If you have ever responded to a behavioral emergency in a professional setting, such as a hospital or school, you might recall experiencing a lot of uncoordinated activity among a group of highly educated, capable, and well-meaning professionals. They may even have seemed to make things worse, rather than better. In retrospect, you might not even be able to put your finger on exactly what went wrong.
Maybe after responding to a lot of behavioral emergencies yourself, you start to accept that they always end with at least one negative consequence, such as an injury, restraint, complaint, reprimand, investigation, criminal charge, lawsuit, or a staff member who becomes so fed up, frustrated and emotionally exhausted that they finally throw in the towel and quit. But do behavioral emergencies have to end badly, in some manner, just by their very nature?
If behavioral emergencies in your workplace end too often with some sort of physical, organizational, legal, or emotional injury, or some combination of them, then your staff needs what scores of other institutions, agencies, and businesses have come to rely on with a unified approach that is guided by the First Responder Philosophy.
POLE: Physical, Organizational, Legal, and Emotional Safety
The POLE acronym is what Vistelar uses to describe the various forms of workplace safety that effective conflict management programs address.
The first installment in this three-part series of articles presented two case studies of actual responses to behavioral emergencies in hospitals that were obviously chaotic and dangerous. To the untrained eye, the level of chaos and danger in both cases might have seemed unavoidable; however, to the eye trained in the First Responder Philosophy (FRP), they were both glaring examples of lost opportunities for team coordination and safety, despite all the well-meaning efforts of those involved.
To be sure, hindsight is 20/20. But the First Responder Philosophy is about foresight — knowing what to do when a staff member first becomes aware of an emergency, during an emergency, and even after an emergency when it’s time to debrief and write the reports. The focus of this article, therefore, is this question: “Can the activity of emergency responders be coordinated well enough, even as an emergency is developing, to make their responses more effective and safer?”
For over 30 years, hospitals and mental health facilities, community clinics and social service agencies, prisons and jails, schools and other institutions have been keeping people safer and serving them better, by coordinating the activity of staff members from varying disciplines, by using the First Responder Philosophy.
|THE FIRST RESPONDER PHILOSOPHY (FRP)
The origins of the First Responder Philosophy date back to the 1980s, with a team of specialized defensive and tactical instructors, behavioral health providers, healthcare professionals, and social workers who were responsible for some of the earliest work in the field of consistent emergency and trauma-informed response models and training for first responders and human service professionals.
In many ways, and quite before its time, they developed an innovative approach to coordinating the training and response of emergency responders from varying jurisdictions and disciplines. The FRP is now a model for training and directing Behavioral Emergency Response Teams (BERT) in hospitals and schools, Correctional Emergency Response Teams (CERT) in jails and prisons, and other response teams from varying institutions, such as residential facilities, youth service agencies, and schools.
I first learned the FRP in 1991. As a young man at the time, the requirement seemed excessive and I was not exactly sure why we had to memorize the FRP; but just after a few weeks of responding to medical emergencies, behavioral emergencies, patient restraints, full-on brawls, the occasional fire alarm or hazardous materials event, and miscellaneous other emergencies I had never anticipated, I understood completely why the FRP was so important.
And during the next 30 years of working in various high incident frequency environments, the FRP went with me everywhere I went. So, when it was my turn to decide how to develop and train a facility’s emergency responders, I insisted that they memorize the FRP as well.
The First Responder Philosophy applies to all emergencies, so ultimately it led the way to meaningful training in preparing corrections officers to respond to inmates struggling with mental health challenges and emotional crises. This is notable because jails and prisons experience behavioral emergencies at even higher rates than hospitals. Corrections and law enforcement professionals experience more conflict and violence than any other profession, but behavioral and medical healthcare and the social service fields are at the top of the rung in the private sector for conflict, violence, and subsequent injuries to workers. So naturally, that is where we saw the Unified Tactical Training System go next.
During the 1980s, the re-institutionalization of mental health patients to jails and prisons was beginning to peak, making correctional facilities the largest and most prevalent mental health facilities in the nation. By the 1990s, the UTS and the FRP to hospitals and emergency rooms, where the mentally ill were also forced to turn for help after the breakup of the institutional mental health system. Now, using the FRP, let’s see how it would apply to the second case study presented in article one of this series; specifically, the case of the assault on staff members at a rural Critical Access Hospital.
1) Arrive, 2) Assess, 3) Alarm…
Prior to the arrival of an ambulance to an Emergency Department (ED), an EMS team will typically call the hospital and provide an estimated time of arrival (ETA), which is the ARRIVE phase of the FRP. They’ll also notify them of the level and type of medical emergency, in this case, a cardiac emergency, which represents the ASSESS phase. At that point, the ED will issue a cardiac code alert, notifying all the cardiac team members to immediately assemble at the ED, which is the ALARM phase of the FRP. The assembled team will then 4) EVALUATE the patient’s immediate need in order to 5) STABILIZE their condition.
But in this case, as with many others, there was another emergency unfolding at the same time – a possible disturbance involving the patient’s husband in the waiting room lobby. So the team needed another angle to ARRIVE, ASSESS, ALARM and beyond, for the second emergency.
Now that the patient was being cared for, the husband of the patient came through the front door and demanded to see his wife. During the actual incident that is the basis for the story, one of the nurses in the ED responded to intervene with the husband, while the rest of the team saw to the patient’s needs. Shortly after the encounter between the husband and the nurse, both a receptionist and the nurse were assaulted and injured. Let’s see how applying the FRP might have resulted in a different outcome. We will accomplish this by rewriting the story through the lens of the FRP, from the exact beginning to some possible different conclusions.
Story: A Husband in Crisis
Then one day, an ambulance came in through the back, with a pulseless and non-breathing patient. The EMTs had started CPR and were breathing for her, using an AMBU bag. Quickly the team assembled and went to work.
|Note: After “ARRIVE”, the first step in the FRP, in which a responder
first becomes aware of an emergency, step two is “ASSESS”, in which
the responder determines the level and type of emergency, i.e., Disturbance, Fire, Medical, Miscellaneous, or a combination of these. The responder is then able to complete step three, which is to make the appropriate “ALARM”, i.e., summon the appropriate assistance and assets to the scene before the responder is engaged so heavily that the opportunity to summon help is lost. Failure to ASSESS and ALARM are common errors committed by responders to behavioral and other institutional emergencies, often resulting in delayed and uncoordinated responses to institutional emergencies.
ARRIVE: Just then, the receptionist pushed open the ED doors from the lobby and shouted, “We need help out here!”
The charge nurse asked Emerson to break away and go and see what the problem was. In order to ASSESS the situation, Emerson first asked the receptionist a few questions.
“What’s wrong?” Emerson asked the receptionist.
“It’s the husband of the heart attack patient that just came in. I think he’s been drinking. He’s very angry, yelling, cursing, and demanding to see her now!” replied the receptionist, excitedly. Emerson was then able to assess that they were dealing with a disturbance emergency.
At that point, the next step in the FRP is the ALARM phase, which requires that other people be notified of the emergency and summoned. At this small rural Critical Access Hospital, there was no security staff, so Emerson asked the EMS crew, who had just finished their verbal report to the cardiac team, to stand by with her while she spoke to the patient’s husband. She also asked the receptionist to call the hospital facilities department to send any available staff members over to standby for a potential disturbance. She also asked her to call the sheriff’s department to update them on the situation.
4) Evaluate, 5) Enter 6) Stabalize…
Emerson then proceeded to EVALUATE the emergency, to determine any possible threats, risks, or hidden dangers. She first asked the receptionist to describe the man. She then asked if he arrived alone and if there were other people waiting in the lobby. She also asked if he was armed or had anything in his hands and if he had made any verbal threats. Finally, she asked why she thought he had been drinking.
The receptionist said he was a large man about 50 years of age, appeared to be unarmed, was cursing and yelling, but made no verbal threats at that point. Then she said she could smell alcohol on his breath when he yelled at her and he appeared to be unsteady and slurring his speech.
Then Emerson asked the two EMS crew members if they had any information on the man and they said he was well known in the community for drunk and disorderly behavior and for being a “hot head”, and that they weren’t surprised that he was causing a disturbance.
Finally, Emerson listened at the door, but could not hear the man yelling. She could, however, see through the small observation window that he was wearing an angry expression, was dirty and disheveled, and pacing with his fists balled up at his sides.
Just then, a facilities worker arrived to assist. Emerson then briefed the team and together they devised a quick response in order to ENTER when safe and appropriate and STABILIZE the scene and the man, verbally if they can and physically if they must.
The team determined that it was appropriate to intervene because other patients might arrive for care and they need to be available for them. Also, it could be another 30 minutes or more before a sheriff’s patrol might arrive, depending on their availability, how fast they were moving, and how far they were coming from. They agreed that they shouldn’t wait and instead attempt to address the man’s needs, rather than let him stew and possibly escalate any further.
The EMS crew gave Emerson the man’s name, and it was determined that she would address him first. The facilities department technician and one of the EMS crew would stage just outside the entrance to the ED treatment area, so they could watch, hear, and respond instantly, if needed. That way they could remain off stage, so as not to appear threatening and overstimulate the man any further.
The receptionist would exit the side door to avoid walking past the angry man and stage outside the public entrance, where she would redirect any patients or visitors to an alternative entrance when they arrived. She would also call the sheriff’s department back, if needed, and ask them to respond more quickly. Emerson and the EMS tech were now ready to ENTER the scene and attempt to STABILIZE him with their professional presence and Emerson’s verbal skills.
Distance affects the comfort level of people interacting with you and your personal safety. There are three points where you should evaluate risk – whether you are approaching someone, or they are approaching you. Managing proxemics allows you to scan for risks and evaluate a space, before entering it.
Key elements to be effective at Proxemics:
Emerson, with one of the EMS crew to support her, entered the lobby to address the angry man. She wore a confident expression while standing ten feet away to see how he would react. The EMT stood off to the side to watch for her safety while avoiding escalating the man.
Before she could speak, the angry man looked at her and yelled, “Do you work here?”
Since the man was angry, with his fists balled and slurring his words, Emerson decided to stay back at 10 feet to communicate, while opening with a Universal Greeting.
|The Universal Greeting has four steps:
The Universal Greeting establishes rapport (step 1), explains who you are and identifies your source of authority (step 2), explains what you want and why they should care (step 3), and then encourages the other person to talk (step 4).
“Yes. Hello, I’m Emerson, one of the nurses here at the hospital, are you Mr. Jenkins?”
“Yeah, I’m Bob Jenkins. Where’s my wife?” he replied sternly.
“Mr. Jenkin’s, your wife is in the emergency room and the doctor is with her. As soon as I can, I will ask the doctor to talk with you, but she’s very busy helping your wife right now. Is there someone else who can come here and be with you while you wait for news?”
“She had a heart attack! That’s what her sister said!” the man said excitedly.
“We are working with your wife now, so we need to put all our efforts into helping her. Can we call some of your family or friends to wait with you?”
“I don’t care about that! I want to see her now!” he demanded.
At that point, the story could have ended several ways. Emerson could have kept attempting to de-escalate him and get his cooperation. After all, she was doing a nice job of communicating verbally and nonverbally, up to that point. Perhaps despite her best attempts to de-escalate the situation, he might have lunged toward her. But being ten feet away, she would have had the opportunity to retreat and time for her team to intervene. Or maybe the sheriff’s patrol was nearby and would arrive just in the nick of time, while Emerson stood safely back at ten feet, continuing to de-escalate Mr. Jenkins.
But based on Emerson’s approach using the FRP, and the time it took her to 1) ARRIVE, 2) ASSESS, 3) ALARM, 4) EVALUATE, 5) ENTER, and start to 6) STABILIZE the man and the scene, by using Proxemics 10-5-2, the Universal Greeting and other methods, the family would have likely arrived in the middle of it and taken their family member in hand, restoring safety for all, as they did during the actual encounter. But this time they would arrive in time to avoid another tragedy, instead of walking in and seeing their loved one standing over two injured healthcare workers lying on the floor at his feet.
But even when bad things do happen, the FRP continues to guide responders’ steps, by giving them a template for how to 7) CHECK MEDICAL STATUS for injured persons; 8) MONITOR LONG TERM the medical, mental, and security needs generated by the incident;
9) COMMUNICATE with the necessary people before, during and after the incident; and finally, 10) DOCUMENT and DEBRIEF after the incident, to complete the necessary reports in a manner that is clear and concise and pass on the lessons learned from the encounter.
The above was an example of the FRP in action and how it can provide foresight into an emergency, in order to guide responders’ steps to maximize efficiency and safety, instead of reacting unprepared to whatever is thrown at them. In the next installment, we will look at responses to an even greater number of co-occurring emergencies, during another “really bad day” on the job.