The Public Safety Group Blog

Let’s consider these three scenarios:

Scenario A: You are returning to the station after a call, and your partner pulls up to a coffee shop so you can run in and grab a snack. You notice there were five cars in the lot and a few cars in the drive-up window line, yet when you get inside you cannot find anyone. Fishy…hmmm. So, do you focus on the coffee menu and write this off to it being hard to get post-pandemic help in your community, or do you wonder if the clerk is getting robbed in the back room?

Scenario B: You roll up at 2 a.m. to a private house at the end of a dark street for a call involving a patient who fell. Does it concern you that there are no lights on in the house? Would it concern you if there was loud music and screaming coming from the house?

Scenario C: You are the first ambulance arriving at what was dispatched as a two-vehicle collision with minor injuries on the shoulder of the interstate. As the first unit on the scene, whose responsibility is it to deal with the high-speed traffic flying by? Do you think about an intoxicated driver plowing right into the patient’s car or your ambulance?

What is the one thing that unites these three scenarios for a first responder? Each scene could play out in a variety of ways. It is up to first responders to make quick determinations, and to assume the scene is never safe.

According to Nancy Caroline’s Emergency Care in the Streets, Ninth Edition, “Ensuring scene safety is a dynamic process requiring constant reassessment. This process, which in the past was often thought of simply as a task to be 'checked off' at the start of the encounter, should not be undervalued."

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I am not suggesting that emergency responders be paranoid, or quietly sneak around like ninjas, but becoming situationally aware and constantly monitoring the scene throughout the call could save lives. Read on to learn why situational awareness is so important for first responders and how it can be taught.

What Is Situational Awareness?

Situational awareness is defined as the state of being aware of what is happening around you and recognizing the potential for threats to yourself or others. This material is covered in the EMS Safety Course Manual, Third Edition. We have learned over time that it should be incorporated into every moment of every call.

Consider the following data:

It is hard to find a single location where the Emergency Responder injuries and deaths are reported for each year. So, I made my own chart using data from the National EMS Memorial Service, the Officer Down Memorial Page, and the U.S. Fire Administration.

Table #1 - Emergency Services Responder Deaths in 2022*

(*NOTE: The three databases used for this table had some overlap in cause, for example: heart attack/stress and duty related illness.)Below are a few key takeaways from the data:

• A study using NFPA's Fire Incident Data Organization (FIDO) found that from 2000 to 2020, a total of 89 firefighters were killed. This included 19 firefighters struck by a fire department vehicle and 70 struck by a non-fire department vehicle.
• In the year 2020 there were 64,875 injuries reported in the line of duty for firefighters. In the same year there were 18,568 assaults of police involving injuries.
• In 2020, the National Institute for Occupational Safety & Health estimated there were 16,900 injuries and illnesses among EMS workers treated in hospital emergency departments.
• Failing to find the data already packaged and ready for analysis, the Cumberland Valley Volunteer Firemen’s Association/Emergency Responder Safety Institute has worked on collecting, analyzing, and sharing emergency responder struck-by incidents. In the past four years (2019 – 2022), they tracked incidents where emergency responders were struck and killed by a vehicle while working at a roadway scene. The data reveals 205 fatalities as follows: 82 (law enforcement officers), 33 (firefighter/EMS providers), 74 (tow operators), 10 (road service technicians), and 6 (DOT personnel/safety service patrol operators).

Responders Perceptions: How Do You Train for Scene Safety?

As noted in the 2022 EMS Trend Survey, one of the greatest safety threats to responders is complacency. The definition of complacency is self-satisfaction, accompanied by unawareness of actual dangers or deficiencies. This could be on the part of the responders as well as their leadership.

To be frank, “ignorance is bliss” is not an acceptable excuse for looking the other way on safety issues. SOPs need to be in place and enforced to keep the work environment as safe as possible. Does your agency have a seat belt policy, yet some responders still do not buckle up?

Some training programs offer scenarios during their training where the scene is not safe (for example, the patient with an altered mental state has a simulated weapon on him, the family members suddenly become aggressive towards the EMS providers, simulated shots are fired, or a drunken driver slams his vehicle into the patient’s vehicle while care is being provided).

This is all helpful in encouraging the providers to continue to be situationally aware and constantly monitor the safety of the scene. The bottom line is that regardless of where the call occurs (a private suburban home, on a busy highway during rush hour, at a local convenience store/gas station, a local nursing home, in a bar noted as a violence hotspot, at a fire scene, etc.), it is a location with people you do not know and there are too many variables to assure that the scene is safe.  

Let’s just say it, teach it, and practice it every day. Today’s mantra should be, “The scene is never safe.”

Preventing Roadway Fatalities and Injuries Through Scene Safety Education

In 2022, the DOT released their National Roadway Safety Strategy (NRSS) declaring that death and serious injuries on roadways are unacceptable. They set a long-term goal of reaching zero roadway fatalities. The strategy introduces a “Safe System Approach” that emphasizes preventing fatalities and serious injuries over simply preventing crashes. Thus, DOT is recommending that transportation organizations should not assume responsibility ends when a crash occurs. Caring for those injured in a crash to prevent their injuries from becoming fatal is just as critical. They term this “post-crash care” and quality EMS is a key element of post-crash care. Specific actions found in the NRSS to enable safer post-crash care are as follows:

• Develop and implement an outreach plan for EMS personnel for on-scene safety and traffic incident training.
• Advance Traffic Incident Management (TIM) training and technologies targeted at improved responder and motorist safety.
• Expand the use of and support for the National EMS Information System —the national database that is used to store U.S. EMS data — by funding applied research and data quality improvements.
• Improve delivery of EMS, in collaboration with Federal Interagency Committee on EMS (FICEMS) and National EMS Advisory Council (NEMSAC) guidance, by focusing on shortening ambulance on-scene response times.

Specifically, the strategy states, “DOT is committed to taking action within its scope and statutory responsibilities to make advances in survivability through delivery of equitable and impartial post-crash care, including EMS and 9-1-1.”  State EMS officials have a long history of collaboration with state highway safety officials. This increased effort through the NRSS encourages EMS and 9-1-1 leaders to further demonstrate how these agencies can work together to achieve shared goals.

Sounds to me like it is time, if you have not done so already, to renew friendships with your county and state traffic safety officials. Since reducing death and injury on the roadways is at the core of highway safety officials’ work, it’s important to remind them of the critical role EMS responders play in achieving that objective.

Equipping EMS and 9-1-1 systems with sufficient resources and funding helps to ensure they can provide optimal care to crash victims. In turn, injury severity and long-term costs may be reduced. Post-crash care is the last best chance to prevent serious injury or death.

When states are developing or revising their Strategic Highway Safety Plans, they should invite their state EMS office and 9-1-1 authority counterparts to provide their unique input.

TIM: Making Our Jobs Safer on the Roadways

To increase safety for first responders, while helping the highway safety folks meet their NRSS objectives, instructors can encourage all employees to take a four-hour National Traffic Incident Management (TIM) course.

Managing the scene of a crash and providing a safe environment for first responders and passing travelers are critical elements of delivering effective post-crash care. Transportation incidents, which include crashes as well as flat tires and other issues, are the second most common cause of death among both police officers and firefighters, and the leading cause of death among tow truck operators.

Moreover, up to 20 percent of crashes are estimated to be secondary in nature, meaning that they occur as the result of an earlier incident. DOT estimates that the likelihood of a secondary crash occurring increases by 2.8 percent for every minute the primary crash obstructs a travel lane or poses another type of hazard. Safe and quick incident clearance is critical to addressing not only crash survivability and first responder safety, but also the safety of passing road users.

The TIM program consists of a planned and coordinated multidisciplinary process to detect, respond to, and clear traffic incidents so that traffic flow may be restored as safely and quickly as possible. Effective TIM training reduces the duration and impacts of traffic incidents; improves safety of motorists, crash victims, and emergency responders; and reduces frequency of secondary crashes.

The goal of the Federal Highway Administration’s TIM Program is to continuously improve the safety of responders and road users, the reliability of travel, and the efficiency of incident and emergency response through institutionalization of TIM programs. In addition, it would be worth your time looking into the NAEMT’s safety course.

Finally, you might have noticed I left out one of the causes of fatalities and injuries to emergency responders: driving the emergency vehicle and properly using lights and sirens. Well, we are in the middle of updating the EVOS book and course so there will be more on this important topic in future articles. Stay tuned!

• Highway Scene Safety 101: Training and Best Practices for EMS & Firefighters
• Author’s Opinion: Emergency Vehicle Operator Safety Training Needs Standardization
• Lights and Siren Use in EMS is Changing. Here's What You Need to Know

About the author:

Bob Elling, MPA, Paramedic (retired) – has been a career paramedic, educator, author, and EMS advocate since 1975. He was a paramedic with the Town of Colonie EMS Department, Times Union Center, and Whiteface Mountain Medical Services. He was an Albany Medical Center Clinical Instructor assigned to the Hudson Valley Community College Paramedic Program. He has served as National and Regional Faculty for the AHA and was involved in many successful life-saving legislative campaigns with the You’re the Cure Network. He also served as paramedic and lieutenant for New York City EMS, paramedic program director and associate director of the New York State EMS Bureau. He has authored hundreds of articles, videos, and textbooks to prepare the EMS provider for their career. Bob is the ECSI Medical Editor for CPR and First Aid Series of products and the Co-Lead Editor of Nancy Caroline’s Emergency Care in the Streets.