Lessons to apply: Welfare check incident became a LODD
NIOSH line of duty death investigation recommendations for conducting welfare checks are applicable to every EMS agency
This article originally appeared in the December 6, 2018 issue of the Paramedic Chief Leadership Briefing, Welfare checks | Internal situational awareness | Opioid collateral damage. Read the full briefing and add the Paramedic Chief eNewsletter to your subscriptions.
This article, originally published December 5, 2018, has been updated with current information from the "Sharon Road Safety Investigation Report and Summary".
NIOSH released a line of duty death investigation on October 10, 2018 into the April 15, 2016, fatal shooting of firefighter-paramedic John Ulmschneider. The report recommended changes to procedures, uniforms and personal protective equipment to prevent similar incidents. Prince George's County, Maryland release its "Sharon Road Safety Investigation Report and Summary" on January 24, 2019.
What happened: Firefighters, some dual trained as EMS providers, responded to the home of Darrell Lumpkin for a “check on the welfare” request after Lumpkin’s brother called 911 because he couldn’t reach his sibling, who suffered from diabetes. After loudly announcing themselves, firefighters forced entry through the front door before police arrived because they believed Lumpkin was suffering from a medical emergency.
Lumpkin, from about 10 feet away, fired on the responders with a handgun as the door swung open. Ulmschneider, shot in the chest, died from his wound. Firefighter Kevin Swain, along with Lumpkin’s brother, were wounded.
NIOSH investigates: The National Institute for Occupational Health and Safety conducts independent investigations of firefighter line of duty deaths. “Report F2016-06: Career Fire Fighter Killed and Volunteer Fire Fighter Seriously Wounded When Shot during a Civilian Welfare Check—Maryland” and other NIOSH LODD reportsare in-depth investigations of the fatal incidents, contributing factors and key recommendations to prevent similar incidents in the future. NIOSH wrote these specific to the Ulmschneider investigation:
- Police were not on scene at time door was forced open.
- Firefighter identification (lack of standardized station uniform) and time of evening.
- Lack of communication of important information to responders (presence of firearms in residence).
- Resident did not acknowledge multiple attempts by fire department to contact him verbally and by knocking on front door.
- Firefighters/paramedics not wearing ballistic vests or personal protective equipment.
- Fire, EMS, police departments and dispatch agencies should ensure that police are the primary agency initially assigned to “check on the welfare” of occupants and that information regarding weapons in a residence are communicated to all of the responding agencies.
- Fire and EMS departments should implement standard operating procedures requiring firefighters and EMS providers to present themselves in uniforms that readily identify them to be emergency responders.
- Fire, EMS, police departments and dispatch agencies should ensure important responder safety information is requested during the call taking process and that information is transferred into the dispatch system and provided to first responders.
Prince George's County Fire/EMS Department investigates: The "Sharon Road Safety Investigation Team Report," similar to the NIOSH investigation, details the incident response and includes a series of recommendations. Those recommendations are:
- The Department will review and consider changes in dispatch procedures.
- Revise General Order 06-19 so that it clearly outlines the appropriate steps to managing an incident requiring forcible entry into an occupancy.
- The Department should revise General Order 10-01 referencing personnel uniforms and equipment.
- Enhance existing annual training requirements to include forcible entry tactics, identifying and managing risk, self-defense and de-escalation techniques.
- Create a pilot program to evaluate the use of Ballistic Vests.
- Improve command and control of incidents, particularly those that require a multi-agency response.
- Improved personnel accountability tracking system.
- Improve assistance and counseling services available to Fire/EMS Department employees/members.
- Update the Fire/EMS Department’s Line of Duty Death General Order.
- Develop and periodically update a database to accurately track all employee/member training and certifications.
- The Department should revise General Order 03-13 and mandate the carry and use of portable radios by all personnel actively engaged in an incident.
- The Department should train personnel on the use of MDC/MDT’s and ensure they are working properly.
Welfare checks by fire and EMS
At the time of the incident, it was known that fire and EMS personnel were responding to a welfare check. The NIOSH investigation reported:
“During calendar year 2016, the department (Prince George’s County Fire/EMS) responded to a total of 5,959 "check on the welfare" incidents [emphasis added] resulting in 7,654 individual unit responses. This equates to approximately 16 per 24-hour shift. The department dispatched an engine with the EMS unit to assist in these incidents (force entry) 28 percent of the time.
The fire department estimated that less than 20 percent of all “check on the welfare” calls result in the fire department providing patient care.
“Check on the welfare” represented four percent of the department’s 148,506 2016 call volume.
What’s important for your agency's response to welfarce checks
For paramedic chiefs, the value of a NIOSH LODD investigation lies in looking inward to apply the lessons to their department’s response (in this case, to welfare check incidents). Here are six questions to answer:
1. How often does your agency respond to welfare checks?
Four percent of calls for welfare checks feels high to me. How does that compare to your jurisdiction?
Population, population density, demographics, and social and cultural variables are just a few of the factors that influence the frequency of “check on the welfare” incidents.
Every agency – small or large, rural or urban – responds to welfare checks. Provider safety is always a top priority.
“Follow your instincts when going on a welfare check without police present,” Gina Perschau-Becker, the Allina Health New Ulm EMS ambulance operation supervisor said. “If it feels 'off,' dispatch police out to check safety ahead of time. We never know what we will run into. If we don’t keep our personnel safe, or more to the point – if they don’t keep themselves safe – there is no one to help the patient we were called for in the first place.”
2. Who is the primary responder to welfare checks?
NIOSH recommends, “police are the primary agency initially assigned to ‘check on the welfare’ of occupants.”
In Butler County, Kansas all “check on welfare” calls are initially handled by law enforcement.
“My best advice is to work with dispatch and law enforcement for them to handle these calls or to ensure an officer is present when your crews show up,” Chad Pore, Butler County EMS director wrote to me about welfare checks in his jurisdiction.
“In the instance your crews do respond to one of these type of calls without law enforcement present, I would suggest they do not attempt any forcible entry until law enforcement is on scene. In our area, the decision to make a forcible entry in these situations is determined by law enforcement.”
3. What is your welfare check protocol? How should the protocol be updated?
I spoke with Chief Marc Bashoor (ret.), the department chief at the time of Ulmschneider’s death. In 2016, police responded to welfare checks as a low priority and responded when available. Fire and EMS responded, as is the case in many jurisdictions, to welfare checks right away. The fire and EMS personnel then decided to wait for law enforcement or not wait to make forcible entry based on incident conditions.
“We didn’t have a defined SOP before the event,” Bashoor said. “One week after, I gave what I considered ‘common sense’ interim guidance that fire/EMS would only force entry ahead of the police if they:
- Saw something (as in the patient’s body through a window), or
- Heard something (as in an alarm or person’s voice), or
- Smelled something unusual.”
4. How do we train personnel for welfare checks?
Use your own experience, responses to known high-utilizers in your response area or news reports of welfare checks that turned violent to have facilitated discussions with your crews or companies. A case-based learning discussion should cover:
- Following a welfare check SOP or protocol.
- Sizing up the scene.
- Notifying a patient entry is being made.
- Donning department-issued uniforms and PPE.
- Assessing a patient you can only partially assess.
- Seeking concealment and cover.
- Escaping violent encounters.
Make sure participants understand that risks on a welfare check, like any EMS response, exist on a spectrum from lethal violence to lifting strains and sprains. Risk assessment and mitigation is a dynamic process that is ongoing throughout any EMS response.
Mike Taigman, Improvement Guide for FirstWatch, told me that in the places he’s worked most welfare checks were handled by law enforcement and forced entry was either for a patient EMS crews could see or for a patient yelling for help. Taigman shared this important reminder:
“Anticipate that folks involved in a welfare check didn’t ask for help, don’t know that help is coming and might be altered from clinical or organic causes. Be prepared to be met with hostility and self-defense inspired violence. Those are normal, rational and reasonable responses to someone forcing their way into a home.”
5. Should every EMS provider have body armor?
6. How do we reduce welfare checks?
Welfare checks are resource intensive responses (police officer, engine company, ambulance crew) which often result in an unsatisfactory outcome, such as no patient present, a non-billable transport refusal, or a civilian distressed by their broken door or window.
For patients who generate multiple and regular welfare checks, the goal shouldn’t be making a transport or no transport decision. Instead, strive for a lasting intervention through the use of response data, community paramedic check-ups and social service referrals.