The first in a series on defensive tactics for EMS providers. To view an interview with the author, Kip Teitsort, on his DT4EMS training, click here.

The EMS community started 2009 with the murders of two providers and a lot of press regarding scene safety. On January 17, EMT Melissa Greenhagen, 37, was shot in the chest by a stranger outside a hospital in Glasgow, MT. Then, 13 days later, EMT Mark Davis, 25, was fatally shot during a response to a private residence in Cape Vincent, NY.

It is a tragedy that the deaths of these comrades did not receive more national attention. But to many, it comes with the territory. Even when EMS providers aren't gunned down on duty, they face daily threats of abuse and assault from patients and others. Days before Greenhagen's murder, the Edmonton Journal reported a patient pulling a loaded gun on paramedics in the back of an ambulance. One medic, according to witnesses, had to run from the vehicle and hide behind a fire truck. The providers did not receive any physical injuries, but likely endured a large psychological impact.

According to a 2005 NAEMT study, the No. 1 injury to EMS providers is assault, with 52% of those surveyed saying they'd been attacked on the job. According to Brian Maguire, DrPH, MSA, a clinical associate professor at the University of Maryland, Baltimore County, who studied the issue, "The risk of nonfatal assault resulting in lost work time among EMS workers is 0.6 cases per 100 workers per year. The national average is about 1.8 cases per 10,000 workers per year. So the relative risk for EMS workers is about 30 times higher than the national average."

The problem is also bad for hospital workers. In 1999, the Bureau of Labor Statistics estimated that 2,637 nonfatal assaults occurred to this population--a rate of 8.3 assaults per 10,000 workers. This rate is significantly higher than the rate for other private-sector industries, which is around 2 per 10,000 workers. Healthcare providers are more likely to be assaulted on the job than police officers or prison guards.

The Occupational Safety and Health Administration (OSHA) has identified violence in the medical setting as a potential hazard, and found the training of medical staff to identify and deal with potential violence ineffective. The Emergency Nurses Association (ENA) notes that "Healthcare organizations have a responsibility to provide a safe and secure environment for their employees and the public," and that "emergency nurses have a right to take appropriate measures to protect themselves and their patients from injury due to violent individuals."

But no matter how many studies are conducted, there remains a reluctance on the part of EMS agencies and hospital administrators to provide training to effectively address workplace violence. Some may not recognize the extent of the problem, and thus don't perceive the need for training personnel in basic defensive measures. Some erroneously perceive using defensive tactics as fighting, or a form of aggression/offense. Whatever the reason, it poses a problem: If a person is not trained properly to respond to acts of aggression, they will respond to them, when they occur, with "caveman" style tactics that can be inappropriate, excessive and difficult for an employer to legally and morally defend.

Defend, Escape
Proper instruction in basic personal defensive measures makes sense for emergency medical providers and organizations that employ them. Our company, Defensive Tactics for EMS (DT4EMS, www.dt4ems.net), was created by EMS providers to train prehospital and emergency department personnel to recognize, prevent, avoid and escape physical assaults. Our primary focus involves physical measures for self-defense and the repulsion of attacks, with additional focus on areas like verbal skills, the legal, moral and ethical aspects of self-defense, and good documentation for protection after the fact.

This type of training meets key recommendations by OSHA that employers 1) provide a workplace violence protection program for employees, and 2) that such training be provided by individuals who specialize in the field of defensive training.

DT4EMS is not a martial-arts type program that teaches offensive fighting skills, nor is it a law enforcement-style course based on control or pain-compliance techniques. We do not believe EMS or ED personnel should try to subdue or arrest violent individuals. DT4EMS emphasizes recognition, avoidance and escape from violent situations. The 4 in our name represents the four "battles" faced by providers in violent encounters:

1) The battle of the mind--This concerns the survival mind-set: Knowing the difference between a patient and an attacker. Knowing when it's appropriate to use force in self-defense. Mentally rehearsing the skills needed to repel an attack.

2) The battle of the street--Having nonaggressive physical tactics that work under stress. Having escapes from common attacks and steps to take in the face of violent encounters.

3) The battle of the media--Providers who respond inappropriately to bad situations will get much more publicity than those who are victims of assault. In our cell phone/YouTube age, good customer service, with a nonaggressive posture and appropriate verbal skills, is essential.

4) The battle of the courtroom--Providers must know the laws of self-defense and patient restraint, as well as proper documentation.

In coming months, we will share the basics of our approach in a series of articles appearing exclusively on EMSResponder.com. Following the series, DT4EMS founder Kip Teitsort will provide instruction at this year's EMS EXPO, October 26--30 in Atlanta.

Six Steps
At the crux of the DT4EMS approach is a series of six steps:

1) Don't be on an unsafe scene--This is not always possible. Obviously, providers are often assaulted on scenes they thought were safe. But we should strive to stay away from areas known to be trouble-prone. This will be the subject of our next article, appearing in July.

2) Awareness--Providers must be aware of their surroundings to prevent assaults. Be mindful of who is around and pay attention to the little things: What is being said? What are people's moods? Where are the exits, should the scene become unsafe?

3) Maintain a safe distance--If a scene starts going south, a provider should keep his/her hands up and open (a posture of nonaggression) and back away to about 6--8 feet, if possible (see Figure 1). This body language makes it clear the provider is not the attacker and not looking for a fight. Verbal skills are important at this stage, when words can still defuse a potentially violent situation.

4) Double tap parry--The DTP is the primary physical skill taught to defend against the majority of frontal attacks. It has three overlapping parts: the parry, momentary elbow control, and distraction (see Figure 2). The DTP can be used in a variety of situations toward the ultimate end of escape.

5) Basic ground defense--If the DTP failed, contact (punch, grab, push, etc.) was made and the provider was knocked to the ground, the provider would tuck their chin, bring their knees up and yell on their way down. BGD tactics (Figure 3) can keep an attacker from mounting (straddling) the fallen provider.

6) Escape the mount--If a provider is knocked down and mounted by an attacker (Figure 4), this teaches them how to escape and use BGD to create space.

In practice, the goal of each of these steps is to get the provider back to the step before, and ultimately return them to step No. 1, and get them away from an unsafe scene. There is no perfect system for self-defense, but these six steps represent a proven framework for improving your chances of deterring/repelling an attack and coming home safely.

Conclusion
In EDs and ambulance bases across the country, providers tell tales of assaults by patients and bystanders. Many regard it as coming with the territory of their jobs, and many attacks go unreported, keeping administrators unaware of the scope of the problem and not taking measures to address it.

Being a victim of assault is not accepted in any other profession--why should it be accepted in the medical field? DT4EMS teaches providers to recognize and avoid unsafe scenes, deter and repel attacks by patients and others, escape danger when it arises, and document conflicts for the protection of their departments and careers.

In coming months, we will look at the components of DT4EMS' six-step process in greater detail. For Part 2 of this series, check back in July.

Kip Teitsort is the founder of DT4EMS. He is a veteran paramedic and a police officer who is experienced as an EMS educator and a certified law enforcement defensive tactics instructor. Kip continues to train in several martial arts, including Kali/silat, submission grappling and kickboxing. Kip is a featured speaker at EMS EXPO, scheduled to be held October 26--30 at the Georgia World Congress Center, Atlanta, GA. For more information, visit www.emsexpoevents.com.