Full text of DOI:10.1080/10903120290938012

INJURIES FROM ASSAULTS ON PARAMEDICS AND FIREFIGHTERS
IN AN URBAN EMERGENCY MEDICAL SERVICES SYSTEM
C. Crawford Mechem, MS, MD, Edward T. Dickinson, MD,
Frances S. Shofer, PhD, David Jaslow, MD, MPH
ABSTRACT
Such acts of violence can result in injury to the pre-
hospital care providers. Fear of future violence victim-
Objective. To determine the nature and frequency of
injuries resulting from assaults on paramedics and firefight-
ers in a large, fire department-based emergency medical
services (EMS) system. Methods. This was a descriptive
study involving retrospective analysis of an occupational
injury database. All injury reports involving assaults from
1996 to 1998 were reviewed. Variables examined included
the employee’s age, sex, work assignment, and activity
being performed when assaulted, the time of day and day of
the week of the assault, the nature of the injury, whether
medical care was sought, and whether time was lost from
work. Assaults were classified as “intentional,” if the perpe-
trator intended to harm the victim, or “unintentional,” if the
injury resulted from a patient’s inadvertently striking the
victim due to an acute medical condition. Results. There
were 1,100 injury reports submitted during the study peri-
od, of which 44 (4.0%, 95% CI 0–10.9%) involved an assault.
Paramedics were assaulted in 35 (79.5%) of these incidents
and firefighters in nine (20.5%). Forty-one assaults (93.2%)
occurred during patient care activities. Medical attention
was sought in 36 incidents (81.8%), and in 14 (31.8%) the
employee lost time from work. Twenty-six assaults (59.1%)
were classified as intentional and 17 (38.6%) as unintention-
al. One (2.3%) could not be classified. Conclusions. In this
EMS system, injuries resulting from assaults were uncom-
mon. However, due to their potential impact on the victims
and the EMS system as a whole, policies and procedures
should be developed to minimize these incidents. Key
words: emergency medical services; violence; wounds and
injuries.
ization may also become a major occupational stres-
sor, affecting a provider’s performance and general
well-being.2 From an EMS system perspective, such
fear may also have a negative impact on employee
retention, as some emergency care providers leave the
profession out of concern for their personal safety.3
The reality that heath care providers are the victims
of violence in the workplace has been receiving
increased attention in the past decade. Bureau of
Labor Statistics data for 1993 revealed that health care
workers and social service workers have the highest
incidence of injuries from assaults of all professions.4
For example, a 1994 survey study of 364 public health
field workers who visited patients in their homes as
part of sexually transmitted disease and tuberculosis
control programs revealed that 38% had experienced
acts of violence in the course of their work. These
ranged from verbal threats to physical attacks and
rape.5 That prehospital care providers are the victims
of violence is not surprising, given the prevalence of
violence in emergency departments (EDs). Of 127 U.S.
teaching hospital ED medical directors responding to
a violence survey, 41 (32.3%) reported at least one ver-
bal threat against an employee daily, and 23 (18.1%)
described a threat involving a weapon one or more
times a month.6 In a 1996 survey of ED employees in
an urban, tertiary hospital, 60 of 106 (56.6%) respon-
dents had been assaulted at work that year.3
PREHOSPITAL EMERGENCY CARE 2002;6:396–401
Several studies have attempted to quantify the prob-
lem of violence directed at prehospital medical
providers through surveys or direct observation. For
example, a survey of EMS personnel from the
Albuquerque Fire Department revealed that 90% had
been the victim of abuse or a violent act committed by
a patient, a patient’s family member, or a bystander at
the scene at some point during their careers.2 Another
survey of 490 EMS providers revealed that 61% had
been assaulted on the job, with 25% of these sustaining
an injury from the assault.7 Finally, a study of the
Metropolitan Nashville/Davidson County, Tenn-
essee, fire department-based EMS system reported
that during 737 hours of direct observation, 5% of runs
involved verbal or physical aggression directed
against an emergency responder by either the patient
or a bystander.8
Emergency medical services (EMS) personnel care for
victims of violence on a routine basis. However, they
themselves can also become the victims of violence
inflicted by patients, family members, or bystanders.1
Received January 5, 2002, from the Philadelphia Fire Department
(CCM, ETD, FSS, DJ), the Department of Emergency Medicine,
Hospital of the University of Pennsylvania (CCM, ETD, FSS), and
the Department of Emergency Medicine, Temple University
Hospital–Episcopal Division (DJ), Philadelphia, Pennsylvania.
Revision received May 2, 2002; accepted for publication May 6,
2002.
Presented at the annual meeting of the Society for Academic
Emergency Medicine, San Francisco, California, May 2000.
Address correspondence and reprints to: C. Crawford Mechem,
MD, Department of Emergency Medicine, Hospital of the
University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA
19104-4283. e-mail: <mechemc@mail.med.upenn.edu>.
The risk of being assaulted appears to be very real
among EMS personnel. The objective of this study was
396

Mechem et al. ASSAULTS ON PARAMEDICS AND FIREFIGHTERS
397
TABLE 1. Total Run Volumes* and Number of
Firefighters and Paramedics Employed by the Philadelphia
Fire Department for the Years 1996, 1997, and 1998
to examine this issue in more detail by determining
the number of assaults on paramedics and firefighters
in a large urban EMS system, the percentage of
assaults that resulted in injuries, whether medical care
was sought, and whether the employee lost time from
work as a result of the incident.
1996
1997
1998
Total run volume
343,869
169,024
347,237
171,907
363,106
176,343
Paramedic run volume
Paramedics employed
Females (%)
163
13 (8.0%)
164
13 (7.9%)
251
41 (16.3%)
METHODS
Study Design
Firefighters employed
Females (%)
1,946
10 (0.5%)
1,984
10 (0.5%)
1,988
10 (0.5%)
This was a retrospective, descriptive study of occupa-
tional injuries to paramedics and firefighters working
for a large metropolitan fire department. A database
of all injuries reported from January 1, 1996, to
December 31, 1998, was analyzed, looking specifically
for those classified by the fire department safety offi-
cer as resulting from assaults. All reports resulting
from assaults were reviewed in detail by one of the
authors (CCM). However, due to the large number of
all injuries reported during the study period, no
attempt was made to read the remaining reports not
related to assaults. This study was approved by the
Institutional Review Board of the University of
Pennsylvania.
*Run volumes include all emergency medical services, fire, and rescue runs
by basic life support and advanced life support units, engines, ladders, fire
chiefs, and specialty units.
Philadelphia employee injury report form. Informa-
tion collected includes employee demographics; time,
date, and location of incident; area of the body injured
and the type of injury; the mechanism of injury; what,
if any, medical treatment was provided; and any haz-
ardous conditions that may have existed at the time of
the incident. A written narrative that describes the
incident in detail is completed by the reporting officer
and included in the report. The form is then forward-
ed to the appropriate department unit supervisor and
to the PFD Safety Office. A separate form, completed
by the Safety Officer, describes whether time was lost
from duty and, if so, for what duration. The data con-
tained in the injury reports are entered into a comput-
erized database that is maintained by the Safety
Office.
The standardized injury report includes a separate
section to be completed if the employee was assaulted
and, if so, whether the injury resulted from a gunshot;
a stabbing or cutting; being struck with an object; a
fall; being kicked, bitten, or punched; or another
mechanism. The form does not explicitly define what
is meant by an assault, but the implied definition is an
incident in which one person inflicts harm on another.
All injury reports in this category were reviewed in
their entirety by one of the authors (CCM). By reading
the narratives, it was possible in most cases to deter-
mine whether the injury was deliberately inflicted or
whether it occurred during the care of a delirious
patient who inadvertently injured the provider.
Incidents that involved a person deliberately attempt-
ing to harm the employee were classified, for the sake
of this study, as “intentional assaults.” “Unintentional
assaults” referred to those situations where a patient
with altered mental status as a result of an acute med-
ical problem or intoxication struck out at the employ-
ee without apparent intent to do harm. A second
author (EDT) reviewed the same reports with the
intent of confirming the classification of cases as inten-
tional or unintentional. The two reviewers were in
agreement in all but one case, which was adjudicated
by a third author (DJ).
Study Setting and Population
The study involved assaults on paramedics and fire-
fighters of the Philadelphia Fire Department. The
Philadelphia Fire Department (PFD) is the sole 9-1-1
emergency medical response agency for the City of
Philadelphia and serves a population of approximate-
ly 1.5 million. In 1996 the PFD operated 22 advanced
life support (ALS) ambulances staffed by two para-
medics each and 13 basic life support (BLS) ambu-
lances, each staffed by two firefighter emergency med-
ical technicians (EMTs). Firefighters routinely worked
on BLS units for only a few days at a time and were
then reassigned back to their regular engine or ladder
company. In 1998, the number of ALS units had
increased to 27, while the number of BLS ambulances
decreased to ten. In addition, all 89 engine and ladder
companies serve as first responder units and have at
least one EMT on board. The total run volumes and
the numbers of personnel employed for the years
1996, 1997, and 1998 are presented in Table 1. Run vol-
umes include all fire, rescue, and EMS runs by ALS
and BLS units, fire engine and ladder companies, fire
chiefs, and specialty units.
Study Protocol
Injuries due to assaults were identified from review of
the PFD occupational injury database covering the
three-year study period. When a paramedic or fire-
fighter is injured on duty, a report is completed by the
employee and his or her immediate supervisor.
Details are entered on a standardized two-page City of

398
PREHOSPITAL EMERGENCY CARE OCTOBER / DECEMBER 2002 VOLUME 6 / NUMBER 4
classified as intentional. These constituted 2.4% of all
occupational injury reports during the study period.
Seventeen assaults (38.6%) were unintentional, consti-
tuting 1.5% of all injuries. The assault could not be
classified as intentional or unintentional in one (2.3%)
case. The average age of victims of intentional assault
was 37.0 (±8.2) years, while the average age of victims
of unintentional assault was 33.8 (±8.4) years. In the 37
incidents where the sex of the assailant could be deter-
mined, 23 (62.2%) were male, and 14 (37.8%) were
female. In cases of intentional assault, 14 (53.8%) of the
assailants were male, and eight (30.8%) were female.
The sex of the assailant was not specified in four
(15.4%) cases. In cases of unintentional assault, nine
(52.9%) of the assailants were male, and six (35.3%)
were female. The sex of the assailant was not specified
in two (11.8%) cases.
Measurements
Variables examined included age, sex, rank, and work
assignment; type of activity being performed when
injured; whether the incident occurred during a fire or
medical run; the type of injury; time and day of the
injury; whether medical care was required; and
whether time was lost from work.
Data Analysis
Data are reported as means ± standard deviations for
continuous parameters and percentages with 95%
confidence intervals (CIs) for categorical data where
applicable. Data were analyzed using SAS statistical
software (Version 8, SAS Institute, Cary, NC).
RESULTS
One thousand one hundred occupational injury
reports were filed from 1996 to 1998. Of these, 44
(4.0%, 95% CI 0–10.9%) were classified as assaults,
meaning they were caused by another individual
(Table 2). The mean age in this group was 36.5 (±8.4)
years. Thirty-five (79.5%) of the assault cases involved
paramedics, and nine (20.5%) involved firefighters.
Forty-one (93.2%) occurred during patient care activi-
ties. One assault occurred when a paramedic was
backing an ambulance into a firehouse, and another
occurred when a paramedic asked a citizen to move a
car blocking egress from a firehouse. A third occurred
when a firefighter was extinguishing a trash can fire
and was assaulted by a bystander. This case was the
only assault that occurred during firefighting activity.
All other injuries from assaults on firefighters
occurred when they were working in BLS units or
assisting paramedics. Forty-two (95.5%) assaults
involved male personnel. The most frequent types of
assault were being punched (35.7%), kicked (16.7%),
and struck with an object (9.5%).
The 44 assaults resulted in 56 injuries, as seven
employees suffered multiple injuries from the same
incident. Furthermore, five employees were assaulted
twice during the study period. The most common
types of injuries were contusions (35.7%), strains/
sprains (17.9%), and scratches (12.5%). Twenty-three
(52.3%) assaults occurred on the night shift (6 PM–8
AM), while 21 (47.7%) occurred during the day. Twenty
(45.5%) occurred on a weekend (Friday, Saturday, or
Sunday). In 36 (81.8%) cases, personnel sought treat-
ment at a medical facility. In the remaining eight inci-
dents, the employees required no treatment or were
administered first-aid at the scene. Fourteen (31.8%,
95% CI 3.8–60%) assaults resulted in time lost from
work, while 27 (61.4%) resulted in no time lost. In
three cases (6.8%), it was not possible to determine
from the documentation whether time was lost.
DISCUSSION
Our finding that 4.0% of occupational injuries resulted
from an assault is in keeping with previous research.
A 1992 retrospective chart review examined all occu-
pational exposures and injuries among Baltimore
County Fire Department EMS personnel. Of 226 iden-
tified cases, 12 (5.3%) resulted from an assault. Two of
these involved injuries inadvertently inflicted by chil-
dren. One of these resulted from a bite by an infant
and the other from a toddler’s poking the provider in
the eyes.9 The latter two cases illustrate a potential
hazard of any retrospective review of reported
assaults. Unless a standardized definition of assault is
established in advance, it is possible for the data to
include cases that were not in keeping with the intent
of the study. In the present study, by reviewing the
actual injury reports it was possible to determine the
probable intent of the perpetrator of the assault in all
but one case. In 59.1% of the cases, the assaults were
intentional, while in 38.6% of the cases, the assaults
appeared to be inadvertent, similar to the injuries
inflicted by the small children noted above.
Our findings are consistent with those of another
recently-reported prehospital study in which violence
occurred in 8.5% of 4,102 patient encounters. Physical
violence, threats of violence, and verbal abuse were all
included. The violence in half of these incidents was
directed at prehospital providers, while in the other
cases it was directed at other individuals at the scene.
The number of violent incidents resulting in injury to
the prehospital provider and the nature of these
injuries were not reported. Of those patient encoun-
ters involving physical violence against the provider,
the majority involved situations where the patient was
resisting care.10 This is in contrast to the present study,
in which the majority of assaults resulting in injury to
providers appeared to be intentional.
Twenty-six (59.1%, 95% CI 38.3–80%) assaults were
While the total number of injuries from assaults on

Mechem et al. ASSAULTS ON PARAMEDICS AND FIREFIGHTERS
399
TABLE 2. Injuries to Firefighters and Paramedics
Case
Title*
Sex
Circumstances
Time Lost
Intent (I/U)†
1
2
3
4
5
6
7
8
FSP
FSP
FSP
FF
FSP
FSP
FSP
FSP
FSP
FF
Male
Female
Male
Male
Female
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Sprains/strains from restraining violent patient
Assault by bystander causing facial trauma
Assault by patient causing multiple contusions/abrasions
5-year-old female patient bit FF’s arm
Intoxicated patient kicked FSP in face, causing laceration
Strained knee while treating combative patient
Patient punched FSP in face, causing contusion
Kicked in groin by disoriented patient
Assault by bystander, causing facial contusion
Wrist abrasion sustained while restraining patient
Punched by patient’s family member, causing contusion
Facial contusion after being struck with thrown object
Assault by violent patient, causing elbow abrasion
Assault by violent patient, causing lip contusion
Kicked in stomach by violent patient
No
No
Yes
No
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
Unknown
Yes
No
No
No
Yes
Unknown
Unknown
Yes
Yes
No
Yes
No
Yes
Yes
No
U
I
I
U
I
U
I
U
I
I
I
I
I
I
I
U
I
I
I
I
I
I
I
U
U
U
I
U
U
I
U
I
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
FF
FSP
FSP
FSP
FSP
FSP
FSP
FSP
FF
FSP
FSP
FF
FSP
FSP
FSP
FF
FSP
FSP
FSP
FSP
FSP
FSP
FSP
FSP
FSP
FSP
FF
Right arm scratch from combative patient
Left wrist sprain after being tackled by patient
Facial contusion from rock thrown by bystander
Punched/kicked by patient, causing multiple contusions
Bottle thrown by bystander, causing finger contusion
Punched in face by patient, causing contusions
Punched in head by bystander while extinguishing fire
Groin pull after being assaulted by patient
Shoulder strain while struggling with delirious patient
Shoulder strain while struggling with delirious patient
Soft-tissue injuries when struck by overdose patient
Thumb strain after being attacked by bystander
Finger/wrist sprain inflicted by delirious patient
Forearm scratch inflicted by mentally challenged patient
Scratches to neck and chest by violent patient
Face/arm contusion by violent patient
Facial laceration after assault by bystander
Back contusion after being struck by patient with belt
Contusions/laceration after being struck by patient
Bite to hand by patient with altered mental status
Arm laceration inflicted by combative patient
Cuts/contusions from demented patient
Cuts/contusions from demented patient
Cigarette burn and bite by suicidal patient
Scratches to face and neck by combative patient
Kicked in knee while restraining patient
Ankle sprains/head trauma while restraining patient
Bitten in thigh by violent patient
I
I
U
U
U
U
U
I
No
No
Yes
No
No
No
No
Yes
Yes
No
FF
FSP
FSP
FSP
FSP
FSP
FF
I
U
Unknown
I
Kicked and punched in face by patient
No
*FSP = fire service paramedic; FF = firefighter.
†I = intentional, U = unintentional.
PFD employees was small, the potential consequences
of such injuries should not be underestimated. These
include the physical and psychological impact on the
employee injured, the associated medical expenses,
the cost associated with time lost from work, and the
effect on morale of all employees. The psychological
impact of assaults on prehospital care providers is
poorly understood. Once again, most of the informa-
tion available on this subject comes from ED employ-
ees. In one study of ED staff who had witnessed or
been the victim of an assault while at work, 25%
described decreased performance for the rest of the
shift, 24% reported impaired performance for the rest
of the week, and 19% for an even longer period.
Seventy-three percent of the respondents stated they
felt at least some fear of patients, either because of
overt acts of violence or because of the potential for
violence. Thirty-eight percent of the respondents con-
sidered a job outside of health care because of work-
place violence. Of 18 respondents who no longer
worked in the ED, 12 (67%) stated they had left the job
in part because of violence.3 Similarly, in a survey of
390 emergency medicine residents and recent gradu-
ates, 62% stated they worried about their own safety
while at work.11 Thus, violence or the threat of vio-
lence on emergency providers can have a major
impact on the victims and their colleagues.
Several steps may reduce the risk of violence to EMS
providers. These include specific policies and training
dealing with the management of violent or potentially

400
PREHOSPITAL EMERGENCY CARE OCTOBER / DECEMBER 2002 VOLUME 6 / NUMBER 4
violent patients and scenes.12 While the importance of
such measures seems intuitively obvious, they do not
appear to be widespread. One survey study of EMS
providers revealed that only 35% stated that their
agencies had policies for dealing with violent patients,
and 28% stated they had received formal training on
managing violent situations.7 Such training can
address techniques to defuse potentially violent situa-
tions before they escalate, how to stay safe if the situ-
ation does escalate, and when to retreat.12 Training
can also cover the medical causes of violent behavior,
including those that require rapid diagnosis and treat-
ment, such as hypoglycemia, hypoxia, or head
injury.13 Written policies on the use of restraints could
increase the safety of providers caring for combative
patients. At the same time, judicious use of restraints
could decrease the risk of accidental injury to the
patient.
Other steps to reduce the risk of violence to EMS
providers include the simultaneous dispatching of
law enforcement officers on calls associated with vio-
lence or the potential for violence. When scene safety
is uncertain, EMS should stay at a distance from the
actual incident until the scene has been cleared by
police. There should also be a mechanism in place for
EMS personnel to request rapid law enforcement
backup if they feel threatened or if violence has erupt-
ed. EMS providers’ uniforms should have an appear-
ance distinct from those of law enforcement, so the
two cannot be confused and the health care provider
cannot be targeted by mistake.12 Finally, some EMS
agencies have purchased bullet-resistant soft body
armor for their employees. While this equipment may
protect personnel from certain types of weapons, it is
no replacement for proper training. Body armor is also
only effective if worn and may be extremely uncom-
fortable to wear in warm weather.14
The finding that far more paramedics than firefight-
ers were assaulted is noteworthy, given that at the
time of the study the PFD employed almost ten times
as many firefighters as paramedics. One possible
explanation is the much higher call volume of the ALS
and BLS units compared with engine and ladder com-
panies. Another possible explanation lies in the cir-
cumstances in which the two groups work. First, PFD
paramedics work in teams of two that must frequent-
ly care for combative or delirious patients. At times
they may also be isolated in the midst of hostile
crowds. Thus the potential for injury seems high. On
the other hand, when PFD firefighters respond to
fires, the likelihood of violence is less than in patient
care situations. When firefighters working on first
responder engine or ladder companies do respond to
medical calls, they are working in groups of four or
more. They therefore have backup readily available.
They also arrive on scene wearing bunker gear, which
can be both protective and intimidating to people at
the scene. In addition, because paramedic units in
most cases arrive shortly after the first responder
companies, the firefighters have only limited patient
contact, making the potential for assault even less. In
the present study, eight of nine injuries resulting from
assaults on firefighters occurred while they were
working in BLS units or assisting paramedics, empha-
sizing the higher-risk nature of patient care.
LIMITATIONS AND FUTURE QUESTIONS
There are several limitations to this study. Its retro-
spective design raises the possibility of the inclusion
of inaccurate or incomplete data. While the records of
the 44 assaults were reviewed in detail, the rest of the
1,100 records were not. It is therefore possible that
cases may have been missed due to misclassification
or other reasons. In addition, since the database
includes only cases reported to the Safety Office, there
may have been many other assaults against PFD per-
sonnel that they did not report. Reasons for not filing
reports could include employees’ considering inci-
dents to be minor or perhaps feeling embarrassed to
admit that they had been assaulted. In addition,
potentially violent situations that did not result in
actual injury to an employee were not included. Such
situations would include threats with weapons, verbal
abuse, or attempted assaults in which the perpetrator
was restrained before actually causing an injury. Thus,
the total number of reported cases may underrepre-
sent the scope of the problem. Finally, the lack of a
universal definition of what constitutes an assault is
another potential source of bias. A patient with altered
mental status due to a medical emergency who strikes
a paramedic with flailing arms during an attempt at
intravenous line placement for the sake of this study
would have been considered to have committed an
assault. However, that patient has a clearly different
intent than does someone who deliberately punches a
paramedic in the face. To address this distinction,
assaults were further classified as intentional or unin-
tentional in an effort to account for the probable intent
of the perpetrator.
One question meriting further research is what
impact violence or the threat of violence has on
employee retention in busy EMS systems, especially
those in major metropolitan areas. Out-of-hospital
medicine can be a demanding profession under the
best of circumstances. Working in a high-crime or oth-
erwise potentially violent area can place an additional
burden on already stressed employees. However, a
violent incident may take a similar or even greater toll
in smaller EMS systems were violence is less com-
monly encountered and so not viewed as part of the
job. A related question is whether the perception that
EMS may be a potentially dangerous profession deters
some people from entering it as a career. Similarly, are

Mechem et al. ASSAULTS ON PARAMEDICS AND FIREFIGHTERS
401
prehospital care providers attracted to, or deterred
from, EMS systems with either a higher or lower risk
of violence?
References
1. Lucas R. Violence in the pre-hospital setting. Emerg Med Clin
North Am. 1999;17:679-83.
A final question worthy of future investigation is the
role, if any, of personal protection equipment or train-
ing for prehospital personnel. For example, it may be
tempting to supply all employees with body armor or
pepper spray or provide them with self-defense train-
ing. While this may make the employees feel more
secure, it is unclear whether such steps would actual-
ly make them safer. The effect that such measures
could have on the public’s perception of EMS person-
nel should also be considered.
2.Pozzi C. Exposure of prehospital providers to violence and
abuse. J Emerg Nurs. 1998;24:320-3.
3.Fernandes C, Bouthillette F, Raboud JM, et al. Violence in the
emergency department: a survey of health care workers. Can
Med Assoc J. 1999;161:1245-8.
4. U.S. Department of Labor, Occupational Safety and Health
Administration. Guidelines for preventing workplace violence
for health care and social service workers. OSHA 3148, 1998.
Website: http://www.osha-slc.gov/SLTC/workplaceviolence/
guideline/html.
5.Schulte JM, Nolt BJ, Williams RL, Spinks CL, Hellsten JJ.
Violence and threats of violence experienced by public health
field-workers. JAMA. 1998;280:439-42.
CONCLUSIONS
6.Lavoie FW, Carter GL, Danzl DF, Berg RL. Emergency depart-
ment violence in United States teaching hospitals. Ann Emerg
Med. 1988;17:1227-33.
In this EMS system, 4.0% of occupational injuries
resulted from assaults. The majority of these incidents
occurred during patient care activities, and a majority
appeared to be deliberate acts of violence. A dispro-
portionate number of victims were paramedics when
compared with firefighters. Despite the fact that
injuries from assaults constituted a small percentage
of total work-related injuries in this setting, many
required medical attention and resulted in time lost
from work. They therefore had a significant impact on
the employee and on the EMS system as a whole.
Therefore, specific steps should be taken to increase
the awareness of EMS personnel to the risk of violence
and to minimize the number of violent incidents.
7.Corbett SW, Grange JT, Thomas TL. Exposure of prehospital
care providers to violence. Prehosp Emerg Care. 1998;2:127-31.
8.Mock EF, Wrenn KD, Wright SW, Eustis TC, Slovis CM.
Prospective field study of violence in emergency medical serv-
ices calls. Ann Emerg Med. 1998;32:33-6.
9.Gershon RRM, Vlahov D, Kelen G, Conrad B, Murphy L.
Review of accidents/injuries among emergency medical servic-
es workers in Baltimore, Maryland. Prehosp Disaster Med. 1995;
10:14-8.
10.Grange JT, Corbett SW. Violence against emergency medical
services personnel. Prehosp Emerg Care. 2002;6:186-90.
11.Anglin D, Kyriacou DN. Residents’ perspective on violence and
personal safety in the emergency department. Ann Emerg Med.
1994;23:1082-4.
12.Holroyd BR, Nabors MD. Dealing with violence in the prehos-
pital setting. West J Med. 1993;159:597.
13. Tintinalli JE. Violent patients and the prehospital provider. Ann
Emerg Med. 1993;22:1276-9.
14. Limmer D. 10 commandments for EMS survival. J Emerg Med
Serv. 2000;25(8):24-30.
The authors acknowledge Battalion Chief Thomas Comerford of the
Safety Office of the Philadelphia Fire Department for his assistance
in data collection and thoughtful review of the manuscript.