EMERG-ing data: Multi-city surveillance of workplace violence against EMS responders

Abstract

Problem:

Between 1980 and 2021, emergency medical services (EMS) calls experienced a 421% increase, while calls for fires declined by 55%. The more exposure, the more the opportunity for workplace violence (WPV). Due to the non-existence of a reporting system that captures physical and verbal violence, it has been difficult to quantify the degree of WPV experienced by the U.S. fire and rescue service.

Methods:

To describe WPV in three large metropolitan fire departments, an existing data system was modified. The EMERG platform was selected because it is one of the most confidential data systems available to collect exposures.

Results:

In a one-year pilot of EMERG, 126 events were reported. Verbal violence was present in 81% of all reports, with physical violence only at 19%. Patients were the most frequently reported assailant (73%).The most frequently reported injury was emotional stress (70%). Six percent of all injuries reported moderate-to-major physical injury severity, and 30% reported moderate-to-major mental injury severity.

Discussion:

Verbal violence as a contributor to first responder stress is often underestimated. This pilot shows that it can and should be captured. That mental injury severity was consistently rated higher than physical injury severity across all injuries is not surprising given the prevalence of verbal violence reported and because physical violence has emotional sequela.

Summary:

Data from the EMERG reporting system give us evidence, on a larger scale than has ever existed for the fire and rescue service, that verbal and physical violence, and the resultant emotional stress and mental injury severity, is an issue that needs further attention and resources.

Practical Applications:

In order to ensure robust surveillance, it remains likely that triangulation of multiple data sources will still be required to approximate the true burden.

1. Problem

Systematic literature reviews (1978–2016) of violence against first responders using peer-reviewed and industrial literatures found that between 57% and 93% of Emergency Medical Services (EMS) responders reported having experienced an act of workplace violence (WPV) at least once in their careers (Taylor et al., 2017; Murray et al., 2020). EMS responders are workers with paid or volunteer EMS duties, including firefighters, Emergency Medical Technicians (EMT), and paramedics. Paramedics are EMS responders with additional education and advanced clinical skills.

According to Koritsas (2009), WPV has verbal and physical forms. Verbal violence is defined as using offensive language, yelling, or screaming with the intent of offending or frightening. Physical violence is defined as physically attacking or attempting to attack. It includes behaviors such as punching, slapping, kicking, or using a weapon or other object with the intent of causing bodily harm. It also includes property damage or theft (e.g., theft of the ambulance, medication bag), sexual harassment, and sexual assault (Koritsas et al., 2009). The World Health Organization (WHO) expands on this definition to encompass the physical and psychosocial impacts of WPV on employees, stating that violence can be an “explicit or implicit challenge to their safety, wellbeing, or health” (World Health Organization, 2002).

The National Fire Fighter Near-Miss Reporting System identified the most common mechanism of injury on EMS runs to be assault (Taylor et al., 2015). Acts of violence experienced by EMS responders have been described as “hit on the arm during a struggle,” “punched in the eye,” “jumped up and punched right in the face,” and “head butted” (Taylor et al., 2016). While physical assaults are the most reported, systematic reviews of EMS responder WPV revealed that verbal violence is the most prevalent type of violence experienced, and patients being the most prevalent assailant (Taylor et al., 2017; Murray et al., 2020). Verbal violence is the most common form of violence experienced, but it is often not captured in formal reports because workplace incidents without a resultant physical injury are not covered by workers’ compensation. Patient-specific predictors of violence include drug or alcohol intoxication, mental illness, and underlying health conditions (e.g., seizure, hypoglycemia; Taylor et al., 2015).

In 2021, the National Fire Protection Agency (NFPA) reported an estimated 72% of all emergency calls to fire departments were for medical services. In that year, there were 26 million EMS calls to fire departments, a 10% increase from 2020 (National Fire Protection Agency, 2022). The 911 system in the United States is strained by high call volume of non-emergent and low-acuity calls, which make up a large percentage of the workload for EMS responders. As a result of this tenuous system, EMS responders have reported high occupational stress (Cannuscio et al., 2016). Acute and chronic stress, including secondary traumatic stress (also known as compassion fatigue), can result in numerous health symptoms, including severe mental illness (van der Ploeg et al., 2003; Renkiewicz et al., 2022). Occupational stress also plays a contributing role in the high rate of suicidal ideation and suicidal attempts among EMS responders (Stanley et al., 2015; Stanley et al., 2016; Renkiewicz et al., 2022). Exposure to WPV, compounded by pre-existing and cumulative occupational stressors, can have a devastating impact on the physical and psychological health of EMS responders.

Past research has examined reports of violence by EMS responders with the goal of identifying trends in violent encounters. These involve short, post-call questionnaires (Grange & Corbett, 2009) or the examination of the Longitudinal EMT Attributes and Demographics Study II (LEADS II), which collected retrospective exposures to violence (Gormley et al., 2016). However, national violence reporting systems specific to EMS responders are not known to be part of fire and rescue infrastructure. We sought to investigate reporting of violence by modifying an existing confidential reporting system (EMERG) and piloting it with EMS responders in three large metropolitan fire departments. The goals were to: (1) capture reporting of both physical and verbal violence, and (2) analyze reported data to understand the incidence of WPV experienced by fire-based EMS responders.

2. Method

2.1. Partners

Three fire departments and their union locals participated in the study: International Association of Fire Fighters (IAFF) Local 58 and Dallas Fire-Rescue Department; IAFF Local 22 and the Philadelphia Fire Department; IAFF Local 145, San Diego Association of Prehospital Professionals (SDAPP), Teamsters 911, American Medical Response (AMR), and San Diego Fire-Rescue Department. This collaboration was part of a larger workplace violence study, the Stress and Violence to fire-based EMS Responders (SAVER) project (Taylor et al., 2019; Taylor et al., 2022; Murray et al., 2020). The EMERG aim of the SAVER study was union-led and department-supported, meaning unions took the leadership role in recruitment and retention because our previous research found that department members were more comfortable reporting injuries to their unions than to their departments (Taylor et al., 2016).

For the confidential violence reporting system, we partnered with the Center for Leadership, Innovation and Research in Emergency Medical Services (CLIR) (now part of the Center for Patient Safety, https://www.centerforpatientsafety.org/pso). CLIR was involved in several initiatives to improve safety culture, including an incident reporting system called Emergency Medical Error Reduction Group (EMERG). CLIR created EMERG to improve patient and provider safety by encouraging incident reporting, analysis, and sharing of best practices to improve the safety, quality, and consistent delivery of all emergency medical services. The EMERG reporting system was selected for use in the present study because it was a certified Patient Safety Organization (PSO), therefore all data submitted are protected under the Patient Safety and Quality Improvement Act of 2005, codified at 42C.F.R. Part 3, as “Patient Safety Work Product” and are privileged and confidential. This means reports from firefighters and EMS responders are anonymous and protected from discovery and punitive use.

2.2. EMERG Modifications

The existing EMERG reporting system was not specific to EMS responders, nor specific to violent event reporting. Modifications were made to the EMERG system that responded to the needs of the fire and rescue service broadly, and the participating study sites specifically. A diverse group of members from each study site, including leadership, union, paramedics, and dispatch representatives present at the SAVER Model Policy Collaborative (Taylor et al., 2022) contributed to the modification and refinement of the EMERG violence report. Emphasis was made to keep the report as similar as possible across departments to allow for detailed analysis, with small variations to accommodate differences in titles and roles between the departments, as well as other regional/local elements. Each study site was provided a secure, private, department-specific password enabled webpage containing the EMERG report. The only required field on the report was the narrative question “Tell us what happened.” The report also collected voluntary information about the incident, assailant, victim, and injury type, cause, and severity. Please see the Appendix for the data collection instrument. The EMERG pilot began in December 2019 and ended in November 2020. This study was approved by the Drexel University Institutional Review Board.

2.3. EMERG data management

The research team were made analytical contractors to EMERG. Upon completion of the Alliance for Quality Improvement and Patient Safety’s Confidentiality Training (AQIPS; https://www.aqips.org/), they were permitted to extract each department’s data for research purposes. Data from each department were tabulated individually and entered into a combined master dataset. De-identified summary reports were created and shared with the study sites at the end of each quarter. For Quarters 1–3, the number of reports per department were too small to guarantee anonymity, so an aggregate report was shared with the study sites. For Quarter 4, department-specific cumulative reports were developed. Prior to any dissemination of the quarterly reports, drafts were reviewed by CLIR’s legal counsel to ensure all necessary protections of the patient safety status were abided. All reports were inspected and approved for internal dissemination to the departments by CLIR’s legal counsel. Departments were then provided the summary reports and discussions were held with the research team via video conference.

2.4. EMERG data analysis

EMERG reports were analyzed in Excel. Variables included the date and time of the incident, place of assault, method of violence, demographics, and injury type. Certain variables were manually coded. For example, the variable “method of violence” was comprised of multiple response categories (e.g., choked, grabbed, and slurs and hate speech) that would then be grouped together by three separate categories: physical violence, verbal violence, and both verbal and physical violence. Missing data were not imputed. Descriptive summary statistics and data visualizations were included in each quarterly and final report. When data were available, violence reports were cross-referenced with fire department’s workers’ compensation claims for violence-related injuries to evaluate the degree of reporting.

2.5. Health communications campaign and implementation

A comprehensive health communication campaign was developed for each study site. First, a communication needs assessment was completed by the primary labor union and department contacts to ensure that the materials, communication channels, and strategies would resonate with their membership. Next, messaging materials were designed to create awareness of the EMERG system and its protections, empower EMS responders to report all violence exposures, and communicate joint department and union support for reporting all episodes of verbal and physical violence from patients, families, and bystanders to EMERG – regardless of whether an injury occurred. Emphasis was placed on educating how verbal violence may lead to direct psychological outcomes and behavioral health impacts. At the start of each quarter, study sites issued a joint memo from the department’s safety officer and/or EMS commissioner along with the union president to their membership to signify the importance of reporting to EMERG. Lastly, each department identified communication “champions” responsible for creating a culture of reporting and delivering encouragement reminders to members to report their exposures to verbal and physical violence. The champions also served as an internal feedback loop so that comments from the field and insights as to how EMERG and the message campaign was being received could be communicated to the research team. Membership feedback was an important element of EMERG reporting and contributed to the development and preparation of materials for the communication campaign, as updated communication toolkits were provided each quarter.

The communication toolkits were tailored to each department, developed in advance with input from the study site champions. In Quarter 1 (December 2019), departments were given a “launch box,” containing instructional flyers, promotional flyers, and magnets. Materials were distributed and placed in high-traffic areas in stations, ambulances, and hospital EMS rooms. All materials were customized with QR codes and log-in information. The toolkit also featured a FAQ document for department champions and EMS field supervisors, who served a crucial role in empowering members to report their violent encounters. Departments were also provided a digital toolkit, featuring copies of all flyers, a social media campaign “Saturday Safety Tips,” and videos from department and union leaders, department members, the research team, CLIR, and other industry partners. The digital toolkit became the primary method for disseminating communication materials in March 2020 at the start of the COVID-19 pandemic. Approximately five media elements were developed per department each quarter, totaling over 60 flyers across the entire EMERG campaign.

3. Results

3.1. Quantitative data

The EMERG reporting system received 126 violent event reports from three departments in one year. Assailants and responders were predominantly male, with assailants being slightly older on average (TABLE 1).

Table 1.

EMERG Report Demographics (n = 126).

AGE: average (range)
Assailants	Responders
45 (18–91)	34 (20–58)	Years
45	9	Unknown/missing
GENDER: n (%)
Assailants	Responders
91 (72.2)	93 (73.8)	Male
32 (25.4)	33 (26.2)	Female
2	0	Unknown/missing
JOB EXPERIENCE: average (range)
Assailants	Responders
N/A	10 (1–30)	Years
RACE: %
Assailants	Responders
2%	0%	Alaskan Native
3%	1%	Asian
43%	5%	Black/African American
1%	0%	Native American
16%	8%	Latino
4%	1%	Middle Eastern
1%	0%	Native Hawaiian
37%	78%	White
1%	1%	Choose not to say

Since only the free text response was required, the total number of responses in each figure varies from the total reports received. The “Method of violence” category was filled in for 124 out of 126 reports (98%). Physical violence was present in 41% (n = 51) of reports, with “verbal only” (40%, n = 49) more common than “physical only” (19%, n = 24) [data not shown].

Eighty-two (82) injuries were found in 68 reports [Fig. 1a]. Emotional stress was the most common injury reported (n = 52). Six percent of all injuries reported moderate-to-major physical injury severity, and 30% reported moderate-to-major mental injury severity (Fig. 1b).

Fig. 1.

Injury Type.

1a: Injury Type (n=82)

1b: All Injuries (n=82)

1c: Physical injury only (n=40)

1d: Emotional Stress Injury Only with no mention of physical injury (n=42)

The case inclusion criteria for “physical injury only” required that the person sustained a physical injury alone or in combination with emotional stress. Of the 40 physical injuries reported, 10 had emotional stress also selected as a form of injury (25%). Looking at physical injuries only, 13% were determined to have physical injury severity from moderate-to-major, whereas 28% of physical injuries were reported as having moderate-to-major mental injury severity (Fig. 1c).

The case inclusion criteria for “emotional stress injury only” was if the respondent only reported one injury, that cause was emotional stress, and no other physical injuries were noted (n = 42). Looking at the mental injury severity ratings of emotional stress injuries only, 57% were rated as minor, 29% as moderate, and 5% as major (Fig. 1d). Across all injury types, emotional stress injury was rated as having higher severity than physical injury.

Patients were the most common assailant (73%, n = 90), and agitation and intoxication were reported as the top two underlying conditions related to violence against responders. Assailants were reported as male in 73% (n = 91) of responses (Fig. 2).

Fig. 2.

Violent person type, gender, and underlying condition.

2a: Violent Person(s) of 123 respondents reporting

2b: Violent Person(s) Gender of 125 respondents reporting

2c: Underlying Condition of Violent Persons of 104 respondents reporting

We asked the responders about notification of fire department leadership and law enforcement involvement regarding the violent event. Fifty-two (52) percent of participants did not report the violent event to their department (n = 64). Law enforcement was on scene 44% of the time (n = 54), and assailants were arrested in 16% of reports (n = 19) (TABLE 2).

Table 2.

Departmental Notification and Police Involvement.

	Did you report this incident to your department?		Was law enforcement notified of the incident?		Was law enforcement present on scene?		Was the assailant(s) arrested?
	n	%	n	%	n	%	n	%
No	64	52%	51	41%	68	55%	88	75%
Yes	52	42%	67	54%	54	44%	19	16%
Unknown	7	6%	6	5%	1	1%	10	9%
Total	123	98	124	98	123	98	117	93

3.2. Narrative data

Examples of free-text responses to the prompt, “Tell us what happened” describing the event are organized by type of violence (e.g., physical, verbal, both) in Table 3. This was a required field with no limits on word length and respondents were very detailed in their descriptions as the following example and Table 3 illuminate. Complete reports are available in the online Appendix (n = 126).

Table 3.

Examples from EMERG Narrative Data by Violence Type.

Physical	Verbal	Both
“As we arrived, the patient reached down into the lifeguard’s medical bag and pulled out a pair of scissors and began cutting himself, then standing up waving the scissors in a threatening manner towards the crews. Patient was agitated, erratic, not making sense or following instructions.”	“After the run the patient was walking away the boyfriend walked up to the window of the rescue asking what the patient told EMS. EMS asked the patient to back up because he was not wearing a mask. The patient then states I am going to shoot you. EMS drove away from boyfriend.”	“During transfer from wheelchair to gurney of a combative psych patient I was punched in the left jaw by the patient. He threatened to assault all personnel on scene and while I was trying to remove items from his lap so they wouldn’t get dropped or broken during the transfer he swung on me and connected.”
anywhere from 10 to 12 minutes.”	outfit and letting his hair down so he wouldn’t be recognized). I had to be escorted to my car because he tried following me to my car after work.”
chair, she grabbed my left forearm and scratched me, digging her fingernails in, breaking the skin and causing an inch-long laceration which bled. Patient continued to squeeze my arm and dig the fingernails in, causing further bruising. I was unable to remove her hand from my arm as I was lifting her.”	the women until police arrived to assist. No physical assault occurred. This incident was the 5th in a string of verbal and physical violence related incidents I had in a one-month period.”	security very loudly and aggressively.”

We were in transport to the hospital with an individual who was in custody for ingesting 40 g of heroin (per the patient and officer). We picked the patient up at the jail. The officer stated he was going to be following the ambulance to the hospital because he was a single officer in his car and no one else was available to ride in the ambulance. Prior to transport while still at scene with police, the patient was placed in soft restraints due to behavior and concern of EMS safety. The patient was moved to the ambulance where transport continued to hospital. Once the ambulance began traveling, the patient told me to remove the restraints. The restraints remained and were not adjusted. Patient was able to, at one point, unbuckle his shoulder straps. Once patient was able to unbuckle the straps, he leaned forward and began trying to bite the restraint knot on the gurney. Patient was stopped from this act. The patient was able to remove his legs from under the seatbelt buckle. Patient swung his legs over to the bench seat and was able to kick a pair of trauma shears loose from the bench seat seatbelt harness. This act, once noticed of what his intentions were, was also immediately stopped. Paramedic went to jump seat in the ambulance to stand by and monitor the patient. The patient was able to kick the IV tray and have items from the IV tray go loose. At this time, partner pulled the ambulance over and requested police. Partner came to assist me in the ambulance, and we noted the patient was able to gain control of a pair of scissors in the ambulance. A fight to seize the scissors from the patient began. The patient was in a sitting position on the side of the gurney with his legs off the side to his left. By now, the right arm restraint had broken and the patient had movement of his right arm freely, the strap on his left arm had pulled so hard that he had more movement to his left arm as well, unsure if the restraint on his left arm held up and kept him restrained. Once noted the patient had scissors in his hand, this was called out loudly in the back of the ambulance for the safety of my partner and I. A “cover now”* was aired on the radio for immediate assistance from the police. Over four minutes went by before the first officer showed up at scene. Dispatch on the fire dispatch medical had to confirm our location, they also sent a “cover now” and officers to the wrong location as my partner and I attempted to restrain a patient with a deadly weapon. Patient held the scissors in an aggressive manner. I was able to grab one end of the scissors and repeatedly told the patient to release his hand but he did not. Patient was told several times to relax and cooperate and did not. This gives me the impression he had a high intent of harming either himself or EMS crew. Patient was placed in a carotid restraint by me in the ambulance and was controlled from there forward. Patient dropped the pair of scissors in the ambulance. Patient was controlled until police arrival at scene. Once the police arrived, they took custody of the patient. Medic continued transport of the patient to hospital where he was evaluated. Entirety of the call is all recorded on our monitor.

*“Cover now” is a code used by the responder for immediate assistance due to imminent danger

We asked respondents, “In your opinion, what caused this violent event?” (Table 4) Thirty-seven (37) percent felt that the event was caused by the assailants’s drug or alcohol use. EMS responders specifically noted “ETOH” (ethyl alcohol), PCP (phencyclidine) and K2 (a synthetic cannabinoid) as substances used most often among violent patients. Twenty-three (23) percent reported that the violent event was caused by the assailant’s general agitation or dissatisfaction with EMS response, especially regarding slow response times or perceived low quality of care.

Table 4.

Provider Opinion of Underlying Cause.

Cause	n	%
Drugs/alcohol	47	37.30%
Blank	20	15.87%
Agitation/Dissatisfaction with EMS	29	23.02%
Unknown	13	10.32%
Mental health diagnosis	7	5.56%
Underlying medical condition	6	4.76%
Law enforcement presence	4	3.17%
Total	126

4. Discussion

The one-year pilot of the modified EMERG reporting system received 126 violent event reports from three metropolitan fire departments. Verbal violence was more commonly reported than physical and was present in 81% of all reports. As we have seen in our prior review of the scientific and gray literatures, verbal violence was the more common form of workplace violence experienced by this group of fire and rescue service members (Murray et al., 2020). Patients were the most common assailants, and their top two conditions were agitation and intoxication.

Of all injuries reported, emotional stress was the most common. This seems logical given the prevalence of verbal violence reported and because firefighters have previously reported that physical violence has emotional sequela (Taylor et al., 2016). Additionally, 25% of physical injuries also had mention of a concurrent emotional stress injury. Mental injury severity was consistently rated higher than physical injury severity across all injuries.

We include all narratives reported in an online supplement so that the scientific community and public may more deeply appreciate the lived experiences of those who respond to 911 calls. It is distressing to read these narratives and realize what EMS responders deal with every day. Multiplying each story with the increasing number of calls that EMS is running, it is very easy to visualize how this must be exacting an emotional toll. Violence should not be an accepted or expected part of the job, but it has been for decades. This study, along with the supporting scientific and grey literatures, supports the need for systems-level approaches to violence prevention in the fire and rescue service, with a focus on and primary prevention.

There are limitations to consider with this study. First, nonresponse bias may be present, as those who reported to the system may have been more motivated to do so than colleagues who did not. Second, there were no restrictions implemented in EMERG to limit how many times an individual responder reported an event nor were there restrictions on how many responders could report the same event. Upon inspection of the narratives, we did not find any duplicate reports by the same person for one event, but we did observe multiple reports by different people of the same event. We estimate that this was less than 10% of all reports.

Third, most data elements were collected through predetermined checkboxes. Brief definitions were provided for each category. While there is always the possibility that respondents may not have understood the categories or definitions, this was proactively addressed by having each fire department contribute to the final data elements. EMS responders are used to filling out first report of injury forms with similar categories, in addition to being skilled healthcare providers, so we feel confident that they know the difference between emotional stress and head injury. For the same reason, we also feel confident that they can objectively approximate categories such as injury severity, despite the self-reported nature of the EMERG report and individual subjectivity of certain response categories. Additionally, the data captured the opinions and descriptions of the EMS responders, so there could be misclassification error in data on patient characteristics. Data were not linked to Patient Care Reports, which would have allowed for more detailed descriptions of the patient, their medical history, and medical treatment provided.

Lastly, as this was a feasibility pilot, the findings presented here are only representative of the three large-metropolitan department participants and are not generalizable to the United States fire and rescue service. Data that we collected for the last 10 years through our relationship with one of the three departments show an annual average of 5–10 workers’ compensation claims for violent injury. With EMERG, even though it was a new system, we saw quadruple the number of reports in six months than we saw in one-year previously. In this department, the number of violent events reported to workers’ compensation in 2019 was 24, while the number to EMERG was 47. Since we did not capture unique identifiers in EMERG, we are unable to discern why there was a difference in reporting. It may be that EMERG captured more events because it included both verbal and physical violence, whereas workers’ compensation systems only capture injury from physical violence resulting in lost time.

Due to the non-existence of a widely available reporting system that captures physical and verbal violence, it has been difficult for researchers to quantify the degree of WPV experienced by the U.S. fire and rescue service. While there are limitations to this study, the findings are remarkable because we have collected the industry’s largest sample of real-time verbal violence reports to date. This is significant because resources, both funding and otherwise, to investigate this issue are challenging to secure. Indeed, EMERG and the larger SAVER grant that the present study is seated within, is the very first FEMA-funded grant to address the EMS-side of the fire service. These data give us evidence, on a larger scale than has ever existed for the fire and rescue service, that verbal and physical violence, and the resultant emotional stress and mental injury severity, is an issue that needs further attention and resources.

The strengths of this study include the modification of an existing reporting system by the fire and rescue service for the purpose of workplace violence data collection. The strong understanding of EMS responders who participated in the pilot about the importance of reporting verbal violence showed that it can and should be captured. The communication campaign that emphasized the importance of reporting both physical and verbal violence likely strengthened EMS responder understanding of verbal violence and the need to report such events. We were glad to see this reporting outcome since violent events without physical injury are not captured anywhere. While we wait for the development of more inclusive violence data reporting systems, there are actions that unions, fire departments, and EMS agencies can take immediately to protect their members. The fire and rescue service developed SAVER Model Policies (Taylor et al., 2022) and Systems-level Checklist (Taylor et al., 2019), which are ready for implementation. These interventions are fire-service specific, but organizations that routinely encounter workplace violence (such as health care and education) could easily adapt them to their unique contexts. Any agencies wishing to receive help with policy adoption and subsequent evaluation are encouraged to contact the authors.

5. Summary

In one year of EMERG operation, we received 126 reports from three fire departments. Verbal violence was the most frequently reported type of violence (81%) and the most frequently reported injury was emotional stress (70%). A closer look at the method of verbal violence revealed general verbal violence (68%), verbal violence using slurs and hate speech (45%), and graphic threats (39%) as the top three types of verbal violence encountered. We wish to amplify the discussion of verbal violence in the results of this study because it is often underestimated as a contributor to EMS responder stress. While physical violence may make the front page of the newspaper, it is dealing with the day-to-day insults and slights that accumulate psychologically in an EMS responder’s mind. These moral injuries may find their equivalency with physical injuries and in fact may exceed them in terms of their longevity and impact on performance. The results from the EMERG reporting system can inform estimates of workplace violence in the fire and rescue service, however, to ensure useful surveillance, it remains likely that triangulation of multiple data sources will still be required to approximate the true burden. It would be helpful if other national data sources collecting violence exposure data collaborate to harmonize their methods and data dictionaries.

Biographies

Dr. Jennifer Taylor is the Director of the Center for Firefighter Injury Research & Safety Trends (FIRST) and the Arthur L. and Joanne B. Frank Professor of Environmental & Occupational Health. Her research unites evidence from the fields of injury prevention and control, quality improvement, and occupational safety. She received her PhD in Health Policy and Management from the Johns Hopkins Bloomberg School of Public Health and holds the Certified Professional in Patient Safety board certification.

Regan Murray is the assistant director of the Center for Media, Technology, and Health in the Department of Health, Human Performance and Recreation at the College of Education and Health Professions at the University of Arkansas. Prior to joining the U of A, Ms. Murray was FIRST Center project manager of the Stress and Violence in fire-based EMS Responders (SAVER) project from 2017 to 2020. She holds a BA in African Studies and History from St. Lawrence University, and an MPH in Community Health and Prevention from the Drexel University Dornsife School of Public Health.

Margaret Binzer is the past legal counsel for CLIR. She serves as the Executive Director of the Alliance for Quality Improvement and Patient Safety, the nation’s leading professional association for PSOs and their healthcare provider members that leads efforts to measurably improve patient safety and the quality of patient care by fostering the ability of providers to implement a culture of safety and high reliability. Ms. Binzer spearheaded the Patient Safety and Quality Improvement Act (PSQIA) while serving as senior health counsel for the U.S. Senate Health, Education, Labor and Pensions Committee.

Captain Robert Borse, Dallas Fire-Rescue Department and IAFF Local 58. He served the study site champion for the SAVER project in Dallas, TX. He is the chairperson of Dallas Fire-Rescue EMS Council and an Adjunct Instructor at Dallas Fire-Rescue. Lt. Borse received his BA from the University of Dallas.

Andrea Davis is the Associate Director for the Center for Firefighter Injury Research and Safety Trends (FIRST). Ms. Davis oversees the day-to-day operations of the FIRST Center, including all research grants and contracts, management of all FIRST Center staff and students, and serves as the qualitative expert on our team. Ms. Davis, who holds the designation of Certified in Public health (CPH) from the National Board of Public Health Examiners, received a BA degree from the University of Delaware, an MLA from the Harvard University Extension School, and an MPH in Environmental and Occupational Health from the Drexel University Dornsife School of Public Health.

Ms. Victoria Gallogly is the Outreach and Communication Coordinator for the Center for Firefighter Injury Research and Safety Trends (FIRST). Ms. Gallogly manages and updates the FIRST Center’s website, social media, and press, and also assists with day-to-day research activities at the FIRST Center. Ms. Gallogly received a BS in Public Health with a minor in Communication in 2021 and an MPH in Environmental and Occupational Health with a minor in Communication, Culture, and Media in 2022, both from the Drexel University Dornsife School of Public Health as part of the accelerated BS/MPH program.

Rozhan Ghanbari is a research scientist for the Maternal, Child and Adolescent Health Division in the Epidemiology, Surveillance and Federal Reporting Section at the California Department of Public Health. She received her BS in Public Health from the University of Alabama at Birmingham and her MPH in Epidemiology with a minor in Public Health Emergency Preparedness from the Drexel University Dornsife School of Public Health.

Lieutenant Diane McKinsey is a paramedic with the City of Philadelphia Fire Department and IAFF Local 22. She served the study site champion for the SAVER project in Philadelphia, PA. She serves on the Mayor’s Diversity, Equity and Inclusion cohort committed to creating a more equitable Philadelphia.

Battalion Chief David Picone is the health and safety officer for the City of San Diego Fire-Rescue Department and IAFF Local 145. He served as the study site champion for the SAVER project in San Diego, CA. He received the 2020 Chief Sandy Davis Safety Officer of the Year Award. Chief Picone received his BA in Vocation Education, Fire Management and Science from California State University Long Beach.

Gary Wingrove is the previous Executive Director of the Center for Leadership, Innovation, and Research in EMS (CLIR). He is now the President of The Paramedic Foundation. He also serves as Director of Strategic Affairs for Mayo Clinic Medical Transport in Minnesota and he is President of The Paramedic Foundation. He is past president of the National Emergency Medical Services Management Association, chairs the International Roundtable on Community Paramedicine and is president of The Paramedic Foundation, and is a former Minnesota state EMS director. He serves on Community Paramedicine committees of the National Association of EMS Physicians, the National Association of EMTs and the National Association of State EMS Officials.

Appendix. SAVER EMERG Violent Reporting Form data elements

Question	Response Categories
EVENT DESCRIPTION
Event description/details (free response)	• Tell us what happened: [text box] *
	• Incident # (from your CAD system): [text box]
	• Date and Time of Incident: [text box]
Phase of call when violence occurred (select all that apply)	• On scene
	• Medical Treatment
	• Transportation
	• Emergency Department
	• Other: [text box]
Place of assault (select all that apply)	• Ambulance
	• Fire Apparatus or Emergency Vehicle
	• Home or Residence
	• Street or Highway
	• Healthcare Facility
	• Nursing Home
	• Prison or Jail
	• Firehouse
	• Office Building
	• Bar or Restaurant
	• Arena or Sporting venue
	• Retail store
	• School
	• Homeless shelter
	• Industrial place and Premises
	• Park or Public Area
	• Lake, River, Ocean, Beach, or Bay
	• Other Location: [text box]
Method of violence (select all that apply)	• Verbal violence
	• Intimidation
	• Property damage or theft
	• Sexual Harassment
	• Sexual Assault
	• Human Bite
	• Spit at
	• Peed on
	• Push/shove
	• Kicked
	• Grabbed
	• Choked
	• Struck/punched
	• Weapon: ambulance equipment
	• Weapon: mace, pepper, chemical
	• Weapon: club, bat
	• Weapon: knife
	• Weapon: firearm
	• Weapon: explosive
	• Other: [text box]
Event address (free response)	If you would like to provide the address of the incident, please do so here: [text box]
Did you have prior knowledge of this being a violent location and/or person? (Choose one)	• Yes
	• No
Did you receive this information from: (choose one)	• CAD
	• Dispatcher
	• Law Enforcement
	• Previous experience with Patient or Location
	• Other
ABOUT YOU
Practitioner level (choose one)	• Single Role Firefighter
	• Single Role EMT
	• Single Role Paramedic
	• Firefighter/EMT
	• Firefighter/Paramedic
	• Supervisor/Manager
Experience (free response)	• How many total years of Fire/EMS experience do you have?
	• How many years have you been in this department? [text box]
Gender (choose one)	• Female
	• Male
	• Other
Race (select all that apply)	• Alaska Native
	• Asian
	• Black/African American
	• Caucasian
	• First Nation/Native American
	• Hispanic
	• Native Hawaiian/Pacific Islander
	• Other
	• Choose not to report
Injury type (select all that apply)	• Emotional Stress
	• Burn
	• Chemical exposure, including mace/CS, drugs
	• Gunshot wound, blast injury
	• Head Injury/Concussion
	• Infectious exposure, any route
	• Muscle or joint sprain/Strain
	• Stab, puncture, impalement
	• Sexual assault
	• Smother/suffocation/strangulation
	• Soft tissue
	• Other
Physical Injury Severity (select all that apply)	• Minor (no care required)
	• Moderate (medical care received)
	• Major (hospitalized)
	• None
Mental Injury Severity (select all that apply)	• Minor (e.g., bothered me, but no big deal)
	• Moderate (e.g., stayed with me for a day or more)
	• Major (e.g., interrupted my ability to work, not over it yet)
	• None
Event consequences (select all that apply)	• Loss of work time (temporary)
	• Reassigned to light duty
	• Permanent injury/disability
	• Job resignation/dismissal
	• Professional mental health counseling/care
	• CISM debrief/defuse
	• Assault charges or suit filed
	• Substance abuse
	• Loss or inability to sleep
	• Loss of appetite
	• Anxiety
	• Fear
	• Nightmares
	• Unknown at this time
	• No consequences
	• Other
ASSAILANT INFORMATION
Number of assailants (free response)	• Number of assailants: [text box]
Assailant description (choose one)	• Patient
	• Patient’s family/household member
	• Bystander
	• Other
Assailant age (free response)	• Assailant age: [text box]
Assailant gender (choose one)	• Female
	• Male
	• Undetermined
Assailant race (select all that apply)	• Alaska Native
	• Asian
	• Black/African American
	• Caucasian
	• First Nation/Native American
	• Hispanic
	• Native Hawaiian/Pacific Islander
	• Other
	• Choose not to report
If the patient committed the violence you experienced, what was their underlying medical condition or state? (Select all that apply)	• Diabetes
	• Altered state of consciousness/mental status
	• Agitation
	• Seizures
	• Intellectual or behavioral disability
	• Intoxication or substance abuse (drugs or alcohol)
	• Trauma
	• Mental illness
	• None known
	• Other: [text box]
In your opinion, what was the intent of the violence you experienced? (Choose one)	• Unintentional
	• Intentional
	• Unknown or Unsure
GENERAL INFORMATION
Did you report this incident to your department? (Choose one)	• Yes
	• No
	• Unknown
Was law enforcement notified of the incident? (Choose one)	• Yes
	• No
	• Unknown
Was law enforcement present on scene? (Choose one)	• Yes
	• No
	• Unknown
Was the assailant(s) arrested? (Choose one)	• Yes
	• No
	• Unknown
	• Other: [text box]
Cause of event (free response)	• Provide your opinion as to the cause of this violent event: [text box]
Event prevention (free response)	• Provide any suggestions that would prevent another similar event

^*Indicates a required field

Online Supplement_Narratives by violence type

Verbal Violence Only

1. In the back of the rescue during patient care initially patient was being non compliant with cops. After trying to talking with patient, patient was being noncompliance with ems by refusing to answer questions about demographics using vulgar language. After saliva splatter from pronunciation and apology that followed with it, patient then became angry. Explained to patient it was an accident. Threatened to attack patient once he gets out of hand cuffs. Delaying care when wouldnt answer questions about age for 12 lead by saying things about attending mothers age and genitalia. After refusing medication that delayed care, patient threatened to look up attending address and attack patient. When talking to police after dropping patient off, patient began to intimidate attending medic

2. Verbally assaulted by the operator of a vehicle involved in a traffic accident

3. Verbally assaulted multiple times, threatened with violence

4. Patient told me “f@$! You” when I attempted to get identification from her

5. A male resident became irate towards us after I asked patient if he used any drugs and/or alcohol tonight. Male resident made various threats towards us with some being sexual in nature. We left apartment swiftly and male continued screaming at us and as we were assessing patient in the safety of the ambulance that male came outside and screamed more violent threats at us.

6. Male patient became combative swinging arms and legs and making verbal threats towards me and others at scene. Patient was found unconscious with cyanosis, Narcan was administered and high flow O2. When patient returned to an alert status verbal and physical barrage occurred.

7. Received call for unresponsive male in auto on scene was found several people standing around a parked car as I approached the vehicle a Women who claimed to be an ER nurse said that the person in the car had OD just then the woman in the car got out and I asked her if she was alright and she said she was fine that she was sitting in her car waiting for her food order. I then said alright and started to walk away when the first woman got angry and said that’s it your not going to do anything and I said first of all I don’t know who you are and second there was nothing for me to do. Then she asked my name and said I would be hearing from a Battalion Chief. She was very angry I felt threatened by her actions. Again she said that I didn’t know her but I would. The other woman got in her car because she was clearly afraid of the other woman and drove off.

8. Dispatched for a sick person. On arrival the patient said he wanted to go home, he said call me a fucking cab. We informed him we can take him to the hospital but we can’t call him a cab. The patient stated “don’t get wise with me mother fucker. I’m a marine and I will kick your fucking ass.” The EMT calmly told the patient to calm down there is no need for that. That we are here to help him. He sat back down and did not speak until the arrival of the medic unit.

9. Father of patient verbally abusive and confrontational with engine company and medics. Crews remained professional and were eventually able to calm down father.

10. This afternoon one of my dispatchers received a 911 caller from a irate male asking her to tell him about “Frazzledrip.” She wasn’t familiar with the term and asked him for clarification. He began yelling and using foul language and requested the supervisor. At the time I wasn’t available and she tried to get his information so I could call him back, he was barely listening to her and continued to yell, curse, and began using racial slurs including the N word. Eventually he disconnected the line. A couple hours later he called again and another dispatcher answered the phone and it was much of the same asking her about Frazzledrip, cursing and racial slurs. Fortunately I was available to take his call at this time once he was transferred to me it was more of the same. Just in case there was a possibility Frazzledrip was somehow fire related I did google the term while he was on the line. Once I realized it referenced political conspiracy theories I advised the caller that this isn’t fire related which resulted in more slurs and verbal abuse and eventually he disconnected. He called back a short time later and again got a dispatcher who immediately transferred the call to me, and when I answered he disconnected again.

11. While assessing a patient we were approached and interrupted by multiple bystanders. We were victims of verbal abuse while caring for a patient.

12. Rescue was dispatched to a medical emergency. When we arrived we found a patient that was complaining of having a nosebleed. During assessment of the patient the patient got extremely agitated and continued to threaten to assault EMS crew for asking questions. Patient then started to urinate next to EMS and yell at EMS that he could do whatever he wanted. EMS tried to calm patient and further assess and treat him but patient continued to yell and threaten crew until he left the scene. No further assessment, treatment or altercations occurred after patient left scene.

13. Medic crew was dispatched for a seizure. Patient walked down in no distress. Told EMS and Engine crew he had abdominal pain. Upon asking questions related to why he said seizures. Patient said F You guys. Flicks us off and walks out of ambulance in no distress. Verbally abusing us and 911 system.

14. Responder was about to leave when a male employee approached the ambulance driver, causing him to stop transportation to the Emergency Room. The male employee appeared agitated informing the responder of how the paramedics did not get a temperature check when entering “His” establishment. Responder assured the male employee that emergency personnel, routinely and daily, check for fever, and that the responder was not aware of their own fever check routine. The male employee became agitated and accusatory, asking for quite a bit of information. Meanwhile, the paramedic, after realizing that they were not transporting the patient, went to the front of the ambulance to find out why the ambulance was not going to the emergency room for adequate patient care. At that time the male employee became even more agitated. After the paramedic advised the ambulance driver to proceed with transportation, the male yelled at the two medics, saying “Get the **** off my property. Take yall’s **** off my property.”

15. After the run the patient was walking away, the boyfriend walked up to the window of the rescue asking what the patient told ems. EMS asked the boyfriend to back up because he was not wearing a mask. The patient then states ‘I am going to shoot you.’ EMS drove away from boyfriend.

16. Upon rejoining the medic crew the patient was muttering something. I told him “I don’t know what that means” and was immediately verbally abused with a profanity laced diatribe labeling me both “the devil” and “racist cracker”

17. Responder arrived on scene to find a female leaning on the bed dry heaving. As responder walked into the room her daughter told us she has had this before and that she has a “gastrointestinal thing” and “it’s worse than an ulcer.” Her daughter kept telling us “She needs to go STAT”. Responder attempted to ascertain more information from both the woman and her daughter to better understand her condition and how best to treat it. Her daughter continued to interrupt the responder saying “they don’t care about you”. She told us “she coded the last time this happened” and “That hospital can’t do anything for her, she needs to go to a different hospital.” Responder told her if her condition is that serious we would need to take her to the closest appropriate facility. Her daughter then got verbally aggressive with responder saying “you can get the f*** out of my house,” and “you are a racist son of a b****.” Responder was never even able to speak to the patient. Patient’s daughter chased EMS outside screaming once again.

18. Patient was verbally abusive to EMS. Patient repeatedly cussed at EMS during patient assessment.

19. Upon making patient contact the suspected patient began cursing and using racial slurs towards responders without provocation.

20. EMS was called for medical emergency by police at airport baggage claim. 3 EMS arrived on scene to find caregiver of patient very irritated and mad that EMS was called out. Patient has insulin issues and we were called for evaluation. Patient was alert and oriented he is not considered a patient at this time. Caregiver gave EMS and police very verbal abusive treatment to the needs and concerns at this time we together were verbally assaulted and made me feel insufficient towards work. Engine crew had patient sign and we left.

21. EMS was attempting to treat a patient w/ shortness of breath when the patient’s wife began to verbally abuse EMS continually interrupting EMS and shouting at EMS stating that we were refusing to help the patient. When asking for ID, the wife shoved it at EMS and yelled “There! Thats what you wanted!” When asked to please put out her cigarette due to patient’s shortness of breath, wife yelled at EMS “I can do what I want!!” and continued to smoke.

22. This call was a respiratory failure patient that coded on us before we could stabilize/transport. Throughout the incident, the patient’s wife, identifying as a former nurse, berated responders and repeatedly attempted to dissuade them from providing care in the field, per protocol. The woman did not respond to therapeutic speech or attempts to explain current resuscitation science, and threatened to ‘make you regret it’, as far as not immediately transporting the patient.

23. Verbally abused by patient’s family because we took the patient to the closest facility instead of the hospital of his choice

24. Patient was cursing and threatening me

25. Patient verbalizing threats with racial slurs, aggressively charging towards EMS, spitting at providers

26. Patient stated I looked mean and called me a cunt. He repeated this 3x. I did not say 2 words to this man. He treated my male partner with respect and kept calling me names.

27. Verbal abuse from patient using profanity. Called dumb/stupid because of our routing to the hospital.

28. Patient verbally abused and threatened crew member. Patient stated he is going to crack crew member’s ribs and repeatedly calls crew ‘stupid’and ‘idiot’

29. While finishing up an against medical advice at the scene, a elderly woman who appeared homeless walked up and spat at the ambulance. As a crew we did not engage the woman. We left the scene and was dispatched to another call.

30. Responded to a man down in the alley - upon arrival found a male passed out drunk with a large pitbull - patient awoke and became agitated towards crews and non-compliant. Patient was intoxicated and was also aggravated at a bystander with two large dogs. He refused to comply and back down, yelling and acting irrational towards both my crew and the bystander. We found ourselves in the middle of the argument with the bystander. Police were not at scene. Patient had no chief complaint, he was only sleeping and etoh. Police arrived after calling for a no code cover and took the patient into custody.

31. Patient made several verbal threats against me and my partner. He was doing the same thing to the engine crew when we arrived to the scene.

32. When we were trying to ask the patient what was going on he would yell ‘just take me to the f***ing hospital’ and called us a Motherf***er.

33. Responder arrived on scene to find a 52 year old male, lying in bed, complaining of lower leg pain in both legs for a week. Patient was alert to EMS and stated he had been to the doctor twice but they did not do anything and the swelling is getting worse and so is the pain. Responder evaluated patient. Responder offered transport to hospital. Patient’s brother stated he wanted him to go to another hospital. Responder attempted to talk to patient and explain that we did not want to travel to hospitals further away when the patient’s brother began yelling at us saying we did not want to take him to the hospital. Responder attempted to calm the brother down saying that we wanted to take him but the brother began yelling at us to get out. Responder attempted to speak to the patient but the brother continued to yell and curse at responder. Responder told the patient we wanted to transport him but the patient told us to leave because he did not want to argue with this broither. Responder attempted to speak to the brother so that could transport but the brother yelled for us to leave. Audio of the brother yelling was obtained.

34. My partner and I were verbally assaulted and threatened with physical harm by the son of our patient. No physical harm came to either of us

35. I’m reporting on behalf of one of our female employees. She was left a highly inappropriate note on her vehicle at her work station by an unknown person. It was sexually explicit and harassing which greatly upset her.

36. I noticed a women on the beach who hadn’t moved her position of laying down all day, I asked a Park Ranger to check on her level of consciousness and he noticed she had several cans of alcohol by her side and the park ranger flagged down the Police Department. The Police notified me she was citied once early in the day for having an alcoholic beverage on the beach and the they would escort her off the beach. She than become verbally aggressive not only to me but as well as the police officers. She called me multiple derogatory words and complained for being disturbed on the beach. She called me a “bitch” and also stated, “ That stupid, ass lifeguard needs to mind her own business”. She was than escorted off the beach by police and was arrested on scene.

37. I received a 911 call in which the caller became very aggitated after being asked her phone number. Upon asking clarification as to why she believed the patient was on drugs, she began swearing at me and became verbally abusive in a continuous rant, and hung up before any description of the patient or triage could be conducted.

38. Patient was verbally aggressive with our crew. She cussed at us and threatened us. She took our cleaning spray and threw it outside the rig. She flipped tables and chairs over at the hospital. She charged at me and at hospital security very loudly and aggressively.

39. Patient was being verbally aggressive with police and medics. Patient called me a ‘cunt’. Not cooperative with personnel.

40. We ran on a mixed race female after she was involved in an altercation. We tried to assess her injuries and she kept yelling at us to fix the situation. She repeatedly cut EMS off while we attempted to ascertain the extent of her injures, saying we weren’t listening and what were we going to do about it. She then started acting like we were calling the cops on her with the intent of getting her arrested (our crew was all Caucasian). At one point she knelt down and put her hands behind her back despite us continuing to try and assess her physical needs. Eventually she just walked away…So basically she called us there, yelled at us, accused us of being racist, and then left.

41. Patient mother yelling at EMS and getting into EMS personal space. With patient on stretcher mother continued to increase verbal violence towards crew while physically barricading the door with her body but yelling at EMS to take patient to hospital.

42. The patient became violent and began to curse and threaten me. Saying “Fuck you, Imma get you touched you! What the fuck are you doin?” Finally, we got to the ER and went to place the patient in the bed in the hallway. Patient began to violently lash out at everyone, cursing and threatening me and everyone around him, “Imma get y’all touched, Fuck y’all! I’m from the streets! I don’t wanna get in the bed, Imma sue the city.” Patient said racial slurs at others. Patient almost got out of the stretcher threatening to hurt someone. Security was able to pull him back onto the stretcher. Patient continued to yell and curse at everyone for 10 mins.

43. Verbally abusive homeless person refused to leave train station by transit police. States unable to walk and forced EMS to carry him out. Walked without assistance once at hospital. Transit shut down all handicap entrances and exits. Transit police called EMS to clear homeless people from train station.

44. A homeless person with no apparent life threatening illness refused to walk upstairs for police. Person told police to “get that chair the ambulance has”. No elevator access was available to get to the patient. Police advised patient be carried up the steps. Ladder crew called to assist medic unit to carry person up 3 flights of steps. The ladder captain called for a transit supervisor to come on scene to figure out why the train station has no elevator access and why station was fenced off from entry. Patient was verbally abusive to EMS and self ambulated himself in triage at hospital.

45. Patient was extremely belligerent towards crew.

46. Medic unit responded to a sick female, Ladder company also responded for forced entry. After Ladder made entry into patient’s apartment, EMS made patient contact. Patient was sitting upright unassisted. Patient complaining of right arm and right leg numbness following a flu shot. Once fire personnel left scene patient began insulting EMS crew. Patient demanded EMS crew find multiple different wigs and clothes and demanded EMS dress the patient. Patient states they urinated on themselves and the floor so EMS needed to clean it. When EMS explained they would cover the patient appropriately with sheets while moving them to the ambulance the patient lashed out calling EMS unprofessional and ignorant. Patient stated EMS was there to do what she wants. Patient states they are unable to walk or move limbs however they are able to bear weight, pivot, use cellphone, etc without issue. While attempting to obtain demographic information patient was extremely hostile and belligerent towards crew. Patient transported to hospital without complications. Upon arrival patient expressed she was very displeased with the hospital she was taken too. Patient care and report given to ER nurse and ER Dr.

47. A large crowd was cursing at Ladder company and Medic unit, threatening them while trying to tend to a patient

48. Lifeguard co-worker and I noticed a surfer under the pier. I asked to go out and make a warning but was told to stand-by so the Main Tower could contact him with a PA over the intercom. The surfer seemed to not hear the PA or ignored it because he continued to surf waves in the swim zone. The main tower than dispatched a downstairs guard to contact him on the board but by the time they got out on the board, the surfer made it into the designated surf zone. Approximately 15 minutes later the surfer started paddling back north into the swim zone making his way towards the pier. My lifeguard co-worker asked me to contact the surfer to inform him of the rules of the surf and swim areas. I took out my rescue board and paddled out to contact the man. As I approached him, I waved him towards me to notify him that I was trying to speak with him and he yelled, ‘I know what I’m doing! I approached him closer and when I was a few feet away I stated, ‘Hi Sir, did you happen to hear the PA earlier?’ I could immediately tell he was agitated, and he aggressively stated, ‘Where the fuck are you from? You have no idea what the fuck you are talking about. I have been surfing here for (some amount) years!’ At this point we were both laying prone on our boards with my board pointed at a right degree angle towards his, I noticed I was getting close to hitting his board so I sat up to turn counter clock wise but the nose of my board swiped the right rail of his board. I stated,’Sorry about that sir’ and he became increasingly angry and aggressive with his body language and tone. He sat up on his board, lunged with his body as if he was going to swing at me and pointed at me saying, ‘That’s fucking assault, you just assaulted me you stupid bitch, I’m going to press charges against you bitch’. In hopes of deescalating the situation I replied to him saying, ‘Sir please calm down, I’m not trying to cause an issue. He continues on insulting me, by saying things like ‘You’re an asshole I’m going to sue you’, ‘You fucking bitch, you just assaulted me’, ‘I’m pressing charges against you’, all while physically pointing at me and being very aggressive with his body language. At this point I raised my hand into the air for assistance in fear that he may become physical with me in some way. I heard the Main Tower say something over the intercom and I immediately decided to paddle back into the beach on the board. As I was paddling away I could hear him continuing to curse at me. I retreated to my tower and met with crews to assess the situation. The surfer than continued to paddle to the North side of the pier, a different unit handled the situation from there.

49. I asked the caller on the phone to verify her address. She then got upset and stated I was yelling at her and was rude and continuously screamed profanities at me. I attempted to continue on with the call, however, the caller continued to cuss at me and eventually hung up without getting through to the triage questions. She then called back multiple times but hung up before anybody was able to get any information.

Physical Violence Only

1. PCP patient spit in my face as he was being loaded into ambulance on stretcher

2. Patient punched me in face as we tried to place him in the stair chair. Male was intoxicated.

3. Patient intentionally coughed into my face several times

4. Male high on k2. Rolling around in street. 2 female medics together. Bystanders had to help us get him on the stretcher. While he was throwing himself around he kicked me in the face. Once in the squad he spit multiple times on the floor and back doors. He had to be restrained at the hospital

5. Entered a home for a pregnancy/miscarriage to find a patient in bed with a large caliber handgun in bed next to them. This house is a known drug house. Police were not assigned or at scene of this incident. Patient did not threaten to use the weapon on us, but it surprised us all and made us very uneasy because we all realized that if she had wanted to she could have easily used it against us and we would have been defenseless. We removed the patient from the room to ambulance as quickly as possibly and departed scene due to several other individuals in the home that were acting suspicious of our presence.

6. While transporting a lucid post seizure patient, the patient turned towards me and stated he wanted out of the ambulance and began to punch me in the face and continue to hit and attack me. I was able to get on top of the patient and restrain him until my partner and assistance arrived.

7. While in the observation tower, I observed a male citizen lying on his side, high and dry on the rocks at a specific beach. The citizen was continuously swinging his arm against the jetty rocks. I sent a Lifeguard Unit to investigate the disposition of the person, aware that it could be a psychiatric patient. Unit responded and made contact with the citizen then requested medics and police to respond because the male was altered. An additional lifeguard responded to back up the unit. They gained general compliance and walked the patient to the unit. While sitting on the tailgate, the male attempted to get up. At that time, our lifeguard stood in front of him and directed him to stay seated, advising he had nothing to worry about. At that time, the male remained seated, put his arms behind his back, then rocked forward to stand up. The male swung and missed with his right hand, then swung with his left and struck our lifeguard on his right cheek. There was a large amount of blood on the male’s fist that made contact near our guard’s mouth. The male continued to go after guards while they maintained safe distances. Police elevated their response to Code 3 until the male began to walk south bound and was not an immediate threat to lifeguard safety. Police responded and detained the male on the beach and remained combative throughout the assessment and transport. The medic unit transported to the hospital, accompanied by PD.

8. While on scene of a medical aid for a patient under the influence of alcohol the patient punched my firefighter/paramedic in the stomach while helping the patient to the gurney.

9. Patient grabbed/struck my face while securing her to the gurney.

10. Male patient covered in vomit from presumed overdose became combative flailing arms and legs, to the point of striking EMS providers to the point where he was sedated and chemically restrained during transport

11. A possibly high female became combative outside of her residence. She hit and kicked us. We had her on the stretcher and had to restrain her until help arrived out of fear for our and her safety. During that time i repeatedly was kneed in my torso over several minutes.

12. Medic crew was physically assaulted by a male patient found down on the street after smoking PCP

13. While assessing a patient who was intoxicated and involved in a motor vehicle accident, he grabbed my butt. He also attempted to grab my breast after that incident

14. While responding to a 911 call, a presumed homeless man threw a decent sized rock estimated the size of a closed fist at our ambulance. The vehicle struck somewhere on the ambulances front right side.

15. We responded to a parking lot for a 30s year old male that was unconscious on the ground. Security guard at scene reported to us that he had seen the patient drinking alcohol throughout the day. When we got to scene we attempted to arouse the individual using verbal and painful stimuli. Patent responded by making grunting sounds. We proceeded to take vital signs as the ambulance arrived. We loaded the patient on to the gurney by lifting him and he began to speak and complained that his knee hurt. In the back of the ambulance he became more agitated so we attempted to calm him and explained to him that he can leave if he wishes. He eventually exited the rear of the ambulance, extremely agitated and verbally assaulting crew on scene. He then started moving towards two of the crew members who were attempting to calm him down. He got within arms reach and appeared as if he was going to physically assault the crew members. Crew members brought him to the ground and restrained him until police arrived. Patient was transported to the hospital with police officer and fire department personnel restrained, and continued to be aggressive and verbally assault crew members.

16. Medic crew was responding to a level one, code response call, when a male made a running start and threw, a beer bottle at our moving apparatus.

17. Medic crew arrived at emergency room to take patient to another facility for further care with dementia and weakness. On scene CNA notified EMTs that patient was previously combative. RN also stated patient was combative. Patient sheeted to gurney. I was bucking in it to gurney when he kicked me in the abdomen.

18. Altered and restrained patient after using unknown drugs and being awoken by narcan: patient grabbed my hand with a restrained hand and squeezed my fingers awkwardly. Almost broke a finger but luckily squirmed out of his grip. Then patient sat up abruptly and headbutted my shoulder while we were still restraining him. No lasting injuries sustained.

19. My partner and I were wheeling in our patient into the emergency room when we passed by a guy who was verbally assaulting someone with security behind him. The person waited for me to pass then shoved me on my left shoulder causing me to let go of my gurney at that moment I turned around and shoved him back and security took him to the ground.

20. Patient was given Narcan. Patient became increasingly verbally abusive towards EMS personnel. Patient began throwing equipment at EMS and police was on scene when called over to the rescue they arrested the patient for a parole violation.

21. A male patient repeatedly hit on me while I was doing my medical assessment and treating his hypoglycemia. He continued to make uncomfortable sexual comments even after his sugar was raised to within normal limits.

22. I was assessing an elderly lady with dementia who was agitated and combative. I needed to dress the patient and lift her onto the stair chair. The patient was very agitated when I dressed her, grabbing and pinching my arms and hands, and trying to hit me. When I lifted the patient into the stair chair, she grabbed my left forearm and scratched me, digging her fingernails in, breaking the skin and causing an inch long laceration which bled. Patient continued to squeeze my arm and dig the fingernails in, causing further bruising. I was unable to remove her hand from my arm as I was lifting her.

23. I got punched a couple of times in the stomach and chest in the back of the ambulance by a combative patient.

24. Engine crew responded for a patient at the lifeguard tower who was feeling suicidal. Police were not at scene yet, only lifeguards. As we arrived, the patient reached down into the lifeguards medical bag and pulled out a pair of scissors and began cutting himself, then standing up waving the scissors in a threatening manner towards the crews. Patient was agitated, erratic, not making sense or following instructions. The lifeguard at the scene was able to place handcuffs on the patient while we called for a “cover now” for police. No crewmembers or lifeguards were injured.

Both Verbal and Physical Violence

1. Patient was outside in the middle of the street attempting to physically assault random people as well as verbally attacking them. Police were called and attempted to calm the patient with no success. EMS was called for a male high on narcotics. The male was walking all around in the middle of the street yelling and screaming in Spanish. Once in the ambulance and on the stretcher, the patient began spitting at crew members, pinching, and began kicking and swinging his arms towards police and EMS. The patient continued to scream and yell. Police rode with patient and EMS to hospital for safety.

2. Intoxicated female kept trying to bite EMS, biting one provider without breaking the skin. Also she kept threatening to throw up on crew. Also verbally abusive

3. Male patient was aggressive and violent towards EMS. Base command contacted and patient was given a sedative to calm him and help us get him out of the facility. Patient then began sexually harassing me. He was very graphic and then threatened to grab and touch me in a sexual manner. Patient had to be physically restrained for my safety. During entire ride to hospital and in ER patient continued to sexually harass me.

4. Family and friends of patient became violent with EMS on scene while providing emergency treatment for seizing patient. While treating patient in hotel room family yelled at EMS, pushed between EMS and seizing patient and made verbal threats. Once patient was treated she began spitting at EMS and family verbally threatened violence again toward EMS. While attempting to extricate patient from hotel family pushed EMS and Fire crew while attempting to pull patient off stretcher. Once EMS left scene three cars with family members attempted to follow medic unit while operating at emergency speed. Family ran red lights and stop signs chasing ambulance.

5. Was open hand slapped by an intoxicated patient. No injuries

6. An intoxicated woman wanted to kill herself. She was insulting my partner and being aggressive. Once calmed down patient was moved to the truck and placed on the stretcher. During transport she pulled out a switch blade style knife. No one ended up getting hurt because knife was taken away.

7. Had to restrain a patient that was violent and combative towards EMS and police. Patient was also verbally abusive towards EMS

8. Medic crew verbally assaulted and spit on by assault victim.

9. We were in transport to the hospital with an individual who was in custody for ingesting 40g of heroin (per the patient and officer). We picked the patient up at the jail. The officer stated he was going to be following the ambulance to the hospital because he was a single officer in his car and no one else was available to ride in the ambulance. Prior to transport while still at scene with police, the patient was placed in soft restraints due to behavior and concern of EMS safety. The patient was moved to the ambulance where transport continued to hospital. Once the ambulance began traveling, the patient told me to remove the restraints. The restraints remained and were not adjusted. Patient was able to, at one point, unbuckle his shoulder straps. Once patient was able to unbuckle the straps, he leaned forward and began trying to bite the restraint knot on the gurney. Patient was stopped from this act. The patient was able to remove his legs from under the seatbelt buckle. Patient swung his legs over to the bench seat and was able to kick a pair of trauma shears loose from the bench seat seatbelt harness. This act, once noticed of what his intentions were, was also immediately stopped. Paramedic went to jump seat in the ambulance to stand by and monitor the patient. The patient was able to kick the IV tray and have items from the IV tray go loose. At this time, partner pulled the ambulance over and requested police. Partner came to assist me in the ambulance and we noted the patient was able to gain control of a pair of scissors in the ambulance. A fight to seize the scissors from the patient began. The patient was in a sitting position on the side of the gurney with his legs off the side to his left. By now, the right arm restraint had broken and the patient had movement of his right arm freely, the strap on his left arm had pulled so hard that he had more movement to his left arm as well, unsure if the restraint on his left arm held up and kept him restrained. Once noted the patient had scissors in his hand, this was called out loudly in the back of the ambulance for the safety of my partner and I. A cover now was aired on the radio for immediate assistance from the police. OVER FOUR MINUTES WENT BY BEFORE THE FIRST OFFICER SHOWED UP AT SCENE. Dispatch on the fire dispatch medical had to confirm our location, they also sent a cover now and officers to the WRONG LOCATION as my partner and I attempted to restrain a patient with a deadly weapon. Patient held the scissors in an aggressive manner. I was able to grab one end of the scissors and repeatedly told the patient to release his hand but he did not. Patient was told SEVERAL times to relax and cooperate and did NOT. This gives me the impression he had a high intent of harming either himself or EMS crew. Patient was placed in a carotid restraint by me in the ambulance and was controlled from there forward. Patient dropped the pair of scissors in the ambulance. Patient was controlled until police arrival at scene. Once the police arrived, they took custody of the patient. Medic continued transport of the patient to hospital where he was evaluated. Entirety of the call is all recorded on our monitor.

10. We had to support a police officer who was engaged in hand to hand combat with a large drunk man. Man kicked my captain, captain fell onto his back. We all submitted the man. He repeatedly cursed at and threatened us from that point on. He went so far as to insist he’d remember our faces and attack us in the future.

11. While transporting a patient, he became verbally aggressive with me yelling profanities. Patient began to show signs of physical aggression. I dropped the head of the gurney to prepare to better control my patient when he swung his left hand upwards punching me in the face. Patient knocked my glasses and hat off me and it knocked me back into the captains chair. I immediately began trying to control and restrain my patient with my partners help until help arrived.

12. Units were called to a street corner for an intoxicated male with lacerations from punching parked vehicles. Patient was calm and read directable on scene no violent threats or behavior. Patient made comments about disliking female interns face and became violent punching and biting crewmembers. Cover now was called took three crewmembers and police officers to restrain patient.

13. Engine and medic unit were dispatched to a report of an unconscious person, intoxicated, next to a running vehicle in the alley. Engine crew made contact and the patient became combative and began swinging and kicking us. He was too drunk to get up on his own, so we backed off and decided to not touch the patient until police arrived. Due to poor communication between fire dispatch and police dispatch, police were never notified we were in the alley. After 10 to 15 minutes of waiting police arrived to assist. Once police stood the patient up for us to assess and move him to the gurney, he became extremely combative. Punching, kicking, spitting on police crews and medic and engine crewmembers. It took 8 of us to subdue the patient until police could handcuff him.

14. Wife accessed 911 for her husband who was on a four day ‘alcohol binge.’ Upon arrival, the patient threatened us if we didn’t leave him alone. He advised us that he could open the door and get his weapons or have his dog attack us. We advised him that we had a legal obligation to treat him medically and that it was his wife’s wish. As soon as we attempted to move him, he attacked us. We swiftly restrained him and called for police back up. While we were awaiting the police, he managed to bite and chew through the restrains.

15. As we attempted to assess our patient, the patient became verbally agressive and swung his arm at us as he yelled “Don’t fucking touch me.” We backed off and requested cover from police. Patient eventually eloped without further incident as we awaited police. We have a past history with this patient. Two months prior he threatened to kill us and we ended up in a physical altercation with him that included punches, kicking, and spitting.

16. Intoxicated patient was verbally abusive, became physically combative, and threw an empty liquor bottle at us without hitting anyone.

17. EMS arrived on scene to a male that has called EMS several times, mostly for arm pain received in an alleged work incident multiple years ago. Wife of patient is always on scene, and she is always very nice and very helpful. EMS did a full assessment on patient and when we told him his blood pressure, he said “check it again, that ain’t what my machine said.” EMS explained to patient that we did a manual blood pressure which is the most accurate. Patient became very agitated and began yelling curse words and racial slurs at EMS. EMS tried to calm patient down but he just became more angry, making violent threats towards medics and telling us to get out of his house. Patient continued yelling threats and racial slurs as EMS left. EMS called supervisor who met us at location and witnessed some of the behavior. Wife on scene also backed EMS stating that the patient started cursing and threatening EMS and was not provoked by EMS at all.

18. Male who was presumably intoxicated and under the influence of illegal substance was lying on train tracks. In an attempt to move him to safety, the individual began to kick and punch at our engine crew. Due to the safety for the patient and our crew he was wrestled to the ground to await for police.

19. This call was a response to an adult male high on ‘wet’ (cigarettes dipped in embalming fluid). We arrived to find this individual acting bizarrely. When we attempted to approach the male to make contact, he became agitated and charged at us, attempting to grab us. We avoided injury and requested police assistance. Shortly after police arrived the man fled the scene

20. Verbally and physically assaulted by intoxicated patient.

21. I was kicked in the face by a patient (on the ambulance) suspected to be on PCP. The patient was being brought in by another crew and I went to assist them as they asked for help. I had seen the patient for a minute before I was kicked.

22. Early Saturday morning on March 28th we responded to a house fire. With a report of an occupant still on the second floor. While attempting to get to the top of the steps and search for the occupant, the occupant himself tried to climb the steps and get upstairs to impede firefighting efforts. I told him he needs to go outside and let us do our jobs. With that said, he bull rushed me dislodging my mask and helmet and proceeded to fight me at the top of the steps. Where I was is known as above the smoke line, blinded by smoke, my dislodged mask, and helmet for anywhere from 10 to 12 minutes. I had minor smoke inhalation and some bruising to my cheek where the mask and helmet were dislodged. The occupant was below the smoke line. I was treated at the hospital and released the same day.

23. The patient admitted to alcohol use. The patient was combative while the crew was trying to help her to the ambulance with police. My partner was almost bitten and I was hit and scratched.

24. Patient was combative, kicking his legs and swinging his arms, cursing at EMS

25. A transient tore out a bush and used it to threaten my coworker and I. He was trying to intimidate us. We were just trying to get him to leave. He asked us very racially insensitive questions and pointed the tree branch at us saying he could use it as a weapon. He postured in my face saying he should knock my teeth out. I said I wouldn’t go anywhere until he left. My partner came closer to back me up and he left while yelling expletives at us.

26. We had a patient spit at us during a medical aid. Her boyfriend had Covid symptoms and was in close contact with a coworker that was Covid positive.

27. During transfer from wheelchair to gurney of a combative psych patient coming out of a skilled nursing facility I was punched in the left jaw by the patient. He threatened to assault all personnel on scene and while I was trying to remove items from his lap so they wouldn’t get dropped or broken during the transfer he swung on me and connected.

28. Called to private residence for a possible seizure. Patient was found down in bathroom, combative. Both crew members punched and kicked multiple times. Patient required 6 people to be fully restrained.

29. A member of the public was sexually harassing me for an hour. I asked him to leave several times, but he did not. I finally asked him to leave raising my voice and he began to shout at me, rubbing his genitals and came inches from me until another beach patron intervened to protect me. The cops were called, but they immediately released the man harassing me. He then began to stalk me the rest of the day while I was working (after changing his outfit and letting his hair down so he wouldn’t be recognized). I had to be escorted to my car because he tried following me to my car after work.

30. Me, nothing. But my crew was involved in an altercation on scene of a motor vehicle crash.

31. Arrived on scene with police already talking with patient. Patient willing got into back of ambulance to be further evaluated. Once in back of ambulance. Patient became extremely hostile. Screaming at both myself and my partner. Patient stated, ‘Fuck you and the police!’ After that we explained that we are here to help and we asked her to calm down. She started swinging her arms and asked to leave the ambulance. I got out of the ambulance and watched her sit on the sidewalk until her girlfriend came and picked her up.

32. Person pulled knife on EMS while trying to secure him into ambulance

33. Aggravated assault by a patient high on PCP and pulled me from my ambulance. I was forced to defend myself and what followed was i was spit on twice, hit, scratched and bitten. I defended myself and my partner till law enforcement officials arrived.

34. Crew involved in verbal altercation with a patient, patient exited vehicle. patient returned and threw a chair at ambulance’s passanger window shattering window.

35. I was attacked, punch in the ears with a cellphone

36. Patient on mentally disordered involuntary hold (5150) became combative. She then threatened to shoot me multiple times when she got out of the hospital.

37. Patient was agitated and combative, tried to bite, kick, hit, and spit on crews. Patient kept telling crew members they were raping her because she was being physically restrained. Patient kept calling transport crew, fire crew, and police, ‘rapists.’ Patient was oriented enough to ask that her restraints be removed, but kept yelling, swearing, verbally abusing, and trying to assault and batter ambulance and fire crew.

38. Patient made sexual advances towards EMT partner and yelled obscenities as well as stuck fist in my face

39. While working as a paramedic on an ALS ambulance, we had a female patient who threatened myself and the Mobile Intensive Care Nurse, charged at my EMT partner, threw ambulance equipment out of our ambulance, and flipped a table inside the emergency department waiting room hall. Patient made comments of a possible attack on ambulance personnel while ‘walking from the ambulance to their car.’ Patient has history of schizophrenia.

40. Pt became violent in the back of the ambulance without warning and attacked crews, kicking, spitting, hitting, wrestling.

41. Called to a private residence with a man in 80’s who was behaving erratically and threatening his daughters. While assisting patient to gurney after explaining that he had to go (with assistance of police) patient struck me with hands and feet. Restrained patient in soft four point restraints shortly thereafter

42. I was verbally assaulted and my partner was sexually harassed.

43. Attacked with object, punched in the face 3 times, and bit on hands and legs.

44. Patient attempted to punch EMS provider when attempting blood pressure assessment.

45. Patient threatened provider with death and bodily harm and then patient attempted to assault providers

46. Dispatched to intoxication with fall. Throughout contact, patient verbally harassed EMS and fire crews. While in the back of the ambulance, patient threatened to physically harm paramedic, and shortly after attempted to punch medic in the arm.

47. I’ve noted/noticed that near EVERY contact with the public can go sour more quickly than in the past years. I would not know the exact cause; as I vary my approach with each contact, depending on the situation/violation. I see not just “entitlement…” but open defiance. I expect one per day at this point, but many times it’s been multiple events of racial slurs, threats, non-compliance/aggressive behavior, taunting, spitting. I’m aware that I “present” in a certain manner, (white male/bald/2010lbs/50’s) so I vary my initial contacts; hands in pockets, removing my sunglasses/hat, a “greeting” and introduction. In general, I’m aware of the weight I carry so I tend to tread lightly. There have been several times/events that I was unable to use the bathrooms in a particular response area for fear of my safety.

48. Our patient we picked up from a private residence upon assessment, throughout medical treatment and during transport he made sexual advances towards and asked me if he could “put his Dick in my pussy, and did I want his tongue in my pussy”. Then I asked what his birthday was for demographics and he stated “your mom” and then proceeded to say similar things as in “your mom loves my dick, she let’s me 69 her all weekend”. Etc.

49. Because of COVID we are treating stingray patients outside of the tower. I had a female patient wearing a bikini towards the end of the evening. Her female friend was with her. First an old man got himself involved by asking us for more water. I realized he was just trying to talk to the girls so I told him to go away. He stayed very nearby until I again told him to get lost. A couple minutes later a younger guy was inserting himself in between the patient and myself. I asked if he was a friend of the patients and he nodded and said, “Yeah.” The patient and the female friend quietly shook their heads, “No.” So I asked the female patient directly, “Do you know him?” She again quietly shook her head “no.” So I got assertive and told the guy to get lost. He immediately became enraged and started yelling at me. He said, “What are you, gay?” So because I knew he was trying to insult me, I responded, “Super!” Then he called me homophobic. Which makes no sense at all so I just looked at him. He kept shouting so I kept pointing away from us and telling him to get lost. He pointed at me and made a fist and punched his other hand several times and pointed at me again. He did leave but it was pretty exhausting to have to keep creepy guys away from my patient and her friend.

50. Went to cite someone for failing to supply a personal flotation device to a baby on a water bike rental. Owner and his partner were non compliant, verbally abusive, and eventually physically assaulted 3 of my coworkers.

51. Patient yelling racial slurs, shoving and trying to force EMS away from him