Emergency medical services operations during civil unrest: Best practices from lessons learned
Keywords:EMS, emergency medicine, civil unrest, mass gathering
During periods of civil unrest, emergency medical services (EMSs) clinicians will be called upon to provide care to those impacted, including those who are actively instigating violence. Working during periods of civil unrest poses significant operational and security challenges to EMS leadership and clinicians. This review provides best practices for EMS operating during periods of civil unrest through analysis of after action reports from Baltimore, Maryland; Charlottesville, North Carolina; Minneapolis, Minnesota; and Washington, DC.
United States Code: Office of law revision counsel, US house of representatives. Available at https://uscode.house.gov/browse/prelim@title18/part1/chapter12&edition=prelim. Accessed May 13, 2022.
Glossary: Federal Emergency Management Agency. Available at https://training.fema.gov/programs/emischool/el361toolkit/glossary.htm. Accessed June 14, 2022.
Department of the Army: Civil disturbance operations. Available at https://irp.fas.org/doddir/army/fm3-19-15.pdf. Accessed May 15, 2022.
Maryville University: History of civil unrest in America: Capitol Hill riots. Available at https://online.maryville.edu/blog/civil-unrestin-america/#:~:text=Political%20grievances%20(including%20opposition%20to,unrest%20aren’t%20mutually%20exclusive. Accessed May 15, 2022.
Braha D: Global civil unrest: Contagion, self-organization, and prediction. PLoS One. 2012; 7(10): E48596.
National Youth Rights Association: Organizing a protest, walkout or boycott. Available at https://www.youthrights.org/action/toolkit/organizing-a-protest/. Accessed June 5, 2022.
Federal Emergency Management Agency: Civil unrest response: Operations. US Fire Administration. Available at https://www.usfa.fema.gov/operations/civil_unrest/operations.html. Accessed June 6, 2022.
Civil Unrest Lessons Learned: International fire chiefs association. August 2020. Available at https://www.iafc.org/iCHIEFS/iCHIEFS-article/civil-unrest-lessons-learned. Accessed June 22, 2022.
O’Toole K, Former Chief, Seattle Police Department: Notes from the field: A sensible response to civil disturbance. Available at https://nij.ojp.gov/topics/articles/notes-field-sensible-response-civildisturbance. Accessed March 7, 2018.
ICS Resource Center: Federal emergency management agency. Available at https://training.fema.gov/emiweb/is/icsresource/. Accessed June 20, 2022.
Department of Health and Human Services: Emergency Management and Incident Command System: Public Health Emergency, Office of the Assistant Secretary for Preparedness and Response. Available at https://www.phe.gov/Preparedness/planning/mscc/handbook/chapter1/Pages/emergencymanagement.aspx. Accessed June 20, 2022.
Lincoln E, Freeman C, Strecker-McGraw M: EMS incident command. StatPearls. Revised September 2022.
Kaye AD, Cornett EM, Kallurkar A, et al.: Framework for creating an incident command center during crises. Best Pract Res Clin Anaesthesiol. 2021; 35(3): 377-388. DOI: 10.1016/j.bpa.2020.11.008.
Goldstein S, LeeAnne M, Roarty J: EMS zones of care. StatPearls. Revised February 2022.
Safety Zones: US environmental protection agency. Available at https://www.epa.gov/emergency-response/safety-zones. Revised November 15, 2021. Accessed June 23, 2022.
Montgomery HR, Drew B: Tactical combat casualty care (TCCC) update. J Spec Oper Med. 2020; 20(2): 152-153. DOI: 10.55460/8BYBKQQG.
Pourshaikhian M, Abolghasem Gorji H, Aryankhesal A, et al.: A systematic literature review: Workplace violence against emergency medical services personnel. Arch Trauma Res. 2016; 5(1): E28734. DOI: 10.5812/atr.28734.
Hallett N, Dickens GL: De-escalation of aggressive behaviour in healthcare settings: Concept analysis. Int J Nurs Stud. 2017; 75: 10-20.
Blair EW, Woolley S, Szarek BL, et al.: Reduction of seclusion and restraint in an inpatient psychiatric setting: A pilot study. Psychiatr Q. 2017; 88(1): 1-7.
Garner DG, Jr, DeLuca MB, Crowe RP, et al.: Emergency medical services professional behaviors with violent encounters: A prospective study using standardized simulated scenarios. J Am Coll Emerg Physicians Open. 2022; 3(2): e12727. DOI: 10.1002/emp2.12727.
Byers M, Russell M, Lockey DJ: Clinical care in the “hot zone.” Emerg Med J. 2008; 25(2): 108-112.
Erich J: 10 lessons for managing civil unrest. EMS World. 2020. Cited from the internet July 2022. Available at https://www.hmpgloballearningnetwork.com/site/emsworld/article/1224397/10-lessons-managing-civil-unrest. Accessed May 3, 2022.
Lum C, Schallhorn J, Lum F, et al.: Ocular injuries and blindness caused by crowd control measures in civil protests. Ophthalmology. 2020; 127(10): 1424-1425. DOI: 10.1016/j.ophtha.2020.08.005.
Tidwell RD, Wills BK: Tear Gas and Pepper Spray Toxicity. Treasure Island, FL: StatPearls Publishing, 2021.
Schep LJ, Slaughter RJ, McBride DI: Riot control agents: The tear gases CN, CS and OC—A medical review. J R Army Med Corps. 2015; 161(2): 94-99.
Olajos EJ, Salem H: Riot control agents: Pharmacology, toxicology, biochemistry and chemistry. J Appl Toxicol. 2001; 21(5): 355-391.
Carron PN, Yersin B: Management of the effects of exposure to tear gas. BMJ. 2009; 338: B2283-B2283. DOI: 10.1136/bmj.b2283.
Kim YJ, Payal AR, Daly MK: Effects of tear gases on the eye. Surv Ophthalmol. 2016; 61(4): 434-442.
Barry J, Hennessy R, McManus J: A randomized controlled trial comparing treatment regimens for acute pain for topical oleoresin capsaicin (pepper spray) exposure in adult volunteers. J Prehosp Emerg Care. 2008; 12: 432-437.
Lartizien R, Schouman T, Raux M, et al.: Yellow vests protests: Facial injuries from rubber bullets. Lancet. 2019; 394(10197): 469-470. DOI: 10.1016/S0140-6736(19)31764-7.
Ali R, Poggi J, Doberstein CA, et al.: Rubber bullet induced traumatic brain injury. J Craniofac Surg. 2021; 32(6): 2189-2192. DOI: 10.1097/SCS.0000000000007733.
Haar RJ, Iacopino V, Ranadive N, et al.: Death, injury and disability from kinetic impact projectiles in crowd-control settings: A systematic review. BMJ Open. 2017; 7: e018154. DOI: 10.1136/bmjopen-2017-018154.
National Law Enforcement Policy Center: Crowd management. 2019. Available at https://www.theiacp.org/sites/default/files/2020-08/Crowd%20Management%20FULL%20-%2008062020.pdf. Accessed June 25, 2022.
Hospital Safety Center: Hospital preparedness, security paramount during the Baltimore Riots. Available at https://www.accreditationqualitycenter.comcontent/316779/topic/WS_HSC_HSA.html. Accessed February 23, 2022.
Wen LS, Warren KE, Tay S, et al.: Public health in the unrest: Baltimore’s preparedness and response after Freddie gray’s death. Am J Public Health. 2015; 105(10): 1957-1959. DOI: 10.2105/AJPH.2015.302838.
ASPR TRACIE, US Department of Health and Human Services: Healthcare preparation for and response to local civil unrest. Available at https://files.asprtracie.hhs.gov/documents/healthcare-preparationfor-and-response-to-local-civil-unrest.pdf. Accessed May 3, 2022.
CBS News Los Angeles: Anti-police protesters yell ‘We hope they die’ outside hospital where wounded deputies were taken. 2020. Available at https://www.cbsnews.com/losangeles/news/sheriffs-deputies-shot-compton-anti-police-protest/. Accessed June 5, 2022.
Brow C: Protestors force legacy salmon creek hospital into lockout. Clark County Today. January 30, 2021. Available at https://www.clarkcountytoday.com/news/protestors-force-legacy-salmoncreek-hospital-into-lockout/. Accessed June 6, 2022.
Lee Jenkins J, Mason M: A long night in the emergency department during the Baltimore, Maryland (USA) riots. Prehosp Disaster Med. 2015; 30(4): 325-326. DOI: 10.1017/S1049023X15004914.
National Fire Protection Agency: Civil unrest. Available at https://www.nfpa.org/-/media/Files/News-and-Research/Resources/Fire-service/Responder-Forum/2015-NFPA-responders-forum-Civil-Unrest-Paper.ashx?la=en. Accessed May 28, 2022.
Office of Emergency Management, City of Baltimore: Incident management. Available at https://emergency.baltimorecity.gov/about-us/what-we-do/incident-management. Accessed June 4, 2022.
Police Executive Research Forum: Lessons learned from the 2015 civil unrest in Baltimore. Available at https://www.policeforum.org/assets/2015baltimorecivilunrest.pdf. Accessed June 2, 2022.
Federal Emergency Management Agency: Report of the joint fire/police task force on civil unrest: Recommendations for organizing and operations during civil unrest. Available at https://www.usfa.fema.gov/downloads/pdf/publications/fa-142.pdf. Accessed June 2, 2022.
Lough F: Medical care during civil unrest, protests and mass demonstrations. In Pikoulis E, Doucet J. (eds.): Emergency Medicine, Trauma and Disaster Management. Hot Topics in Acute Care Surgery and Trauma. Cham: Springer, 2021. DOI: 10.1007/978-3-030-34116-9_36.
Maguire BJ, O’Neill BJ, O’Meara P, et al.: Preventing EMS workplace violence: A mixed-methods analysis of insights from assaulted medics. Injury. 2018; 49(7): 1258-1265. DOI: 10.1016/j.injury.2018.05.007.
National Public Safety Telecommunications Council: Prehospital notification in time-sensitive medical emergencies what EMS agencies and emergency departments should know. 2018. Available at https://nasemso.org/wp-content/uploads/Prehospital_Notification_Time_Sensitive_Medical_Emergencies_Report_180907.pdf. Accessed June 3, 2022.
Donohue D: Preparing for civil unrest. National Fire Academy. Available at https://nfa.usfa.fema.gov/pdf/efop/efo248668.pdf. Accessed January 27, 2023.
EMS Mental Health: Substance abuse and mental health services administration. US Department of Health and Human Services. Available at https://www.samhsa.gov/resource/dbhis/emsmental-health. Accessed June 4, 2022.
Hennepin Healthcare Department of Emergency Medicine: The city is burning! EMS response to civil unrest. Available at https://www.beaumont.edu/docs/librariesprovider2/innovations-in-emergency-care/jones-civil-unrest.pdf?sfvrsn=d2ee75fb_2. Accessed June 4, 2022.
Erich J: Making the most of street medics. EMS World. 2020. Available at https://www.hmpgloballearningnetwork.com/site/emsworld/article/1225266/making-most-street-medics. Accessed June 6, 2022.
Wicentowski D: How street medics are organizing to treat teargassed, injured ferguson protestors. Riverfront Times. December 1, 2014. Available at https://www.riverfronttimes.com/news/how-streetmedics-are-organizing-to-treat-tear-gassed-injured-ferguson-protesters-2588268. Accessed June 4, 2022.
Ackerman J: Tactical emergency casualty care and the art of practicing nonmaleficence in harm’s way. AMA J Ethics. 2022; 24(2): E150-E153.
Illescas C, Crummy K: Aurora theater shooting report shows delays in fire, ambulance response. Denver Post. April 30, 2013. Available at https://www.denverpost.com/2013/04/30/aurora-theatershooting-report-shows-delays-in-fire-ambulance-response/. Accessed January 28, 2023.
Mueck R: Active shooter incidents: The rescue task force concept. Domestic Preparedness. 2017. Available at https://www.domesticpreparedness.com/healthcare/active-shooter-incidents-therescue-task-force-concept/. Accessed February 4, 2023.
Eldridge TE: Cops could use first aid to save lives. Many never try. 2020. The Marshall Project. Available at https://www.themarshallproject.org/2020/12/15/cops-could-use-first-aid-to-save-livesmany-never-try. Accessed February 3, 2023.
Copyright 2007-2023, Weston Medical Publishing, LLC
All Rights Reserved