1. Keeping the Peace: Violence Against Emergency Medical Providers Rebecca Jeanmonod M.D. Albany Medical College Department of Emergency Medicine

2. Almost all of you will be victims during your career.

3. Overview Epidemiology Recognition Prevention Beyond prevention Self-defense Teaching points

4. The Scope of the Problem Percentage of EMS calls involving violence to provider?

5. The Scope of the Problem Percentage of EMS calls involving violence to provider? 5%

6. The Scope of the Problem Percentage of EMTs injured per year?

7. The Scope of the Problem Percentage of EMTs injured per year? 50%

8. The Scope of the Problem Percentage of residents assaulted?

9. The Scope of the Problem Percentage of residents assaulted? 33%

10. Survey of 170 ED Directors 32% report verbal threats daily 18% report threat with weapons monthly

11. In One Trauma Center 25% of trauma victims carry a lethal weapon 8 incidents per year involving weapons 4 patient fatalities in 15 years 6 staff injuries in 15 years

13. 1995 in US Hospitals 42 homicides 1463 physical assaults 67 sexual assaults 165 robberies, 47 armed

14. What About Pre-Hospital?

15. Survey of paramedics over 12 years How many assaults per provider?

16. What About Pre-Hospital? Survey of paramedics over 12 years How many assaults per provider? –Nine total

17. What About Pre-Hospital? Survey of paramedics over 12 years How many assaults per provider? –Nine total –170 blunt injuries

18. What About Pre-Hospital? Survey of paramedics over 12 years How many assaults per provider? –Nine total –170 blunt injuries –73 lacerations

19. What About Pre-Hospital? Survey of paramedics over 12 years How many assaults per provider? –Nine total –170 blunt injuries –73 lacerations –2 GSW, 10 stabbings

20. What About Pre-Hospital? Survey of paramedics over 12 years How many assaults per provider? –Nine total –170 blunt injuries –73 lacerations –2 GSW, 10 stabbings –8 fractures, 9 dislocations

21. What About Pre-Hospital? Survey of paramedics over 12 years How many assaults per provider? –Nine total –170 blunt injuries –73 lacerations –2 GSW, 10 stabbings –8 fractures, 9 dislocations –1 burn

22. Michigan 2005 Violence more common against females 45% of assailants were intoxicated 33% of assailants were mentally ill 10% of assailants were not patients

23. Michigan 2005 Violence more common against females 45% of assailants were intoxicated 33% of assailants were mentally ill 10% of assailants were not patients

24. Michigan 2005 Urban equivalent to other locations

25. Where Violence Occurs

26. Where the Wild Things Are “Bad” area of town Bars Mass gatherings Everywhere else

27. Where the Wild Things Are “Bad” area of town Bars Mass gatherings Everywhere else You are faced with an undifferentiated patient or scene.

28. Where the Wild Things Are “Bad” area of town Bars Mass gatherings Everywhere else You may have limited visualization.

29. Where the Wild Things Are “Bad” area of town Bars Mass gatherings Everywhere else You may have limited personnel.

30. Where the Wild Things Are “Bad” area of town Bars Mass gatherings Everywhere else You have limited pharmacotherapy.

31. Where the Wild Things Are “Bad” area of town Bars Mass gatherings Everywhere else You may have limited training.

32. Where the Wild Things Are “Bad” area of town Bars Mass gatherings Everywhere else You have a job to do.

33. The Problem of Recognition: The Scene

38. High-risk chief complaints

39. The Problem of Recognition: The Scene High-risk chief complaints –Gunshot wound –Drug overdose –Bar fight

40. The Problem of Recognition: The Scene High-risk chief complaints High-risk locations

41. The Problem of Recognition: The Scene High-risk chief complaints High-risk locations –Poorly lit –Areas that could conceal or cover –Only one entrance or exit

42. The Problem of Recognition: The Scene High-risk chief complaints High-risk locations High-risk times

43. The Problem of Recognition: The Scene High-risk chief complaints High-risk locations High-risk times –Nights –Holidays –Weekends

44. The Problem of Recognition: The Patient

45. Calm Irritable Verbal Physical

46. The Problem of Recognition: The Patient Calm Irritable Verbal Physical Best time to intervene Worst time to intervene Hardest to recognize Easiest to recognize

47. Everyone Has a Breaking Point

48. Reasons Why Patients Become Violent Altered mental status and medical illness –Seizure –Hypoxia –Head injury –Hypoglycemia

49. Reasons Why Patients Become Violent Altered mental status and medical illness Fear or anxiety

50. Reasons Why Patients Become Violent Altered mental status and medical illness Fear or anxiety Frustration

51. Reasons Why Patients Become Violent Altered mental status and medical illness Fear or anxiety Frustration Drugs or alcohol –Cocaine –Ecstasy –PCP

52. Reasons Why Patients Become Violent Altered mental status and medical illness Fear or anxiety Frustration Drugs or alcohol Just plain mean

53. Recognition in the Calm Patient Prior history

54. Recognition in the Calm Patient Prior history Substance use

55. Recognition in the Calm Patient Prior history Substance use In custody

56. Recognition in the Calm Patient Prior history Substance use In custody Mental illness

57. Organized Violence Ink Clothing Gang colors

58. Beyond Calm

59. Signs of Trouble Complaining loudly Interrupting Agitated Pacing Can’t sit still

60. Bad to Worse Sweating Dilated pupils Abrupt, angry movements Accusations Insults Threats

61. Point of No Return Standing and leaning into you Yelling Finger pointing Fist clenching Chest beating

62. If you feel like smacking him, he’s probably thinking the same thing.

63. The Downward Spiral

64. Prevention: Scene Approach Recognize scene potential

65. Prevention: Scene Approach Recognize scene potential Turn off lights and sirens when near scene

66. Prevention: Scene Approach Recognize scene potential Turn off lights and sirens when near scene Scan for cover and concealment

67. Prevention: Scene Approach Recognize scene potential Turn off lights and sirens when near scene Scan for cover and concealment Park outside the “kill-zone”

68. Prevention: Scene Approach Recognize scene potential Turn off lights and sirens when near scene Scan for cover and concealment Park outside the “kill-zone” Park so you can pull forward to leave

69. Prevention: Patient Approach Recognize patient potential

70. Prevention: Patient Approach Recognize patient potential Identify yourself

71. Prevention: Patient Approach Recognize patient potential Identify yourself Respect the patient’s space

72. Prevention: Patient Approach Recognize patient potential Identify yourself Respect the patient’s space Avoid tunnel vision

73. Prevention: Patient Approach Recognize patient potential Identify yourself Respect the patient’s space Avoid tunnel vision Evacuate patient quickly

74. Prevention: Patient Approach Recognize patient potential Identify yourself Respect the patient’s space Avoid tunnel vision Evacuate patient quickly Be alert to weapons on secondary survey

75. Intervention in Early Stages Recognition

76. Intervention in Early Stages Recognition Make eye contact

77. Intervention in Early Stages Recognition Make eye contact Empathy and validation

78. Intervention in Early Stages Recognition Make eye contact Empathy and validation Call the patient by name

79. Intervention in Early Stages Recognition Make eye contact Empathy and validation Call the patient by name Don’t trap the patient

80. Intervention in Early Stages Recognition Make eye contact Empathy and validation Call the patient by name Don’t trap the patient Call for help early

81. Intervention in Early Stages Recognition Make eye contact Empathy and validation Call the patient by name Don’t trap the patient Call for help early Be cognizant of body language and tone

82. Intervention: Defuse or Detonate Defuse –Show of force –Medication Detonate –Physical restraints –Chemical restraints

83. Intervention: Defuse or Detonate Defuse –Show of force –Medication Detonate –Physical restraints –Chemical restraints

84. One study showed reduction in aggression from 37% to 3% by instituting preventive training.

85. A study in VAs showed 92% decline in violence by institution of preventive measures.

86. Rules of Engagement Rule 1: Protect yourself Rule 2: Protect your co-workers Rule 3: Protect bystanders Rule 4: Protect the violent patient

87. If he has a gun and wishes to commit suicide, let him.

88. Rules of Engagement Rule 1: Protect yourself Rule 2: Protect your co-workers Rule 3: Protect bystanders Rule 4: Protect the violent patient In that order

89. Protect Yourself Maintain access to the exit Communicate roles with partner Maintain visual contact with partner Keep your body at an angle to the patient Keep your hands in front of your body Wear gloves Don’t allow outsiders in and out of scene

90. Protect Your Co-workers Communication Planning Support

91. Protect Bystanders Isolation Control Speed

92. Protect the Violent Patient Minimum necessary force Multiple providers Timing Follow-through

93. When a Patient is Asking For It Be prepared to overwhelm the patient If he does not back down immediately, restrain him If he then bargains, restrain him

94. Safe Restraining Identify a leader Body at an angle to patient Hands up in front of face Head down Gloves 6 providers Leader gives order and everyone acts simultaneously

95. Who Does What “Leg, leg, arm, head, arm” 6 th person gets supplies

96. The Head Protect patient during take-down No strangling Once down, jaw thrust –Prevents biting –Prevents spitting

97. The Arms One hand on wrist –Prevents scratching One hand on elbow –Prevents punching –Prevents sitting

98. The Legs One hand on ankle –Prevents writhing One hand on knee –Prevents kicking –Prevents rolling Extra providers on knees

99. The Goal

100. Not the Goal

101. Rules of Restraint Document necessity No prone positioning

102. Sedative Medications Versed Valium Haldol

103. Sedative Medications Versed Valium Haldol Class D in pregnancy

104. Sedative Medications Versed Valium Haldol Lowers seizure threshold Increases arrhythmias Prolonged sedation

105. If He Needs Restraints, He Needs Medication

106. When There Are Weapons

107. “Hey, Doc, wanna see my piece?”

108. “No, no thank you, though I appreciate the offer.”

109. Weapons in the Calm Patient Do not have the patient remove the weapon himself If police are present, have them remove the weapon

110. Patients with Knives Police If attacked –Yell –Get close with your arm under knife arm –Hit with something blunt –Do not disarm and defend –Beware of lefties

111. Patients with Guns Most fatal shootings occur within 9 feet If you are at or near 9 feet…

112. Patients with Guns Most fatal shootings occur within 9 feet If you are at or near 9 feet… Drop your gear Run

113. Patients with Guns Most fatal shootings occur within 9 feet If you are closer than 9 feet…

114. Patients with Guns Most fatal shootings occur within 9 feet If you are closer than 9 feet… Redirect gun Keep talking

115. Patients with Guns Most fatal shootings occur within 9 feet If you are well beyond 9 feet…

116. Patients with Guns Most fatal shootings occur within 9 feet If you are well beyond 9 feet… Duck Stay down

117. If He Hasn’t Drawn the Gun One hand on gun hand preventing draw Other hand “subduing” patient

118. If He Hasn’t Drawn the Gun One hand on gun hand preventing draw Other hand “subduing” patient –Eyes –Head –Groin

119. Don’t Be Paranoid, But… Know places to duck in and around rig Know more than one way out Know where police station is

120. Chance Favors the Prepared Mind

121. In Summary Pre-hospital violence is common

122. In Summary Pre-hospital violence is common Violence can be predicted and prevented

123. In Summary ED violence is common Violence can be predicted and prevented Organization and communication equals safety

124. In Summary ED violence is common Violence can be predicted and prevented Organization and communication equals safety Protect yourself and your co-workers

125. In Summary ED violence is common Violence can be predicted and prevented Organization and communication equals safety Protect yourself and your co-workers Ensure scene safety

126. In Summary ED violence is common Violence can be predicted and prevented Organization and communication equals safety Protect yourself and your co-workers Ensure scene safety If attacked with a knife, attack back

127. In Summary ED violence is common Violence can be predicted and prevented Organization and communication equals safety Protect yourself and your co-workers Ensure scene safety If attacked with a knife, attack back If attacked with a gun, have a plan

128. In Summary ED violence is common Violence can be predicted and prevented Organization and communication equals safety Protect yourself and your co-workers Ensure scene safety If attacked with a knife, attack back If attacked with a gun, have a plan

129. The End Thanks for Your Time and Attention