www.bcas.ca

www.ceep.ca

CAEP 2009

EMS Preparedness for Tactical Violence

Karen Wanger MDCM, FRCPC

Regional Medical Director

BC Ambulance Service

Disclosure

• I do not have an affiliation (financial or otherwise) with any commercial organization that may have a direct or indirect connection to the content of my presentation.

• And I am not Demi Moore...

Learning objectives

• Understand “tactical EMS” vs. “tactical EMS”

• Learn what the perceived preparedness status is of front line responders in Canada

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Introduction

• Paramedics are essentially the only medical personnel routinely at the scene of violent episodes

• 8.5% of scenes are the result of some form of violence

• Up to 90% of EMS staff report an episode of violence directed at them.

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Tactical Violence

• Defined as: – “the deployment of extreme violence in

a non-random fashion so as to achieve a tactical or strategic goal”

• Preparation for Tactical Violence is a routine part of training for police and military but not EMS

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Tactical Violence

• Tactical violence = multi agency approach

• Targeted violence + law enforcement = change from “normal” EMS response mode

• Safe and efficient functioning specific training including training with the other responding agencies.

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Tactical Teams

• A few• These teams are generally deployed

in advance of a call when law enforcement is planning a tactical manoeuvre.

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Tactical Violence

• Violence that is “tactical” in nature employed by an outside “agency” as in terrorism would occur without warning.

• The estimated time to scramble a specialist tactical team is roughly one hour

• Front line paramedics would be required to manage the scene for that time.

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Violence

• Paramedics are experienced and well versed in dealing with interpersonal violence on calls.

• Patient/patient or “perp”/patient. • Violence towards a paramedic is

generally one-on-one from a patient and is understood by the paramedic

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Tactical v. responders

• A large component of “intentional/random” violence or violence directed towards responders changes everything.

• Including subsequent processing.

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Targeted tactical - management• Isreali paramedics approach tactical

violence scenes differently from other MCI’s. It is understood that secondary devices aimed at responders are a reality.

• Casualties are moved quickly and the scene emptied in minutes.

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Are we prepared?

• Survey of pre-hospital providers in BC and Ontario

• January to June 2006• Daniel Kollek and Michelle Welsford. • Addressed the self-reported training

and readiness in the following areas:

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Survey topics:

• 1. Training for response to a tactical violence or terrorist scene;

• 2. The level of comfort responding to a complex event (mass casualty, violent, etc);

• 3. The level of comfort in detecting and dealing with the emotional impact of providing care;

• 4. The added emotional impact caused by violence, clinical load, and child injuries at the event scene.

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Topics and Methodology

• Emotional impact was assessed by grading response to a variety of scenarios including violence and tactical violence, and the presence of combinations of adult and paediatric victims.

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Population

• Ontario and BC paramedics and first responders

• Posted on a website only accessible by individuals knowing its complex address.

• Invitation by email and poster in Ontario• In BC email invitations to paramedics

through BC Ambulance. FR’s invited via FCABC distribution.

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Survey questions

• 3 basic areas:1) Scenarios – quantify degree of distress

1 (“not distressing to any significant degree”) to 5(“distressing to the degree that you would not be able to deliver care”)

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Survey questions

• 2) Report degree of training and comfort in responding to the following events:– Fire– Response to an unstable building– Response to a terror event– Response requiring use of elevated PPE– Response to a tactical violence situation

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Survey questions

• 3) Ability to recognize emotional distress in self or partner and comfort with CISD

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Results

• 1028 respondents–Mostly male (75%)–Mostly PCP (55%)– Age 36-50 (48%)–Wide range of years of experience– Predominantly front line personnel

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Results - training

• Regarding “procedures to follow in responding to a tactical violence scene where there my be further violence” 77% of 876 respondent stated they had received no training.

• 92% of 289 respondents stated police to be in control of site access in a tactical violence situation but 4.5% “did not know” who would be in control of the scene.

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Results - training

• “...trained to function under conditions of tactical violence”. 89% of 288 respondents – “never” (46%) or “>1yr”

• Only 27% of 291 respondents had “..any field exercise with other (non-medical) first responders”. 37% had exercised more than 1 year ago and 36% “never”

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Results – emotional impact

Not distressing

Slightly distressing

Moderately distressing

Would not be able to resume work

Would not be able to deliver care at the scene

Total Emotional Impact Value

Average Emotional Impact Value

(weight 0)

(weight 1)

(weight 2) (weight 3)

(weight 4)

1 1 adult injured1 adult dead

342 (0) 492 (492) 0 (0) 12 (36) 1 (4) 532 0.63

2 1 adult injured1 child dead

51 (0) 211 (211) 512 (1024) 75 (225) 1 (4) 1464 1.72

3 1 adult attacked1 child dead

34 (0) 177 (177) 541 (1082) 99 (297) 1 (4) 1560 1.83

4 1 adult injured1 child attacked and dead

27 (0) 137 (137) 520 (1040) 172 (516)

3 (12) 1705 1.98

5 20 adults killed accidentally, five injured

39 (0) 136 (136) 456 (912) 224 (672)

1 (4) 1724 2.01

6 20 adults killed purposely, five injured

31 (0) 84 (84) 432 (864) 297 (891)

12 (48) 1887 2.20

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Results – emotional impactI never have unwanted memories of distressing events

3.1%

I would process the event immediately and it would not bother me for any significant length of time

26.4%

It will take me up to a week to process this event 30.8%

It will take me up to a month to process this event 13.2%

It will take me over a month to process this event 11.5%

I do not think I would ever get over witnessing such an event

15.1%

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Comfort levels – event response

Very uncomfortable

Slightly uncomfortable

Unsure Reasonably comfortable

Very comfortable

Fire 57 (7%) 61 (7.4%) 52 (6.3%) 224 (27.4%)

425 (51.9%)

Unstable building

113 (13.8%) 126 (15.4%) 173 (21.1%)

275 (33.6%)

132 (16.1%)

Terror event

153 (18.7%) 154 (18.8%) 266 (32.5%)

186 (22.7%)

60 (7.3%)

In PPE 103 (12.6%) 136 (16.6%) 166 (20.3%)

247 (30.2%)

167 (20.4%)

Tactical violence

103 (12.6%) 157 (19.2%) 196 (23.9%)

264 (32.2%)

99 (12.1%)

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Comfort level – distress recognition

Very uncomfortable

Slightly uncomfortable

Unsure Reasonably comfortable

Very comfortable

Recognising self distress

31 (3.8%) 57 (7%) 124 (15.1%)

353 (43.1%)

254 (31%)

Recognising distress in others

21 (2.6%) 50 (6.1%) 100 (12.2%)

441 (53.8%)

207 (25.3%)

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Comfort level - support

Very uncomfortable

Slightly uncomfortable

Unsure Reasonably comfortable

Very comfortable

Receiving anonymous counseling

55 (6.7%) 81 (9.9%) 98 (12%) 247 (30.2%)

338 (41.3%)

Receiving group counseling

67 (8.2%) 87 (10.6%) 103 (12.6%)

266 (32.5%)

296 (36.1%)

Progress

• MCI training• Awareness training

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Discussion

• Targeted tactical violence is a reality• Some paramedics are trained to

back up police in tactical situations organized and controlled by PD

• A paucity of front line paramedics are trained to respond in a situation of tactical violence targeted at first responding crews. Some don’t even know who would be in charge.

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Discussion

• Even the “lesser” of the factors in the scenarios more than doubled the emotional impact of the event as rated.

• These factors are not unusual (child injury, assault, etc)

• Emotional self care is not part of standard training for paramedics

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Discussion

• Monitoring for psychological impact is not routinely carried out although some services have implemented post incident debriefing.

• 97% of respondents admitted to occasional unwanted memories of distressing events with 31% stating it would take up to a week to process the event and 15% stated they did not think they would “ever get over witnessing such an event”

• 26% stated they would process the event immediately and it would not bother them for any significant length of time.

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Tema Conter Foundation

www.tema.ca

Conclusions

• Inadequate numbers of EMS personnel are prepared to function at a scene of terror or tactical violence directed at responders. Awareness and education should be provided

• The emotional effect on paramedics of violence requires greater attention

Thank you for your attention