RSS

Defensive Training for EMS – Neccessary?

In a word – YES

I have written on many occasions how lucky I am to be attending the Paramedic Program I do.  As if I needed another reason to believe it was the right choice for me, from what I can tell it is one of only two paramedic schools in the entire country that offers defensive training for EMS providers as part of their paramedic students education.

I think this is an EXCELLENT idea and should be something more of us get. If not in our schools then certainly when we enter the workforce.

Before you get your 5-11s in a twist hear me out.

I am a former Marine, trained in hand to hand combat, defending myself was never really something I was worried about until I took this class. Was I schooled that I wasn’t as capable with my hands as I believed I was? No, in fact, I was schooled that the way I had been trained may very well severely injure someone unintentionally. Marine Corps hand to hand is all about aggressive tactics, how to hurt people enemies, not how to be truly defensive.

What’s the difference you might ask… ask Alan Miller a former Denver Paramedic who was sentenced to 12 years in prison  for assaulting a patient in the back of the ambulance. (http://firegeezer.com/2009/11/14/denver-paramedic-sentence-to-12-years-for-assaulting-patient/)

I’m not even going to comment on that case, or what happened there, I wasn’t in the ambulance so I don’t know what happened. I do know that whatever happened the injuries the patient received were severe enough that Miller is now doing a 12 year bid.

Having not had the DT4EMS class, that could have very well been me, or any of the 10 to 15 of my classmates who had some sort of “fight training” prior to our class.

Just today a study was released that found 2/3rd of the paramedics in the study have been assaulted on the job – read the report here 

Let’s face it folks pre hospital providers get assaulted – it happens – WAY more often then we care to admit. Regardless of what you are told by your senior partners, supervisors, forum trolls or even medics from back in the “rampart” days IT IS NOT PART OF THE JOB.

I know some of you are saying “don’t be a dick and you wont have to worry about it”

How do I know… I’ve had people tell me that. It is precisely that type of pervasive attitude that makes assaults on providers go unnoticed and under-reported. One of the main focuses of the class is customer service and how to use that aspect of the job to help diffuse a potentially violent situation.

If you are among those who think it doesn’t happen – PLEASE go to the DT4EMS site and take a look at the forums there (here’s a link) and read about the stories that don’t necessarily make the news.

 

Take a look at this video from the DT4EMS website:

 

Another thing I don’t want you to assume about this class – the purpose IS NOT to turn you into a ninja, an assassin or even Billy Bob bad ass paramedic – the purpose IS to get pre-hospital providers to know what to expect in certain situations and how to react should the “worst” occur.

For the basic level class we spent 16 hours between classroom and “the mats”  training to protect yourself in 4 areas

As defined by DT4EMS the four areas are:

  1. Preparing the mind – getting past the initial resistance to defending yourself
  2. Preparing for the street – training in real world techniques to increase your chances of survival
  3. Preparing for the media – How to defend yourself and still APPEAR to be the victim and non aggressive
  4. preparing for the courtroom – know the laws and how to represent yourself as a PROFESSIONAL

 

Yes, the bulk of the time is spent working on defensive tactics and how to be out of the way when an patient turns into an aggressor, but the class itself is so much beyond that.

Interview techniques, on scene responsibilities, survey stances, the assessment L, what a reactionary gap is and why you should try to maintain one, the six steps of DT4EMS self defense, moving in angles and circles, winning the R.A.C.E and R.A.C.E -2- R.E.A.C.T., the 6 D’s (types of potentially violent encounters), when a patient is no longer a patient, scene survey tips, global overviews, levels of response, physical fitness, the list goes on and on

It’s much much more than the perception that it’s a fight class.

Sadly, the pictures taken during the classes don’t show those parts because they don’t make for great action shots… but they are equally important aspects of the training.

Before I get to the pictures of our class – I URGE you to go take a look at the DT4EMS website and get a more in depth look into the program and what it’s founder Kip Teitsort had in mind when he developed the program.

The web site is here DT4EMS

Here are some of the pictures from our class – yes they all emphasize the physical techniques (because they make good pictures) but again the class is much much more than just this stuff.

 

Even without the F.I.S.T. suit, do you have any trouble figuring out which one of these two is the aggressor and which one is the "victim" - How much better does this look then the firefighter who was kicking a patient in the video?

 

After a double tap parry a simple shove is often all that is needed to create separation and allow you to escape.

 

Probably the smallest girl in class - with the instructor as the attacker - will the techniques taught work for her too?

After a double tap parry - a "distracting blow" is quite effective in taking down the attacker - any question whether she can now escape or not?

Using a double tap parry to deflect the attackers blow...

Following the double tap parry with a distracting blow to the ear - notice the open hands

The elbow control takedown drill...

Elbow control takedown step 2

Even experienced people can have trouble - I should not have ended up on top of him after the take down

Escaping from a choke hold - step 2 .The first step is to bury your "meathooks" between the attackers arm and your throat before dropping to your knee

The last step of escaping from a choke... bending forward and twisting your body to pull the attacker down

For the very last part of class we got to “go against” the instructors while they were wearing a F.I.S.T. suit, this part of the class was entirely optional, but it gave us the opportunity to put the skills we just learned in practice.

Here are some pics from my “encounter”

 

Assuming a defensive posture and anticipating the right hook that is about to come my way... A double tap parry followed by a shove will give me some space, but he still has about 50 seconds of the minute long attack to go.

The attacker retreating after a distracting knee to his thigh... that pissed him off and we ended up on the ground lol

It took him about 15 seconds to get through the basic ground defense in the suit, but after escaping the mount - I ended up in this position as the whistle blew ending my minute long session. This is perhaps the only picture that doesn't have a purely defensive feel to it.

I know there was a picture of the smart ass pose I took with my arms flexed sitting on his back… but mysteriously it wasn’t on the camera when I uploaded the pics… Damn, I wanted to put it on the graduation plaque for him 😉

At one point it was one of the instructors (Jeff) vs one of the bigger guys in class - he was a former deputy sheriff and is a big boy... the F.I.S.T. suit wasn't enough to save Jeff from stepping into a distracting blow that laid him out. I only include it to bust Jeff's chops - it is neither a focus of the class nor an intended outcome of a distracting blow... but Brad didn't have any trouble getting away from this attacker, and that after all is the goal.

My last and final point about this excellent class – while you may never ever need any of the physical techniques taught – chances are you wont have to actually do one of those surgical crics they taught you in paramedic school either, but if you do need it – it sure is nice to know isn’t it?

If this class only ever saves ONE provider from harm – I can say for certain that all the effort Kip put into organizing this class will have been worth for him.

DT4EMS – I HIGHLY recommend it – it was an absolute blast of a class and just may save someones life on the streets one day.

 

 

 

Posted by on December 30, 2011 in Defensive Training, EMS, Paramedic School, Scene Safety

1 Comment

Tags: , , , , ,

Target Fixation

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 [1]

Image credit

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. [2]

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. [2] 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

  1. Unconsciously incompetent – we don’t even know what we don’t know – sadly ALOT of providers fall into this category
  2. 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)
  3. 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)
  4. 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:

  1. Strategic parking on arrival
  2. A scene report from the passenger seat – fire is GREAT at this
  3. Scanning the windows of the house/vehicle as we approach
  4. Take the wheels/cot over land through the yard approaching at a diagonal instead of up the walk
  5. 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
  6. Is there a crowd, pet, “bad actor” on scene
  7. Are people running in the opposite direction you are going
  8. 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
  9. 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?
  10. Do you ask – who else is here when you arrive at a house
  11. Do you stand in front of the door when you knock
  12. Do you identify the way out and position yourself with unobstructed access to that route
  13. Do you walk around the rig instead of between it and the car with the slumped over driver in it?
  14. Do you approach a vehicle like the one above from the passenger side?
  15. 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/

 

 

Posted by on October 6, 2011 in EMS, EMT, Scene Safety, Warning bells

4 Comments

Tags: , , , , ,

Reminders

6 hours to go until the end of my set, it’s been 42 pretty busy hours, not quite stand up, but close. I should be laying down and trying to get a little rest before the tones drop again, but I was reminded about some pretty important stuff on two specific calls this 48 and we can all always use a little reminder every now and again, so I thought I would share them while the biggest safety concern you have is burning your retinas from staring at the computer screen.

Everyone who has ever taken an EMT exam of any kind is all too familiar with the way practicals work and the ritual we all do at the beginning of each one… walk in the room, do your best jazz hands for the proctor while uttering the words – BSI is the scene safe… they are drilled into our heads from day one of EMT class and reinforced every time we go on a call that sets off our spidey sense. We say them so often that they become some sort of absurd joke by the end of classes. Relegated to the back of our mind where all the stuff we have repeated ad nauseam lives, that’s where it’s supposed to be so you don’t have to think about it. Every once in a while I realize I have gotten too comfortable in my role and I take something like scene safety for granted.

What about you? What about those calls where the spidey sense isn’t tingling, the calls that are seemingly innocuous? I mean if you are ever going to get caught with your pants down it isn’t going to be in a rough and tumble neighborhood at 0300 in a dark lit alley – just typing that set off all kinds of warning bells. If you are going to have a problem it’s more likely going to be on a brightly lit street in the middle of the day for a seemingly benign call.

I had two reminders over this set of the importance of scene safety – one I handled very well – in fact I was the person that deemed the scene unsafe and made the “good call” to get PD in and US out… Turned out there was no threat on that call. The other one I didn’t handle nearly as well, and while nothing happened it could have gone WAY bad.  Let’s look at both and pick apart what went right and what went wrong… maybe you’ll see yourself in my actions and come away with a valuable reminder.

Call number 1

Dispatch information: call came in from a medical alarm company, unknown problem with Fire Dept.

Arrival: we were first unit on scene, middle of the afternoon, nice neighborhood – on approach I notice blinds in all the windows are closed except the window next to the front door where they are pulled up. Approaching the front door I notice a keybox hanging from the knob – which is common here when the patient has a medical alarm. I motion for our EMT third rider student to stand behind me on the side if the door and knock loudly announcing our presence, this is repeated a couple of times. After the third try I tell my partner (and the student) I’m going to walk around the house. I start by looking in the window, and while the house has been totally silent I peered through the open blinds and lying on the bed not 3 feet from where I was standing was a hunting rifle, there were no sheets on the bed no other furniture visible and no patient or other occupant that I could see. I relayed the information to my partner who immediately radioed in for PD. He and our student headed for the ambulance while I quickly scanned the yard. Nothing was seen in the yard, so I headed for the bus… EMT student safely inside the ambulance my partner and I in the road behind the ambulance with it between us and the house. We are on the phone with dispatch when the engine arrives… I quickly run down what we’ve found while my partner gets the information on where the key is located from dispatch. He tells me that there is a key under the brick next to the air conditioner… I now have 4 fire fighters on scene to watch windows so I decide to go investigate the key location… there is a brick, there is no key. While turning from there to head back out I must have caught something out of the corner of my eye or heard a faint cry because something compelled me to walk to the back gate and peer through the side that opens and when I did I found our patient lets just call her nanna lying on the ground with her leg shortened and externally rotated.

RIGHT ACTIONS: we parked in a safe location, our approach was solid, our attempt at contact was from a protected position next to the door, I noticed the “threat” identified it to my partner and the student and we all headed for the bus to wait for the calvary to arrive. We investigated again when we had more eyes and ultimately found the patient

WRONG ACTIONS: We didn’t actually leave the scene, we waited in the street. We didn’t actually wait for the calvary to arrive… PD is who should have ultimately found that patient  – not me.

The thing that bothered me about that call was that nanna was crying out for us from the back porch but we didn’t hear her and she laid there suffering for longer than she should have because of that rifle I saw. Do I fault myself for that absolutely not, I know pulling back was the right call but it still bothered me on some level.

Call 2 ~ (the next day)

Dispatch: 90 F with pneumonia

Arrival: Again first on scene – well-lit middle of the day apartment complex that looks like it could have been a hotel at one point. Fairly good neighborhood, although the appearance of the building is rather run down. I park the rig in the parking lot and notice an elderly couple sitting about 25 feet away waving at me on my side of the rig. I glance back over my shoulder and see my partner is heading to the back of the bus for our gear and to fetch our student rider, I start over toward the couple I see sitting there one is a slender male mid 60’s the other is a small female sitting in a wheelchair slightly slumped over. I approach the couple assuming the lady n the chair is the patient. When I get to them the male says its my mom she’s got pneumonia, she’s been real sleepy and feverish since last night, and he starts to walk toward the apartment – I follow. Upon entering I notice a male to my right asleep on the couch head toward the door, his back covered with more “bumps” then I can count, the place is run down and unkept but by far not the worst place I’ve ever seen across the room to my left is a hospital bed with a frail old woman lying in it and my first thought was “OH SHOT” this lady is way sick. I jump right in… she’s breathing and she’s breathing FAST I can hear and see that without even thinking about it so I begin trying to rouse her, verbal – nothing – sternal rub and yelling she opens her eyes, great making a mental note of “V” I grab her wrist as I hear a commotion behind me… It’s my partner, I never turn I just say I need to O2 bag and the monitor, and I go back to assessing… The engine arrives and more commotion behind me I glance back quickly as I am getting the capnography cannula plugged in to the monitor to see two fire fighters carrying the lady who was in the wheelchair when I got there out, My partner is asking is anyone else here sick? and the paramedic on the rig leans into me as I am hooking up the monitor and says there is hep-c, aids, and c-diff in this house as she hands me a cavi wipe and a pair of gloves… I turn care over to the firefighters long enough to wipe my hands get the gloves on and position the cot… My partner (who is the medic) has now assumed care and when I turn around I see the guy on the couch is not there anymore… After an emergent trip to the hospital and safely delivering our patient – I say to the student I made three critical mistakes on that call – can you tell me what they were…

RIGHT ACTIONS: I immediately realised this patient was very sick and was going to require ALS and I took charge of the patient and her care until my partner was able to do so.

WRONG ACTIONS: First I got out of the rig without gloves, assuming I was still going to be talking when my partner got there and handed em to me. Second I left the rig empty-handed – I walked over to who I thought was the patient with no gear or equipment, third when I saw how sick the patient was I lost track of everything else but her.

I found out after the call that my partner (who has worked at this outlying station for a few years) has had several calls to this address and more than once the male sleeping on the couch has had to be “escorted away” in cuffs for becoming threatening to personnel. It took a minute to get him “out of the way”-  my partner had also assumed those were our patients and momentarily had a sense of oh my god where did my partner go. Because I jumped right in I didn’t accurately communicate my findings to my partner (did I mention HE is the paramedic?) the delay to definitive care for the patient was miniscule maybe 20 seconds BUT my partner was playing catch up because HE had to get the scene secured after I ignored it… I knew this was going to be a hot return before he even had a chance to ask me what we had.  Fortunately for all of us myself especially – I would have never been able to live with my negligence causing a fellow responder injury – nothing happened, but there was a mountain of POTENTIALLY unsafe circumstances.

Did the call from the day before affect my judgement, maybe a little but I wont make excuses. I made a mistake. My over confidence in myself and my underestimation of how serious a call this would be is what I blame it on.Fortunately, I was able to not only remind myself of things that should come second nature, but I was able to turn it into a teaching moment for a new EMT and hopefully, she will have learned from my mistake.

Comfort on scene and in your abilities in a good thing  – until you get complacent – as I’m sure one of my Marine Corps drill instructors said over and over – complacency will get you killed son.

I got caught with my pants down today, I’m sharing it with all of you in the hopes that my mistake will help prevent you from getting too comfortable in your EMT skin and getting caught with yours down as well.

Til next time…

 

 

 

 

Posted by on July 27, 2011 in EMS, Scene Safety

Leave a comment

Tags: , , ,