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How to Manage Your Risk
We accept without question that EMS is a dangerous profession. But what exactly are the greatest threats to providers’ lives and health? If we want to do something about them and develop safer work environments in our future, we need to break down how, precisely, our people get hurt and killed.
Get killed they do: An oft-cited 2002 review of three national databases calculated an annual EMS fatality rate of 12.7 per 100,000 workers, vs. a national average of 5.0 over the same period.1 When our people die, it’s largely in helicopter and ambulance crashes.2,3 Being in transit is indisputably a major danger; the risk of transportation-related injury to EMTs could be as high as five times the national average.4
What doesn’t kill us may make us miss work: A 2007 review of LEADS data determined EMS providers’ incidence of injury with missed work days to be 8.1 per 100 workers,5 vs. rates of 2.9 for nurses and 1.8 for all hospital workers. Another review that compiled data differently reached an injury rate of 34.6 per 100 workers per year.6
Our injuries have been linked to motion and overexertion stress on particular body parts and encompass a lot of the familiar sprains and strains.2,6 Other threats include violence/assaults and exposure to bloodborne pathogens.5 We have higher rates of missed time and medical evaluations than firefighters or police, most of it due to minor trauma.7
There are still many data limitations surrounding EMS death and injury accounting, but it’s not a great mystery where the biggest threats lie.
“The fatality rate is made up of two primary factors: transportation-related cases and assaults,” says longtime EMS safety researcher Brian Maguire, DrPH, a professor at Central Queensland University in Australia. “We have a new look at injuries and fatalities [just] out in Prehospital and Disaster Medicine, and we’re still seeing a fatality a year in the United States from assaults. That’s way too many. And transportation-related cases are still very high. Those are the two areas that need to be addressed.”
Crashes
The helicopter EMS environment has unique characteristics and pertains to a limited audience, so let’s limit our discussion of risk to ground operations.
We know risks in ambulances surround things like restraint use, seating position and how we travel.8 It’s no secret that restrained occupants do better in crashes.8,9 What else has been shown to reduce risk?
“Organizationally, it starts with a culture of safety that says ‘We believe in safety, live safety and put safety out there from a policy and procedure standpoint,’” says David Bradley, BS, NREMT-P, an education specialist with Pennsylvania-based emergency-services insurer VFIS. “Then as you get down the person driving the ambulance, there’s driver selection: Are we selecting the right people? Do we know what their driving records are? Do we have policies in place and train them appropriately?”
That training should involve classroom instruction in risks and best practices, followed by closed-course time, competency testing and ongoing monitoring/refreshing. “It’s truly a soup-to-nuts approach,” says Bradley. “Somebody walks in the door, we can’t just say, ‘Hey, they have a card, they’re OK to drive!’”
For ensuring safe operation, driver-feedback systems have demonstrated results.10,11 In the patient compartment, designs that let providers stay seated (forward- or rear-facing) and restrained obviously improve their odds, as do securing equipment and removing head-strike hazards. Efforts to improve that environment proceed at multiple levels.
But even as we strive toward optimal operation and design, there’s much we can do on the way to reduce our risk of death and injury on the roads.
“We have a lot more control over our fates than perhaps we realize,” says Maguire. “The first step is recognizing that this is a pretty dangerous profession, and transportation-related factors are a big part of the risk. But we have a lot of control over our risks with things like how we drive and wearing seat belts and minimizing distractions. We have to be conscious and determined to do everything we can to minimize our risks.”
That’s on an individual level. At an organizational level, agencies are responsible to collect reliable data surrounding their accidents and close calls, scrutinize it and intervene against discovered risk factors in sound, scientific ways.
Other Injuries
Improving tools have done a lot to help us lift and move patient loads, but EMS remains a profession that often demands more physically than those performing it can give.
“The Bureau of Labor Statistics puts us, from an injury standpoint, at three times the national occupational injury rate,” says Bradley. “Our worker comp rates are high because we get injured more often. It’s repetition; we do a lot more bending, lifting, things like that. And at VFIS it’s our No. 1 patient healthcare claim.”
It’s a challenging phenomenon to intervene against, as people’s body sizes, musculature, work techniques and injury thresholds vary. Against such risks services should look for technological assistance, but also work to help their personnel stay strong and fit. Many provide access to gyms or equipment.
Pre-employment physical abilities testing can also help eliminate candidates not up to the physical rigors of EMS before they try it and get hurt. (More on that in future EMS 2020 content.) Says Bradley: “Personally I believe it’s something we should do. We need to know whether someone’s capable of doing the job.”
Conclusion
There’s much more that can hurt and kill EMS providers, of course, and work continues to flesh out the specifics. In the meantime, leaders of individual services and systems should assess their own operations and look to craft their own interventions for their own risks and circumstances. There are lots of ways to approach it.
“You might say, well, the most important part of the problem is how paramedics are dying,” Maguire says. “Or you might decide to look at the things that lead to paramedics ending their careers. Or you might want to look at what’s causing the most sick days lost. There are many different ways of looking at the issue of safety, and all those things have validity.”
“Every issue is local,” adds Bradley. “Organizations should look at themselves and ask, ‘What are the issues affecting us? Where are our losses? Is everything getting reported? What affects other organizations, and could they happen to ours?’ There are so many lessons out there we could learn; we just have to take them and apply them to what we’re doing.”
Table 1: Steps to Take Now
Every agency is unique and should collect fatality, injury and near-miss data to analyze and better understand its own risk profile. Meanwhile, the largest threats industry-wide, as now documented by years of study, are vehicle crashes and injuries sustained in the course of duty (lifting, moving patients, etc.) Future 2020 content will examine these areas in greater depth and look at ways to mitigate their threat. In the interim, try these steps now:
Vehicle Operation
- Approach with a culture of safety and articulate and enforce safe-driving policies.
- Not everyone should drive your rigs. Check employees’ personal driving records and avoid those with problems operating safely.
- Training should include classroom instruction and time behind the wheel in a controlled setting.
- Monitoring and feedback systems improve the performance of individual drivers and help managers keep better views of their fleets.
- Distracted driving is dangerous in any vehicle. Keep the driver focused on driving.
- In compartment layout, maximize providers’ ability to say seated (forward- and rear-facing) and restrained at all times.
- Reduce head-strike hazards—both things providers can fly into, like cabinetry, and things that can fly into providers, like oxygen tanks. Secure all equipment.
Patient Lifting & Moving
- Use the tools and technologies available to reduce the forces experienced during patient moves.
- Encourage provider fitness (for instance, by facilitating gym memberships, healthy diets, etc.) and asking for help when needed.
- Pre-employent physical abilities testing can help ensure personnel are capable of job demands.
What’s With Women?
Here’s an interesting aspect of injury and fatality risks for EMS: They often appear to be greater for women.
“This is potentially a big issue for us,” says safety researcher Brian Maguire. “We’ve had a few studies now that have looked at things from different perspectives and found indications of disproportionately large risk for females. The first time we saw that was in the [2002] fatality paper. The indication there was for fatal assaults—a risk that’s usually three times larger for males than for females, and in EMS it looked like exactly the opposite.”
There were insufficient data in that study to prove anything statistically, but it was, Maguire says, “an indication that there’s something very different and unusual going on. And in subsequent studies, we’ve also seen indications that females may have disproportionately higher risk for injuries. So that’s a question that needs to be addressed.”
POLICY: Despite policies surrounding vehicle operations and patient movement, EMS injury and death rates remain high.
STRATEGY: Evaluate risks within organizations; craft interventions and measure their effectiveness.
VISION: Fewer crashes and reduced rates of job-related injury and death from all causes.
References
1. Maguire BJ, Hunting KL, Smith GS, Levick NL. Occupational fatalities in emergency medical services: a hidden crisis. Ann Emerg Med, 2002 Dec; 40(6): 625–32.
2. Reichard AA, Marsh SM, Moore PH. Fatal and nonfatal injuries among emergency medical technicians and paramedics. Prehosp Emerg Care, 2011 Oct–Dec; 15(4): 511–17.
3. Houser AN, Jackson BA, Bartis JT, Peterson DJ. Emergency Responder Injuries and Fatalities. RAND Science and Technology, 2004.
4. Maguire BJ. Transportation-related injuries and fatalities among emergency medical technicians and paramedics. Prehosp Disaster Med, 2011 Oct; 26(5): 346–52.
5. Studnek JR, Ferketich A, Crawford JM. On the job illness and injury resulting in lost work time among a national cohort of emergency medical services professionals. Am J Ind Med, 2007 Dec; 50(12): 921–31.
6. Maguire BJ, Hunting KL, Guidotti TL, Smith GS. Occupational injuries among emergency medical services personnel. Prehosp Emerg Care, 2005 Oct–Dec; 9(4): 405–11.
7. Suyama J, Rittenberger JC, Patterson PD, Hostler D. Comparison of public safety provider injury rates. Prehosp Emerg Care, 2009 Oct–Dec; 13(4): 451–5.
8. Becker LR, Zaloshnja F, Levick N, Li G, Miller TR. Relative risk of injury and death in ambulances and other emergency vehicles. Accid Anal Prev, 2003 Nov; 35(6): 941–8.
9. Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis. Prehosp Emerg Care, 2001 Jul–Sep; 5(3): 261–9.
10. Levick NR, Swanson J. An optimal solution for enhancing ambulance safety: implementing a driver performance feedback and monitoring device in ground emergency medical service vehicles. Annu Proc Assoc Adv Automot Med, 2005; 49: 35–50.
11. Myers LA, Russi CS, Will MD, Hankins DG. Effect of an onboard event recorder and a formal review process on ambulance driving behaviour. Emerg Med J, 2012 Feb; 29(2): 133–5.
