# FACTS ONLY: violence and death by violence in EMS



## mycrofft (May 23, 2011)

*WHAT IS THE SELF-DEFENSE NEED FOR EMS?​*
Let's cut to the chase. If EMS is such a dangerous occupation, it will be reflected in labor and law enforcement statistics and the statements of health care, law enforcement and safety officials.

Everyone cites stories of "bravery under fire on the job", but when it comes to level-headed threat analysis, we are required to go to the documented facts.

*No anecdotes. *

 This thread is to collect official statements (by administrators, legislators, bureaucrats) as directly quoted in the press or via correspondence; official statistics; and other direct verifyable data as may be gatherable regarding the danger of assault, battery, and subsequent injury, disability and/or death caused by a client/patient, a bystander, or a coworker/other official responder.  PLEASE skip the quote that characterizes and concentrate upon the ones which contain quantifable data, preferably not just totals, get the ones including per capita and mean or average figures versus the population they represent. And try to "dis-include" sources with an agenda to promote such as gun abolishment groups, the NRA, American Nazi Party, Greenpeace, etc. An roganization's policy statements would be educational too.

Please include primarily field EMS workers, but to make sure we see the whole field, let's include the entire field of health workers (please try to focus on hospitals and EMS) and firefighters, since EMS workers in contact with field originating patients work there too.  


(I have come to realize and respect that folks like to talk about weapons and they have a right to do so, but in this one place, let's dis-entangle fact from faith and get to the bone on this, like rational professionals).


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## mycrofft (May 23, 2011)

*Start it off: Bureau of Labor Statistics, 1997 to 2009, homicides*

http://www.bls.gov/iif/oshwc/cfoi/work_hom.pdf

PS: I have emails pending reply from the Detroit Violent Crime Taskforce, and the NREMT.


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## BandageBrigade (May 23, 2011)

I dont the nremt will get you much, since they handle testing. I  bet any figures you have are under reported.  How much has osha and like organizations gotten involved in safety regulations when.you are in the back(the real dangerous aspects, ie the need for forward facing seats, seatbelt use, ect)


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## LucidResq (May 23, 2011)

National EMS Memorial Service - Of course these are mostly MVA-related, but there's a few LODDs caused by violence in there.


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## WolfmanHarris (May 23, 2011)

http://emj.bmj.com/content/24/11/760.full

Link goes to full text article. Below is the abstract. 



> Abstract
> 
> Background: International studies have shown that some 60% of paramedics have experienced physical violence in the workplace, and between 21–78% have experienced verbal abuse. To date, there is no Australian literature describing Australian paramedics’ experience of workplace violence.
> 
> ...



Biggest problem with this study; it's done by survey. We need good operational definitions to start collecting proper information on this topic.

For example, I'm sure our Workplace Safety and Insurance Board (WSIB) has records of the number of Paramedics who have claimed benefits as the result of violence, BUT, this will only covers violence resulting in a a claim.


Anything below this and we start getting too geographically specific. It doesn't advance the profession to collect information for an individual service and respond to that.

How many instances of violence result in neither a workplace insurance claim, lost time or a police report? Of course how do we track these incidents then? The above linked study was only able to get a 28% response rate.


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## WolfmanHarris (May 23, 2011)

Further studies via Pubmed. I haven't had the chance to actually read these and can't speak to their quality but have presented them to advance the discussion.

Abstracts only, but when I get to work tomorrow I'll see how many of these journals I have access to and can maybe pull some more info from.

"Exposure of French Emergency Medical Personnel to Violence" Duchateau et al. 
http://www.ncbi.nlm.nih.gov/pubmed/12534120

"Violence Against Emergency Medical Services Personnel" Grange and Corbett. Preshospital Emergency Care. April-June 2002.
http://www.ncbi.nlm.nih.gov/pubmed/11962565
(I have full txt on this one through my subscription)

"Hurting Those Who Save: Violence Against EMS" Spivak. Emergency Medical Services. May 1998.
http://www.ncbi.nlm.nih.gov/pubmed/10179414
(No Abstract or full txt but maybe someone has access to this journal. I've never heard of it though.)

It is worth noting that the majority of articles that came up under violence referred to Nurses and staff in long term care facilities. Given their prolonged exposure, patient population I would not be surprised in the least to see that their rates of violence against providers far surpassed our own.


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## mycrofft (May 23, 2011)

*OK, coming in.*

OSHA figfures...I'm not getting much there because I've been focusing on homicides, which are unambiguous statistics. Intreresting is the comparison of homcides of health workers by friends/associates versus patients.

I sent an email to BLS asking for specifics, or at least the categories EMS workers are summed into.


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## mycrofft (May 23, 2011)

*Lucid, good point about MVA versus homicide.*

By my myopic count, 16 in Calif. The same state lost 11 peace officers to homicide last year.


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## mycrofft (May 23, 2011)

*Wolfman, that's why I'm focusing on homicides.*

Incidentally, my googling turned up a few press articles about New Zealand and Australia. No homicides cited, but they are citing a growing trend towards ambulance personnel being slapped or otherwise manhandled.

Whenever I read or hear about "the skyrocketing problem of ____", I usually find there is an equal or faster increase in the type of folks who will fall prey to that sort of thing, so the per capita rate is same or lower.


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## mycrofft (May 23, 2011)

*Bandagebrigade I think you're right.*

Sometimes whomever reads you email will have a lead, though.


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## Stingray91 (May 24, 2011)

A paramedic that I met came into the office when a guy on PCP threw her to the floor on the ambulance. Her partner wrapped her arm up & took her to the office. She was in alot of pain & couldn't fill out the sign in packet, so I helped her out with that & her vitals. The doctor examined her & gave her a script to get an x-ray at the hospital. When she brought the results back, thankfully it wasn't broken, but she did have to come back for a few follow up appts. Just made me think how you always have to be on guard, especially in the city.


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## Aidey (May 24, 2011)

I think any official statistics are going to be skewed because of the number of assaults that don't get reported,or get reported and don't go anywhere because the charges are dropped or whatever.


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## BandageBrigade (May 24, 2011)

mycrofft said:


> Sometimes whomever reads you email will have a lead, though.




No doubt- it never hurts to ask.


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## mycrofft (May 24, 2011)

*Progress report*

Bureau of Labor Statistics (BLS) sent a reply including multiple URL's. I will send back for a clarification of what job classes EMS workers fall into. Sending query to IAFF.


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## IAems (May 24, 2011)

*The study's a little outdated, but . . .*

Hope this helps, I remember reading about it in JEMS a while back.  Google: "Occupational Fatalities in Emergency Medical Services: A Hidden Crisis".  It was a study by an EMT-P published by the American College of Emergency Physicians reviewing some of the statistics your looking for, but he was only able to search 1992 - 1997 (the study was published in 2002, I believe).  Anyway, it shows that throughout that period a total of 10 EMS workers were killed by homicide alone.


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## LucidResq (May 24, 2011)

Since we're including all health care workers, I'll tell you we send PD out to take assault reports for staff members several times a week at our local detox facility.


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## mycrofft (May 24, 2011)

*IAems, got a URL for me?*

Sounds interesting! The end of that time frame coincides pretty closely with the beginning of the BLS figues on their website.


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## mycrofft (May 24, 2011)

*Lucid, sure. I didn't think about that.*

I imagine detox, psych and Alzheimers wards/faclites generate batteries daily.

I've had my innings with detox and OBS/dementia patients too.


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## mycrofft (May 24, 2011)

*Clarification on terminology*

ASSAULT: A purposeful attempt to create an unwanted contact with another. Swinging a baseball bat at someone is an assault.

BATTERY: the baseball bat makes contact; an unwanted touching. 

HOMICIDE: in this case, loss of life due to a battery intended to harm the EMS worker.

For the purposes of this execise, I want to limit this to intentional "serious" batteries which cause injury with the reasonable potential to hospitalize or kill the victim (EMS worker). Since the big question is supplying EMS workers with lethal force, we are talking life and limb and purposeful assault.

An interesting extension would be all uses for defense iclduing one's partner or patient, but not today. Feel free to start yout own thread!


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## IAems (May 24, 2011)

http://www.paramedicduquebec.org/documents/EMS_Fatalities.pdf


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## mycrofft (May 25, 2011)

*OK, prelim peek a IAems's article:*

EMS deaths per ACES article
http://www.paramedicduquebec.org/documents/EMS_Fatalities.pdf
In a five year period (1992-1997) nation-wide:

91 probable EMS worker on the job deaths; includes Physician assistants, nurses, aides/orderlies/attendants, and *technologists/technicians.*

67 were MVA's
14 were "other" , including suicide (?)
*10 were "assaults", of which 7 were GSW; most were female.*

So, average of 2 assaultive deaths a year, versus 18.2 average on the job deaths a year including assaultive deaths.

NOTE: does not differentiate between assaults by patients, co-workers, or others.


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## Aidey (May 25, 2011)

1997 is the newest data they have?


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## mycrofft (May 25, 2011)

*ADDENDUM to ACES article*

http://www.paramedicduquebec.org/doc...Fatalities.pdf 
This sample would not include persons fulfilling an EMS role without the official job descriptor (firefighters, law enforcement) or volunteers/good samaritans. It does include workers in hospitals.


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## Melclin (May 26, 2011)

*Interesting thread*



WolfmanHarris said:


> http://emj.bmj.com/content/24/11/760.full



I know the guy who did that study and I reckon his feet were the biggest threat to workplace safety going around, forget drug affected psych patients. 




mycrofft said:


> Incidentally, my googling turned up a few press articles about New Zealand and Australia. No homicides cited, but they are citing a growing trend towards ambulance personnel being slapped or otherwise manhandled.
> 
> Whenever I read or hear about "the skyrocketing problem of ____", I usually find there is an equal or faster increase in the type of folks who will fall prey to that sort of thing, so the per capita rate is same or lower.



There is a fair bit of talk about the rise in assaults on our service. My understanding is that they are mostly minor in a physical sense, like being slapped or threatened, but they tend to cause people to go off on stress leave. 

Its an issue I'm interested in because I did a bit of work with aggression management techniques in regards to mental health emergency management. Early on in my education, a paramedic told me that not a single paramedic in the entire service has been punched who didn't deserve it. That's a bit extreme, but there is some validity to the idea. I would submit that a lot (not all) of assaults happen due to poor aggression management. We learned a bit about it at uni, and Ambulance Victoria put us through some excellent assault prevention training before we went on road, but I don't know that the message has been heeded. 

When I get back to work, I'll see if I can find some actual stats that are allowed to be public.


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## mycrofft (May 27, 2011)

*Melclin thanks ("good on you"?)*

The "They deserved it" comment is going to bother some folks, since it's "everyone's right" to work in a safe working envirojnment (tell that to bomb disposal and law enforcement officers), I think they meant some folks don't use common sense or they treat patients/otherts in a manner that will likely precipitate some sort of retaliation.
Yeah, let's see those figures.


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## mikeward (May 27, 2011)

*From a lecture I delivered*

One of the challenges Brian Maguire had in doing his doctorial research into EMS workplace fatalities was the lack of a central database.


Occupational fatalities in emergency medical services: a hidden crisis.
Ann Emerg Med. 2002 Dec;40(6):625-32.

Analysis was conducted by using data from 3 independent fatality databases: the Census of Fatal Occupational Injuries (1992 to 1997), the National EMS Memorial Service (1992 to 1997), and the National Highway Traffic Safety Administration's Fatality Analysis Reporting System (1994 to 1997). Using the highest cause-specific count from each of the databases, we estimate that there were at least 67 ground transportation-related fatalities, 19 air ambulance crash fatalities, 13 deaths resulting from cardiovascular incidents, 10 homicides, and 5 other causes, resulting in 114 EMS worker fatalities during these 6 years. We estimated a rate of 12.7 fatalities per 100,000 EMS workers annually, which compares with 14.2 for police, 16.5 for firefighters, and a national average of 5.0 during the same time period. CONCLUSION: This study identifies an occupational fatality rate for EMS workers that exceeds that of the general population and is comparable with that of other emergency public service workers.


Subsequent study by Maguire shows that the INJURY rate of ems personnel TWICE as high as firefighters. 


Occupational Injuries Among EMS Personnel

PREHOSPITAL EMERGENCY CARE 2005;9:405–411

 Four hundred eighty nine cases met the DOL inclusion criteria. The overall injury rate was 34.6 per 100 full-time (FT) workers per year (95% confidence interval [CI] 31.5–37.6). “Sprains, strains, and tears” was the leading category of injury; the back was the body part most often injured. Of the 489 cases, 277 (57%) resulted in lost workdays, resulting in a rate of 19.6 (95% CI 17.3–21.9) per 100 FT workers; in comparison, the relative risks for EMS workers were 1.5 (95% CI 1.35–1.72) compared with firefighters, 5.8 (95% CI 5.12–6.49) compared with health services personnel, and 7.0 (95% CI 6.22–7.87) compared with the national average.

INJURIES FROM ASSAULTS ON PARAMEDICS AND FIREFIGHTERS IN AN URBAN EMERGENCY MEDICAL SERVICES SYSTEM

PREHOSPITAL EMERGENCY CARE 2002;6:396–401

Objective. To determine the nature and frequency of injuries resulting from assaults on paramedics and firefighters in a large, fire department-based emergency medical services (EMS) system. Methods. This was a descriptive study involving retrospective analysis of an occupational injury database. All injury reports involving assaults from 1996 to 1998 were reviewed. Results. 

There were 1,100 injury reports submitted during the study period, of which 44 (4.0%, 95% CI 0-10.9%) involved an assault. Paramedics were assaulted in 35 (79.5%) of these incidents and firefighters in nine (20.5%). 

Forty-one assaults (93.2%) occurred during patient care activities. Medical attention was sought in 36 incidents (81.8%), and in 14 (31.8%) the employee lost time from work. 

Twenty-six assaults (59.1%) were classified as intentional and 17 (38.6%) as unintentional. One (2.3%) could not be classified. 

Conclusions. In this EMS system, injuries resulting from assaults were uncommon. However, due to their potential impact on the victims and the EMS system as a whole, policies and procedures should be developed to minimize these incidents.


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## mycrofft (May 27, 2011)

*mikeward, good bunch of data*

The first article was identical in wording to the American College of Emergency Surgeons article I cited above in the prelim review. Citations are gold, thanks. I'll see if I can take them with me when I'm gone for the next two weeks (starting the 31st).

Every article so far ends with a note to the effect that, while this is not a common occurance, it is potentially serious and deserves better tracking and that procedures need to be thought out to make the workplace safer.

My feeling is that the following questions are lurking under the surface:


How many of these are unavoidable as long as we make contact with, or ride alone with, patients in the back of an ambulance? 

What setting did they occur in; ambulance, on scene, or at ER/etc.?

How many of these are going to be apporpriately addressed with threat or application of "lethal force", "less lethal force", "manual resistance" (i.e., martial arts), or just need procedural changes (i.e., no moving resistant patients without law enforcement performing the physical control, no response to  reported assaults or batteries or scenes of those or homicides without the perp or suspect being in custody)?

How many of these would be helped by wearing of protective equipment (Kevlar)?

How many of these were "ad hoc" attacks, neither by concealed weapons or by taking a weapon from someone authorized to carry it (security guard, responder), versus weapons on the person of the patient?

How many involved an assaultive bystander, or at-large perp or suspect on the scene?

Many of these are going to remain unanswered in the big picture due to the type of recordskeeping that is done. PD's will have this sort of raw data, but it's not really in our purvey to get it, or is it? ALso, maybe unions will when they cover the EMS workers (IAFF for fire EMS, I have no idea who is covering non-fire EMS workers). 

PS: NREMT says they don't do business over email, period.


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## Luno (Jun 1, 2011)

*Well, you're on quite a tear, aren't ya *



mycrofft said:


> The first article was identical in wording to the American College of Emergency Surgeons article I cited above in the prelim review. Citations are gold, thanks. I'll see if I can take them with me when I'm gone for the next two weeks (starting the 31st).
> 
> Every article so far ends with a note to the effect that, while this is not a common occurance, it is potentially serious and deserves better tracking and that procedures need to be thought out to make the workplace safer.
> 
> ...



Unfortunately, I think that you've misunderstood the field that you're attempting to get "facts" from... As a good MD friend of mine says, "EMS? That's an evidence free zone..."  The problem is that there is a lack of adequate research and documentation for the majority of what we do, and how we do it.

I see a large issue with your demand for "facts" and studies within the field for assaults on providers.  It's kind of like researching wife aggressor/husband victim domestic violence, the majority of the cases simply are not reported.  Whether it's a delusion that we are here to "save people" or the simple shock when we are assaulted, the majority of incidents do not get reported, much less tracked.  I believe that a good place to start with statistics would of been with DT4EMS, since it was kinda his niche... (Kip, you still out there?)  We can stand on a soap box, moan and conjecture, but unless we change the mindset, and start to realize that it is an issue and provide safe avenues for reporting and assistance, this will just be another dirty EMS secret pushed under the rug.  I've been assaulted numerous times, and they're documented in the run report, but there is no current way to document or track those assaults.  I will just add this to the growing list of poorly documented and researched EMS procedures and issues...


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## mycrofft (Jun 11, 2011)

*Apologize for the delay, I'm away from computers.*

Yeah, I'm on a tear. Yeah stuff is underreported, that's why I'm trying to focus on job related homicides, they are harder to sweep under the carpet. The Philadelphia study, while not up to the minute, seems to have some rigor.
Not seeing more or newer data here.


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## mycrofft (Jun 30, 2011)

*OK, to sum it up (no more data received)*

As a field ems worker you are probably more likely to die in a "civil dispute" (someone you know or love) than on the job due to patient or bystander violence. Certainly more likely to die in a traffic or other accident.

I was talking with an aquaintance who was in law enforcement and does carry a concealed weapon, and he pointed out some facts/opinions he had, to whit:

1. When you are carrying a gun lawfully, now you not only have to protect yourself, but the firearm. 
2. If you produce a firearm, even during the threat or comission of a crime, the person you point it at can claim self defense if they shoot first. This defense has worked against law enforcement on duty. Not that you will think about this in a real life or death situation, but it could make people bent on violence more likely to try to defend themselves than let you shoot them.
3. You do not wear your sidearm without intent of using it, you do not produce it to wave around and discourage people; the only time you might "cover" someone is when that person is immediately about to be handcuffed and booked, and you must be prepared to shoot that person. No such thing as a "warning shot", and in fact discharging a firearm in such a manner is probably illegal in and of itself. (When you go out the door, you tell yourself "I'm going to kill someone today"; when you come home and lock your gun away, you say "Good, I didn't shoot anyone today").
4. There are many rules about discharging your weapon. You must be proveably convinced life is on the line. You must not discharge the weapon if the "background" (what is also in the line of fire behind the target) is unknown or may place others in danger. You must not fire at or from moving vehicles. You must not fire if the distance is such that the target is unlikely to be reliably hit.
5. Even if you fire justifiably, that does not protect you against civil actions including lawsuit or dismissal from your job.

So, personally, I am more convinced than ever that I would never want to carry a concealed firearm, and that the scenarios for it being appropriate and beneficial in a field EMS sense are vanishingly minisucle.


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