Target fixation is defined by Webster’s dictionary as: a process by which the brain is focused so intently on an observed object that awareness of other obstacles or hazards can diminish. Also, in an avoidance scenario, the observer can become so fixated on the target that the observer will end up colliding with the object 
The term seems to have originated from World War II fighter pilots, who spoke of a tendency to want to fly into targets during a strafing or bombing run, focusing so intently on their target everything else faded from consciousness.
That’s really interesting, but how in the world does that relate to EMS? Replace an observed object with patient and you’ll see where I am going with this.
We as providers are called to bad scenes, to violent crimes, to people’s home courts – not all of those people will be happy to see us. Sometimes, we get so fixated on the sick patient that we forget about everything else in the surroundings… I wrote about a time when this happened to me here
Wait a minute we are the good guys/gals why would anyone want to hurt us?
In 2005 NAEMT cited assault as the leading cause of injury to EMS providers accounting for 52% of all line of duty injuries. 
We all joke and make jazz hands saying BSI/Scene safe during our testing, but I seriously wonder how many of us forget that the world isn’t such a nice place sometimes, and we, fellow providers, are often on the front lines of that nastiness.
In that same study NAEMT found that only 21%of us expressed our safety as our primary concern.  That says a lot about the people who dedicate their lives to helping others, but it also shows how vulnerable we often are.
Let’s look at a couple less than obvious scenes, any of these sound familiar to you:
You respond to a street party for a DK (local term for intoxicated party) with a head lac – I know it’s a stretch to imagine such a call… Your “windshield survey” reveals of crowd of about 100 people in the street – many of them jumping up and down and waving their arms – you exit the vehicle and hear several people yelling in your direction “damn, it took you guys 15 minutes to get here – what the hell…” Undaunted, you make your way to the patient – he has a baseball sized egg in the middle of his forehead complete with a 5 or so inch lac – your evaluation of the patient reveals he has an alcohol like odor on his breath, and he is not orientated to anything but self… he has to go to the hospital because you legally can’t leave him here – he adamantly refuses – and when he realizes his refusals are falling on deaf ears – he resorts to screaming – “OW YOU ARE HURTING ME ” the crowd wasn’t on your side to begin with and now they are all squarely focused on you and what you are doing to their friend… More screams “I’M NOT GOING ANYWHERE WITH YOU MOTHERF***ERS – YOU CAN’T MAKE ME GO” Somewhere in the crowd a lone voice says loud enough for you to hear it “They can’t do that – we gotta stop this”
That one might have made your
spidey medic-sense tingle – how bout this one
You respond to an abdominal pain call for a 68 YO F – U/A you find a nice home, in a nice neighborhood, the house is well-lit and there is a family member standing in the open door waiting for you. You grab your gear and head for the door, as you enter, a gorgeous yellow lab nudges you wanting to be pet – you look at the family member in the doorway and the individual says “oh that’s just Ole Yeller, he doesn’t bite”, with a smile you reach down pat the pooches head and continue in to your patient. She is pale, cool diaphoretic and on her nightdress is the faintest hint of coffee ground emesis… you go to work
As you palpate the woman’s abdomen she lets out a pain induced cry – from the corner of the room
Cujo Ole Yeller, the gorgeous yellow lab you pet on your way in, hears her cry and springs into action to protect his master from the people hurting her.
Neither of those is a scene you would necessarily “stage” for – maybe the first one depending on your system. For the first one I would expect PD on scene, does that mean that violence can’t happen? Are two EMS providers and a couple of officers enough to “handle” the crowd?
The second call could easily be just you and your partner.
Did you anticipate the outcomes? Did you recognize the risks? Did you prepare for them?
As responders we tend to fall into 1 of 4 categories with regards to our street medicine – I suggest we also fall into these same categories with our scene safety assessments
- Unconsciously incompetent – we don’t even know what we don’t know – sadly ALOT of providers fall into this category
- Consciously incompetent – holy crap I don’t shit, how the hell did I ever get out of school – (Step 1 to becoming an awesome provider)
- Consciously competent – I have a clue and if I focus really hard on what I’m doing I can pull it off – (There is a REAL danger of target fixation here)
- Unconsciously competent – It’s all second nature to me – it just happens and I don’t have to think about it much
How does one advance from one stage to the other – Practice and experience, time and exposure. This is the same way we can get good at recognizing hidden threats on scene.
How many of us do any or all of the following:
- Strategic parking on arrival
- A scene report from the passenger seat – fire is GREAT at this
- Scanning the windows of the house/vehicle as we approach
- Take the wheels/cot over land through the yard approaching at a diagonal instead of up the walk
- Identify the last shred of cover we can hide behind if we need to – from that point forward you are in no man’s land
- Is there a crowd, pet, “bad actor” on scene
- Are people running in the opposite direction you are going
- Do you pull up lights and sirens blaring, or are you discreet and shut down a couple blocks away – leaving only the running lights on as you arrive
- Do you search your patients before you get in the box with them? If so do you take their belongings or remove them from easy access?
- Do you ask – who else is here when you arrive at a house
- Do you stand in front of the door when you knock
- Do you identify the way out and position yourself with unobstructed access to that route
- Do you walk around the rig instead of between it and the car with the slumped over driver in it?
- Do you approach a vehicle like the one above from the passenger side?
- Do you stand in front of the elevator doors waiting for them to open, maybe even chatting with your partner (Bad guys often have to leave via the same route we enter)
Just a few examples of things we can and should do on calls. Some of them are controversial sure – (I would LOVE to debate some of them if you disagree) ALL of them will help you get home safely at the end of the shift.
Expect the unexpected.
For most of us when we evaluate a patient we start with the worst possible thing that could be wrong with the patient – Chest pain calls are MI’s until proven otherwise, man down calls are full arrests until proven otherwise – then we begin to rule those life threats out through our assessment and questioning until we arrive at an accurate picture of what is wrong with our patient.
Why is our scene size up any different? Shouldn’t every call start out by ruling out all the life threats – to YOU?
1 – http://www.websters-online-dictionary.org/definitions/Target+fixation
2 – http://www.ems1.com/ems-products/press-releases/16033-NAEMT-Finds-High-EMS-Injury-Rate/