Even though Prehospital acute care exists for almost a century, Emergency Medical Services systems (EMS) are considered a relative new addition to the Healthcare systems. Thus, the importance of copying with emergency medical services staff health problems is something that became obvious only the recent 15 years. Yet, it should be considered a fundamental organizational issue for every EMS system.
Emergency medical systems are considered a relative new addition to the Healthcare systems. Prehospital acute care history goes back to 17th century, yet the first Emergency Medical Service (EMS) system is formed in the USA, only in 19731-2. Legislation about EMS systems in the majority of European countries was enacted in the 1990s and 2000s3. However, even now (2018), the state of EMS still varies drastically from developed to developing countries4. Thus, it is no surprise that copying with emergency medical services staff health problems is something that became obvious only the recent 15 years. Yet, it has emerged as one the most serious problem that EMS systems are facing today.
The magnitude of the problem.
EMS staff is continuously exposed to stressful and dangerous conditions. The pressure comes both from the working environment (e.g. crime or accidents’ scenes) and the nature of the cases paramedics are handling (medical emergencies).
USA studies report EMS fatality rate of 7.0 per 100.000 full-time equivalents (FTE) EMS workers (95 per cent confidence interval CI:4.7-9.3), while the average for all workers is 4.0 and 6.1 for firefighters for the same study period (4 years)5.Other studies raise the number to 12.7 fatalities annually6. Relevant Australian reports mention even higher numbers (9.3 fatality rate) in some areas7.
The data for non-fatal injuries reveal an even more dramatic image: EMS personnel rate of injury in USA is 3 time higher than the national average for all occupations: 349.9 cases of lost of workdays per 100.000 FTE8. Data available from other Poland report an annual accident rate of 5.34/100 paramedics9. The majority of them are related to weight lifting and transportation; yet cases of assault or violent crime are not absent too10. In fact, violence against EMS personnel is more common than once though and violence-related injuries are 22 times higher than the national (US data) average10.
Contact with a variety of stressor factors in a day-to-day basis, poses also a threat to mental and psychological health of EMS workers. Even though adequate data are still missing, the available published studies shows a devastating picture. EMS providers’ rates who contemplated suicide were 10 times higher than the average population, whereas the percentage difference of EMS providers who attempted suicide to reported percentage of general population is even greater11. Post Traumatic Stress Disorders (PSTD) and depression are an evenly serious problem. Different studies from several countries and EMS systems report different figures: yet, they all are high. Estimates of prevalence of PTSD range from 20 per cent in USA up to 94 per cent in Iran12-13. A recent meta-analysis of 27 studies (30.878 ambulance personnel) report 11 per cent rate for PTSD, 15 per cent for depression, 15 per cent for anxiety, and 27 per cent for general psychological distress14. The already complicated situation is even more perplexed with the high estimated prevalence of burnout among EMS professionals15. The latter affects negatively not only EMS workers’ health status and wellbeing, but also the available EMS workface.
Scenario in Greece
The Greek EMS system was founded in 1986 with the foundation of the National Center of Emergency Care (NCEC or ‘????’); which is entirely funding by state budget. NCEC centrals are located in Athens, yet the country is divided in 12 independent branches; each of them with its own dispatch center. Ambulance and DCs are staffed with EMTs, while EMS physicians are also engaged in prehospital acute care both as DC coordinators or Mobile Intensive Care Units physicians at the scene16. There are over 3600 EMTs and 100 EMS physicians in the system. Yet, only recently (2015), occupational medical specialists were engaged with the surveillance of the staff. Data about staff health problems are scarce and they are coming mainly from regional studies. Nevertheless, reported problems are in accordance with the aforementioned literature17-18. Unfortunately, the impact of economic crisis and the refugees’ inflow crisis that Greece had to cope with the last years has not been yet fully evaluated. However, it will not be a surprise if factors such constantly increasing population needs, underfunding of public sector, unevenly distribution of health recourses, medical understaffing and “brain drain” phenomenon19 aggravate the situation for EMS providers.
Most of the EMS providers around the world have little or no training in copying with the aforementioned problems, and especially with emotional and psychological effects of traumatic incidents. Most of them rely on colleagues and family for support20, while even in the systems where Employee Assistance Programs (EAP) or special Critical Incident Stress Debriefing (CISD) team exist, the majority of EMS staff are not satisfied with the EMS Mental Health services provided by their agency21.
The condition in the Greek EMS is no difference. There is no training for copying emotionally with critical incidents (e.g. a child’s death) and there is little training about injuries prevention. Underfunding of the system due to economic crisis resulted in materials and equipment overuse; creating an even more dangerous working frame. At the same time, the system was not flexible enough considering caring staff with health or mental problems. Usually, an internal rotation within the agency is taken place (for example EMS with somatic injuries are moved to DCs, and those with psychological distress disorders are assigned to post with less responsibilities), but this is not always enough.
In order to copy with the problem, we need to properly record it and understand it. Local and national databases should be established in order to collect EMS workface data. In older systems, this has been already suggested20, yet this an essential issue for any EMS system. The character and the diversities of the EMS systems around the world pose a additional challenge to every Healthcare administration. Each database should, on one hand include, unique features of the system for the given area/country and on the other hand, be uniform enough so that safe conclusions could be made.
Further academic research is also necessary to fully comprehend the problem. Team approach by EMS personnel, physicians, nurses, local officers, engineers and managers is needed in order to evaluate every aspect of prehospital acute care.
Education about personal safety awareness and copying mechanisms of critical incidents are essential for any new or experienced EMS staff. This education should start from day one in the EMS academies.
EAP, CISD teams and other possible care support programs for EMS professional is an aspect that every comprehensive EMS system should establish.
Maintenance of equipment and technological improvement is equally important. From specialized patient chairs in ambulance vehicles to GIS communication and software –assisted dispatch triage, EMS Managers should remember that all of that “inclusions” are aiming not only the consumers (patients) but also the providers.
Finally, modification, updating, enactment and enforcement of policy and proper legislation measure would create a work system safer for its workers, a human management system flexible enough to meet and predict human resources needs. For example, such an update in internal regulation of Greek NCEC is planned till the end of 2018.
EMS systems should care both for the care seekers and the caregivers. The latter creates a whole new perspective for the management of available human resources. Strategies to cope with the issues that arise, as time passes and EMS providers are transforming from … heroes to humans with problems, may be the key for a more efficient EMS system.
1. Emergency Medical Services Systems Development Act of 1973. Hearings. 93rd Congress, 1st Session, on §504.and §654. Washington, DC: United States Congress, Senate, Committee on Labor and Public Welfare, Subcommittee on Health; 1973:691–694.
2. Shah MN. The Formation of the Emergency Medical Services System. Am J Public Health. 2006 March; 96(3): 414–423. doi: 10.2105/AJPH.2004.048793
3. Emergency Medical Services Systems in the European Union. WHO Regional office of Europe 2008. Available form: https://www.google.com/search?q=+EMS+systems+in+Europe&ie=utf-8&oe=utf-8&client=firefox-b#
4. Prasanthi P. Emergency Services in India. Asian Healthcare & Management.
Available from: https://www.asianhhm.com/healthcare-management/emergency-services-india
5. Reichard A, March S, Moore P, Fatal and nonfatal injuries among emergency medical technicians and paramedics. Prehosp. Emerg. Care 2011; 15(4):511-517.
6. Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupatiional fatalities in emergency medical services.:a hidden crisis. Am Emerg Med 2002;40(6):625-32
7. Maguire BJ, O ‘Meara PF, Brightwell RF, O’ Neill BJ, Fitzgerald GJ. Occupational injury risk among Australian paramedics. Med J Aust. 2014;200(8)477-480
8. Pakowska a, Szatko F. Ulrichs M. Work-related ccidents and sharp injuries in paramedics- illustrated with an example of a multi-special hospital, located in Central Poland. Int J Environ. Res Public Health. 2017;14:901;doi:10.3390/ijerph14080901
9. Trembley A, Page D. It EMS still the most dangerous profession? JEMS 2014:39 (7): 1-4.
Available from: https://www.jems.com/articles/print/volume-39/issue-7/departements-columns/research-reviews/ems-still-most-dangerous profession.
10. Maguire BJ, O’Meara PF, O’ Neill BJ, Brigthwell R. Violence against emergency medical services personnel: A systematic review of the literature. Am J Ind. Med. 2018; 61:167-180. doi:10.1002/ajim.22797
11. Newland C, Barber E, Rose M, Young A. Critical stress: survey reveals alarming rates of EMS provider stress and thoughts of suicide. JEMS 2015; 40(10):30-34.
12. Regehr C, Alden LE, Fullerton LM. Exposure to human tragedy, empathy, and trauma in amblance paramedics. Am J Otrhopsychiatry 2002; 72:505-513.
13. Iranmanesh S, Tirgari B. Bardsiri HS. Post-traumatic stress disorder among paramedic and hospital emergency personnel in south Iran. World J. Emerg. Med. 2013;4(1):26-31.
14. Petrie K, Milligan –Saville J, Gayed A, Deady M, Phelps A, Dell L, Forbes D, Calvo RA, Glozier N, Harvey SB. Prevalence of PTSD and common mental disorders amongst ambulance personnel: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol 2018. https://doi.org/10.1007/s00127-018-1539-5
15. Crowe RP, Bower JK, Cash RE, Panchal AR, Rodriguez SA, Olivo-Marton SE. Association of Burnout with Workforce-Reducing Factors among EMS Professionals. Prehosp Emerg. Care 2017; 22(2):229-236. doi:10.1080/10903127.2017.1356411
16. Aslanidis T. Emergency pre-hospital challenges: Greece. ICU Management & Practice 2018; 18(2): 106-108.
17. Katsavouni F. Psychosomatic effects on professionals working for the protection and the rescue of citizens. 2014. School of Physical Education and Sport Science. Democritus University of Thrace Thesis No 35103. Available from: http://hdl.handle.net/10442/hedi/35103
18. Frajiou A. Muskuloskeletal disorders among Greek personnel ambulance in Emergency Prehospital Care. School of Medicine, School of Health Sciences University of Thessaly 2013. Available from: ir.lib.uth.gr/bitstream/handle/11615/44063/11978.pdf?sequence=1&isAllowed=y
19. OECD/European Observatory on Health Systems and Policies (2017), Greece: Country Health Profile 2017, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels. Available from: http://dx.doi.org/10.1787/9789264283404-en
20. Minnie L, Goodman S, Wallis L. Expose to daily trauma: The experiences and copying mechanism of Emergency Medical personnel. A cross-sectional study. African J Em Med. 2015; 5(1):12-18. doi:10.1016/j.afjem.2014.10.010
21. National EMS Management Association. Mental Health and Stress in Emergency Medical Services. 2016.
Available from: www.nemsa.org/images/pdfs/Mental_Health_and_Stress.pdf
22. Goodwin J, Lane P, Heeden G, Britton S, David T, Dunham C, Heath R, Kaul K, Slattery J, White J. NAEMT National Survey on EMS Mental Health 2016. Available from: https://www.naemt.org/initiatives/initiatives-landing-page.