The Myth of the Safe Scene

In the last few years, federal authorities have recommended EMS teams consider entering active-shooter scenes with law enforcement,¹ which runs contrary to the fundamental scene safety concepts taught in EMS classes for decades. Some agencies have supported this concept of rescue task forces, while others are more hesitant, especially without ballistic helmets and vests.¹ Here are a few consideration points.

You Can't Prevent All Attacks

Recently on a public safety forum, an agency was looking for assistance creating an SOG to clear locations on 9-1-1 calls. The request said, We are looking to write new guidelines about entering homes or businesses on emergency calls and making sure there is no threat to responders going in. They were seeking someone who would be Looking in all rooms for any threat, keeping an eye on people in that home or business for a possible threat, scanning for weapons such as guns, knives, etc., and overall making sure the scene is secure when going on calls... Slowing down and not rushing into a possible hostile environment.² 

This author missed one very key concept: If you’re going to get ambushed, there is very little that can be done to prevent it. 

Look at the Long Beach firefighter killed while checking out a fire alarm in a retirement home in 2018.³ Or the New York EMT shot by a patient on a medical run in 2009.⁴ Or the Dallas paramedic shot while treating a shooting victim in 2017.⁵ All these providers were injured or killed with little to no warning, and the calls they were initially dispatched to were not violent in nature.

Even trained and armed officers can’t always prevent their own deaths at the hands of such assailants. The only way to prevent every attack is to lock yourself in your vehicle inside the locked station and never go outside. This job is inherently dynamic, potentially dangerous, and you can get hurt. 

That all said, there are some things you can do to minimize threats. The most important is to maintain situational awareness and not get tunnel vision. If you feel the situation is deteriorating or there is a threat to any member of the EMS crew, then everyone leaves the scene immediately and you request police assistance, regardless of the patient condition. This isn’t abandonment, because EMS crews aren’t required to sacrifice their lives to care for patients. Stage elsewhere until PD arrives to secure the scene. 

Scene Safety Is Rarely Black and White

What is an unsafe scene? 

An ambulance is dispatched to a shooting victim at a major urban intersection, and dispatch advises the shooter is no longer on scene. Is it an unsafe scene? Potentially. Should you stage? Maybe.

Is there anything wrong with checking out the scene from half a block away, seeing a man down and evaluating whether to drive your ambulance to him, then loading him in the back of the ambulance and leaving the scene in less than two minutes? You can drive around the corner to do some bleeding control and patient stabilization before taking the patient to the hospital. 

What happens when the police have an extended ETA? It happened in Jackson, Miss., in 2010. A city council member wanted his city to change ambulance companies after a shooting victim waited 23 minutes for assistance because police hadn’t secured the scene.⁶ His exact words? “You have got to take the risk!” Most within the EMS community disagreed, but this discussion still occurred.

What about the dispatch for an assault victim? Should the ambulance crew stage? Dispatch should ask where the assailant is—and if they are told the attacker is gone, has the “threat” left the scene as well? Is it a good decision, patient carewise, to make patient contact, maintain situational awareness, transport to the hospital, and let law enforcement meet the victim at the ER to fill out the report?

How about a psychiatric emergency—does every behavioral or psychiatric patient require law enforcement? Assuming the dispatcher asks if they are violent or have any weapons (if the answer is yes to either, then absolutely wait for PD before making patient contact), many psychiatric patients simply want help and are looking for a ride to the ER. Simply having a behavioral or psychiatric disease does not mean they are a threat.

The last classic unsafe scene is an intoxicated person or overdose. Are these calls unsafe? It depends. I have never had an unconscious person attack me. If the caller is reporting multiple unconscious patients, I’m thinking environmental threat, which I’ll need additional resources to mitigate.

During my 20 year career in EMS, I have only experienced one opioid overdose patient who woke up swinging after getting naloxone. Once he realized what was happening, he calmed down. Most OD patients tend to be either embarrassed or thankful EMS was called. That isn't to say you will never experience a violent overdose, only that it won't happen every time. It's also why we give only enough naloxone to restore respirations: Our goal is not to wake people up when they can potentially become violent.

For most calls dispatched as unconscious patients with no mention of the cause, we didn’t stage. We didn’t consider it until the “intoxicated” component was added.

For the conscious ODs, the first question I ask is, “Do they want help?” If they want my help, more often than not they are calm and go willingly to the hospital. If they don’t and we try to force them to get help, then law enforcement needs to be involved, and we should back out until they arrive.

Does Law Enforcement Make a Scene Safe?

My partner was once assaulted by a patient. We weren’t in a dangerous neighborhood, nor was there any reason to feel unsafe based on dispatch information or initial scene size-up. Where was PD? Standing right next to us. That didn’t prevent the assault. Fortunately my partner was not seriously hurt.

EMS is a soft target. In general our personnel don’t carry weapons on duty, nor is it their role to enforce laws and arrest criminals. Can having law enforcement officers at the scene help make scenes safer? Absolutely. But no scene is ever 100% safe. New threats can arise, old threats can evolve. What is under control one minute may not be the next. 

Realize also that the rescue task force concept suggests EMS crews enter scenes (with law enforcement) before they are fully secured and deemed “safe,” to save as many lives as possible. EMS must be properly trained and equipped to assume such responsibility. 

What’s the Answer?

There is no perfect foresight, but we need to teach our crews to survey entire scenes and realize that the sooner we get us and the patient to the ambulance and away, the fewer the risks. We also need to realize there is strength in numbers—if a two-person ambulance crew might be viewed as an easy target, a three-person engine company, one or two LEOs, and a second ambulance crew become much harder. 

From a legal standpoint, we need to advocate for stronger laws that protect EMS personnel from being assaulted and push for prosecutors and officers to charge attackers with more serious crimes when we are attacked. A law is only as good as it’s applied.

All too often on-scene assaults go undocumented and unreported, and we don’t have an accurate count for how often it happens. An agency might file an internal incident report, but a police report is rare. Advocate for stronger protections if your state laws are lacking and demand prosecution of cases where there was criminal intent. 

The idea that we’re safe because we’re only there to help is a mistake. EMS providers do get attacked, and in many cases nothing could have prevented it. Keep your head on a swivel and watch out for each other. Don’t assume the patient won’t hurt you. Maybe supervisors and single-person EMS units should rethink the idea of responding solo—while that provider is focused on their patient, who’s watching their back? 

As educators we need to stop having students simply parrot the phrase “scene safe” all the time. We need them to realize what makes a scene unsafe when they’re already with the patient. And just because a scene isn’t 100% safe doesn’t mean we don’t have a job to do.

How can we trust EMTs and paramedics to make treatment decisions but not decide whether a scene is safe enough to enter? Perhaps it’s time to focus some of our attention and resources toward a better understanding of (and appreciation for) scene safety.  

References

1. U.S. Fire Administration. Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents. 2018 Sep; www.usfa.fema.gov/downloads/pdf/publications/active_shooter_guide.pdf.

2. Firehouse.com. Help creating new Operating Guidelines, https://forums.firehouse.com/forum/firefighting/firefighters-forum/2093474-help-creating-new-operating-guidelines.

3. Chan S. Long Beach firefighter shot and killed while responding to call; suspect charged. CNN, 2018 Jun 25; www.cnn.com/2018/06/25/us/long-beach-firefighter-shot-killed/index.html.

4. EMS World. New York EMT Shot and Killed by Patient. 2009 Feb 1; www.emsworld.com/news/10339763/new-york-emt-shot-and-killed-patient.

5. McLaughlin EC, Simon D. Suspect in shooting of paramedic found dead, Dallas mayor says. CNN, 2017 May 2; www.cnn.com/2017/05/01/us/dallas-firefighter-shooting/index.html.

6. Statter D. Mississippi politician blasts ambulance service for staging at shooting scene waiting for cops. Says “You have got to take the risk”. STATter 911, 2010 Sep 22; www.statter911.com/2010/09/22/mississippi-politician-blasts-ambulance-service-for-staging-at-shooting-scene-waiting-for-cops-says-you-have-got-to-take-the-risk/.

Dan Greenhaus, BS, NREMT, has worked as a firefighter and EMS professional throughout his 20 year public safety career. He is currently a firefighter/EMT in Wake County, N.C., serving with the Wake New Hope Fire Department, and is an EMS instructor within the North Carolina Community College system. Reach him at Dan@ESECTraining.com