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Provider Safety: What Are the Big Threats?

EMS personnel face inherent risks. They provide emergency care in the streets, mountains, apartments, fields, and everywhere in between. Providing care and transportation in all weather, day and night, on scene and in motion, is a hazard. EMS providers are three times more likely than the general public to be injured in a transportation accident and twice as likely as other industry employees to suffer an injury on the job that requires time off work. NIOSH finds us at greater risk for occupational injuries and assault than workers in any other profession in the U.S.1 

Threats: The Big Four

An infographic from NIOSH outlines our major threats.2 

Personal movement—More than 22,000 EMS providers present to emergency departments annually for on-the-job injuries. The majority of these are full-time employees who’ve been on the job for less than 10 years. Their injuries are predominantly due to body movements, slips, trips, and falls. 

When providers apply for EMS jobs, they must be determined to be both physically healthy and capable of doing the job. Many agencies have implemented physical ability testing. The problem with work is that over time, we become lazy. Our joints stiffen, and we lose flexibility. Our attention to the details of safe operations often falters, and we can develop bad habits. Many resulting injuries could be reduced or minimized with proper training on lifting, moving, and transferring people and equipment, along with instruction on proper stretching and body mechanics. Agencies could consider hiring occupational therapists to develop initial and recurrent training.

To reduce slips and falls, we must educate personnel to be aware of their environment and adjust for hazards. Require durable, slip-resistant footwear.

Exposures—EMS providers live among the blood and bodily fluids of the people they serve. They are also susceptible to the illnesses that go along with them. Personal protective equipment (PPE) will only take us so far in this world of sharp needles, coughing and sneezing patients, bleeding wounds, and other possible exposures. 

It is imperative that EMS personnel use protocols and SOPs that minimize their risks of exposure. From use of N95 masks and power exhaust when transporting flu patients to wearing those gloves and face shields despite hating how we look in them, we don’t have to be pretty, just safe. 

A comprehensive exposure-control plan should address all standard precautions. Personnel at all levels can work together to engineer controls and decontamination procedures that meet or exceed OSHA’s bloodborne pathogens standard.

Assaults—In most jurisdictions it is a felony to assault a police officer. The same cannot be said of EMTs and paramedics. The society providers work in today is much different than it was in the past. 

EMS providers remain at regular risk of assault. While some agencies are issuing body armor, it doesn’t help in all situations and is cost-prohibitive for many agencies.

The most cost-effective means to address assault is to focus on situational awareness, de-escalation skills, and working closely with our public safety partners. Some jurisdictions may find it worthwhile to offer self-defense training. Programs for dealing with assault and violence must include both policies and training.

Transportation incidents—EMS is in the transportation business, and that is where most of our deaths occur. Transportation-related events are the No. 1 killer of EMS providers.

We must buy the safest vehicles for field personnel. An ambulance with a plywood box isn’t usually as safe as one with a total steel body constructed and tested as an OEM vehicle without modifications. A growing body of literature distinguishes other features and approaches with proven benefit. 

The lack of proper restraint in EMS transport is a chronic problem. Drivers don’t wear restraints, attendants routinely operate in the back without belts, and sometimes even patients may not be properly restrained. The driver must ensure all appropriate restraints are used, including the shoulder harness for patients. Many drivers and passengers have died after being ejected from crash-survivable accidents, and many attendants and patients have been seriously injured and killed by not being properly restrained in the back of the ambulance. 

Equipment must also be suitably restrained. Unsecured oxygen cylinders can go flying in accidents. Arms have been broken, skulls cracked, teeth knocked loose. Properly securing equipment is nothing to be taken lightly. Homemade oxygen cylinder restraints are usually inadequate, as are EKG monitor straps installed locally in lieu of a proper mount.

Photos by accident investigation teams show equipment mounts pulled loose during accidents where jerry-rigged restraints had wood screws holding equipment that should have been bolted. Cargo nets meant to catch attendants at the heads of bench seats have been pulled from their ceiling anchors by poor mounting practices (and in fact you shouldn’t have side-facing seating at all). As an industry, EMS must assure everything has a proper place and all items are secured adequately. Too many agencies buy and stock ambulances without buying equipment made for their ambulances or ambulances made for their equipment. All equipment and mounts should be commercial grade. 

Commercial drivers have standards to meet. EMS drivers, not so much. Some jurisdictions require a special class, others nothing. Drivers should be trained, educated, and in-serviced on how to properly drive, care for, and evaluate their vehicles. Ideally they would learn to drive as if they were driving a limousine, carefully and smoothly.

Time is usually not of the essence. Most wrecks occur on fairly straight country roads in daylight during good weather. Most serious accidents happen at intersections. How many of those drivers were inadequately trained?

Next Steps

Where do we go from here? We require buy-in from all stakeholders. Field providers, supervisors, management, maintenance, and medical directors must all be involved to ensure successful changes within EMS systems. 

Getting quality personnel who are mentally and physically able to do the job is paramount. From there we can mold them into quality providers. Start with physical ability testing and training on the tools and methods used to move patients and equipment. Follow these with in-service training on how to properly lift and move equipment safely to prevent repetitive stress/motion injuries. Mechanics or maintenance personnel can show employees the proper way to inspect their rig—tire pressures, tread wear, door and compartment latches and seals, vacuum and oxygen systems, braking and cooling, and fluids and fueling systems.

Field training officers should work with personnel after their vehicle and moving/lifting orientations to organize their workspace within the ambulance to prevent them from having to unbuckle during transport.

Risk management for the safety of EMS providers requires policies, procedures, buy-in, and engineering of our workspaces to mitigate poor consequences. Don’t learn that at the cost of your people’s safety.  


1. OSHOnline. Ambulance Workers Are More Likely to Get injured—and Assaulted—on the Job. 2019 Dec 3;

2. National Institute for Occupational Safety & Health. Emergency Medical Services Workers: How Employers Can Prevent Injuries and Exposures,

John M. Dabbs is an EMS consultant and investigator for the Tennessee Office of EMS. 


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