Transcript violence
Keeping the Peace: Violence Against Emergency Medical Providers Rebecca Jeanmonod M.D. Albany Medical College Department of Emergency Medicine Almost all of you will be victims during your career. Overview • • • • • • Epidemiology Recognition Prevention Beyond prevention Self-defense Teaching points The Scope of the Problem • Percentage of EMS calls involving violence to provider? The Scope of the Problem • Percentage of EMS calls involving violence to provider? 5% The Scope of the Problem • Percentage of EMTs injured per year? The Scope of the Problem • Percentage of EMTs injured per year? 50% The Scope of the Problem • Percentage of residents assaulted? The Scope of the Problem • Percentage of residents assaulted? 33% Survey of 170 ED Directors • 32% report verbal threats daily • 18% report threat with weapons monthly In One Trauma Center • • • • 25% of trauma victims carry a lethal weapon 8 incidents per year involving weapons 4 patient fatalities in 15 years 6 staff injuries in 15 years 1995 in US Hospitals • • • • 42 homicides 1463 physical assaults 67 sexual assaults 165 robberies, 47 armed What About Pre-Hospital? What About Pre-Hospital? • Survey of paramedics over 12 years • How many assaults per provider? What About Pre-Hospital? • Survey of paramedics over 12 years • How many assaults per provider? – Nine total What About Pre-Hospital? • Survey of paramedics over 12 years • How many assaults per provider? – Nine total – 170 blunt injuries What About Pre-Hospital? • Survey of paramedics over 12 years • How many assaults per provider? – Nine total – 170 blunt injuries – 73 lacerations What About Pre-Hospital? • Survey of paramedics over 12 years • How many assaults per provider? – Nine total – 170 blunt injuries – 73 lacerations – 2 GSW, 10 stabbings What About Pre-Hospital? • Survey of paramedics over 12 years • How many assaults per provider? – Nine total – 170 blunt injuries – 73 lacerations – 2 GSW, 10 stabbings – 8 fractures, 9 dislocations What About Pre-Hospital? • Survey of paramedics over 12 years • How many assaults per provider? – Nine total – 170 blunt injuries – 73 lacerations – 2 GSW, 10 stabbings – 8 fractures, 9 dislocations – 1 burn Michigan 2005 • • • • Violence more common against females 45% of assailants were intoxicated 33% of assailants were mentally ill 10% of assailants were not patients Michigan 2005 • • • • Violence more common against females 45% of assailants were intoxicated 33% of assailants were mentally ill 10% of assailants were not patients Michigan 2005 • Urban equivalent to other locations Where Violence Occurs Where the Wild Things Are • • • • “Bad” area of town Bars Mass gatherings Everywhere else Where the Wild Things Are • • • • “Bad” area of town Bars Mass gatherings Everywhere else You are faced with an undifferentiated patient or scene. Where the Wild Things Are • • • • “Bad” area of town Bars Mass gatherings Everywhere else You may have limited visualization. Where the Wild Things Are • • • • “Bad” area of town Bars Mass gatherings Everywhere else You may have limited personnel. Where the Wild Things Are • • • • “Bad” area of town Bars Mass gatherings Everywhere else You have limited pharmacotherapy. Where the Wild Things Are • • • • “Bad” area of town Bars Mass gatherings Everywhere else You may have limited training. Where the Wild Things Are • • • • “Bad” area of town Bars Mass gatherings Everywhere else You have a job to do. The Problem of Recognition: The Scene The Problem of Recognition: The Scene The Problem of Recognition: The Scene The Problem of Recognition: The Scene The Problem of Recognition: The Scene The Problem of Recognition: The Scene • High-risk chief complaints The Problem of Recognition: The Scene • High-risk chief complaints – Gunshot wound – Drug overdose – Bar fight The Problem of Recognition: The Scene • High-risk chief complaints • High-risk locations The Problem of Recognition: The Scene • High-risk chief complaints • High-risk locations – Poorly lit – Areas that could conceal or cover – Only one entrance or exit The Problem of Recognition: The Scene • High-risk chief complaints • High-risk locations • High-risk times The Problem of Recognition: The Scene • High-risk chief complaints • High-risk locations • High-risk times – Nights – Holidays – Weekends The Problem of Recognition: The Patient The Problem of Recognition: The Patient Calm Irritable Verbal Physical The Problem of Recognition: The Patient Hardest to recognize Calm Best time to intervene Irritable Verbal Easiest to recognize Physical Worst time to intervene Everyone Has a Breaking Point Reasons Why Patients Become Violent • Altered mental status and medical illness – Seizure – Hypoxia – Head injury – Hypoglycemia Reasons Why Patients Become Violent • Altered mental status and medical illness • Fear or anxiety Reasons Why Patients Become Violent • Altered mental status and medical illness • Fear or anxiety • Frustration Reasons Why Patients Become Violent • • • • Altered mental status and medical illness Fear or anxiety Frustration Drugs or alcohol – Cocaine – Ecstasy – PCP Reasons Why Patients Become Violent • • • • • Altered mental status and medical illness Fear or anxiety Frustration Drugs or alcohol Just plain mean Recognition in the Calm Patient • Prior history Recognition in the Calm Patient • Prior history • Substance use Recognition in the Calm Patient • Prior history • Substance use • In custody Recognition in the Calm Patient • • • • Prior history Substance use In custody Mental illness Organized Violence • Ink • Clothing • Gang colors Beyond Calm Signs of Trouble • • • • • Complaining loudly Interrupting Agitated Pacing Can’t sit still Bad to Worse • • • • • • Sweating Dilated pupils Abrupt, angry movements Accusations Insults Threats Point of No Return • • • • • Standing and leaning into you Yelling Finger pointing Fist clenching Chest beating If you feel like smacking him, he’s probably thinking the same thing. The Downward Spiral Prevention: Scene Approach • Recognize scene potential Prevention: Scene Approach • Recognize scene potential • Turn off lights and sirens when near scene Prevention: Scene Approach • Recognize scene potential • Turn off lights and sirens when near scene • Scan for cover and concealment Prevention: Scene Approach • • • • Recognize scene potential Turn off lights and sirens when near scene Scan for cover and concealment Park outside the “kill-zone” Prevention: Scene Approach • • • • • Recognize scene potential Turn off lights and sirens when near scene Scan for cover and concealment Park outside the “kill-zone” Park so you can pull forward to leave Prevention: Patient Approach • Recognize patient potential Prevention: Patient Approach • Recognize patient potential • Identify yourself Prevention: Patient Approach • Recognize patient potential • Identify yourself • Respect the patient’s space Prevention: Patient Approach • • • • Recognize patient potential Identify yourself Respect the patient’s space Avoid tunnel vision Prevention: Patient Approach • • • • • Recognize patient potential Identify yourself Respect the patient’s space Avoid tunnel vision Evacuate patient quickly Prevention: Patient Approach • • • • • • Recognize patient potential Identify yourself Respect the patient’s space Avoid tunnel vision Evacuate patient quickly Be alert to weapons on secondary survey Intervention in Early Stages • Recognition Intervention in Early Stages • Recognition • Make eye contact Intervention in Early Stages • Recognition • Make eye contact • Empathy and validation Intervention in Early Stages • • • • Recognition Make eye contact Empathy and validation Call the patient by name Intervention in Early Stages • • • • • Recognition Make eye contact Empathy and validation Call the patient by name Don’t trap the patient Intervention in Early Stages • • • • • • Recognition Make eye contact Empathy and validation Call the patient by name Don’t trap the patient Call for help early Intervention in Early Stages • • • • • • • Recognition Make eye contact Empathy and validation Call the patient by name Don’t trap the patient Call for help early Be cognizant of body language and tone Intervention: Defuse or Detonate • Defuse – Show of force – Medication • Detonate – Physical restraints – Chemical restraints Intervention: Defuse or Detonate • Defuse – Show of force – Medication • Detonate – Physical restraints – Chemical restraints One study showed reduction in aggression from 37% to 3% by instituting preventive training. A study in VAs showed 92% decline in violence by institution of preventive measures. Rules of Engagement • • • • Rule 1: Rule 2: Rule 3: Rule 4: Protect yourself Protect your co-workers Protect bystanders Protect the violent patient If he has a gun and wishes to commit suicide, let him. Rules of Engagement • • • • Rule 1: Rule 2: Rule 3: Rule 4: Protect yourself Protect your co-workers Protect bystanders Protect the violent patient In that order Protect Yourself • • • • • • • Maintain access to the exit Communicate roles with partner Maintain visual contact with partner Keep your body at an angle to the patient Keep your hands in front of your body Wear gloves Don’t allow outsiders in and out of scene Protect Your Co-workers • Communication • Planning • Support Protect Bystanders • Isolation • Control • Speed Protect the Violent Patient • • • • Minimum necessary force Multiple providers Timing Follow-through When a Patient is Asking For It • Be prepared to overwhelm the patient • If he does not back down immediately, restrain him • If he then bargains, restrain him Safe Restraining • • • • • • • Identify a leader Body at an angle to patient Hands up in front of face Head down Gloves 6 providers Leader gives order and everyone acts simultaneously Who Does What • “Leg, leg, arm, head, arm” 6th person gets supplies The Head • Protect patient during take-down • No strangling • Once down, jaw thrust – Prevents biting – Prevents spitting The Arms • One hand on wrist – Prevents scratching • One hand on elbow – Prevents punching – Prevents sitting The Legs • One hand on ankle – Prevents writhing • One hand on knee – Prevents kicking – Prevents rolling • Extra providers on knees The Goal Not the Goal Rules of Restraint • Document necessity • No prone positioning Sedative Medications • Versed • Valium • Haldol Sedative Medications • Versed • Valium • Haldol Class D in pregnancy Sedative Medications • Versed • Valium • Haldol Lowers seizure threshold Increases arrhythmias Prolonged sedation If He Needs Restraints, He Needs Medication When There Are Weapons “Hey, Doc, wanna see my piece?” “No, no thank you, though I appreciate the offer.” Weapons in the Calm Patient • Do not have the patient remove the weapon himself • If police are present, have them remove the weapon Patients with Knives • Police • If attacked – Yell – Get close with your arm under knife arm – Hit with something blunt – Do not disarm and defend – Beware of lefties Patients with Guns • Most fatal shootings occur within 9 feet • If you are at or near 9 feet… Patients with Guns • Most fatal shootings occur within 9 feet • If you are at or near 9 feet… Drop your gear Run Patients with Guns • Most fatal shootings occur within 9 feet • If you are closer than 9 feet… Patients with Guns • Most fatal shootings occur within 9 feet • If you are closer than 9 feet… Redirect gun Keep talking Patients with Guns • Most fatal shootings occur within 9 feet • If you are well beyond 9 feet… Patients with Guns • Most fatal shootings occur within 9 feet • If you are well beyond 9 feet… Duck Stay down If He Hasn’t Drawn the Gun • One hand on gun hand preventing draw • Other hand “subduing” patient If He Hasn’t Drawn the Gun • One hand on gun hand preventing draw • Other hand “subduing” patient – Eyes – Head – Groin Don’t Be Paranoid, But… • Know places to duck in and around rig • Know more than one way out • Know where police station is Chance Favors the Prepared Mind In Summary • Pre-hospital violence is common In Summary • Pre-hospital violence is common • Violence can be predicted and prevented In Summary • ED violence is common • Violence can be predicted and prevented • Organization and communication equals safety In Summary • ED violence is common • Violence can be predicted and prevented • Organization and communication equals safety • Protect yourself and your co-workers In Summary • ED violence is common • Violence can be predicted and prevented • Organization and communication equals safety • Protect yourself and your co-workers • Ensure scene safety In Summary • ED violence is common • Violence can be predicted and prevented • Organization and communication equals safety • Protect yourself and your co-workers • Ensure scene safety • If attacked with a knife, attack back In Summary • ED violence is common • Violence can be predicted and prevented • Organization and communication equals safety • Protect yourself and your co-workers • Ensure scene safety • If attacked with a knife, attack back • If attacked with a gun, have a plan In Summary • ED violence is common • Violence can be predicted and prevented • Organization and communication equals safety • Protect yourself and your co-workers • Ensure scene safety • If attacked with a knife, attack back • If attacked with a gun, have a plan The End Thanks for Your Time and Attention