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20 Posts authored by: jmontes Employee

FEMA recently posted an article pointing to a report on violence against EMS practitioners. It shows what EMS are up against in the field; yet as a 16-year EMS veteran I can’t help but think no matter how thorough the report is, it only tells half the story.

 

EMS professionals often don’t report the violence they encounter on the job. Physical abuse can take many forms. Assaults can be minor or may not result in injury to the provider. Some are downright deadly like an incident in Arkansas last year when a volunteer firefighter was fatally shot while on an EMS call. Others are fatal for the assailant, as was the case in 2016 when a Boston Police officer shot and killed a mentally unstable man that was assaulting officers and the EMS workers who were trying to help him. The same day that FEMA posted their article about EMS violence, the district attorney in Boston ruled that the police officers were justified in killing that man.

 

In my experience riding the ambulance, managing emergency services for large municipalities and as the NFPA liaison responsible for engaging with stakeholders about EMS best practices and health and wellness, I’ve learned that many providers do not report instances of violence for many of the same reasons that I didn’t. During my career, I was assaulted several hundred times by patients but only reported about 15 incidents (because I suffered some form of injury) and only went to court six times when charges were pressed.

 

It is believed, although it has not been studied yet, that not reporting violence against EMS is widespread throughout the United States. Providers don’t report assaults to law enforcement or supervisors, so oftentimes administrators are unaware of the magnitude of this problem.  There are many individual factors why EMS workers don’t report violent incidents. Here are the ones that influenced my decisions:

  •  I felt sympathetic towards the sick and impaired, and didn’t want to get them in trouble 
  • I was assaulted by patients who were suspected to be under the influence of some controlled substance, and law enforcement was hesitant to charge them because they wanted them to be medically cleared
  • I may have not had a visible injury
  • There was no injury
  • I felt peer pressure to act like I was tough and that the assault didn’t affect me
  • I simply accepted it as “part of the job”

 

The EMS violence study is a tremendous starting point - although it only focuses on EMS workers employed by large, urban fire departments. This is likely due to lack of data. There are some noteworthy observations from the study including:

  • EMS workers are more likely to be assaulted by patients than their firefighter colleagues
  • Gender does not determine who gets assaulted
  • There is a disconnect between EMS workers in the field and the dispatchers who collect information about the medical emergency
  • There is a general lack of knowledge about preventing violent EMS attacks. Free online training opportunities, like this National Institute for Occupational Safety and Health course, can help
  • Signage in the back of ambulances stating “it is a felony to assault a first responder” may deter patients from assaulting EMS workers. These are used in Canada and the United Kingdom. They show support for EMS workers
  • Computer-aided dispatch (CAD) systems should utilize a flag system so that dispatchers can alert EMS workers about prior patient-initiated violence at the location. Urban departments in Dallas and Montgomery County, Pennsylvania have this feature
  • Fire departments can reduce provider stress levels by looking into more personnel to ensure that EMS workers have breaks during their shifts to encourage occupational recovery
  • Management should support EMS providers during legal proceedings after an assault occurs

 

The strength of the data out there clearly demonstrates a need for further and deeper exploration into this subject.  Another consideration is encouraging EMS workers to report violent incidents to programs such as the CLIR EMS self-reporting tool so that more robust data can be collected.

Today marks the one year anniversary of the attack at the Pulse Nightclub in Orlando.  At the NFPA, we honor the 49 innocent individuals that were taken that day by marking this week as the beginning of the development of NFPA 3000: Standard for Preparedness and Response to Active Shooter and/or Hostile Events

 

The Pulse incident, along with several others throughout the past year, highlight a need for first responders, emergency managers, facilities, hospitals, and communities as a whole to be on the same page when these incidents occur.  The resilience displayed in places like Orlando, Boston, London, Connecticut, and many others show that we as a community can and must work together to ensure that we never allow terror or evil to win.  NFPA 3000 will give communities a resource to be prepared in the event that the unthinkable happens.

 

The process of developing NFPA 3000 began with a request by Fire Chief Otto Drozd III from Orange County Florida in October of 2016.  Since then, we have sought public comment and committee applications to form a Technical Committee to develop the Standard.  In just four short months we received over 100 positive comments and committee applications.  In April of 2017, the NFPA Standards Council unanimously approved the new Standard and Technical Committee.

 

The Technical Committee is chaired by Richard Serino, recently retired COO of the Federal Emergency Management Agency, former Chief of Boston EMS, and current faculty member at Harvard University.  The Committee has representatives from the DHS, DOJ, FBI, International Association of Police Chiefs, International Association of Fire Chiefs, National Association of EMTs, IAFF, EMS Labor Alliance, Hospitals, Facility Managers, Private Security, Universities, and more.  This broad group collectively brings over 200 years of experience to the table, many of which include experience responding to active shooter/hostile incidents.

 

On June 9, 2017 Chief Drozd authored an editorial in the Orlando Sentinel highlighting his reasons for requesting that the Standard be developed.  One important issue that he points out is that there are numerous guidance documents from individual organizations, but currently no consensus standard.  He also speaks to the inspiration he felt in the aftermath of the Pulse attack and his motivation for wanting a tool for others to use so that more lives can be saved in the future.  We honor those that were lost at the Pulse with this work and hope that others may live on thanks to the lessons learned and their memories.  As Chief Drozd says, “So that Others May Live.” 

 

The NFPA and the Technical Committee need the help of the public to make this the best standard it can be.  Anyone can come to a meeting or make inputs and comments to the draft once it is posted.  If you would like to know more and follow along with the development of NFPA 3000, please go to www.nfpa.org/3000 and then click "receive email alerts" to receive updates on the development process as they are posted.  Its a big world, let's protect it together!

In Part 1 of this series we discussed a novel example of a total wellness program.  In Part 2 we discussed ways you and your department can implement a Total Wellness Program in your service starting tomorrow.  This time we will talk about the future.  One of the really cool things the @NFPA does is send our staff liaisons out as much as is possible and reasonable so we can learn what new practices and resources are out there and bring that information back to our technical committees.  Our technical committees ultimately decide what is put into a code or standard but even if somethings don’t make it in, we as an organization want to make sure we are sharing that knowledge and information with the world. In my very short time with the association I have been so lucky to have been able to travel and learn from innovators all over the Country.  There are some really amazing things on the horizon for our emergency responders.  From innovative technology that uses the biometric sensors in smart phones to better track exposure times, to resiliency programs that focus on not just the responder but their families as well and create a healthy means for them to work through their stresses and issues.

 

One of the coolest concepts that is being discussed is the “Tactical Athlete.”  This is the best term I have ever heard to describe our responders.  Now you may hear this and think it “tactical, like totally tough and kick in doors and chase bad guys” but that’s not what they mean by this.  The context in which this was first presented is in the world of injury management.  Traditionally, if a responder gets hurt, they go to see an occupational health physician and that doctor refers them to specialists, but manages their injury and rehabilitation.  In the world of the tactical athlete, injuries are managed by sports medicine physicians.  This is because a first responder isn’t like someone who works in an office environment.  Occupational doctors see patients and try to best manage their care to get them back to their specific occupation.  For the most part, not always but mostly, these are people who work in an office or manufacturing who have a repetitive use injury and need to be rehabbed just enough to get back to work. 

 

Our first responders don’t fit into these traditional occupational boxes.  While there are many occupational doctors who have taken time and made effort to understand

the needs of responders and looked at innovating their care, there is still things that a sports medicine doctor has access to that they don’t.  Our responders sometimes do repetitive motion (ie; EMTs lifting and moving patients), go from complete rest to running upstairs and ladders (ie; fire fighters), and even go from an excited state to a completely aerobic state (ie; police officers in a foot chase).  All of this variation and stress takes a toll on the body similar to an athlete who exercise and makes repetitive motions for their skill but also has moments of complete change.  Your body must be flexible and maintained in such a way that it can handle these stresses. This flexibility and maintenance is what the sports medicine doctors specialize in.  A sports medicine physician also can reduce the time in which a responder is out of work. They do this by accelerating the time it normally takes to get imaging, make care decisions, and perform procedures.  In the traditional model, you would still have to see an orthopedist but after being referred and possibly treated by an occupational physician first.  There are less layers in the new model.

 

I spent some time with a sports medicine physician recently discussing this model.  Dr. Jennifer Luz is a sports medicine physician with Steward Healthcare in Boston and is one of the team physicians for the Boston Ballet, Boston Cannons Lacrosse team, Boston Breakers Women’s Soccer Team, and several local colleges.  Dr. Luz has always had an interest working with first responders as the granddaughter of a police chief and the daughter of a federal agent.  She was a resident at Spaulding Rehabilitation Hospital in Boston and was involved in the care of victims and responders that where at the events of the 2013 Boston Marathon.  Dr. Luz recently made as simple analogy; “If Tom Brady hurt his shoulder, he would have an MRI within a day and surgery within a week.  This would be to not only expedite his recovery, but also to prevent any further damage while waiting for care or approval to receive care.  Why is a first responder any different?  Don’t we need to get them healthy and back at working helping/protecting us?”  This point illustrates the importance of changing our mindset and looking at responders in a different way.

 

There’s more to the tactical athlete concept than just the way responders are cared for.  There’s a component of maintenance that must accompany the care.  Maintenance of not just the body but also of the mind and spirit.  Many departments are looking at innovative ways to promote health and wellness as it relates to tactical athletes.  Some are working with companies to improve fitness like Boston with their O2X program.  Others are bringing in Yoga instructors to increase endurance and flexibility.  In Indianapolis they are conducting a nutrition study measuring the heart walls of fire fighters and trying to create ways to reduce cardiac issues in the fire service.  There is a behavioral component too.  Finding mental health clinicians that understand the responder world and life, performance coaches, mindful coaches, and working with families to integrate them into department life. 

 

When you step back and look at all of this, you have to ask… Why?  For too long being a responder has been too dangerous of a job.  Too many have died both on the job or too early after suffering a heart ailment or from the terrible effects of cancer.  How many have left the profession due to mental illness? How many of your co-workers both past and present have taken their lives?  How many families have been broken up because of the ravages and stress of these jobs?  How much money have you or others lost by being unable to work, either at your job, or if you’re a volunteer, at your day job because of an injury suffered helping others?  How much money has your department spent covering your shifts or expenses while you are out injured?  Is this money that could have gone to other programs?

 

The world of working as a first responder is hard.  The hours are long, the calls can be stressful, and frequently people feel like they are alone.  The long shifts and especially busier call volume days can create terrible eating habits and reduce your exercise and effort when you aren’t at work.  Many first responders get home for their shifts and just “crash out” this is the phenomenon of decompressing and isolating yourself while eating and watching tv or playing video games.  This frequently occurs because of the time they spend in a heightened state of adrenaline or excitement on their shifts and the body dumping and wanting to achieve balance.  Many feel as though their work is a family and their home is a family, but they have difficulty integrating the two.  The total wellness program and tactical athlete concept, as conceptualized, will intervene, help develop healthy eating and exercise practices, improve mental performance and coping mechanisms, and include their loved ones and make them feel as though they are a part of this process.  Long term benefits could include, reducing the number of cardiovascular issues, behavioral health issues, and cancer victims.  For the department they will reduced overtime and worker’s comp expenses, have an easier time keeping staffing adequate, and improve moral.  I know that for me (pictured)... This is something I certainly would have loved to be a part of in my time on the streets!  It’s a win-win! 

              In Part 1of this series we discussed a model Total Wellness Program and some of the benefits it has experienced since its inception.  In this part we will discuss the concepts that have been coming up all over the Country and some recommendations you can take for your agency and start working on them right away.

              I am sitting at the National EMS Physicians Association conference in New Orleans and have sat in on two separate lectures and a full working group with over 50 members all discussing first responder health and safety and what can they as medical directors do to help our responders.  Last week, I attended the Safety and Apparatus Symposium presented by the Fire Department Safety Officers Association, a group who's motto is to improve the health and safety of all first responders. There they discussed several trends including annual physical fitness testing, health and wellness program concepts, department safety cultural challenges, and cancer prevention.  At all of these events, along with the NFF meeting that was discussed in Part 1, several themes seemed to resonate across the board regarding safety and health.  They are outlined below:

 

  • Make a commitment to invest in the concept of a total wellness program.
  • Create a peer support program, where the line staff determines who the peer support team is comprised of.
  • Provide your peer support personnel with training on stress management and information on getting further help for members.
  • Partner with your surrounding medical community to provide services to employees.
  • Work with metal health clinicians who have a solid understanding of what ALL first responders go through. Assure that you provide them with opportunities to learn more about what this life is like.
  • Create a culture of safety from the top down and a zero tolerance policy regarding safety violations.
  • Establish what must be reported to senior staff and what should remain privileged and make all staff aware of the difference and the line.
  • Create support network and communication networks for members families.
  • Provide administrative support for the program.

 

Investing in a total wellness program is beneficial to a department on so many levels, but let’s stick to financial.  Every year departments of all shapes and sizes, including volunteer services struggle with staffing due to injuries and leaves.  This becomes very expensive and time consuming by back filling spaces, paying overtime, and struggling to find appropriately trained personnel for the open spots.  While most departments rely on worker’s compensation to cover the salary and medical expenses of the injured party, there is still a cost to departments for their lost time.  Also, when on leave for a personal illness or injury, departments still have to cover for the lost time.  On a volunteer department, especially one with already low staffing, this can be devastating.  They may be required to request mutual aid from neighboring departments or, in some cases, have to pay for their areas to be covered.  Another financial benefit is patient generation.  Hospitals, medical providers, and mental health providers want volumes of patients.  They are more likely to partner with your department knowing that in the future it will lead to patients coming in their door.  Plus, some want to help their community or just think it’s really cool to work with first responders.  On a hospital level, imaging, surgeries, and rehabilitative care are all huge money generators and by working closely with a department to streamline their facilities processes to meet the needs of first responders they can create a profitable win-win situation. 

When you are creating one of these programs you need to have buy-in from your line personnel.  The all to frequent error many departments make is to have a command level officer be in charge of these programs and then select who they want to be the peer support staff.  By having the line staff elect/select the people that they want to go to a department instantly builds trust.  One of the things many first responders express is that they are concerned that in the small world of their departments, their personal information can spread quickly.  By having people they trust ion these roles and training those people on the value of confidentiality and what must be reported and what is best referred, they can have that trust.  One novel recommendation is to create a survey with the names of all department members, then have staff select their top three people that they talk to when they don’t know something or have a problem.  Then take, let’s say the top ten vote getters and there is your peer support team!  This will show the line staff that the program is about them and not management controlling them and will, hopefully, foster participation.

   Working with families is a huge missing component in most first responder organizations throughout the Country.  Be it as a result of scheduling, the hours, and/or the stressors, frequently our loved ones don’t truly understand why we are acting the way we are.  Further, they often don’t know or can’t comprehend the things personnel are going through.  There are studies out there that show the divorce rate of first responders to be at over 80%. There could be many causes for this but at the end of the day, this additional stress does not make for a healthy department or work environment.  By making the significant others of responders feel involved and supported, every day not just when something bad has happened, you are making part of the family.  Frequently different department members call their co-workers their “brothers and sisters.”  Well how would one think their home family would feel about them having a completely separate work family?  While for some bringing their home and work together may be uncomfortable or something that they are not used to.  Having your spouse and family understand better the things you are going through and what others in their shoes are experiencing will only improve their total understanding and hopefully create a more healthy and supportive environment. 

   Creating one of these programs isn't easy, and certainly isn't free.  But this is the price that must be paid to support those that help us all every day.  Next week we will talk about what the @NFPA is doing today and what the future holds for wellness in Part 3.

   

On a recent trip to Baltimore, I was fortunate enough to participate in the National Fallen Fire Fighters Foundation’s planning meeting as they develop a guide for behavioral wellness for fire departments.  It’s exciting to see that some of the source materials they are using come from the NFPA 1500 series of standards.  While at the meetings, we received a presentation from the Denver Fire Department about their “Total Wellness Program.”  This program looks at firefighting not as just any other profession, but rather as individuals who are high performance athletes and who need constant maintenance of their minds and bodies to be able to handle the stress and rigors of the job.     

              The Denver program has a variety of services available to department members.  They can choose to see one of dozens of therapists who have agreed to work with first responders and have taken the time to ride along in order to understand the toll of the job on one’s mind and body (a couple are even former first responders).  They can see wellness and performance coaches who help them with making healthy choices and give them tips on how to keep their minds engaged.  They use nutritionists to make sure they are eating right and their bodies are fueled appropriately.  Denver even hired two full time physical therapists to work with both injured and non-injured members to ensure they stay fit and healthy.  The coolest part is the medical care; they are using orthopedists that specialize in caring for professional athletes to provide care to injured members.  These specialists have greatly increased the speed in which injured members are imaged and receive procedures, thus they are back on the job faster. 

Another great feature is that the program isn’t just for department members; their significant others and families participate as well.  They are part of a message group, have separate meetings with clinicians, do group events such as fund raisers and exercise classes, and are a part of all department sponsored functions.   The idea to include families came a department funeral where the Chief asked the wives to sit with their husbands.  Instead of a sea of blue with the significant others excluded to the back of the church, they were together, this proved to be a huge success with many saying they felt a part of the family and wanting to be more involved.  The DFD estimates that for every dollar they have spent on the program, they have saved three dollars in what they would have lost on the various leave types for employees. They also have seen a 42% reduction in annual workman’s comp costs.

              Learning about this program made me think to my time working on the streets.  As we look at Part 2 of this series, please comment on your experiences in your careers and whether a program like the one described above would help you or your departments.  Let us know what steps you are taking to improve wellness and what needs to change.  Next week we will talk about some of the concepts you recommend and will present some of the recommendations from the NFFF meeting and workshops. 

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