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?
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
The Problem of Recognition: The
Scene
The Problem of Recognition: The
Scene
The Problem of Recognition: The
Scene
The Problem of Recognition: The
Scene
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
The Problem of Recognition: The
Patient
Calm
Irritable
Verbal
Physical
The Problem of Recognition: The
Patient
Calm
Hardest to Best time to
recognize intervene
Irritable
Verbal
Easiest to Worst time to
recognize
Physical
intervene
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 • Detonate
– Show of force – Physical restraints
– Medication – Chemical restraints
Intervention: Defuse or Detonate
• Defuse • Detonate
– Show of force – Physical restraints
– Medication – 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”
6th 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
Class D in pregnancy
• Valium
• Haldol
Sedative Medications
• Versed
• Valium Lowers seizure threshold
• Haldol 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