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Assume the best of your patients and prepare for the worst

Prevent and survive an attack by pre-planning your fight or flight response


“As an EMS professional, you must have pre-planned responses to escalating aggression and displays of intent to commit violence while on scene or in the back of the rig,” writes Martin.

Sam Costanza


“As an EMS professional, you must have pre-planned responses to escalating aggression and displays of intent to commit violence while on scene or in the back of the rig,” writes Martin.

Sam Costanza

The recent stabbing of a Mt. Sinai EMT in New York City is simply the latest in a trend of increasingly common interpersonal violence committed against EMS professionals on the job. It is far past time to address this issue both at the level of individual EMS professionals and as system/agency/department leadership in frank and unapologetic terms.

As an EMS professional, you must have pre-planned responses to escalating aggression and displays of intent to commit violence while on scene or in the back of the rig. Your scene and turnaround times – even your job or your license – are not worth your life or limb. Challenge both your mentality and current state of practical planning to see where you might be vulnerable.

Consider as a framework from which to build your personal plans, the Advanced Law Enforcement Rapid Response Training (ALERRT) organization’s “Citizen Responder to Active Shooter Event” training material. The course identifies three stages in the response to a high stress incident: denial, deliberation and decisive movement. This model of critical incident response extends beyond the context of the active shooter incident and applies fully to violent assaults against medics and EMTs on scene and in the rig.

  • Denial. Moments spent in the denial stage steal the time you have to act before the event hits its greatest momentum. Cut down your denial time by reminding yourself on every shift, “it can happen to me.” Freezing in astonishment or asking “why?” will not slow unfolding events or protect you in any way. A violent assault against you is not your fault, but it is your problem.
  • Deliberation. Moments spent in deliberation similarly steal your time to act. Cut down your deliberation time by pre-planning your responses. Where are you? Where is your gear? Where are your fellow crewmembers? Where is the shortest path out? What tools do you have around you?
  • Decisive movement. This is the only phase of response in which you are empowered to potentially affect the outcome of an event. Acceptance in advance and preparation enable you to maximally affect the evolution of events on your scene and in your rigs. Assume the best of your patients and prepare for the worst. Consider during your physical exams, routinely exposing, inspecting and palpating the waistline and pocket areas. Implements of violence, of any form, are likely to be stored and deployed from the waistline. It may also be prudent to check the ankles and feet, as various tools can also be stored and deployed from concealment under a pant leg or in a boot. Consider, in a patient who is resistant to physical examination of the waistline or ankle/foot area, but otherwise cooperative, that they may have something they prefer you not find. If you find that you do not trust your patient’s motivations, those suspicions are likely founded. Your brain is tuned to look out for your welfare and feed you subconscious clues even if you cannot yet articulate a very specific fear. Trust your instincts.

Take realistic threats seriously

An 80-year-old, 80 lb female suffering from altered mental status because of her raging catheter-associated UTI may not present a significant physical threat, despite her stated intent to cause you harm. However, you should believe people when they tell you they want to commit violence against you and take realistic threats seriously..

In many states, making a directed threat of violence constitutes a criminal act of assault. You have no ethical, moral or professional obligation to accept assault as “part of the job.” If a patient begins to threaten you while on scene, you may employ de-escalation strategies so long as it remains safe to do so. If the patient cannot be de-escalated promptly and safely, be prepared to cease the attempt to render care, rapidly vacate the scene and call for law enforcement. That patient’s choice to interfere with their own care, further endanger their own welfare in delaying management of their ostensible condition and take on the role of a criminal actor is fully theirs, not yours.

If a patient begins to make verbal threats of violence during transit and cannot be promptly de-escalated, be prepared to call a halt to the truck, get out of the back, get in the cab (if the cab is isolated), lock the doors and call for a police response. No amount of agency property damage within the ambulance a patient might commit is worth your life or limb. Should the patient exit the rig, be prepared to drive away from any person who is attempting to forcefully enter the cab of the truck to do violence to you. It is simply not your responsibility to attend to the welfare of a violent criminal actor who is demonstrably and actively intent upon doing you bodily harm, whether or not they first called 911 and signed your consent form.

Do not ever tolerate patients undoing stretcher straps. A patient must either give informed consent to safe transportation to the hospital, which means being properly secured in the stretcher for the entire transit, or they simply do not consent to the transit. If a patient is un-belting themselves and will not heed counsel to cease, stop the rig. If the patient is doing so while threatening violence, take the threat seriously and evacuate the back of the rig. Call your supervisor and/or law enforcement. Patients who are under arrest, under emergency detention, or who are being treated and transported under the doctrine of implied consent must be secured in a manner which they cannot easily escape. That may include handcuffs, four-point restraints, a chest belt which buckles behind the patient where they cannot reach, or patient safety sedation as dictated by your agency’s policies and procedures.


Read more:

How to make scene safety a core part of every EMS response

Attacks on EMS providers by the very people we are trying to help are becoming all too common: Review your safety practices and training

Plan for fight or flight

Have a “flight” plan. Do not place monitors and bags in places which block or significantly obstruct your ability to get to an exit. Always have at least one egress door which you can get to quickly. Have an understanding with your crew about the difference between a command to halt which means “take the next exit and pull into a parking lot” and one which means “start pressing the brake this second.”

Have a “fight” plan. Sometimes, de-escalation is not possible. Sometimes, escalation happens quickly and egress out of the truck may not be an option when the outside environment is moving at freeway speeds. Consider the tools in your vicinity, including those which might be improvised into tools of self-defense. Read and understand the legal statutes in your state which define the justified use of force in self-defense.

Finally, push your local, regional and national professional organizations to support regulatory and legislative efforts which escalate penalties against offenders who commit acts of assault, battery and other criminal aggression against first responders during the course of their duties.

Daniel Martin is an emergency medicine physician assistant, licensed paramedic, boarded tactical paramedic, author, consultant on matters of tactical paramedicine policy and practice, and educator in matters of both EMS and personal safety. He holds multiple instructor credentials across relevant disciplines. He currently is working on the ambulance in the area of San Antonio, and offers training to EMS agencies and ER personnel on handling armed patients and occupational firearm safety.