Your Captain Speaking: Before You Hit Me! Workplace Violence in EMS Part 2
Dick: “Samantha, previously we talked about what the options are if you are the target of workplace violence. In a manner, we got the cart-before-the-horse. Might be good to talk about how to avoid the situation in the first place!”
Before we dive deep into this, let me explain the concept of the “Oh-Da Loop.” It’s the acronym OODA Loop, but most pronounce it Oh-Da Loop. This is a decision-making process used by the military and means “Observe, Orient, Decide, Act.” The U.S. Marines fully embrace the concept while the Navy uses a slightly different wording. Many books and articles go into depth on the Oh-Da Loop but that’s not what we’re going to cover in this article. What we are going to cover is this critical item: If you can get inside an adversary’s OODA loop, you can defeat their bad intentions just about every time.
You’re on scene with a patient and a moment ago he said “Don’t touch me,” and now he’s clenching his fists. My actions would be to either back away or leave the room. Where is he in the OODA loop? Where are you? By having this pre-decided, I can react faster.
I bet he had just about Decided and was close to the next step-Act. There are pre-attack indicators we will discuss and are specific to EMS but in the example, he has given you two of them. If you see two pre-attack indicators, I’d suggest you increase distance or fully disengage—act—before the patient can. The patient was just about to act but now he has to go back to the start of another OODA loop because you got inside of his loop.
Pre-Attack Indicators
For EMS, we have a very different set of indicators than those of someone who is about to commit robbery or assault. In this article think of both Signs and Symptoms, which we are used to looking and listening for. What do we see (signs) and what do we hear or feel (symptoms)?
For police, a suspect not showing, and refusing to show their hands puts the police on high alert. In EMS, we can ask the question gently “Can I see your hand(s)?” and we have very good medical reasons to do so. You can think of multiple things right now that you’d look at on a patient’s hands—they tell a story! A patient may not want to show you their hands or arms because they’re afraid you’re going to use an IV. It could also be that they’re holding a weapon. A patient who repeatedly touches their waist band or a pocket may, literally, be practicing for the withdrawal of a firearm or a knife. There are many real-world videos confirming this. Especially concerning if they are standing up. Act first by already having made a decision if you see this behavior.
Grooming
A person who is about to attack will often stroke their beard or hair in a “grooming” fashion before an attack. It’s a distraction to you, and the fight will be on shortly. Most likely this will occur if the patient is standing rather than sitting. Think of a dark street and an individual crossing the street towards you and “grooming” their beard or stroking their hair. Where are they in their OODA loop? You don’t have a lot of time to observe and orient.
Facial Expressions
Being able to read the face of a person is important. What does a face look like just before they attack? Often, they will focus on the target, eyes narrowed, nostrils flared, teeth clenched and perhaps showing, jaw muscles tensed, and for me, the eyebrows furrowed. This is only a superficial list but know that sometimes a fearful look can be mistaken for an angry one.
“I don’t want you to touch me.”
This is a powerful verbal symptom, and I wouldn’t ignore it. There are a lot of reasons for a patient to make this statement. Some people just hate being touched. It may be religious, such as a Muslim woman saying it to a male non-Muslim.
How about a different approach? A simple thing I did in the back of the ambulance when doing a head-to-toe exam, I would ask, “Can I see your hand?” and then use both their hand and my hand to examine an area. By extending their hand to me, it implies consent. For example, I want to check the abdomen and guide their hand to the upper right quadrant and press their hand down gently. My fingers can go between theirs to get a direct tactile feel. If there is pain on palpation, they will move both our hands away. I don’t have to press down until I get a scream. A “Don’t touch me” statement and withdrawing from me is a clear communication not to physically touch and provide a soft approach. It will take more time, but you can still provide great patient care.
Off Comes the Shirt
I can’t explain it, but often, if a person is arguing with authority (police, firefighters, EMS) and they take their t-shirt off in a fast, violent manner-it means they are getting ready to fight. It might be a bluff, but I would treat it as real.
“Come here, I can’t hear you.”
Actually, had this one. Patient used a finger to beckon me closer, his eyebrows pinched together, and his eyes narrowed, and a menacing grin showed but only for a moment. It was a micro expression. Nope, not having any of that. That guy had already Decided and was about to Act in the OODA loop. I cut inside his loop, and he had to go back to beginning. It’s not time to let your guard down. He (or she) is trying to figure out a new approach and went back to the observe and orient phase of the OODA loop.
Straps on the Gurney
Use all the straps on the gurney, even those hated shoulder straps. If a patient wants to take a swing at you is restrained with all the straps, you can more easily slid out of hitting range. If you have a patient who keeps pulling their feet out from the straps and/or is trying to undo the buckles, you have an immediate problem and need to react now. I’d rather not get to this point and would simply wrap some tape around the buckle and mumble something about “been having trouble with that buckle.” I never did have anyone attempt to remove the tape from a buckle; I guess they knew it was too much of a giveaway. We want to avoid a patient on the loose in the back of an ambulance or jumping out of a moving ambulance.
Have You Identified Two or More Pre-Attack Indicators in Your Patient?
If you have multiple indicators, then have a plan to react right away. Each circumstance will be different, but you may need to increase distance, call for additional support, or even totally disengage. Look for the situations before they develop.
Samantha: “Dick, when we worked together, we would know how to read each other. If you put a hand down by your side and waved me back a little, I’d know you were seeing something develop. I would follow you lead without asking “What’s up or Why?” A little tug on the back of your shirt was all that I needed to communicate with you that I have an uneasy feeling. Talk about it with your partner. It’s Crew Resource Management (CRM), but that's a topic for another day.”
For some more information on the OODA Loop, check out Utilizing the OODA Loop in Emergency Medical Situations, by Mathew Buhrle, Medium, May 15, 2020.
About the Authors
Dick Blanchet, (Retired) BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Missouri, and Illinois for more than 22 years. As a Captain with Atlas Air for 22 years on the Boeing 747, he has more than 21,000 flight hours. A USAF pilot for 22 years, he flew the C-9 Nightingale Aeromedical aircraft and retired as a Lt. Colonel. A USAF Academy graduate with a Bachelor of Science degree, his Masters in Business Administration is from Golden Gate University. Email contact- ACLS911@aol.com
Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia (IL) EMS, and full time at the St Louis South City Hospital Emergency Department as a Paramedic. She was recently recognized as a GMR Star of Life.
