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

Almost all of you will be victims during your career.

Overview Epidemiology Recognition Prevention Beyond prevention Self-defense Teaching points

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

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

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

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

The Scope of the Problem Percentage of residents assaulted?

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

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

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

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

What About Pre-Hospital?

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

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

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

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

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

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

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

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

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

Michigan 2005 Urban equivalent to other locations

Where Violence Occurs

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

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

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

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

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

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

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

The Problem of Recognition: The Scene

High-risk chief complaints

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

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

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

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

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

The Problem of Recognition: The Patient

Calm Irritable Verbal Physical

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

Everyone Has a Breaking Point

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

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

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

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

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

Recognition in the Calm Patient Prior history

Recognition in the Calm Patient Prior history Substance use

Recognition in the Calm Patient Prior history Substance use In custody

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

Organized Violence Ink Clothing Gang colors

Beyond Calm

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

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

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

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

The Downward Spiral

Prevention: Scene Approach Recognize scene potential

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

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

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

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

Prevention: Patient Approach Recognize patient potential

Prevention: Patient Approach Recognize patient potential Identify yourself

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

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

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

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

Intervention in Early Stages Recognition

Intervention in Early Stages Recognition Make eye contact

Intervention in Early Stages Recognition Make eye contact Empathy and validation

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

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

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

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

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

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

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

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

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

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

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

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

Protect Your Co-workers Communication Planning Support

Protect Bystanders Isolation Control Speed

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

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

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

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

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

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

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

The Goal

Not the Goal

Rules of Restraint Document necessity No prone positioning

Sedative Medications Versed Valium Haldol

Sedative Medications Versed Valium Haldol Class D in pregnancy

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

If He Needs Restraints, He Needs Medication

When There Are Weapons

“Hey, Doc, wanna see my piece?”

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

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

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

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

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

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

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

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

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

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

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

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

Chance Favors the Prepared Mind

In Summary Pre-hospital violence is common

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

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

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

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

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

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

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

The End Thanks for Your Time and Attention