Occupational risks for EMS personnel in the United States

By Brian J Maguire, DrPH, MSA, EMT-P; Paul M. Maniscalco, PhD(c), MPA, MS, EMT/P, LP, CHEP; Daniel R. Gerard, MS, RN, NREMT-P; Scot Phelps, JD, MPH, paramedic; Barbara J. O’Neill, PhD, RN; Lawrence E. Tan, JD, NRP, CHEP, BCMP; Kathleen A. Handal, MD

On February 5, 2024, the Occupational Safety and Health Administration (OSHA) posted a notice of proposed rulemaking (NPRM) to issue a new safety and health standard titled: “Emergency Response Standard” [1]. The proposed standard is meant to replace the existing Fire Brigades Standard. The new standard “would address a broader scope of emergency responders and would include programmatic elements to protect emergency responders from a variety of occupational hazards” [1]. The proposed Standard defines emergency responders as “firefighters, emergency medical service providers, and technical search and rescuers” [1].

The agency requested comments on all aspects of the proposed rule, and the authors submitted a written response on May 21, 2024 [2]. In November and December 2024, OSHA held a public hearing.

The following is a transcript of testimony given at the OSHA proposed Emergency Response Standard rulemaking public hearing on Nov. 14, 2024. It has been modified for readability and to add citations. The testimony was given by Dr. Brian Maguire.

Testimony

To begin, I wish to thank OSHA for taking on this task to issue a new safety and health standard. The emergency medical services clinicians have one of the most dangerous jobs in the U.S. and new safety measures are desperately needed.

Over the next few minutes, I will share a little about my background, quantify the problem, and make specific recommendations. I am currently the senior epidemiologist at a medical research laboratory. I also have the privilege of being involved with the emergency medical services profession since 1975. As a paramedic, I saw first-hand the many dangers associated with EMS work. My EMS background includes two decades in the New York City EMS system where I worked as a clinician, educator, researcher, manager and agency president.

As an EMS leader, I always had a focus on safety. But then one day, one of my ambulances was involved in a serious collision. I responded to the scene and found the ambulance upside down in the middle of the avenue. In my subsequent efforts to find ways to reduce the chances of another collision, I discovered that there was almost no research on EMS safety [3]. That led me to do a doctoral degree in public health. My doctoral research was the first to quantify how the risks for EMS clinicians compared to the risks in other occupations [4]. I am a Senior Fulbright Scholar and was one of the first paramedics in the world to be appointed as a full university professor. My more than 120 publications include many that are focused on the occupational risks for emergency medical services clinicians.

In our efforts to quantify the problems, we must first understand the context, that EMS in the U.S. suffers from a lack of adequate funding [5-8]. This lack of funding results in enormous problems, including a fragmented system with large differences in quality and availability by jurisdiction, turnover rates of 25-40% per year, salaries about half of what are paid to comparable professionals, and extremely high injury and fatality rates [8-11].

The inadequate funding has resulted in, for example, a 10-times difference in an EMS patient’s chances of survival depending on which community the patient is in when they have an emergency event [8]. It results in over 2,500 counties in the U.S. not having access to immediate EMS care [9]. The lack of sufficient funding has also resulted in a lack of resources to devote to EMS occupational safety.

And although we are here today to focus on emergency responders, it is important to note that the huge inadequacies in EMS funding also impact OSHA’s core mission, because no one can ensure “America’s workers have safe and healthful working conditions,” when a large proportion of those workers do not have access to EMS, and a large proportion of those workers will have a 10-times lower survival rate than workers in other areas [12].

When we seek to quantify EMS risks, we must note the following eight facts:

1. There are approximately one million EMS clinicians who work in the nation’s 20,000 emergency medical services (EMS) agencies, and respond to 40 million calls for assistance each year [13].
2. Each year in the U.S., about 11 EMS clinicians are killed and about 8,000 are severely injured [4,14].
3. The injury rate for EMS clinicians is more than four times higher than the rate for all U.S. workers [15].
4. From 2003 to 2020, 153 EMS clinicians died in transportation related events [14].
5. From 2010 to 2020, over 400 EMS clinicians suffered from serious violence-related injuries [15].
6. In 2020 alone, more than 11,000 EMS clinicians suffered serious injuries and more than 2,000 EMS clinicians suffered serious back injuries; many of these injuries may have been career-terminating events [15].
7. Last month at the American Public Health Association Conference, I presented the results of a new research project that showed that women in EMS have higher injury rates than men in EMS [16].
8. The last fact I will share is that although firefighting and EMS have both been included in a list of the 10 most dangerous jobs in the U.S., the dangers for EMS are fundamentally different than the dangers for fire [17]. The injuries are different, the fatalities are different, the risks are different. For example, the rate of violence-related injuries is 7-times higher for EMS clinicians compared to firefighters [18]. Research does not show as many chronic diseases for EMS compared to fire; however, it is very possible that the difference in chronic disease rates is because so few EMS personnel stay in EMS long enough to be captured by the research.

Those are some of the facts we know – what we do now know are the details and circumstances of those EMS injury and fatality events. We have very little information about how those 11 EMS clinicians are killed every year. Even for the transportation-related fatalities, we have very little information on what, if any, safety precautions were being used at the time of the fatality or what safety training the clinician had in advance.

For the more than 400 EMS clinicians who are violently assaulted every year, we know essentially nothing about what, if any safety measures were in place, or what training they had [19]. And although we now know that women have higher injury rates than men in EMS, we have no information on the reasons for this difference [16].

We have little information on the hours worked by EMS clinicians, their sleep or how these factors are impacting their injury and fatality rates. Nor do we know the specific risk factors for clinicians working in rural versus urban environments.

Based on those facts, here are our three key recommendations:

1. Because the dangers for EMS are fundamentally different than the dangers for fire, efforts focused on reducing the risks for one group will do little to reduce the risks for the other group. Therefore, rules, regulations and required training must be tailored to each specific workforce.
2. Similarly, since we now know that occupational risk in EMS varies by sex, any rules, regulations or training must have at least some sex-specific components.
3. Since we do not have sufficient information on which to develop adequate rules, policies, regulations or training, we urge OSHA to work with NHTSA, IAEMSC, NAEMT, NASEMSO and others to collaboratively develop solutions that will save lives, reduce risks and improve care. We suggest this be an iterative process of testing initiatives in small pilot projects before rolling out new initiatives to the larger community. This will allow the development of evidence-based solutions while also not placing an unmanageable financial burden on EMS agencies.

In summary, efforts to develop new safety initiatives for EMS will result in improved safety for EMS and improved care for the workers that OSHA oversees, as well as improved service for the 40 million people who call EMS for help every year. To some, the anticipated outcomes associated with a safer EMS system may seem like fantasy, but these systems are operating successfully in many other countries where a well-funded EMS system provides both optimal clinical care and a safe working environment. This suggested process will provide OSHA the best opportunity to ensure that EMS clinicians, and America’s workers, all have safe and healthful working conditions.

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REFERENCES

1. Occupational Safety and Health Administration. Emergency Response Standard. February 5, 2024. Available at: https://www.federalregister.gov/documents/2024/02/05/2023-28203/emergency-response-standard. Accessed: December 10, 2024.
2. Maguire BJ, Maniscalco PM, Gerard DR, et al. The 2024 Occupational Safety and Health Administration, Emergency Response Standard: A pathway to reduce the high rates of occupational fatalities, injuries, and illnesses among paramedicine clinicians. May 21, 2024. Available at: https://www.regulations.gov/comment/OSHA-2007-0073-1565. Accessed: May 22, 2024.
3. Maguire BJ, Porco FV. EMS and Vehicle Safety. Emerg Med Serv. 1997; 26(11):39-43.
4. Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency medical services: A hidden crisis. Ann Emerg Med. 2002; 40(6):625-632.
5. Maguire BJ, O’Neill BJ, Maniscalco PM, Gerard DR, Handal KA. Will an Ambulance Be Available When You Call? Inside Sources. September 10, 2020. Available at: https://www.insidesources.com/will-an-ambulance-be-available-when-you-call/. Accessed: September 15, 2020.
6. U.S. Centers for Disease Control and Prevention. Emergency Medical Services (EMS): A Look at Disparities in Funding and Outcomes. 2024. Available at: https://www.cdc.gov/ems-community-paramedicine/php/us/disparities.html. Accessed: October 16, 2024.
7. U.S. National Highway Traffic Safety Administration, National EMS Advisory Council. EMS Funding and Reimbursement. 2016. Available at: https://www.ems.gov/NEMSAC-advisories-and-recommendations/2016/NEMSAC_Final_Advisory_EMS_System_Funding_Reimbursement.pdf. Accessed: August 14, 2021.
8. Institute of Medicine. Emergency Medical Services: At the Crossroads. The National Academies Press. 2007. Available at: https://www.nap.edu/download/11629. Accessed: March 21, 2021.
9. Jonk Y, Milkowski C, Croll Z, Pearson K. Ambulance Deserts: Geographic Disparities in the Provision of Ambulance Services [Chartbook]. Maine Rural Health Research Center; May 2023. Available at: https://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1013&context=ems. Accessed: July 28, 2023.
10. AAA/Avesta. Ambulance Industry Employee Turnover Study. 2019. Available at: https://ambulance.org/wp-content/uploads/2019/07/AAA-Avesta-2019-EMS-Employee-Turnover-Study-Final.pdf. Accessed: April 19, 2020.
11. Sledge M. New Orleans EMS Has 40% Turnover, Officials Say. J Emergency Medical Services. November 7, 2022. Available at: https://www.jems.com/administration-and-leadership/new-orleans-ems-has-40-turnover-officials-say/. Accessed: April 25, 2023.
12. Occupational Safety and Health Administration. About OSHA. Available at: https://www.osha.gov/aboutosha. Accessed: December 10, 2024.
13. The National Association of State EMS Officials (NASEMSO), and the Office of EMS, National Highway Traffic Safety Administration (NHTSA), U.S. Department of Transportation. National Emergency Medical Services (EMS) Assessment. 2020. Available at: https://nasemso.org/wp-content/uploads/2020-National-EMS-Assessment_Reduced-File-Size.pdf. Accessed: February 26, 2023.
14. Maguire BJ, O’Neill BJ, Al Amiry A. A Cohort Study of Occupational Fatalities among Paramedicine Clinicians: 2003 through 2020. Prehosp Disaster Med. 2023; 38(2):153-159.
15. Maguire BJ, Al Amiry A, O’Neill BJ. Occupational injuries and illnesses among paramedicine clinicians; analyses of U.S. Department of Labor data (2010 – 2020). Prehosp Disaster Med. 2023; 38(5):581-588.
16. Maguire BJ. Poster: Occupational risks for women in the emergency medical services (EMS) profession (2011 to 2020). American Public Health Association Annual Meeting; October 28, 2024; Minneapolis, MN.
17. Picchi A. America’s 10 most dangerous jobs. CBS News. August 11, 2016. Available at: https://www.cbsnews.com/media/americas-10-most-dangerous-jobs/. Accessed: May 19, 2024.
18. Maguire BJ, Maniscalco PM, Gerard DR, et al. Workplace Violence Prevention for Paramedicine Clinicians: Proposed U.S. Bill Addresses a Data Collection Gap. Journal of Emergency Medical Services. May 12, 2023. Available at: https://www.jems.com/commentary/workplace-violence-prevention-for-paramedicine-clinicians-proposed-u-s-bill-addresses-a-data-collection-gap/. Accessed: June 11, 2023.
19. Maguire BJ, O’Neill BJ. EMS personnel’s risk of violence while serving the community. Am J Public Health. 2017; 107(11):1770-1775.