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FIRST - Firefighters

Stress and Violence in fire-based EMS Responders (SAVER)

While much of the work by the Center for Firefighter Injury Research and Safety Trends (FIRST) has focused on the injury and safety outcomes of firefighters, our research focus has grown to be inclusive of fire-based Emergency Medical Services (EMS). In the United States, EMS is responsible for as much as 70 to 90 percent of the work done by fire departments. With calls increasing approximately 20% each year (NEMSIS, 2016), EMS responders are increasingly expected to do more with less. Increased call volume and exposure to patients increases the risk for injury and illness for EMS responders. Read more about how increased call volume and other industry strains affect EMS responders in A Strained 9-1-1 System and Threats to Public Health.

Despite working in a profession characterized by helping people, an estimated 2,100 EMS workers visited U.S. hospital emergency departments in 2011 to treat an injury resulting from patient violence (CDC, NIOSH Workplace Safety, 2013). Previous research by the FIRST Center confirmed the issue of patient violence by using data from the National Fire Fighter Near-Miss Reporting System (NFFNMRS), a secure and non-punitive reporting system created by the International Association of Fire Chiefs. We reviewed emergency medical call reports and analyzed their narrative text fields. Of 185 reports, violence (n=48) was the most commonly identified mechanism of near-miss or injury. We found that emergency medical responders were threatened or assaulted by patients, as well as family members and bystanders. Common underlying factors included: violent patients, patients with mental health issues, and patients with particular health conditions (e.g. seizure, hypoglycemia). Learn more about the full scope of workplace violence against EMS responders in the Violence Against Fire-Based EMS Responders FACT SHEET

From a local perspective, this problem of violence affects the Philadelphia Fire Department (PFD)--an urban, inner city department serving 1.5 million people. Data from the Firefighter Injury Research and Safety Trends (FIRST) project served as a catalyst to investigate this particular issue more deeply. We gathered injury data from the Philadelphia Fire Department Safety Office for the period 2005-2011 and analyzed it by cause of injury stratified by males and females. Most causes of injury were of equivalent proportion between males and females. However, the “struck by” category showed a disproportionate percentage of females (22%) who reported this cause of injury compared to their male counterparts (9%). To investigate the “struck by” injuries more deeply, the narratives from the first reports of injury were reviewed. These narratives often referred to violence by a patient as the injury cause. However, most females in the PFD are paramedics, so we stratified by occupation and the gender difference disappeared. But paramedics (compared to firefighters) were 14 times more likely to experience a struck by injuries from a patient. Read more about violence against EMS responders in Expecting the Unexpected: A Mixed-Methods Study of Violence to EMS Responders in an Urban Fire Department.

To view the media's perspective on patient-initiated violence to paramedics and EMTs, read "Banged Up and Burned Out: Assaults by Patients Against Paramedics & EMTs".

In September 2017, the FIRST Center was awarded a $1.5 million dollar grant by FEMA for the project, “Stress and Violence in fire-based EMS Responders (SAVER),” which responds to seven of FEMA’s national prevention priorities on firefighter safety projects “designed to measurably change firefighter behavior and decision-making”. SAVER was the first FEMA R&D grant to address the EMS side of fire. 

SAVER investigated the organizational, mental health, and injury burden that fire-based EMS responders carry as they respond to an increasing community demand for services. 

EMERG Violent Reporting System


There is no uniform system that captures verbal and physical violent exposures to fire-based EMS responders. As part of the SAVER project, FIRST modified an existing violent-event reporting system provided by the Center for Leadership, Innovation, and Research in EMS (CLIR) to increase reporting of verbal and physical violence. EMERG, a highly confidential violence reporting system, was used to capture first-hand accounts of workplace violence from three partnering metropolitan fire departments--Philadelphia Fire Department, Dallas Fire-Rescue, and Sand Diego Fire-Rescue. When possible, reports to EMERG were cross-referenced with workers’ compensation claims for violence-related physical injuries to evaluate under-reporting. Additionally, all EMS calls to the participating fire departments were analyzed by linking dispatch data to patient care reports to better understand community need and clusters of high utilization.


A full analysis of EMERG reports was completed in 2021. This data revealed a narrative of workplace violence experienced by fire-based EMS responders. Key findings indicated that most violent events occurred at night, with the most frequent form of violence being verbal. Medics reported that patients would often scream, yell, and intentionally insult them. This resulted in emotional stress being the most frequent injury experienced by first responders.


Ultimately, the funding provided by FEMA allowed the FIRST Center to study the complexities of violence against EMS responders by obtaining baseline frequency and variability of assault, along with other contributing circumstances to these events (e.g. legal system, community expectations, work environment, etc), and increasing violence reporting mechanisms. Once this baseline is firmly established, the path will be laid for the development of targeted interventions to reduce violence to EMS workers.


SAVER Systems Checklist 


Using findings from a USFA/IAFF-funded systematic review of academic and industrial literature conducted by FIRST, we developed a systems-level checklist for violence against fire-based EMS responders that speaks to each phase of emergency response, including two new phases that emerged as a result of our analysis of the literature. Read USFA Mitigation of Occupational Violence to Firefighters and EMS Responders for insight into this analysis.


The SAVER Systems-level Checklist is an innovative application of traditional checklists, designed to shift the onus of safety and health from that of the individual first responder to the organization by focusing on actions that the leadership team (departments and union) can institute through training, policy, and environmental modifications. In July 2018, the FIRST Center convened 41 diverse subject matter experts representing 27 different fire service and EMS organizations, government, academia, unions, and fire departments for the two-day “Systems Checklist Consensus Conference (SC3)” to facilitate consensus-building, collaboration, and evaluation of the checklist. During the two-day meeting, national stakeholders came to consensus on the efficacy, utility, and usability of the systems-level checklist.  



Check out "Drexel conference focuses on how to keep EMTs safe from violence" for a media perspective on this issue.


The Systems-Level Checklist is ready to be implemented in all fire and rescue departments across the nation. Evaluation of the checklist’s effectiveness uses a mixed methods approach: interviews and focus groups combined with a quasi-experimental repeated-measures design using validated psychological scales for organizational outcomes (burnout, engagement, job satisfaction, etc.), mental health outcomes (depression, PTSD, etc.), and injuries pre- and post- intervention.



SAVER Model Policies


In early 2020, fire service leaders were once again brought together with the goal of refining the Systems-Level Checklist. With 174 items, it was decided that the length and comprehensiveness served as challenges to implementation. Rating all Checklist items on feasibility of implementation produced an 80-item list. These were divided into 8 distinct categories that became the draft SAVER Model Policies.


Condensing these 80 items into just 8 domains prompts fire and rescue departments who implement the Model Policies to enact a policy, a standard operating procedure (SOP), or standard operating guideline (SOG) that supports their EMS responders. These policies/SOPs/SOGs include:

  1. Mission Statement: A department should have a strong organizational commitment to EMS, which will elevate and prioritize EMS work to the level that fire suppression usually receives.
  2. Defining Violence: A department should use common language in the definition of violence throughout their policies, SOPs, and SOGs.
  3. Dispatch - Communication & Coordination: A department should established a collaborative and communicative relationship between dispatch, EMS responders, and law enforcement, providing EMS with ample notice, knowledge, preparation, and protection on calls.
  4. Assessment & Communication of Scene Conditions: A department should establish concrete procedures for assessing scene safety and communicating needs during unsafe conditions.
  5. SOPs During Patient Care: A department should establish polices, procedures, and practices to protect EMS responders during patient care activities.
  6. Readiness to Return to Service: A department should give EMS providers the autonomy to decided what resources they need to support their physical and mental well-being after each and every call.
  7. Reporting of Violence: A department should encourage their membership to report all incidents of verbal and physical violence experienced on the job.
  8. Mental & Physical Health Support: A department should identify and provide access to resources that EMS responders can use to support their physical and mental well-being to sustain a healthy department overall.

While the organization has 80 items to worry about, rank-and-file only have 6. These are the SAVER Pause Points:

SAVER Pause Points

The Pause Points empower the individual responder to speak up to their organization by sharing their experiences in the field as a way to give feedback on how the SAVER Model Policies are working. Pause Points flatted the organizational hierarchy by giving autonomy and decision-making power to those who historically had little.

Learn more about how to implement the Systems-Level Checklist and the Model Policies in your department TODAY!

Find out more on our work addressing violence against EMS Responders:

Model Policies to Protect US Fire-Based EMS Responders From Workplace Stress and Violence

A Systematic Review of Workplace Violence Against Emergency Medical Services Responders

Creation of a Systems-Level Checklist to Address Stress and Violence in Fire-Based Emergency Medical Services Responders

OSHA Executive Summary: Violence Against Emergency Medical Services (EMS) Responders

Mitigating Violence Against First Responder Teams: Results and Ideas From the Hackmanathon

Injury Risks of EMS Responders: Evidence from the National Fire Fighter Near-Miss Reporting System

If you would like more information about our EMS portfolio or are interested in telling us more about your experience, please e-mail FIRST Director, Dr. Jennifer Taylor,