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Implementing a training program to prevent EMS assaults

Learn how ATCEMS identified EMS training goals and implemented an assault reporting function to protect providers from violence


The moral, ethical and legal obligation prehospital providers have to our patients means we are often exposed to potentially dangerous situations.

Photo/Walt Settlemyer

EMS personnel are frequently exposed to potentially violent situations while performing their duties. A review of research indicates there is an increasing number of assaults on EMS personnel across the globe.

Austin-Travis County EMS (ATCEMS) conducted a survey of its personnel and found the incidence of assaults was similar to that experienced in other agencies and it was unacceptably high. Another important finding: many providers who answered the survey expected to be assaulted and felt that being assaulted was just part of the job.

We also learned that much research has been conducted into the frequency of assaults, the types of assaults and predictors of assaults; however, there is little research about the effectiveness of various interventions on the frequency and impact of assaults on EMS personnel. So, what changes should EMS organizations and providers make to reduce assaults?

Video: Gordon Graham on violence prevention

Assault reporting as a KPI

ATCEMS decided that it was important to begin to change its culture towards one that does not accept assaults on EMS personnel as a characteristic of the job and to provide EMS training that focuses on predicting violence, avoiding threats, escaping dangerous situations, and using defensive techniques when necessary. We also started to continuously measure the number of assaults after a period of re-training as a key performance indicator.

To accomplish this, we introduced a new training program and implemented a new assault reporting procedure to capture data about assaults when they occur. Previously, we only captured assault data if an injury occurred because reporting was tied to injury reports. The reporting focused on the injury and captured little information leading to the assault.

As prehospital providers, we have a moral, ethical and legal obligation to our patients, regardless of the circumstances. This means that we are often exposed to potentially dangerous situations. EMS providers, who commonly respond as a team of two, even have to continue care after being assaulted.

ATCEMS has actually had a Defensive Tactics program for some time now, however, as assaults on our EMS providers increased, we realized that it was time to change our training and rethink how we approached potentially violent patients. A team of us developed a list of over-arching attributes that we needed in a training program to provide our medics with a skillset that is safe, highly effective and quickly acquired. The over-arching attributes included:

  • Consideration of the unique EMS environment
  • The ineffectiveness of reactionary self-defense models
  • The need for de-escalation techniques
  • Detection of early warning signs that a potentially violent situation is developing

We identified the following 10 criteria that we believed were important in any EMS training program that we would implement:

  • Patient safety
  • Provider safety
  • A clear method for providers to follow
  • Understanding the importance of physical positioning
  • The effects of certain drugs and alcohol on aggression
  • The effects of certain medical conditions on mentation and aggression
  • Terminology – when a patient becomes an assailant and vice versa
  • Adjusting response to gain and maintain control
  • Steps for developing a plan of approach
  • Effective teaching techniques to make learning new skills easy

Finding a training program that met the criteria we identified was a major challenge, however, with support from the whole organization, we succeeded in identifying a program that was built on a model they call the three Ds, which stand for Detect, Defuse, Defend. The course includes recognizing pre-contact cues, understanding the cycle of human behavior, understanding the fear response that proceeds and accompanies violent encounters, and how to negotiate emotion through the entire process of a violent encounter.

Implementing an EMS training program

The program helps us to understand early detection of the possibly violent patient, to use de-escalation techniques, both verbally and physically, and prepares providers to handle the combative patient safely and effectively if the need arises. Further, the course enables us to protect the patient’s safety, protect our providers, and support a positive perception of the provider and EMS agency. In this way, we meet our principles to ensure our moral, ethical and legal obligations to the people we are charged to protect and minimize our risk.

Agencies interested in a similar program should consider the steps they need to take to ensure success. Here are the actions that we took to implement an EMS training in combatting violence against responders:

  • Increased awareness of assaults among our providers – we conducted a survey, held discussions, and developed a record-keeping system to track assaults as a key performance metric
  • Gained support from our agency’s leadership, our employee association and our medical directors
  • Took time to develop overarching criteria and learning objectives that we wanted to achieve
  • Evaluated various programs and solutions, and spent extra time getting to know the ones we believed would meet our needs
  • Invested in a train-the-trainer program
  • Conducted several training sessions to sharpen our delivery

The program we designed has been very successful in giving our providers the ability and confidence to handle potentially violent situations. Our department implemented this new program as an employee-based initiative. We start by training our newest providers in our training academy. Next, we focused on implementing an awareness level of the training to our entire field and communications staff through our quarterly continuing education sessions. This presentation was an overview of the program and focused on the pre-contact cues and a brief look at the program.

The feedback we received was highly positive. We also trained our community health paramedics, who operate alone most of the time.

Though we have built a very robust program, we have several more goals to reach as a system. We want to continue to provide training to all our field staff and we would like to become a regional resource for agencies in the central Texas region. To that end, ATCEMS will sponsor a regional train-the-trainer program at our training facility. The program is called, “The Violent Client Interaction Management Instructor” program and it is the very first of its kind in the United States.

Training programs such as this are vital to our industry. Designed properly, they strongly support provider safety and patient safety. Support from agency leaders, including our chief and our executive team, is vital. Their support helped us take an employee-based approach and succeed.

Our new assault reporting process will help us identify trends and continuously improve and refine both our training program and our tracking process. The feedback from our providers has been very positive and we have also begun to garner interest from some of our surrounding agencies. It’s an excellent opportunity to share the knowledge we’ve gained and begin to reduce assaults against EMS providers.

This article was originally posted May 26, 2020. It has been updated.

Walt Settlemyre is a U.S. Army veteran and a paramedic with Austin Travis County EMS. A career paramedic for 27 years, he has worked in 911 systems primarily as a special operations rescue medic. While still working in field operations for ATCEMS, he left the rescue team to focus on building the Defensive Tactics Program and training both ATC personnel and other providers in the region.

He is a current certified trainer in both the SPEAR System Defensive Tactics and Gracie Survival Tactics (GST). A Jiu Jitsu practitioner, he is a blue belt under Eddie Bravo Black Belt Curtis Hembroff at 10th Planet Jiu Jitsu in Austin, Texas. Walt can be reached at