an ambulance parked at the entrance of an emergency department

Addressing Racism and Bias in Emergency Medical Services

By Stephen Wood

Law enforcement rightfully has taken a bulk of the national criticism for their actions in four recent cases of police brutality.

But in each of these instances, emergency medical services (EMS) providers were also on the scene. EMS providers serve the public and have a duty to act. In these four scenarios, there was a failure of this duty.

On May 25th, former Minneapolis police officer Derek Chauvin pressed his knee onto the neck of George Floyd, an African-American man being restrained by police for allegedly attempting to purchase goods with a counterfeit twenty dollar bill. Derek Chauvin had Mr. Floyd in a prone position and pressed his knee into Floyd’s neck for over nine minutes. Video footage reveals that Floyd made several statements that he could not breathe and then became flaccid and unresponsive. Chauvin continued pressure on Floyd’s neck despite these pleas and despite Floyd becoming unresponsive. Floyd is later seen being loaded into an ambulance, limp and lifeless. Floyd died from the relentless pressure of Chauvin’s knee on his neck — an autopsy confirmed that he succumbed to asphyxiation.

This egregious act prompted a national outcry against police brutality and racial injustice, resulting in demonstrations across the country. Chauvin has since been charged with second degree murder, and the three other officers who were also present, J. Alexander Kueng, Thomas Lane, and Tou Thao, have been charged with aiding and abetting second-degree murder. This is just the beginning of a national discussion around police policy and procedure, as well as the crisis of racism.

The video also shows paramedics from the Hennepin Healthcare system, the 911 provider for the city of Minneapolis. While it has gone largely unreported, the actions of the Hennepin paramedics were well below the standard of care for a victim of cardiac arrest. In response to the paramedics actions Hennepin Healthcare EMS Chief Marty Scheerer stated that his paramedics “did everything right” in their treatment of George Floyd. The video, however, tells another story.

A review of the video shows that EMS arrives with a two-person crew. One of the paramedics comes over to Floyd, with Chauvin’s knee still compressing Floyd’s neck, and checks for a pulse. Floyd is, at this point, limp and unresponsive. The paramedic does not request that the officer remove his knee from Floyd’s neck, despite what appears to be the lack of a pulse. Instead, the two-person crew walk back to the ambulance to unload a stretcher. One minute after the pulse check, the paramedic taps officer Chauvin on the shoulder and he finally removes his knee from Floyd’s neck.

He is loaded in the ambulance one minute and forty-four seconds after the pulse check. The ambulance departs the scene, without initiating any treatment, including CPR, a full two minutes and forty seconds after the pulse check.

The Eric Garner case is another example of inadequate emergency care. This case involved police officers applying a “choke hold” to detain Garner, accused of selling single, unstamped cigarettes on the street in Staten Island. Like the Floyd case, EMS arrives on scene, performs a pulse check and then does nothing at all. Even though Garner is unresponsive, they do not position him to ensure an adequate airway or administer oxygen. Cardiopulmonary resuscitation was not initiated until six minutes after the initial pulse check. Garner later died. As a result of a review, the four involved EMS providers were relieved of their duties, a response that indicates their negligence.

On August 24, 2019, Elijah McClain was detained by police after being reported as a suspicious person. Police approached and then subdued McClain, with several officers holding him to the ground. He repeats several times that he can’t breathe while police hold him to the ground and firefighter-paramedics stand nearby, at times seen on video with their hands in their pockets. It is reported that McClain vomited several times while being held to the ground. Aurora Fire Department paramedics administered ketamine, a dissociative agent used in anesthesia, to help law enforcement subdue the already restrained McClain. This drug was administered while McClain was fully restrained on the ground. He later sustained a cardiac arrest during transport and died.

In August of 2016, Tony Timpa, a man with a history of schizophrenia, called 911 stating that he was afraid and in need of help. When the Dallas police arrived, Timpa was on the ground having been handcuffed already by a private security guard. Timpa was restrained by the police, face down. At one point a police officer states, “I can hear him snoring.” Though Timpa had been motionless for several minutes, a Dallas paramedic administers an intramuscular injection of haloperidol, a potent antipsychotic. Timpa is loaded onto a stretcher; in the ambulance the paramedics determine that he is in cardiac arrest. A full 4 minutes elapses before CPR is initiated.

In all these incidents, EMS had an opportunity to administer cardiopulmonary resuscitation but did not. In two instances, medications were administered in a setting that would be considered unsafe by all accounts. Whether through complacency, intimidation, systemic racism, bias against mental illness, or because of some other underlying issue, EMS providers did not provide the standard of care.

This should be concerning to EMS professionals, the medical community, and the public. In some of the most charged incidents of recent times, which all include video footage of EMS care, there are obvious and egregious failures. This raises significant ethical concerns. If these failures to act were underpinned by racism, prejudice, or even complacency, then EMS is in a dangerous place. There is a need for greater scrutiny as to the reasons that in these incidents, care was not provided.

There is an opportunity to both reflect and to correct this with a national agenda for EMS. Integrating curricula on unconscious bias, disparities in care, and systemic racism is a national imperative.

There are documented issues regarding disparate care for pain management, cardiac and stroke care, as well as care of those with mental health issues. EMS training must incorporate pedagogy and ethical discussions on these issues into an array of didactic, simulation, and hands-on learning to counter these disparities. It is the responsibility of medical directors, EMS educators, and policy makers to integrate this curriculum and to advance this platform for the profession.

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Stephen Wood

Stephen P. Wood, MS, ACNP is an acute care nurse practitioner practicing emergency medicine in Boston, Massachusetts, and a fellow in bioethics at the Center for Bioethics at Harvard Medical School in Boston.

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