By Brian J. Maguire, Dr.PH, MSA, EMT-P
Barbara J. O’Neill, PhD, RN
Scot Phelps, JD, MPH, Paramedic
Paul M. Maniscalco, PhD(c), MPA, MS, EMT/P, LP
Daniel R. Gerard, MS, RN, NRP
Kathleen A. Handal, MD
The devastating effects of the COVID-19 pandemic resonate around the world. Escalating infection and death rates are reported daily. While emergency medical services clinicians have been operating at the far forward front lines of the COVID-19 pandemic from the start, their infections, lost work time, long-term clinical manifestations and deaths have not been adequately reported or recorded [1]. In this article, we examine currently available EMS COVID-19 mortality data in order to describe the extent of EMS losses and to compare the risks for EMS clinicians to the risks for other related professions.
Throughout the pandemic, EMS clinicians with limited personal protective equipment (PPE) have been treating patients in their homes and at trauma sites where they have had little to no opportunity to maintain safe distances from patients. They have to lift, move and carry their patients, increasing the possibility of mask leaks from movement and increasing respiratory demand from the effort. Sustained shortages of PPE have meant that EMS clinicians, their patients, their coworkers and their families have been at increased risk of contracting the virus [2-7].
These increased risks are especially alarming because we already knew that EMS personnel are at higher risk of injuries and fatalities than other professions. Pre-pandemic research showed that EMS clinicians have occupational fatality rates comparable to police and firefighters and far above the rates of other healthcare workers [8,9].
EMS COVID-19 illnesses and fatalities in New York
Much of the pandemic data available on COVID-19 related risks and fatalities among EMS clinicians have been reported out of New York City (NYC), a place that had been the United States epicenter for the virus. In NYC, EMS clinicians typically respond to about 4,000 emergency calls a day; at times during the pandemic, demand swelled to over 7,000 calls a day [4,4].
At the end of March in NYC, 573 of 4,408 FDNY EMS clinicians had confirmed cases of COVID-19 (rate = 130 per 1,000 persons), compared to 1,198 cases among the 11,230 firefighters (rate = 107); this means that the relative risk was 20% higher for EMS clinicians than for firefighters [10]. During the first week of April, 24% of EMS clinicians were on sick leave, compared to 17% of FDNY firefighters and 17% of NYPD officers [11,12].
By July 6, 2020, four FDNY EMTs, one FDNY EMS mechanic, and one NYC hospital-ambulance-based 911 paramedic had died from the virus [13]. By Sept. 8, 2020, eight EMS personnel in New York State had died from COVID-19 [14]. One FDNY EMS clinician stricken by the virus spent 44 days in the intensive care unit and is still struggling to recuperate [15]. Another was intubated and placed on a ventilator [16]. Three FDNY EMS clinicians in NYC have died by suicide since April [17].
Reports in the wake of COVID-19 indicate that EMS clinicians are retiring and resigning due to the strains of the pandemic coupled with the high risks and low pay of the job [18,19]. The response to addressing these problems has been slow in coming. One reason is because there is a paucity of data describing deaths by profession at the national level. These data are necessary for any risk mitigation planning.
Determining the COVID-19 risks to EMS
The analysis of existing data described here can help demonstrate the scope of the problem and points to areas that need to be immediately addressed. Hopefully, at some point in the near future, there will be a central site that will list all the professionals who have fallen during the pandemic. In the meantime, there is no uniform reporting of cases or fatalities by occupational group, nor is there one source for all occupational fatalities.
Thus, our objectives in this report is to describe what is known about the COVID-19 related mortality for EMS clinicians and to determine how the risk of COVID-19 related fatality among EMS clinicians compares to the risk for firefighters, police, nurses and physicians.
In order to meet those objectives, we used the most reliable data from sources available at the time of this study.
For EMS clinicians, we used the reports of EMS line-of-duty deaths published by EMS1. For fire and police, we used the reports from FireRescue1 and Police1.
Fatalities among nurses was posted by National Nurses United [20]. For physicians, we used a Sept. 9, 2020 report published in “The Guardian” [21]. For the total number of individuals per profession in the U.S., we used the 2020 U.S. Bureau of Labor Statistics, Occupational Handbook [22]. Calculations were made using a formula of the number of fatal cases divided by the total number of people in the profession, multiplied by 100,000 to get the number of cases per 100,000 people in each profession.
Examining the data on EMS deaths from COVID-19
As of Sept. 8, 2020, EMS1 listed 36 EMS clinicians who had died from COVID-19 between March and early September 2020 [14]. Thirty-five of the victims were male. Of the 36, 21 death notices included the age of the victim. Chart 1 shows the age distribution.
Chart 1. Age distribution of EMS clinicians who died from COVID-19. (N = 21)
The date of death is listed for all 36 victims. Chart 2 shows the distribution of cases by month, with April exhibiting the highest number. Note that President Trump declared the COVID-19 pandemic a national emergency on Mar. 13, 2020. On Apr. 3, 2020, the CDC recommended the use of face masks. On Apr. 7, 2020, 2,000 COVID-19 deaths were reported by Johns Hopkins University. By Apr. 14, 2020, more than 23,000 Americans had died of the virus.
Chart 2. EMS clinicians COVID-19 fatalities by month of death in 2020. (N = 36)
The 36 victims came from 11 states. Figure 1 shows the distribution of states. Thirty-six percent of the EMS clinicians were from New Jersey and 22% from New York. It should be noted that although we expect that most of these victims died in their home states, at least one Colorado EMS clinician died while on the FEMA national ambulance contract (NAC) deployment to New York City under the National Response Framework Emergency Support Function #8 Public Health and Medical Services [23].
Figure 1. Distribution of EMS COVID-19 fatalities by the home state of the victim.
Using the reports for COVID-19 related fatalities for firefighters (N=44), police (N=100), nurses (N=167) and physicians (N=25), we used the formula ((cases/population)*100,000) to compute the number of cases per 100,000 persons [20,21,24,25]. Chart 3 shows the number of fatalities per 100,000 persons in each of the professions.
Chart 3. COVID-19 deaths per 100,000 persons for EMS, fire, police, nurses and physicians in the U.S.
The four COVID-19 fatal cases among the 4,408 FDNY EMS clinicians is equivalent to 91 fatalities per 100,000 persons. As of Sept. 20, 2020, there were 204,118 COVID-19 deaths in the U.S.; the number of deaths per 100,000 U.S. population is 62 [26].
Long-term consequences of COVID-19 infection
From the data we collected, it is evident EMS personnel are at a higher risk of dying from COVID-19 than other healthcare or emergency services professionals. For example, we estimate the number of EMS personnel COVID-19 related deaths is about three times higher than nurses and about five times higher than physicians. Thus, being part of the far forward front line has had undue consequences. Keep in mind, too, that in addition to the sources cited here, there are other attempts to track COVID-19 related fatalities among healthcare workers, but identifying EMS personnel among the casualties is not possible.
Medscape has collected the names of over 1,800 deceased healthcare workers from 64 countries [27]. The list was created by voluntary submissions from family, friends and coworkers of the deceased. Among the list are about 100 individuals with EMS-related descriptors, 447 who are described as a nurse and 163 described as a physician.
We believe the EMS data currently available represents only the tip of the iceberg. We do not know the actual number of EMS personnel who have died from COVID-19 and we do not know about the long-term consequences of the illness amongst those who survived. Almost 20 years after the September 11 attacks in the U.S., we still have EMS personnel reporting long-term health problems that range from depression to cancer [28]. We have less than one year of experience with COVID-19, yet scientific and anecdotal reports of “long haulers” present a bleak and dismal health outlook for those who have recovered. COVID-19 survivors may suffer further from myocarditis, hypercoagulopathy and chronic respiratory impairment [29-31].
Another horrific COVID-19 related outcome has been suicide. Three deaths by suicide of FDNY EMS clinicians this year are distressing reminders of this hazard [17,32,33]. The United Nations wrote an urgent report noting the need for immediate action to address mental health emergencies associated with the pandemic. Of particular concern was the intense effects on “frontline healthcare workers and first responders” [34]. Articles have also noted the high risks of mental health emergencies among front-line health workers, and reports have documented that EMS clinicians are feeling overwhelmed and abandoned [35,36].
Precise fatality counts are further complicated as some fire departments in the U.S. provide some level of EMS service. Therefore, firefighters providing EMS services who died from COVID-19 might be listed as firefighter fatalities and EMS clinicians who are employed by a fire department might also be listed as firefighter fatalities. Among the 36 individuals listed on the EMS line-of-duty deaths page, seven had a word in their description that was associated with firefighting. Among the 44 deaths listed as firefighters, 10 had EMS related words in their descriptors (e.g., that the deceased was an EMT).
Mitigating the risk of COVID-19 to EMS clinicians
The COVID-19 risks EMS personnel face can and must be mitigated. We cannot wait any longer for all the data on deaths and illness to tell us there is a problem, because the data are not currently being adequately collected on a national level. One of the first steps is to take action to assess the problem (do a scene assessment).
In order to do that, we need a system capable of tracking adverse outcomes, such as injuries, fatalities and pandemic-related events. Beyond tracking fatalities, a centralized system should also track COVID-19 related illnesses, test results, days of lost work and other critical information, such as the availability of PPE for EMS clinicians.
We have not begun to measure the long term COVID-19 health effects nor, more importantly what it will do to the healthcare providers who are affected and what the impacts are on the workforce moving forward. We cannot begin to quantify the magnitude of this incident without a uniform reporting format and the ability of every community in the U.S. to report information on EMS clinician health into a centralized database. The processes critical to setting this up now are crucial for those affected by COVID-19 and will be essential for future pandemics. A federal agency, perhaps NIOSH, must be charged with documenting and publishing the risks to the workforce.
Second, EMS clinicians need the proper tools to do their job and to do it safely. Throughout the pandemic, there were numerous reports of EMS clinicians not having sufficient supplies of N95 masks and protective gear to protect them on calls [2-4]. The responsibility for ensuring a safe response clearly falls on the employer and the system, rather than forcing EMS clinicians to make the choice between helping others and putting themselves, their patients, their coworkers and even their families at risk [37]. An earlier version of OSHA guidance from the United States Department of Labor stated, “Healthcare workers must use proper PPE when exposed to a patient with confirmed/ suspected COVID-19 or other sources of COVID-19.” The OSHA list of required PPE included “disposable N95 or better respirators” [38].
Finally, at the clinician level, we should continually remind ourselves of the importance of straightforward known effective actions, such as practicing social-distancing, frequent hand-washing and wearing appropriate PPE – not only on calls – but also during any time you are in close contact with anyone not in your immediate family. These are our three most powerful tools for protecting ourselves, and protecting our coworkers, our patients and our families.
Capacity, support and ongoing training
Improving EMS safety and protecting employee health ultimately requires making improvements to the system, using lessons learned from around the world to continually improve pandemic-related communications and operating procedures.
System improvement also means ensuring that the system is adequately funded. Current funding models, including inadequate reimbursement from Medicare and Medicaid, have left the system, and the EMS clinicians, exposed to unreasonable dangers.
Funding is needed to provide EMS clinicians professional salaries and benefits, and to have systems in place that ensure the safety of personnel. Adequate funding is also needed to prepare for disasters, including creating adequate surge capacity, providing adequate support systems and offering sufficient ongoing training.
The available data reported here demonstrate the increased COVID-19 fatality risks among EMS clinicians who have been operating on the far-forward front lines of the pandemic. Both the system and the personnel need immediate support to continue this critical life-saving work.
ABOUT THE AUTHORS
Brian J. Maguire, Dr.PH, MSA, EMT-P
Dr. Brian Maguire began his career as a New York City paramedic. He went on to achieve a doctoral degree in public health and was one of the first paramedics in the world to be appointed as a university professor. He is a Senior Fulbright Scholar and an adjunct professor at both Central Queensland University in Australia and Mitchell College in Connecticut. Brian has been one of the most published researchers in the world in the area of paramedic safety. Dr. Maguire now works as an epidemiologist for Leidos in Connecticut, where his work is focused on improving occupational health and safety for the U.S. military.
Barbara J. O’Neill, PhD, RN
Dr. O’Neill is an associate clinical professor and Urban Service Track coordinator at the University of Connecticut School of Nursing. Her research includes studies on violence against paramedics.
Scot Phelps, JD, MPH, Paramedic
Scot Phelps is a paramedic and paramedic educator whose previous positions include New Jersey State EMS director, assistant commissioner of health for Emergency Management for the City of New York, associate professor of public health at Southern Connecticut State University, assistant professor of public administration at Metropolitan College, and assistant professor of emergency medicine at the George Washington University School of Medicine.
Paul Maniscalco, PhD(c), MPA, MS, EMT/P, LP
Paul M. Maniscalco has over 40 years of public safety and emergency management response, supervisory, management and executive service and presently serves as a senior executive consultant to several governmental bodies and private sector organizations. Previously he has held an academic appointment as lead research scientist and principal investigator with The George Washington University – Office of Homeland Security-Center for Emergency Preparedness and Resilience and also served as a faculty member and subject matter expert to the Louisiana State University-National Center for Biomedical Research & Training-Academy of Counter-Terrorism Education. Maniscalco is president emeritus of the International Association of Emergency Medical Service Chiefs and is also a former president of the National Association of Emergency Medical Technicians. He worked for over 20 years in the New York City Emergency Medical Services as a deputy chief, instructor and paramedic.
Daniel R. Gerard, MS, RN, NRP
Daniel Gerard is the EMS coordinator for the City of Alameda FD and serves as the Vice President of the International Association of EMS Chiefs (IAEMSC). He is currently working on his doctorate. He is a recognized expert in EMS system delivery and design, EMS/health service integration, and service delivery models for out of hospital care. Gerard has worked with the Centers for Medicare and Medicaid Services on EMS integration into accountable care organizations.
Kathleen A. Handal, MD
Dr. Handal is an emergency medicine physician, educator, author and podcaster with an extensive background in all aspects of EMS worldwide.
Author’s note: The views expressed in this paper are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government. The authors have no conflicts of interest. There was no funding for this project.
References
1. Maguire BJ PS, Maniscalco PM, Gerard DR, Gienapp A, Handal KA, O’Neill BJ. Paramedicine Strategic Planning: Preparing the ‘far forward’ front lines for the second COVID-19 wave. JEMS. May 14, 2020. Available at: https://www.jems.com/2020/05/14/paramedicine-strategic-planning/. Accessed 14 May 20.
2. Moghe S. EMS workers expected to keep working after coronavirus exposure. CNN. March 21, 2020. Available at: https://www.cnn.com/2020/03/21/us/ems-workers-covid-19-exposure/index.html. Accessed: 26 Jul 20.
3. Watkins A. N.Y.C.’s 911 System Is Overwhelmed. ‘I’m Terrified,’ a Paramedic Says. NY Times. March 28, 2020. Available at: https://www.nytimes.com/2020/03/28/nyregion/nyc-coronavirus-ems.html. Accessed: 26 Jul 20.
4. Pilgrim E, O’Brien K, Margolin J, Francis E. EMS on the front lines dealing with ‘madness,’ sleeping in their cars to avoid infecting their families. ABC News. March 31, 2020. Available at: https://abcnews.go.com/Health/ems-front-lines-dealing-madness-sleeping-cars-avoid/story?id=69901930. Accessed: 26 Jul 20.
5. McCarthy N. EMTs: Overlooked and Underpaid During Pandemic. Nyack News. August 15, 2020. Available at: https://nyacknewsandviews.com/2020/08/overlooked-and-underpaid-pandemic-illuminates-hardships-of-emt-work-2/. Accessed: 16 Aug 20.
6. Staff. The federal government’s supply of masks, gloves and gowns is nearly gone. NY Times. Apr 1, 2020. Available at: https://www.nytimes.com/2020/04/01/world/coronavirus-live-news-updates.html?searchResultPosition=2#link-d414cf4. Accessed: 3 Apr 20.
7. Wedell K. After Six Months of Coronavirus, PPE Still Lacking. EMS World. July 1, 2020. Available at: https://www.emsworld.com/news/1224569/after-six-months-coronavirus-ppe-still-lacking. Accessed 13 Sep 20.
8. 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.
9. Sepkowitz KA, Eisenberg L. Occupational deaths among healthcare workers. Emerg Infect Dis. 2005;11(7):1003.
10. Prezant DJ Z-OR, Schwartz T, et al,. Medical Leave Associated With COVID-19 Among Emergency Medical System Responders and Firefighters in New York City. JAMA-Open. 2020;3(7):e2016094.
11. Maisel T. Hundreds of New York City firefighters, EMTs out sick as coronavirus cases rise. QNS. April 4, 2020. Available at: https://qns.com/story/2020/04/04/hundreds-of-new-york-city-firefighters-emts-out-sick-as-coronavirus-cases-rise/. Accessed: 14 Jul 20.
12. Southall A. Virus’s Toll on N.Y. Police: 1 in 6 Officers Is Out Sick. NY Times. April 3, 2020. Available at: https://www.nytimes.com/2020/04/03/nyregion/coronavirus-nypd.html. Accessed: 26 Jul 20.
13. Staff. COVID-19: EMS deaths. Tracking the coronavirus-related deaths of EMTs and paramedics. EMS1. July 6, 2020. Available at: https://www.ems1.com/coronavirus-covid-19/articles/covid-19-ems-deaths-jk5zWFziwYVYUaM4/. Accessed 12 Jul 20.
14. Staff. COVID-19: EMS deaths. Tracking the coronavirus-related deaths of EMTs and paramedics. EMS1. Sep 8, 2020. Available at: https://www.ems1.com/coronavirus-covid-19/articles/covid-19-ems-deaths-jk5zWFziwYVYUaM4/. Accessed 13 Sep 20.
15. Bernstein L. A long road home. Hugo Sosa survived the ICU. But for coronavirus patients like him, that’s just the start of recovery. Washington Post. June 9, 2020. Available at: https://www.washingtonpost.com/health/2020/06/09/coronavirus-ventilator-rehabilitation/?arc404=true. Accessed: 26 Jul 20.
16. Goldberg N. NYC paramedic hospitalized with coronavirus sedated, breathing with ventilator as condition worsens, family says. NY Daily News. March 24, 2020. Available at: https://www.nydailynews.com/coronavirus/ny-coronavirus-fdny-paramedic-young-virus-20200324-74tadm2skjb7zeuwb2xhwvtfoi-story.html. Accessed: 26 Jul 20.
17. Barone V, Edelman S. Off-duty FDNY EMT commits suicide, the third to take their life this year. NY Post. July 17, 2020. Available at: https://nypost.com/2020/07/17/off-duty-fdny-emt-commits-suicide/. Accessed: 20 Jul 20.
18. Cerullo M. Emergency medical technicians are quitting their jobs — COVID-19 makes it too dangerous. CBS News. August 13, 2020. Available at: https://www.cbsnews.com/news/ems-workers-retiring-higher-rates-coronavirus-pandemic/. Accessed: 16 Aug 20.
19. Breen V. Paramedics and EMTs Under Staggering Stress in Era of Disease and Disruption. The City. July 28, 2020. Available at: https://www.thecity.nyc/2020/7/28/21345899/paramedics-and-emts-under-staggering-stress. Accessed: 29 Jul 20.
20. Staff. Honor Fallen Nurses: Honoring Nurses Lost In The Fight Against COVID-19. National Nurses United. https://honorfallennurses.org/nurses-weve-lost/. Published 2020. Accessed 13 Sep., 2020.
21. Staff. Lost on the frontline. Hundreds of US healthcare workers have died fighting Covid-19. We count them and investigate why. The Guardian. September 9, 2020. Available at: https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database. Accessed: 13 Sep 20.
22. U.S. Bureau of Labor Statistics. Occupational Handbook. https://www.bls.gov/ooh/. Published 2020. Accessed Sep 14.
23. Gross J. Colorado Paramedic Who Came to Help New York Dies From Covid-19. NY Times. May 2, 2020. Available at: https://www.nytimes.com/2020/05/02/nyregion/paramedic-paul-cary-coronavirus-nyc.html. Accessed: 26 Jul 20.
24. Staff. COVID-19: Firefighter deaths. Tracking the coronavirus-related deaths of U.S. firefighters. FireRescue1. Aug. 5, 2020. Available at: https://www.firerescue1.com/coronavirus-covid-19/articles/covid-19-firefighter-deaths-la0l8Hf2UzjRdTPC/. Accessed 13 Sep 20.
25. Staff. COVID-19: Law enforcement deaths. Tracking the coronavirus-related deaths of U.S. police officers and other LE personnel. Police1. Sep 11, 2020. Available at: https://www.police1.com/coronavirus-covid-19/articles/covid-19-law-enforcement-deaths-3ftkdPnVffq55iHU/. Accessed 13 Sep 20.
26. U.S. Centers for Disease Control and Prevention. United States COVID-19 Cases and Deaths by State. September 15, 2020. Available at: https://covid.cdc.gov/covid-data-tracker/#cases_totaldeaths. Accessed 15 Sep 20.
27. Staff. In Memoriam: Healthcare Workers Who Have Died of COVID-19. Medscape. https://www.medscape.com/viewarticle/927976#B. Published 2020. Updated 17 Sep 20. Accessed 20 Sep 20.
28. Yip J, Webber MP, Zeig‐Owens R, et al. FDNY and 9/11: Clinical services and health outcomes in World Trade Center‐exposed firefighters and EMS workers from 2001 to 2016. Am J Ind Med. 2016;59(9):695-708.
29. Hékimian G, Kerneis M, Zeitouni M, et al. COVID-19 acute myocarditis and Multisystem Inflammatory Syndrome in adult intensive and cardiac care units. Chest. 2020.
30. Jain U. Effect of COVID-19 on the Organs. Cureus. 2020;12(8).
31. Syrek R. Trending Clinical Topic: Chronic COVID. Medscape. June 26, 2020. Available at: https://reference.medscape.com/viewarticle/931942 Accessed 20 Sep 20.
32. Moynihan E, Otis GA, Burke K, Tracy T. ‘He was an amazing son': Off-duty FDNY EMS lieutenant takes his own life, second EMS suicide this year. NY Daily News. June 20, 2020. Available at: https://www.nydailynews.com/new-york/nyc-crime/ny-off-duty-fdny-ems-lieutenant-suicide-20200620-f5vmh3sdobemrcrtzo5uwqffty-story.html. Accessed: 13 July 20.
33. Edelman S, Moore T, Narizhnaya K, Balsamini D. EMT John Mondello kills himself after less than three months on the job. NY Post. April 25, 2020. Available at: https://nypost.com/2020/04/25/nyc-emt-commits-suicide-with-gun-belonging-to-his-dad/. Accessed: 13 Jul 20.
34. Policy Brief: COVID-19 and the Need for Action on Mental Health. United Nations. 13 May, 2020. Available at: https://www.un.org/sites/un2.un.org/files/un_policy_brief-covid_and_mental_health_final.pdf. Accessed 31 Jul 20.
35. Rossi R, Socci V, Pacitti F, et al. Mental health outcomes among front and second line health workers associated with the COVID-19 pandemic in Italy. medRxiv. 2020.
36. Hoffman J. ‘I Can’t Turn My Brain Off': PTSD and Burnout Threaten Medical Workers. NY Times. May 16, 2020. Available at: https://www.nytimes.com/2020/05/16/health/coronavirus-ptsd-medical-workers.html?searchResultPosition=2. Accessed: 31 Jul 20.
37. U.S. Department of Labor. Occupational Safety and Health Administration. Personal Protective Equipment. Occupational Safety and Health Standards. Part 1910.134. Available at: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134. Accessed 22 Sep 20.
38. U.S. Centers for Disease Control and Prevention. COVID-19. Healthcare workers and employers. 2020. Available at: https://www.osha.gov/SLTC/covid-19/controlprevention.html#healthcare. Accessed 4 Apr 20.