol who escorted them to the patient in an upstairs bathroom. Personnel began a focused history and assessment of the patient. The male became agitated, complaining that the units were not doing enough, and began to use profanity. Personnel tried to calm him, explaining what they were doing for the patient. The male then stated that he was going to kill the responders, repeating his threat three times. Emergency personnel began trading off the task of calming the man. The man then left the responders and went down a hallway. Responders followed and observed him retrieve a firearm from a nightstand drawer. The man’s wife yelled for him to put it back, and he did so. He then proceeded to attack a responder by elbowing him in the face. After responders attempted to defend themselves, the man attempted to retrieve his firearm again. He was wrestled to the floor, and law enforcement was called. Responders subdued the man until law enforcement took him into custody.
Responders sustained multiple injuries attempting to defend themselves from throat trauma, scratches, and abrasions. Where did things go wrong? At what point should the warning signs have been seen? What would you have done?
MINIMIZING THREATS
Practice the following precautions on all emergency calls that tell you something is not right. Maintain your path of egress, and always identify more than one, if possible. Never put anything or anyone between you and an exit. Responders should continually and consistently ask themselves, “What am I going to do if this becomes a hostile environment?” As a company officer, I commonly look down hallways or peek into open rooms even on the seemingly routine emergencies. I attempt to see into every room between my crew and the exit to ensure there are no surprises behind us if we need to leave in a hurry. Do not open closed doors in a residence unless directed by the occupants; you wouldn’t want responders looking into rooms in your house without permission. When you do open closed doors, do so from the side of the door. Never stand in the threshold squaring your body in the doorway when you open it. Such a stance places you squarely in what law enforcement refers to as the “kill zone.”
If possible, separate the patient from others. This can be tricky, especially in domestic violence situations. The aggressor doesn’t want the victim out of his sight for fear of what he may reveal. The back of the ambulance can solve this problem quite effectively. How do you think the previous story of the drunken assailant would have ended if responders had removed the patient to the ambulance at the first sign of agitation from the male bystander? Interviewing a patient in the ambulance as opposed to in the environment in which he is found can be beneficial, especially if he is a victim of violence. The back of the ambulance allows for isolation. Responders can keep all other bystanders away. Citing patient privacy to persistent bystanders should give personnel the leeway needed to conduct a thorough history of the event. When providers and the patient are alone, challenge the story if there are doubts as to what really happened. The ambulance also provides additional security in that most if not all doors can be locked. If an aggressor attempts to gain access to the patient, responders can simply lock the doors and call for help.
Request a law enforcement officer if deemed necessary based on what is observed from the scene. Accomplish this without being overheard by the bystanders or the patient. When multiple bystanders or interested parties are within the scene, put one responder on each person. If this cannot be accomplished, ask people to leave to provide the patient some space, or remove the patient from the environment. Again, the back of the ambulance is a good spot.
Another good practice is to incorporate any responder not directly involved in patient care as a lookout. The responder simply continuously observes the scene for potential threats. Those involved in patient care can experience tunnel vision and not observe the scene escalating into a hostile one. The best candidate to be the lookout most commonly will be the officer, as most company officers are not needed to provide patient care. Again, use only the personnel needed. When patients or bystanders become argumentative, responders should leave the area and notify law enforcement. The true way to ensure scene safety is to identify current and potential threats and take the appropriate action before something happens, not after. Try not to get into a situation in the first place.
CALLING FOR HELP
Eliminating radio codes in favor of plain talk is now common practice. Departments are now finding need for duress codes as a vehicle for maintaining safety. NFPA 1500, Fire Department Occupational Safety Health Program, 8.10.5, requires departments to develop standard communication methods that indicate personnel are in danger and require law enforcement response.7 Plain English transmissions from the scene of an assault or a domestic violence incident may increase danger by alerting aggressors that additional assistance is being requested. Work with your law enforcement and dispatch centers to develop standardized duress codes.
Many radio manufacturers incorporate an emergency button that automatically switches the radio to an emergency channel and alerts the dispatcher. Policies and procedures are essential to avoid inadvertently placing a crew in additional danger by dispatch transmissions inquiring about the emergency button activation. Typically, when an emergency button is activated, a simple update on status request from the dispatch center should be transmitted. If the situation is a true emergency and not an accidental activation, responders will provide the appropriate duress code. If no answer is given by the activated radio or an incorrect code is transmitted, a law enforcement response should be initiated.
PERSONAL PROTECTIVE EQUIPMENT
NFPA 1500 7.1.2. states, “Protective clothing and protective equipment shall be used whenever the member is exposed or potentially exposed to the hazards for which it is provided.”8
The “Superman Complex” is a term that exists within the law enforcement community and is frequently heard during academy training sessions. The complex refers to many situations but is most applicable to the officer who wears a bulletproof vest. A responder with Superman Complex is one who becomes lackadaisical and relies on the vest to protect him instead of taking precautions to prevent an incident. Officers will put themselves in danger more frequently because they are wearing a vest. Unfortunately, the vest provides no protection if the responder is shot in the head.
As the NFPA standard suggests, provide PPE for the hazards that employees will face. My position is to not put oneself in the hazardous environment in the first place. Many metropolitan areas throughout the country have a substantial and continuous threat to responders from gunfire; these departments outfit their personnel with body armor. However, each organization must recognize the Superman Complex and train its personnel to stay away from violent scenes until law enforcement has neutralized the threats. Agencies need to be clear that the issuance of body armor is to protect responders from stray rounds or if the shooter or shooters become mobile and threaten their staging area. The use of body armor to protect responders not only at a scene of violence but also in a bad area with a history of violence is understandable. Let law enforcement address the hazard and mitigate the violence portion. Unfortunately, that may delay patient care. The polar opposite is a positive; responders should not become the victims.
EMS has become a large part of what firefighters do every day. There are hazards to responding to all emergency calls and to taking the appropriate action. Fighting fires is no longer the only physical threat to our safety. We must continue to consider violent scenes as hazardous to our safety, respond appropriately, maintain awareness, identify and minimize threats, and be prepared to call for assistance under distress. All of these elements cannot be created on the spot. Training and interagency coordination are paramount. Create scenarios and drills that incorporate your department, local police, and EMS transporting agencies. Working together keeps everyone on the same page. As with all training, remember that practice creates repetition, not perfection. Keep the training different and interesting, or personnel will simply check the box each year and chalk it up as another class “we have to do.”
REFERENCES
1. Munding HM. “Violence Against Firefighters: Angels of Mercy Under Attack.” Executive Fire Officer Program – Leading Community Risk Reduction R-280 (2006).
2. Fahy, LeBlanc, Molis. Firefighter Fatalities in the United States 2008. NFPA Fire Analysis and Research Division.
3. Swartz N. Personal Communication. NFPA Fire Analysis and Research Division (March 2012).
4. Audrey Reichard, MPH, OTR. E-mail Communication. Surveillance and Field Investigations Branch, Division of Safety Research, National Institute for Occupational Safety and Health, Morgantown, WV (March 2012).
5. Hanna E. Personal Communication. Austin Fire Department, Engine Company 24 (August 2008).
6. www.firefighterclosecalls.com/news/fullstory/newsid/69343.
7. NFPA 1500, Occupational Safety and Health Program, 2007 Ed. (Ch 8 Sec. 10 Para 5 Pg 26) National Fire Protection Association.
8. NFPA 1500, Occupational Safety and Health Program, 2007 Ed. (Ch 7 Sec. 1 Para 2 Pg 16) National Fire Protection Association.
STEVEN C. HAMILTON is a 16-year fire service veteran and a career lieutenant with the Fort Jackson Fire Department in Columbia, South Carolina. He is a certified EMT-B, fire instructor II, and fire officer III. He is also a reserve deputy with the Richland County (SC) Sheriff’s Department. Hamilton served for four years in the U.S. Air Force as a firefighter in Texas and is a former volunteer firefighter from New York State. Hamilton is also a former assistant instructor at the South Carolina State Fire Academy and is an NREMT-basic instructor for his jurisdiction.
