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Evaluation of the injury profile of personnel in a busy urban EMS system
Evaluationof the InjuryProfile of Personnelin a Busy UrbanEMS System PAUL T. HOGYA, MD,* LLOYD ELLIS, MDT The occupational injury profile of emergency medical technicians (EMT@ and paramedics is not well described. We retrospectively studied 264 injuries over a 3.5year period in a busy urban EMS system. low back strain was the most common injury &I/264,36%), with EMTs suffering a siuniilcantly hipher injury rate than paramedics (0.33 Y 0.17 injuries/ person-years at risk, P = .03). Lifting caused 68B3 (62.4%) of back injuries, and most occurred at the scene to which personnel were dispatched (66/93, 62.4%). The back injuries were recurrent in 31% of personnel. The data showed trends toward higher overall injury rates among EMT8 compared wlth paramedics (0.83 v 0.65, P = 0.057) and women compared with men (0.86 Y 0.60, P = 0.11). There was a significantly higher injury rate amon personnel less than 30 years of age compared with those 30 years or older (0.66 v 0.39, P = 0.01). Over 25% of the personnel injured had more than one Injury per year. There wes no correlation between injury rates and )ob experience. Approximately 96 Injuries accounted for 461 compensation days with low back strain the cause of 375 days (78%). Our ilndinus suppest a hiph incidence ol occupational injury in EMS personnel with EMTs and persons under 30 years of age at hi6her risk. Guidelines for prevention pm9rams are su66ested. (Am J Emerg Med 1990;8:306-311. 0 1996 by W.9. Saunders Company.)
Injuries to fire fighters are well described and documented in the literature.le3 Emergency medical technicians (EMTs) and paramedics are exposed to similar dangers, but little is written about their injury profile.4 As emergency medical services (EMS) expand across the United States this data has a wide range of potential effects including (1) the adverse effects on the individual rescue workers involved, (2) the explicit public costs, including compensation for the cost of medical care and for wages during recuperation with the potential for lifetime compensation for a permanently disabling injury, and (3) the implicit public costs of (A) the rescue units out of service because of injured personnel, (B) the erosive effect on performance because of the potential for injury, (C) the high turnover rate of personnel, and (D) the difficulty of developing a career orientation when personnel are unlikely to complete 10 years in a dangerous occupation. We chose to examine the injury protile of an urban EMS system in order to identify the scope of the problem and potential risk factors for injury such as age, sex, and level of experience and training. We used this information to develop guidelines for an injury prevention program. From the ‘University of Pittsburgh Affiliated Residency in Emergency Medicine, Pittsburgh, PA, and the TDepartments of Emergency Medicine and Surgery, Case Western Reserve University School of Medicine, Cleveland, OH. Manuscript received July 3, 1989; revision accepted October 30, 1989. Address reprint requests to Dr Hogya: 800 Forest Ave, Zanesville, OH 43701. Key Words: Injuries, EMTs, paramedics, low back strain. 0 1990 by W.8. Saunders Company. 07356757/90/0804-0009$5.00/O 308
METHODS We retrospectively studied 254 injuries over a 3Y’-year period in a busy urban EMS. The EMS system averaged 65,280 total calls per year during the study period. We defined the type and frequency of injuries to EMTs and paramedics. Furthermore, we classified the causes in order to define risk factors that might be helpful in the design of an injury prevention program. The duty records and injury report sheets of the EMS were reviewed from January, 1980 to June, 1983. In 1980, a strict policy of reporting any job-related injury was instituted. A detailed report sheet was required for each incident. All injuries were diagnosed by an emergency physician from one of the system hospitals or by a private physician at or near the time of the injury. The reports were reviewed by the assistant director of the EMS system, and a decision was made regarding compensation time. Updated physician reports were required for more serious or chronic injuries. Using the International Classification of Diseases, adapted (ICDA)-8th revision,’ injuries were identified, abstracted, coded, and summarized. From each retrieved record, information was recorded on the demographic characteristics (age, sex, EMT or paramedic level training, and years of experience), time and locale of injury, nature and cause of injury, and total compensation days as a result of the injury. The cause and type of injury were coded using the E code categories from the ICDA-8th revision.5 All coding was performed by a single investigator. When a problem was encountered with coding, it was resolved by an independent epidemiologist. Data were analyzed between groups using the two-tailed Wilcoxon Rank-Sum test, and the a error was set at 0.05. A standard statistical software package (Epistat, 1986, Epistat services, Richardson, TX) was used for data analysis. RESULTS A total of 254 injuries were included during this period from January, 1980 to June, 1983. The number of EMTs and paramedics fluctuated during that time, but there remained a male to female ratio of 3.7:1. The mean age was 28 years with a range of 19 to 40 years. A total of 93 (36%) low back strains were coded, making it the most commonly reported injury. The remaining injuries were generally of a minor nature (Table 1). There were several significant injuries of low frequency (Table 2). A more detailed evaluation of low back strains showed a trend toward a higher injury rate in women compared with men (0.43 v 0.23 injuries/person-years at risk, P = .ll). Emergency medical technicians had a significantly higher rate of back injuries at a rate of 0.33 injuries/person-years at risk compared with a rate of 0.17 among paramedics (P = 0.03). There was no correlation between age or years of
HOGYA AND ELLIS m INJURY PROFILE OF EMS SYSTEM
369
Table 1. Description of Injuries
Table 3. Causes of Back Injury
Injury
ICDA
Back Strain Nonspecific Contusions Toxic Effect of Gases Ankle Sprains Head/Neck Contusions Other Strains Lower Extremity Contusions Trunk Contusions Finger Contusions Shoulder/Arm Sprains Open Finger Wounds Wrist/Hand Sprains Shoulder/Arm Contusions Other (Unclassified)
846 929 987 845 920 847 927 922 928 840 883 842 923 999
Total(%)
Cause
93(36) 18(7) 15(6) 12(5) ll(4) 16(4) 9(4) 9(4) 8(3) 6(3) 6(3) 6(3) 4(2) 21(8)
Lifting Fall on Same Level With Patient Motor Vehicle Accident Fall on Same Level Without Patient Other
experience and a higher rate of back injury. The lifting of patients or equipment was responsible for 58 (62.4%) of low back strains (Table 3). The highest number of back injuries (58/93,62.4%) occurred at the scene of the response. A total of 31% of the back injuries were recurrent injuries. The injury rate from 1980 to 1983 among EMTs ranged from 0.70 to 1.1 [mean = 0.831 and the paramedic rate ranged from 0.40 to 0.70 [mean = 0.551. There was a trend toward a higher injury rate among EMTs compared with paramedics (P = .057). The injury rate among men ranged from 0.50 to 0.70 [mean = 0.501 compared with a rate among women of 0.60 to 1.4 [mean = 0.861. There was a trend toward a higher injury rate among women compared with men (P = .ll). There was a significantly higher injury rate among personnel younger than 30 years (0.65 injuries/ person-years at risk) compared with those 30 years of age or older (0.39, P = .Ol). The causes of injury were equally distributed among lifting, falls with and without patients, assaults by patients or bystanders, and motor vehicle accidents (Table 4). The primary geographic location of injuries was the site to which the unit was dispatched, with 50% reported at a building, house, street, or fire. A total of 31% of the injuries occurred in the ambulance with 5 1% of those due to motor vehicle accidents while responding to or transporting patients (Table 5). The monthly occurrence of injury was variable, with the most reported during the month of January (12%) and the Table 2. Significant Injuries of Low Frequency Injury
ICDA
Total
Laceration of Head Open Wound of Hand Open Wound Knee/Ankle Rib Fracture Closed Head Injury Facial Fracture Fracture of Radius Fracture of Metacarpal Fracture of Patella Fracture of Ankle Dislocated Jaw Heat Injury
873 882 891 807 850 802 813 815 822 824 830 992
5 4 4 3 3 1 1 1 1 1 1 1
ICDA
Total(%)
E919
58t82.4)
E885P E812 E885 E999
13(14.0) 12(12.9) 8(8.5) 4(4.2)
least during September (6.1%). It was noted that the combined months of December, January, and February accounted for 32% of the injuries with only a total of 24. I% of the responses occurring during those months. Our data showed an equal injury pattern among the shifts with 34% of the injuries reported during the 7am to 3pm shift (32% of runs), 37% during the 3pm to llpm shift (42% of runs), and 29% during the llpm to 7am shift (26% of runs). We evaluated the injury rate of personnel based solely on their years of experience on the job and found no statistically significant increased rate of injury among less experienced personnel (Fig 1). We also studied the problem of accident-prone individuals. Over 25% of the personnel injured had more than one injury per year, although the minority were recurrences of the same injury. Nearly 7% of personnel reported more than two injuries per year. One woman, an EMT with 3 years of experience, reported six injuries over the recorded time period. Approximately 96 injuries accounted for 481 compensation days, with low back strain resulting in 375 (78.0%) days off with wages. No reported injury during this time period resulted in permanent disability.
DlSCUSSlON Emergency medical service systems employ personnel with different levels of training and experience. Recently, the focus of research has been limited to the impact of their clinical skills6p7 Unlike fire fighters, little is known about the risk of occupational injury in this group. We suspected low back strain to be a common injury considering the frequency with which personnel lift heavy paTable 4. Causes of Injury Cause Lifting Injuries Falls Falls Falls with stretcher Assaults By patients By bystanders Motor Vehicle Accidents Collisions Sudden stopping Equipment-Related Stair chairs and cots Oxygen tanks Poisoning by Gas/Vapors Smoke Inhalation Miscellaneous
ICDA
Total(%)
E919
Total(%) 93(36)
45(18) E885 E885P
30(12) 15(6)
E980 E981
30(12) t 3(5)
E812 E819-1
35(14) 3(l)
E928-2 E928-1 E878 E876-1
13(5) 3(l)
43(17)
38(15)
1W)
1O(4) 5(2) 4(2)
AMERICAN JOURNAL OF EMERGENCY MEDICINE W Volume 8, Number 4 l July 1990
310
Table 5. Geographic Location of Injuries Total(%)
Total(%)
Location
127&O)
Scene Building/House Street/Sidewalk/Alley Fire Ambulance Hospital Base Station Administrative Headquarters
89(35) 33(13) 5(2) 79(31) 28(lt)
1w 4(l)
tients and equipment, and it did account for 36% of the injuries. The importance of this injury is that it has potential for recurrence and permanent disability. Further evaluation uncovered a trend toward a higher rate of back injuries among women compared with men. Emergency medical technicians had a significantly higher rate of back injuries than paramedics. The predominant causes of injury were lifting, falls while lifting or carrying patients, and motor vehicle accidents. It was theorized that older personnel, despite increased experience, might show an increased incidence of injury because of the physical demands. Individuals over the age of 30 years had a significantly lower total injury rate than those under 30 years. It is possible that these individuals exercise more caution, both in potentially dangerous situations and routine activities, as our data show that experience did not correlate with lower injury rates. Interestingly, the job is a
Ratio (injuries/person-years
at risk)
‘I;
youthful one, with 90% of all EMTs and paramedics under 30 years of age. One might expect a higher incidence of injury during the winter months, with snow and ice making transportation hazardous. Indeed, the months of December, January, and February accounted for 34% of the total injuries, although only 24.1% of the total system responses were reported during those months. It may be helpful to reinforce safe lifting and driving exercises during that time of year in order to reduce the incidence of injuries. We evaluated injury rates among the three work shifts, suspecting individuals on certain shifts may be more vulnerable to injury. Our data tended to show an equal injury pattern among shifts. The injuries we studied commonly occurred in the field, where conditions are more unpredictable and dangerous. Over 50% were reported at the building, house, street, or fire to which they responded. This data suggests a need to address issues of scene safety. We should reevaluate current efforts in scene hazard education as it relates to EMS personnel. Perhaps a more detailed study of the common scenes encountered would show predictable pitfalls that may lead to injury. Additionally, experienced crew members, familiar with a broad range of scene scenarios, could be teamed with less experienced personnel to help them avoid potential injury situations. The data demonstrated that certain individuals were more accident prone than others. It may be efficient to target these individuals in a given system, identify individual risk factors, and provide additional training and assistance during high risk activities such as heavy lifting, driving, or working in dangerous situations (eg, fires, hazardous material incidents, multiple vehicle accidents). Occupational injuries have broad implications to an EMS system, the most important of which is lost work days. In this study, approximately 96 injuries resulted in 481 total injury days, 375 (78%) of which were due to low back strain. This data raises several questions with regard to injury prevention: Are the current training programs for all prehospital personnel adequately focusing on the importance of the proper techniques of lifting, and is adequate driver training provided in preparation for operating an ambulance? Do female personnel require extra assistance in certain situations, such as lifting heavy equipment and patients? If so, crew assignments should reflect this need. Are paramedics inherently more careful, or are they better trained in techniques of avoiding injury than EMTs?
0
0.5
1
1.6
2
2.5
3
3.5
4
4.6
5
6.6
6
Years of experience FIGURE 1. Plot of the proportion of injuriesper populationat risk versus years of experience.
The answers to these questions are elusive. Despite standardized curriculums, personnel have diverse training backgrounds that add other variables. It is important, however, for administrators of EMS systems to consider these questions as they apply to their systems. Only through more detailed research will we be able to tease out the necessary information to design effective programs of injury prevention.
HOGYA AND ELLIS m INJURY PROFILE OF EMS SYSTEM
A number of potential sources of bias were identified in this study. It is possible some injuries may have escaped detection. These were presumed to be minor in nature since no compensation time was granted, and no formal report was submitted. In addition, compensation time may have been underestimated because personnel may have used allotted sick or personal days to recuperate from an injury if compensation time had not been approved. During the evaluation or design of an EMS system, one must recognize the significant potential for occupational injury. An accurate injury reporting system identifies accidentprone personnel, insures appropriate recuperation time for deserving individuals, and assists administrators in determining the personnel required to meet the demands of a system at any point in time. This information provides a framework for programs designed to prevent injuries in EMS personnel, potentially reducing system costs and increasing job satisfaction. CONCLUSIONS Emergency medical service personnel, a group with diverse backgrounds and training, suffer a high incidence of occupational injury. This may comibute to increased system costs, job dissatisfaction, and high turnover rates. Emergency medical technicians have a significantly higher rate of back injuries than paramedics, although their overall injury
311
rates are not significantly different. Further research into better educational programs, focused on scene safety, improved lifting techniques, and advanced driver training, and targeted for populations such as EMTs and personnel under 30 years of age, are suggested to combat these occupational risks. The authors gratefully acknowledge Donald M. Yealy, MD, for his thoughtful review of the manuscript.
REFERENCES 1. Halliday WR: Back injuries in fire fighters. J Med 1979;23: 720 2. Dibbs J: Fire fighters and coronary heart disease. Circulation 1962;65:943-946 3. Loke J: Acute and chronic effects in fire fighters on pulmonary function. Chest 1960;77:369-373 4. Johnson DW, Hammond RJ, Sherman RE: Hearing in an ambulance paramedic population. Ann Emerg Med 1980;9:557561 5. National Center for Health Statistics: International Classification of Diseases, adapted, Eighth Revision. In: Vital and Health Statistics, vol 1, Tabular list, PHS Pub No. 1693, Washington, DC: NCHS, 1967 6. Dean NC, Hammond PJ, Hawker PJ: Effect of mobile paramedic units on outcome in patients with myocardial infarction. Ann Emerg Med 1988;17:1034-1041 7. Donovan PJ, Cline DM, Whitley TW, et al: Prehospital care by EMTS and EMT-Is in a rural setting: Prolongation of scene times by ALS procedures. Ann Emerg Med 1989;16:495-500
Injuries to fire fighters are well described and documented in the literature.le3 Emergency medical technicians (EMTs) and paramedics are exposed to similar dangers, but little is written about their injury profile.4 As emergency medical services (EMS) expand across the United States this data has a wide range of potential effects including (1) the adverse effects on the individual rescue workers involved, (2) the explicit public costs, including compensation for the cost of medical care and for wages during recuperation with the potential for lifetime compensation for a permanently disabling injury, and (3) the implicit public costs of (A) the rescue units out of service because of injured personnel, (B) the erosive effect on performance because of the potential for injury, (C) the high turnover rate of personnel, and (D) the difficulty of developing a career orientation when personnel are unlikely to complete 10 years in a dangerous occupation. We chose to examine the injury protile of an urban EMS system in order to identify the scope of the problem and potential risk factors for injury such as age, sex, and level of experience and training. We used this information to develop guidelines for an injury prevention program. From the ‘University of Pittsburgh Affiliated Residency in Emergency Medicine, Pittsburgh, PA, and the TDepartments of Emergency Medicine and Surgery, Case Western Reserve University School of Medicine, Cleveland, OH. Manuscript received July 3, 1989; revision accepted October 30, 1989. Address reprint requests to Dr Hogya: 800 Forest Ave, Zanesville, OH 43701. Key Words: Injuries, EMTs, paramedics, low back strain. 0 1990 by W.8. Saunders Company. 07356757/90/0804-0009$5.00/O 308
METHODS We retrospectively studied 254 injuries over a 3Y’-year period in a busy urban EMS. The EMS system averaged 65,280 total calls per year during the study period. We defined the type and frequency of injuries to EMTs and paramedics. Furthermore, we classified the causes in order to define risk factors that might be helpful in the design of an injury prevention program. The duty records and injury report sheets of the EMS were reviewed from January, 1980 to June, 1983. In 1980, a strict policy of reporting any job-related injury was instituted. A detailed report sheet was required for each incident. All injuries were diagnosed by an emergency physician from one of the system hospitals or by a private physician at or near the time of the injury. The reports were reviewed by the assistant director of the EMS system, and a decision was made regarding compensation time. Updated physician reports were required for more serious or chronic injuries. Using the International Classification of Diseases, adapted (ICDA)-8th revision,’ injuries were identified, abstracted, coded, and summarized. From each retrieved record, information was recorded on the demographic characteristics (age, sex, EMT or paramedic level training, and years of experience), time and locale of injury, nature and cause of injury, and total compensation days as a result of the injury. The cause and type of injury were coded using the E code categories from the ICDA-8th revision.5 All coding was performed by a single investigator. When a problem was encountered with coding, it was resolved by an independent epidemiologist. Data were analyzed between groups using the two-tailed Wilcoxon Rank-Sum test, and the a error was set at 0.05. A standard statistical software package (Epistat, 1986, Epistat services, Richardson, TX) was used for data analysis. RESULTS A total of 254 injuries were included during this period from January, 1980 to June, 1983. The number of EMTs and paramedics fluctuated during that time, but there remained a male to female ratio of 3.7:1. The mean age was 28 years with a range of 19 to 40 years. A total of 93 (36%) low back strains were coded, making it the most commonly reported injury. The remaining injuries were generally of a minor nature (Table 1). There were several significant injuries of low frequency (Table 2). A more detailed evaluation of low back strains showed a trend toward a higher injury rate in women compared with men (0.43 v 0.23 injuries/person-years at risk, P = .ll). Emergency medical technicians had a significantly higher rate of back injuries at a rate of 0.33 injuries/person-years at risk compared with a rate of 0.17 among paramedics (P = 0.03). There was no correlation between age or years of
HOGYA AND ELLIS m INJURY PROFILE OF EMS SYSTEM
369
Table 1. Description of Injuries
Table 3. Causes of Back Injury
Injury
ICDA
Back Strain Nonspecific Contusions Toxic Effect of Gases Ankle Sprains Head/Neck Contusions Other Strains Lower Extremity Contusions Trunk Contusions Finger Contusions Shoulder/Arm Sprains Open Finger Wounds Wrist/Hand Sprains Shoulder/Arm Contusions Other (Unclassified)
846 929 987 845 920 847 927 922 928 840 883 842 923 999
Total(%)
Cause
93(36) 18(7) 15(6) 12(5) ll(4) 16(4) 9(4) 9(4) 8(3) 6(3) 6(3) 6(3) 4(2) 21(8)
Lifting Fall on Same Level With Patient Motor Vehicle Accident Fall on Same Level Without Patient Other
experience and a higher rate of back injury. The lifting of patients or equipment was responsible for 58 (62.4%) of low back strains (Table 3). The highest number of back injuries (58/93,62.4%) occurred at the scene of the response. A total of 31% of the back injuries were recurrent injuries. The injury rate from 1980 to 1983 among EMTs ranged from 0.70 to 1.1 [mean = 0.831 and the paramedic rate ranged from 0.40 to 0.70 [mean = 0.551. There was a trend toward a higher injury rate among EMTs compared with paramedics (P = .057). The injury rate among men ranged from 0.50 to 0.70 [mean = 0.501 compared with a rate among women of 0.60 to 1.4 [mean = 0.861. There was a trend toward a higher injury rate among women compared with men (P = .ll). There was a significantly higher injury rate among personnel younger than 30 years (0.65 injuries/ person-years at risk) compared with those 30 years of age or older (0.39, P = .Ol). The causes of injury were equally distributed among lifting, falls with and without patients, assaults by patients or bystanders, and motor vehicle accidents (Table 4). The primary geographic location of injuries was the site to which the unit was dispatched, with 50% reported at a building, house, street, or fire. A total of 31% of the injuries occurred in the ambulance with 5 1% of those due to motor vehicle accidents while responding to or transporting patients (Table 5). The monthly occurrence of injury was variable, with the most reported during the month of January (12%) and the Table 2. Significant Injuries of Low Frequency Injury
ICDA
Total
Laceration of Head Open Wound of Hand Open Wound Knee/Ankle Rib Fracture Closed Head Injury Facial Fracture Fracture of Radius Fracture of Metacarpal Fracture of Patella Fracture of Ankle Dislocated Jaw Heat Injury
873 882 891 807 850 802 813 815 822 824 830 992
5 4 4 3 3 1 1 1 1 1 1 1
ICDA
Total(%)
E919
58t82.4)
E885P E812 E885 E999
13(14.0) 12(12.9) 8(8.5) 4(4.2)
least during September (6.1%). It was noted that the combined months of December, January, and February accounted for 32% of the injuries with only a total of 24. I% of the responses occurring during those months. Our data showed an equal injury pattern among the shifts with 34% of the injuries reported during the 7am to 3pm shift (32% of runs), 37% during the 3pm to llpm shift (42% of runs), and 29% during the llpm to 7am shift (26% of runs). We evaluated the injury rate of personnel based solely on their years of experience on the job and found no statistically significant increased rate of injury among less experienced personnel (Fig 1). We also studied the problem of accident-prone individuals. Over 25% of the personnel injured had more than one injury per year, although the minority were recurrences of the same injury. Nearly 7% of personnel reported more than two injuries per year. One woman, an EMT with 3 years of experience, reported six injuries over the recorded time period. Approximately 96 injuries accounted for 481 compensation days, with low back strain resulting in 375 (78.0%) days off with wages. No reported injury during this time period resulted in permanent disability.
DlSCUSSlON Emergency medical service systems employ personnel with different levels of training and experience. Recently, the focus of research has been limited to the impact of their clinical skills6p7 Unlike fire fighters, little is known about the risk of occupational injury in this group. We suspected low back strain to be a common injury considering the frequency with which personnel lift heavy paTable 4. Causes of Injury Cause Lifting Injuries Falls Falls Falls with stretcher Assaults By patients By bystanders Motor Vehicle Accidents Collisions Sudden stopping Equipment-Related Stair chairs and cots Oxygen tanks Poisoning by Gas/Vapors Smoke Inhalation Miscellaneous
ICDA
Total(%)
E919
Total(%) 93(36)
45(18) E885 E885P
30(12) 15(6)
E980 E981
30(12) t 3(5)
E812 E819-1
35(14) 3(l)
E928-2 E928-1 E878 E876-1
13(5) 3(l)
43(17)
38(15)
1W)
1O(4) 5(2) 4(2)
AMERICAN JOURNAL OF EMERGENCY MEDICINE W Volume 8, Number 4 l July 1990
310
Table 5. Geographic Location of Injuries Total(%)
Total(%)
Location
127&O)
Scene Building/House Street/Sidewalk/Alley Fire Ambulance Hospital Base Station Administrative Headquarters
89(35) 33(13) 5(2) 79(31) 28(lt)
1w 4(l)
tients and equipment, and it did account for 36% of the injuries. The importance of this injury is that it has potential for recurrence and permanent disability. Further evaluation uncovered a trend toward a higher rate of back injuries among women compared with men. Emergency medical technicians had a significantly higher rate of back injuries than paramedics. The predominant causes of injury were lifting, falls while lifting or carrying patients, and motor vehicle accidents. It was theorized that older personnel, despite increased experience, might show an increased incidence of injury because of the physical demands. Individuals over the age of 30 years had a significantly lower total injury rate than those under 30 years. It is possible that these individuals exercise more caution, both in potentially dangerous situations and routine activities, as our data show that experience did not correlate with lower injury rates. Interestingly, the job is a
Ratio (injuries/person-years
at risk)
‘I;
youthful one, with 90% of all EMTs and paramedics under 30 years of age. One might expect a higher incidence of injury during the winter months, with snow and ice making transportation hazardous. Indeed, the months of December, January, and February accounted for 34% of the total injuries, although only 24.1% of the total system responses were reported during those months. It may be helpful to reinforce safe lifting and driving exercises during that time of year in order to reduce the incidence of injuries. We evaluated injury rates among the three work shifts, suspecting individuals on certain shifts may be more vulnerable to injury. Our data tended to show an equal injury pattern among shifts. The injuries we studied commonly occurred in the field, where conditions are more unpredictable and dangerous. Over 50% were reported at the building, house, street, or fire to which they responded. This data suggests a need to address issues of scene safety. We should reevaluate current efforts in scene hazard education as it relates to EMS personnel. Perhaps a more detailed study of the common scenes encountered would show predictable pitfalls that may lead to injury. Additionally, experienced crew members, familiar with a broad range of scene scenarios, could be teamed with less experienced personnel to help them avoid potential injury situations. The data demonstrated that certain individuals were more accident prone than others. It may be efficient to target these individuals in a given system, identify individual risk factors, and provide additional training and assistance during high risk activities such as heavy lifting, driving, or working in dangerous situations (eg, fires, hazardous material incidents, multiple vehicle accidents). Occupational injuries have broad implications to an EMS system, the most important of which is lost work days. In this study, approximately 96 injuries resulted in 481 total injury days, 375 (78%) of which were due to low back strain. This data raises several questions with regard to injury prevention: Are the current training programs for all prehospital personnel adequately focusing on the importance of the proper techniques of lifting, and is adequate driver training provided in preparation for operating an ambulance? Do female personnel require extra assistance in certain situations, such as lifting heavy equipment and patients? If so, crew assignments should reflect this need. Are paramedics inherently more careful, or are they better trained in techniques of avoiding injury than EMTs?
0
0.5
1
1.6
2
2.5
3
3.5
4
4.6
5
6.6
6
Years of experience FIGURE 1. Plot of the proportion of injuriesper populationat risk versus years of experience.
The answers to these questions are elusive. Despite standardized curriculums, personnel have diverse training backgrounds that add other variables. It is important, however, for administrators of EMS systems to consider these questions as they apply to their systems. Only through more detailed research will we be able to tease out the necessary information to design effective programs of injury prevention.
HOGYA AND ELLIS m INJURY PROFILE OF EMS SYSTEM
A number of potential sources of bias were identified in this study. It is possible some injuries may have escaped detection. These were presumed to be minor in nature since no compensation time was granted, and no formal report was submitted. In addition, compensation time may have been underestimated because personnel may have used allotted sick or personal days to recuperate from an injury if compensation time had not been approved. During the evaluation or design of an EMS system, one must recognize the significant potential for occupational injury. An accurate injury reporting system identifies accidentprone personnel, insures appropriate recuperation time for deserving individuals, and assists administrators in determining the personnel required to meet the demands of a system at any point in time. This information provides a framework for programs designed to prevent injuries in EMS personnel, potentially reducing system costs and increasing job satisfaction. CONCLUSIONS Emergency medical service personnel, a group with diverse backgrounds and training, suffer a high incidence of occupational injury. This may comibute to increased system costs, job dissatisfaction, and high turnover rates. Emergency medical technicians have a significantly higher rate of back injuries than paramedics, although their overall injury
311
rates are not significantly different. Further research into better educational programs, focused on scene safety, improved lifting techniques, and advanced driver training, and targeted for populations such as EMTs and personnel under 30 years of age, are suggested to combat these occupational risks. The authors gratefully acknowledge Donald M. Yealy, MD, for his thoughtful review of the manuscript.
REFERENCES 1. Halliday WR: Back injuries in fire fighters. J Med 1979;23: 720 2. Dibbs J: Fire fighters and coronary heart disease. Circulation 1962;65:943-946 3. Loke J: Acute and chronic effects in fire fighters on pulmonary function. Chest 1960;77:369-373 4. Johnson DW, Hammond RJ, Sherman RE: Hearing in an ambulance paramedic population. Ann Emerg Med 1980;9:557561 5. National Center for Health Statistics: International Classification of Diseases, adapted, Eighth Revision. In: Vital and Health Statistics, vol 1, Tabular list, PHS Pub No. 1693, Washington, DC: NCHS, 1967 6. Dean NC, Hammond PJ, Hawker PJ: Effect of mobile paramedic units on outcome in patients with myocardial infarction. Ann Emerg Med 1988;17:1034-1041 7. Donovan PJ, Cline DM, Whitley TW, et al: Prehospital care by EMTS and EMT-Is in a rural setting: Prolongation of scene times by ALS procedures. Ann Emerg Med 1989;16:495-500