Chapter 21 P. Daniel Patterson, Matthew D. Weaver, and David Hostler The delivery of prehospital emergency care by EMS personnel, including EMS physicians, is physically and mentally demanding. In contrast to many other occupations, the need or demand for prehospital care is not scheduled, and the amount of physical or mental work required for each patient is unpredictable. EMS workers must possess both physical strength and aerobic capacity to safely access and extricate patients. An EMS worker must lift and move patients onto stretchers, hospital beds, and other equipment, which requires core strength and flexibility [1]. Many EMS workers are at risk of injury due to poor physical health and conditioning. Other common EMS activities, such as driving/operating ambulances, pose significant safety risks to both patient and EMS worker [2,3]. A large proportion of fatal injuries while on the job are the result of driving ambulances or other EMS vehicles (e.g. “fly cars,” helicopters). Preventing fatal and non-fatal injuries in the EMS setting requires a multifaceted approach [2]. There are few studies of EMS worker occupational fatalities. A recent study of the Bureau of Labor Statistics (BLS – this acronym will be used in this chapter for this agency, and not for Basic Life Support) Census of Fatal Occupational Injuries (CFOI), years 2003–2007, identified 65 fatalities and showed that the rate of fatalities for compensated EMS workers exceeds the rate of the general working public (6.3 per 100,000 full-time equivalents (FTE) versus 4.0 per 100,000, respectively) [4]. A recently published study using the same dataset for the same time period (2003–2007) identified six fewer fatalities (n = 59) [5]. An earlier study by Maguire et al. involved a collation of events from multiple databases: the BLS CFOI, Fatality Analysis Reporting System (FARS), and National EMS Memorial Service database [6]. Findings suggest that the rate of occupational fatalities among EMS workers may be more than 2.5 times greater than rates experienced by the general working public [6]. Most documented EMS occupational fatalities have been linked to motor vehicle or aircraft crashes. A retrospective review of the FARS data from 1987 to 1997 determined that more than half (53%) of ambulance crashes involved an ambulance crossing an intersection. The review identified 339 ambulance crashes, 405 fatalities, and 838 injuries [7]. A majority of fatalities resulting from an ambulance crash involved the ambulance driving in emergency mode, also known as “lights and sirens” [7]. In Maguire and Smith’s study of BLS data, 86% (n = 51) of documented fatalities were linked to transportation [5]. Findings from the same BLS dataset by Reichard and colleagues linked 76% of fatalities to crashes involving motor vehicles and aircraft [4]. There are few studies exploring non-fatal injuries among EMS workers. A study by Reichard and colleagues identified an estimated 99,400 non-fatal injuries between 2003 and 2007 that were severe enough to be evaluated and treated in emergency departments [4]. Based on standardized coding in the Occupational Injury and Illness Classification Manual (OIICS), 33% were linked to “bodily exertion and exertion,” 21% to “exposure to harmful substances or environments,” and 18% to “contact with objects and equipment” [4]. The most common non-fatal injury diagnoses were sprain/strain (38%), contusion/abrasion (17%), and laceration/puncture (14%). The neck and back were the most commonly cited body parts affected by non-fatal injury (31%), suggesting that lifting and moving patients and/or equipment are common causes of injury. Research by Suyama and colleagues examined worker compensation reports for three public safety bureaus (police, fire, and EMS) in a large urban area [8]. The study determined that the absolute frequency of reported injuries was higher for police and fire compared to EMS. When adjusted for the size of the workforce, however, the rate of injuries that led to lost work time was highest among EMS workers [8]. Emergency medical services workers face repeated exposure to bodily fluids, including blood, elevating their risk of infection and illness from human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Findings from a 2002 survey sample of 2,664 paramedics determined that the rate of any exposure to blood in past 12 months was 6 per 10,000 calls and 3.7 per 10,000 patients [9]. Most exposures appear to involve intact skin and were attributed to the higher frequency of uncontrolled bleeding in the prehospital setting versus in-hospital [10]. There is a high probability that a violent patient will injure EMS workers [11–15]. Corbett and colleagues determined that >60% of EMS workers in a southern California urban system were assaulted while on the job [12]. A separate study by Mock and colleagues determined that EMS workers are exposed to at least one violent patient or event every 19 calls/patients [14]. A more recent study by Grange and Corbett determined that while violent patients accounted for <9% of patient encounters, more than half (53%) involved violence (verbal or physical) against EMS workers [15]. While it is widely known that EMS workers are often exposed to violence and violent patients, few EMS workers report receiving enough training to respond appropriately and safely [11,12]. One limitation of previous research is underreporting of injuries through the required or standard channels within organizations. As many as 32% of injuries go unreported to employers due to a complex set of factors, including but not limited to stigma associated with being injured, worker-perceived low injury severity, and other unknown factors [16]. Anonymous reporting via survey research may reveal that the proportion of EMS workers injured while on duty is greater than that counted based on injuries reported to the emergency department, employer injury logs, or worker’s compensation databases. Recent research by the University of Pittsburgh’s EMS Agency Research Network (EMSARN) shows that a large proportion of EMS workers are injured during shiftwork. Figure 21.1 shows self-reported injury data from 2,367 EMS workers in the US and Canada taking part in EMSARN research studies in 2011 and 2012. When asked to reflect on the previous 2 months, nearly half of EMS workers (45.8%) self-report injuries occurring during shifts. Injuries while lifting or moving patients were the most common injury type reported. Figure 21.1 EMS worker self-reported injury. Source: Data from the 2011 and 2012 cohorts of the EMS Agency Research Networks (EMSARN.org) and responses version 2 of the EMS Safety Inventory (EMS2-SI). Ambulance crashes are not an uncommon occurrence, with somewhere between 4% and 9% of all EMS providers having been involved in ambulance crashes [17,18]. Drivers involved in ambulance crashes are at increased risk for additional ambulance crashes in the future [19]. Half of drivers involved in crashes have been involved in multiple crashes [20]. Risk of an accident is also increased for younger/inexperienced drivers and those reporting sleep problems [18]. Ambulance crashes represented the greatest source of tort claims against EMS agencies in one analysis of a national insurance company, comprising 37% of all claims [21]. Crashes are also the leading cause of fatal injury [6].
Occupational injury prevention and management
Introduction
Occupational fatalities
Occupational injuries
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