NFPA Journal

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In October 2015, emergency medical technicians Kelly Adams and Al Royas were dispatched just after midnight to a gritty section of midtown Detroit to help a woman with an injured ankle. When they arrived, the woman’s boyfriend insisted that he ride along in the ambulance to the hospital. When the EMTs refused, the man punched Royas in the head, then drew a box cutter and slashed Royas in the hand and under the eye. In an attempt to save her partner, Adams grabbed a stool from the ambulance and struck the attacker twice; unfazed, he punched Adams, then used the box cutter to slash a deep gash the length of Adams’s left cheek, from her ear to the corner of her mouth. Battered and bloodied, the EMTs were eventually able to barricade themselves in the ambulance and drive to the emergency room.

The attack was more violent than most, but it’s no anomaly; across the country and around the world, in locations both rural and urban, evidence suggests that responders are now enduring historically high levels of violence at the hands of the people they are trying to help. “We fight all the time,” Adams told a local news station three weeks after the attack. “It just never makes it to TV.”

Spend time with any cop, EMT, or firefighter who has run enough medical calls, and the war stories come pouring out. Responders are frequently bit, spat at, kicked, punched, and cursed at. Sometimes they’re beaten, stabbed, and even shot at. Hand-to-hand grappling with drunk, high, mentally disturbed, or enraged patients has become a normal part of the gig.

“Quite frankly, this is a contact sport,” Rick Smith, the police chief in Wakefield, Massachusetts, and the outgoing vice president of the International Association of Chiefs of Police, told me. “Most of us say, ‘Oh, don’t worry about it, it’s part of the job.’ But the reality is that society does not do a good job understanding and taking care of this problem.”

Jennifer Taylor, director of the Center for Firefighter Injury Research & Safety Trends (FIRST) at Drexel University, has interviewed dozens of responders who have suffered violence on the job. Many of those responders feel abandoned, she says. “People on the EMS side of fire really want to talk about this issue, because nobody has been thinking about it,” she said. “They feel like they get the s--- beat out of them and no one cares.”

One glaring indication of society’s apparent apathy toward responder violence is how little we know about basic questions surrounding the problem, including how often it happens and why. Currently, there is no widely used centralized system for reporting attacks against responders, and no state or federal laws or standards requiring personnel to report when they are abused. For a variety of reasons, many responders don’t voluntarily report attacks, and few academic studies have looked into it closely. Instead, the issue has remained mostly invisible to the mainstream public, researchers, and often even to department leaders.

What data and anecdotal evidence is available, however, paints an alarming picture. A 2015 survey of roughly 1,800 EMS personnel in the United States found that 69 percent had experienced some form of violence on the job in the previous 12 months. A third had been punched, slapped, or scratched; about 30 percent had been spat at; 11 percent had been bitten; and more than two-thirds had been verbally abused. Similar studies in Australia and Canada found that between 75 percent and 88 percent of responders there had experienced violence in the last year.

The only semi-official statistics that exist come from the National Institute for Occupational Safety and Health, which estimates that about 3,500 EMS workers in the U.S. were sent to the hospital in 2016 with injuries resulting from work-related violence, though most experts agree that the actual figure is much higher.

Despite the lack of hard data, every expert in the field I spoke with—including union leaders, researchers, national responder organization leaders, and responders themselves—said there’s little doubt, based on what they see and hear, that attacks on responders are at an all-time high. Some cited the opioid epidemic as a reason; others pointed to the significant increase in medical calls over the past few decades; and others simply cited the breakdown of social decorum.

Whatever the reason, all that static is taking its toll. A 2015 survey of more than 4,000 responders in the U.S. found that 6.6 percent had attempted suicide, which is more than 10 times the rate in the general population. Other studies suggest that responder substance abuse is rampant, and retention rates, especially for EMS personnel, are falling.

“I think the situation is dire—and I can say that because I’ve talked to paramedics all over the country,” Taylor told me. “When I ask paramedics to tell me about their physical injuries they sustain when they’re assaulted, they don’t want to talk about that—they want to talk about the psychological impact.”

Many have contemplated suicide, she says. Others have left the profession, while some who have remained say they are so jaded that they no longer care about the patients they serve.

“They see it as an injustice that they report these incidents and nobody is charged. Then they have to go back to work tomorrow and act professional to someone who might spit in their face, vomit on them, push them off the back of the rig, or steal the drugs off the ambulance,” Taylor said. “Who signs up for that kind of job? You wouldn’t if you knew what was going on.”

The medical call factor

According to many experts, a major underlying reason for the increased violence and stress plaguing the fire service and other EMS providers is the dramatic rise in medical call volumes. According to NFPA, fire service EMS calls have increased about 350 percent over the last 30 years, including a nearly 50 percent jump in just the last decade. In New York, FDNY reports that more than 80 percent of the department’s total runs are now medical-related, which is in line with the fire service nationally, according to the International Association of Fire Fighters (IAFF). Despite that, staffing levels have remained relatively flat for a decade or more.

“One of the things we’ve seen coming out of the recession is that a lot of municipalities—especially urban, metro, and even suburban communities—are growing outwardly and upwardly and in population, but fire department resources by way of personnel and capital investments are not increasing,” Thomas Breyer, the IAFF director of fire and EMS/GIS operations, told me.

In Philadelphia, where Drexel University is located, the fire department routinely sees a 20 percent increase in EMS calls year over year, Taylor told me. “But I can assure you they do not have a 20 percent increase in staff,” she said.

As a result, some fear the system in place is reaching a breaking point. Responders are increasingly worn out, disillusioned, depressed, and tired of holding out a helping hand only to be met with ingratitude, a closed fist, or worse. John Montes, an emergency services specialist at NFPA and a longtime EMT in Boston, said that the violence can manifest itself in different ways over time for both EMS workers and patients. He described a friend, also an EMT, who described the profession as “a dream job” and came to work each day in a perfectly pressed uniform. Over time, though, it wore him down. “Then one day he transported a prisoner to the hospital and the prisoner bit him so hard it broke the skin and his saliva got into the EMT’s bloodstream,” Montes said. “The patient refused to take any communicable disease tests, so the EMT had to go on hardcore antibiotics, which affected him so bad that he ended up in the hospital for a week with internal bleeding. Four months later, my friend transports another prisoner and the guy spits on him, and my friend retaliated.”

Out of anger, the EMT hit the patient; the hospital reported the incident to the department and the EMT was promptly fired. “He did what he did because of all of the other terrible things that had happened to him, and he did not get enough care and support for those things,” Montes said. “Is it right what he did? No. But it’s not right what happened to him, either.”

Montes knows of at least 16 friends and former EMS colleagues who have taken their own lives in recent years. Others have quit under the weight of the job, or were also fired after snapping at violent patients. The problem has reached the point where it can’t be ignored any longer, he told me.

“First responders have higher rates of suicide and substance abuse than the rest of the population, and people are asking why,” he said. “It’s the concept of death by a thousand papercuts, and those assaults are big papercuts. People are starting to see this as a big issue, and it’s finally starting to be brought out into the light.”

As the emotional toll on responders receives more attention, money is starting to flow toward research projects to develop strategies that can help. In September 2017, the Federal Emergency Management Agency awarded Taylor’s FIRST program a $1.5 million Assistance to Firefighters grant (AFG) to study stress and violence in fire-based EMS—the first-ever AFG grant to fund a project focused on the EMS side of the fire service. The project, called “Stress and Violence in fire-based EMS Responders (SAVER),” aims to develop comprehensive systems checklists that fire departments and firefighter unions can use to reduce worker stress and injury related to on-the-job violence [see “Responder Advocate,” next spread]. The researchers will also work with departments and unions in four pilot-program cities to encourage broad use of a confidential violence reporting tool called EMERG, which was developed by the Center for Leadership, Innovation, and Research in EMS.

Taylor and others maintain that violent events have been woefully underreported for decades, partly because departments don’t push responders to report, and partly because responders often choose not to. Many responders view dealing with violence as simply part of the job, and the “suck it up, buttercup” attitude is pervasive, responders told me. Others worry that reporting certain experiences, like being punched by a senile senior citizen, would be met with derision back in the station, and some responders fear being picked on or perceived as weak. Some don’t report violent incidents out of sympathy for their mentally ill patients.

Taylor said it’s important to have the unions play an important role in the development of the confidential reporting tool, because firefighters tend to trust their peers more than their departments when it comes to sharing work-related injuries, and will be more likely to speak up. Drexel researchers will also have access to each of the test departments’ workers’ compensation data and will be able to compare the disparity between the official incidents reported to departments and the number of violent incidents that come in through the EMERG reporting tool.

“I know in Philadelphia, the fire department has an average of 5 to 10 workers’ comp reports per year from injuries suffered from assault, but the firefighter’s union in Philly tells us that people are getting assaulted there every day,” Taylor says. “We hope the study will help us get at a better approximation of the truth.”

‘A long way to go’

While research is vital to understanding the levels of violence responders face and how to better protect and prepare them, other strategies are happening in parallel. Many U.S. states, for instance, have passed laws that make it a felony to assault an EMT or firefighter, a step that may dissuade some would-be assailants. Canada and Australia have also begun media campaigns to highlight the violence responders experience in hopes that a better educated public will help slow the surge of EMT assaults happening in those countries.

Some departments have also begun to hang signs on ambulances with messages like “It is NOT OK to assault paramedics”; FDNY recently began displaying a decal informing patients that assault against EMTs can result in seven years in prison. Increasingly, departments are implementing new strategies such as flagging particular addresses in their dispatch systems where violence has occurred in the past to let responders know to be prepared or to call on police units to assist.

While these measures can make a dent in the problem, lasting improvement must involve a seismic shift on multiple fronts, akin to the battle the fire service is currently waging against the high incidence of cancer in firefighters, several experts told me. That means changing the culture to remove the stigma around mental health and reporting violence, as well as developing more and better training, improving tactics of responders and dispatchers, and creating EMS industry standards that prioritize and better define safety.

“We still have a very long way to go,” Breyer of IAFF told me, adding that the chapter on self-care and safety has long been the shortest one in EMS textbooks. “We are just starting to become cognizant that violence is an exposure just like breathing in carcinogens—it is all part of your mental and physical health and is a silent killer.”

Vince Robbins, president of the National EMS Management Association, told me that many EMTs currently receive no training on some of the biggest threats they encounter in the field, including violence from patients, hostile crowds, and how to mentally and physically defend themselves in hostile situations. Some of those without training are lucky enough to be paired with veterans who can explain what it’s like when a patient pulls a knife. Others are left to learn through terrifying first-hand experiences, which can have significant emotional ramifications, he said.

“You come into this industry with an expectation that the person you’re helping will be grateful and thankful,” Robbins said. “When that person ends up spitting at you or throwing something at you or calling you names, or has family members verbally abusing you, it affects you emotionally. You feel rejected and hurt emotionally. It’s not so much the physical pain. I think it’s the emotional shock.”

Robbins is also president of the Monmouth-Ocean Hospital Service Corporation (MONOC), the largest EMS agency in New Jersey. According to Robbins, all new MONOC EMTs are taught lifesaving skills, such as always having an exit available in any room or situation, having a radio and being in reach of a panic button, and knowing when to leave a scene if a patient or a crowd becomes threatening. They are also encouraged to come forward to talk about and report incidents, seek therapy, and take mental health days, Robbins said.

Whether an EMT receives any of this type of essential training and support, however, is “generally related to the size of an organization and the resources available,” Robbins said. “More and more of the larger organizations like ours are beginning to implement this kind of training, but the smaller agencies, particular volunteer and rural or suburban agencies, probably don’t get a lot or any training.” He describes the training situation as “a mish-mash” and believes it needs to change. “How to protect yourself from violence and harassment should be taught as part of the EMT-Paramedic National Standard Curriculum right alongside all of the other things they need to know,” he said.

Robbins is in a good position to achieve that. He is currently chair of the National EMS Advisory Council, a 25-person committee that, among other things, makes recommendations to the federal government regarding changes to the EMT national training curriculum. He told me that violence and mental health are topics that have received a lot of attention on the council lately and that he’s confident the committee will recommend modifying the national curriculum to include training on violence and safety. It may be two years or more until any changes are made, however, and perhaps longer before the guidance filters down to the states. “It’s a long process, but it’s thorough and comprehensive,” he told me.

'No industry-wide entity'

Some have wondered if NFPA could do more to help improve the training, health, and wellness standards that non-fire-based EMS providers must follow. The organization provides significant guidance on firefighter safety, procedures, and health programs, which crosses into fire-based EMS, but has little to say about other models of EMS, which comprise the majority of the industry.

Currently, the organization has four documents that speak directly to all EMS, including NFPA 1999, Standard on Protective Clothing and Ensembles for Emergency Medical Operations, NFPA 473, Standard for Competencies for EMS Personnel Responding to Hazardous Materials/Weapons of Mass Destruction Incidents, and NFPA 1917, Standard for Automotive Ambulances. NFPA’s primary non-fire-based EMS guidance comes via NFPA 450, Guide for Emergency Medical Services and Systems, which organizations can use to assess planning, policy, communications, and other systematic operations. The guide, however, minimally addresses EMS worker health and safety, with mentions that each agency should have and implement “a comprehensive health and safety plan” and that “health and wellness programs should be in place to prevent participant illness and injury.”

It’s too early to tell whether more specific guidance about what a health and wellness program is and how to create one will appear in the upcoming 2020 edition of NFPA 450, which is currently in revision. “With the increasing interest in the subjects of violence and responder health, it will be interesting to see if there are public inputs or comments related to increasing safety recommendations within the guide,” said Montes, who is the document’s staff liaison.

With violence against EMS personnel increasing worldwide, some advocates do believe the industry is ripe for much more comprehensive guidance around personnel health and safety. For more than 30 years, the fire service has benefited from the landmark standard NFPA 1500, Fire Department Occupational Safety, Health, and Wellness Program, which over that period has helped slash firefighter line-of-duty deaths by 40 percent and injuries by 30 percent. However, nothing like it exists in the EMS world currently.

The limited number of national EMS standards has a lot to do with how fragmented the industry is, Robbins told me. About 20 percent of EMS services are fire-based; 20 percent are hospital-based; 20 percent are private, for profit, businesses; and the rest is a smattering of volunteers, hybrid systems, and other models, he said. “There is no way to get all the cats herded, and no way get those distinct entities to work together,” he said. “We all have a different way of looking at the world, and frankly different revenue streams that don’t always align. It’s been very difficult to speak with one voice.”

Through its standards development process, NFPA has a long history of bringing together disparate, and often competing voices, to develop consensus on some of the thorniest and most important issues facing first responders of all stripes. A recent example is the development of NFPA 3000™ (PS), Active Shooter/Hostile Event Response (ASHER) Program, where experts in EMS, fire, law enforcement, government, and others came together to create an interagency set of guidelines around active shooter preparedness and planning. Whether there is an appetite among the many different EMS groups for NFPA’s assistance in crafting more safety standards, however, is another matter.

When I posed the question to Robbins, who sits on the NFPA 450 technical committee, he said that NFPA would likely have a long, steep hill to climb if it were to try and have a larger presence within the EMS world. “Unfortunately, virtually all of the industry right now views NFPA as a pro-fire-based-EMS organization—non-fire-based EMS agencies are reluctant to see NFPA as a neutral player and are unwilling to cooperate with them,” he told me. “I think it will take a long time for this to change. So we remain with no industry-wide entity that is viewed as credibly neutral, for all stakeholders to support.”

While fragmentation in the industry may continue to be a challenge, most experts agree that activity around responder violence and mental health is beginning to coalesce, and positive change is happening, albeit slowly. It can’t come soon enough for the thousands of responders like Kelly Adams and Al Royas who willingly risk their lives to go into the night to help whoever rings. The stakes are also high for those of us who rely on those responders. If we can’t protect the men and women in uniform, Taylor warns, who will be there to protect and help us on the worst day of our lives?

“We’ve hung out this shingle that says that if you call 911 when you have a problem, help will arrive. If that’s our value set as a society, then we have to support the people responding to the call,” she said. “If they are so fried that they don’t care anymore, if they are so tired that they can’t think ‘why is she paralyzed, what drug do I need to give her?,’ then people are literally going to die. This can’t be the status quo, because this system is going to blow. Not just for departments, but for patients, communities, everyone.”

JESSE ROMAN is associate editor for NFPA Journal. Top Photograph: Getty Images