What to Know About Protests

In the current climate agencies may have to respond to mass gatherings more frequently. For many this need may be completely novel, with no prior history of such events in their jurisdiction. 

In recent years mass gatherings and political and social protests have created a unique set of problems for scene management and patient injury patterns to which response agencies must adapt. The size and scope of these incidents can vary widely, from small-scale protests in smaller or remote towns to massive efforts like the 2017 Women’s March, which drew an estimated 3.5–4.5 million people. 

Since 2017 there have been more than 21,000 protests with more than 13 million participants in the United States.¹ The vast number of these are orderly and peaceful. However, with the advent of social media they can be created and advertised rapidly, thus limiting the time agencies have to prepare. 

Anticipate crowd movement and potential pathways by understanding that “large human crowds exhibit fluid-like collective behavior that can be predicted based solely on hydrodynamic theory.”² That means large crowds flow much like water through a stream: Motion is collective and ripples both forward and backward, moving around objects and taking the path of least resistance. Crowds act as a single body, not a mass of individual people. This knowledge can let command better plan points of entry and exit for crews and potential barriers the crowd may encounter. 

Injuries and Treatments 

Tear gas

Officially known as riot-control agents (RCAs), the chemical compounds that comprise tear gas affect numerous body systems by causing irritation to the eyes, mouth, throat, lungs, and skin. The effects of RCAs are short-acting and relative to location. They last anywhere from 15–30 minutes as long as the person is no longer in the vicinity of the agent and has been decontaminated. 

The onset of these agents is instantaneous as they are emitted into the air as fine droplets or particles. Patients may experience blurred vision, runny/burning nose, chest tightness, coughing, wheezing, shortness of breath, burns, rash, nausea, and vomiting. Long-lasting exposure or a large dose in an enclosed area with little to no ventilation can potentially cause blindness, glaucoma, respiratory failure, and death as a result of severe chemical burns of the airway. 

Appropriate treatment starts with removing the patient from the area concentrated with RCA. Remove all contaminated clothing but avoid pulling clothing over the head, as residue may contact the patient’s eyes, nose, or mouth. For blurry vision and redness in the eyes, rinse with plain water for 10–15 minutes. For respiratory patients, steroids and bronchodilators are appropriate to assist respiratory effort.

Pepper spray

Pepper spray’s effect on the body is similar to that of tear gas. The primary goal of oleoresin capsicum (OC) spray is to reduce an individual’s aggressive behavior. Symptoms of OC deployment include eye tearing, coughing, gagging, shortness of breath, and loss of motor skills and muscle coordination. OC effects can be greatly reduced simply by wearing safety glasses prior to deployment. 

Overspray is a common result of OC deployment that can directly affect and temporarily impair responders. Considering OC is oil-based, there is an appropriate treatment for its victims: First, prevent cross-contamination by not touching the area. Soap and water can be effective, as well as baby shampoo to help break down the oils. Another viable option is milk. Follow this up by rinsing affected areas with plain cool water. 

Some people have the reflex to start rinsing immediately. This may seem effective, but relief will be short-lived, as there needs to be a breakdown of the oils for any effective reduction of OC symptoms.

Pepper balls

Pepper balls are paint balls containing the RCA CS (chlorobenzylidene malononitrile) or PAVA powder (another chemical irritant, pelargonic acid vanillylamide) rather than paint. The amount of irritant is minuscule in relation to OC and tear gas. The benefit of pepper balls is the contamination is more localized. 

Along with launchable tear gas canisters, pepper balls have a projectile injury component. The same treatment path applies for this type of irritant; however, careful physical examination is required, especially if the projectiles contacted vulnerable portions of the body.

Rubber bullets

Trauma from the use of rubber bullets can be significant, and severity largely depends on the range and location of the impact as well as rapid access to medical care. These objects are inherently inaccurate and can deviate from their intended target location greatly during flight. A look at wounding patterns found that of 1,984 victims injured by rubber bullets, 58 (3%) died as a result of their injuries, and more than 300 suffered permanent disability. These were most often associated with strikes to the head and neck. 

Data also showed that of all those struck by rubber bullets, almost 71% had severe injuries.³ Ocular injuries can be severe, and those patients should be immediately removed from the crowd and taken for further evaluation at a hospital with ophthalmologic capabilities. Of those struck in the limbs, orthopedic injury is most often seen and should be addressed as needed. Severe vascular injury can occur from rubber bullets regardless of strike location, and initial symptoms may not be indicative of a greater underlying injury.⁴ 

Nightstick fractures

A rather unique injury pattern found in counterprotesters is an isolated fracture of the ulnar shaft, also known as a “nightstick fracture.” This most often occurs when a person places their arm above their head to deflect an incoming blow from a nightstick, fracturing only the outer bone of the forearm. These fractures may not appear severe, but a large proportion of them require surgical intervention and reduction. Take these patients for radiological evaluation and care from an orthopedic specialist.⁵

Scene Suggestions

Decontamination prep

Modification of existing kits may be necessary for protest response. Some older methods for reducing irritation from tear gas or pepper spray have been shown to have no more effect than copious amounts of water.⁶

The application of milk may be necessary in large quantities for crowds suffering from exposure to pepper spray, pepper balls, or other capsaicin-based RCAs. When a mass gathering is anticipated, it can be purchased and stored ahead of time; however, when a spontaneous event occurs, a unit may have to be sent to a local grocer to acquire it. Application should be symptom-based. Use spray bottles to reduce excess. 

Another item needed in quantities not normally kept will be saline for flushing of eyes exposed to tear gas. Saline bags can be hooked up to a nasal cannula, which is then placed over the bridge of the nose to irrigate the eyes. Syringes can be drawn up with sterile water or saline as well. 

Mass decontamination

If riot control chemicals are used, there may be a need to decontaminate possibly hundreds of people. Perform gross decon using fire apparatus and hoses prior to any patients entering transport rigs or being sent to local EDs. If victims may self-transport without assistance from fire or EMS, early notification to hospitals is important to allow them to establish their own decon systems prior to patient arrival. When performed, decontamination should be swift and use copious amounts of water. Hypothermia will be a concern, so consider ways to warm and dry these victims. 

Rig positioning

Park all apparatus, both transport and nontransport, out of the anticipated path of the gathering. Position vehicles so they are pointed outward, away from the crowd, for rapid exit should the need arise. Security at these events dictates that if crews leave the apparatus, at least one member should be left to watch the rigs and be equipped with a radio to contact law enforcement or the rest of the crew if trouble arises. 

Aid stations

Aid stations may be of benefit if positioned appropriately. They should be a primary location for wounded or sick to be taken to by mobile crews and serve as a temporary stop before further care. These locations should be within a short distance of the gathering but not so close as to be overrun if the crowd shifts suddenly. Position them safely out of the main flow path. If security becomes an issue, abandon the post. 

Crew preparations

Crew preparation is key. Departments big and small, urban and rural now have to deal with these events. Utilizing your law enforcement counterparts for preparation will help get fire/EMS personnel in the appropriate mind-set. Learning how local officers will be deploying into a demonstration, as well was what types of less-lethal munitions will be used, can curb the element of surprise when it comes to treating victims. Having a knowledge of rapid trauma care and the basics of TCCC/TECC guidelines will be a vast benefit to delivering the right treatment at the right place and right time. Reach out to your neighboring agencies to obtain their policies and procedures to help you develop your own. 

Obtain gas masks or CBRN filters for normal SCBA masks in advance and store them according to manufacturer recommendations. Train on their use, focusing on the appropriate time to wear them and how to efficiently deploy the filters. 

Transport considerations

Transport decisions will be fluid. A predetermined MCI plan should be in place to help identify how many beds are available and where to send specific patients. Trauma triage protocols will help you decide where your patients should go based on their injuries. Contact your base station hospital to assist in planning. Keep in mind your trauma centers for trauma, burn centers for burns from chemical irritants as well as thermal injuries from fires, and hospitals with advanced respiratory care abilities for treatment of respiratory patients.

Unified command

Expecting success without unity is foolhardy. Setting up unified command prior to scheduled events or as soon as possible during impromptu protests will give you the best opportunity to keep your personnel and citizens safe. Utilizing the Incident Command System (ICS) and unified command can bring organization to a protest response and eliminate confusion. Everyone plays a part in these events: law, fire, EMS, hospitals, government, utilities, transportation, and more. If an emergency operations center is opened, ensure appropriate representation for your department’s specific emergency support functions. 

Establish a communications plan with both primary and secondary channels from the outset. Multiple backup channels may be necessary, as recent events have shown primary channels being hacked or radios taken from officers and then tied up with music or distracting tones. 

Final Thoughts 

Don’t forget the mental health of providers once these events have concluded. Long-term effects can be significant and need to be addressed. 

Mass gathering events can occur within almost any jurisdiction, be either planned or spontaneous, and regardless of their reason can require the rapid response of local emergency services to treat hundreds of patients. Having a plan in place and training on how to respond is important, but so is the ability to rapidly adapt the response to the needs of the event. Anticipation of injuries and crowd movement can provide a significant benefit to command and improve the overall response and safety for all involved.  

References 

1. Count Love, https://countlove.org/statistics.html.

2. Bain N, Bartolo D. Dynamic response and hydrodynamics of polarized crowds. Science, 2019 Jan 4; https://science.sciencemag.org/content/363/6422/46.

3. Haar RJ, Iacopino V, Ranadive N, Dandu M, Weiser SD. Death, injury and disability from kinetic impact projectiles in crowd-control settings: a systematic review. BMJ Open, 2017; 7(12).

4. Wani ML, Ahangar AG, Ganie FA, et al. Pattern, Presentation and Management of Vascular Injuries Due to Pellets and Rubber Bullets in a Conflict Zone. J Emerg Trauma Shock, 2013 Jul; 6(3): 155–8.

5. Ali M, Clark DI, Tambe A. Nightstick Fractures, Outcomes of Operative and Non-Operative Treatment. Acta Medica (Hradec Kralove), 2019; 62(1): 19–23.

6. Stopyra JP, Winslow JE III, Johnson JC III, Hill KD, Bozeman WP. Baby Shampoo to Relieve the Discomfort of Tear Gas and Pepper Spray Exposure: A Randomized Controlled Trial. West J Emerg Med, 2018 Mar; 19(2): 294–300.

Sidebar: Major Marches and Protests in Recent U.S. History

Protest: Iraq War protest

• Cause: Iraq War
• Date: Feb. 15, 2003
• Estimated size: 10 million–15 million

Protest: March for Our Lives

• Cause: Gun control
• Date: March 24, 2018
• Estimated size: 1.2 million–2 million

Protest: March on Washington

• Cause: LGBTQ rights
• Date: April 25, 1993
• Estimated size: 800,000–1 million

Protest: Million Man March

• Cause: Unity among Black communities
• Date: Oct. 16, 1995
• Estimated size: 400,000–1.1 million

Protest: Women’s March

• Cause: Women’s rights
• Date: Jan. 21, 2017
• Estimated size: 3.2 million–5.2 million

—Source: Business Insider

Brandon Heggie is a firefighter/paramedic who has worked in fire and EMS for over a decade and currently serves a busy cross-staffed department. His experience includes serving as a tactical medic on a SWAT team and as a high-angle rope-rescue technician. 

Brad Keating  is a fire-medic for Rocky Mountain Fire in Boulder, Colo. He served for two years as medical program coordinator for the Colorado Springs Fire Department and worked for a decade as a firemedic for Clearwater Fire and Rescue in Florida, where he served as a SWAT medic, rescue diver, and flight medic. He holds a master's degree in disaster management from the University of South Florida.