Safety First or Saving Lives? How Medical Responders Would Decide when Facing an Active Violent Incident. Results from an Explorative Cross-National Survey

Nils Ellebrecht; Anna Joval; Tomer Kaplan; Oren Wacht; Eric S. Weinstein

doi:10.1515/jhsem-2022-0051

Enjoy 40% off

academic books on De Gruyter Brill *

Article

Safety First or Saving Lives? How Medical Responders Would Decide when Facing an Active Violent Incident. Results from an Explorative Cross-National Survey

Nils Ellebrecht , Anna Joval , Tomer Kaplan , Oren Wacht and Eric S. Weinstein

Published/Copyright: May 30, 2024

Published by

Become an author with De Gruyter Brill

Submit Manuscript Author Information Explore this Subject

From the journal Journal of Homeland Security and Emergency Management Volume 22 Issue 1

Abstract

In recent years, public authorities and rescue services have been discussing how Medical First Responders (MFRs) should behave in an Active Violent Incident (AVI) where it is necessary to weigh up self-protection and the rescuing of others. The aim of this exploratory study is to generate a preliminary picture of how European MFRs position themselves on this and related questions. With the help of a network of experts, an AVI scenario and accompanying questionnaire were developed and pretested. A refined version was then distributed among MFRs in eight European countries and Israel. We performed descriptive statistics and tested for significant differences among the participating countries. 1164 MFRs completed the survey. In the absence of police protection, a majority of respondents opted against providing immediate casualty care (56.6 %). Under certain circumstances, however, the rest decided in favour. More than 65.5 % did not fear disciplinary or legal consequences for not providing assistance immediately. Even with police protection, one in ten respondents would still not enter a “yellow zone”, one in four would leave this to Emergency Medical Services (EMS) units specifically trained for such operations. While there are very few strong contrasts between MFRs with different work experience, roles (supervisor/instructor) or additional qualifications (e.g., firefighting, military service), there are significant differences between MFRs from participating countries. Most notably, (1) only Norwegian participants identified, on average, a clear paradigm shift from “safety first” to “controlled risk taking”; (2) while 69.8 % of the Austrian cohort were unwilling to enter without being escorted by the police, among Norwegians MFRs the figure was 42.7 %; (3) the question whether “weapons” are “useful” equipment in such a scenario is particularly divisive (ranging from 14.3 % of German to 58.9 % of Israeli respondents). Although most of the questions were answered in the same way by a large majority, significant differences can be observed, especially between countries. We offer various explanations for these and discuss whether MFRs can actually remain passive given the situational normative forces inherent to an AVI.

Keywords: emergency medical services; risk assessment; self-protection; ethical dilemma; weapons; tactical casualty care

Corresponding author: Nils Ellebrecht, PhD, Centre for Security and Society, University of Freiburg, Werthmannstr. 15, 79098 Freiburg im Breisgau, Germany, E-mail: nils.ellebrecht@soziologie.uni-freiburg.de

Funding source: Horizon 2020 Framework Programme

Award Identifier / Grant number: No. 786670

Acknowledgements

We would like to thank NO-FEAR’s project team (particularly: Su Anson, Catherine Bertrand, Rachele Brancaleoni, Francesco Della Corte, Cornelia Madalina Dusciuc, Barbara Juen, Stefan Kaufmann, Alexander Kreh, Michael Lindenthal, Monica Linty, Natasha McCrone, Paloma Covadonga Rey Paterna, Frederik Francois Siem, Paloma Miravet Gonzales) as well as Kilian Bertho, Cristina Guerrero Camacho, Tina Ivanov, Marta Trayner, Britta Seifer, Lukas Simon Steiner and others for their support during the various stages of this study (especially in questionnaire development and translation and for promoting the survey in their countries).

Research ethics: The study obtained positive feedback from NO-FEAR’s External Ethics Review Board. Magen David Adom’s (MDA) research committee (the committee is composed of MDA management representatives, senior physicians and researchers) approved the dissemination of the survey among MDA personnel. Compliance with European Union’s General Data Protection Regulation was monitored by NO-FEAR’s Ethics Advisor, Saverio Caruso. Personal data collected and used is limited to the participant’s occupation, country of work and work experience (in years). As no further personal data was collected, the survey remained completely anonymous.
Informed consent: Not applicable.
Competing interests: The authors declare that they have no competing interest.
Data availability: SPSS dataset available by request.

List of Abbreviations

AVI: active violent incident
CC: Contingency coefficient
DEPA: Dispositivo Especial Preventivo Actos Antisociales (Preventive Action in Urban Riots and Antisocial Acts)
EMS: emergency medical services
EMT: emergency medical technician
FEMA: United States Federal Emergency Management Agency
IPRED: International Preparedness & Response to Emergency & Disasters
MCI: Mass Casualty Incident
MFR: Medical first responder
PPE: Personal Protective Equipment
TECC: Tactical Emergency Casualty Care
TEMS: Tactical Emergency Medical Support/Services
TRU: Tactical Response Units

References

Akremi, Leila, and Nina Baur. 2011. “Kreuztabellen Und Kontingenzanalyse.” In Datenanalyse Mit SPSS Für Fortgeschrittene 1, edited by Leila Akremi, Nina Baur, and Sabine Fromm, 169–210. Wiesbaden: VS.10.1007/978-3-531-93041-1_9Search in Google Scholar

Baker, Randy. 2017. Responding to an Active Shooter. Stop the Killing. Stop the Dying. Texas Tech University Police Department. https://www.depts.ttu.edu/coe/safety/documents/ActiveShooterNotes.pdf (accessed January 10, 2024).Search in Google Scholar

Bayerisches Staatsministerium des Innern und für Integration. 2018. Handlungskonzeption Für Die Bewältigung Lebensbedrohlicher Einsatzlagen Durch Die Nichtpolizeiliche Gefahrenabwehr.Search in Google Scholar

Blix, Sigurd W., Jørgen Melau, Nina Thorvaldsen, and Inger Lund-Kordahl. 2021. “Norwegian Emergency Medicine Systems’ Training and Equipment for Penetrating Injuries: A National Survey-Based Study.” Disaster Medicine and Public Health Preparedness 16 (2): 1–4, https://doi.org/10.1017/dmp.2020.440.Search in Google Scholar

C3 Pathways. 2024. Active Shooter Incident Management. Stop the Killing. Stop the Dying®. https://www.c3pathways.com/asim/basic (accessed January 10, 2024).Search in Google Scholar

Cabral, Howard J. 2008. “Multiple Comparisons Procedures.” Circulation 117 (5): 698–701. https://doi.org/10.1161/CIRCULATIONAHA.107.700971.Search in Google Scholar

Callaway, David W., E. Reed Smith, Jeffrey S. Cain, Geoffrey Shapiro, W. Thomas Burnett, Sean D. McKay, and Robert L. Mabry. 2011. “Tactical Emergency Casualty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in High Threat Environments.” Journal of Special Operations Medicine 11 (3): 104–22. https://doi.org/10.55460/8bum-kreb.Search in Google Scholar

Chovaz, Matthew, Raj V. Patel, Juan A. March, Stephen E. Taylor, and K. L. Brewer. 2018. “Willingness of Emergency Medical Services Professionals to Respond to an Active Shooter Incident.” Journal of Special Operations Medicine: A Peer Reviewed Journal for SOF Medical Professionals 18 (4): 82–6. https://doi.org/10.55460/rqn5-wwby.Search in Google Scholar

Devrient, Uwe, and Christoph Brodesser. 2017. Einsätze Bei Besonderen Einsatzlagen (EBE). http://www.rotkreuzhandbuch.de/doku.php?id=ebe (accessed June 24, 2022).Search in Google Scholar

Dopelt, Keren, Oren Wacht, Refael Strugo, Rami Miller, and Talma Kushnir. 2019. “Factors that Affect Israeli Paramedics’ Decision to Quit the Profession: A Mixed Methods Study.” Israel Journal of Health Policy Research 8 (1): 78. https://doi.org/10.1186/s13584-019-0346-0.Search in Google Scholar

Eastridge, Brian J., Robert L. Mabry, Peter Seguin, Cantrell Joyce, Terrill Tops, Paul Uribe, Olga Mallett, et al.. 2012. “Death on the Battlefield (2001–2011). Implications for the Future of Combat Casualty Care.” Journal of Trauma and Acute Care Surgery 73 (6 Suppl 5): S431–7. https://doi.org/10.1097/TA.0b013e3182755dcc.Search in Google Scholar

Ellebrecht, Nils, and Anna Joval. 2022. “Active Violent Incident: Medical First Responders’ Perception of People’s Willingness to Help.” Médecine de Catastrophe – Urgences Collectives 6 (4): 241–6, https://doi.org/10.1016/j.pxur.2022.10.004.Search in Google Scholar

Fabio, Anthony, Myduc Ta, Stephen Strotmeyer, Wei Li, and Eric Schmidt. 2002. “Incident-Level Risk Factors for Firefighter Injuries at Structural Fires.” Journal of Occupational and Environmental Medicine 44 (11): 1059–63. https://doi.org/10.1097/00043764-200211000-00012.Search in Google Scholar

FEMA, and U.S. Fire Administration. 2013. Fire/EMS Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents. https://www.usfa.fema.gov/downloads/pdf/publications/active_shooter_guide.pdf.Search in Google Scholar

Fender, David L. 2003. “Controlling Risk Taking Among Firefighters.” Professional Safety 48 (7): 14–7.Search in Google Scholar

Fricker, Ronald D. 2016. “Sampling Methods for Online Surveys.” In The SAGE Handbook of Online Research Methods. 2nd ed., edited by Nigel G. Fielding, Raymond M. Lee, and Grant Blank, 184–202. London: SAGE Publications.Search in Google Scholar

Goldstein, Scott, LeeAnne M. Martin Lee, and Joseph Roarty. 2021. EMS Zones of Care. https://www.ncbi.nlm.nih.gov/books/NBK436017/.Search in Google Scholar

Gries, Joachim, and Simon Ziegler. 2012. “Retter Im Gefahrenbereich.” Cellesche Zeitung. https://www.cz.de/Celle/Blaulicht/Retter-im-Gefahrenbereich (November 21, 2012).Search in Google Scholar

Harkness, Janet. 1999. “In Pursuit of Quality: Issues for Cross-National Survey Research.” International Journal of Social Research Methodology 2 (2): 125–40. https://doi.org/10.1080/136455799295096.Search in Google Scholar

Heiskell, Lawrence E., and Richard H. Carmona. 1994. “Tactical Emergency Medical Services: An Emerging Subspecialty of Emergency Medicine.” Annals of Emergency Medicine 23 (4): 778–85. https://doi.org/10.1016/s0196-0644(94)70314-0.Search in Google Scholar

Hong, Oisaeng, Dal Lae Chin, Stephanie Phelps, Jamie Feld, and Stephen Vogel. 2012. “Occupational Injuries, Duty Status, and Factors Associated with Injuries Among Firefighters.” Workplace Health & Safety 60 (12): 517–23. https://doi.org/10.1177/216507991206001203.Search in Google Scholar

Hossfeld, Björn, Thomas Wurmb, Florent Josse, and Matthias Helm. 2017. “Massenanfall von Verletzten – Besonderheiten von „bedrohlichen Lagen“. [Mass casualty incident – special features of “threatening situations”].” Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie: AINS 52 (9): 618–29. https://doi.org/10.1055/s-0042-120229.Search in Google Scholar

Jacobs, Lenworth. 2014. “The Hartford Consensus: How to Maximize Survivability in Active Shooter and Intentional Mass Casualty Events.” World Journal of Surgery 38 (5): 1007–8. https://doi.org/10.1007/s00268-014-2481-7.Search in Google Scholar

Johnson, Keith H. 2014. Changing the Paradigm: Implementation of Combined Law Enforcement, Fire, and Emergency Medical Service (EMS) Cross-Disciplinary Response to Hostile Events. Master’s thesis, Naval Postgraduate School. https://apps.dtic.mil/sti/pdfs/ADA620912.pdf.Search in Google Scholar

Kelley, Kate, Belinda Clark, Vivienne Brown, and John Sitzia. 2003. “Good Practice in the Conduct and Reporting of Survey Research.” International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care 15 (3): 261–6. https://doi.org/10.1093/intqhc/mzg031.Search in Google Scholar

Kirkwood, Skip, and Kip Tietsort. 2012. “Violence against EMS Providers: What Can We Do about it?” EMS World 41 (8): 44–51.Search in Google Scholar

Lavrič, Miran, Danijela Gavrilović, Ivan Puzek, and Rudi Klanjšek. 2019. “Values and Value Shifts in Four Countries of South-East Europe: Retraditionalization, Erosion of Trust and the Decline in Public Morality.” Facta Universitatis. Series: Philosophy, Sociology, Psychology and History 18 (2): 55–66. https://doi.org/10.22190/FUPSPH1902055L.Search in Google Scholar

Lippay, Christoph, and Mario Pröhl. 2018. Taktische Eigensicherung im Rettungsdienst: Gefahren erkennen – richtig reagieren. Edewecht: Stumpf + Kossendey.Search in Google Scholar

NO-FEAR consortium. 2023. European Polica Brief: ‘SCENE SAFER’ – A New Concept for Scene Safety Evaluation. https://no-fearproject.eu/wp-content/uploads/2023/06/NO-FEAR-policy-brief-SCENE-SAFER-1.pdf (accessed January 11, 2024).Search in Google Scholar

Pennardt, Andre, and Richard Schwartz. 2014. “Hot, Warm, and Cold Zones: Applying Existing National Incident Management System Terminology to Enhance Tactical Emergency Medical Support Interoperability.” Journal of Special Operations Medicine: A Peer Reviewed Journal for SOF Medical Professionals 14 (3): 78–9. https://doi.org/10.55460/onf2-wpxe.Search in Google Scholar

Rinnert, Kathy J., and William L. Hall. 2002. “Tactical Emergency Medical Support.” Emergency Medicine Clinics of North America 20 (4): 929–52. https://doi.org/10.1016/S0733-8627(02)00036-6.Search in Google Scholar

Schmidt, Michael S. 2013. “In Mass Attacks, New Advice Lets Medics Rush in.” The New York Times. https://www.nytimes.com/2013/12/08/us/in-mass-attacks-new-advice-lets-medics-rush-in.html (accessed December 7, 2013).Search in Google Scholar

Schwartz, Shalom. 2013. Cultural Values as Constraints and Facilitators of Socio-Economic Change. Moscow: Powerpoint Presentation for the Lecture at the Higher School of Economics. https://www.hse.ru/en/ma/socpsy/news/100399092.html (accessed June 11, 2022).Search in Google Scholar

Smith, Reed E., and John B. Delaney. 2013. “Supporting Paradigm Change in EMS’ Operational Medical Response to Active Shooter Events.” Journal of Emergency Medical Services. https://www.jems.com/training/supporting-paradigm-change-in-ems-operational-medical-response-to-active-shooter-events-2/ (December 1, 2013).Search in Google Scholar

Received: 2022-10-24

Accepted: 2024-03-19

Published Online: 2024-05-30

You are currently not able to access this content.

Articles in the same Issue

https://doi.org/10.1515/jhsem-2022-0051

Keywords for this article

emergency medical services; risk assessment; self-protection; ethical dilemma; weapons; tactical casualty care