The Art of Awareness for Emergency Medical Calls

Civilian responders have successfully acquired many skills that were originally developed by military services. Situational awareness is one such skill that would be beneficial to adapt to the civilian members of the emergency medical services. Maintaining a heightened sense of awareness would help responders stay “in the loop.”

While the term “situational awareness” has entered mainstream vocabulary fairly recently, the theory and concept have been known to the military for a long time. Originally developed by Col. John Boyd and coined by the United States Air Force, the situational awareness phase involved the “observe” and “orient” portion of the observe-orient-decide-act (OODA) loop. Losing situational awareness means being “out of the loop.”

A definition specific to emergency medical services (EMS) comes from a 2011 article that stated, “Situational awareness is usually defined as the need or ability to have a high level of attentiveness to the environment in a dynamic situation, or making the proper decision and acting on it in the most appropriate fashion.”

Understanding the Concept

Col. Jeff Cooper from the United States Marine Corps further solidified the overall concept with what is known as “Cooper’s Color Code of Awareness.” Cooper’s Color Code breaks down the amount of mental attention given into a perspective of different levels. The five stages explained by this model include:

  • “White,” which is compared to a sleeping state, unprepared and unready to take action;

  • “Yellow,” which is prepared and alert, but relaxed;

  • “Orange,” which is a state of readiness to take action as a result of a specific alert, threat, or danger;

  • “Red,” which is the fight or emergent reactionary phase (action mode); and

  • “Black,” which was added in recent years to represent the stage where one is unable to react, essentially frozen or in shock – a phase of system overload.

This model is applicable not only to the patient care aspects of EMS, but also to personal situational awareness when EMS providers are evaluating a scene for risks and threats. While on emergency scenes, EMS personnel are most often in an orange condition, ready to take action.

Frequent evaluation of the scenario, heightened awareness of the environment and the people in that environment, and possibly the early recognition of a threat toward responders or an adverse change in a patient condition allow for development of a plan for action while maintaining an orange condition. Of course, many EMS providers maintain a yellow condition while secure in their stations, but it is safest to maintain an orange level of awareness on the street to stay ahead of potential conflict or adverse situations. However, outside factors and distractions – phones, conversations, or other pressing matters – affect the ability to maintain an orange state, which could be a critical error when it comes to safety.

Situational Awareness at the Provider Level

One of the more palpable areas where the aforementioned definitions become more operationally critical is when examining situational awareness at the EMS provider level. As EMS providers – whether responding to an emergency or having actually arrived on scene – the most valuable commodity in any situation is information. Likewise, the only way to manage the scene is to gather as much information as possible.

The development of incident situational awareness continues beyond the initial “Is the scene safe?” question that EMS providers are taught to ask in their initial training course. Similar to the patient assessment the EMS provider performs on each patient to develop a differential diagnosis and a treatment plan, providers utilize assessment processes on each scene to evaluate environments and incidents long before arriving at the location and throughout the work shifts. The goal is to develop situational awareness for responders by adding to the input of information. Examples of information input include:

  • Utilization of dispatch information to determine the need for more, or different types of, resources;

  • Evaluation and understanding of potential hazards that may have caused the injuries requiring treatment, or information sharing for other responders of hazardous conditions prior to their arrival, such as electrical wires down or a hazardous odor resulting in multiple unconscious patients;

  • Recognition of a particular safety issue, such as an item on scene that could be used as a weapon, resulting in further evaluation, moving the item to a safe distance, or even backing out of the scene; and

  • Early recognition of behavioral indicators such as body language from a patient, patient’s family member, or other bystander before an attack against responders occurs.

Incorporating the aforementioned into patient and scene assessments can spell the difference between safety and danger. Understanding issues such as checking patients for weapons, understanding which patients could potentially be disoriented and/or dangerous, and reading the body language of the patient/patient’s family should be on the EMS providers’ minds on scene and especially before relocating patients, or others, into the ambulance.

Relevant Examples

One example of this type of situation occurred with an EMS crew in 2009 in Alexandria Bay, New York, when a patient became agitated toward an EMS crew providing care. The patient grabbed a rifle from a nearby bedroom, firing at the EMS crew, striking and killing one of the emergency medical technicians (EMTs).

Another example happened in Omaha, Nebraska, in 2013 and involved a patient who was in custody of law enforcement and searched by an Omaha police officer before having seizure-like activity. Once in the ambulance, the patient stood up, turned around with a gun, fired it twice, and injured the attending paramedic and herself. The patient made terroristic threats, including statements regarding the possession of an improvised explosive device and how she was willing to detonate it, as well as communicating threats of having additional ammunition intended for responders to avoid jail time as she reached into her waistband.

Barriers & Challenges to Situational Awareness

Certain factors, or barriers, can challenge the success of achieving strong situational awareness. Perception, or theea of reality, is easily affected through experiences and current expectations. By reacting to a current incident in a similar fashion as a previous experience – using outdated information or interpreting an incident based on what is expected to occur versus what is actually occurring – could result in altered awareness.

Complacency and overload are contrasting challenges for responders. Complacency is one of the greatest compromising factors on the EMS providers’ state of situational awareness. No matter how many times an EMT sees a specific patient or a similar scene, it is imperative to stay ahead of the situation. Assuming everything is under control and allowing complacency to take over could eventually affect vigilance.

By contrast, information overload could cause analysis paralysis for responders. Both of these scenarios may result in experiencing the black level of awareness discussed earlier. Fatigue affects many facets of the EMS profession, including situational awareness. In order to be aware, EMTs must be sharp, keeping their heads on a swivel to recognize the changing environment. This requires proper rest to avoid easy distraction.

The foundational elements that comprise situational awareness have applicability to EMS. Forward-thinking EMS providers must endeavor to incorporate these elements in the same manner as in the military and law enforcement realms.

Seth Komansky

Seth J. Komansky, MS, NRP, is deputy director and chief of operations for the Wake County Department of Emergency Medical Services (EMS) in Raleigh, North Carolina. He is responsible for the day-to-day operational function of Wake County EMS response units and personnel. He supports the paramedics, EMS techs, field training officers, and district chiefs. He is also responsible for special operations, which includes community special event support, EMS Honor Guard, bike team, hazardous materials medical response, and tactical paramedic program. Additionally, he manages the Wake County EMS Medical Intelligence Unit and serves as the statewide EMS field liaison officer coordinator at the N.C. Information Sharing and Analysis Center, North Carolina’s state fusion center based at the N.C. State Bureau of Investigation. He has a Master of Science in homeland security management from the Homeland Security and Terrorism Institute at Long Island University.

Raphael M. Barishansky

Raphael M. Barishansky, DrPH, is a public health and emergency medical services (EMS) leader with more than 30 years of experience in a variety of systems and agencies in positions of increasing responsibility. Currently, he is a consultant providing his unique perspective and multi-faceted public health and EMS expertise to various organizations. His most recent position prior to this was as the Deputy Secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health, a role he recently left after several years. Mr. Barishansky recently completed a Doctorate in Public Health (DrPH) at the Fairbanks School of Public Health at Indiana University. He holds a Bachelor of Arts degree from Touro College, a Master of Public Health degree from New York Medical College, and a Master of Science in Homeland Security Studies from Long Island University. His publications have appeared in various trade and academic journals, and he is a frequent presenter at various state, national, and international conferences.



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