1. www.bcas.ca

2. www.ceep.ca

3. CAEP 2009 EMS Preparedness for Tactical Violence Karen Wanger MDCM, FRCPC Regional Medical Director BC Ambulance Service

4. Disclosure I do not have an affiliation (financial or otherwise) with any commercial organization that may have a direct or indirect connection to the content of my presentation. And I am not Demi Moore...

5. Learning objectives Understand “tactical EMS” vs. “tactical EMS” Learn what the perceived preparedness status is of front line responders in Canada

6. CAEP 2009 Introduction Paramedics are essentially the only medical personnel routinely at the scene of violent episodes 8.5% of scenes are the result of some form of violence Up to 90% of EMS staff report an episode of violence directed at them.

7. CAEP 2009 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 Tactical Violence is a routine part of training for police and military but not EMS

8. CAEP 2009 Tactical Violence Tactical violence = multi agency approach Targeted violence + law enforcement = change from “normal” EMS response mode Safe and efficient functioning specific training including training with the other responding agencies.

9. CAEP 2009 Tactical Teams A few These teams are generally deployed in advance of a call when law enforcement is planning a tactical manoeuvre.

11. CAEP 2009 Tactical Violence Violence that is “tactical” in nature employed by an outside “agency” as in terrorism would occur without warning. The estimated time to scramble a specialist tactical team is roughly one hour Front line paramedics would be required to manage the scene for that time.

12. CAEP 2009 Violence Paramedics are experienced and well versed in dealing with interpersonal violence on calls. Patient/patient or “perp”/patient. Violence towards a paramedic is generally one-on-one from a patient and is understood by the paramedic

13. CAEP 2009 Tactical v. responders A large component of “intentional/random” violence or violence directed towards responders changes everything. Including subsequent processing.

14. CAEP 2009 Targeted tactical - management Isreali paramedics approach tactical violence scenes differently from other MCI’s. It is understood that secondary devices aimed at responders are a reality. Casualties are moved quickly and the scene emptied in minutes.

15. CAEP 2009 Are we prepared? Survey of pre-hospital providers in BC and Ontario January to June 2006 Daniel Kollek and Michelle Welsford. Addressed the self-reported training and readiness in the following areas:

16. CAEP 2009 Survey topics: 1.Training for response to a tactical violence or terrorist scene; 2.The level of comfort responding to a 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.

17. CAEP 2009 Topics and Methodology Emotional impact was assessed by grading response to a variety of scenarios including violence and tactical violence, and the presence of combinations of adult and paediatric victims.

18. CAEP 2009 Population Ontario and BC paramedics and first responders Posted on a website only accessible by individuals knowing its complex address. Invitation by email and poster in Ontario In BC email invitations to paramedics through BC Ambulance. FR’s invited via FCABC distribution.

19. CAEP 2009 Survey questions 3 basic areas: 1) Scenarios – quantify degree of distress 1 (“not distressing to any significant degree”) to 5(“distressing to the degree that you would not be able to deliver care”)

20. CAEP 2009 Survey questions 2) Report degree of training and comfort in responding to the following events: –Fire –Response to an unstable building –Response to a terror event –Response requiring use of elevated PPE –Response to a tactical violence situation

21. CAEP 2009 Survey questions 3) Ability to recognize emotional distress in self or partner and comfort with CISD

22. CAEP 2009 Results 1028 respondents –Mostly male (75%) –Mostly PCP (55%) –Age 36-50 (48%) –Wide range of years of experience –Predominantly front line personnel

23. CAEP 2009 Results - training Regarding “procedures to follow in responding to a tactical violence scene where there my be further violence” 77% of 876 respondent stated they had received no training. 92% of 289 respondents stated police to be in control of site access in a tactical violence situation but 4.5% “did not know” who would be in control of the scene.

24. CAEP 2009 Results - training “...trained to function under conditions of tactical violence”. 89% of 288 respondents – “never” (46%) or “>1yr” Only 27% of 291 respondents had “..any field exercise with other (non-medical) first responders”. 37% had exercised more than 1 year ago and 36% “never”

25. CAEP 2009 Results – emotional impact Not distressing Slightly distressing Moderately distressing Would not be able to resume work Would not be able to deliver care at the scene Total Emotional Impact Value Average Emotional Impact Value (weight 0)(weight 1)(weight 2)(weight 3)(weight 4) 11 adult injured 1 adult dead 342 (0)492 (492)0 (0)12 (36)1 (4)5320.63 21 adult injured 1 child dead 51 (0)211 (211)512 (1024)75 (225)1 (4)14641.72 31 adult attacked 1 child dead 34 (0)177 (177)541 (1082)99 (297)1 (4)15601.83 41 adult injured 1 child attacked and dead 27 (0)137 (137)520 (1040)172 (516)3 (12)17051.98 520 adults killed accidentally, five injured 39 (0)136 (136)456 (912)224 (672)1 (4)17242.01 620 adults killed purposely, five injured 31 (0)84 (84)432 (864)297 (891)12 (48)18872.20

26. CAEP 2009 Results – emotional impact I never have unwanted memories of distressing events3.1% 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 event30.8% It will take me up to a month to process this event13.2% It will take me over a month to process this event11.5% I do not think I would ever get over witnessing such an event15.1%

27. CAEP 2009 Comfort levels – event response Very uncomfortable Slightly uncomfortable UnsureReasonably comfortable Very comfortable Fire57 (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 event153 (18.7%)154 (18.8%)266 (32.5%)186 (22.7%)60 (7.3%) In PPE103 (12.6%)136 (16.6%)166 (20.3%)247 (30.2%)167 (20.4%) Tactical violence 103 (12.6%)157 (19.2%)196 (23.9%)264 (32.2%)99 (12.1%)

28. CAEP 2009 Comfort level – distress recognition Very uncomfortable Slightly uncomfortable UnsureReasonably comfortable Very comfortable Recognising self distress 31 (3.8%)57 (7%)124 (15.1%)353 (43.1%)254 (31%) Recognising distress in others 21 (2.6%)50 (6.1%)100 (12.2%)441 (53.8%)207 (25.3%)

29. CAEP 2009 Comfort level - support Very uncomfortable Slightly uncomfortable UnsureReasonably comfortable Very comfortable Receiving anonymous counseling 55 (6.7%)81 (9.9%)98 (12%)247 (30.2%)338 (41.3%) Receiving group counseling 67 (8.2%)87 (10.6%)103 (12.6%)266 (32.5%)296 (36.1%)

30. Progress MCI training Awareness training

31. CAEP 2009 Discussion Targeted tactical violence is a reality Some paramedics are trained to back up police in tactical situations organized and controlled by PD A paucity of front line paramedics are trained to respond in a situation of tactical violence targeted at first responding crews. Some don’t even know who would be in charge.

32. CAEP 2009 Discussion Even the “lesser” of the factors in the scenarios more than doubled the emotional impact of the event as rated. These factors are not unusual (child injury, assault, etc) Emotional self care is not part of standard training for paramedics

33. CAEP 2009 Discussion Monitoring for psychological impact is not routinely carried out although some services have implemented post incident debriefing. 97% of respondents admitted to occasional unwanted memories of distressing events with 31% stating it would take up to a week to process the event and 15% stated they did not think they would “ever get over witnessing such an event” 26% stated they would process the event immediately and it would not bother them for any significant length of time.

34. CAEP 2009 Tema Conter Foundation www.tema.ca

35. Conclusions Inadequate numbers of EMS personnel are prepared to function at a scene of terror or tactical violence directed at responders. Awareness and education should be provided The emotional effect on paramedics of violence requires greater attention

36. Thank you for your attention