Risk vs Benifit Analysis – An Apology to Melissa

I belong to several EMS groups on social media. Recently one of the boards got rolling on the topic of active shooter scenarios and some systems that are integrating non-tactical EMS into their active shooter scene management. The idea is to teach EMS personnel how to enter an active killer scene and assist with care and evacuation of areas that have already been cleared by the first wave of law enforcement. EMS personnel are shielded by multiple law enforcement officers who protect the EMS crews while they perform critical interventions and evacuate the wounded.

This system is designed to bring care to victims on scene faster and prevent tragedies like Dave Sanders and Gerardo Hernandez. It is a low risk operation that gets some EMS folks riled up. That’s where Melissa comes in. To be fair, Melissa is not alone. She represents a large body of EMS caregivers who feel that EMT’s and paramedics enter the scene when it has been made completely safe and not a moment before. Melissa is well spoken, respectful and thoughtful in her answers which makes her a perfect spokesperson for this opinion. She uses phrases like “Make it safe or get the patient to me.”, “Dead paramedics aren’t much use.” , “That’s not my job.” and “Ensure my safety.”

Melissa believes that we can operate in EMS in a bubble of safety. She believes that because that’s what we taught her. And for that I apologize. You see, that incorrect belief system isn’t Melissa’s fault. Melissa had a team of EMS instructors that taught her that we wait until the scene is completely safe and then we enter and render care. She was taught that injured EMS personnel change the context of the whole scene and delay care to the primary injury. She was taught that we don’t make decisions regarding our safety, we let others establish our safety.

I suspect Melissa is a good student and she is probably a dead-on good caregiver. When she was taught about scene safety in EMT and Paramedic class she listened well and took those lessons to heart. Today, she is able to make a good solid argument regarding the role of EMS in violent encounters. And now, as an EMS instructor, I think I owe her an apology, because I think we may have done her and all of our other students a disservice.

So what should we have taught Melissa?

Instead of teaching Melissa that EMS care is a no-risk environment, we should have taught her that every minute she works on the street, there will be risks to her safety and she will need to make a risk vs benefit analysis on every scene. We should have taught her that she was entering a field where she would be five times as likely to be assaulted on the job than the rest of the non-ems workforce. We should have told her that her risk of injury or death in a motor vehicle accident was unacceptably high and that she would be forced to operate on roads in inclement weather that were every bit as dangerous as the inside of a burning building.

Melissa is a mother and a wife who seems to love her job. She values her safety and I can respect that. My biggest concern for Melissa and every other EMS caregiver like her is that they might not be recognizing the huge risks involved in EMS care. If Melissa balks at the prospect of engaging a pretty-darn low-risk scenario because of the off chance that police might place her in harms way, I fear that she might not be recognizing all the risks endemic to our jobs.

That’s my biggest concern with teaching the sterile no-risk curriculum to our EMT and Paramedic students. When we teach the wait-till-everything-is-safe mantra, we also teach people to stop recognizing the true and inherent risks present on every scene. And for that, we might owe our students and apology. Be safe out there.



  1. For anyone who is interested, here is an article on what various groups and agencies are looking at doing in regards to this: