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Home > Topics > Safety
October 25, 2012
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The Art of EMS
by Steve Whitehead

When — and how — to get out of Dodge

Our focus on addressing scene safety first can sometimes lead us to let our guard down once we've entered the scene

By Steve Whitehead

Sometimes the best advice comes in the simplest of terms. A reader of mine recently passed on a bit of wisdom that his field instructor had impressed upon him years earlier. His advice is worth passing on here.

When it comes to scene safety, here are the two most important things:

  • Always knowing when to get out of Dodge
  • Always knowing how to get out of Dodge

Like most wise yet simple statements, this one deserves closer inspection. Let's break this seemingly simple piece of advice down and explore it in a bit more detail.

What does it mean to "get out of Dodge"?

The phrase "get out of dodge" comes from the old West series "Gunsmoke," which was set in Dodge City, Kan. In the series, Marshal Matt Dillon was fond of telling villains that they needed to "get out of Dodge."

Since then, the phrase has evolved to mean get out of anywhere fast.

When we learn about scene safety and scene control, we spend a bunch of time focusing on our initial scene survey and determining if the scene is safe to enter. Our focus on addressing scene safety first can sometimes lead us to let our guard down once we've entered the scene and initiated patient contact.

Losing your scene safety focus after you've entered the scene is a little like a lifeguard going off duty as soon as all the children have entered the pool. In truth, the longer we remain on scene, the greater the possibility of things going sideways.

To remain safe, we should develop the habit of knowing when it's time to leave the scene, and we should always have an exit strategy.

How do we know when to get out of Dodge?

Each cycle, my EMT students run what we call "the violent husband scenario." It's designed to present a realistic safety dilemma to the students and demonstrate how conflicting priorities can complicate routine EMS care.

We allow the students to enter the scenario and initiate patient contact with an emotionally distressed but stable female victim who is resistant to leaving. After a few minutes of patient contact, an angry, intoxicated scenario-husband enters the scene and begins threatening the crew. The person playing the husband character is directed to slowly make increasingly aggressive gestures and threats until the crew recognizes the need to exit.

Some groups will remain on scene and refuse to leave the patient, behind even after the scenario-husband has threatened to go get his gun, left the room and returned with the fake firearm in hand, brandishing it in the crew members' faces.

In the scenario debriefing, the discussion invariably turns to patient abandonment. Many of our students steadfastly maintain that they are required, either legally or morally, to remain with the patient regardless of personal safety concerns.

Let's slay that medical/legal/ethical dragon right now: You are never required to stay in an unsafe environment in the interest of patient care.

Let me put it another way: If you enter a scene and make patient contact and the scene then becomes unsafe, you can fall back to a safe position and manage the threat from a safe distance until scene safety can be reestablished.

Keeping yourself safe is not separate from patient care; it is patient care. The worst thing you can do for your patient is become injured. Once you are injured, you become the primary focus of the medical resources on scene, and your patient's emergency becomes an afterthought. There is nothing noble about becoming injured on your patient's behalf.

If you can bring the patient with you when you leave, great -- do so. If you cannot, return as soon as your safety is reestablished. If you are a safe distance away and you are doing what you can to mitigate an on-scene danger, you have not abandoned your patient.

This is an interesting contradiction of EMS scene management. If a safety threat is immediately recognized during the scene size-up, most responders will refuse to enter. But if a safety threat is introduced after responders have entered the scene, most of us will wait far too long before we decide to leave.

Always be willing to leave. If a threat is escalating, pack your things and back away. If things go bad in a hurry, be prepared to leave everything behind and get out of Dodge.

How do we know how to get out of Dodge?

In fire academy, it's impressed upon firefighter recruits that it's more important to know how to get out of a structure than how to get into a structure. Cadets crawl almost blind through smoke-filled rooms, dragging hose lines and surrounded by odd furniture and screaming instructors.

As they move through the structure, they are expected to remember the locations of doors and windows. If an instructor senses that a recruit is disoriented, he'll stop them and holler, "Where is your closest exit?"

In EMS, we don't receive that kind of intensive training in situational awareness. Yet EMS personnel go inside buildings and get stuck in bad situations with alarming frequency.

As you enter a scene, a million things are running through your head. Your complaint-based differential diagnosis is probably primary in your thoughts, followed by the look, feel and smell of the scene and the people present. Next, you're considering your patient's location, initial presentation and to whom you will be delegating your initial scene priorities. It's a lot for anyone to take in.

I'd like you to add another thought to your list. Ask yourself, "If I need to get out of here fast, which way will I go?"

Also consider how long it will take for everyone on your crew to exit. If you're going to bail, everyone needs to decide to bail together. There's no sense in getting out of Dodge if you accidentally leave one ranger behind to fend for him- or herself.

The longer it's going to take to get everyone out of Dodge, the less tolerant you can be of anything that feels wonky. If you are in a kitchen with a large sliding door that opens to a big yard with good egress, you may be able to manage a bit of hostility.

If you are on the third floor of an apartment complex and everyone is crowded in the back bedroom, you need to start breaking up the party at the first sign of trouble. Make it clear to everyone on scene that you and your crew have no intention of staying if everyone isn't cooperating and respectful.

Often, caregivers and emergency personnel will know that it's time to leave, but they won't want to be the first one to say, "Let's get the heck out of here."

Don't ever hesitate to say, "I think we need to leave, y'all." Know when it's time to pack up the horses, and know the best route out of Dodge.

About the author

Steve Whitehead, NREMT-P, is a firefighter/paramedic with the South Metro Fire Rescue Authority in Colo. and the creator of blog The EMT Spot. He is a primary instructor for South Metro's EMT program and a lifelong student of emergency medicine. Reach him through his blog at steve@theemtspot.com or at Steve.Whitehead@EMS1.com.
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