Scene safety and body substance isolation (BSI) are some of the first phrases taught to EMTs to consider before every scenario. “Scene is safe, BSI” in fact almost becomes a mantra during training scenarios. There are some scenarios however in which scene safety is not a given.
All medical providers, not just medics and EMTs need to be aware of the unique challenges inherent in every scenario. Sometimes a patient will be in a hazardous location or weather condition which requires adaptations. Other times a patient may require the use of inherently dangerous procedures such as an extrication that places the rescuer at risk.
More frequently, however, providers are being exposed to potentially violent encounters that place themselves and patients at risk. This article will attempt to give a brief overview of plausible scenarios providers may find themselves in, ways to mitigate the risks, and also special considerations when treating patients in a hostile environment.
Workplace violence is a serious and unfortunately growing area of concern for many people, especially those in healthcare. Workplace violence can be anything on a spectrum from harassment and verbal threats to assaults and even homicide. It is one of the leading causes of workplace fatalities in the United States.
NIOSH classifies the types of workplace violence based on the relationships of those involved. Healthcare workers are most susceptible to being attacked by patients and coworkers, but may also be subject to attack from those they know outside of work and by those carrying out completely random acts of violence.
All workers are potential victims to these sorts of acts, but those who work with high acuity and unscreened patients such as those in the emergency department or on-scene calls can be particularly at risk, from patients, family members, or third parties. Screening and prevention are the best techniques to reduce harm to those trying to aid patients.
All workplaces should have written and enforced policies and guidelines concerning workplace violence and prevention. High-risk environments such as those mentioned should implement active screening techniques tailored to their environment. Security personnel and metal detectors are just some of the possible tools to consider.
No matter one’s thoughts on the likelihood of violence occurring to them, or any perceived invulnerability, or the undesirableness of having to take any precautions at all, there will always be a risk to any worker. As such, workers must maintain prudent practices in every patient encounter.
Surveying the scene and being able to recognize potentially unsafe conditions remains the primary intervention. EMS crews may call for police escort prior to entering. Hospital workers should call for security before a situation escalates. Having proceeded cautiously, it is essential to recognize that situations may change and that patients still need to be treated. Simple, implementable acts that are useful in any encounter should be practiced and become second nature; this includes placing yourself between the patient (and onlookers) and an exit so that it cannot close behind you. Maintain physical distance if you are uncomfortable at all and continually reassess the situation to see if you should leave the area immediately. Additionally, it is important to recognize that some patients will not be calm regardless of what anyone else does. Verbal de-escalation should always be the first attempted action. De-escalation techniques and responding to hostile patients in a tiered, controlled manner is beyond the scope of this article, but it should always be rehearsed and practiced for the safety of both staff and patients.
A brief review of news casts will reveal that violent acts may occur at any time, at any place, regardless of precautions or plans put into place. When these acts occur, there is unfortunately little that untrained and/ or unarmed individuals or groups can do. The best course of action is to follow the Department of Homeland Security’s “Run, Hide, Fight” campaign. 
This campaign emphasizes the broad responses possible when faced with an imminent threat. The first consideration is to leave the area of the threat. Even those with tactical training are vastly unprepared to deal with an active shooter if they themselves are unarmed. Everyone’s best option is to get as far away from the scene as fast as possible.
When this is not possible, it may become necessary to hide. It is essential to try to minimize the chance of being found or targeted by minimizing visual access as well as other potential signs of presence such as cell phones or conversations. Try to hide in an area away from the threat and in an area that has potential cover. Cover will provide some sort of physical protection from the threat. It is important to realize that weapons such as firearms can usually penetrate simple barriers such as doors. Doors and other barriers that do not offer physical protection from the threat at least offer visual concealment, or cover and should be maximized by locking doors and creating barriers to access for instance.
The third option to consider is to fight back. This is usually a last-ditch effort because as already mentioned, responding to an attacker without greater or at least equal firepower is inherently dangerous with far greater odds of defeat, but may be the only option left. Critics of the Run, Hide, Fight model point out that the “Fight” portion may be necessary as the first step, to try to provide the opportunity to get away. It should not necessarily be considered a linear progression.
These recommendations follow the broad outline for most people involved in a hostile threat. There are those whoever who are not unarmed or merely reacting to an active threat, but actively engage it. Many lessons on active shooters have been learned over the years with one of the key takeaways being that an active engagement of the threat is the best possible option to stop further harm. Most law enforcement agencies now advocate and practice threat interdiction immediately rather than previous models such as waiting to gather resources. These teams’ mission is to find and neutralize the threat.
A number of these teams will have embedded medical personnel as well. These individuals are trained and equipped for tactical engagements. Tactical medicine is covered in other articles, but broad overviews are important to recognize for all providers who find themselves in a hostile environment.
The first key is to recognize that patient care is distant secondary objective to neutralizing the threat. The best medicine in these situations is to prevent additional casualties. Depending on manpower and resources available, personnel may be available to extricate the wounded using buddy carries and casualty evacuation. They should be moved to the nearest safe zone when able.
When moving through engagement areas, it is important to recognize the possible “zones.” The Red (or Hot) Zone is an area that is uncleared and still maintains an active threat. A Yellow (Warm) Zone has been cleared but not fully secured while the Green (Cool) Zone is secured and relatively safe from further threat.
No provision of care should take place in the Red Zone beyond quick instructions for self-aid or evacuation back to a Yellow zone where expedient field care such as tourniquets or needle decompressions can be performed before evacuation back to a Green Zone with a casualty collection point.
Medical personnel may stage in the green zone or yellow zone depending on their level of training and tactical experience. Those personnel accompanying responders into a red zone must be prepared to be actively engaged and respond as part of the rest of the team prior to gaining the time or space to pull casualties out of the red zone. When moving between zones, it is important to keep communication and follow protocols to ensure they are not mistaken as an additional threat.
No personnel, regardless of training, should try to join or respond to a tactical situation by further inserting themselves unless they are on the team designated to respond and only then as part of the coordinated effort. Those not involved in threat neutralization need to avoid movements and engagements except as noted above when it becomes necessary for their own situation to escape and/or survive as this creates a dangerous tactical environment that places themselves, other potential victims, and responders in difficult and dynamic situations that may make mistaken identities or needless additional casualties a possibility.
In summary, violent situations are an unfortunate possibility wherever you are. Always be aware of your situation and practice basic measures that can help mitigate your involvement from being caught in one. If you find yourself in a hostile environment, Run, Hide, or Fight, and allow those responding to do their job with as little interference as possible.
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