Scene Safety Tips for Violent Patients and Bystanders

BSI! Scene safe!

How often do we repeat that mantra during clinical simulation scenarios? In my experience, it’s heard from crews during nearly all of my testing days with EMS providers. In getting to the meat of clinical practice, we gloss over the fact that a scene indeed might not be safe.

Consider the following scenarios:

Driving through a residential subdivision at night, an ambulance looks for a police staging area while responding to a domestic dispute call. Thinking they are away from the scene, the ambulance parks at a curb in front of a row of houses only minimally lit.

Suddenly a man with a rifle appears on the deck of one of these homes. He raises his gun toward the ambulance crew, but is shot and killed by unseen police before he can fire.

A 5-year-old boy is laying on a couch in his parent’s living room complaining of a severe headache. His mother advises EMS that he has had a high fever as well. Before the crew has time to consider a possible infectious disease exposure to meningitis and put their masks on, the father arrives on scene and is irate. He does not want his son going to the hospital and orders the crew to leave the house. When they seem slow to carry out his command, he becomes angrier and advances to within a foot of the providers while threatening violence if they do not leave. They quickly exit the home.

Violent patients or bystanders
The subject of scene safety is extremely broad, encompassing body substance hazards, roadway traffic control, and chemical exposures, to name a few. For this article, I want to narrow the subject to scenes involving potentially violent patients or bystanders.

These situations are representative of the potential risks faced by EMS, firefighters and police on a regular basis. While national statistics on threats and violent acts perpetrated on EMS crews do not seem to be available, the occurrences are likely commonplace.

Indeed, any cursory review of internet media reveals frequent accounts of assaults on EMS crews. Every experienced provider I spoke to while researching this topic had several harrowing stories to relate regarding some of their encounters in these circumstances over the years.

The following information is a synopsis of these EMS crews’ experiences and recommendations. Additionally, the two excellent references listed below provided source material.

Characteristically high risk scenes include:

• Assaults
• Domestic disputes
• Overdose cases
• Situations involving recreational drugs and alcohol
• Psychiatric problems especially ones involving potential or threatened suicide
• Gunshot wounds or stabbings
• Calls with limited, or no information or involving “a man down”
• Outdoor roadway scenes

But the reality is that no scene is safe. That’s what instructors teach crews in our EMS service. Approach all scenes with this in mind for maximum safety. A call that seems routine with no apparent danger to providers can devolve rapidly into one that does involve threat. Moreover, a patient familiar to EMS and previously thought to be safe can become a risk on the next call.

Things to remember
There are few things that we can do in our interaction with patients and bystanders that may reduce the likelihood of making a potentially bad situation into a very bad one.

• Remember that all of us want our “personal space.” The closer we get to a hostile individual, the more likely he or she may react much more negatively. Try to give them space while taking with them in hopes that they may calm with conversation from a distance. Additionally, realize that a patient or bystander that gets too close to providers may be a threat. If a potentially violent individual invades our personal space, we have much less ability to protect ourselves from an assault.
• Be flexible in your approach to patients, keeping in mind that some times cultural differences may play a role in difficult interaction. While our patients often come from very divergent backgrounds or lifestyles, it’s best not to be judgmental.
• Maintaining eye contact with the patient and others in the conversation is important. It’s usually a good idea to verbalize and explain to the patient and bystanders what is being done and is planned.
• Non-verbal communication cues can either help or hurt a situation. Try to avoid sending negative cues, no matter how unintentional. Sometimes subtle things like a roll of the eyes in response to a comment from a patient may be in fact be perceived by the patient as an insult and provoke a reaction that was avoidable.
• Conversely, be alert for the non-verbal cues that patients or bystanders send us. Darting eyes, sudden movements, pacing clenching and unclenching of fists suggests a potentially volatile individual who may be close to exploding.

Despite our best efforts at limiting provocation of patients or bystanders, sometimes negative interactions may not be avoided. As a result, here are some basic scene tactics that can be used on all calls that may reduce the risk of injury to providers:

• Stage safely away from a high risk scene until law enforcement permits EMS entry.
• Even if law enforcement has cleared a scene, recognize that this does not guarantee the scene is safe.
• As a rule, don’t park the EMS vehicle directly in front of the scene.
• Avoid standing in front of windows.
• Don’t stand directly in front of an entry door. Stand to the side of the door.
• If a voice from inside a building says to “come on in, the door’s open,” strongly consider waiting for law enforcement. If you think that it is likely safe, open the door from the side and enter cautiously after pausing for a brief time.
• Light up a dark scene. But if using a flashlight, keep it to the side and not in front of you as potential assailants will target a flashlight.
• Always locate an alternate exit than what you entered through, if one exists.
• Keep yourself between the patient and bystanders and an escape exit.
• Avoid assessing patients in a kitchen whenever possible. Many potential weapons reside in a kitchen.
• In addition to using the secondary survey as a physical assessment tool, be alert for the possibility of a hidden weapon at that time,
• Maintain scene awareness throughout the call. At least one crew member should be primarily assigned to observe the scene for potential physical threats and other safety hazards. Avoid tunnel vision.

In aviation, they use a term called “situational awareness.” Situational awareness is an excellent phrase summarizing the concepts above with regard to scene safety.

In short, it’s critical to maintain awareness of the scene situation at all times, in order to maximize protection of EMS crews and others.

Many groups are now appropriately focusing on EMS Safety. Typically, these efforts are directed at vehicular transport, providers and an emerging emphasis on patient safety.

Less has been done to address scene safety as a part of these initiatives. Hopefully, more work will focus on this very important component of safety, including the establishment of a national data-base of these incidents.

No matter what develops in the future, we should all strive for situational awareness on every scene, today.

References:
Dernocoeur, KB, Street Sense Communication, Safety and Control 3rd ed. Redmond, WA: Laing Research Services; 1996

Remsberg, C, The Tactical Edge, Surviving High-Risk Patrol Carrollton, TX: Calibre Press Inc; 2002