The Trip Report: Could the Attack Have Been Stopped?

Reviewed This Month

Preventing EMS Workplace Violence: A Mixed-Methods Analysis of Insights From Assaulted Medics.  

Authors: Maguire BJ, O’Neill BJ, O’Meara P, Browne M, Dealy MT. 

Published in: Injury, 2018 Jul; 49(7): 1,258–65. 

Anyone who has worked on an ambulance long enough has had to deal with a violent or threatening patient, family member, or person on scene. These situations are all too common in our field, and unfortunately, anecdotal evidence and some published literature suggest EMS workplace violence events are increasing.

While there has been some research describing workplace violence in EMS, this month’s Trip Report reviews a manuscript focused on preventing it. The authors had the novel idea to actually ask EMS providers who have been victims how they thought these incidents could be prevented. 

This was an international study, promoted in four countries. The authors also distributed a survey link at EMS meetings and conferences, sent e-mails, had stories published in magazines, and even used social media to elicit participation.

The authors used a World Health Organization definition of violence: “Physical violence refers to the use of physical force against another person or group that results in physical harm, sexual, or psychological harm. It can include beating, kicking, slapping, stabbing, shooting, pushing, biting, and/or pinching, among others.” It included 163 questions about demographics, career experience, job title, hours worked, and violence-related experiences. 

This manuscript focused on just one of those questions: Specifically, individuals who indicated they’d been physically attacked on duty within the last 12 months were asked if they thought the incident could have been prevented. If they said yes, they were asked to describe how. 

The authors reviewed the responses and identified common themes. They used a Haddon Matrix to organize their findings into six groupings. Commonly used in injury prevention, the Haddon Matrix is a method to group factors or attributes into categories before, during, and after an event. It is often used to develop interventions. 

Results

There were 1,778 individuals from 13 countries who replied. The manuscript did not report which countries were included, nor did it report a response rate. The authors likely lacked a reliable denominator to calculate a response rate due to the multiple methods used to distribute the survey. 

Of those who responded, 633 reported an assault within the previous 12 months—more than a third of respondents! About one-third of those who reported an assault (203) indicated they believed it could have been prevented. Almost all of those (193, 95%) added a free-text response describing how. 

The six themes identified were: 

1) Human factors: Specific populations and de-escalation techniques—This theme included aggressors with mental health issues or those who had alcohol or drugs in their system, as well as responding to calls in dangerous neighborhoods. A contributing factor identified within this theme was insufficient training on how to prevent and manage aggressive behavior. Recommendations to prevent these incidents included training EMS professionals in verbal de-escalation techniques and having law enforcement present for calls in neighborhoods known to be dangerous. 

2) Equipment factors: Self-defense equipment, restraint equipment, and resources—This theme included situations in which an aggressor likely should have been chemically or physically restrained. Contributing factors included low-quality restraints and lack of availability of chemical measures to restrain or subdue an aggressor. Measures recommended for prevention included the ability to administer ketamine for excited delirium, training and the ability to use OC spray, early application of restraints, and self-defense training. 

3) Operational environment factors: Systemwide advance warning—This theme included situations where the aggressor was known to be violent. Contributing factors included staff at pickup locations such as nursing homes, prisons, and hospitals who failed to warn the EMS providers of the patient’s violent behavior. Recommendations to prevent these types of incidents included providing warning to EMS providers when a patient or addresses have been associated with violence previously. 

4) Social environment factors: Public and interagency awareness and support—This theme included suggestions that better collaboration and support among “ambulance agencies, legislators, the public, nursing homes, jails, dispatch services, police, fire departments, and hospitals” were required to prevent violence against EMS providers. A contributing factor was the inability of EMS providers to refuse to treat threatening drunk or abusive patients. Recommendations included better awareness among the public and other healthcare and public safety personnel regarding the risks of violence faced by EMS as well as legislation with stronger punishments for assaults on EMS providers. 

5) Human factors: Situational awareness—This theme included situations where the EMS provider acknowledged their role in the prevention of violent events. Contributing factors included not paying attention to warning signs or not taking appropriate precautions for a patient known to be violent, as well as not paying attention to personal positioning such as standing too close. A recommendation for prevention was better personal awareness of positioning that may make EMS providers vulnerable to attack. 

6) Operational environment factors: Law enforcement operations—Some comments indicated better collaboration with law enforcement was necessary to prevent violence against EMS providers. Contributing factors included the speed at which law enforcement took steps to arrest aggressors, and common phrases respondents indicated they’d heard police say to patients that EMS providers identified as triggers of violence (e.g., “Either go with them or go with us!”). A recommendation for prevention was to have law enforcement officers initially manage all drug- or alcohol-related calls and have EMS respond once it can be reasonably assured no threat of violence is present. 

Firearms

One finding the authors noted was that although there’s an ongoing conversation regarding the merits of having EMS providers carry firearms on duty, no responses to this survey indicated having a gun would have helped prevent the violent event.

The authors also noted the importance of a reliable, comprehensive data-collection system to support reporting of violent events in the EMS workplace. They said assessments of other questions on their survey indicated that 44% of assaults against EMS workers went unreported to management.  

Limitations

This study was limited by an inability to ask respondents follow-up questions. There also may have been recall bias if respondents didn’t recall past events accurately. Also, those who responded may not accurately represent the full international EMS community, and the results may not accurately reflect themes that arise in single jurisdictions or agencies. 

Most notably, it does not appear the survey allowed participants to save responses and return to finish later. It's likely that a significant number of individuals simply got tired of answering questions or chose not to begin once they saw that 163 questions were included. The inability to calculate a response rate is also a limitation. 

Conclusion

This was the first survey to ask an international population of EMS professionals who were victims of workplace violence how these events can be prevented. I commend the authors for giving EMS professionals the opportunity to express how they think they could be safer on duty. I hope you read this manuscript, because there were other interesting aspects we didn’t have room to discuss. 

Antonio R. Fernandez, PhD, NRP, FAHA, is research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill.