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The Need for Occupational Health Law in the EMS field

Erich Bonilla

California State University, San Bernardino

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The Need for Occupational Health Law in the EMS field

With its ever-changing work conditions Emergency Medical Service (EMS) personnel are

exposed to hazard not associated with other types of employment. Even though “the federal

government has guided the development of EMS through consensus documents” (It’s time for an

EMS health and safety agenda, 2007) “none of these documents adequately address the health

and safety of faced by the EMS workforce” (It’s time for an EMS health and safety agenda,

2007). The lack of a unified direction has allowed EMS agencies to address these issues in a

manner that best serves their purpose. This is further exacerbated because of the different

approaches to EMS, such as public service providers, third service providers and private

providers, which contract with local governments to provide emergency (911) services. To better

understand the challenges faces by EMS personnel, we must understand how the Occupational

safety and health law can be better applied to the EMS field, and relate the regulatory standards

described by Occupational Safety and Health Administration (OSHA) to the types of issues faced

by EMS personnel. This will also require us to investigate the different approaches each EMS

provider takes when addressing any health and safety (physical and mental) issues faced by their

personnel. There is also a need to examine if any of the EMS service providers compile data on

injuries and safety issues and if so is the information is kept internal or shared externally to

improve their employees working conditions. We must also attempt to understand the internal

training provided by the EMS service providers and how it can impact the employees

understanding of the health and safety culture within the organization, and their role in this

culture. Finally, we will attempt to understand the impact these issues have on employee morale

and how it can lead to poor patient and employee outcomes.

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Stress

Stress impacts EMS personnel on a daily basis, this comes from multiple facets of the job

including, not knowing what their next response might involve, when they will have to respond

to a call, or the circumstances surrounding their next response (need for personal safety). This is

compounded by the working conditions faced by some of the employees, where they might not

be able to have any down time, not have permanent stations so they can exit the vehicle between

calls or even obtain a meal due to the call volume being experienced by the department. OSHA

has recognized some of these issues and attempted to create anti-stress guidelines to mitigate

these situations, but once again it was left to the individual agencies to determine how to best

implement these guidelines. Even when an agency attempts to address some of the stress causing

components, the work life balance faced by EMS personnel is difficult to manage. OSHA’s

guideline for work/life balance says that employers should “educate employees about the

importance of a healthy work/life balance,” (Sprayberry, 1999) but how are employees supposed

to accomplish this is not address, and as such many EMS agencies do not address this issue. This

difficultly in achieving a work/life balance occurs because of the 12 hour shifts usually

associated with the work environment, and the fact that many people in EMS work more than

one job to provide for their families. While some agencies have begun addressing the need to

improve the lives of their employees, others have not and will continue to see the negative

impact of having their employees becoming sick or injured, such as delayed responses. This is

especially true for private sector EMS employees who will continue to work multiple jobs

because of the low wages offered by their employer, and the practice of paying overtime after 40

hours, instead of overtime after 8 hours. Improving the salary of these employees could help
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improve the work/life balance and allow these employees to pursue other activities that could

mitigate their stress and allow them to have productive time with their family. To mitigate stress

related to the emergency responses, many providers have partnered with local dispatching

agencies to make sure their mobile dispatching terminals (MDT’s) display as much information

to their employees. This information can help alleviate any stress the employees may feel when

responding to an emergency. While there have been improvements in the information received by

the employees regarding their response, and in some instances salary scales have been improved,

very little has been done to improve the working conditions of the employees in busy EMS

systems. Improving the working conditions of the employees would go a long way for reducing

the mental stress. Many private EMS agencies operate using a system status model, which

distributes ambulances throughout the response area based on historical call data, so the EMS

agency can manage the reception of 911 responses. (Jacobs, Waheed, Heller, & Appel, 2017)

This put the additional stress on the employees because even when not responding to a call, they

might have to deal with the stresses of the area traffic, and not being able to disengage from their

work requirements, because of a required post move to maintain the system status model. This

also makes it difficult to plan a meal period, because the employees do not know if they will

have to respond to a call, move to a different posting location and if there will be food available

in that area they are assigned too. If OSHA was to address this issue there is a possibility that

some of the stress associated with the job could be eased and we could have better health

outcomes for these employees.

Job Safety.

Job safety is an issue every EMS employee must learn to manage. “Emergency medical

services provider deliver medical care to seriously injured and ill patients and are at risk for
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occupational injury themselves from needlesticks body fluids exposures” (Eliseo et al., 2012).

While most EMS providers have training that imparts knowledge of proper techniques when

dealing with sharps or biohazardous waste, learning to manage an agitated patient takes practice

because of the individualized response needed to manage the agitated person. Lack of training in

this matter could result in assaultive behavior by the individual the EMS personnel are

attempting to assist. This is why, “an observational study from Tennessee notated that verbal and

physical violence was directed at EMS providers on 5% of all patient encounters” (Eliseo et al.,

2012). Issues like this could be minimized if through proper training, including de-escalation

techniques.

Along with the training EMS providers receive in regard to safe procedures, they also

have also established protocols that attempt to minimize the likelihood of work related injuries,

“however, adherence to safety precautions is inconsistent among health care workers in general”

(Eliseo et al., 2012). Part of the reason safety precautions are inconsistent is that “employees

perceptions regarding their organization’s commitment to safety (i.e., safety climate) correlates

with the degree of conformity with safe work practices” (Eliseo et al., 2012). Having OSHA

provide guidelines for safety training is just one step needed to reduce the likelihood of work

related injuries. As stated above though, if the employees do not feel that safety is not a priority

to the employer, then they will not adhere to the agencies safety protocols. The employees are

likely to develop this sentiment when they see that there is a consistent lack of equipment,

equipment is not maintained properly, the protocols change without the agency being proactive

in the dissemination of information, or if they feel there is favoritism among the employees.

Having EMS agencies address these internal issues could help improve the safety culture of EMS

agencies, which in turn would improve the health of the employees. Having regulating agencies
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that set minimum requirements on equipment availability not just in the unit, but within the main

deployment center can help create a feeling among the employees that should a need arise, faulty

equipment could be replaced with ease. When you pair this, with an EMS agency willingness to

share information with their employees, it could impact the feelings that there is favoritism

displayed by the EMS agency. All these changes, while not requiring large changes to a

companies’ daily operations but, could help foster a stronger sense of belonging. The growing

sense of belonging by the employees, could lead to them becoming invested in the safety culture

within the organization, leading to lower incidences of occupational injuries, mental health

issues, and low morale. Finally, employee retention could impact employee safety, if employees

are consistently being replaced then there is no sense of comradeship within the workforce. This

leads to EMS personnel doing things in the manner they feel more comfortable, without taking

their work partner into account. As stated by Patterson et al. (2016) “Familiarity between

teammates varies in the EMS setting, and less familiarity is associated with greater incidence of

workplace injury” Employee retention allows EMS agencies to continue to enforce proper injury

prevention techniques, that will become second nature to employees that have some seniority

within the company, which is why policies that address employee retention need to be

developed.

Delivery Methods.

The manner an EMS provider delivers their service to the community also impacts the

health of the employees. If they are part of an existing fire service agency, they usually receive

the same benefits as firefighters. This includes working out of a station, which would limit the

response area and the amount of driving that must be done by EMS personnel, this is also true of

third service agencies, ambulance services provided by a local government. Working out of a
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dedicated station allows EMS personnel to be in a temperature-controlled environment when not

responding to a call. This has the additional benefit of allowing the employees to exit the vehicle

and stretch, this improves the circulation within the body and minimizes the possibilities of

negative health outcome like deep vain thrombosis (blood clots in the legs) which can dislodge

and lead to pulmonary embolism. Not being in a vehicle for 12 hours also minimizes the amount

of vehicle exhaust that EMS personnel are exposed too. Finally, by having a station there is the

added benefit of lower incidences of injuries, this is true because “sitting for prolonged periods

of time can be a major cause of back pain, cause increased stress of the back, neck, arms and legs

and can add a tremendous amount of pressure to the back muscles and spinal discs”

(“Ergonomics for Prolonged Sitting,” n.d.), and “ambulance may be cramped and uncomfortable,

and posting has been shown to increase back injury rates” (Morneau and Stothart, 1999). Unlike

third services or public service ambulance services, private EMS agencies tend to use a system of

response optimization known as “System Status Management (SSM), in which ambulances are

distributed throughout a city according to historical call data”(Jacobs et al., 2017). This limits the

amount of time EMS personnel can be outside of the vehicle, especially during inclement

weather, high heat index days, or poor air quality days. Even when outside of the vehicle, there is

exposure to vehicle exhaust because of the need to maintain the vehicle electronics operational.

Addressing this style of service delivery through an OSHA, state or even local guideline could

help improve working conditions of EMS personnel, and by default improve their health.

Record Keeping.

While EMS personnel experience higher levels of injuries and stress related to their work,

there is minimal information available from providers as to the types of injuries and their related

impacts on the workforce. The Centers for Disease Control and Prevention does keep a
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“collection of data on nonfatal injuries among EMS workers” (“CDC - Emergency Medical

Services Workers,” 2018) but this information is a compellation of data obtained from hospital

records review, and workers’ compensation claims and not directly sourced from the EMS

providers. This creates discrepancies in the data which could corrupt the results of anyone who is

attempting to establish injury trends within the workforce. To address this issue, a national data

base should be created, which will allow researchers to better investigate the rates and

implications of injuries and sickness among the EMS workforce. This would force employers to

try to address the issues leading to sickness or injury within their division, as well provide a way

for regulating agencies to verify that adequate training and employee safeguards are in place.

Having a national database will also help with the creation of policies, because it would create

researchable data, and allow EMS agencies to begin to work in a unified direction, to create

national standards for both the providers and the employees.

Morale.

Low employee morale is an issue faced by many companies where there a heavy demand

on employees by management and the workload is ever increasing. This is exacerbated by the

public’s idea that public service EMS providers have higher training and therefore should be

respected, while EMS personnel working for a private EMS service are viewed as having less

training and therefore provide subpar care. In part this has to do with a lack of understanding

from the public, and the lack of community outreach events in which private EMS participate in,

which limitis the opportunities for the community to develop a relationship and understanding of

private EMS agencies. This lack of relationship with the community occurs is in part to the

business practices of the company, and in part due to some employees seeing their job as a

stepping stone to get to their goal. These feelings lead to employees not becoming invested in the
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company, which then leads to a feeling of disenfranchisement from the company and community

they serve. Feeling disenfranchised can also impact the moral of the employees because they see

that they sacrifice themselves to serve a community, yet the community does not respect them,

which leads to some to employees leaving the field, which further impacts the working

conditions and mental health of the remaining EMS personnel. This is not a problem usually

associated with public service EMS, because they get to enjoy better relationships with the

community and build better comradeship between employees since they have less employee

turnover. Addressing issues regarding morale will also help address some of the issues regarding

mental health (stress) “Low morale can possibly lead to anger issues, workplace violence, stress,

depression, and a lack of self-worth” (Dill, 2018). Addressing issues with regards to employee’s

health, workplace injuries, the development of national databases and public education about the

roles of private EMS services in a community will help improve morale among the employees

and could help improve the high turnover associated with private EMS, as well as provide better

patient outcomes. This would occur because an employee that is working in an environment

conducive to their work tasks, are more likely to provide better patient care because they become

invested in their workplace.

Conclusion.

Understanding the challenges faced by EMS providers is an issue that is of paramount

importance to all and requires the attention of agencies such as OSHA and federal, state and local

regulating agencies. Developing policies that will help address the health concerns, both

mentally and physically, of those that serve the community, not only protects the service

providers, but also protects the public from receiving subpar care in an emergency. The first step

needed to accomplish though, has not been addressed in any of the previous government
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publication. Developing an outline that addresses the health and safety issue faced by EMS

personnel, will allow regulating agencies to formulate a plan of action, and set standards on the

EMS providers. This will improve the health outcomes of EMS personnel as well as improve

their mental health statues, which has been associated to better health outcomes for the patients

in their care. This can only be accomplished by developing protocols that mandate injury and

sickness be reported and submitted to a centralized database, which will allow researchers to

conduct studies on ways to improve the working conditions associated with the EMS field. This

research can then help frame future policy development which can provide a framework of

regulations and protocols to improve the working conditions, and associated stress encountered

on the job. Being tasked with the protection of employee, OSHA should lead the way in the

development regulations that specifically target the issues faced by EMS personnel and should

partner with researchers to develop better injury and sickness reporting methods.
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References

CDC - Emergency Medical Services Workers: Injury and Illness Data - NIOSH Workplace

Safety and Health Topic. (2018, April 2). Retrieved May 13, 2018, from

https://www.cdc.gov/niosh/topics/ems/data.html

Dill, J. (2016, February 22). Fire/EMS Department Morale: Can it lead to Behavioral Health

Issues? Retrieved May 11, 2018, from

http://www.fireengineering.com/articles/2016/02/fire-ems-morale.html

Eliseo, L. J., Murray, K. A., White, L. F., Dyer, S., Mitchell, P. A., & Fernandez, W. G. (2012).

EMS Providers’ Perceptions of Safety Climate and Adherence to Safe Work Practices.

Prehospital Emergency Care, 16(1), 53-58. doi:10.3109/10903127.2011.621043

Ergonomics for Prolonged Sitting. (n.d.). Retrieved May 15, 2018, from

https://www.uclahealth.org/spinecenter/ergonomics-prolonged-sitting

It's time for an EMS health and safety agenda for the future. (2007). Emergency Medical

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Jacobs, K., Waheed, S., Heller, N., & Appel, S. (2017). Emergency Medical Services in

California:, 31.

Morneau, P., & Stothart, J. (1999). My aching back. The effects of system status management

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Services, 24(8), 36-47. Retrieved May 7, 2018.

Patterson, P. D., Weaver, M. D., Landsittel, D. P., Krackhardt, D., Hostler, D., Vena, J. E., …

Yealy, D. M. (2016). Teammate familiarity and risk of injury in Emergency Medical

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https://doi.org/10.1136/emermed-2015-204964
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Sprayberry, N. (1999). OSHA Anti-Stress Guides Applied to EMS. EMS Manager and

Supervisor, 1(4), 1-4.