Combating Violence Against First Responders: A Systems Approach

Thank you, Teresa, for having me.

It’d be my pleasure, and I’m really grateful to the U.S. Fire Administration and also the FEMA Assistance to Fire Grants Program because it was the FEMA Research and Development Grants Program that enabled us to do a lot of this work. So in 2017, we were awarded the first FEMA R&D grant to look at the EMS side of fire.

And that’s really important because as you’ve said in your introduction, it’s 72% of the work that fire departments do now, and we’re just not really structured to, at this point, to handle the increasing demand that we’re called to provide. So it’s really important that we point those research and development resources towards this issue.

That’s what we did. We developed at the FIRST Center 2 things. The SAVER – which stands for stress and violence to fire-based EMS responders – the SAVER systems-level checklist, and then the SAVER model policy. So I’ll talk about both of those things with you today. And I just wanna say at the beginning that while we focused this work on the EMS side of fire, when it comes to the stress of the job and the violence that we encounter, both firefighters and EMS responders are at risk, right?

If you go to a house fire, which turns out to be an arson, where the person who set the fire intends to actually pull out a long gun and fire at the firefighters when they’re coming – that is also an act of violence.

We really don’t have in the United States good data on this problem of violence, how often it’s encountered, who encounters it.

What are the characteristics of the people committing violence? And this is something that’s being worked on at USFA and at the FIRST Center and at NEMSIS and various other organizations around the country. So I think we’re going to see some really good movement about how do we understand the surveillance of these events and how often they happen.

We are also doing media scans at the FIRST Center about what’s being talked out on EMS1 and various other platforms and the print media and other types of social media to try to get a handle on this problem.

But at the end of the day, we already know that regardless of how variable the numbers are, that this workplace hazard is extracting a price tag from our first responders.

So, the SAVER model policies and the systems-level checklists were created to address some of that. They don’t address some of the other things that pertain to your earlier points about how we have not adequately staffed the fire and rescue service on the EMS side to be able to respond with proper attention to this increase in call volume.

So when we look at the number of firefighters available to respond to fires, it’s about 1½ firefighters to every fire. When we look at the number of firefighters and EMS responders to who are available to respond to this increased demand, this 421% increase from 1980 to present. It’s a 22 to 1.

We have 22 EMS calls for every available responder. That’s not – if you have to have at least 2 on an ambulance, we’re already way out of whack in terms of that ratio. So that’s another issue that this doesn’t necessarily address, but is a really important one for your audience to understand, that there’s a bit that we can do to help individual responders and how they deal with it.

There’s a lot more we can do to help their fire departments and their labor unions respond, and that’s what we’re gonna talk about today. But at the end of the day, we still have not enough people to do the work, not enough ambulances in the field.

And improper regard for the wear and tear physically and emotionally that this type of gap is taking on our first responders. So that’s what the stress and violence, the checklist, and the model policies are starting to address. And I’m very excited that, as we talk through this today, Teresa, there’s also something coming up that’s going to be very helpful for the nation.

So the FIRST Center has partnered with the International Association of Fire Fighters to develop an online course about workplace violence that’s gonna be coming out in the spring. And it’ll have a big splash during the Redmond/Barbera Symposium this summer.

And we’re excited to be able to provide a curriculum for fire departments to use for its EMS responders, for its firefighters and any EMS entity, whether it’s fire-based or not, will be able to access this course, learn how to prevent these issues, learn how to adopt these policies, learn how to deescalate situations.

And we’re also building a second follow-up course for the IAFF where there’ll be an in-person training where they can go through simulations and practice some of the skills that they’ll learn in the online course.

So, uh, and all of that, all of those initiatives are funded by the FEMA AFG program in one form or another. So without that funding, addressing this very important problem would not be possible.

So with regard to the SAVER systems-level checklist, I just wanted to start with who was involved.

Um, because I want the audience to understand that anyone we could think of who we thought could weigh in on this was invited to the creation of the SAVER systems-level checklist. What we did first is we read all of the – the geeky literature from the scientists in the peer-reviewed literature.

But we also did something that scientists don’t often do. We went to the gray literature. We went to the industrial literature, and it turns out, Teresa, for 40 years, EMS responders have been talking about the fact that they’re getting beat up out there, that they are mentally exhausted. And what they do in the various EMS journals that are out there is they’ll talk about “This is what I do,” or “This is how I deescalate patients,” or “This is what I do when things are going from cool to hot.”

And there was no codification of all of that. There was no bringing of that together. So at the FIRST Center, we studied that, and research actually didn’t catch on to the issue of violence against EMS responders until about, you know, 10, 15 years later, right? So often if we don’t look at the industrial literature, we are often, as scientists, really out of it.

And so, we wanted to not only honor what’s been stated for that period of time, but learn from it. So this checklist and the model policies express what has been said in the industry for so long. We had about 50 thought leaders in fire and EMS who came and sat with us for 2 days where we went through all of the findings from the industrial and scientific literature, and we codified these into 174 items that became the SAVER systems-level checklist.

But then also, Teresa, what we did is we asked those attendees to say “How feasible are the implementations of these items?” So you can imagine the amount of coffee these people had to have. So when they voted on what was most feasible, meaning it could be done in 3 to 6 months in a fire department, there were 80 items that emerged, and that became the SAVER systems-level checklist that was published in the journal “Occupational Health Sciences.”

It’s available on the FIRST Center’s website. But as we sat with those checklist items, Teresa, and we thought about their implementation, the 3 fire departments who stayed with us to do the implementation – Philly, San Diego and Dallas – said it’s too much. So we actually sat with those 80 items and we started to pivot them and think about what themes did they fall into? How did they sit together as a family of ideas?

And it turns out that 8 themes emerged and they became expressed in our collaboration with the fire department as the SAVER 8 model policies.

The beautiful thing that’s in that paper that’s important for the audience is these 3 fire departments and various thought leaders did a SWOT analysis – a strength, weaknesses, and opportunities and threats analysis – of the policies to think about, to pre-think what would happen during the implementation of the policies that might threaten their success.

What strengthens that success? What are the opportunities we have? So that’s all contained in there.

It basically reads like a toolkit for implementation, and we at the FIRST Center are standing by for any fire department who wants to implement these policies. To help them evaluate the impact on their wellbeing. And we have a tool that was also developed with FEMA funding called FOCUS. It’s the Fire Service Organizational Culture of Safety survey version 3.0 that’s available now that has a huge new mental health module that will evaluate all kinds of things around safety and fire departments, but particularly can be used to study the implementation of these policies against stress and violence.

Yep.

we’re gonna talk about the SAVER model policies and checklists as an organizational intervention for the fire service. But the course we’re building for the IAFF is actually targeted at the individual responder because while you’re waiting for your department and union to get these things going, what do you do?

Because the next run you’re going on, those policies haven’t infiltrated your organization yet. So there is, you know, we wanna focus on the individual level to give them some new information about how they can deescalate and how they can protect themselves during violent events. But really at the end of the day, as you’ve said so well, Teresa, if the organization does not take responsibility for the fact that violence is a workplace hazard, just like PFAS, just like particulates during overhaul, just like structural members falling on you in a fire, or you know, the possibility of a needle stick during a patient encounter.

That’s the responsibility of the organization. The fact that these hazards exist in the work environment is not the responsibility of the individual EMS provider or firefighter. It’s the organization’s job. And so that’s what I love about this checklist is an organizational intervention. It’s a checklist for the people who employ the responders, right?

It does, as you say, take the onus of the fact that I’m going to get assaulted on this job off of me and asks the organization to set policies in place that protect me each step of the way. Things that I might not even see that are protecting me, and that’s the ideal, is that the workers should just focus on patient care and excellence, and the organization should focus on policies, procedures and practices that have their back.

So let’s talk a little bit about that and this is – it’s in public health. You mentioned we’re at the School of Public Health at Drexel University, and public health is really focused on primary prevention. Let’s prevent the hazard of violence from ever touching a firefighter, right?

How do we do that?

Well, we set up policies that give them space, control – and one of the main things about the systems-level checklist is giving the worker choice and feedback to the system. So we’ll talk in this podcast about the pause points that EMS responders use to tell the system that something’s not working and that signals to the system that the policies as they’re being implemented aren’t correct, aren’t being done correctly or there are modifications that need to be made.

It gives control to the worker to say, “we’re getting slammed out here. You gotta – you gotta help us.” So, and I think oftentimes with worker safety, we often give people lots of checklists for here’s how to make sure you don’t get a needle stick, or here’s how to make sure you don’t get, you know, trapped in a fire.

And we do all those things to make sure they provide good community service, but no one has their back to make sure that they’re protected. So that’s what this is.

Yeah, sure.

So if you see a placard in the back of your ambulance that says “Have a complaint with your experience, call City Hall this number.” And that sends a message to the worker that I’m being watched. It’s assumed I’m going to provide bad care.

And it is totally detached from the fact of what the work is really like. And we’ve found this, Teresa, and other work we’ve done with like district attorneys and things. When we look at felony assaults to first responders, they think – and the judicial thinks – it’s just a part of the job. I mean, even with law enforcement officers, it’s not on their job description.

Right?

You know, even though they’re armed to deal with those things. So – so we need to – and the good thing about the collaborations we have at the FIRST Center with all of those fire service organizations and fire departments is they get that. And, you know, the frustrating thing is that there’s lots of things – there’s policies out there at the state and federal level that say fire departments ought to do something about violence at work.

And they say you should have policies and practices, but they don’t offer any of them. So we developed them with the fire and rescue and EMS services to do that. Right?

So we now have policies that can work for fire departments and even freestanding EMS providers. Honestly, they could work for hospitals and bricks-and-mortar health care providers as well.

We now have those policies to put in place to protect folks, and that was done because the fire service knew they needed it and they collaborated with us to bring those to fruition. And we got to bring the voices of people who have been screaming into the silence, into the void, about what’s happening in the field.

So I think the challenge for us, Teresa, is just to make sure every fire department who wants to protect their members can get access to these policies and can get access to the technical assistance and that we have the ability to evaluate the impact, so, because we need to establish that evidence bank that these policies move that needle.

Yeah, I love talking about the SAVER model policies because they follow the natural flow of an EMS run, but they start with even before the tones go off. What are the policies, procedures and practices that are in place in your fire department that say to you that you matter, that your safety matters?

And so, the very first policy is the mission statement of the fire department.

So this isn’t what’s happening during a patient care event. This is what is the policy. And the goal of this policy is to establish an organization-driven focus on the health and safety of members as they respond to calls, including EMS workers, right?

And so, because there’s the potential for violence on every call, the policies here focus on ensuring that the organization has defined their role and espoused values around keeping their workers safe. So the policy statements require clear statements about the importance of safety, health, and wellbeing and aftercare for members, as well as minimizing concerns to rank power and distribution of available resources.

So the goal of the mission statement is to establish a strong organizational commitment to EMS that will elevate and prioritize EMS work to the level that fire suppression receives. So this is revolutionary, right? Because the EMS side of fire has always considered themselves to be second-class citizens or the redheaded stepchild, but they’re doing 72% of the work.

So you have to establish in a mission statement that EMS is valued equally with fire suppression, and you need to actually then act that out as leaders in the fire department, as leaders in the union, that these things matter. It’s our bread and butter, right?

And so it’s not that fire isn’t – doesn’t have its mental health burden. It certainly does, and there’s a lot of resources that are required for fire suppression. It’s just bringing EMS up as an equal part of what goes on. So in the first model policy, there are 7 aspects to how that policy gets implemented, and the beauty of the SAVER model policies is the model word, meaning that your fire department can take these policies and modify them to your local culture.

You can change the language. You can insert SOPs or SOGs. If you already have an aspect of the policies in place, you just incorporate it. If you don’t have any policies, this gives you a roadmap, right? You don’t have to go out and figure it out for yourself. The fire and rescue service and the scientific community have done that for you, right?

And so this is your roadmap. You plug it in, take it off the shelf, plug it in, and then the one thing I wanna express, Teresa, about the model policies is that they will do absolutely no good if they get incorporated into the policy binder of a fire department and no one knows they exist.

Communication and training on the policies, feedback from the members about how they’re working or not, is critical, and we’ve built in a feedback loop through the pause points that I’ll get to at the end after I go through all the 8 model policies that provide that feedback loop. So a fire department, they shouldn’t even implement these policies if they’re not gonna listen to the workforce, if they’re not gonna put in good channels of communication because it won’t work. Right?

So the policies are an organizational systems-level intervention to change the dialogue within fire departments and within unions about workplace violence.

And one of the things that’s really driving it, and Dr. Moore-Merrell just talked about this last week, is that we have generational changes occurring in the fire department, and Generation Z, they are talking about mental health and well-being. They expect workplaces to be healthy. They expect workplaces to respect work-life balance.

Well, these policies are gonna move that needle. Right? And the older ones of us in the fire rescue service, the “suck it up, buttercup” generation, are gonna have to get on board with this because we have been paying a price that we didn’t really even understand. We have been paying with our mental health, we have been paying with injury, we have been paying with disease.

So let the new generation lead us into a safer, healthier fire service. Let the newer generation help us really say, yes, EMS is important and we need to resource it appropriately, and we’re gonna start with policies and we’re gonna listen to the workers when they say: “That’s not it. It’s not working for me.”

So it’s all about creating better, more porous communication and fire departments, and a mission statement that says we value equally all duties, roles and responsibilities in our department. Fire, EMS, and we don’t talk about EMS as something other or else or different from, right?

Um, some fire departments provide bag lunches for their EMS providers cuz they can never get to sit down at the kitchen table.

So they get how busy and burnt they are. But the policy needs to say it cuz when you join a fire department, you see that we value fire suppression and EMS equally, or all hazards. Then you get a sense that you belong there.

So that’s the first policy. And there’s, you know, I won’t go into all of the aspects, but in the paper everyone can read the 7 subsections of that policy.

The second policy, actually, is defining violence, right?

So people think, oh, well it’s if I get physically assaulted by a patient or a bystander, that’s violence. But actually, the largest type of violence experienced by firefighters and EMS providers is verbal: threats, slurs, things about your identity – you’re fat, you’re black, you’re a woman, you’re this, you’re that.

All of those things have a physiological response in our hormones. They’re stress hazards and they affect our mental health as well as our physical health. So defining violence is really important. So policy 2 adapts a standard violence, and this includes things like verbal abuse, property damage, intimidation, physical abuse, sexual harassment and sexual assault.

Those are the large buckets. And so we need to train people on what those definitions are, what constitutes an experience of violence. And of course, the eighth model policy is all about reporting those events. So we have good data about their occurrence. So training is a core component of every model policy.

The third policy is about dispatch and communication and coordination.

So the goal of this policy is to establish a collaborative and highly communicative relationship between EMS dispatch and law enforcement, so that information is shared concerning violent locations, patients and other circumstances in a timely manner. Law enforcement frequently has more data on locations than fire dispatch does.

The policy includes statements about flagging specific locations so that dispatch can know that when they send responders to a location that there was an assault there previously or there was some sort of violent events.

It ensures that the proper equipment is provided. It ensures a specific radio frequency to share this information and training to ensure that the policies are put into place properly.

The fourth policy is – extends that a bit to assessment and communication of scene conditions. So there are 2 goals in this policy.

The first is to establish procedures for assessing scene safety and communication of needs during unsafe conditions. And the other really important one is to establish standard language understood by everyone that communicates that a member is in trouble and immediately initiate actions to rescue the member without further need for input or clarification.

Now, we get into the space during an EMS call where we’re actually providing patient care. And this is, of course, the intimate time where a provider and a patient are very close together, and this is where a lot of violence occurs. The verbal violence, the physical violence.

So the fifth model policy is standard operating procedures during patient care.

And the goal of this is that there’s a lot of guidelines for what you’re supposed to do during patient care, but this actually is about what the SOPs are for: protecting the EMS responder as well as the patient. So the policy includes provisions for an integrative approach to patient care that includes safe practice procedures related to removal of weapons from patients, securing patients physically or chemically, and a provision for training all personnel on those policies.

So this is a large model policy. It has 9 components and they range from things like a policy that has been put into place that tells EMS providers when they can leave the scene with or without the patient.

Right, because there are concerns with, “I’m gonna get sued for patient abandonment.” If your life and safety – this is an immediately dangerous life and safety situation, the policy says that is not gonna happen. Leave, right?

And that has to be clear for people or they won’t do it. And they’ll stand with a violent patient or a scenario where they’re outnumbered or they need additional resources.

And remember, it could be the patient, but it could also be a bystander. So now you’ve got someone who has clinical need, but their boyfriend or partner, excuse me, has pulled a weapon, right? And so you’ve still got someone in cardiac arrest and now you’ve gotta deal with this. So then patient safety becomes a huge issue if provider safety isn’t attended to first.

In these standard operating procedures during patient care, we also give – you start to see the autonomy given to the EMS provider in larger scope than before. Like the use of physical or chemical restraints which may require medical control calls or may be given to the on-call provider. The use of body armor when appropriate, and making sure that a decision to don body armor is supported by the team and the department. Deciding who can ride in the back of the ambulance or in the cab.

Because a lot of times, particularly when you think about domestic violence situations, the partner wants to come along, but they’re actually the perpetrator, whether you know that or not.

So give the autonomy in policy that the EMS provider gets to decide who goes or doesn’t. And it ends there.

And then also being able to have policies that lets – if you’re going to the ER – that lets the hospital know that this patient has been violent. You need to set up your protocols. We need an appropriate handoff here. So that’s about a, there’s a lot here about what needs to happen during patient care before they actually transport, right?

Now. The sixth policy is about, and you’ve mentioned this readiness to return to service.

So now I’ve handed off the patient at the ER, and I need to do a check-in with myself, right? What have I experienced? What have I seen? Am I ready? And this actually was when we did the SAVER systems-level checklist, people were like, how do we do that?

Yep.

It’s time. Right. So, you know, fire chiefs are always talking to me about – they give me these great things of lingo like, “We do more with less.” Well a fire chief said to me, “We do less with less,” right?

If you’re gonna only give me this many paramedics and EMTs and ambulances, this is your new response time.

2 more.

The seventh policy is reporting of violence.

If I don’t have data, and I am willing to testify at any city council, any congressional session around the country about this problem, but if you are not reporting verbal and physical violence, I don’t have a leg to stand on. No one who cares about violence to clinicians, be it fire and EMS or hospital, has good enough data. We need to report this.

So this is report the data so that we can learn. Departments and unions should provide a safe culture of reporting and make sure all incidents are taken seriously and responded to. And so we want these reports to be taken seriously. Philadelphia, for example, developed an SOG for “Here’s what company officers should do when a member is assaulted,” including support for court if they have to go, if it’s a felony assault case, so we can do more.

And these policies provide a roadmap for what should the department do, and fire departments are now sending us their own processes and SOGs so that we have this repository of models that people can use to express this is how we do it.

We’ve written papers on felony assault should stick about what fire departments and their unions should be doing.

If it’s a felony assault, if it does go to court, people are very surprised by all of this. So it’s actually a part of the last policy, which is mental and physical health support. And the goal of this policy is to identify and provide access to resources for EMS responders to assist their physical and psychological wellbeing. The policy acknowledges both the reality and the need for attention to the mental health and wellbeing of members.

… the last policy, which is mental and physical health support.

Therefore, the policy includes statements requiring the department to engage in internal and external resources to target issues of mental health, adopt a nonpunitive policy that encourages members to notify others and use resources available to them, and even includes assistance for responders who need legal help with the judicial process when violently assaulted.

Those are the 8 model policies, Teresa. They are ready for implementation today. They have been run through the ringer. The bullseye has been up there. The fire and rescue service has figured out how they can work, how they can’t work, they’re ready for implementation. So that’s the SAVER model policies; that is what they are intended to do.

Our Focus 3.0 assessment enables fire departments to measure the mental health outcomes of implementing these policies. So again, at the FIRST Centers, there’s lots that we do to not only develop the policies but measure the impact. And so we encourage all of your listeners to take that Focus 3.0 assessment to implement these policies and to contact the FIRST Center to let us know how we can help you, because there is no training out there for the fact that this is a violent job on fire and EMS sides.

We developed that training with the IAFF. We’ve developed the model policies. Please, please implement the policies because that’s how you make the change.

Please, please assess your department’s mental wellbeing with Focus so that you know where you’re at.

And this is how we make change throughout the fire and rescue service. And it’s until we deal with the staffing things that we talked about at the beginning, Teresa, this is our reality. So implementing these policies is critical because I don’t see on the horizon this influx of dollars and EMS providers and paramedics and cross-trained firefighters.

I don’t see that coming. So we’ve gotta do something to slow it down. As Gordon Graham says, we gotta slow this down and really make sure that the people who have said “Yes, I will do this work” are whole and healthy, and get a break and get some time because they see the worst of everything our society experiences.

And they’re still saying, yes, I’ll go. Can we give them something? These policies can give them that.

Absolutely.