Table 2 Overview of themes supported with quotes

Theme 1: Training/Tools

 •But I would also like to see some policy – some training, because we have very minimal training in diffusion. I’m not looking for self-defense stuff, because we shouldn’t be fighting. That’s not my issue.” Participant Y

 •I would go back to the idea of having training on how to defend ourselves. How to disarm a patient or situation. Actual hands-on self-defense training. It shocks me that we don’t have any at all, really. Participant C

 •There have been some requests for different self-defense training and things like that, that were pushed back in favor of ‘No, we’re just going to focus on de-escalation and reporting.’” Participant P

 •You still don’t have to attack a paramedic. But the intervention is focused on it’s the paramedics’ fault that they are assaulted. Participant B

 •And I guess just after a couple of years on the job I realized that if the 911 call doesn’t involve them, I can ask them to leave. I can’t necessarily ask the patient to go away because they called 911. They’re in medical distress. But anybody who doesn’t need to be involved, I can ask them to leave. And ask the police to say if they won’t leave, you need to arrest them and get them out of here. Participant U

 •De-escalation, all that kind of stuff. I find that we don’t have a lot of that. And we deal with a lot, like a lot of violence. Participant Y

 •We also have checks in place whereby we contact the family before each visit, a phone call. And we have a checklist that we go through. And that’s done each time before we attend that resident. Participant R

 •I think for us as community paramedics, everybody is – we have a big responsibility for our own safety. We’ve been given the tools. We just have to use them. […] I mean number 1 is remove yourself from the situation. Participant R

 •Most of CPs now have public event kind of thing, like a wellness clinic. And that’s where we invite people to come see us if they want to see us if we have any concerns at all. And that way we’re never in a situation where we might be caught alone with them or where there is any threat to us. Participant Q

Sedation / restraints / spit hoods

 •There is a big push for that, and everyone is very proud of the fact that they don’t restrain patients chemically or physically. Participant X

 •I had a call recently, and the guy was being aggressive. The police didn’t want to do much, but my partner got an order to sedate the patient, and that made everything go smooth on the call. No danger. Participant Y

 •And then, in terms of what people want in the future, there is a lot of equipment, like spit-hoods, and soft restrains that are available to us, but we’re not using them here. Participant S

Theme 2: Support for refusal of care / staging

 •I also don’t think we’re terribly supported by the act that governs us. So, the ambulance act is very, very limited capability for paramedics to refuse going in to help somebody. Participant K

 •And I guess the problem is, what if that patient has had an opioid overdose, and they’re slowly decreasing respiratory. And that’s the balance on the other side, there is a potential hazard for that patient. That’s the balance. Participant X

 •I mean number 1 is remove yourself from the situation. And that’s been spoken to very well by everybody. That’s the ultimate solution for us. Participant R

 •So, you’re constantly saying is my job worth potentially staging, is my safety worth potentially saving, and it’s that argument and that call. Participant V

 •If I walk in and someone says, ‘Fuck off’, I want the ability to just say ‘Okay, see you later. I’m not helping you.’ It’s never going to happen. And that’s not what we signed up for. But if they’re going to treat us badly, then I want the ability to just walk away and say an ambulance is not going to be helping you. Participant U

 •Because we’ve had calls, there was a call in [city], where the paramedics didn’t feel safe. Didn’t enter the home. And the patient died as a result. And those paramedics ended up being punished pretty severely for that. So, the whole idea, it’s our discretion on scene, is sort of a grey area. Participant R

 •Here actually, if a paramedic calls dispatch and says ‘Hey, I’m just not going. I’m going to stage.’, they’re actually really supportive. Participant K

 •We’re required to enter a potentially unsafe scene and only leave if there is explicit evidence of danger. Participant T

Theme 3: Prevention strategies

 •So, whether it’s us being a little – meeting with hospitals and actually developing a transportation policy for these patients. You will always send an escort. They will always have medication available to sedate the patient, etc. That sort of thing. I think those are the sort of things that we can be proactive on. Participant X

 •I think more public education could really help too. I’ve seen the videos that they’ve put out in Australia. Participant I

 •If you get on the bus in [city], there is a little sign that says, ‘Assaults on the bus driver, whoever, blah blah blah, will not be tolerated.’ I’m never seen such a sign in an ambulance. Participant C

 •I think advertising is certainly a part. We want to shape the public conversation around this and want to let people know that the behavior is not acceptable. Participant T

 •There is a discussion around putting those stop signs in the back of ambulances. And I’m actually against it, personally. Because you see you got them in Australia, and it hasn’t done anything. […] Threats have to be immediate, realistic and enforceable. If we say, violence threats will not be tolerated, you will be kicked out the ambulance. Somebody reads that and goes ‘Okay, make me.’ Participant P

Theme 4: Communication / Information sharing

 •I look at it in a different way to, that unfortunately we get too much information before we go stage. They should just tell us it’s a violent incident. Shouldn’t tell us anything about – shouldn’t tell us where it is. They should give us a general area to stay in, take the human factor out. Participant Y

 •All I know it’s a horrible system where the police have so much information than us on every address. Participant Y

 •One of the biggest places there where we see a gap is in information sharing. […] I think in lot of cases there is not sufficient information transferred from a sending facility in regard to the patient. Participant R

 •But there has been really inconsistent action taken by dispatch. And dispatch is not employed by us. They’re a different entity. So you can’t really control what they actually do. Participant S

 •They’re our first line of defense. Dispatchers. Participant S

 •Generally speaking, when we go to a place, like a known drug dealers house or something that police are aware of, they’ll let us know. And usually they’ll say don’t enter the building until police have arrived. Participant V

 •I think we have the same issues that everyone in the world does. We feel the information is often incomplete. And that doesn’t allow us to complete an accurate risk assessment of the scene. And that is not in any way a dispatcher’s issue. Participant N

 •Here actually, if a paramedic calls dispatch and says ‘Hey, I’m just not going. I’m going to stage.’, they’re actually really supportive. Participant N

 •Yeah, police called us for this. And then they’re not on the road. Why are we going? Particpant U

 •We’ll show up for domestic disputes before police. Participant I

 •Same thing, we used to always be – when I worked in [city], we were the first call for all dropped 911 calls. And I’m like ‘Why are we doing dropped 911 calls?’ Participant Y

Theme 5: Flagging

 •They can flag, but the process to flag is not very… […] it expires in a year. Participant Y

 •It’s usually a repetitive thing. Like 3 or 4 times we’ve been to this address and every time we’re dealing with it. It will eventually pop up. And sometimes police will have flags, that we don’t know about. So they contact [dispatch]. Participant V

 •So, one of the things that we historically had trouble with is reluctance from some parts of the organization to what we call as flagging an address. Participant P

 •It’s not common practice. It’s difficult – it’s not super difficult to do. But there are institutional or bureaucratic processes to try and discourage it, I would say. Because nobody wants to take the responsibility if someone moves and then we don’t go in and grandma dies. Participant P

Theme 6: Dispatch

 •Because they’ve had a conversation with the people on scene already. And nobody else has at that point, right? They’re the only ones that have that information. So there is a trust factor that has to exist between our dispatch and us. Participant V

 •So for us – we’re not dealing with face-to-face violence, but you’re observing that. And we get attacked verbally. Participant M

 •There is no riding third man in Dispatch. There is no option to know this kind of call is going to trigger me, so I’m not going to take any of those kind of calls. You don’t know. Before you answer, you have no idea what you’re getting into. Participant M

Uniform

 •We dress very similar to the police. […] A lot of people misunderstand that we’re there to help medically. We’re not there to charge and do that. Participant V

 •I find also, us looking some much like police officers has given me issues in my career. I’ve been attacked because we look so much like cops. Participant Y

 •Yeah, I think generally on the downtown east side paramedics are viewed favorably. […] I do feel like I’m in a bit in a suit of armor when I’m in my uniform down there. Participant C