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

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”

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

• 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