EMS consistently ranks among America’s riskiest jobs.1 EMTs have higher rates of work-related injuries then the general workforce and are three times more likely to get hurt and experience lost work days than all private industry workers. The No. 1 reason for first responders leaving the profession is having sustained soft tissue musculoskeletal injury (MSI) from patient handling.
Each year back injuries cost the economy nearly $50 billion in direct medical bills and lost revenue, and $20 billion of this cost comes in injuries related to the healthcare profession. This exceeds the cost of back injuries in construction, mining, and manufacturing.2 Each individual back sprain carries an anticipated direct cost of just over $18,000 in physician and medical bills, lost income, and employer costs.
One-quarter of all EMS workers experience career-ending back injuries within the first four years of their career.3 The CDC monitors EMS workers’ injuries, and in the most recent data set available, more than 27,000 EMS workers experienced on-the-job injuries and illnesses, and more than 21% of those injuries were to the lower back.3
In 2017 the CDC and NIOSH came out with six recommendations for reducing risk in EMS. While some of these should be common sense, there is still poor adherence to many of the recommended risk-mitigation steps. The CDC identified these key measures:
Protect workers and promote safety, health, and well-being through workplace policies, programs, and activities.
Promote safe patient-handling techniques.
Protect workers from exposures to blood and other potentially infectious body fluids.
Prevent slips, trips, and falls.
Improve motor vehicle safety.
Prevent violence by patients.
Soft Tissue Injuries
Fully half of these recommendations mitigate against soft tissue injuries, the cost of which can be staggering for both organizations and individuals. Organizational costs include:
Overtime to backfill the shift of the injured employee. The employee covering the OT is also more likely to sustain an injury on their OT shift due to fatigue, call volume, working with new partner, or altered routine;
Morale may suffer as call volume often increases due to staffing shortages, leading to additional risk exposure;
Caring for the injured employee requires time to investigate the claim, forms and paperwork, doctors’ visits, and navigating workers’ compensation and the healthcare system. This also includes a case manager, HR staff to keep the claim moving forward, and care for the employee, plus a risk manager to determine the root cause of the injury. Plus, few if any EMTs can survive on 66% of their normal pay; this is another source of stress to the injured employee, who may try to return to work early, further increasing their risk of secondary trauma;
Organizations are responsible for accommodating injured employees back into the workforce if possible. If the employee is not able to return to work, then the organization is responsible for the employee’s disability claim. Plus, the employer now needs to hire, train, precept, and educate a new employee. This includes prehire physical-abilities testing, physicals, background checks, training time, uniforms, and more. These costs can range from $7,000 per occurrence just for turnover (not including injury) to a total annual median agency cost of turnover of $72,000.4
Insurance rates will increase based on total number of employees, claim rate, severity, and lost work days. Plus, OSHA-recordable lost work days can weigh heavily on an organization’s rates and ability to secure insurance if and when their claims exceed a determined limit.
We often describe the above as the “churn” all organizations struggle to deal with (poor employee health, injuries, turnover, overtime costs, and morale). Left unchecked, the churn can spell the end of some services or cause others to struggle.
When Are Providers at Risk?
Most injures in EMS are predictable—and if they’re predictable, they’re preventable.
We see injuries occurring in two predictable phases. First, we see severe, career-ending injuries occurring early in people’s careers. The majority of these injuries occur within the first 1–4 years.5 I can recall, as a new paramedic, my FTOs telling me to slow down, reminding me that it wasn’t my emergency. While I heard them, this sage advice made no sense to me then, as I had a poor frame of reference and an even poorer understanding of where my risk was coming from. No one taught me where risk lay, and all I observed in the field was risky behavior I believed normal.
We see a second big spike about 15 or so years into the job. Age, call volume (repetition), and health issues all take their toll at about this point in the career of an EMT. At this point EMTs have also learned the tricks of the trade, many their own tricks. This brings about a level of comfort where they may let their guard down or become lax with safety and safety procedures. We also see that many of their “tricks,” especially as they pertain to patient handling, are often very risky, potentially leading to injury from repetitive motion disorder or cumulative traumas.
The disconnect is vast and diverse as it pertains to injury prevention, first responder wellness, and resiliency. All three are connected, yet our profession has treated them as if they have no bearing on each other. We can throw technology and engineered solutions at the problem, yet the fact remains that the job is physical, has always been physical, and will always require the responder to be fit for duty.
Based on the accompanying graphic, we can clearly see that injury has many etiologies.
1. As society has become more sedentary, so has our workforce. Responders are spending more time in their trucks posting and running from call to call. The longer we sit, the greater the risk of injury.
2. No matter how we disguise it, EMS will always require a degree of lifting, pushing, pulling, carrying, etc. But when was the last time you were taught a scientifically validated and evidence-based system of safe patient and equipment handling? Sadly, the answer is likely never—or maybe you just got something via video from a manufacturer or a general safety video from an insurer. And we wonder why there is a 25% or more attrition rate from injury during the first three years of employment!
To meet the recommendations from the CDC, EMS organizations must stop handing down dangerous practices and employ true safety systems. If you still allow your crews to move patients bed to bed on a bedsheet, your service lacks a true safety system.
3. EMTs, partially through faulty training and partially through years of poor biomechanics, still use their backs as lifting mechanisms. The hips and legs should bear patient loads, with the torso muscles acting to stiffen the trunk, thus sparing the spine. Until we teach responders to do this, injury will remain the primary cause of attrition. Watch an athlete who has been trained on how to squat and deadlift pick up a long spineboard or scoop stretcher vs. an EMT who has not—the difference is staggering.
4. As a profession we have to stop simply picking patients up to put them on the cot. EMTs must be trained to understand—and employers must invest in the tools and educational process to support—that if they have to put their hands on a patient to pick them up, they have already failed.
5. The more deconditioned, fatigued, poorly fed, and physically stressed an EMT becomes, the poorer their muscle firing patterns become. When muscles have poor firing patterns, load and motion are transferred elsewhere, and we know where that is!
6. Obesity plays a huge role in injury. From additional joint compression, altered movement patterns due to body mass (which puts both partner and patient at higher risk), and poor sleep due to airway abnormalities to cardiovascular disease, obesity is the proverbial elephant in the room. EMS to this point has just not dealt with it.
Many of the points made above can be quickly addressed through a validated job task simulation physical abilities test. Test prehire and annually, as this is the first warning sign if an employee is no longer fit for duty. Better to test and then “prehab” the employee then to wait until they are injured or injure someone else.8
Stress and resiliency are a major piece of the safety puzzle. The normal physiological stress response is a temporary phenomenon, which acts to prepare the neuroendocrine, musculoskeletal, and cardiovascular systems to respond appropriately to a stressful event. Through activation of the hypothalamic-pituitary-adrenal (HPA) axis, glucocorticoids (cortisol) are synthesized and secreted at a higher rate from the adrenal cortex.
Simultaneously, sympathetic nervous system (SNS) activation results in increased secretion of catecholamines (epinephrine and norepinephrine) from the adrenal medulla. Under normal, healthy circumstances, the stressful signal terminates, and through a negative feedback mechanism, glucocorticoid secretion drops and stimulation of the HPA axis decreases, while simultaneously SNS activity and catecholamine secretion decrease, and homeostasis is restored.6
Dysfunctions in the physiological stress response are seen when, over time, the magnitude or duration of stress on the body exceeds its ability to cope. When this occurs the adrenal glands (responsible for glucocorticoid and catecholamine secretion from the adrenal cortex and medulla, respectively) are unable to respond appropriately in relation to the magnitude of stress.
This is known as adrenal exhaustion or adrenal insufficiency.7 In a military setting, a variety of factors can contribute to adrenal insufficiency, namely overtraining stemming from excessive endurance exercise without appropriate recovery, operational demands, psychological stress, lack of sleep, and inadequate nutrition.
Frequently it is cumulative stress, rather than one single stressor, that tips the balance and creates an adrenal exhaustion scenario.7
This is exactly what happens to first responders and is a primary cause of the stress, fatigue, obesity, risky behavior, and soft tissue injuries we desire to eliminate.
Become a Safety Advocate
How can we expect EMTs to remain resilient and risk-averse when their system by design breaks them down? From an operations perspective it is far cheaper to keep an employee healthy and on the job to retirement than to constantly hire new employees who will only stay for a few years. It’s far less expensive to have a fit employee who’s free from injury than to pay for the claim when they undergo an MI, CVA, or MVC on duty. It is far easier to invest in an EMT’s education before they experience substance abuse issues, poor health, PTSD, anger issues, risky behavior, or worse.
It is up to us as a profession to teach new and incumbent responders how to survive the job. Stop rushing new employees through haphazard training just to get them on the street. Instead, teach them how to be fit for duty, employ sleep hygiene strategies, eat in the field, and make them experts at safe patient handling and equipment use.
Educate them about risk in EMS, the root causes of injuries, exposures, slips, and assaults before they hit the street. We should all become safety advocates, and that starts with how your department approaches the risky business of EMS.
1. Centers for Disease Control and Prevention. Emergency Medical Services Workers: How Employers Can Prevent Injuries and Exposures, https://www.cdc.gov/niosh/docs/2017-194/pdfs/2017-194.pdf.
2. EMS Back Injury Facts, www.mytactical.com.
3. Centers for Disease Control and Prevention. Emergency Medical Services Workers—Injury and Illness Data, https://www.cdc.gov/niosh/topics/ems/data.html.
4. Patterson PD, Jones CB, Hubble MW, et al. The longitudinal study of turnover and the cost of turnover in EMS. Prehosp Emerg Care, 2010 Apr 6; 14(2): 209–21.
5. Widman SA, LeVasseur MT, Tabb LP, Taylor JA. The benefits of data linkage for firefighter injury surveillance. Injury Prevention, 2018; 24(1): 19–28.
6. Szivak TK, Kraemer WJ. Physiological readiness and resilience: Pillars of military preparedness. J Strength Cond Res, 2015 Nov; 29 Suppl 11: S34–9.
7. Kurz T, Zagorski M. Science of Sports Training: How to Plan and Control Training for Peak Performance, 2nd ed. Island Pond, VT: Stadion Publishing, 2001.
8. Busch J. Are You Fit for Duty? EMS World, www.emsworld.com/article/11143454/are-you-fit-duty.
Sidebar: Fitness Facts
First responders will die up to 12 years sooner than civilians.
Sleep is the only time you are getting better. It sets your appetite and hormone cycles.
Sleepy driving is the same as drunk driving.
Stress, poor sleep, poor diet, and poor fitness cause the low amounts of free testosterone common in first responders. This directly impacts morbidity and mortality.
Insufficient sleep and poor wellness accelerate death. Cumulatively they make us dumber, fatter, slower, and weaker.
The only way to fix this is deep normal sleep. Ever have someone come back from an injury and say the three weeks off the truck is the best they’ve ever felt? It’s because they got back on a normal sleep/wake cycle.
Normal deep sleep and HPA axis balance are the keys to provider resiliency. Most psychotic events and suicide attempts are preceded by long periods of insomnia or poor sleep.
There is a fourfold higher risk of PTSD when in a state of chronic fatigue and HPA axis dysfunction.
—Source: Behind the Shield podcast, docparsley.com
Bryan Fass has dedicated the past 10 years to changing the culture of fire-EMS from one of pain, injury, and disease to one of ergonomic excellence and provider wellness. Fass has leveraged his sports medicine, athletic training, spine rehabilitation, strength and conditioning, and paramedic experience to become an expert on prehospital patient handling and first responder wellness. Fass will be a featured speaker at EMS World Expo 2018, held Oct. 29–Nov. 2 in Nashville. Reach him through www.fitresponder.com.