Trending Topics

Why we need critical thinking for scene assessments

In the real world it is impossible for a scene to be 100% safe; therefore we must constantly assess risk


I am concerned that EMS providers have not been taught, have not learned, or have decided not to critically think about the issue of staging. Like our approach to driver training, we seem to have decided to rely on hope and luck for our guidance.

Photo/Getty Images

A Milwaukee television station investigated a call where a patient waited 31 minutes after calling 911, while the ambulance staged down the street. Police, sent to “secure” the scene, did not appear in a timely manner for reasons that are not quite clear.

Two concerns arose from this incident

The coverage of this event created a frenzy of discussion on various EMS social media outlets, and after reading much of it, participating a little, and thinking about it a lot, I have two concerns.

First, I am worried that the EMS community’s approach to scene safety and staging has been reduced to a set of bullet point rules, some of which aren’t as universal or as dogmatic as they seem.

Second, I am concerned that EMS providers have not been taught, have not learned, or have decided not to critically think about the issue of staging. Like our approach to driver training, we seem to have decided to rely on hope and luck for our guidance. And to again use one of my favorite quotes, as Rudy Giuliani said, “Hope is not a strategy.”

Constantly assess scene safety

For years, we have done the concept of scene safety a disservice. At the beginning of every EMTs career, they take a series of skills tests. They are taught, as a critical element, to recite upon arrival that “The scene is safe and I have my BSI in place.”

This single psychomotor performance, repeated many times, is the root of the problem. New medics learn to treat scene safety like a joke; a safety survey is a parrot-like event; no changes in behavior result from it.

They also learn that scene safety is only considered upon arrival at a call. I promise you that it is not.

Early in my career I responded to a “normal” house call for an elderly woman in respiratory distress. The house was calm, the door was open, and the patient was alone, we thought.

After treatment, she felt better, and of course didn’t think that she needed to go to the hospital. We knew that if she did not, in 30 minutes she would be calling again. As we tried to persuade her, a door opened down the hall, and a young man, her grandson, appeared – wearing only Jockey shorts and brandishing a large silver pistol.

Our “safe” scene had just become about as unsafe as it gets. Exit stage left! No paperwork, no signatures, nothing. Get out!

Scenes must constantly be assessed for safety, and changes in approach made as the environment changes. We need to train, practice and test to a different standard.

The scene is never totally secure

The concept of “staging” and “we won’t enter a scene that is not secure” is theoretically a good one. In application, our daily practices leave much to be desired – except that no scene is totally secure. Ask the staff at the nursing home in the rural town of Carthage, North Carolina, where an active shooter arrived on a quiet Sunday morning and exchanged gunfire with a local police officer – killing eight in the process.

Since the scene can never be 100 percent secure keep in these three important points in mind:

  1. The presence of law enforcement does not make a scene secure
    Bad guys may still be present, and now you have more people with guns. The likelihood of gunfire is substantially increased. Bodies do not care whether bullets come from good guns or bad guns.
  2. The absence of law enforcement does not mean that a scene is “not secure”
    EMS goes on calls every day without law enforcement. Most of the time, it works out fine. Sometimes it does not.
  3. Because an illness or injury might have involved violence does not make the scene dangerous (not secure)
    This is where a little critical thinking is involved. In the Milwaukee incident the patient had been stabbed. She also reported that the assailant had left the scene. Police did not arrive in a timely manner. Was the scene dangerous? Was the scene any more dangerous than the usual house call?

We can’t be sure about the actual or potential danger. The EMS crew on the scene did what they thought was right. But what about the rest of us, and our patients, going forward?

EMS is a risky business

We take calculated risks every day in providing EMS to our communities. Our greatest risk, we undertake without even thinking – we drive to calls. We make choices about how to move our patients – stretcher, stair chair, ambulation – that involve risks to ourselves and our patients.

But on the subject of violence or potential violence, we are pretty thoughtless. Yet we know that for patients with traumatic injury, time is critical to survival. Should we, without critical thought or analysis, stage away from the scene for an indeterminate time while our patient bleeds out? Or can we critically evaluate the scene safety, and make some decisions using our good judgment?

I know how the EMS choir will respond, “The most important thing is responder safety!” And, “My goal every day is to go home safely at night!”

Yes, we all believe that. But critically examined if we put responder safety above all else drive our decisions, then we should remove the lights and sirens from the ambulance. We should never exceed the speed limit or drive through a red light. Instead, we make critical decisions – about how we get our skills and services to our patients. And most of the time that critical thinking and analysis works out well.

Critically think about staging and scene safety

How about if we take the same approach to staging and scene safety? How about, when we hear about a worrisome scene, we gather the information available and make an intelligent, informed, considered decision about whether the benefits of our entrance in to that scene outweigh the risks? And how about if EMS chief officers develop policies, train their people, and support their decisions, whichever way they go?

The active-shooter response and training professionals have established that delayed onset of care will result in death from hemorrhage and airway and ventilation compromise. The risk of death from delayed care is also true in penetrating chest and neck trauma, as well as a small number of other conditions. We use judgment in all of these situations, and sometimes it works out pretty well.

I welcome the opportunity to discuss with you the application of critical thinking to the scene size-up in the comments.

This article, originally published on March 11, 2015, has been updated.

Skip Kirkwood has been involved in EMS since 1973, as an EMT, paramedic, supervisor, educator, manager, consultant, state EMS director, and chief EMS officer. He is a past president of the National EMS Management Association, is a vigorous advocate for the advancement of the EMS profession, and a frequent speaker at regional and national EMS conferences.