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EMS Preparedness for Tactical Violence Daniel Kollek MD Co-authors: Michelle Welsford MD Karen Wanger, MD

Introduction Paramedics are essentially the only medical personnel who are routinely at the scene of violent episodes Reportedly 8.5% of scenes are the result of some form of violence Up to 90% of EMS staff report an episode of violence directed towards them

Tactical Violence Defined as: “ the deployment of extreme violence in a non-random fashion so as to achieve a tactical or strategic goal” Preparation for T.V. is a routine part of training for police and military but not EMS

Tactical Violence Response to a scene involving tactical violence involves multiple agencies. The addition of targeted violence and law enforcement requires different operational procedures compared to more typical EMS responses Safe and efficient functioning at such a scene requires specific training including training with the other responding agencies (e.g.ICS).

Methods Survey of pre-hospital providers in BC and Ontario Survey addressed the self reported training and readiness in the following areas:

Survey topics 1. Training for response to a tactical violence or terrorist scene; 2. The level of comfort responding to complex event (mass casualty, violent etc); 3. The level of comfort in detecting and dealing with the emotional impact of providing care; 4. The added emotional impact caused by violence, clinical load and child injuries at the event scene.

Topics and methodology Emotional impact was assessed by asking respondents to grade responses to a variety of scenarios including violence and tactical violence, and the presence of combinations of adult and pediatric victims.

Results 1028 respondents 77% of 876 respondents stated they had received no training “…in procedures to follow in responding to a tactical violence scene where there may be further violence” 4.5% of responders “did not know” who would be in control of such a scene

Results 89% of 288 respondents were “never” (46%) or “more than a year ago” (43%) “…trained to function under conditions of tactical violence.” 70% of 289 respondents had never reviewed the tactical violence plan in the community s/he serves

Scenarios. Raw data with weighted scores in parentheses Not distressing Slightly distressing Moderately distressing Would not be able to resume work Would not be able deliver care at the scene Total Emotional Impact Value Average Emotional Impact Value (weight 0) (weight 1) (weight 2) (weight 3) (weight 4) 1 1 adult injured/1 adult dead 342 (0) 492 (492) 0 (0) 12 (36) 1 (4) 532 0.63 2 1 adult injured/1 child dead 51 (0) 211 (211) 512 (1024) 75 (225) 1464 1.72 3 1 adult attacked/1 child dead 34 (0) 177 (177) 541 (1082) 99 (297) 1560 1.83 4 1 adult injured/1 child attacked and dead 27 (0) 137 (137) 520 (1040) 172 (516) 3 (12) 1705 1.98 5 20 adults killed accidentally, five injured 39 (0) 136 (136) 456 (912) 224 (672) 1724 2.01 6 20 adults killed purposely, five injured 31 (0) 84 (84) 432 (864) 297 (891) 12 (48) 1887 2.20

Duration of emotional impact I never have unwanted memories of distressing events 3.1% I would process the event immediately and it would not bother me for any significant length of time 26.4% It will take me up to a week to process this event 30.8% It will take me up to a month to process this event 13.2% It will take me over a month to process this event 11.5% I do not think I would ever get over witnessing such an event 15.1%

Comfort responding to event by event type Very uncomfortable Slightly uncomfortable Unsure Reasonably comfortable Very comfortable Fire 57 (7%) 61 (7.4%) 52 (6.3%) 224 (27.4%) 425 (51.9%) Unstable building 113 (13.8%) 126 (15.4%) 173 (21.1%) 275 (33.6%) 132 (16.1%) Terror event 153 (18.7%) 154 (18.8%) 266 (32.5%) 186 (22.7%) 60 (7.3%) In PPE 103 (12.6%) 136 (16.6%) 166 (20.3%) 247 (30.2%) 167 (20.4%) Tactical Violence 157 (19.2%) 196 (23.9%) 264 (32.2%) 99 (12.1%)

Conclusions EMS personnel routinely respond to episodes involving violence, are frequently subject to violence personally, and are increasingly exposed to tactical violence As assessed by this survey: Few EMS personnel in Canada have training in the response to tactical violence, many have a significant degree of discomfort responding to these scenes, and many predict significant distress from tactical violence scenarios.

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