Annals of Emergency Medicine
Volume 40, Issue 6 , Pages 633-635, December 2002

Keeping rescuers safe☆☆☆

Department of Emergency Medicine, The Brody School of Medicine, East Carolina University, Greenville, NC.

Address for correspondence: Herbert G. Garrison, MD, MPH, Department of Emergency Medicine, The Brody School of Medicine, East Carolina University, Greenville, NC 27858-4354;E-mail hgarriso@pcmh.com.

Article Outline

Abstract 

[Ann Emerg Med. 2002;40:633-635.]

 

See related article, p. 625 .

No one will ever argue that out-of-hospital emergency medical care is without risk to its practitioners. Emergency medical services (EMS) work often requires potentially hazardous actions: caring for patients in difficult environments or surrounded by agitated friends or relatives, traveling through uncontrolled intersections to arrive or depart, being exposed to potentially infectious bodily fluids, and carrying heavy patients to a vehicle for transport. Risk to self is a part of out-of-hospital care—just as it is, to some degree, for many forms of health care.

Once risk to self (providers) is assumed to be present, the only practical option is to make sure that we know the magnitude and nature of those risks and we help EMS workers conduct their activities in a manner that keeps them safe. An EMS worker injured on the job imparts significant financial and, sometimes, emotional costs to the agency and society, in addition to not being available to help others.

So, how are we doing with the goal of keeping EMS workers safe? There have been very few studies examining this question. The handful of published investigations focus on a single locality or region, have small sample sizes, or rely on self reports.1, 2, 3, 4 They have established that EMS workers are sometimes injured on the job. Notwithstanding, the current literature does not tell us how EMS compares with similar occupations or what we should do to improve the situation.

To advance our understanding, in this issue of Annals , Maguire et al5 provide a new look at the problem. Based on their data and analysis, they declare that the rate of EMS occupational fatalities is so high that there is a crisis. Because of the paucity of literature on the important subject of job-related injuries in EMS, we welcome this paper. There is much to be commended about the methods Maguire et al used: they examined multiple databases over multiple years, and they were systematic and conservative in their judgment of EMS-related fatalities. But is there really a “crisis”?

In determining their headline rate—“12.7 EMS fatalities per 100,000 workers”—Maguire et al5 used for their denominator the number of US EMS workers estimated by the federal Bureau of Labor Statistics (BLS). However, others claim that the number of US EMS workers is more than 5 times higher than the BLS estimate.6 Depending on which denominator is used, the EMS occupational fatality rate is either very high or, relatively, not high at all. Some may argue that every EMS response has some risk and, therefore, the small number of EMS deaths per year should be a comfort rather than a worry. The problem is that we don't really know how many EMS workers there are or which ones we should count. Do we count just the paramedics or just those employed full-time? What about all those volunteers who may respond to lots of calls?

The denominator problem makes it difficult to compare EMS rates of occupational injuries with those of similar occupations, like police officers and firefighters. Other factors make it additionally difficult to determine true exposure rates. How often are police, fire, and EMS workers exposed to really serious risk? Many EMS workers are also firefighters, which confounds our dilemma even further. How many of the fire and EMS deaths or injuries represent the same person?

Although flawed like any descriptive study in which the true exposure rate is unknown, the article by Maguire et al5 serves an important purpose: It confirms the fact that working in EMS can lead to injury. EMS workers sometimes die in the line of duty. This should cause us to ask why and make us work harder to improve the situation. It also raises other questions. Are the deaths only the tip of an EMS occupational injury iceberg? How many EMS workers are not reporting to work because of nonlethal yet incapacitating injuries, such as back injuries?

For EMS workers, it is easier to hear than to practice the principle that their safety is the top priority. Avoiding danger is counterintuitive to rescuers, who feel that being a rescuer means going into a situation when others are going in the opposite direction. Such was the case on September 11, 2001, when a single event took the lives of more rescuers than we usually lose in years.7 The job of a rescuer, whether EMS, fire, law enforcement, or other, is to rescue, which all too often means to rush toward danger rather than avoiding it.

However altruistically motivated, this reflex rushing in contradicts the teaching of most EMS experts. As related by Meade and Dernocoeur,9 the “key to maximizing the safety of all rescuers is to follow a plan that places self-preservation first.” This principle is usually observed by EMS workers on calls involving violence when there may be advance knowledge that someone on the scene is “armed and dangerous.” But in other situations, where it might be just as logical to be careful of one's own safety, rescuers may impulsively put their lives on the line and, as Maguire et al5 establish, end up losing them.

This type of thinking—rescue first, my safety later—is associated with trends that worsen safety in some EMS agencies. (It would be unfair to indict all EMS agencies, some of which have outstanding safety practices.) These trends are: (1) safety training is sparse—almost an afterthought; (2) there is disparate availability and use of personal protective equipment; and (3) the understanding of EMS work processes and the appropriate role of EMS safety is limited.

To reach the goal of maximizing the safety of all rescuers, we have to truly change our thinking about EMS priorities. Professional EMS management tells us that the first priority for emergency workers and their leaders must be the prevention of job-related injury and illness—the maintenance of healthy and fit staff who are available and able to fill the needs for which they are hired. This paradigm shift requires that EMS workers become more involved in injury prevention.10, 11

In addition to changing our priority thinking, we need more research on those factors that lead to injury in EMS workers. Ideally, there should be a surveillance system that tracks every occurrence of EMS on-the-job injury and illness. At the very least, we need a national database that tracks the deaths of all public safety workers—EMS, fire, and law enforcement. In addition, more in-depth study is needed to determine where to put the prevention emphasis. Scene safety, safe driving, hazards of direct patient care, and personal health are all options for additional emphasis.

At the very least, there needs to be substantially more emphasis on safe driving. Maguire et al5 found that more than half of the EMS fatalities involved ground transportation. The most dangerous times for EMS are when they are inside their truck when it is moving or when they are working at a crash scene near other moving vehicles. As the de facto lead federal agency for EMS, the National Highway Traffic Safety Administration should pay special attention to keeping EMS personnel safe when they are on the road. A recently released white paper12 on protecting emergency responders on the highway has many useful recommendations.

Finally, a word on the role of technology. The rescuers in the World Trade Center towers were handicapped by a previously identified technologic failure of their communications systems.13 Emergency workers must have communication systems, with backup systems, that work. Every rescuer, whether law enforcement, fire, or EMS, should have the means to communicate with their supervisors and with each other all the time. This means they all need communication devices that work everywhere. Although achieving this will be expensive, we know that such communication is vital to serving the patients and protecting the providers.

Some parts of an EMS provider's job can be hazardous, although we still don't know exactly how hazardous. Yet, like all health care providers, EMS providers have a duty to take care of their patients. That is the sole reason for their profession. The main challenge for those of us who lead them, and for EMS workers themselves, is to make sure that we are doing the right things to keep both our rescuers and our patients safe.

Back to Article Outline

References 

  1. Gershon RRM, Vlahov D, Kelen G, et al.  Review of accidents/injuries among emergency medical services workers in Baltimore, Maryland. Prehosp Disaster Med. 1995;10:14–18
  2. Hogya PT, Ellis L. Evaluation of the injury profile of personnel in a busy urban EMS system. Am J Emerg Med. 1993;8:308–311
  3. Schwartz RJ, Benson L, Jacobs LM. The prevalence of occupational injuries in EMTs in New England. Prehosp Disaster Med. 1993;8:45–50
  4. Tortella BJ, Lavery RF. Disabling job injuries among urban EMS providers. Prehosp Disaster Med. 1994;9:210–213
  5. Maguire BJ, Hunting KL, Smith GS, et al.  Occupational fatalities in emergency medical services: a hidden crisis. Ann Emerg Med. 2002;40:625–632
  6. Heightman AJ. EMS workforce. A comprehensive listing of certified EMS providers by state and how the workforce has changed since 1993. J Emerg Med Serv JEMS. 2000;25:108–112
  7. US Fire Administration Web site . USFA releases preliminary firefighter fatality statistics for 2001 [press release]. Available at http://www.usfa.fema.govSeptember 3, 2002; Accessed
  8. O'Shaughnessy J. Remembering September 11th [letter]. Ann Emerg Med. 2002;39:459
  9. Meade DM, Dernocoeur K. Partner down!. J Emerg Med Serv JEMS. 1999;28(50):93
  10. Garrison HG, Foltin GL, Becker LR, et al.  The role of emergency medical services in primary injury prevention. Ann Emerg Med. 1997;30:84–91
  11. Griffiths K. Injury prevention takes root. EMS evolves to assume expanded mission. J Emerg Med Serv JEMS. 1999;24:56-60–62-64
  12. Cumberland Valley Volunteer Firemen's Association . Protecting emergency responders on the highways: a White Paper. US Fire Administration Web site. Available at www.usfa.fema.govSeptember 3, 2002; Accessed
  13. Dwyer J. Radio problems could last for years, Fire Department says. New York Times Web site. Available at www.nytimes.comSeptember 18, 2002; Accessed on

☆ Dr. Garrison is supported in part by the Injury Prevention Research Center, University of North Carolina at Chapel Hill.

☆☆ Reprints not available from the author.

PII: S0196-0644(02)00662-5

doi:10.1067/mem.2002.129940

Refers to article:

  • Occupational fatalities in emergency medical services: A hidden crisis

    Brian J. Maguire, Katherine L. Hunting, Gordon S. Smith, Nadine R. Levick
    Annals of Emergency Medicine December 2002 (Vol. 40, Issue 6, Pages 625-632)

Annals of Emergency Medicine
Volume 40, Issue 6 , Pages 633-635, December 2002

Article Tools