www.bcas.ca
www.ceep.ca
EMS Preparedness for
Tactical Violence
Karen Wanger MDCM, FRCPC
Regional Medical Director
BC Ambulance Service
CAEP 2009
Disclosure
• I do not have an affiliation (financial or
otherwise) with any commercial
organization that may have a direct or
indirect connection to the content of my
presentation.
• And I am not Demi Moore...
Learning objectives
• Understand “tactical EMS” vs. “tactical
EMS”
• Learn what the perceived preparedness
status is of front line responders in
Canada
Introduction
• Paramedics are essentially the only
medical personnel routinely at the scene
of violent episodes
• 8.5% of scenes are the result of some
form of violence
• Up to 90% of EMS staff report an episode
of violence directed at them.
CAEP 2009
Tactical Violence
• Defined as:
– “the deployment of extreme violence in a nonrandom fashion so as to achieve a tactical or
strategic goal”
• Preparation for Tactical Violence is a
routine part of training for police and
military but not EMS
CAEP 2009
Tactical Violence
• Tactical violence = multi agency approach
• Targeted violence + law enforcement =
change from “normal” EMS response
mode
• Safe and efficient functioning specific
training including training with the other
responding agencies.
CAEP 2009
Tactical Teams
• A few
• These teams are generally deployed in
advance of a call when law enforcement is
planning a tactical manoeuvre.
CAEP 2009
Tactical Violence
• Violence that is “tactical” in nature employed by
an outside “agency” as in terrorism would occur
without warning.
• The estimated time to scramble a specialist
tactical team is roughly one hour
• Front line paramedics would be required to
manage the scene for that time.
CAEP 2009
Violence
• Paramedics are experienced and well
versed in dealing with interpersonal
violence on calls.
• Patient/patient or “perp”/patient.
• Violence towards a paramedic is generally
one-on-one from a patient and is
understood by the paramedic
CAEP 2009
Tactical v. responders
• A large component of “intentional/random”
violence or violence directed towards
responders changes everything.
• Including subsequent processing.
CAEP 2009
Targeted tactical - management
• Isreali paramedics approach tactical
violence scenes differently from other
MCI’s. It is understood that secondary
devices aimed at responders are a reality.
• Casualties are moved quickly and the
scene emptied in minutes.
CAEP 2009
Are we prepared?
• Survey of pre-hospital providers in BC and
Ontario
• January to June 2006
• Daniel Kollek and Michelle Welsford.
• Addressed the self-reported training and
readiness in the following areas:
CAEP 2009
Survey topics:
• 1. Training for response to a tactical violence or
terrorist scene;
• 2. The level of comfort responding to a complex
event (mass casualty, violent, etc);
• 3. The level of comfort in detecting and dealing
with the emotional impact of providing care;
• 4. The added emotional impact caused by
violence, clinical load, and child injuries at the
event scene.
CAEP 2009
Topics and Methodology
• Emotional impact was assessed by
grading response to a variety of scenarios
including violence and tactical violence,
and the presence of combinations of adult
and paediatric victims.
CAEP 2009
Population
• Ontario and BC paramedics and first responders
• Posted on a website only accessible by
individuals knowing its complex address.
• Invitation by email and poster in Ontario
• In BC email invitations to paramedics through
BC Ambulance. FR’s invited via FCABC
distribution.
CAEP 2009
Survey questions
• 3 basic areas:
1) Scenarios – quantify degree of distress 1
(“not distressing to any significant degree”) to
5(“distressing to the degree that you would
not be able to deliver care”)
CAEP 2009
Survey questions
• 2) Report degree of training and comfort
in responding to the following events:
– Fire
– Response to an unstable building
– Response to a terror event
– Response requiring use of elevated PPE
– Response to a tactical violence situation
CAEP 2009
Survey questions
• 3) Ability to recognize emotional distress
in self or partner and comfort with CISD
CAEP 2009
Results
• 1028 respondents
– Mostly male (75%)
– Mostly PCP (55%)
– Age 36-50 (48%)
– Wide range of years of experience
– Predominantly front line personnel
CAEP 2009
Results - training
• Regarding “procedures to follow in responding
to a tactical violence scene where there my be
further violence” 77% of 876 respondent stated
they had received no training.
• 92% of 289 respondents stated police to be in
control of site access in a tactical violence
situation but 4.5% “did not know” who would be
in control of the scene.
CAEP 2009
Results - training
• “...trained to function under conditions of
tactical violence”. 89% of 288
respondents – “never” (46%) or “>1yr”
• Only 27% of 291 respondents had “..any
field exercise with other (non-medical) first
responders”. 37% had exercised more
than 1 year ago and 36% “never”
CAEP 2009
Results – emotional impact
Not
distressing
Slightly
distressing
Moderately
distressing
Would not
be able to
resume
work
Would not
be able to
deliver
care at the
scene
(weight 0)
(weight 1)
(weight 2)
(weight 3)
(weight 4)
Total
Emotional
Impact
Value
Average
Emotional
Impact
Value
1
1 adult injured
1 adult dead
342 (0)
492 (492)
0 (0)
12 (36)
1 (4)
532
0.63
2
1 adult injured
1 child dead
51 (0)
211 (211)
512 (1024)
75 (225)
1 (4)
1464
1.72
3
1 adult
attacked
1 child dead
34 (0)
177 (177)
541 (1082)
99 (297)
1 (4)
1560
1.83
4
1 adult injured
27 (0)
1 child attacked
and dead
137 (137)
520 (1040)
172 (516)
3 (12)
1705
1.98
5
20 adults killed
accidentally,
five injured
39 (0)
136 (136)
456 (912)
224 (672)
1 (4)
1724
2.01
6
20 adults killed
purposely, five
injured
31 (0)
84 (84)
432 (864)
297 (891)
12 (48)
1887
2.20
CAEP 2009
Results – emotional impact
I never have unwanted memories of distressing events
3.1%
I would process the event immediately and it would not
bother me for any significant length of time
26.4%
It will take me up to a week to process this event
30.8%
It will take me up to a month to process this event
13.2%
It will take me over a month to process this event
11.5%
I do not think I would ever get over witnessing such an event 15.1%
CAEP 2009
Comfort levels – event response
Very
uncomfortable
Slightly
uncomfortable
Unsure
Reasonably
comfortable
Very
comfortable
Fire
57 (7%)
61 (7.4%)
52 (6.3%)
224 (27.4%)
425 (51.9%)
Unstable
building
113 (13.8%)
126 (15.4%)
173 (21.1%)
275 (33.6%)
132 (16.1%)
Terror event
153 (18.7%)
154 (18.8%)
266 (32.5%)
186 (22.7%)
60 (7.3%)
In PPE
103 (12.6%)
136 (16.6%)
166 (20.3%)
247 (30.2%)
167 (20.4%)
Tactical
violence
103 (12.6%)
157 (19.2%)
196 (23.9%)
264 (32.2%)
99 (12.1%)
CAEP 2009
Comfort level – distress
recognition
Very
Slightly
Unsure
uncomfortable uncomfortable
Reasonably
comfortable
Very
comfortable
Recognising
self distress
31 (3.8%)
57 (7%)
124 (15.1%)
353 (43.1%)
254 (31%)
Recognising
distress in
others
21 (2.6%)
50 (6.1%)
100 (12.2%)
441 (53.8%)
207 (25.3%)
CAEP 2009
Comfort level - support
Very
Slightly
Unsure
uncomfortable uncomfortable
Reasonably
comfortable
Very
comfortable
Receiving
anonymous
counseling
55 (6.7%)
81 (9.9%)
98 (12%)
247 (30.2%)
338 (41.3%)
Receiving
group
counseling
67 (8.2%)
87 (10.6%)
103 (12.6%)
266 (32.5%)
296 (36.1%)
CAEP 2009
Progress
• MCI training
• Awareness training
Discussion
• Targeted tactical violence is a reality
• Some paramedics are trained to back up
police in tactical situations organized and
controlled by PD
• A paucity of front line paramedics are
trained to respond in a situation of tactical
violence targeted at first responding
crews. Some don’t even know who would
be in charge.
CAEP 2009
Discussion
• Even the “lesser” of the factors in the
scenarios more than doubled the
emotional impact of the event as rated.
• These factors are not unusual (child injury,
assault, etc)
• Emotional self care is not part of standard
training for paramedics
CAEP 2009
Discussion
• Monitoring for psychological impact is not
routinely carried out although some services
have implemented post incident debriefing.
• 97% of respondents admitted to occasional
unwanted memories of distressing events with
31% stating it would take up to a week to
process the event and 15% stated they did not
think they would “ever get over witnessing such
an event”
• 26% stated they would process the event
immediately and it would not bother them for
any significant length of time.
CAEP 2009
Tema Conter Foundation
www.tema.ca
CAEP 2009
Conclusions
• Inadequate numbers of EMS personnel
are prepared to function at a scene of
terror or tactical violence directed at
responders. Awareness and education
should be provided
• The emotional effect on paramedics of
violence requires greater attention
Thank you for your attention