Charlotte NC Oct 7 2017 Jason Adams’ last call was every EMS provider’s worst nightmare.

He responded in January 2016 for a man in reported seizure. Just 29, Adams was the closest medic in a volunteer system—the address was on his street. He entered the North Little Rock home of Mark Eugene Pruitt, who it would later be discovered had been using cocaine. Pruitt—startled awake, he said, to the sight of a stranger approaching his bedroom at 5 a.m.—came up firing. Multiple shots struck Adams, who died later at a nearby hospital.

That’s truly the worst-case scenario for any emergency provider answering a call. Not far behind is what happened to Ben Vernon and Alex Wallbrett.

The San Diego firefighters answered a routine June 2015 call for an intoxicated man down. Their initially calm scene spun out quickly when bystander Ryan Allen Jones became agitated and pulled a hunting knife. As Vernon retreated, Jones rushed him and stabbed him twice in the back, piercing a lung and just missing a kidney. When Wallbrett came to his partner’s aid, Jones stabbed him three times.

Unlike Jones, Vernon and Wallbrett survived and returned to work—Vernon, a trainer with San Diego Fire-Rescue, with a very personal lesson.

“The most dangerous call I’ve done in my career,” he told local media, “was the most routine thing I’ve ever done… It just shows how dangerous this job can be on a daily basis.”

It’s doubtful you need another reminder of that these days. Virtually everyone with any real tenure in EMS has been menaced or threatened, if not actively assaulted. Fewer, thankfully, have been shot or stabbed.

We’re far from thorough in tracking such violence against responders, but last year researchers from Drexel University who were investigating apparent higher injury rates for women in an urban fire department instead found its paramedics to be 14 times more likely to be violently hurt on the job than its firefighters.

“There’s definitely been a shift in society’s response to EMS providers,” says Peter Dworsky, corporate director of support services for the New Jersey healthcare cooperative MONOC and a member of the NAEMT’s EMS Safety Committee. “We’re being put into situations we were not normally put into in the past—domestic violence calls, even actual shootings when the police are not available. They’re tied up, and we’re getting there first.”

Respondents in the Drexel study noted some complementary themes: They often don’t get enough information from dispatch to know what they’re walking into. Backup can be slow in coming when a safety issue arises. And many receive no training on defending themselves or controlling combative patients.

Overall, violent crime in the U.S. has declined dramatically since the early 1990s.5 But even as the NFPA chronicled a recent decrease in on-duty firefighter deaths, it noted that “violence against firefighters is not as rare as some might think” and cited 22 firefighters fatally assaulted on duty since 1996.

“We respond to a lot of violent incidents, and at one time being attacked wasn’t even something we thought about. Now we don’t respond in on them until the police declare the scene safe,” says Roy Winston, who became Cincinnati’s fire chief this year following nearly three decades with the department. “Twenty-nine years ago when I got here, we usually got to calls before the police, and we’d go right in and start working on the patient. Nowadays we stage two blocks away at a minimum before we even go in, and hopefully the scene will be safe enough for us to do our jobs. Things have definitely changed.”

Maybe it’s better reporting. Maybe it’s the high-profile nature of some recent attacks. Maybe, despite larger trends, assaults on EMS and fire actually are increasing.

Whatever’s driving it, there’s a growing feeling among many leaders that departments should be doing more to protect their personnel. And when the ultimate threats involve bullets and blades, there comes greater interest in the ultimate protection. That’s the advanced defensive apparel once reserved for soldiers and cops: body armor—ballistic and/or stab protection, usually in the form of vests.

In the 2017 EMS Trend Report produced by EMS1.com and Fitch & Associates, 44% of responding EMS agencies said they’d either purchased body armor for their personnel or planned to budget for it. Just 18% said they didn’t believe it was needed.7

“If our crews have something like this to protect them, then that’s one less thing they have to worry about while they focus on the patient,” says Cleveland EMS Commissioner Nicole Carlton, whose department was an early adopter of armor for its providers. “You have to be proactive for safety. Even though our crews still have to be aware at all times of what’s going on around them while they’re tending to patients, this is something that can provide them an additional level of comfort. We want to make sure their vital organs are protected if something goes sideways.”

EMS World spoke to four big-city combined fire/EMS departments for this article. All four either use body armor or are obtaining it.

“We’d always thought we’d be able to go into any warm zone in coordination with police and extract folks,” says Kansas City Fire Chief Paul Berardi, whose department is seeking to fund armor in its next budget. “What changed my mind was hearing presentations on some of the challenges they had with the Pulse nightclub shooting. That helped prompt us. I know Orlando has gone to body armor, and many of the major cities are now using ballistic protection.”

“I always thought we in the fire service would never find ourselves in a situation where we would have to provide vests,” agrees Albuquerque Fire Chief David Downey. “Now here I am the chief, 25 years later, and I’m distributing vests. It’s ironic how things have changed, but I didn’t want to be the chief who didn’t act, then regretted it when a tragedy happened.”

For departments making the move, that’s the most persuasive argument. Ballistic vests aren’t cheap—but they’re worth far less than the life of an EMT or medic. Newer, lighter models are also more comfortable and flexible for prolonged wear on the job.

“At the end of the day, you have to be comfortable,” says Carlton. “You’re starting IVs, you’re doing CPR, you’re intubating patients, and you have this vest on. So we needed something thin that they could take off at the hospital or their base and be comfortable.”

That points to a unique aspect of Cleveland’s body armor policy: It requires the vests be worn all the time.

Cleveland first began providing body armor for its EMS personnel in 1990, but until recently providers only wore it on calls with an anticipated potential for violence—shootings, stabbings, etc. But as of December 2015, the department began mandating its use at all times.

“There was lots of violence toward paramedics about that time, and I wanted our people to get home safely,” says Carlton. “They had equipment that could help them do that, if we made sure they wore it and it wasn’t just sitting in their jump bags.”

The new policy was largely borrowed from Cleveland police. It requires all operational employees to wear their vests at all times on duty, including in ambulances and at special events. They can remove them in their stations and at hospitals, in court and during training.

The new vests are Level IIIA (see sidebar) Second Chance brand from Pennsylvania’s Atlantic Tactical. The previous model was thicker and heavier than today’s users typically find optimal—designed for wear at dangerous scenes but not for entire shifts. That, along with a less comprehensive policy for its use, meant vests were used inconsistently.

The new policy and upgraded gear is being accompanied by a review of uniform shirts with a goal of enhancing their breathability. “Comfort throughout the day is important,” says Carlton. The vests aren’t hot, she adds, but “it’s important administratively to make sure the air conditioners are working in your trucks.”

In Albuquerque they’re taking a different approach, mandating the armor on certain call types but leaving it to providers’ discretion on others.

Albuquerque Fire’s battalion chiefs already carried vests, helmets and first-aid kits for active shooters and other direct threats, but in March leaders began expanding the protection to all riding positions. They’re using level IIIA vests from GH Armor of Tennessee.

“We just saw that you might need a vest in more than just active-shooter situations,” says Downey. “I was pleasantly surprised at the acceptance of the first distribution of ballistic vests, so when it came time to discuss having them as just an everyday complement to your PPE—like a helmet or gloves or face shield or gown—they understood the vest is just another PPE option you can have and use based on your decision-making and instincts.”

Berardi notes that body armor is in keeping with current ideas about EMS response to mass shootings—that we need to get farther forward and get faster help to casualties.

Kansas City Fire was already on board with those efforts; leaders had worked to train local police in skills like tourniquet use and hemorrhage control. During one of those sessions, a real mass shooting erupted nearby. The city’s emergency community had also endured the 2004 near-murder of Mary Seymour, a paramedic with its old MAST service who was shot twice in the chest while responding to a house fire.8

Together that’s created a pretty receptive audience. “All of us who are first responders—police, fire and EMS—are subject to encountering these situations at a moment’s notice,” says Berardi. “So to have the proper equipment, training and practice is essential to reacting to them.”

Winston had similar thoughts in Cincinnati, where, last summer, someone shot at an ambulance and provider.9 Then an assistant chief, he began pushing for a more thorough approach to armor. At the time the department used police hand-me-downs and didn’t have enough for everyone.

Now chief, Winston is leading a process of fitting and outfitting all 850 of his providers. One of the department’s four districts has already gotten its gear; the other three are scheduled to before year’s end. The vests—level II from Galls—are required to be worn on certain violent and high-threat calls but not all the time.

“As you look around the country and see the violence that’s occurred against firefighters and EMS, I think the mind-set is changing,” Winston says. “I think people are open to more security, depending on some of these circumstances we become involved in. Some of these domestic runs in particular—you just never know how people are going to act.”

As usual in EMS, one size does not fit all. Body armor probably isn’t necessary for every provider in every department across America. But for those with sufficient resources and risk, might it be a worthwhile investment?

Here are some aspects to consider.

Baseline violence levels—While you never know where a shooter may turn up, some communities are more dangerous than others. If you don’t have a lot of violence against fire and EMS, or a lot of violence in general, you may not need body armor.

“Do a risk analysis,” suggests Dworsky. “Has there been violence directed at your crews? When you investigate a violent act against a crew, what was behind it? Is it that they confused your staff with the police? Is it that your crew went in when it should not have? Did they just get caught up in a mob mentality? What was the type of violence perpetrated against it?”

• Type—Body armor comes in multiple levels. Ballistic vests may not offer stab protection. Comfort during prolonged wear is essential. Research your options and trial different possibilities.
• Cost—Ballistic vests can run $700–$800 per person with protective panels and have a shelf life of around five years. Besides capital budgets, grant funds may help departments obtain them. Classifying its vests as PPE got Albuquerque access to grant funds from its state fire marshal’s office.
• Policy—Chiefs face a dilemma here: Mandate vests be worn at all times, and you risk noncompliance. Leave it to providers’ discretion, and they may not have one on when it’s needed. However you craft a policy, it’s good for buy-in to involve the front-liners who will be most affected.
• Training—Any new equipment or policy must be supported by training, and body armor may bring a special challenge: If it brings a feeling of imperviousness to harm, EMS wearers may not behave with appropriate restraint.

“It doesn’t make people invincible, but people often feel invincible, so they have a bit of an attitude change when they put on a ballistic vest—like, ‘You can’t hurt me!’” says Dworsky. “Well, I can still hit you in the head or kick you in the groin—you’re not protected there. But we often see people exhibit a little more bravado when they have safety equipment on.”

• Politics—Vests worn over uniforms or on routine calls may send an inadvertent message.

“We didn’t want to appear to be militarizing ourselves,” says Downey. “We had a long conversation with the mayor and city’s chief administrative officer about the impression we wanted to avoid. We didn’t want it to be misconstrued as a message about the culture of the city—that it’s a violent culture, and if we don’t do this, something bad might happen. It wasn’t any of that, but I anticipated some concerns about the image of it. So we were deliberate in sitting down with our firefighters and discussing our reasoning and striking the balance between mandatory and not mandatory.”

• Identity—Could EMS providers wearing visible vests be confused for cops by potential troublemakers? Does merely displaying them blur a line between medical help and law enforcement? If not for you, what about that next intoxicated or excited delirium patient?

In Cincinnati, police (dark pants, white shirts) and firefighters (dark blue pants and shirts) were always distinguishable, but then a few years ago police switched to darker shirts. “That similarity is definitely a concern,” says Winston. But the vests may be a way to help mitigate it.

“They’re bright red and say Fire,” notes Winston. “We used to not want to identify the fact that we were wearing them, but now, since people can really distinctively tell fire from the police, we do allow them to be worn on top of their uniform shirts as well.”

“We’ve really worked to make sure our identifiers are very big,” says Carlton. “The EMS lettering, the big green trucks we drive… EMS has been a separate division here since 1975, and the community understands and appreciates the work we do. We haven’t had anybody yet confuse us with the police.”

Albuquerque’s vests were originally labeled Fire but changed to EMS to avoid any confusion.

“I thought, Well, if somebody has a gun in their hand, and you have the word Fire on your vest, they’re not thinking fire department, they’re thinking fire the weapon!” says Downey. “So we changed all our vests to clearly indicate EMS—just an example of trying to make our identity very clear.”

• What should accompany it?—Body armor of course does not negate the need for and value of situational awareness, conflict resolution, verbal de-escalation and even self-defense training. Departments concerned about safety should complement any armor usage with an emphasis on these skills as well.
• No perfect solutions—Note the numerous high-profile public-safety victims of violence body armor would not have helped. Detroit EMTs Kelly Adams and Alfredo Rojas were infamously slashed in the hands and face.10 Dallas fire-medic William An, shot in May, was struck in the arm and leg, nearly dying from a nicked femoral artery.11 In 2001 a New Mexico officer died when a bullet went between the protective panels of his vest into his chest.12 Remember that ballistic vests and even full-suit body armor aren’t a magic bullet.

“The ballistic vest is not the single answer. There are multiple facets to solving the problem,” says Dworsky. “You have to have engineering controls, you have to have education. That’s what we do. Because just giving everybody ballistic vests may actually make the problem worse.”

Conclusion

If you think it’s time for body armor in your EMS or fire department, you’re certainly not alone. But know there’s more to implementing it than just buying and handing it out. Cost, training and policy land mines have to be balanced. Ultimately, though, body armor is just another tool providers can use to stay safe on the job.

“It looks to me like what’s being accepted around the country—and I think it’s best to adhere to best practices—is ballistic protection for every position on the rig,” says Berardi. “We work in a labor/management format here, so we’ll decide whether we’re going to put it on every position or maybe just certain apparatus. And we’ll decide what type of protection we want, and whether that will include helmets as well. But the purchase of ballistic protection is something the IAFF supports. The main thing is that we communicate, have a plan and are able to execute that plan properly.”

“We also have to convince our crews that sometimes it’s OK to leave,” adds Dworsky. “I’m not thrilled with you just dropping a $35,000 defibrillator on the floor and running out. But I can go buy another defibrillator. I can’t run down to my local Wal-Mart and buy another paramedic.”

EMSWorld

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