“Felony assault should stick:” Assaulted EMS responders’ frustration and dissatisfaction with the legal system

Abstract Introduction The prevalence of violence to first responders is reported in ranges of approximately 40% to 90%. Pennsylvania has a felonious assault statute to address such violence, but the prosecutorial process has been noted to cause first‐responder dissatisfaction. Methods An exploratory qualitative study using individual interviews with snowball sampling was conducted with the Philadelphia District Attorney's office to understand the prosecutorial process when a first responder is assaulted and injured in a line of duty. The Philadelphia Fire Department provided a list of first responders who sustained a work‐related injury from a patient or bystander assault so that particular cases could be discussed during the interviews. Results Emergent themes fell into two categories: factors that lead to a charge (prosecutorial merit, intent, and victim investment), and the judge's discretion in sentencing (“part of the job” mentality, concern for the defendant, and the justice system's offender focus). Immediately actionable tertiary prevention recommendations for fire departments, labor unions, and district attorney's offices were developed. Conclusion Violence against fire‐based emergency medical service (EMS) responders is a persistent and preventable workplace hazard. While felonious assault statutes express society's value that it is unacceptable to harm a first responder, this study found that such statutes failed to provide satisfaction to victims and that support when going through the court process is lacking. Assaulted EMS responders, their employers, and labor unions would benefit from the recommendations provided herein to help them extract a stronger sense of procedural justice from the legal process.

the physical injuries sustained from violent acts, the resulting increased mental stress also leads to lower work productivity and decreased job satisfaction. 4 In a systematic review of the literature, Maguire et al 3 found a 60% to 80% prevalence of workplace violence among EMS responders. His earlier work found excess mortality 5 and morbidity 6 among US EMS workers. The former study found that 57% of the injury cases resulted in lost workdays, impacting workforce productivity. Physical assaults by patients caused about 37% of injuries and fatalities. 2 Another systematic literature review, published in 2018 by the US Fire Administration, reviewed both the academic and industrial literature to explore how occupational violence to firefighters and EMS responders could be mitigated. 7 In studies that measured prevalence of violence throughout a first responder's career, between 57% to 93% of EMS responders reported they had experienced either verbal or physical violence at least once in their career. 7 About 40% of EMS in the United States is provided by fire departments. 8 In a study with the Philadelphia Fire Department, paramedics had 14-fold higher odds of assault-related injury compared to firefighters. 1 Interviews and focus groups conducted with the injured to better understand the assault phenomenon revealed issues with dispatch, training, community expectations, and the legal system. 1 The last theme was very compelling in that many first responders felt that those who assault them do not face true punishment for their actions: And I went to court, and this is where it's disheartening, because that's supposed to be felony assault…And I'm wasting my time going to court two and three times…I knew there was no confidence in the system…I mean, you shouldn't be able to do that to someone who's trying to help you. Felony assault should stick. (John, Firefighter-EMT) 1 I know we have a law here that if you assault a paramedic, firefighter, police…you're supposed to be charged with a felony. That rarely ever happens. You know, most of the time, you go in there alone…Our medics go alone…You sit there alone…And [the assailant] will explain how sorry they are and what they did to you. And the judge says, "okay"…And that's all you get. (Jane, Paramedic) 1

| First-responder felonious assault law
The purpose of this study was to learn about the processing and disposition of cases that come before the Philadelphia, PA District Attotney's (DA's) office when a Philadelphia Fire Department firefighter, emergency medical technician (EMT), or paramedic has been assaulted by a patient or bystander. The Philadelphia Fire Department (PFD) is a 2700-member department with 63 stations, 55 ambulances, and one of the highest EMS call volumes in the nation. About 71% of the 378 849 annual calls are for EMS services. 9 It is the largest fire department in Pennsylvania, and one of 16 US (<1%) departments that serve populations over 1 million. 10 PFD is not typical of most fire departments in the US, as approximately 75% are volunteer (unpaid) and 70% of departments have only one station. 11 In Pennsylvania, Title 18, Chapter 27, Section 2702 of Pennsylvania Constitution Statute explicitly states that it is a felony to assault a member of the protected class: A person is guilty of aggravated assault if he: attempts to cause or intentionally, knowingly or recklessly causes serious bodily injury to any of the officers, agents, employees or other persons defined in subsection (c), as a member of the protected class while they are in the performance of duty. 12 Subsection (c) defines those members in the "protected class" as follows: Firefighter, probation/parole Officer, the Attorney General, the Governor, District Attorney, Lawyers, Parking Enforcement Officer, any person employed to assist any Federal, State or local law enforcement official, any teaching staff member or school board member, and all emergency medical services personnel. The term "emergency medical services personnel" includes, but is not limited to, doctors, registered nurses, licensed practical nurses, nurse aides, paramedics, EMTs and members of a hospital security force while working within the scope of their employment. 12 Simple assault is the intentional use of force or violence against another person that involves minor injury or a limited threat of violence. It is normally charged as a misdemeanor. Aggravated assault is a stronger form of simple assault, usually involving a deadly weapon and/or intent to cause serious bodily harm. It is normally charged as a felony. Simple assault against a member of the protected class is treated differently and considered a more serious crime. What would typically be a simple assault is escalated to an aggravated assault and is, therefore, a felony.
Theoretically, prosecution under this law would result in either a first-or second-degree charge. However, many first responders feel that those who assault them do not face appropriate punishment for their actions: Well, the prosecution phase is a sore spot… The resolution to it was very disappointing. The person was able to plead and get some kind of a deal where they didn't serve any jail time. They didn't get put on probation. They were given what they call ARD. I don't think they received a just punishment for what they did. (Unpublished data, Dr.

Jennifer Taylor, personal communication)
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Through an exploratory qualitative research study with those who prosecute such cases on behalf of the DA office, we sought to understand this prosecutorial pathway in light of the fact that the process led to first-responder dissatisfaction.

| METHODS
The research team contacted a senior member of the Philadelphia DA's office. After an initial interview, snowball sampling was used to ask for other potential colleagues who had important perspectives relevant to the study goal. We were particularly interested in DAs who had prosecuted an EMS responder case based on a list of assaulted members provided by the fire department. We also sought DAs of various ranks having diverse experiences in trial, charging, and diversion divisions to understand the prosecutorial process. From that initial interview, four additional district attorneys were identified and interviewed. Participants were contacted via phone and email and were invited to participate in the study. Written informed consent was obtained from each participant before the start of each interview. All interviews lasted no longer than 60 minutes. A semistructured interview guide was developed to assist with the collection of the data (Table 1).
Questions addressed the job demands and pressures experienced by District Attorneys, how they prosecute cases of first-responder assault, and their experiences with perpetrators of these assaults. The Drexel University Institutional Review Board approved the study protocol.
With the assistance of the Philadelphia Fire Department, a list of first responders who sustained a work-related injury from a patient or bystander assault was provided to the DA's office so that they could retrieve records and discuss particular cases during their interviews.
The individual interviews took place in various locations (eg the research team's office or the District Attorney's office). Before this study, the researchers knew none of the participants. The interviews were conducted by all authors, each of whom has training in qualitative methods. Interviews were audio recorded and then transcribed by a professional transcription agency. Once transcribed, all unique identifiers were removed from the transcripts.
A structure was developed by the research team (Table 2) to facilitate the coding of the data using NVivo qualitative data analysis software (version 10, 2012; QSR International Pty Ltd). The authors read each transcript in their entirety and used an iterative process to develop the coding structure. As the transcripts were coded and analyzed, the authors looked for similarities and disparities in points of view. Both JYW and JAT coded all five transcripts using NVivo software and had a 96.7% interrater agreement across all nodes and all sources. Using an iterative approach, the authors reviewed the data and summarized key findings through a series of meetings. JAT and ALD reached consensus on the cross-cutting themes and patterns within the data.

| RESULTS
Themes identified in the analysis fell into two categories: factors that lead to a charge, and the judge's discretion in sentencing. The most salient themes that emerged from the first category were: prosecutorial merit, intent, and victim investment. In the second, a "part of the job" mentality, concern for the defendant, and the offender-focused approach of the justice system emerged. Quotations included are identified using numeric values to preserve the anonymity of participants.
T A B L E 1 Interview guide for District Attorney's (DA's) staff • Tell me what it is like to work in the office of the DA.
• Describe for me the demands of your job, in terms of getting through your caseload.
• Do you feel pressure from the public to prosecute these offenders because they are first responders?
• Do you think your stress levels at work effect the dispositions given to offenders?
• Tell me about the role that the Philadelphia DA's office plays in assaults to first responders.
○ How are cases referred to your office?
• What options are at your disposal in the prosecution of these cases?
• How much discretion do you have in determining the sentence?
○ Are individuals usually offered Accelerated Rehabilitative Disposition, referred to a mental health facility or social service?
○ Are people that are diagnosed with mental illnesses given a different process in these court cases?
○ What about the homeless population?
• Can you explain to me what the Accelerated Rehabilitative Disposition Program is and what purpose it serves?
○ How do you feel when you see these cases being presented?
• Tell me what you think is going on with the individuals who make these assaults.
○ Do you think the stress levels of the community contribute to this issue?
• Tell me about cases that made it to court and how the charges were decided.
• What characteristics of the perpetrator do you think affected the sentence?
○ How do you think the minority population gets handled when dealing with these cases?
• Do you think the law, as currently written, is the best way to handle this issue? what's-I thought a broken leg would be a serious injury.
According to some people, that's not a serious injury.
T A B L E 2 Qualitative coding structure • Individual work perception: The way District Attorney's perceive their work (stressful, satisfying, busy, and rewarding).
• Job pressures and demands: Any pressures they experience from the public, law enforcement, or upper level management to prosecute cases.
• Policies: Policies that are currently put in place for the prosecution of cases.
• Formal process: The pathway/steps that occur from arrest until the final disposition of a case.
• ARD: Anything associated with the Accelerated Rehabilitative Disposition Program.
• Informal process: The steps that include: determining intent of crime, gathering background info on offender, and doing character assessment. These steps that will ultimately (informally) affect case outcome.
• Victim's legal expectation: Expectation of how the law should be held up in court based on what is told to the public.
• Victim investment: How invested or concerned victim is regarding follow up of case and case details.
• Injury: The circumstances of the physical injury. The severity of the psychological impact that injury has on individual.
• Offender-focused approach/perspective: Anything related to the justice system not made for the victim, but for offender rehabilitation and being a productive member of society.
• Offender characteristics: Predictors/Factors about patient that may lead to different/special treatment due to underlying circumstances (mentally ill, homeless, medical disability, etc.) • Community stress: Perception of how stress levels may affect the community and things that may cause them to end up in the legal system.
• "Judge's effect": Bias or viewpoint held by judges that may change the final sentence of a case.
• Offender demographics: Whether different factors like gender, race, or location alter when and/or how a case is prosecuted.
• Sympathy: Acknowledgment of or lack of acknowledgment of the psychological impact an assault can have on the individual. Acknowledging that the severity of the injury impacts the charges/ sentencing.
Interviewer: So the psychological impact of this experience to the medic is not even considered.

| Intent
Given that intent is a necessary requirement for a felony charge, DAs were prompted about the conditions necessary to determine intent. While felony assault to first responders requires only "bodily injury" intent, these interviews illuminated that findings of intent are rare due to the circumstances under which they often occur.
If you injure or attempt to injure somebody of the protected class, the law says you're guilty of felony in the second degree. What the fact finder-and that could be a judge or a jury-is enticed to believe by defense attorneys during trial is that it wasn't that big of a deal, and they didn't really intend to do it. And particularly with people who are being treated for injuries, is their action not a

| Victim investment (responder involvement)
After an assault-related injury, it can be very difficult for first responders to seek justice due to resulting physical and emotional pain, the financial loss of taking leave from work, or a loss of faith that the system will actually give them the results they expect. Any perceived lack of investment on the part of the first responder may result in a lesser charge being offered. This is simply a reflection of the pipeline in the DA's office-there are so many cases to charge and process. If the victim does not press charges and stay involved, the prosecutors may feel compelled to move on to the remainder of their workload.

| JUDGE'S DISCRETION IN SENTENCING
In addition to the factors that can determine whether or not a charge is filed, there are factors that can influence whether a felony sentence is served. The data identified that a judge's discretion includes a "part of the job" mentality, concern for the defendant, and the fact that the justice system has an offender-focused approach. These all play a role in determining how a judge decides to sentence a case. These data highlight that while first responders may be a protected class under the law, judges still bring their own perspectives when determining the sentence for each case and often times believe that under the circumstances, violence is to be expected.

| Concern for the defendant
DAs explained how the gravity of a felony sentence, and its subsequent detrimental effects on the perpetrator's life, can influence how a judge determines sentencing of these cases. Because judges understand how debilitating a felony sentence can be for an individual, they have inherent concern for the defendant. Given that some judges also may feel as though violence is "part of the job" for a first responder, concern for the victim is often not reflected in their decisions. These quotes express the severity of a felony conviction in that it can change the course of a person's life. It can prevent a person from getting a job and cause them to be unproductive in the community, so those in the criminal justice system try not to deliver that punishment unless absolutely necessary.

| Offender-focused approach
Data from the Philadelphia DAs office revealed that its criminal justice system is not designed for the victim, but rather it has an offender-focused approach. Its system is more focused on the rehabilitation of the defendant to ensure that whatever brought them into the criminal justice system will not occur again in the future, rather than to serve justice and make the victim feel whole again. This system can often be dissatisfying to the victim, with one DA describing the experience for them as: "The crime has been devalued, and as result, they feel devalued" (DA #1 responder, the realization that many cases do not result in felony sentences removes the hope of procedural justice from first responders.
The criminal law serves multiple functions. It is intended to punish the wrongdoer but in so doing, it is also intended to deter others from wrongdoing. Studies of the deterrent function of criminal law have suggested that its effectiveness rests on the perceived likelihood of getting caught rather than on the severity of the statutory punishment. 13 This suggests that to the extent that felonious assault statutes inadvertently decrease the likelihood of conviction in exchange for increasing the severity of punishment, they will fail to enhance deterrence. But the criminal law often serves an expressive function as well. "Rather than the particular consequences of an action, the concern instead is with upholding certain values and norms through the law, even if the consequences of the passing of such laws are unknown and obscure". 14 In this view, even if the felonious assault laws fail to achieve a deterrent effect on violence against first responders, they may still serve a function of articulating the value of the importance of first responders to society.
However, this function may be undermined when the law is not enforced. A lack of enforcement-or weak enforcement-may communicate to first responders the reverse message: that they are not valued enough for the protection they were promised. 15 Our research illustrated that these areas of the prosecutorial pathway need to be clearly described to first responders so that they have realistic expectations of the judicial system and the outcomes that their cases may receive.
Yellow stars have been added to points in the pathway where organizational support and responder involvement are critical to achieve the desired outcomes. In order for any of these steps to be set in motion, a police report must be filed by the injured first responder. As we learned from our participants, the first responder also needs to be invested in the process at the time that the case is reviewed to ensure that the prosecutor fully understands the severity of the experience for the responder and their desire for full prosecution. All of the starred steps must have strong organizational support extended to the first responder so that they feel that they are not navigating the prosecutorial landscape in solitude.
In the interviews with Philadelphia District Attorneys, findings of intent were found to be rare because of the context in which these cases arise. This removes the ability of assaults against first responders to be prosecuted as felonies. Many of the perpetrators had medical issues (diabetic shock and dementia), mental health issues, and drug or alcohol conditions that prevented an "intent" determination. Because of these reasons, cases "fall out" of the prosecutorial pathway, and nontrial disposition tracks emerge. These include alternative processes that address and rehabilitate the offender, and take the forms of ARD, vet court, mental health court, and drug/alcohol rehabilitation. First responders previously reported their dissatisfaction with an ARD solution. 1 The current investigation found that there are many factors that lead to a charge such as the strength of evidence, the severity of the injury to the first responder, if intent can be determined, and the first responder's investment in the process. It also identified that judges may believe that violence is an expected part of a first responder's job, that judges may have more concern for the perpetrator than the victim, and that the offender-focused nature of the legal system influences sentencing in an unsatisfactory way for the victim. As expressed by one of our participants, "Only 1% of criminal cases go to a jury" (DA #1).
An important limitation of this study was that only DAs were interviewed. The perceptions they shared on how judges act and think are theirs alone. Furthermore, time, resources, and DA workload limited our inquiry to snowball sampling five out of approximately 300 DAs. 16 Snowball sampling was particularly useful in this study design given that the interviewees needed to have experience with cases involving first responders and this sampling technique yields individuals who will be expertly able to speak to the research question. 17 While this was an exploratory study that never intended to randomly select from all DAs, we were satisfied with the diversity of interviewees because they represented distinct and important perspectives in the prosecutorial process such as those that are considered as cases make their way through the trial, charging, and diversion divisions. A senior DA from the administration division made the recommendations of whom we should contact given our goals to understand the prosecutorial process and we trust that direction since it aligned with divisions mentioned in the published pathway ( Figure 1). The authors also felt no additional interviews were needed from DAs since data saturation based on our interview guide was achieved: by the fifth interview, no new themes emerged. 18 One municipal court judge was interviewed, but since we were unable to secure other judges' participation, we did not feel we had sufficient data to include that perspective in this manuscript. | 947 cases. Participants exhibited a level of desensitization to the severity of the physical injury ("Oh, yeah…we're all desensitized"-DA #4), and really no awareness of the psychological injury that so often accompanies a physical one ("they're expected to be able to deal with that"-DA #4). The current Pennsylvania statute is silent on this "second injury." Even though first responders are often working in "big, ugly cities," violence on the job is not an acceptable attribute of their work environment. Philadelphia. Now understanding a district attorney is hard enough because it's like they speak a different language but getting a district attorney to talk is actually the hardest part. This is what was really important about Jasmine. She never gave up. She would call, she would email, she would show up. She would get these people to talk to her. And they could see her passion and they shared with her the intricacies of their discipline and the limitations on what they could do to bring justice to victims.
One month after her MPH graduation in 2015, Jasmine was murdered. Our team was too aggrieved to return to this work. But as the fire service needs to understand these results, and it was the best way to honor her memory, we endeavored to revise the manuscript.
Most of her original thoughts and writings are here, but because it had been years, we went back to the source data and made additional observations, incorporating those with her findings.
Jasmine was committed to the US fire service, to injury prevention, and to occupational safety and health. We all know the personal joy we take when one of our students chooses our disciplinary path. She also wanted to fight for justice. She chose to stand for the paramedics who are called to our homes not knowing what they are about to walk into. The experience she had working with the Philadelphia District Attorney's Office inspired her plan to pursue a law degree so that she could provide critical policy analysis on occupational hazards like assaults. This is the year she would have graduated.
The other thing Jasmine's research showed us, is that in those rare cases where a patient intended to hurt the paramedic caring for them, a felony conviction can be attained only under certain conditions. Jasmine's research showed that the victim and their families needed to stay close to the prosecuting attorneys to ensure that the case received the attention and the sentence that they felt gave them justice from their injury. But primarily, what Jasmine learned about the law and its punishments is that it is only in prevention that we are satisfied. Jasmine learned that paramedics assaulted by patients will really only ever be well if the injury never happens in the first place.
We remain overwhelmed by the irony that Jasmine was declared 'deceased' by the very people she committed her public health career to protect.

ACKNOWLEDGMENTS
The authors wish to thank the study participants from the Philadelphia District Attorney's office for their time and contributions, and the Philadelphia Fire Department for its support and commitment to this study. This manuscript is dedicated to the life of Jasmine Y. Wright, MPH from whose untimely death we are still recovering. Please see the "In

CONFLICTS OF INTEREST
The authors declare that there are no conflicts of interest.

DISCLOSURE BY AJIM EDITOR OF RECORD
Paul Landsbergis declares that he has no conflict of interest in the review and publication decision regarding this article.

AUTHOR CONTRIBUTIONS
JYW and JAT conceptualized and designed the research question which served as JYW's Master's Thesis work at the Dornsife School of Public Health. JYW, JAT, and ALD contributed to the acquisition, analysis, and interpretation of the qualitative data.
All authors contributed to framing and writing the manuscript.
JYW drafted the early versions of this manuscript and then JAT, ALD, and SBR revised and added to the manuscript to achieve this submitted version. JAT, ALD, and SBR have given final approval of this version to be published and they agree to be accountable for all aspects of the work and will answer any questions related to the accuracy and integrity of the data presented in this manuscript.

ETHICS APPROVAL AND INFORMED CONSENT
The Drexel University Institutional Review Board approved this study. Written informed consent was obtained from each participant.