Patient care delays due to scene safety.

Sir,

Recently, responding to a 911 call of ‘gunshots fired’, two law-enforcement officers arrived within a minute and found an unresponsive victim but were unable to allow Emergency Medical Services (EMS) on the scene as a crowd of approximately 30 bystanders became increasingly hostile, both threatening and physically assaulting the officers. Within seven minutes, approximately 20 officers had arrived and the crowd was dispersed.

Once the scene was secured, paramedics found a 31-year-old male with three gunshot wounds to his chest. The patient maintained palpable pulses until just prior to arrival in the hospital. In the emergency department, the patient remained pulseless and unresponsive. Bilateral thoracotomies were performed and the patient was found to have penetration of the superior vena cava without injury to the heart. Open cardiopulmonary resuscitation (CPR) with intracardiac epinephrine was performed and massive blood and plasma transfusions were administrated, but the patient could not be resuscitated.

It is well established that the response time of EMS has a significant effect on morbidity and mortality for patients with severe medical or traumatic conditions. Although EMS delays in patient care have many different causes, no studies examine delays from safety risks for EMS personnel.

On-scene violence and danger is real and not uncommon. Studies of urban EMS systems report violence occurring in 5% of all calls and immediately ending just prior to the arrival of EMS in another 14%.[12] When surveyed, 60-90% of EMS providers reported having been assaulted on the job.[3]

Responding to a shooting, the risks are increased, even if the perpetrator is no longer present. In gang-related violence, there is, frequently, a risk of further attempts at harming the patient or a retaliatory act. In cities where tensions exist between the public and law enforcement, violence can erupt indiscriminately against all first responders.[45]

In the case presented here, it is by no means clear whether the patient would have survived if EMS had been on the scene without delay. The case does serve as a reminder, however, that although we know that provider safety should always take precedence, there is no best practice for EMS security. Different EMS systems have facilities ranging from nothing at all to mandated body armor, police escorts, and armored personnel carriers.[34] Studies are needed to examine what protocols and systems-level planning can maximize safety for both patient and provider.

Simultaneously, health-care providers have a responsibility to educate the public about the effects of crowd anger on limiting the access of care to a victim as well as inciting further violence. Although improving care under any circumstances should remain our goal, decreasing violence ultimately, as a society, is the most effective way of protecting both our patients and ourselves.