The symbol of a red cross has long served to identify medical personnel in the war arena, with the notion that it was immoral to attack those whose primary role was to attend to the injured and dying. In EMS, the Star of Life has served as a similar identifier, along the lines of delineating those of us who are combatants versus non-combatants in the grand scheme which comprises the public safety mission.

As I’m sure you’ve noticed, however it seems that increasingly these days, we’re finding ourselves the target of physical violence, with less restraint on the part of those who are attacking us. The delineation, and the respect which came with it, are fading, and it’s time to start thinking about how to defend ourselves in such a way as to respect that non-combatant delineation, because nobody’s job description should include an expectation of “getting beaten up by my patients and their families.”

“I’m Gonna Kill You”

Pretty much all of us have had to fight with a patient at one point or another in our careers. Most often, these situations have included the violent EDP, the S/P-Narcan-administration opiate abuser (how dare you ruin their high by making them breathe again), and the family member irate at something you did or didn’t do, in their eyes, regarding your patient.

Now, however, crews are finding themselves potential victims of violence in many more circumstances, including the possibility of being held up due to a perception that drugs are available (yes, even for BLS folks – they’re not going to know or listen to the difference), outright attacked because someone isn’t happy with us or just wants to, and by someone who erroneously thinks we’re the police and therefore “fair targets.” (Note: how you dress has a lot to do with that last misperception, and is part of the reason some services are going to a polo shirt for their primary uniform.) These attacks won’t always be just with fists, either – in my own career in big-city EMS, I’ve had knives and other weapons pulled on me several times, with intent to either use them on me, or to force me to let someone out of the truck, and I’m sure some of you have seen the same.

“I’m Not Gonna Let You Kill Me”

Obviously, if someone’s intent is just to leave the ambulance, and they have a weapon pulled, let them out of the truck – our job is not to assess and respond to the possible threat they pose to the public (that’s the police role, and they’re equipped to perform it), it is to survive uninjured. In the words of Arthur, King of the Britons, in Monty Python and the Holy Grail, your best option is absolutely to “run away” if it is at all possible to do so. Throw the gurney across the hallway to block it, drop the O2 bag to create a hurdle in between you and the aggressor, and beat feet to your ambulance, then drive away from the scene – creating distance is the surest way to avoid being attacked. The equipment can be replaced, and even a Lifepak 15 isn’t worth getting hurt over (sorry, budget people who just cringed a bit at that.)

That idea of creating distance brings us to our primary consideration when it comes to defensive tactics in EMS: prevention is the first step in defending yourself. All of us know BSI and Scene Safety when it comes to spitting them back at our EMT Instructor staff and the state examiners, but it’s come time to really understand what that means and look at how it’s applied in the real world. To do that, I’m going to borrow a bit from my own education from the reserve police academy, and subsequent DT classes, and introduce you to a few concepts that you might not be regularly considering when you walk into a call.

This Doesn’t Look Good

One of the most important questions when it comes to your safety goes back to the first paragraph of this article, and you absolutely need to answer this honestly for your own sake: Do I consider myself safer, or protected, simply because of the role that I play, and the uniform I wear to play that role? For cops, this dangerous idea manifests itself in those who believe that simply being a cop is enough for people to obey and not attack them, and for us in EMS, it’s the belief that we’re there for medical purposes, and that everyone will respect that.

Neither are true – there is no fantastical force field that is activated when you walk onto a scene, unlike the world of Harry Potter, and we all too often fall victim to the idea that those who we are there for are going to react to us in a certain way, because we assume we know how the call will go, to an extent, based upon dispatch information or on past experience of “similar” calls. What is true is that no call is predictable, period, and you should never assume that something “similar” will proceed exactly as calls in the past have… just because “nothing happened” on calls before does not mean that nothing will happen on your current one.

Taking that into consideration, “Is the scene safe?” means that you need to be approaching every call with a blank slate, and reacting to what’s actually there as opposed to preconceptions that you might be bringing with you as you walk in the door. Does your gut tell you there’s something seriously wrong, or that you’re in danger? Then get the heck out of there – you are not protected by your role, and you do not deserve to be attacked. Far better to leave and find out you didn’t need to, than to not leave and find out you did. And by the way, the next time you have an unconscious patient, even a medical, make sure you find out if they have a weapon on them, and get it away from them (preferably into the hands of the police) – nobody wants to have a confused, defensive patient who instinctively goes for said weapon when they wake up and don’t know where they are.

Uh Oh, We’re Trapped

But what happens when you are stuck in a situation, either because you didn’t see it coming, or it was a trap or ambush to begin with (don’t think that’s something limited only to cops, by the way)? If you’re in the back of a stopped ambulance, easy solution: get out the side or back door if you can safely do so, and shut it behind you, then get away and call for the police. (Driver, as you exit, take the keys with you – if your partner’s running, that means you need to as well.)

If you can’t get away, however, be it in the back of a moving truck, because you’re pinned into a corner and can’t get to an exit (best avoided beforehand by not letting anyone come between you and your means of escape, if you can), or because you’re actively being attacked, then it’s time to consider what you can do to defend yourself long enough to get away.

Remember: the mentality is just that – to protect yourself. Even the police only use as much force as is necessary to effect an arrest or stop the threat, and we should be approaching this no differently. The police are equipped with a baton, pepper spray, and a firearm, to achieve that goal, but also (depending on policy) are allowed to use “weapons of opportunity,” or alternative objects, when needed. For us, that’s pretty much going to be all we have outside of our own bodies, which should be our primary defensive tools. (We’re not going to get into specific styles of defending yourself using your body here – no “Crouching Tiger, Hidden Oxygen Bottle” stuff – there are plenty of martial arts studios, such as those which teach Aikido, a primarily defensive, force-redirection based discipline, as an example, which will teach you the right way to utilize these techniques.) In terms of the objects you do have, however, it’s important to think about how they would be utilized if you did need to defend yourself from various levels of threat, and what those levels of threat are.

What Am I Facing?

For the police, an often-used general guideline in terms of what level of force to use in a given circumstance (although not universally so, and currently subject to some discussion) is the continuum of force – check out the link here to see the specifics according to the NIJ. The gut of it, however, is the concept that the force you use should be equivalent to the threat you face.

For us in EMS, that means that we’re not going to be smacking people with O2 bottles unless there is a real threat of being immediately killed, or suffering grievous bodily injury, and we have no other option – we cannot escape, we cannot simply push them away, or any other alternative, all of which should come first. You shouldn’t be attacking someone with a weapon, incidentally (that means we’re never going to stab someone with the trauma shears), you should be doing only what you need to in order to disengage and get away from the threat – because attacking them opens you up to having that weapon used on you. None of us is Bruce Lee, and even Bruce Lee would probably avoid the fight if he could. Also, if you ever do find yourself in a situation where you’ve had to do something like this, be aware that you may be charged with assault – you may not be, and the idea of it should never get in the way of defending yourself, but you need to be cognizant of the fact that it may happen, and prepare yourself now for how you’d respond if it did occur.

For lesser threats, we should be looking to tactics which allow us to either gain control of the attacker (neutralizing the threat, which is more in line with our traditional role when it comes to restraining EDP’s), or, again, to get away from them. Something to consider with these lesser threats, however, is that they can evolve into greater threats (like grabbing a knife hidden in the cushion of their easy chair – which actually happened to me), so your defensive efforts must be gone about with the awareness of being in their environment, with an eye towards the fact that you don’t know for sure what’s in arm’s reach, if that’s where you are. Don’t underestimate someone’s willingness to come after you – and always remember the old EDP adage that you can’t reason with the unreasonable.

Concluding

Overall, there’s obviously a lot to think about, and this article really only scrapes the surface of a lot of considerations that we, simply put, need to start thinking about as we go about our daily work. It may be worth approaching the Defensive Tactics instructors at your local police department to talk about their thoughts on some things you might be able to do to defend yourselves, including the critical step of trying to get those into some kind of a policy which protects you if you have to do so. None of us signed up to be combatants – if we wanted to do so, we’d have chosen navy blue – but the truth of the matter is, when it comes down to it, is that you may not have a choice but to become one, and you need to be prepared to go home in the same condition you arrived for your shift in. Be safe, and be aware.

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Greg Bogosian is certified as a Reserve/Intermittent Police Officer by the Commonwealth of Massachusetts, and spent twelve years working as an EMT-Basic, including four years as a field EMT and dispatcher for the City of Boston EMS. He was additionally a member of a Federal medical disaster relief team for ten years, with experience responding to the aftermath of Hurricane Katrina, and the pre-deployment of resources for Hurricane Ike. Greg currently has a passion for educating public safety professionals about matters which impact their lives every day, and welcomes feedback and suggestions in the spirit of ensuring that best practices make it out there for all to benefit from.