Nothing is a routine call anymore
Timothy S. Arnett BS, NREMT-P
 Identify
some of the reasons behind why
violence occurs against EMS workers
 Describe ways to identify potentially violent
situations before they occur
 Identify calls for service that have a
potential for violence
 Describe ways to approach and appropriately
respond to these calls
 Define situational awareness and how to use
it
 Background
 How
does this relate to trauma?
 Can you learn everything in an hour?
 Where do we go from here?
A simple internet search using parameters
‘violent incident emergency response’ will
find results ranging from a one person attack
on an individual responder to massive and
widespread rioting in which entire agencies
came under attack.
In 2004, under the leadership of Executive
Director Ronald J. Siarnicki, the NFFF
expanded its mission to include the
prevention of fire fighter injuries and deaths.
In 2007 a summit was held to better define the
Life Safety Initiative and a white paper was
created that developed 9 specific
recommendations to support the initiative.
2007 Firefighter Life Safety Initiative 12
White Paper Recommendations
1. Improved Dynamic Risk Management for incidents involving violence.
2. Initiate and/or improve communications and relationships with law enforcement responders
in your jurisdiction.
3. Define the role of dispatchers in reducing hazards to firefighters.
4. Prohibit single resource (individual) response to incidents of violence.
5. Require all Law Enforcement responders that may respond to a violent incident in your
community to use an Incident Management System (IMS).
6. Fire department personnel should communicate, face to face, with the law enforcement
component on scene.
7. Recommit personnel and equipment and leave if violence commences or recurs during fire
department operations.
8. Obtain stakeholder understanding and buy-in of response and deployment policies including
non-response and non-engagement at incidents of violence.
9. Fire Departments should strive to ensure their duty uniforms are not similar to, or could be
mistaken for, those of law enforcement personnel.
*NFFF Fire Fighter Life Safety Initiative 12 Final Report

The Emergency Run Today Poses One Of The
Greatest Hazards in Emergency Medical
Services Today. In fact Emergency Medical
Service Personnel are more likely to be killed,
injured and disabled during the course of an
Emergency Run, than contracting AIDS during
direct patient care.
True!!!
Paramedic Shot
Paramedic Killed
On February 23, 2004, A female
Paramedic was shot by a sniper,
according to Metropolitan Ambulance
Services Trust, spokesman Eric Dooley.
The paramedic's name has not been
released, but Dooley stated she has
been with MAST for more than 15
years. Her injuries were classified as
serious, but she was reported to be in
stable condition after undergoing
surgery at a hospital. The paramedic
was with police, fire and other
ambulance personnel who came under
gun fire, striking the paramedic
after they arrived to fight the blaze,
said Capt. Ron Fletcher, a spokesman
for the Kansas City Police Department.
Only the paramedic, a 15-year veteran
of the Metropolitan Ambulance Service
Trust was shot.
On a Friday afternoon, the 13th of
February 2004, Lt. Brenda Cowan, a 12
year veteran of the Division of Fire &
Emergency Services, was slain on duty.
Lt. Cowan was hit by gunfire while
responding to an emergency medical
assistance call on Adams Lane in rural
Fayette County. Lt. Cowan's promotion
was just celebrated at the Fire Training
Center Tuesday, the 10th of February
2004. This was her first duty day
following the promotion ceremony
 Unknown
Emergency
 Sick person in a vehicle
 Injured Person – Something isn’t right
 Person Down
 Attempted Suicide
 Assault
 The list goes on and on
EVERYWHERE
 http://www.wistv.com/story/5224559/elderl
y-man-charged-in-shooting-of-north-carolinaparamedic
 Small
town
 Seemingly routine call
 Elderly male in a vehicle
 Wife wants help taking care of him
 What went wrong?
 What
information did the caller give the
dispatch center?
 Did the dispatch center relay the
information?
 What was the neighborhood like?
 How did you approach the scene?


Lights and sirens?
With police?
 http://www.starnewsonline.com/article/201
30812/ARTICLES/130819953
 Large
City
 Again seemingly routine call
 What things about this cardiac arrest should
make you think?
 Where was the offender when the care was
taking place?
 What
are the policies and procedures for
your department?


Police dispatched on cardiac arrests?
How many personnel are required for a high
priority call?
 Do
you think you or your crew have the
situational awareness to see this brewing?
Many EMS Agencies have established “staging”
policies. Which in essence, when an
Ambulance is dispatched to a violent-crime
scene involving any form of assault need to
stage away from the incident until the police
have secured the scene. Remember the
difference between “police being on the
scene” and “securing the scene” are two
different things. It is possible to have the
police on the scene and the situation is still
volatile. Remember that a secure scene means
the assailant is gone or has been arrested and
Law Enforcement gives the okay to enter the
perimeter.
 http://www.cnn.com/video/data/2.0/video/
politics/2013/04/11/savidge-ga-firemenhostage-standoff.cnn.html
 What
is it?
 Where do I get some?
 What do I do with it once I have it?
 Is there such a thing as too much situational
awareness?
On the afternoon of February 13, 2004, a Lexington Fire
Department unit was dispatched to a report of a woman
down on the ground that may have been shot. The
apparatus was parked away from the scene and crew
members, under Lieutenant Cowan’s supervision,
approached the shooting victim on foot. At the same time
that the fire department had been dispatched to the
medical aid call, police units were dispatched to the same
address for a possible shooting.
As Lieutenant Cowan and her crew bent over to assess the
condition of the victim, gunshots were fired. These bullets
struck Lieutenant Cowan and another firefighter. At almost
the same time, a police officer arrived at the scene and
attempted to use his police vehicle as a shield to protect
the firefighters from further harm. Shots continued to be
fired at the firefighters and other emergency responders. A
police tactical team removed Lieutenant Cowan
approximately forty minutes after the shooting began.
*NFFF Fire Fighter Life Safety Initiative Final Report
 CRIME
SCENE WARNINGS
 FIGHTING OR LOUD VOICES
 WEAPONS VISIBLE
 SIGNS OF ALCOHOL/DRUG USE
 UNUSUAL SILENCE
 KNOWLEDGE OF PRIOR VIOLENCE
ONE DANGER THAT IS
PRESENT AT MANY SCENES IS
THE FAMILY DOG. EVEN ONES
THAT LOOK HARMLESS
COULD ATTACK IF THEY FEEL
THREATENED. BE CAREFUL.
 What




am I talking about here?
Dispatched for an unknown emergency behind
your local convenience store on Christmas.
No additional information
It’s 2 o’clock in the morning
Weather is clear but cold (28 degrees)
 Store
is closed and there are no cars in the
lot.
 Lighting is not good especially around back
 You can drive all the way around the
building.


Do you?
What lights if any do you have on?
 The
caller has left (cell phone hero)
 What’s the status of police?
When you drive around back with all your scene lights on and
no emergency lights you see a seemingly well dressed man
sitting against the wall of the store looking down with a
bottle in his hand.
Position the vehicle so the most amount of light
is shining on the subject.
 Talk to the subject as you approach
 Make sure you can see his hands and what items
he may have with him i.e. bags
 As you assess the subject physically also check
for weapons or others items that may hurt you or
your team

During arrival at
night, keep cab
lights off to
minimize the chance
of being
an easy target. Note
the difference from
outside when the
cab lights are on
(photo A)
and when they are
off (photo B).
*USFA EMS Safety Information
During first contact,
be extremely cautious. Note in
photo A how the EMS provider
has his weight back, and is
prepared
to push away if the patient
comes up quickly. His partner
is
also watching for suspicious
behavior. In photo B, he would
have a much more difficult
time
backing off quickly and safely.
Remain especially observant
until both hands have been
checked for weapons.
*USFA EMS Safety Information
Standing with the feet side-by-side and with
hands in pockets (photo A) or with arms
tightly folded (photo B) is
dangerous. It would probable take too much
time to position hands to deflect an attack,
and it is nearly impossible to back
off quickly without one foot forward. These
postures may also indicate a lack of
compassion on your part.
*USFA EMS Safety Information
An open stance can pacify
a situation. Note the open
hands (which are
nonetheless positioned to
defect a blow!) and the
softening angles of having
one hip
and shoulder back and the
head tilted.
*USFA EMS Safety Information
 We




have all run these calls.
Dispatched for a sick person in a vehicle in a
parking lot.
No additional information from dispatch
Friday at 11pm down the street from the station
Weather is clear and warm
As you approach you notice the vehicle is
running, the drivers door is open and there is
a male sitting in the drivers seat.
What do you do now???
 Pull
behind the vehicle in a defensive
position with the unit.





Traffic stop style - Placing the bulk of the engine
between you and the vehicle
Make sure that you are creating a safe area
around the vehicle from traffic
Call the license plate of the vehicle into dispatch
Call for additional resources if you can’t create
that safety zone
Attempt to make contact with the subject with
your loudspeaker
•In some situations, such
as drivers who are
slumped over the wheel,
•Approaching from
behind is prudent until
the circumstances are
clear.
•Create a “corridor” that
will protect the
approaching EMS
personnel from other
traffic by positioning the
EMS vehicle as shown
*USFA EMS Safety Information
 Approach
first.

the vehicle on the passenger side
This causes confusion on the part of the subject
if they are expecting you to approach.
 While
you are walking up to the vehicle make
sure you are looking inside the vehicle.

Looking for other people as well as weapons,
chemicals, drugs or other items that pose a
threat to your team.
 Make
sure as you make contact with the
subject you can see his hands and anything
around the subject.

Identify yourself (EMT, Paramedic, FF, etc.)
 When
it’s safe to do so make sure the vehicle
is in park and the ignition turned off.
 If it is safe and the patient is able to do so
have them walk back to your unit with you.

They are safer, better controlled and in an
unfamiliar place when they are in the back of
your unit.
 While
they are walking with you or you are
moving them to the stretcher make sure you
are checking for weapons and such in their
pockets, waistband, side. Everywhere!
 http://www.cnn.com/2012/12/24/us/new-
york-firefighters-shooting/
Do you think they thought they would be
shot when they jumped on the fire truck
and headed for the dwelling fire?
 Cover

and Concealment
The consistent use of cover or concealment
opportunities is an important prehospital
tactic. They may be the best chance for
survival in situations that are impossible to
judge ahead of time. (Remember, law
enforcement should precede EMS personnel
to scenes known to be dangerous.)
*USFA EMS Safety Information

An object large enough to hide behind and
strong enough to stop a bullet. Good
examples include a solid tree or telephone
pole, brick or stone walls, steel garbage
dumpsters (the fuller the better). The door
of the EMS unit or a wooden fence may both
seem substantial but usually cannot stop a
bullet, so they cannot be considered
adequate cover. Remember, the best cover in
situations that appear hostile is to stay in a
safe location out of the way while law
enforcement personnel secure the scene.
*USFA EMS Safety Information
A
place that will hide a person from view,
but which may not be capable of stopping a
bullet. The door of the EMS unit and the
wooden fence previously mentioned would
be suitable for concealment. A large bush, or
even shadows, are also appropriate. It is
important to be sure that the structure is
reliably concealing; for example, would the
hiding spot be illuminated by the headlights
of an approaching vehicle?
*USFA EMS Safety Information
Always be aware that
when entering the kill
zone whether a
hazard exists
or not may not be
known until it’s too
late.
Never knock while standing
in
front of the door (photo
A).
Stand well to the side,
either
separately, as shown in
photo B
or on the same side (photo
C) to
minimize the chance of
injury in
the event of an attack.
These nine questions can help you
prepare for your response to a
violent incident.
“With incidents where there is a threat of,
or actual violence, it must be remembered
that a judgment is required to ensure that
risks to personnel are not out of
proportion to the benefits to be gained
from achieving a given task” (Labor
Research Department, 2005). Risk
Management is not new to the fire service.
The balance of perhaps limited potential
benefit in light of substantial risk should
be foremost in every responder’s mind.
As noted by the Columbine Review
Commission (2001), familiarity of personnel
and roles prior to an incident through
training and planning exercises provides for
better communication and operation during
the event. Fire Department personnel should
have access to, and use, law enforcement
intelligence information in order to preplan
response to incidents. This may include
information regarding domestic terrorism,
gang violence, known or suspected drug
factories and/or houses
Response to an incident of violence carries
significant uncertainties. The ability of the
dispatch staff to reduce the uncertainty while
increasing the level of information provided is
critical. It is also helpful for responders to have
the ability to communicate on a specific,
shared, common, radio frequency to remove the
potential for message corruption as it is passed
through another person. Dispatch staff should
critically and carefully monitor the operations
radio channel of personnel responding to and
operating at incidents of violence and perform
Personnel Accountability Report (PAR) checks on
a prescribed interval.
Many jurisdictions have response and
deployment plans that include the dispatch
of individual first responders and/or a single
person in a response vehicle. This should be
prohibited or at least limited to the extent
possible. The ability of a single person to
react to an act of violence is limited. It may
not even be possible to retreat. Responding
and deploying in a group provides added
protection, awareness, and visibility.
Each agency should strive to ensure that the
IMS used in that community is applied as
uniformly as possible. Fire departments
should take a leadership role in assisting
their law enforcement compatriots,
particularly at the street or service delivery
level, to understand and apply the IMS.
Fire department personnel should
communicate, face to face, directly with the
law enforcement component on scene.
Direct face-to-face communication, with
clear understanding of the hazards, risks
associated, potential outcomes, and planned
actions on the part of each agency should
precede any fire department response into a
hazard area.
If fire department operations have
commenced and violence erupts, fire service
personnel should consider leaving the scene
until the law enforcement component has
stabilized the situation.
Fire department personnel may not respond into a
hazard area due to the potential for additional
violence or because the situation is not yet under
control. Some responders and organizations fear
their community will view this in a negative light. A
2005 Labor Research Department report stated ‘the
key issue here is the extent to which fire crews can
make decisions when dealing with an incident and
with the confidence that they will be backed up by
senior management if criticized by the local
community or in the press for leaving a fire to burn
or holding back from attending (responding to) an
incident.” It is imperative for the department
leadership to establish relationships with key
stakeholders in the community to ensure they
understand and support the response protocol.
Uniform insignia, style, and color should be
of sufficient difference that fire department
personnel would not be mistaken for police
officers.
1. If your initial size-up assesses a threat of
confrontation, wait for police assistance.
Do not insert yourself into the situation.
2. If you find yourself in a confrontation where you can
remove yourself to wait for police assistance, do it.
3. If you find yourself in a confrontation that you
cannot remove yourself from:
a) If confronted with non-lethal force (no weapons
are involved), defend yourself and attempt to control
the situation using non-lethal force.
b) If confronted with lethal force, use whatever
means is necessary to eliminate the threat or get out
of the way. At times, this could mean not doing
anything at all that might provoke the attacker. This
would be an appropriate course of action when a gun
is pointed at you.
*NFFF Fire Fighter Life Safety Initiative Final Report

Federal Emergency Management Agency, United States Fire Administration (1994)
EMS Safety, Techniques and Applications. FEMA Publication No. FA-144. U.S.
Government Printing Office.

The National Fallen Firefighters Foundation Firefighter Life Safety Initiative 12 Final
Report. (2013) National Protocols for response to violent incidents should be
developed and championed.

Skip Kirkwood, MS, JD, EMT-P, EFO, CMO, Kip Teitsort. (2012) Violence Against EMS
Providers: What can we do about it? EMS World. HTTP://Violence Against EMS EMSWorld_com.htm

http://www.fireengineering.com/articles/print/volume-165/issue9/departments/fire-service_ems/responding-to-scenes-of-violence.html

http://www.cnn.com/2013/04/10/us/georgia-firefighters-hostage/

http://www.cnn.com/2012/12/24/us/new-york-firefighters-shooting/

http://www.emsworld.com/article/10320697/safe-response-to-incidents-ofviolence

http://www.wistv.com/story/5224559/elderly-man-charged-in-shooting-of-northcarolina-paramedic

http://event.clirems.org/Portals/4/Violence%20Reports/2013/EVENT%20Provider%2
0Violence%20Summary%203Q2013.pdf

http://event.clirems.org/Provider-Violence-Event