Stress, grief and scene safety

1. You findBefore the call: you are getting ready for a shift in which any scene could turn violent.You doPlan. Wear safe clothing (nonslip shoes, reflective gear, body armor in high-risk settings), carry equipment you can manage, keep a portable radio with you, and assign safety roles; one EMT can be the observer.
2. You findOn approach you see or hear signs of violence: broken glass, arguing, weapons, drug or alcohol use, agitated family or bystanders, or pets.You doObserve, from approach to the end of the call. Turn off lights and siren as you near the scene so you do not draw a crowd, and do not stand directly in front of doors.
3. You findViolence develops.You doReact with the 3 Rs. Respond: put distance between you and the threat and get behind cover. Radio: call for police with the location, the number of people and any weapons. Reevaluate: do not go back in until police have secured the scene, and stay alert after that.
4. You findYou arrive at a crash and see a placard on an overturned tanker.You doKeep your distance. Stay well back, read the placard with binoculars, and use the DOT Emergency Response Guidebook for safe distances. Recognize the hazard, protect yourself and others, and notify the hazmat team. Contaminated patients are decontaminated before you treat them.
5. You findA dying patient snaps at you, or a family member is furious with you.You doTolerate the anger without taking it personally; it is one of the stages of grief. Treat the patient with respect and dignity, talk to them directly, listen, and offer realistic comfort. Never give false reassurance.
6. You findAfter a bad call, you or a coworker are irritable, cannot concentrate, are sleeping or eating differently, or are pulling away from people.You doRecognize the signs of stress and act on them: better diet, less alcohol and caffeine, exercise, relaxation techniques, a change of shift or location if needed, and peer support or counseling. Seeking help is a sign of strength.

• The body's stress response has three stages (Selye's general adaptation syndrome): alarm (fight or flight: heart rate and blood pressure rise, pupils dilate), resistance (the body adapts and copes), and exhaustion (resources run out; fatigue and stress-related illness).
• Three stress reactions: acute (during or shortly after an incident), delayed (PTSD: flashbacks, nightmares, irritability, days to years later and lasting a month or more), and cumulative (burnout that builds over years).
• Eustress is positive, helpful stress. Distress is negative stress that harms performance.
• Especially stressful calls: multiple-casualty incidents, infants or children, severe injuries, abuse or neglect, and the death of a coworker.
• After a traumatic event, offer social support (you are not alone), choice and control (small choices), anticipation (explain what happens next) and a plan (reduce confusion).
• Critical incident stress management (CISM) is a system of education, peer support and counseling. Formal group debriefings 24 to 72 hours after an incident are used less often now and are not always recommended.
• Five stages of dying: denial, anger, bargaining, depression, acceptance. Not everyone goes through all five or in this order, and the family may need more support than the patient.
• Cover protects you from projectiles. Concealment only hides you. When you retreat, put 2 obstacles between you and the danger and drop heavy gear.
• What actually kills EMS providers: heart attacks, vehicle collisions and air-medical crashes far more than violence, and back injuries end more careers than violence does.

The wrong idea: A good EMT goes in no matter what. If someone is hurt inside, waiting outside for the police is failing the patient.

What is actually true: Your safety comes first on every call. If a scene is not safe you do not enter, and if it turns violent you retreat, radio for police and stay out until they have secured it. An injured EMT helps no one and adds a patient.

Scene safety is the most important decision on every call. Against violence: plan before the call, observe from approach onward, and react by putting distance and cover between you and the threat, radioing for police, and staying out until the scene is secured. At hazardous materials incidents keep well back, identify the placard, use the Emergency Response Guidebook and call the hazmat team; contaminated patients are decontaminated first. Stress follows alarm, resistance and exhaustion, and shows up as acute, delayed or cumulative reactions; manage it with healthy habits, support and help when needed. Dying patients and families may move through denial, anger, bargaining, depression and acceptance; give respect, listening and honest comfort, never false reassurance.

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