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Assault is not in the EMS job description

One of the biggest problems in ensuring crew safety is a lack of empirical evidence to support policy or training changes

By Joe Kolb, EMS1 Contributor

In the first week of October, two Tabor City, N.C. ambulance crew members were injured when an irate man attacked them as they tended to his girlfriend., In San Antonio, Texas, a man was arrested for choking a female paramedic in the back of an ambulance.

These were just two incidents that made itto the media. What are not mentioned are the hundreds, if not thousands of incidents that occur across the country daily where EMS crews face patients intent in harming the very people attempting to provide care to them, often times not under the best of environmental conditions.

Speak to any EMT/paramedic and they will tell you about the time a patient grabbed them, kicked them, threw a punch at them or spit at them. It’s often considered part of the job and discussed after the run, but rarely documented. Sadly, one of the biggest problems in ensuring the crew safety of crews is a lack of empirical evidence to support policy or training changes.

Being assaulted on the job is not unusual

Researchers at the University of Maryland, Baltimore County presented a discussion on Occupational Safety Risks for EMS workers at a 2009 conference and reported that the EMS assault fatality rate is seven times higher than for other health care workers. And the non‐fatal assault rate is 22 times higher than the national average.

In an article written by Brian Maguire and Sean Smith in the August 2013 issue of Prehospital and Disaster Medicine titled, “Injuries and Fatalities among Emergency Medical Technicians and Paramedics in the United States”[1], injuries to EMTs/Paramedics between 2003-2007 were studied from data obtained by the Department of Labor. Of the 21,749 reported injury cases, 530 were the result of assaults with eight percent of those resulted in fatalities.

An article in the October - December, 2002 issue of Prehospital Emergency Care, written by Mechem, Dickinson, et. al, titled, “Injuries from Assaults on paramedics and firefighters in an urban medical services system”[2], found EMTs/Paramedics in Philadelphia between 1996-1998 submitted 1,100 injury reports submitted during the study period, of which 44 cases involved an assault.

Paramedics were assaulted in 35 (79.5 percent) of these incidents and firefighters in nine (20.5 percent). Ninety-three percent of these incidents occurred during direct patient care activities. Of these, 81.8 percent required medical attention, and in 14 cases (31.8 percent) the employee lost time from work.

Getting attacked is not OK

Many administrators agree that despite these glaring indictments on the hazards of providing pre-hospital care, not enough has been or is being done to protect EMS crews.

Mike Worley, chairman, of the 25 member Tabor City (N.C.) EMS said he is horrified at what happened to his crew.

“My [staff] were hurt really bad and I want people to know what happened,” Worley said.

He echoed how many in EMS and around the country feel about assaults, saying they go unreported the majority of the time, “because we perceive it to be part of the patient’s condition.”

After the attack on his crew, Worley said the service will now change how they report perceived and actual attacks, whether physical or verbal.

“This will make us more aware of what is happening,” Worley said of interventions that can be implemented to mitigate the potential or extent of injuries from a combative patient or by-stander, as was the case in this most recent incident.

He said the assailant was charged with assault and will be prosecuted.

Preparing for the worse

The trend in providing self-defense training is gradually gaining momentum. DT4EMS is one such program, along with the Albuquerque, N.M.-based Global One Defense Solutions, which has developed a full day program addressing these considerations where there is active participation and skill practice by attendees.

Currently training more than 250 EMT and paramedics of the Albuquerque Ambulance Service, Global One Defense Solutions, which is comprised of current and former law enforcement, military, and EMS personnel, emphasizes the reality for the potential of the attack while stressing safety and litigious considerations.

“You don’t want to use offensive martial arts tactics on a patient. It is purely self-defense,” says Gil Baca, CEO of Global One Defense Solutions and a retired New Mexico State Police Commander and an Anti-Terrorism Instructor for the U.S. State Department. “We stress avoidance and escaping dangerous situations.”

In lieu of specific training, Baca said the first and most important component in self defense for EMS is situational awareness. Expect a combative patient and have a mental game plan with your partners as to how the individual will be approached, controlled, and restrained, he said.

“Attempting to de-escalate the situation with verbal commands which should be expressed confidently,” Baca said.

Zane Church, master instructor for all certified Global One Defense Defensive Tactics instructors, emphasizes that EMS providers should not approach the individual directly from the front with your hands at the side.

“Approach the patient at an angle, with your hands up motioning for them to calm down,” Church said. “You also want to be sure to stay more than an arm’s length from the patient while doing this.”

Because of the various positions a patient may be found in, Baca advocates training for real-life situations such as a combative patient who is supine, seated, standing, and coming at you from the front and rear. Most importantly, attacks inside the ambulance are extremely harrowing and dangerous.

“It is important for the EMT/paramedic to know that they are in a self-defense mode and should avoid directly striking the patient," Baca said. "The theory is evade and escape danger."

Finally, because of potential litigation, departments should have written use of de-escalation to self-defense techniques in place.

While attack and injury is always a reality when providing pre-hospital care, preparation can help you while helping others.

Basic self-defense considerations:

  • Always assume the patient will be combative.
  • Find a quick escape route should the patient or bystanders attempt to attack you.
  • It is better to avoid, evade, and escape a combative patient rather than get into a physical altercation with them. In cases where you are confronted with a weapon, more aggressive tactics need to be employed, but first consult with your agency’s legal department as to any standing protocols. 
  • Avoid standing directly in front of a patient. Approach them at a 45-degree angle in a non-threatening manner, keeping your hands up in a calming non-threatening gesture and your feet in a staggered ready position. Just like in sports, keeping your feet staggered will allow you to evade quicker while providing a solid base of support should the patient lunge at you.
  • When having to crouch by a patient avoid the “catcher’s position.” This provides very little support base. 
  • It is recommended your partner stand to the side of the patient to observe for any weapons or additional injuries that may be found on the patient’s back.
  • Verbal cues are important. Always try to de-escalate and calm the patient even while defending yourself.
  • Always maintain situational awareness. As the crew in Tabor City, N.C. learned, it is not always the patient you have to be cautious of.


1. Maguire, BJ, Smith, S, Injuries and fatalities among emergency medical technicians in the United States, Pre-hospital and Disaster Medicine, Aug. 2013, 28(4) p. 376-382.
2. Mechem, CC, Dickinson, ET, Shofer, FS, Jaslow, D, Injuries from assaults on paramedics and firefighters in an urban emergency medical services system, Pre-hospital Emergency Care, Oct.-Dec. 2002, 6(4), p. 396-401.

About the Author

Joe Kolb, M.A. has a 20 year career as an EMT and is the co-founder for the GlobalOne Defense Solutions EMS Self-Defense Program. He is a lecturer in the Criminal Justice program at Western New Mexico University where he specializes in Homeland Security and Transnational Criminal Organization issues. He can be reached at kolbjoseph69@yahoo.com.

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