Chapter 20 P. Daniel Patterson, Matthew D. Weaver, and David Hostler Emergency medical services personnel work in a unique environment and under exceptional circumstances. Work is spontaneous, unpredictable, and often dangerous. There is great diversity in patient age, size, sex, and presenting condition. Care occurs on the side of the road, in patient homes, and in environments that require creative solutions combined with care that is timely and appropriate. An EMS worker may provide routine, non-emergency care for one patient, and then respond urgently to a scene to provide care that is critical, timely, and life-saving. The occupation is rewarding and attracts many who are altruistic or seeking sensation and excitement. Concurrently, the setting and manner of care delivery can be dangerous with numerous hazards and threats to worker wellness and safety. Common hazards and threats include operation of a motor vehicle (often by inexperienced and excitable providers), violent patients, poor general health status, stress, burnout, chronic health effects from shift work, and sleep-related performance impairment. Exposure to blood-borne pathogens is a particular risk in this uncontrolled setting [1]. Many EMS providers are in poor physical condition and suffer from obesity and physical inactivity [2]. Leadership and medical oversight that are strong, objective, and visible may minimize threats and enhance EMS provider wellness. Wellness refers to the physical and mental well-being of the individual. Good sleep hygiene, regular physical exercise, and proper diets are required to maintain individual wellness. A well individual will suffer fewer chronic medical conditions and generally enjoys a higher quality of life and longevity. EMS providers should be physically fit and in good mental health to optimally perform their duties. Self-rated, global assessments of health status are commonly used to assess general wellness and well-being and predict risk of morbidity and mortality [3]. The rate of death among men and women who rate their health as “poor” is significantly greater than that of men and women who rate their health as “fair” or “good” [4]. After adjusting for age, the relative risk of death for men and women reporting poor health versus good health was 2.9, and for those reporting fair health versus those reporting good health was 1.6 [4]. Many EMS workers rate their health as poor and are thus at an elevated risk of early mortality. In a sample of 19,960 EMS workers, 1.8% rated their health as “fair/poor,” 75.5% as “very good/good,” and 22.7% as “excellent” [2]. In a separate study of >500 EMS workers, fewer than 10% rated their health status as “fair to poor,” 64% as “good,” and 27% as “excellent” [5]. These data are comparable to data from the National Health and Nutrition Examination Survey (NHANES 2005–2008) [6]. National estimates show that 17% of adults rate their health as excellent, 66% as very good or good, and <17% as fair or poor [6]. Overweight and obesity, tobacco use, and physical activity are leading indicators of health and wellness [7]. There is no database of health indicators for all EMS workers but data from small studies provide a window onto the current status of EMS worker wellness. Data from the National Registry of EMTs show that nearly three-quarters (71.2%) of nationally registered EMS workers are overweight or obese, 17% currently smoke tobacco, and 75.3% fail to meet recommendations for physical activity [2]. In a convenience sample of 119 EMS workers in Pennsylvania, greater than 80% were classified as overweight or obese, and approximately 15% reported smoking tobacco [8]. A separate study involving 511 EMS workers affiliated with 30 diverse US-based EMS organizations revealed that 77.5% are overweight or obese and 15.5% smoke tobacco [5]. Data from the Behavioral Risk Factor Surveillance System (BRFSS) shows that the percentage of US adults who are obese (BMI >30 kg/m2) varies across states, with a mean prevalence of 24.6% (±3.0%) [9]. The mean percentage of US adults classified as physically inactive was 51.4% (±5.6%) [9]. Data from the National Health Interview Survey (NHIS) show that one in five US adults were considered current cigarette smokers during 2008 and 2010 [10]. The reversible conditions of obesity and smoking are significant risk factors for cardiovascular disease and place EMS workers at risk of future chronic disease conditions such as hypertension. Furthermore, the nature of EMS operations facilitates physical inactivity, which contributes to poor health and reduced longevity [11]. Emergency medical services workers regularly care for patients who are at their moment of greatest need. These moments may involve critical illness or injury and result in stressful reactions by the patient, family members, other bystanders, or the care providers. Repeated exposure to critically ill or injured patients may lead to high levels of work-related stress and stress-related outcomes [12]. Work-related stress can be defined as “a process by which workplace psychological experiences and demands (stressors) produce both short-term (strains) and long-term changes in mental and physical health” [13]. There are numerous theories of stress and the effect/response in humans. A common underpinning of these theories is the belief that psychological stressors have mental and physical effects through a common set of physiological processes [13]. Data show that work-related stressors differ by occupation (e.g. white-collar versus blue-collar), and are affected by work characteristics such as hours worked, role ambiguity, interpersonal conflict, and other factors [14]. High levels of work-related stress can contribute to depressive disorders and poor mental health, physical disorders such as pain, job dissatisfaction, burnout, greater absenteeism, and poor work–family fit [14,15]. Stress among EMS workers has been a topic of research and discussion since the evolution of modern EMS in the 1970s [16]. Our understanding of stress and stressors in EMS remains imperfect, however, due to wide variations across studies that attempt to quantify the magnitude of EMS work-related stress. For example, one study of 658 EMS workers examined work-related stress using the Medical Personnel Stress Survey and determined that the mean survey score exceeded the cut-point for high work-related stress by 19 points [17]. More recent research of 34,340 nationally registered EMS workers showed that ~6% report work-related stress, 6% anxiety, and approximately 7% depression [18]. Studies of severe stress reactions show wide variation in the proportion reporting signs and symptoms of posttraumatic stress disorder (PTSD); however, the trend across studies suggests EMS workers report symptoms of PTSD with greater frequency than the general population [19,20]. Commonly reported stressors include high patient demand [21], shift work and job scheduling [22], medically unnecessary use of EMS resources by the public [23], poor relationships with administration and leadership [23], lack of public recognition, and perceived low pay/income [23]. The outcomes of chronic or acute stress among EMS workers include alcohol use [19], depression [24], burnout, and turnover [25]. While there are limited data on substance abuse among EMS workers, there is growing concern that many in the profession may be at risk. Data from the Emergency Medical Services Agency Research Network (EMSARN) at the University of Pittsburgh School of Medicine’s Department of Emergency Medicine show that a large proportion of EMS workers are incapable of recognizing when stress is present. We have administered the EMS-Safety Attitudes Questionnaire to a group of EMS providers each year since 2010. Figure 20.1 highlights the proportions of EMS workers over time who responded positively (scored ≥75) to the domain of stress recognition. A small percentage of EMS workers report the ability to recognize when stress has a negative effect on their performance across all years and across a diverse sample of EMS agencies. Medical directors and supervisors may wish to invest in worker health and wellness programs that address recognition and treatment of worker stress. Figure 20.1 Percentage of EMS workers who perceive they can determine when stress has a negative impact on performance. The National Sleep Foundation describes normal sleep for adults as 7–9 hours per sleep period. Inadequate sleep is defined as total sleep that is less than 7 hours [26]. Data from the National Health Interview Survey show that the mean amount sleep per night for the average employed US adult is 7 hours [27] yet one-third of US adults reports inadequate sleep [26,28]. Data from the Behavioral Risk Factor Surveillance System show that 31% of adults report inadequate sleep in the previous 24-hour period and approximately 11% in the previous 30 days [29]. Pirrallo and colleagues found that 70% of actively employed EMS workers report at least one sleep problem [30].
EMS provider wellness
Introduction
Wellness of EMS workers
General health
Body weight, tobacco use, and physical inactivity
Work-related stress
Sleep and fatigue
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