Tactical Scene Safety: Part 2

Module 2: Four Steps to Compliance and Control

The highest priority on any call is safety, which is accomplished through compliance and maintained with total scene control: control of self, emotions, situation, patient, crew and bystanders. Compliance occurs when the patient exhibits cooperative behavior; control is established by maintaining compliance throughout the call.

According to Webster's New World Dictionary, compliance is a tendency to give in readily to others; control is defined as: 1. to regulate, 2. exercise authority over, direct, 3. power to direct or regulate. As medical professionals, we must also remain in control of our emotions, actions and the scene. if we lose control of the patient or the situation, safety is immediately compromised.

Tactical Personal Protection (TPP) teaches the EMS provider to detect potentially unsafe situations and thus avoid a violent encounter before it can evolve. First, avoid entering or being on an unsafe scene. If the information provided by dispatch, radio, pager or computer terminal indicates a safety concern, common sense should keep you off that scene and/or indicate the need for law enforcement. Not all EMS systems are the same, so follow your protocols. If you are required to enter all scenes regardless of a safety concern, enter with caution or with law enforcement. If the scene you're on becomes unsafe, leave. This seems so simple, but not all scenes that appear safe are safe. Not everyone who appears "nice" is nice. Total safety awareness has nothing to do with paranoia, worry or anxiety. Rather, it's the ability to consciously and subconsciously evaluate the patient, environment and situation and take note of anything of concern, making adjustments as needed. If the scene gives you an uneasy "feeling," move it, i.e. take the patient to your ambulance for assessment, even if you don't transport.

Detecting Danger

The best way to avoid a dangerous situation is to not be there, or to detect something is "wrong" and leave. To do this, one requires total safety awareness: self-awareness, patient awareness, situational awareness and environmental awareness:

• Self-awareness: Conscious awareness of your actions (posture, stance, hand position and gestures) and communication. Know your "hot buttons" and learn to control them beforehand.
• Patient awareness: Rapid evaluation of the patient's actions, gestures and communication; respecting that the patient possesses the ability to harm you; and assuming there may be a weapon until proven otherwise.
• Situational awareness: Understanding the circumstances that led to the EMS encounter and having the ability to make sense of it. There are variables to this such as the patient's thoughts, perceptions and beliefs.
• Environmental awareness: Conditions of the scene, i.e., location, activities (legal vs. illegal), weather, items of concern, time of day, witnesses and substances (drugs/alcohol). Indication of imminent violence is almost always intuitive--follow your gut! If the dynamics of the scene change so it is no longer safe, and the option of leaving is not available, it doesn't matter how fast law enforcement can get there, you have to regain control of that scene now. As the dynamics change, so should your essence. Remain calm, keep a strong presence and confident appearance, set the boundaries and rules, and stick to them. Adapt, improvise and overcome with body language that says, "I'm not a victim. I'm in control, not you." Use verbal communication that is calm, yet stern and precise.

Problem Patients

Previous experience and statistics were used to establish a group of people with the potential to be difficult to deal with and potentially become violent:

• Intoxicated: Alcohol has the highest correlation of any substance associated with violence.
• Drugs: Both illicit and prescribed medications/drugs (inappropriate use) can cause an altered mental capacity and the potential for violence, whether uncooperative or combative behavior.
• Mental health disorders: Schizophrenia, bi-polar, and depression or suicidal intent.
• Medical condition: Hypoglycemia, post-ictal state, dementia/Alzheimer's, mental retardation, or anything that causes hypoxemia or an altered mental status.
• Paramedic-induced: All people who request care either directly or indirectly (third-party call) deserve courtesy, respect and dignity.
• Psychopath/sociopath/anti-social personality disorder: You will not know who they are unless previously diagnosed. These are very dangerous people, even if they have a calm and gentle demeanor.
• Criminals: They have justified breaking the law--violently or otherwise.

Intentional violence is most commonly due to an intoxicated patient being provoked by a disrespectful or "proud" paramedic. Take nothing personally, especially the opinions, thoughts and statements of an intoxicated person. Mental health disorders and medical conditions resulting in violence are reliably predictable if the patient is a repeat encounter or has a known underlying condition like hypoglycemia with a reliable historian on scene. Criminals and those with personality disorders are not as predictable, especially first-time encounters.

Problem Places

Problem places should be flagged as such by dispatch or some other means in your EMS system. When responding with just two people (ambulance only), make sure to utilize the "Contact & Cover" method of running the call. This concept, which will be illustrated in more detail in upcoming columns, basically means that one responder is the patient contact and the other responder is the cover. The contact person is responsible for patient care/assessment and the immediate scene (3-6-foot perimeter around the patient); the cover person is responsible for the global scene and secondary information. In some cases, the cover person might not enter the scene, but will stay at the entrance to cover. Remember, you're a team, and safety is priority. There are some coincidences or commonalities of assailants. The following list details the commonalities, but is by no means conclusive or absolute:

• Males
• Known criminal history--precedence of abnormal behavior.
• Stressful life events--death of a loved one, divorce, domestic violence, financial difficulties or loss of employment.
• Socio-economic status
• Limited education--low IQ
• Substance abuse
• Gang affiliation
• Childhood conduct problems.

How to Defuse an Escalating Incident

Assertive behavior will stop most incidents from materializing into violence. Remember, you are not to be aggressive, but assertive.

Keep your ground with good posture and a solid base; keep your head up with good eye contact. Display a sense of confidence. Your general stance should demonstrate that you are serious, but not challenging, and "not a potential victim."

Remain calm and collected, with absolute control over your emotions. Be respectful, courteous and kind at all times. Finally, be clear and precise with instructions; set the boundaries and rules, and preface questions with "how" or "what"; avoid "why."

You will also want to display a visual of a confident professional who is "dressed for duty." Uniforms should be the appropriate size, clean and in good repair. A distinct uniform color difference from the law enforcement in your service area is also recommended.

How to De-escalate an Incident

De-escalate an incident is a complement to defusing. Verbal control is not "talking your way out of" a bad situation, but rather talking the other person "into" complete compliance, therefore establishing control over his behavior. When someone feels he has lost all control and there is nothing left to do, he may justify violence in order to keep his dignity and pride. Having verbal control over someone is very powerful and, when used appropriately, can defuse the situation and provide for a "face-saving exit."

Communication is paramount. It can trigger an event to escalate or de-escalate a situation. Never react to a situation; respond and think it through. Four steps to good communication are: 1. Paraphrase, 2. Paraphrase again, 3. Refocus the other person's attention, 4. Say what it is you want to say.

The five-step hard style can be useful when dealing with difficult people:

• Asking stage: (fact-finding…who, what, when, where, how. General, open-ended questions; opinion-seeking…ask for an opinion and allow latitude; and direct, closed-ended).
• Setting the context stage (telling why).
• Presenting options stage (in the other person's best interest).
• Confirming stage (some kind of cooperation is either forthcoming or not).
• No cooperation. Ask the "cooperation question": "Sir, is there anything I could say or do that would get you to do A, B or C? I'd like to think so." If there is still no cooperation, your team will have to act in a pre-planned manner.

LEAPS is another technique used to gain voluntary compliance: Listen, Empathize, Ask, Paraphrase and Summarize.

Finally, avoid phrases such as the following:

• "Calm down"--This suggests they have no legitimate right to be upset. Instead, ask, "What's the matter?" "How can I help?" "Tell me what's going on."
• "Be more reasonable"--same as calm down, it suggests they have no reason to be upset. Instead, "Let me see if I understand your position."

When a complete stranger becomes belligerent and tries to offend you, de-value his words by not giving his words meaning. Value is when something has meaning or gives us meaning. He is trying to control your emotions and anger you. The best defense is to show no emotion and let it pass. Let him "vent," and he will eventually talk himself quiet. Plus, will you really let an intoxicated person who has lost control of his bladder and looks like a fool anger you? Remain non-opinionated, and try not to challenge or provoke him. It's not what you say, but how you say it that matters.

Defend (Last Resort of Safety)

It is completely justifiable to defend yourself, but it is never OK to be aggressive with anyone. The force of defense must only equal the threat level; once the assailant is neutralized, the force is reduced to an appropriate level to remain safe.

In order to develop a survival mentality, in a calm, non-interrupted environment, clarify and come to terms with some personal issues of self-defense prior to having to use it. Convince yourself that you will not be a victim, no matter the situation. Determine your limitations based on physique, personal beliefs, morals and ethics, knowing that you may have to injure someone as a last resort defense. Be comfortable and at ease with your decision. Review and understand the laws in your state, and remember that Tactical Personal Protection was designed to first employ verbal control techniques, followed by physical control that aims to prevent injury. The method of TPP is to protect you on the streets and in a court of law.

Review previous or think of new situations to mentally practice "what ifs."

Remember that an assault can be either an ambush moment or an engaged moment. When imminent violence is detected, shift your mindset from the everyday demeanor to defensive and survival mode.

Emotional Control

A violent incident is a stressful and emotional situation. We must control our emotions during these situations or risk losing complete control. Emotional control is probably the most important piece of TPP. The primary attending or person in charge must remember that others feed off your emotions. Respond with kindness, courtesy and respect.

A major loss or stressful experience will lead to a cycle of emotions, i.e. denial, anger, bargaining, depression and acceptance. TPP follows a different cycle: acceptance (never deny that violence is happening); remain calm and collected (anger will defeat you); control is 100% (never bargain); no emotional shift (debrief after); accept that there was situation requiring control.

Document the incident immediately and accurately with attention to detail. Discuss what happened with the personnel involved, and notify the appropriate superiors as necessary. Take some time off with the ones you love and do things that bring you joy.

Next month, we will look at some theories and empirical data to help us better understand where the idea of Streetwise came from and why. It will also give insight into why the universal system is both effective and easy to learn. Until then be smart, be safe…be streetwise.

Roger Olson is a paramedic with 13 years of EMS experience. He has a BA degree in kinesiology/human biology (CW). He is a black belt with 23 years of training in Kenpo, Tae Kwon Do, Brazilian Jiu Jitsu, Silat, Escrima, Jujitsu and Haganah. He currently works for Platte Valley Ambulance Service in Brighton, CO, teaches part-time at the International Black Belt Academy in Fort Collins, CO, and is the founder of Self-Defense Solutions-"Streetwise," a universal defense system. Contact him at sds.streetwise@gmail.com or medico230@yahoo.com.