A paramedic is called to a wide variety of incidents that can involve single patients to multiple patients, environments such as a patient’s resident to roadways and public gathering venues such as bars, theatres, restaurants, etc

As with all paramedics, you never know what you will have and what you will respond to. Unfortunately, paramedics assaulted are becoming even more day by day.

Our story today tells the experience of a paramedic with 35 years of experience in the ALS (Advanced Life Support),  service that staffs 26 transport capable ambulances and 3 response cars during the day and 16 ambulances with no response cars at night.

Each ambulance is staffed by two ALS paramedics and he response cars are staffed by 1 ALS paramedic. In addition, there are two ALS supervisors on duty every night that are capable of response but generally will only do so when the available ambulance number drops below 3 available units.

The community in which the protagonist lives and works is a municipality comprising of 7 towns and 1 city with a combined population of 609,000 residents. The community has some industry but in mostly a bedroom community with a large number of residents travelling to the areas west.

INTRODUCTION – With all calls, you are given basic patient information which is generally inaccurate with minimal scene information. The only guarantee you have is that in essence ensures you are walking into your call blind to what is truly awaiting you on the other side of the door.

Based on the response request you may respond with only your partner, with allied agencies such as the fire service and police or with the addition of tactical police officers with a request to stage at the scene. When you are requested to stage, you are being advised to respond to the call but stay back until police advise the scene is secure and safe for you to enter.

Although the vehicles from each allied service look completely different, just a few years ago all of the responders looked the same, dark uniforms with only the shoulder crest advising what the responder was. Due to a few incidents, paramedics are now wearing high visibility shirts (bright yellow ) while policing has remained with the dark blues.

Though the uniforms now look different, we still find in a crisis environment, responders are all treated as they are police officers (a uniformed person in authority) and pending on the culture of the patient/bystanders, their home prejudices can easily apply.

With respect to safety, paramedics and firefighters receive extensive training for their specialty but limited training with respect to security. In addition, you could be working with a partner who has less than 6 months experience and hasn’t truly developed their road skills yet. Currently, we operate on a policy that permits use to stage ( Staging entails not entering the scene no matter what is occurring with the patient ) if we feel the scene is to dangerous, but staging involves us being able to fully see the scene and evaluate the changing safety concerns. If the scene is outside, the task is easier than if the call is in a residence.

Within our community we are fortunate that there is no armed conflict amongst countries, but paramedics are still faced with a wide variety of violence that can include guns, knives, assaults, explosive devices, suicides by violence and chemical exposure, chemical warfare, intoxication of alcohol/drugs, motor vehicle accidents and bystander behaviour around any specific scene.

In the past two years my colleagues and I have encountered intoxication both by alcohol and illicit drugs, weapons such as guns and knives, verbal threats for care being provided or not being provided. An example of care not being provided would relate to some patients seeking narcotics for pain management and when they are not administered based on a paramedics medical directives the patient becomes quite irate.

THE CASE – Amongst all of the calls our ambulance service responds too, one type is considered a cover off assignment or “stand-by” which means the community next to you no longer has ems care due to call volume and you are required to attend that area for coverage. Additional information, within our service all though my partner and I are trained to the same level we rotate tasks after every call from attendant to driver and on this occasion, I was driving.

My incident occurred at 02:00 on a Saturday evening in July when coverage is lower within the region but the population temporarily increases in the entertainment areas such as bars/nightclubs from residents of the larger community beside us travelling to our community as the entertainment areas are not as busy.

My partner and I were responding to a standby call when we found ourselves stopped at a red light at a major intersection in town. On the northwest corner is a bar, northeast corner is a McDonalds (fast food restaurant), southeast corner is another restaurant/bar and southwest corner is a gas station.

While sitting at the intersection waiting for the light to change to green, our radio pipped up from our communications centre calling our truck number. They requested we attend an emergency call for a fight in progress in a bar’s parking lot and that police and fire would also be attending the call. The unfortunate problem was that the bar was on the northwest corner of exactly where we were and we witnessed a parking lot that had close to 200 people in it and no other agencies around.

As standard practice, my partner and I advised we were on scene but waiting for police due to the volume of people in the parking lot. Additionally, when people saw us, they began to run away in all different directions. A few moments later, our radio chirped again with updates that began as 1 person stabbed, next update was then 2 stabbed and unknown if assailants are on scene and then 2 stabbed and one struck by a car.

As we were getting the updates, there were no allied agencies on scene and people began running over to our vehicle advising of the injuries. As we advised we were waiting for the police to arrive and secure the scene, we had mixed reactions from the bystanders that ranged from “ Ah, ok” to “ your being racist and letting them die on purpose”.

My partner and I remained in our vehicle and updated our communications centre. Approximately 4 minutes after the initial dispatch, police units began to arrive and secure the scene. As the first two police units arrived, we proceeded to the scene to begin assessing and caring for the patients. We were directed to the first stabbing patient which my partner began care for based on the patient’s acuity while I assessed the remainder of the parking lot for the other patients and verifying no one was injured in the bar.

In total I found 10 patients in all, 4 assaulted by fighting, 1 struck by a vehicle at low speeds and 5 stabbings ranging from a small puncture wound to the chest, puncture wounds to the abdomen and eviscerations. In addition to the 10 patients, each patient had 2-4 hysterical people around them and there were still close to 100 people roaming the parking lot area.

So, as an update, 10 patients with close to thirty hysterical friends around them, 100 people hovering and trying to interfere, 4 police officers and two paramedics. As the second and third ambulances arrived I directed them to the next highest acuity patients.

At that point, the bystanders began to become irate because they felt that the wrong people were being cared for first and that their friends/others should be ahead of all others, no matter the injury. As time progressed in the call, fire services arrived and more police arrived which included regular patrol officers, K9 officers and tactical officers.

Resource staffing in our community equates to a police unit containing one police officer who’s key responsibility is site security, fire unit which contains 4 firefighters ( 2 are able to assist with patient care as one secures their vehicle and one is the officer of the truck ) and can assist with patient care at an EMR level and a paramedic unit which has two paramedics.

Paramedics assaulted are common. My safety concern came when I was reviewing my triage plan and determining how many patients I had remaining. I was reviewing my plan, using the hood of the ambulance as my desk and had my back to the crowd as I felt the scene was secure due to the volume of responders at the scene. While I was updating our communication centre I was rapidly grabbed and pulled away from my task by an irate individual who had his fist raised and demanded we care for his friend immediately and to stop caring for others first.

Thankfully I had my hand still on my portable radio mic and was able to rapidly move my thumb and activate the emergency alarm on the radio. Once the alarm was activated, all ems radios at the scene chimed the emergency alarm which caused all paramedics to stop their activity and look to see who activated the alarm. It seemed like forever but before I was able to say anything on the radio, the individual was tackled to the ground by a tactical police officer and placed under arrest.

After a few minutes to clear my thoughts, we continued our care and ensured all patients were looked after appropriately and professionally, no matter if they were an innocent bystander or assailant.

ANALYSIS – I wasn’t prepared for what happened and I became complacent with the scene as I put my back to the scene and focused on the task at hand. The entire incident happened so quickly, it was difficult to consider any other actions by myself or others. The only plus was that my years of training and experience allowed me to activate my emergency alarm without second-guessing the requirement to activate or the concern of “what will others think”.

As the incident mitigated, I do recall using some explanative language that most likely wasn’t professional and with today’s society of videotaping everything and placing it on social media would not reflect well with myself, my agency or my profession.

At the scene, everyone was busy doing the tasks at hand. When you have an opportunity to sit back and think about things, you realize that working on a patient/scene with your head down 99.9% of the time is safe and acceptable, but that 0.01% of the time is the one that can end your career.

After the incident was complete and all patients were managed and transferred our senior management team brought out our Critical Incident Stress ( CIS ) Team to ensure all involved were ok. Not specifically to one item of the incident but to the incident as a whole. As the group spoke, it became very clear that each team of responders was working in its own bubble and not aware of the entire scene around them.

We trusted everyone to ensure our safety but didn’t take into account the vast difference in numbers between responders and bystanders. With respect to predefined thresholds of acceptable risk, I believe we all were. Everyone in prehospital care is aware of the risks and we work well at ensuring we are safe.

But peer pressure and perceived expectations has a bad way of taking hold when you have responders with a wide variety of experience. My experience may allow me a wider variance to care for and assess a scene as compared to someone who has only been on for a short time.

One of the mitigating concerns that we have is the inaccuracy of our response information. Within my community, one organization controls the communication centre, while a second organization controls the response component. Over the years we have become use to the fact our communication centre never gives us all of the information accurately and has difficulty managing the variances outside of the box while the incident is occurring.

I do understand that they are limited to what information they are given and legislation / SOG’s prevent them from thinking outside of the box. With reference to this call, they felt we had only three patients and had difficulty addressing the now ten patient scene in addition to managing other calls within the region.
When thinking about previous incidents, just over a year ago, same parking lot, same issue, same time of day. The only variance was the fight resulted in a shooting of two individuals and the information came in as a shooting rather than just a fight.

As I review this incident and others that my colleagues have responded too, one thing that became very evident was the cyclical wave of complacency that we all endure. An incident occurs and your senses increase and the way you manage all calls after that changes. As time passes and no incidents occur within your profession, your senses decrease and you fall back into the complacency zone of scene management and patient care.

Was our delay in beginning patient care a factor in the call? I feel it was as it increased the anxiety of the bystanders and patients and many came to a speculated judgement. Though I’m sure the delay added to the anxiety, I would be unsure how to defer the delay as provider safety takes precedence over all else.

Did our training prepare us, yes and no? Specific to our area, we train well on single patient dynamic calls but don’t train well on multiple patient/bystander, very dynamic calls. In the past, we have asked for Post Incident Reviews (PIR) on scene’s that involve multiple patients and in the past, our management team has replied with “There’s no need. Nothing like that will happen again”. As the older managers retire and younger managers take their place, I hope all will change to these dynamic calls as we are very good at the norm but need practice with the unusual and before it’s as a result of attending a to a colleague.