emergency medical services essay

Emergency Medical Services: At the Crossroads (2007)

Chapter: 2 history and current state of ems, 2 history and current state of ems.

Across the country, emergency medical services (EMS) agencies face numerous challenges with regard to their funding, management, workforce, infrastructure, and research base. Though the modern EMS system was instituted and funded in large part by the federal government through the Highway Safety Act of 1966 and the EMS Act of 1973, federal support for EMS agencies declined precipitously in the early 1980s. Since that time, states and localities have taken more prominent roles in financing and designing EMS programs. The result has been considerable fragmentation of EMS care and wide variability in the type of care that is offered from state to state and region to region. This chapter traces the development of the modern EMS system and describes the current state of EMS at the federal, state, and local levels.

A BRIEF HISTORY OF EMS

EMS dates back centuries and has seen rapid advances during times of war. At least as far back as the Greek and Roman eras, chariots were used to remove injured soldiers from the battlefield. In the late 15th century, Ferdinand and Isabella of Spain commissioned surgical and medical supplies to be provided to troops in special tents called ambulancias . During the French Revolution in 1794, Baron Dominique-Jean Larrey recognized that leaving wounded soldiers on the battlefield for days without treatment dramatically increased morbidity and mortality, weakening the fighting strength of the army. He instituted a system in which trained medical per-

sonnel initiated treatment and transported the wounded to field hospitals (Pozner et al., 2004).

This model was emulated by Americans during the Civil War. General Jonathan Letterman, a Union military surgeon, created the first organized system in the United States to treat and transport injured patients. Based on this experience, the first civilian-run, hospital-based ambulance service began in Cincinnati in 1865. The first municipally based EMS began in New York City in 1869 (NHTSA, 1996).

In 1910, the American Red Cross began providing first-aid training programs across the country, initiating an organized effort to improve civilian bystander care. During World Wars I and II, further advances were made in EMS, although typically these were not replicated in the civilian setting until much later (Pozner et al., 2004). Following World War II, city EMS activities were for the most part run by municipal hospitals and fire departments. In smaller communities, funeral home hearses often served as ambulances because they were the only vehicle capable of transporting patients quickly in stretchers. With the advent of federal involvement in EMS in the early 1970s and the articulation of standards at the state and regional levels, these EMS providers were gradually replaced by others, including third-service providers, fire departments, rescue squads, and private ambulances (NHTSA, 1996).

By the late 1950s, prehospital emergency care in the United States was still little more than first aid (IOM, 1993). Around that time, however, advances in medical care began to spur the rapid development of modern EMS. While the first recorded use of mouth-to-mouth ventilation had been in 1732, it was not until 1958 that Dr. Peter Safar demonstrated it to be superior to other modes of manual ventilation. In 1960, cardiopulmonary resuscitation (CPR) was shown to be efficacious. These two clinical advances led to the realization that rapid response of trained community members to cardiac emergencies could improve outcomes. The introduction of CPR and the development of portable external defibrillators in the 1960s provided the foundation for advanced cardiac life support (ACLS) that fueled much of the development of EMS systems in subsequent years.

In 1965, the President’s Committee for Traffic Safety published the report Health, Medical Care and Transportation of the Injured . The report recommended a national program to reduce highway deaths and injuries. The following year, the National Academy of Sciences (NAS) and National Research Council (NRC) released Accidental Death and Disability: The Neglected Disease of Modern Society (NAS/NRC, 1966). That report emphasized that the health care system needed to address injuries, which at the time were the leading cause of death for those aged 1–37. It noted that in most cases, ambulances were inappropriately designed, ill-equipped, and often staffed with inadequately trained personnel. For example, the report

called attention to the fact that at least 50 percent of ambulance services nationwide were being provided by morticians. The report contained a total of 29 recommendations, 11 of which applied directly to prehospital EMS (Delbridge et al., 1998). These included recommendations to (1) develop federal standards for ambulances (design, construction, equipment, supplies, personnel training and supervision); (2) adopt state ambulance regulations; (3) ensure provision of ambulance services applicable to the conditions of the local government; (4) initiate pilot programs to evaluate automotive and helicopter ambulance services in sparsely populated areas; (5) assign radio channels and equipment suitable for voice communications between ambulances and emergency departments (EDs) and other health-related agencies; and (6) develop a single nationwide telephone number for summoning an ambulance. The report also laid out a vision for the establishment of trauma systems as we know them today.

In addition to the momentum that had been provided by the President’s Commission, support for the NAS/NRC report was fueled by surgeons with military experience in Korea and World War II who recognized that the trauma care available to soldiers overseas was better than the care available in local communities. In 1966, Congress passed the Highway Safety Act, which led to the formation of the National Highway Traffic Safety Administration (NHTSA) within the Department of Transportation (DOT). NHTSA was given authority to fund improvements in EMS. Among those improvements, NHTSA developed a national EMS education curriculum and model state EMS legislation. NHTSA’s 70-hour basic EMT curriculum became the first standard EMT training in the United States. The department developed more extensive advanced life support (ALS) training several years later. Also as part of the 1966 act, DOT offered grant funding to states with the goal of improving the provision of EMS.

1970s: Rapid Expansion of Regional EMS Systems

In the early 1970s, additional research and policy planning focused on the unmet needs of EMS. In 1972, the NAS/NRC released another report on EMS entitled Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services (NAS and NRC, 1972). The report expressed concern that the federal effort to upgrade EMS had not kept pace with what was needed. It urged integration of all federal EMS efforts into the Department of Health, Education and Welfare (DHEW, which later became the Department of Health and Human Services [DHHS]). The report also stated that the focal point for local EMS should be at the state rather than the federal level, and that all efforts should be coordinated through regional programs.

In 1973, Congress enacted the EMS Systems Act, which created a new grant program to further the development of regional EMS systems. The intent of the law was to improve and coordinate care throughout the country through the creation of a categorical grant program run by the new Division of Emergency Medical Services within DHEW. This program became a decisive factor in the nationwide development of regional EMS systems. Millions of dollars were earmarked for EMS training, equipment, and research. In total, more than $300 million was appropriated for EMS feasibility studies, planning, operations, expansion and improvement, and research. (In 2004 dollars, this investment equates to $1.3 billion.) Also, in 1974 The Robert Wood Johnson Foundation appropriated $15 million to fund 44 regional EMS projects ($64 million in 2004 dollars). To this day, this remains the largest private grant for EMS system development ever awarded.

An important feature of the grant program was its emphasis on the need for effective planning at the state, regional, and local levels to ensure coordination of prehospital and hospital emergency care. Across the country, state EMS offices began to emerge. With the federal support, states established a total of about 300 EMS regions—most covering several counties—each eligible to receive up to 5 years of funding (NHTSA, 1996). The law also identified 15 essential elements that should be included in an EMS system: manpower, training, communications, transportation, facilities, critical care units, public safety agencies, consumer participation, access to care, patient transfer, coordinated patient record keeping, public information and education, review and evaluation, disaster plan, and mutual aid. The EMS Systems Act helped guide the development of models of service delivery; informed system functions such as medical direction, triage protocols, communication, and quality assurance; and set the tone of the EMS system’s interaction with the larger health care and public health systems. While the act identified ideal components of an EMS system from the federal government’s perspective, however, the organization of systems on the ground, including their scope of practice and overall structure, was fundamentally driven by local needs, characteristics, and concerns. A patchwork quilt of systems began to emerge.

A 1978 report by the NAS/NRC, Emergency Medical Services at Mid-passage , expressed criticism of DHEW and focused on the coordination problem between DOT and DHEW at the federal level (NAS and NRC, 1978). The report criticized the conflicting education standards developed by the two departments and recommended more research and evaluation of EMS system development. By 1981, an agreement between DOT and DHEW to coordinate efforts had been canceled, and the EMS program and DHEW grants had been eliminated.

1980s: Withdrawal of Federal Support and Leadership in EMS

In 1981, the Omnibus Budget Reconciliation Act (OBRA) eliminated the categorical federal funding to states established by the 1973 EMS Systems Act in favor of block grants to states for preventive health and health services. This change shifted responsibility for EMS from the federal to the state level. Once states had greater discretion regarding the use of funds, most chose to spend the money in areas of need other than EMS. Thus the immediate impact of the shift to block grants was a sharp decrease in total funding for EMS (U.S. Congress, Office of Technology Assessment, 1989). Moreover, states were left to develop their systems in greater isolation. Some increased their involvement in EMS, but others chose to cede more authority to cities and counties. Political, geographic, and fiscal disparities contributed to fragmented and diverse development of EMS systems at the local level. In addition, a lack of objective scientific evidence regarding the best models for EMS organization and delivery left many systems in the dark regarding appropriate steps to take.

The structure provided to local EMS systems by state governments varied. Lead state EMS agencies remained in all states, but with varying degrees of authority and funding. Maryland, for example, chose to maintain an active role and retained significant authority at the state level. The Maryland Institute for Emergency Medical Services Systems was established in 1972 and continued to take a strong leadership role in subsequent years. The state elected to provide emergency air and ground transportation as a public service and created a sophisticated trauma system that designates trauma centers on the basis of compliance with standards and demonstrated need (IOM, 1993).

By contrast, California and many other states elected to take a less active role. By default as much as by design, regional and county EMS systems took the lead in designing and managing their EMS programs. California state government maintained responsibility for such issues as investigating EMS system complaints and setting EMS training standards, but otherwise had a diminished role in the overall direction of EMS systems. During the 1980s, some states maintained vestiges of the regional systems that were developed in the 1970s, but other systems were fractured along smaller and smaller local lines. The result was even greater diversity among systems.

In the early to mid-1980s, the role of voluntary national EMS organizations increased. These included the National Association of State EMS Officials (NASEMSO, formerly the National Association of State EMS Directors [NASEMSD]), the National Association of Emergency Medical Technicians (NAEMT), the National Association of EMS Physicians (NAEMSP), the American College of Surgeons Committee on Trauma (ACS COT), and the American College of Emergency Physicians (ACEP) EMS Committee. In 1984, the Emergency Medical Services for Children (EMS-C) program was

established at the Health Resources and Services Administration (HRSA) within DHHS.

In 1985, the NRC report Injury in America: A Continuing Health Problem described the limited progress that had been made in addressing the problem of accidental death and disability (IOM, 1985). The report described the need for a federal agency to focus on injuries as a public health problem. In response, an injury program was established at the Centers for Disease Control and Prevention (CDC) that approached injury prevention and control from a public health perspective. This program was later elevated to the status of a center at CDC—the National Center for Injury Prevention and Control (NCIPC).

During this period, rural EMS development lagged behind. The loss of federal funding and the limited financial resources available in states with large rural populations exacerbated this problem. In 1989, the Office of Technology Assessment released a report detailing the challenges faced by rural EMS (U.S. Congress, Office of Technology Assessment, 1989) (see the discussion of rural EMS below).

NHTSA implemented a statewide EMS technical assessment program in 1988. During these assessments, statewide EMS systems are evaluated on the basis of 10 essential components: regulation and policy, resource management, human resources and training, transportation, facilities, communications, public information and education, medical direction, trauma systems, and evaluation.

1990s to the Present: EMS—Looking Toward the Future

In 1995, through the urging of then NHTSA Administrator Ricardo Martinez, NHTSA and HRSA commissioned a strategic plan for the future EMS system. The resulting report, Emergency Medical Services Agenda for the Future (NHTSA, 1996), outlined a vision of an EMS system that is integrated with the health care system, proactive in providing community health, and adequately funded and accessible (see Table 2-1 ).

TABLE 2-1 New Vision for the Role of Emergency Medical Services

In 1997, NHTSA gathered members of the EMS community to develop an implementation guide for making the recommendations in Agenda for the Future a reality. The implementation guide focused on three strategies: improving linkages between EMS and other components of the health care system, creating a strong infrastructure, and developing new tools and resources to improve the effectiveness of EMS.

Agenda for the Future , now a decade old, has been effective in drawing attention to EMS and placing a spotlight on the vital role played by EMS within the emergency and trauma care system. Several of the goals it set forth, however, have not yet been realized. Its vision, such as placing a focus on the care provided to entire communities rather than individuals and thinking proactively rather than reactively, still represents a significant conceptual leap for most EMS systems. The types of changes envisioned by the Agenda are discussed in the relevant context in the chapters that follow.

More recently, in 2001, the U.S. General Accounting Office (GAO) released a comprehensive study of local EMS system needs and of the state regulatory agencies responsible for improving EMS outcomes. The report characterized the needs as substantial and wide-ranging, and grouped the problems identified under four categories: personnel, training, equipment, and medical direction. The report noted that the extent of local needs was difficult to determine since little standard and quantifiable information exists for use in comparing performance across systems. The report also noted that most of the available information is localized and anecdotal (GAO, 2001b).

The terrorist attacks of September 11, 2001, focused attention on the heroism of public safety personnel (fire, police, and EMS), but also exposed many of the technical and logistical challenges that confront the nation’s public safety systems. Communications capabilities were shown to be grossly deficient among the units that responded to the World Trade Center attacks, and a lack of interoperability and inadequate communications with rescuers within the towers probably contributed to the deaths of many rescue personnel (National Commission on Terrorist Attacks upon the United States, 2004). In the aftermath of the disaster, the federal government took a number of steps to improve response capabilities, including development of the National Response Plan and the National Incident Management System (NIMS) (discussed in Chapter 6 ).

Boxes 2-1 and 2-2 detail the development and recent experience of EMS systems in two U.S. cities.

THE TROUBLED STATE OF EMS

EMS operates at the intersection of health care, public health, and public safety and therefore has overlapping roles and responsibilities (see

Figure 2-1 ). Often, local EMS systems are not well integrated with any of these groups and therefore receive inadequate support from each of them. As a result, EMS has a foot in many doors, but no clear home.

Prehospital EMS faces a number of special challenges. First and foremost, EMS systems throughout the country are often highly fragmented. Although they are frequently required to work side by side, turf wars between EMS and fire personnel are not uncommon (Davis, 2003a, 2004). In addition, as noted above, the events of September 11, 2001, demonstrated that public safety agencies (including fire, police, emergency management, and EMS) often use incompatible equipment and are unable to communicate with each other during emergencies. Many of these problems are

magnified when incidents cross jurisdictional lines. Significant problems are often encountered near municipal, county, and state borders. Where a street delineates the boundary between two city or county jurisdictions, responsibility for care—as well as the protocols and procedures employed—depends on the side of the street on which the incident occurred. One county in Michigan has 18 different EMS systems with a range of service models and protocols. In addition, EMS providers have found that coordinating services across state lines is particularly challenging.

In addition, coordination between EMS and hospitals is often inadequate. While hospital ED staff often provide direct, on-line medical direction to EMS personnel during transport, time pressures, competing demands, and a lack of trust can at times hinder these interactions. In addition, cultural differences between EMS and hospital staff can impede the exchange of information. Upon arrival at the hospital, busy ED staff who are strug-

FIGURE 2-1 The overlapping roles and responsibilities of EMS.

SOURCE: NHTSA, 1996.

gling to manage a very crowded ED often greet arriving EMS units with, at best, a lack of enthusiasm. As a result, clinically important information is sometimes lost in patient handoffs between EMS and hospital staff.

Second, there is little doubt that ED crowding has had a very adverse impact on prehospital care. When an ED is crowded, ED staff may be unable to find the physical space needed to off-load patients. Under these circumstances, EMS units may be stuck in the ED for prolonged periods of time, leaving them out of service for other emergency calls. In addition, ED diversion has become commonplace in many major cities, further hindering the performance of EMS. In major metropolitan areas, it is not uncommon for all of the city’s trauma centers to request ambulance diversion at the same time. When hospital EDs go on diversion status, ambulances may have to drive longer distances and take patients to less appropriate facilities (GAO, 2003). Fully 45 percent of EDs reported going on diversion at some point in 2003, and the problem was especially pronounced in urban areas. Overall, it is estimated that 501,000 ambulances were diverted during that year (Burt et al., 2006).

Although it is likely that ambulance diversions endanger patients, there are no data directly linking ambulance diversions with higher mortality rates. No agency has sponsored a systematic study to examine this question, and fears of legal liability inhibit candid disclosure of adverse events (IOM, 2000). However, a study by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2002) revealed that more than

half of all “sentinel” ED events—defined as “an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof”—were caused by delayed treatment. While this study was not centered on ambulance diversion, its findings are consistent with the argument that delays in treatment resulting from diversion can have deleterious effects on patients.

Third, the cost of maintaining an EMS system in a state of readiness is extremely high, and it is rarely compensated. The EMS reimbursement model used by the Centers for Medicare and Medicaid Services (CMS) and emulated by many payers reimburses on the basis of transport to a medical facility. This model ignores the increasingly sophisticated care provided by EMS personnel, as well as the growing proportion of elderly patients with multiple chronic conditions who frequently utilize EMS. Medicaid typically pays a fixed rate—as low as $25 in some states—for an EMS transport, regardless of the complexity of the case or the resources utilized. The fact that payers generally withhold reimbursement in cases where transport is not provided is a major impediment to the implementation of processes that allow EMS to “treat and release,” to transport patients directly to a dialysis unit or another appropriate site, or to terminate unsuccessful cardiac resuscitation in the field. In addition, many systems of all types provide both 9-1-1 call services and medical transportation. To make up for funding shortfalls, these systems often offset the cost of the former services with revenues from the latter.

EMS is widely viewed as an essential public service, but it has not been supported through effective federal and state leadership and sustainable funding strategies. Unlike other such services—electricity, highways, airports, and telephone service, for example—all of which were created and are actively maintained through major national infrastructure investments, access to timely and high-quality emergency and trauma care has largely been relegated to local and state initiatives. As a result, EMS care remains extremely uneven across the United States. Even when EMS is located within a publicly funded agency such as the fire service, it may receive a disproportionately small amount of fire service funding (including grants and line item disbursements), despite the fact that a large majority of calls to fire departments are medical in nature.

Fourth, EMS agencies face a number of personnel challenges. The training of EMTs and paramedics is uneven across the United States, and as a result, EMS professionals exhibit a wide range of skill levels. There are currently no national requirements for training, certification, or licensure, nor is there required national accreditation of schools that provide EMS training. In addition, recruitment and retention are significant challenges for EMS systems. The work of prehospital providers can be challenging and dangerous. EMS personnel face potential violence from patients; risks

due to bloodborne and airborne pathogens; and dangers from ambulance crashes, which increasingly result in provider fatalities (Franks et al., 2004). In addition, many EMS professionals are frustrated by low pay—the average salary for EMTs is about $18,000 and for paramedics is $34,000 (Brown et al., 2003)—and limited career growth opportunities, especially relative to firefighters and other public servants with whom they work side by side. Worse, they are often treated as second-class citizens by those same colleagues, by the systems in which they work, and by the state and federal institutions that fund and support the services they provide. As a result of these and other challenges, recently surveyed EMS agencies and administrators ranked recruitment and retention as the number one issue they face (EMS Insider, 2005).

Perhaps most disturbing is how little is known about what does and does not work in prehospital emergency care. There is little or no scientific evidence to support many widely employed EMS clinical procedures and system design features. The value and proper application of common clinical practices, such as rapid sequence intubation (Murray et al., 2000; Gausche et al., 2000; Davis et al., 2003; Wang et al., 2004) and cardiac resuscitation (Keim et al., 2004), remain unresolved. Field triage models that are widely considered to be out of date are still in use today. Evidence on the value of delivery models, such as tiered levels of response, intensity of on-line medical direction, type of EMS system (e.g., fire-based, volunteer), and deployment of paramedics, is either nonexistent or inconclusive.

The lack of available data on prehospital care not only discourages research on the effectiveness of prehospital interventions, but also hinders the development of process and outcome measures for evaluating the performance of the system. In fact, policy makers and the public have very little information on how well local EMS systems function and how care varies across jurisdictions.

Rural areas face a different set of problems, principally involving a scarcity of resources. EMS and trauma services are dispersed across wide distances, and recruitment and retention of EMTs and paramedics is a pervasive problem. In rural areas, volunteers make up the majority of the EMS workforce (National Registry of Emergency Medical Technicians, 2003). EMS is the only component of the U.S. medical system that has a significant volunteer component, but in many rural communities, younger residents are leaving as the remaining population becomes more elderly. As a result, the pool of potential volunteers is dwindling as their average age and the demands on their time increase. The closure or restructuring of many rural hospital facilities has further increased the demand on rural EMS agencies by creating an environment that requires long-distance, time-consuming, and high-risk interfacility transfers. The final section of this chapter provides a detailed discussion of rural EMS.

EMS is the first line of defense in responding to the medical needs of the public in the event of a disaster, yet EMS personnel are often the least prepared and most poorly equipped of all public safety personnel. According to New York University’s Center for Catastrophe Preparedness and Response, more than half of EMTs and paramedics have received less than 1 hour of training in dealing with biological and chemical agents and explosives since the September 11 terrorist attacks, and 20 percent have received no such training. Fewer than 33 percent of EMTs and paramedics have participated in a drill during the past year simulating a radiological, biological, or chemical attack. And in 25 states, half or fewer EMTs and paramedics have adequate personal protective equipment to respond to a biological or chemical attack (Center for Catastrophe Preparedness and Response NYU, 2005). These findings call into question the readiness of the current EMS system to deal with potential disasters.

FEDERAL OVERSIGHT AND FUNDING

The federal government is extremely fragmented in its approach to regulating EMS. A host of departments, divisions, and agencies at the federal level play a role in various aspects of EMS, but none is officially designated as the lead agency. With the passage of the Highway Safety Act in 1966, EMS found its unofficial home within NHTSA in DOT. At the time, a principal focus of the government’s effort in EMS was on reducing the number of deaths and disabilities caused by crashes on the nation’s motorways, so this placement within DOT seemed appropriate.

As described above, NHTSA’s Office of EMS has been able to provide significant leadership in the field over the past several decades. Indeed, since the early 1970s, NHTSA is the only federal agency that has consistently focused on improving the overall EMS system (AEMS, 2005a). However, NHTSA’s Office of EMS is a small program within a very large federal department that is devoted to transportation. Obscured as it often is within the vast federal bureaucracy, EMS is sometimes overlooked and at times virtually forgotten. This is evidenced by the fact that to date, EMS has received only a small percentage of homeland security funds allocated by the federal government. Although EMS providers represent a third of the nation’s first responders and have a key mission in treating the casualties of a terrorist strike, they received only 4 percent of the $3.38 billion allocated by the Department of Homeland Security for enhancing emergency preparedness in 2002 and 2003 (Center for Catastrophe Preparedness and Response NYU, 2005).

While NHTSA has served as the informal lead agency for EMS within the federal government, a number of other federal agencies also have a stake in EMS. DHHS houses several programs within HRSA, including

the EMS-C program and the Trauma and EMS Program (although both of these programs have been targeted for elimination in recent federal budgets). HRSA also administers the Office of Rural Health Policy. CMS is responsible for Medicare and Medicaid reimbursement for emergency services, which makes up a significant portion of EMS revenues. CDC’s NCIPC plays an important role in trauma and prevention research that is closely allied with emergency services. The National Institutes of Health (NIH) funds emergency- and trauma-related research. The Department of Homeland Security’s Preparedness Directorate supports emergency preparedness programs through the Chief Medical Officer, the U.S. Fire Administration, the Office of Grants and Training, and other agencies.

In an effort to coordinate the efforts of these various components of the federal bureaucracy, Congress established a Federal Interagency Committee on Emergency Medical Services (FICEMS) in 2005. This group was formed to ensure coordination among the federal agencies involved with state, local, or regional EMS and 9-1-1 systems and to identify ways of streamlining the process through which federal agencies provide support to these systems (see Chapter 3 ).

Federal Funding of EMS

Today, financial support for EMS is provided by the various departments and agencies that have jurisdiction over EMS. An array of federal grant programs provide limited amounts of funding to states, localities, and EMS providers (see Table 2-2 for examples). Typically, EMS receives a very small percentage of the funds devoted to larger programs.

Within DHHS, both HRSA and CDC fund EMS. HRSA operates a number of EMS-related programs, including trauma and EMS (funded at $3.5 million in fiscal year 2005), rural outreach grants ($39 million), hospital flex grants ($39 million), a poison control program ($23 million), and the EMS-C program ($23 million). As noted, however, recent budget proposals would eliminate several of these programs, including trauma and EMS, EMS-C, and the poison control program. By far the largest of the HRSA programs is the Hospital Bioterrorism Preparedness program ($495 million). This program aims to improve the capacity of hospitals, EDs, health centers, EMS systems, and poison control centers to respond to acts of terrorism and other public health emergencies. As detailed in Chapter 6 , however, a very small percentage of these funds is directed to EMS.

CDC operates two large EMS-related programs. The Preventive Health and Health Services block grant ($131 million) provides states with resources to address priority health concerns in their communities. States are also charged with designing prevention and health promotion programs that address the national health objectives contained in Healthy People

TABLE 2-2 EMS-Related Fiscal Year 2005 Federal Funding

2010. These include increasing the proportion of adults who are aware of the early warning signs of a heart attack and the importance of accessing emergency care by calling 9-1-1 (GAO, 2001b). CDC also runs NCIPC, which works to reduce morbidity, disability, mortality, and costs associated with injuries (funded at $138 million in fiscal year 2005). Overall, however, a small percentage of the funds allotted to these CDC programs is devoted specifically to EMS.

The Department of Homeland Security’s Office of Domestic Preparedness awarded nearly $4 billion in federal funding in fiscal year 2005 under its first-responder grant programs—the Firefighter Assistance Grants program ($895 million) and the State and Local Programs fund ($3.1 billion). The latter included $885 million for high-threat, high-density urban areas; $150 million each for port security and rail and transit security; and $135 million for the national domestic preparedness consortium. As detailed in Chapter 6 , however, non-EMS first responders were the primary recipients of these funds.

Federal Reimbursement for EMS Services

In addition to small portions of the federal funding detailed above, EMS systems across the country receive federal funds through reimbursements from the Medicare program. Because the elderly are heavy users of EMS, Medicare represents a very large percentage of billings and collections in a typical EMS agency. Those aged 65 and older are 4.4 times more likely to use EMS than younger individuals, and they represent a growing segment of the population. Since Medicare payments have traditionally been used to cross-subsidize Medicaid and uninsured EMS users, Medicare represents an even larger percentage of total patient revenues for EMS agencies (Overton,

2002). An example from the Richmond Ambulance Authority is shown in Figure 2-2 . In that system, Medicare represents 40 percent of billings, but 55 percent of revenues.

The Medicare program recently completed a 5-year transition to a new fee schedule. Under the old reimbursement system, EMS agencies received two payments per transport. The primary payment was a cost-based, fee-for-service rate that reimbursed EMS for the service provided. The secondary payment was reimbursement for the number of miles the ambulance traveled. Under that system, ambulance services were concerned primarily with reporting their charges and mileage. The new system keeps the mileage reimbursement but abandons the cost-based payment and replaces it with a prospective payment system, similar to the system in place for outpatient health services (Overton, 2002). EMS was the last Medicare Part B provider to transition from a fee-for-service to a prospective payment system. Under the new system, ALS transports are reimbursed at a higher rate than basic life support (BLS) transports, and higher payments are provided for transport in rural areas to reflect the typically long travel times to and from hospitals (MedPAC, 2003).

Overall, the new fee schedule significantly reduces Medicare payments to EMS providers. Two years into the transition to the new system, data indicated that Medicare reimbursements were approximately 45 percent below the national cost average for transport, leading to a $600 million shortfall for services provided to Medicare beneficiaries. As a result, local EMS systems may now need greater subsidization from local governments or may be forced to reduce costs through personnel cuts, reductions in

FIGURE 2-2 EMS patient revenues, Richmond, Virginia.

SOURCE: Overton, 2002.

capital expenditures, or other means. These dynamics illustrate the tension among federal, state, and local governments regarding the locus of responsibility for funding EMS systems across the country.

Medicare payments have significantly shaped the provision of EMS nationwide, as evidenced in several areas, including the availability of responders, the therapeutic interventions provided, treat and release practices, and transport and transfer policies (NASEMSD, 2005). For example, EMS systems relying on Medicare and other third-party payers for significant revenue must generally provide patient transportation to be reimbursed for their services. While the primary determinants of EMS costs relate to maintaining readiness capacity, the primary determinant of payment for services is patient transport. Thus in an urban area that receives a large number of 9-1-1 calls, the cost of readiness is spread over a large number of users, keeping the cost per transport relatively low, whereas in rural areas, the lower volume of emergency calls in relation to the high overhead of maintaining a prepared staff results in very high costs per transport. Although many rural EMS squads rely on volunteers rather than paid EMS personnel to reduce these costs, doing so results in a less stable system.

Federal Regulation of EMS

The current organization and delivery of emergency and trauma care is shaped largely by federal and state legislation. The legal and regulatory framework provides many protections and benefits, but also presents obstacles to achieving efficient and high-quality care delivery.

Emergency Medical Treatment and Active Labor Act (EMTALA)

EMTALA represents one example of how the federal government’s fragmented regulatory structure has resulted in confusion for EMS providers and potential harm to emergency patients. This law, passed in 1986, requires hospitals that participate in the Medicare program to provide a medical screening exam and stabilize all patients that come to the hospital for care before they are discharged or transferred to another hospital. EMTALA was intended to protect access to emergency care by preventing private hospitals from turning away needy emergency patients who are uninsured or underinsured or precipitously transferring these patients to the closest public hospital, a practice known as “dumping” (GAO, 2001a).

Over time, the law has progressively expanded, and it now covers patients seen anywhere on hospital property, which includes ambulances owned and operated by the hospital (Wanerman, 2002; Elting and Toddy, 2003). As a result, hospitals may be required to provide medical screening exams to patients arriving in a hospital-owned ambulance even if the pa-

tient requires immediate care at a regional trauma center because the local hospital does not have the personnel or equipment required to respond effectively to the patient’s critical medical needs. This situation also arises in cases where a ground and an air ambulance are attempting to rendezvous at a hospital’s helipad so that the patient can be transported quickly to a trauma center. Providers in the field have experienced confusion as to whether a screening exam is mandated in this case.

The expansion of EMTALA to include transports by hospital-owned ambulances created a barrier to regional coordination. The goal of regional coordination is to ensure that patients receive the optimal care, and a key component of that task is ensuring that avoidable and costly delays are eliminated. However, EMTALA may require that patients receive initial care at a less-than-optimal facility, creating avoidable delays in the provision of needed care.

This problem is compounded by the fact that no one agency is responsible for making regulatory decisions regarding EMTALA, and as a consequence, federal rules on this issue are not clear. The Office of the Inspector General (OIG) has produced advisories on EMTALA, including a letter of opinion stating that ambulances may take patients directly to hospitals that are appropriate for the patient’s condition (including trauma centers) in cases where there are “regional protocols” in place (DHHS, 2003). However, the OIG is not a rule-making entity and is not responsible for enforcement. CMS’s enforcement of EMTALA has been shown to be highly variable among regions (GAO, 2001a). Consequently, providers across the country are uncertain as to whether EMTALA requires that a medical screening exam be conducted even when a patient requires immediate care at a trauma facility, and there is no simple or straightforward way to have this issue clarified. Various people involved in making the decision at the local level, including the hospital administrator, the hospital’s attorney, the state EMS office, and others, may all have a different point of view. As a result, providers are making decisions that may compromise care based on their own reading of this complex regulatory environment.

Health Insurance Portability and Accountability Act (HIPAA)

The federal regulatory environment has also created confusion with HIPAA. Enacted to regulate the transmission of electronic health data among providers and payers and to protect the privacy of patient health information, HIPAA often presents challenges for providers seeking to share health information with other providers, potentially compromising both patient care and provider protections; it also creates difficulties for investigators seeking to obtain research data. There are exceptions to HIPAA that recognize the unique characteristics of emergency and trauma care, such

as the urgency of care and the potential inability of patients in distress to provide consent (Lewis et al., 2001); however, HIPAA continues to pose a number of impediments to EMS.

The regulatory environment at the federal level does not provide clear assurances regarding HIPAA rules for dispatch centers and radio communications, resulting in guesswork at the local level. EMS represents a small segment of the health care continuum and received little attention during the development of the HIPAA regulations, but the cost of HIPAA compliance for EMS providers is substantial.

Based on their interpretation of current federal rules and their fear of liability, some hospitals believe HIPAA excludes outside agencies from participating in multidisciplinary quality assurance projects. As a result, trauma morbidity and mortality conferences convened by hospitals may exclude EMS personnel. This happens despite the fact that EMS personnel are responsible for transporting patients to the hospital, often have salient information about events on the scene, and may benefit from learning what happened after patients reached the hospital.

HIPAA has created additional barriers to information sharing between hospitals and EMS agencies. For example, EMS agencies may want to assess patient outcomes following hospital transport; however, patient-specific outcome data often are not shared. EMS personnel may also seek to determine whether a particular patient transported to the hospital is suffering from an air- or bloodborne pathogen or some other malady that may compromise the safety of the transporting EMS personnel. But hospitals are often unwilling to share this information with EMS agencies for fear of violating HIPAA regulations, even in cases where such information sharing may be allowable.

For researchers investigating patient outcomes resulting from out-of-hospital interventions such as cardiac resuscitation, it is necessary to obtain outcome information from each of the facilities in which patients were treated. Out-of-hospital and ED records must be linked with hospital records, vital statistics, and coroner’s records when appropriate. The patient identifiers required to perform such linkages are subject to the confidentiality provisions of the HIPAA legislation, making gathering these data difficult in an environment where EMS-related research is already lacking.

EMS OVERSIGHT AT THE STATE LEVEL

In most states, state law governs the scope, authority, and operation of local EMS systems. Each state has a lead EMS agency that is typically a part of the state health department, but in some states may be part of the public safety department or an independent agency. The mission, funding, and size of EMS agencies vary considerably from state to state. For example,

a survey conducted by NASEMSO found that the number of full-time positions within state EMS agencies varied from a low of 4 to a high of 90. Most states have an EMS medical director, though many do not. Table 2-3 shows the range of functions that EMS agencies provide.

State EMS agencies regulate and oversee local and regional EMS systems and personnel. They typically license and certify EMS personnel and ambulance providers and establish testing and training requirements. Some may also be responsible for approving statewide EMS plans, allocating federal EMS resources, and monitoring performance (GAO, 2001b). States have begun to take a more proactive role in trauma planning, with 35 states having formal trauma systems. One key function of many EMS agencies is data collection. However, only about half of state EMS offices have the capabilities to provide information on how many EMS responses occur in their state (Mears, 2004).

In regulating local and regional EMS systems, many state EMS offices are placed in the difficult position of being both an advocate/technical advisor and a regulator. This dual role can create internal conflicts. For example, state EMS offices are often responsible for both ensuring an adequate supply of EMS personnel and regulating those personnel. If an EMS office seeks to increase the educational requirements for EMS personnel, it may also create the type of workforce shortage it is working to avoid. For this reason, other professions separate the regulatory and advocacy roles (Shimberg and Roederer, 1994; Schmitt and Shimberg, 1996).

TABLE 2-3 State EMS Agency Functions

Some states provide direct funding for EMS, which may be derived from vehicle or driver licensing fees, motor vehicle violations, or other taxes. However, EMS funding is subject to cutbacks in tight fiscal environments. Approximately 87 percent of funds for state EMS office budgets comes from in-state revenues. The remaining 13 percent that comes from the federal government includes grants from multiple agencies with diverse priorities. There is currently no single, comprehensive federal vision for the development of the EMS system nationwide. NASEMSO maintains that this situation may have contributed to the lack of sustained and meaningful development in many areas identified in Emergency Medcical Services Agenda for the Future (NASEMSD, 2005).

State Medicaid agencies are responsible for developing Medicaid reimbursement policies for EMS. It is estimated that for most EMS agencies, Medicaid patients represent 20–40 percent of all EMS patients. The proportion of users covered by Medicaid tends to be higher in rural areas. The way EMS services are reimbursed can vary greatly from state to state; however, Medicaid reimbursement rates are almost universally low. As noted earlier, the majority of states use a fee-for-service payment system and a mileage rate for Medicaid reimbursement; five states pay EMS a “reasonable charge,” an amount that the state has decided is reasonable for the public to pay (Kaiser Commission on Medicaid and the Uninsured, 2003). Medicaid reimbursement is typically based on transportation rather than service provided. Thus, for example, EMS agencies in Virginia receive $75 for transporting a patient 0–5 miles to a hospital, regardless of whether the patient was transported by BLS or ALS providers and regardless of the severity of the patient’s condition or the services rendered. In most states, payment is not provided unless the EMS agency actually transports the patient.

NHTSA provides some technical assistance to state EMS agencies through statewide assessments. For the assessments and reassessments, NHTSA serves as a facilitator by assembling a team of experts in EMS development and implementation to work with and advise the state. The state EMS office provides NHTSA and the assessment team with background information on the EMS system, and the technical assistance team develops a findings report. A mid-1990s review of EMS assessments revealed “widespread fundamental problems in most areas,” but the lack of quality management programs was a common theme across systems. The review found that the majority of states did not have quality improvement programs for evaluating patient care, methods for assessing current levels of system resources, or mechanisms for identifying necessary system improvements (NHTSA Technical Assistance Program, 2000). The technical assistance provided to state EMS agencies is critical. All of these agencies face complex structural and operational issues that include system design, reimbursement strategies, quality management, performance improvement, and business

remodeling. EMS administrators are typically career EMS personnel; many have little formal training in organizational management, and there are no standardized courses for providing them with this training (Mears, 2004).

MODELS OF ORGANIZATION AND SERVICE DELIVERY AT THE LOCAL LEVEL

Across the United States today, EMS systems are fundamentally local in nature (GAO, 2001b). Counties and municipalities play central roles in deciding how their systems will be structured and how they will adapt to changes in the environment (e.g., changes in Medicare payment rates or added liability concerns). They determine the organization of the delivery system, the structure of EMS response times, the development of finance mechanisms, and the management of other system components. As a result of this local control, EMS systems across the country are extremely variable and fragmented. This diversity of systems can be viewed as a strength in that it promotes local self-determination and tailors systems to the needs and expectations of local residents. However, it is also a profound weakness, especially in cases where local standards of care fall below generally accepted standards and patients suffer as a result. Across cities, for example, the percentage of people suffering ventricular fibrillation who survive and are later discharged from the hospital with good brain function ranges from 3 to 45 percent (Davis, 2003a). EMS response times overall vary substantially, and many cities do not collect the data necessary to track their performance.

Emergency Dispatch Centers

Today, virtually all Americans (99 percent) have access to 9-1-1 service (National Emergency Number Association, 2004). However, the apparent uniformity of the 9-1-1 system is misleading: the system is actually locally based and operated, and its structure varies widely across the country. There currently exist more than 6,000 public safety answering points (PSAPs), or 9-1-1 call centers, nationwide. These include both primary PSAPs, which field all types of 9-1-1 calls (police, fire, and EMS), and secondary PSAPs, which handle service-specific calls, such as medical emergencies. These emergency call centers are operated primarily by public safety agencies, as well as city and county communications centers, hospitals, and others (see Figure 2-3 ). Over time, it may become necessary to reduce the large number of call centers, especially in the context of disaster preparedness efforts, which dictate a more streamlined emergency call structure in response to catastrophic events.

In 2004, 9-1-1 call centers fielded approximately 200 million emergency calls, including medical, police, fire, and other calls. In some cases, medical

FIGURE 2-3 Agency responsible for dispatch in the 200 most populous cities.

SOURCE: Monosky, 2004.

calls are received by primary call centers and then routed to secondary calls centers with dedicated medical dispatch. In other cases, all calls are handled at the primary call center. When different types of calls are handled by different call centers, the potential for “call switching” and miscommunication is dramatically increased.

Not only do 9-1-1 dispatchers determine the appropriate level of response, but they also often provide prearrival instructions to the caller. The prototype for this process was dispatcher-assisted CPR, pioneered by Eisenberg and colleagues in King County, Washington, and subsequently validated by an independent research team in Memphis. The list of conditions amenable to prearrival instructions was quickly expanded to include, for example, childbirth, seizures, and trauma/bleeding.

Prearrival instructions are designed to enable the caller to provide assistance when certain emergency conditions are present, to protect the

patient and caller from potential hazards, and to protect the patient from well-meaning bystanders who could provide assistance that might do more harm than good (Hauert, 1990). The level of prearrival assistance from the dispatcher can vary from simple advice, such as “call a doctor,” to instructions for performing CPR. Instructions are typically available to the dispatcher on flip cards.

EMS Systems

A survey of EMS systems conducted in 2003 by NASEMSD and HRSA’s Office of Rural Health Policy indicated that there were 15,691 credentialed EMS systems in the United States (Mears, 2004). However, the survey also indicated that the definition of an EMS system varies from state to state, making accurate tabulations nearly impossible. Among the systems identified by the survey, 45 percent were fire department–based, 6.5 percent were hospital-based, and 48.5 percent were labeled as neither (see Figure 2-4 ). The total number of ALS and BLS transport vehicles reported was 24,570. More recent data from the American Ambulance Association (AAA) indicate that there are 12,254 ambulance services operating in the United States (a figure that includes private for-profit and not-for-profit, hospital-based, volunteer, and fire department–based services), and a total of 23,575 ground ambulance vehicles (AAA, 2006).

While no statistics are available to provide greater detail about EMS system types nationwide, the Journal of Emergency Medical Services conducts an annual survey of the 200 largest metropolitan areas in the United

FIGURE 2-4 Types of EMS systems.

SOURCE: Mears, 2004.

TABLE 2-4 Reported Provider Types

States and is able to provide statistics for these areas (Williams, 2005) (see Table 2-4 ). The figures shown do not reflect smaller cities or rural areas. Results of the 2006 survey indicate that 36 percent of ambulance systems in these large metropolitan areas are private (either for-profit or not-for-profit), 32 percent are fire department–based, and just under 10 percent are third-service and hospital-based. However, an overwhelming number of first responders are fire department–based (89 percent).

Fire Department–Based EMS Systems

As is evident from the Mears (2004) survey, a strong plurality of EMS systems nationwide is fire department–based. The number of services has steadily increased over the past several decades as fire chiefs have recognized the central role of EMS in firefighting operations. EMS is an element of the response and service delivery of approximately 80 percent of fire departments in America (U.S. Fire Administration, 2005).

At an operational level, a fire department–based EMS system is one in which EMS is part of the fire department and ambulances are housed in or operate out of fire stations, with integrated dispatch. The integration of fire and EMS varies with each department. Some departments utilize person-

nel whose sole function is to provide EMS, while others utilize dual-role personnel who function as both firefighters and EMS providers. Some fire departments offer a full range of EMS, including BLS and ALS response and transport, while others limit their role to providing first-responder BLS or ALS care without transport.

Fire departments have chief officers who oversee operations and provide leadership at multiple levels. The chief of the department is usually a firefighter and, increasingly, may also have an EMS background, although frequently this is not the case. The organization and leadership of EMS within fire departments vary considerably. Some departments divide EMS and firefighting into separate divisions, while others integrate the two services under general operations. All fire departments that provide ALS must have a physician medical director, whether paid or volunteer; those that provide only BLS services may not.

Fire departments are financed primarily through public funds. Some departments bill for EMS, but collection rates vary. Collections are especially low in urban areas. Many small-town and rural fire departments in the United States, especially the latter, are volunteer, but the number of volunteer firefighters appears to be declining (see the discussion in Chapter 4 ).

In most jurisdictions, EMS calls now exceed fire-related calls by a wide margin. According to the National Fire Protection Association (2005), 80 percent of national fire service calls are EMS-related. This trend is likely to persist as fire prevention techniques continue to improve and as the aging of the U.S. population adds to the projected number of EMS calls.

One advantage of having an integrated fire and EMS system is structural efficiency. Firehouses are traditionally well positioned to serve the local population in most areas of the country. These physical structures can provide a strategic location for the EMS units they house, as well as a place for EMS personnel to rest between calls. Fire departments also provide the administrative infrastructure necessary to manage personnel, provide training, and purchase and maintain equipment and supplies.

But there are also disadvantages to fire-based EMS systems. A series of articles in USA Today documented the cultural divide, discussed earlier, that can exist between EMS and fire personnel (Davis, 2003b). Generally, the orientation of EMS personnel centers on providing medical care, whereas that of firefighters centers on conducting rescue operations and battling fires. As a result, there is some difference between the types of individual who become EMTs and firefighters (Davis, 2003a). These personnel often do not work together in a coordinated fashion.

In many cities, such as Washington, D.C., and Los Angeles, EMS is under the leadership of the fire department, which tends to consider fire suppression its principal mission, with medical services assuming a secondary role (Davis, 2003a). As a result, priority is given to fire suppression when

it comes to training and budget allocations. In many cases, firefighters are paid more than EMS personnel and have separate unions and command structures, even when based within the same fire department. Medical directors who are hired to supervise fire department–based emergency medical response may be viewed as outsiders, and may defer to the fire chiefs on the way resources should be deployed. Over the past decade, many EMS systems have become integrated with the fire service, although there is significant variation with respect to the level of integration.

Hospital-Based EMS Systems

Hospital-based EMS systems may provide stand-alone EMS coverage to a community or may operate in conjunction with a fire department. Typically, a hospital-based service is located at a community hospital and dispatched through a public safety communications system (9-1-1) or routed through a secondary call center that receives dispatches from a 9-1-1 center. Hospital-based systems function as private entities and typically bill for their services.

An advantage of a hospital-based system is that EMS personnel may benefit from the closer relationship between the ED and the hospital and may be better able to maintain professional skills through greater opportunities to observe ED procedures. Hospital-based systems also benefit from the reputation of the hospital with which they are affiliated and may be recognized by members of the community.

A challenge for hospital-based systems is potential competition among services and the need for better coordination of system resources. Since hospital-based ambulances bill for services and provide transport to their base hospital, there is an inherent competition for patients. For example, ambulance companies may seek to advertise their services, providing their own phone number and encouraging people to call them instead of 9-1-1. This may also occur with private ambulance services.

Another challenge in larger communities that use a number of hospital-based systems is optimizing system resources. Hospitals are not always located proportionally to populations or areas of greatest need. Further, depending on state regulations, hospitals may not be required to increase the number of available ambulances if EMS call volumes increase.

Private Systems

In some areas, local governments run their ambulance service by contracting with a private entity—either a local EMS operation or a national company. In these instances, private ambulance companies contract their services to local governments to provide 9-1-1 transports, including person-

nel, equipment, and vehicles. The contracts may or may not require medical oversight. The private firms compete for contracts, typically every several years. Some of these private firms are publicly owned stock-issuing corporations. For-profit providers now operate throughout most of the country.

Private EMS systems face some of the same challenges as fire department–based EMS systems. Some cities have found them to be a more economical alternative than expanding fire departments to provide EMS. However, their profit orientation also makes it more likely that EMS will suffer when contract disputes occur with the municipal agency.

There are several different models for private systems. First, under a level-of-effort model, a local government develops a contract with a private firm for a certain number of ambulances and other resources. The contractor is not held to specific performance standards, but must simply provide the contracted services. Under a performance-based model, the contractor is expected to meet specific performance standards to fulfill the contract. Finally, under a high-performance model, the contract creates a business relationship that tightly aligns the interests of the contractor with public needs. The contractor may be responsible for patient billing and may own some long-term infrastructure items, such as ambulances and medical communications systems. Additionally, an independent body is responsible for performance, medical oversight, and financial oversight; rate regulation; licensing; and market allocation (AAA, 2004).

One difficulty in evaluating the pros and cons of any service model (whether locally or nationally) is the dearth of objective process and outcome data for comparing one model of service delivery or even one ambulance company with another. As a result, local governments frequently rely on crude measures, such as numbers of personnel, numbers of ambulances operating per unit of time, EMS fractile response times by urgency of call, and patient complaints. These are poor proxies for quality of care and outcome-based measures of system performance.

Municipal Services

At the local level, municipal and county governments often deliberate between contracting out to a private EMS company and developing and operating an EMS unit themselves. In many cases, the locality chooses the latter option. This involves purchasing or leasing ambulance units, hiring EMS personnel to provide direct services and administrative personnel to run the program, and stocking ambulances with necessary medical and communications equipment. Some of these operations bill private insurers for services, while others rely solely on direct funding from the city or county.

In Kansas City, Missouri, fire department personnel serve as first responders, but transport is handled through a public utility model. This

model entails a quasigovernmental authority with overall responsibility for EMS transport that owns all the equipment, including ambulances, and carries out billing and other logistical functions, but contracts with a private company for human resources. Kansas City was one of the first major cities to offer EMS transport using this model.

EMS System Staffing: Career- and Volunteer-Based

In career-based EMS systems, providers are paid to staff the ambulance units and have preassigned shifts. Benefits of such a system are thought to include greater standardization in the quality of patient care through employer oversight, mandated training, and quality assurance and improvement. Many states and communities, however, still rely heavily on volunteers to provide ambulance coverage; in particular, volunteer personnel have traditionally been the lifeblood of rural EMS agencies. Volunteers may also have preassigned shifts but generally are not paid for their time, although recent research suggests that a fairly large percentage of volunteers receive financial compensation for their EMS activity (Margolis and Studnek, 2006). Equipment and vehicles are frequently maintained using donations or public funds. Oversight of volunteer systems is sometimes provided by the municipal or county agency responsible for EMS, if one exists. The benefits of a volunteer system include the significant cost savings from not having to pay personnel. However, the challenge is maintaining a response system that consistently meets the public demand for quality services.

Most experts agree that there appears to be a national trend toward decreasing volunteerism and an increase in EMS personnel seeking paid careers. During the early stages of EMS, it was not uncommon for volunteers to be on call nearly 24 hours a day. Today, however, increased time demands, the rise in families’ needs for dual incomes, and vying interests create an environment in which volunteers may donate one specific weeknight or a few hours on a weekend. As a result, rural EMS agencies in particular are currently faced with volunteer staffing shortages, particularly during weekday work hours.

Many systems are a combination of volunteer- and career-based because of the challenges of maintaining an entirely volunteer system. Such combined systems represent an attempt to achieve cost savings while ensuring adequate services to the public. However, the sustainability of each type of system—career, volunteer, and combination—is unclear as a result of the resource demands on career systems and the lack of personnel for volunteer systems.

Air Ambulance Systems

Air medical operations have grown substantially since their inception in the 1970s. Today there are an estimated 650–700 medical helicopters operating in the United States (Gearhart et al., 1997; Helicopter Association International, 2005; Meier, 2005; Baker et al., 2006), up from approximately 230 in 1990 (Blumen and UCAN Safety Committee, 2002; Helicopter Association International, 2005). These helicopter operations are owned and managed by a variety of entities, including for-profit providers, nonprofit organizations such as local hospitals, government agencies such as the state police, and military air medical service providers. Many air medical providers were originally employed as hospital contractors but now work on an independent basis. Typically, the base helipads for these providers are located in airports, independent hangars and helipads, and designated areas of a hospital (Branas et al., 2005).

Air ambulance operations have served thousands of critically ill or injured persons over the past several decades (Blumen and UCAN Safety Committee, 2002). However, there has been growing concern about the safety of these operations. Approximately 200 people have lost their lives as a result of air medical crashes since 1972, and these deaths have been increasing as the industry continues to expand (Blumen and UCAN Safety Committee, 2002; Bledsoe, 2003; Baker et al., 2006). Crashes are often attributable to pilots flying in poor weather or at night. Li and colleagues (2001) found a four-fold risk of a fatal crash in flights that encountered reduced visibility. Baker and colleagues (2006) found that crashes in darkness represented 48 percent of all crashes and 68 percent of all fatal crashes. In addition, some companies are flying older, single-engine helicopters that lack the instruments needed to help pilots navigate safely (Meier, 2005). In 2004 and 2005 a total of 12 fatal air ambulance crashes occurred—the highest number of fatal crashes in two consecutive years experienced in the industry’s history (Isakov, 2006). Recent increases in Medicare payments have led to greater competition in the industry, which has added to concerns regarding safety (Meier, 2005).

Air medical services are believed to improve patient outcomes because of two primary factors: reduced transport time to definitive care and a higher skill mix applied during transport. However, presumed gains in transport time do not necessarily occur, given the time it takes the helicopter crew to launch, find a suitable landing position, and provide care at the scene. This is especially true when the distance to the scene is short. Questions have also been raised regarding the appropriateness of air ambulance deployments in specific patient care situations (Schiller et al., 1988; Moront et al., 1996; Cunningham et al., 1997; Arfken et al., 1998; Dula et al., 2000). A 2002 study found that helicopters were used excessively for patients who were not

severely injured and that they often did not deliver patients to the hospital more rapidly than ground ambulances (Levin and Davis, 2005).

On the other hand, a number of other studies suggest benefits of air ambulance service relative to ground transport. Davis and colleagues (2005) found that patients with moderate to severe traumatic brain injury who received care through air ambulance had improved outcomes. In addition, the study found that out-of-hospital intubation among air-transported patients resulted in better outcomes than ED intubation among ground-transported patients. Patients with more severe injuries appeared to derive the greatest benefit from air medical transport. And Gearhart and colleagues (1997) reviewed the literature and reported 1–12 additional survivors per 100 patients flown.

EMS in Rural Areas

According to the 2000 U.S. Census, 21 percent of the nation’s population lives in rural and frontier areas. Residents of these areas experience significant health disparities relative to their urban counterparts (Pollock, 2001). A large portion of these disparities results from the distinctive cultural, social, economic, and geographic characteristics that define rural America, but the situation also reflects the difficulty of applying medical systems designed for urban environments to rural and frontier communities.

Rural EMS Challenges

Rural EMS systems face a multitude of challenges. A particularly daunting challenge is providing adequate access to care given the distances involved and the limited assets available. Ensuring the delivery of quality EMS to rural populations is also complicated by the makeup and skill level of prehospital EMS personnel and associated issues of management, funding, and medical direction for rural EMS systems. In 1989, the Office of Technology Assessment estimated that three-quarters of rural prehospital EMS personnel were volunteers (U.S. Congress, Office of Technology Assessment, 1989). A more recent national assessment found that 77 percent of EMS personnel in rural areas were volunteers, compared with 33 percent in urban areas (Minnesota Department of Health, Office of Rural Health Primary Care, 2003).

State health directors list access to quality EMS care as a major rural health concern (O’Grady et al., 2002). In a 2003 survey of national and state rural health experts, 73 percent identified access to health care as a priority issue, and EMS access was cited as a primary concern (Gamm et al., 2003; Rawlinson and Crewes, 2003). In its 2004 report Quality Through

Collaboration: The Future of Rural Health , the Institute of Medicine cited EMS as one of four essential health care services for rural residents, along with primary, dental, and mental health care (IOM, 2004).

As noted in Chapter 1 , EMS response times from the instigating event to arrival at the hospital are significantly longer in rural than in urban areas. These prolonged response times occur at each step in EMS activation and response, including time to EMS notification, time from EMS notification to arrival at the scene, and time from arrival at the scene to arrival at the hospital. A 2002 survey found that 30 percent of rural patients fatally injured in a crash (compared with 8.3 percent in urban areas) arrived at the hospital more than 60 minutes after the crash, after the “golden hour” had expired (NHTSA, 2005). These prolonged response times are attributable to the increased distances involved, but also to other factors, such as the limits of 9-1-1 availability in sparsely populated areas. While the availability of 9-1-1 extends to the vast majority of the U.S. population, 4 percent of the nation’s counties still do not have access to basic 9-1-1 (see Chapter 5 ). Moreover, enhanced 9-1-1, which provides geographic data to the dispatch center so the location of an incident can be pinpointed, is difficult to implement when a large portion of the rural population uses rural routes and post office boxes to designate addresses (Gausche and Seidel, 1999). In addition, the small number of ambulances available in some rural regions and the inability to priority dispatch these ambulances if there is only one unit available remain a challenge (Key, 2002).

One of the first obstacles to timely EMS activation in rural areas is the delay that commonly occurs in the discovery of crash scenes. On infrequently traveled rural roads, a long time may elapse before victims are discovered. This delay may be the single largest contributor to prolonged times until transport to a hospital (Esposito et al., 1995). In a study of rural Missouri, only 39 percent of calls alerting EMS came within 5 minutes of the collision, compared with 90 percent in urban study areas (Brodsky, 1992). Automated collision notification systems offer the potential for significant improvement in this area (see Chapter 5 ). In a rural demonstration project conducted by NHTSA during 1995–2000, this technology was demonstrated not only to work, but also to reduce response times (NHTSA, 2001).

When prehospital EMS is activated, there is significant local variation in the type and quality of services provided. Rural EMTs working in an isolated environment while treating a critically ill or injured patient will spend more time with the patient and use fewer resources than urban EMTs or paramedics. Certain clinical scenarios may actually require a greater skill level and more multitasking on the part of rural EMTs as compared with their urban counterparts. As noted, however, EMS systems in rural areas are staffed largely by volunteers with highly variable levels of expertise, training, and experience. A rural EMT may encounter highly critical cases

very infrequently as a result of the small size of the local population and the number of volunteers required to cover a schedule. For the limited number of EMS personnel in a largely volunteer system, formal training and critical care experience are often lacking, and even when such training is attained, the low volume of calls contributes to the degradation of critical care skills. Moreover, access to continuing education may be scarce in rural areas (Key, 2002). Additionally, volunteer organizations experience a higher level of provider turnover, which may reduce the number of experienced volunteers. Taken together, these factors mean that rural EMS providers may be less proficient than urban providers.

A high percentage of rural EMS personnel may be trained only in BLS, and indeed, many rural programs offer only BLS services (Minnesota Department of Health, Office of Rural Health Primary Care, 2003). Even when rural EMTs are trained to perform critical tasks, such as endotracheal intubation, their success rate is poor (Sayre et al., 1998), in part because of the infrequent need to exercise such skills noted above. In one study, despite training, rural EMS personnel were able to intubate only 49 percent of their patients successfully. Cited as possible explanations for this low success rate were training deficiencies, infrequent intubation opportunities, and inconsistent supervision (Bradley et al., 1998). Likewise, Spaite (1998) pointed out that rural EMS personnel with defibrillator training may defibrillate a patient only two or three times in a decade, emphasizing a pivotal role for the use of automated external defibrillators. In addition, even when ALS is available in rural areas, the services have repeatedly been demonstrated to be provided at much lower levels of quality than in urban settings (Gausche et al., 1989; Svenson et al., 1996; Seidel et al., 1999).

The availability and qualifications of EMS medical directors are also an issue. Many of these individuals have little or no experience in EMS medical direction. A survey of state EMS directors indicated that recruitment of medical directors is frequently very difficult and that providers serving in that role are often primary care physicians with little or no emergency medicine training. While on-line continuing medical education is becoming more available, it has been slow to take hold; moreover, such training can impart cognitive information, but typically does not teach technical and procedural skills. Nevertheless, the use of telemedicine and distance learning allows previously inaccessible training to penetrate remote areas, while new, more realistic and dynamic patient simulators enable case-based honing of critical skills and decision-making abilities. These tools may be able to offset some of the problems with skill deterioration due to the limited experience attained in rural areas (McGinnis, 2004).

Addressing Rural EMS Challenges

A number of strategies for optimizing EMS resources have been proposed to deal with the paucity of funding, response units, and other resources in rural areas. One such proposal is the dynamic load-responsive deployment of ambulance units. With this approach, ambulances are positioned strategically throughout an area and are dispatched centrally in an effort to reduce response times. Determination of where to position individual units is based on the demand in each area combined with the distance to be traveled, using an established average response time. In one study, load-responsive deployment in a rural area resulted in a 32 percent increase in the number of calls responded to within the established time allowance of 8 minutes (Peleg and Pliskin, 2004). While promising, however, this approach is not possible in very isolated rural communities where EMS units are staffed by volunteers who respond from home.

Another method found to increase the efficiency of EMS systems in rural areas is the establishment of regionally based systems. Such systems may be organized in countywide or larger areas, with ambulances being prepositioned in strategic locations and dispatched centrally (Key, 2002). Basic EMS providers and fire departments scattered throughout the area can act as first responders, with fully equipped units responding after dispatch. Such a system has been used successfully on San Juan Island, a rural island off the coast of Washington State. Killien and colleagues (1996) demonstrated a survival to discharge rate for out-of-hospital cardiac arrest of 22 percent employing this type of system, whereas most studies in rural areas have found survival rates of less than 10 percent (Killien et al., 1996). One of the largest rural regional EMS systems in the United States is that of the East Texas Medical Center. This system serves nearly 17,000 square miles over 17 counties, with 85 ambulance units and two helicopters. Units are dispatched through a central 9-1-1 dispatcher using a modern global positioning system for geographic information (East Texas Medical Center Regional Healthcare System, 2004). In this way, a large rural area encompassing many counties can be served by an EMS system with up-to-date equipment and resources that could not be sustained financially by any one county alone.

Another issue pertinent to rural settings is the involvement of citizens or lay first responders who can provide first aid, start CPR, and take other measures while awaiting the arrival of EMS. The 2005 World Health Organization report Prehospital Trauma Care Systems strongly recommends such citizen engagement, particularly in resource-poor communities that cannot afford costly or sophisticated EMS systems (Sasser et al., 2005). Training dispatchers to give prearrival instructions can help reinforce citizen involvement, with or without prior CPR and first-aid training. Although the current standard for CPR training is a 4-hour class taught by a paid instruc-

tor, research has shown that citizens can teach themselves CPR with a video and inexpensive manikin in 30 minutes (see Chapter 4 ). Numerous benefits can result, including more consistent provision of first aid, rapid access to bystander CPR, enhanced community response to disasters and mass-casualty events, and possibly more rational use of EDs and EMS assets.

Role of EMS in Rural Public Health

Individuals in rural communities have less access to the full range of essential public health services than their urban counterparts (U.S. Congress, Office of Technology Assessment, 1989). Many such areas have no local county or city public health agency, and those public health departments that do serve rural areas have few if any staff with formal public health training (Pollock, 2001). As a result, the rural EMS system often assumes a broader role in the community than the typical urban system with regard to both the medical needs of individuals and the public health and safety of the community overall. Because of the lack of physicians and nurses and other medical facilities, it is not unusual in rural communities for EMS to provide informal evaluation, advice, and care that are never reflected in an EMS patient’s record and do not involve transportation (McGinnis, 2004). The lack of public health departments may require rural EMS personnel to assume leadership roles in tasks performed traditionally by public health departments, such as immunizations (Pollock, 2001). Finally, the lack of capacity of rural public health departments and a limited rural public safety infrastructure result in greater reliance on rural EMS personnel to participate in disaster preparedness relative to their urban counterparts (Spaite et al., 2001).

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Emergency Medical Services (EMS) is a critical component of our nation's emergency and trauma care system, providing response and medical transport to millions of sick and injured Americans each year. At its best, EMS is a crucial link to survival in the chain of care, but within the last several years, complex problems facing the emergency care system have emerged. Press coverage has highlighted instances of slow EMS response times, ambulance diversions, trauma center closures, and ground and air medical crashes. This heightened public awareness of problems that have been building over time has underscored the need for a review of the U.S. emergency care system. Emergency Medical Services provides the first comprehensive study on this topic. This new book examines the operational structure of EMS by presenting an in-depth analysis of the current organization, delivery, and financing of these types of services and systems. By addressing its strengths, limitations, and future challenges this book draws upon a range of concerns:

• The evolving role of EMS as an integral component of the overall health care system.

• EMS system planning, preparedness, and coordination at the federal, state, and local levels.

• EMS funding and infrastructure investments.

• EMS workforce trends and professional education.

• EMS research priorities and funding.

Emergency Medical Services is one of three books in the Future of Emergency Care series. This book will be of particular interest to emergency care providers, professional organizations, and policy makers looking to address the deficiencies in emergency care systems.

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Emergency Medical Services Essays

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The emergency department is a fast-paced and challenging environment where healthcare professionals must be prepared to handle a wide range of medical emergencies. Whether you are a student studying to become a nurse or doctor, or you are already working in the emergency department, having a solid understanding of various essay topics can help you enhance your knowledge and skills in this field.

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• The role of emergency medicine physicians in the emergency department
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A Systematic Review of Workplace Violence Against Emergency Medical Services Responders

Regan m. murray.

1 Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA

Andrea L. Davis

Lauren j. shepler, lori moore-merrell.

2 International Association of Fire Fighters, Washington, DC, USA

William J. Troup

3 United States Fire Administration, Emmitsburg, MD, USA

Joseph A. Allen

4 University of Utah Health, Salt Lake City, UT, USA

Jennifer A. Taylor

Associated data.

Emergency Medical Service (EMS) responders deliver patient care in high-risk, high-stress, and highly variable scenarios. This unpredictable work environment exposes EMS responders to many risks, one of which is violence. The primary goals of this systematic literature review were to (1) define the issue of violence experienced by EMS responders and (2) identify the risk factors of violence associated with the EMS profession. An innovative inclusion of industrial literature with traditional peer-reviewed literature was performed. Of 387 articles retrieved, 104 articles were assessed and reviewed. Career exposure for EMS responders to at least one instance of verbal and/or physical violence was between 57 and 93 percent. There is a great need for rigorously designed, nationally representative examinations of occupational exposures in order to better understand the temporal associations of violence, cumulative occupational stressors, and the outcomes of physical and psychosocial injuries that are occurring as a result of exposures to violence.

Introduction

The Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health (NIOSH) define workplace violence (WPV) as “violent acts, including physical assaults and threats of assaults, directed toward persons at work or on duty.” 1 The often unrecognized psychosocial component of violence is further refined in the World Health Organization’s definition of WPV as “incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.” 2 Health-related industries, particularly those involving patient care, experience the highest rates of WPV compared to all other industries—with patients described as the most significant contributor to provider injuries resultant from violence. 3

In the United States, the Emergency Medical Services (EMS) profession is comprised of approximately nine hundred thousand paid and unpaid (volunteer) EMS providers, responsible for an estimated annual patient volume of twenty-two million. 4 Due to the lack of a centralized licensing body, capturing a true estimate of the total number of EMS agencies and providers on a national level is difficult. 5 Increasingly, 911 emergency response systems are experiencing a departure from fire-related calls, toward a greater number of calls for EMS. 6 Of the 34.7 million calls to 911 in 2017, the average majority (64%) were for medical assistance 7 with some fire departments experiencing upward of 80 to 90 percent of their call volume dedicated to the EMS side of their work. 8 In 2015, there were twenty-nine million calls for EMS services, a 23 percent increase from 2014. 9 This increase represents a continually growing trend in the United States. Subsequently, the 911 response system is strained and increasingly calling upon EMS responders to deliver services 6 contributing to their feelings of being “banged-up and burned out.” 10 Feelings of burnout coupled with exposures to violent incidents can have lasting impacts upon EMS providers. 11

Increased community demand for services necessitates increased patient interactions, thereby increasing the injury potential to EMS responders. In 2016, approximately three thousand five hundred EMS responders were treated in the emergency department (ED) due to injuries sustained from violence. 12 A retrospective cohort study of nationally registered Emergency Medical Technicians (EMTs) found that assault was the cause for 8 percent of fatal injuries. 4 While these numbers may seem small in comparison to the nature and cause of other leading occupational injuries and fatalities in the fire and rescue service, there is evidence to believe injuries related to violence are vastly underreported due to the nonexistence of policies, procedures, and practices to support reporting of such incidents. 6 , 11 Yet, work-related injuries among EMS responders were three times higher than the national average for all other occupations in 2013. 4 The rate of occupational fatalities among paramedics is more than twice the national average for all occupations and comparable to the rates of police and firefighters at 12.7 per one hundred thousand workers per year. 13 The rate of nonfatal injuries among paramedics is more than five times higher than the national average for all workers at 34.6 per 100 full-time workers per year. 14 Fatal assault (i.e., homicide) was found to be the third leading cause of death for EMS workers upon review of three fatality databases. 13

Serving as a crucial public health safety net, EMS is in a constant state of response to the persistent and emerging health needs of the community. 15 As a result, EMS responders are expected to provide patient care in unpredictable and ever-changing environments, and while some occupational hazards are “clear and imposing,” others, like violence, can be “insidious and silent.” 16 While legally, no EMS responder must unreasonably place their own life in jeopardy as maintained in the Occupational Safety and Health Act’s (OSHA) General Duty Clause, Section 5(a)(1) of 1970, 17 the expectations of the community coupled with the internalized belief among responders that they exist to serve frequently place the safety of the responder as secondary to the safety and well-being of the patient. 18

Less than a decade after the formal recognition of the EMS system in 1973, 19 industry publications mentioning violent patient encounters began to surface. 20 The year 1978 marks the beginning of a decades-long conversation by the EMS industry about violence experienced in the workplace when the phenomenon “aggression begets aggression” was first noted. 20 Similar sentiments continue to be voiced by emergency medical providers four decades later. 11 By contrast, the first academic study was published in 1993. 21 Research on violence against EMS responders categorized violence as verbal abuse, physical abuse, property damage or theft, sexual harassment, sexual assault, and intimidation. 22 – 27 Acts of violence against EMS responders have been reported as “struck by patient,” “punched in the face by a drunkard,” “tackled by a large man,” and “assaulted by a combative patient.” 11 Formal recognition of this issue is increasing; however, compared to other healthcare settings, WPV in the prehospital setting is inadequately described and requires further consideration. 21 , 24 , 27 – 31

The primary objective of this literature review was to describe what is known about the phenomena of violence against EMS responders by patients and bystanders. An innovative approach was taken to include academic and industrial publications. The second objective of this literature review was to identify risk factors and outcomes of violence in EMS.

Literature Search Strategy

This systematic review was conducted in accordance with the preferred reporting items for systematic reviews from the PRISMA-P checklist. 32 Review of industrial literature has been excluded from prior academic research on this topic. We chose to include the voices and perspectives of the industry to provide a more complete and comprehensive representation of the violence experienced by EMS responders. Three academic databases (PubMed, CINHAL, and Web of Science) were utilized systematically and iteratively to collect manuscripts from peer-reviewed and industrial trade journals, using EMS-specific terminology ( Table 1 ). Medical Subject Headings (MeSH) operationalized the search by providing delineated sets of terms allowing various levels of specificity and contributing to the collection of relevant literature. As such, the term “Emergency Responder” when used with the MeSH subject heading automatically included the terms Emergency Medical Technician, Firefighter, and Police in the search results. MeSH subject headings were only used if the MeSH hierarchical terms were relevant to the field of EMS (e.g., “emergency responder” was used with MeSH headings because it returned results pertaining to EMTs and firefighters). In each database, operands and operators (e.g., “AND,” “OR,” and “NOT”) increased the number of relevant manuscripts as they permitted emphasis on desired search terms (e.g., assault OR violence) and excluded any unwanted subjects or terms (e.g., police). Additionally, the asterisk indicated in Table 1 denotes searching for a derivate of the search term.

Literature search terms used to retrieve academic peer-reviewed literature and industry publications through PubMed, CINHAL and Web of Science.

Note . Asterisk denotes searching for a derivative of the search term.

Selection of Articles for Review

The literature review was conducted in three phases: Phase 1 involved evaluating each article based on its title, abstract, and keywords; Phase 2 involved reviewing, assessing, and documenting titles and abstracts in chronological order; Phase 3 involved reviewing, assessing, and documenting the full articles of those deemed relevant based on the first two phases. In Phase 3, literature was coded per an iterative process in which major themes were recognized and cataloged. Phase 3 also included manual searches of the retrieved articles for additional references. A total of 104 full-text articles were reviewed for in-depth analysis based upon prioritization and relevance to our research question ( Figure 1 ).

Flow diagram of literature search and retrieved results.

Criteria for Inclusion and Exclusion

The researchers decided the inclusion or exclusion of specific articles based on the process described here, which is consistent with current literature review convention. 33 Articles were excluded if (1) they did not discuss violence to EMS providers, (2) were published in a non-English language, (3) full-text versions were unavailable, and (4) were not in a prehospital environment or ED. All literature relating to the issue of violence in EMS published prior to 31 December 2016 was considered. Endnote, a referencing software tool, was used to assist with deduplication, ease of access, and citation of manuscripts. Special effort was made to find evaluated studies that would give rise to an evidence base of effective violence prevention interventions. While academic literature allows for enumeration and quantification of violence, industry publications discuss specific knowledge neglected by the scientific literature and provide a rich contextual portal into the realities of EMS work. Therefore, it was determined early in the literature search that industry-specific publications, such as trade journals and magazines would be included in this review.

Of the 104 articles we retained for analysis, thirty-six were from industrial trade journals and sixty-eight articles were from academic journals (see online supplements Tables 2 and 3 ). Of the sixty-eight peer-reviewed articles, twenty-seven articles provided some estimate of violence (see online supplement Table 4 ). Of the twenty-seven articles measuring the prevalence of violence, fifteen articles defined or described the types of violence being measured.

The articles retained for analysis revealed eight key themes: “evolution of the definition of workplace violence,” “estimates of violence,” “psychosocial impact (stress),” “EMS responder-level characteristics,” “characteristics of perpetrators of violence,” “reporting/underreporting,” “industry best practices, policies, and procedures,” and “intervention and policy opportunities.” The tables include a descriptive statement, summary of major findings, and weight of evidence assessment for each article.

Evolution of the Definition of WPV

Definitions of WPV in EMS have gradually evolved to encompass more comprehensive classifications as the EMS system has developed. For instance, one of the first industry definitions of WPV defined it as “violent client behavior destructive to self, others or property.” 34 As previously stated, evaluation of the definition became inclusive of psychological impacts including cumulative stress and burnout. 2

Often, the definitions used to measure violence in research are purposefully selected and operationalized by the researcher, thereby resulting in varying violence measures. 35 In EMS-focused research on WPV, many survey studies do not define violence for the participants. When no definition of violence is predetermined or defined, it may be concluded that the interpretation of violence may vary significantly from participant to participant. 35 Across selected studies, no standardized definition of violence was used. Of studies measuring frequency of violence, 37 percent (ten out of twenty-seven articles; see online supplement Table 3 ) did not define or differentiate between types of violence (i.e., verbal assault versus physical assault). 4 , 21 , 26 , 27 , 36 – 41 In 15 percent of studies (four out of twenty-seven), violence was determined after using other proxy terms such as “homicide” or injury-related terms. 11 , 13 , 14 , 42

The lack of a standardized definition of WPV is problematic when attempting to describe the prevalence of violence, risks of exposure, and types of violence experienced. The American College of Emergency Physicians has recognized this limitation and has emphasized the importance of categorizing violence against EMS responders. 43 In response, we found the work of Koritsas et al. to be comprehensive and more highly utilized than any other definitions in the EMS literature, defining types of WPV against EMS responders:

• Verbal abuse: a patient/client, their friend(s), family member(s), other professional(s), or work colleague(s) using offensive language, yelling, or screaming with the intent of offending or frightening you. It can include threats of abuse over the phone but excludes sexual harassment and sexual assault.
• Property damage or theft: a patient/client, their friend(s), family member(s), other professional(s), or work colleague(s) causing damage to, or stealing property belonging to you, your family, or your workplace. It includes damage to or theft of a vehicle, personal effects, home contents, office equipment and supplies, or office furnishings. Attempted theft of the above items is also included.
• Intimidation: a patient/client, their friend(s), family member(s), other professional(s), or work colleague(s) purposely threatening, following you, or using gestures to purposely offend or frighten you.
• Physical abuse: a patient/client, their friend(s), family member(s), other professional(s), or work colleague(s) physically attacking you, or attempting to attack you. It includes behaviors such as punching, slapping, kicking, or using a weapon or other object with the intent of causing bodily harm.
• Sexual harassment: any form of sexual propositioning or unwelcome sexual attention from a patient/client, their friend(s), family member(s), other professional(s), or work colleague(s). It includes behaviors such as humiliating or offensive jokes and remarks with sexual overtones; suggestive looks or physical gestures; inappropriate gifts or requests for inappropriate physical examinations; pressure for dates; and brushing, touching, or grabbing excluding sexual touching (e.g., the genital or breast area).
• Sexual assault: any forced sexual act, rape or indecent assault perpetrated by a patient/client, their friend(s), family member(s), other professional(s), or work colleague(s). It includes brushing, touching, or grabbing of the genitals or breast. It also includes attempted sexual assault. 29

Thus, where applicable, we describe the extant literature in the following terms: verbal abuse, property damage or theft, intimidation, physical abuse, sexual harassment, and sexual assault. 29

Estimates of Violence

The key methods used to quantify the problem of violence against EMS responders have been cross-sectional surveys, direct observations, and injury reports. These methodological variations do not permit cross-comparisons between studies because they do not contain the same population denominator, and the intervals of violence measurement vary. While some studies assess career exposure, others compare rates of violence occurring over the last twelve months, three months, or one month. Thus, we can only describe the estimates and ranges of violence that exist compared to the population from which they were collected, and the appropriate time frame measured (see online supplement Table 4 ).

To date, there have been four studies conducted in the United States that may be considered nationally representative. These four studies utilized survey data from nationally certified EMS responders participating in the Longitudinal EMT Attributes and Demographics Study (LEADS) administered by the National Registry of EMTs. 5 , 15 , 44 , 45 These data are the most comprehensive information on demographic characteristics and occupational injuries and exposures in EMS responders at the present time. Gormley et al. 44 note that while the National EMS Certification is required in forty-six states, nationally certified EMS responders are found in each state.

In studies measuring career prevalence, between 57 and 93 percent of EMS responders reported having experienced at least one act of verbal and/or physical violence during their career. 21 – 24 , 26 , 27 , 46 – 48 A 2013 LEADS found that among the 1789 respondents of nationally registered EMTs in the United States, 69 percent experienced at least one form of physical and/or verbal violence in the last twelve months. 44 Furthermore, 44 percent experienced one or more forms of physical violence over the same study period. 44 Gormley et al. 44 defined violence in seven categories: cursing or making threats; punching, slapping, or scratching; spitting; biting; being struck with an object; stabbing or stabbing attempt; and shooting or shooting attempt. A New England study with a convenience sample of EMTs found the prevalence rate of violence to be 20.3/100 full-time employees/year. Thirty-eight percent of those surveyed reported multiple assaults within the last six months, and one EMT reported being assaulted nine times during that same six-month period. 38 Conversely, crude estimates from a study conducted in Southern California found a much lower frequency of 0.4 assaults per year per prehospital care provider. 27 Non-U.S. studies find comparable rates, with studies ranging from 67 to 88 percent of respondents whom reported some form of verbal and/or physical violence in the last twelve months. 22 , 23 , 46 In a mixed methods study of violence on rural and urban EMS responders in Sweden, rates of verbal and physical violence in the last twelve months were 67 and 78 percent, respectively, showing similar rates to U.S. violence exposures. 46 In this same study, an additional 35 percent reported being victimized at least every three months. 46

Verbal abuse, physical assaults, and intimidation were the most frequently reported types of violence. 22 , 23 , 25 – 27 , 49 Verbal violence was repeatedly described as the most prevalent form of occupational violence that EMS responders reported. 22 , 23 , 25 , 26 , 44 , 46 , 48 , 50 , 51 The range of verbal violence ever experienced by EMS responders is estimated to be between 21 and 88 percent. 23 , 25 , 28 , 46 The range of physical violence ever experienced by EMS responders is estimated between 23 and 90 percent. 2 , 52 Sources of physical violence varied. The most frequent source of physical violence was “struck by” attempts, followed by “punching, slapping, or scratching,” “spitting,” and “biting.” 22 , 26 , 39 , 44 , 53 The least frequent types of physical violence experienced by EMS personnel were “stabbing or stabbing attempts” and “shooting or shooting attempts.” 44 Minor injuries from these actions of violence include minor bruises and abrasions, whereas more serious injuries included contusions, hematomas, sprains and strains, eye injuries, facial injuries, bites, lacerations, dislocations, and fractures. 27 , 47 , 53

Psychosocial Impact (Stress)

While we found robust evidence on the expected physical outcomes of violence against EMS responders, equally concerning information was discovered about the psychosocial impact of experiencing violence in this work. Some research found violence to be the leading cause of stress, 26 and stress found to be the most frequent injury reported by EMS survey respondents. 38 Violence exposure also has been associated with increased levels of stress, fear, and anxiety in EMS responders. 41 Oftentimes, stress is a result of exposure to traumatic incidents in the field. A systematic review of occupational risk factors in EMS found that between 82 and 100 percent of responders reported experiencing a traumatic event. 54 Numerous studies place prevalence rates of posttraumatic stress disorder in EMS responders to be greater than 20 percent. 54 – 60

Stress has been categorized not only by exposure to traumatic incidents but also by exposure to the monotonous operational characteristics in EMS such as paperwork, lack of administrative support, low wages, long hours, irregular shifts, and cynical societal attitudes toward public safety officers. 61 , 62 Attitudes about job performance, job stress, and lack of job satisfaction have been found to impact employee retention rates. 63 , 64 Cumulative stress associated with the monotonous duties or low acuity calls and experiences with violence has led to EMS responders feeling decreased empathy toward their patients and desensitized from their job as a whole. 6 , 11 , 65 Chronic organizational stressors in combination with cumulative exposure to critical incident stress, such as violence, can increase the risk for negative psychological outcomes like posttraumatic stress disorder. 54

Chronic organizational stress and cumulative critical incident stress from repeated traumatic exposures can also lead to organizational outcomes such as burnout. Burnout, defined as a “syndrome of emotional exhaustion and cynicism,” 66 is one of many organizational outcomes that may arise as a result of violence experienced by EMS responders. The question of whether or not violence would eventually lead to burnout was first raised by the industry in the early 1990s, 62 yet there is little known about the issue, and studies of burnout in EMS have been described as lacking. 60 , 67 , 68 Despite this, burnout has been identified as a potential factor associated with decreased levels of quality patient care. 65 , 69 Furthermore, mixed methods studies conducted in Sweden and the United States found that violent encounters alter the patient–provider relationship. 11 , 46 Similar to findings in EDs, 69 , 70 a 1998 study found that 7 percent of survey respondents within one urban fire department considered leaving EMS as a direct result of the violence they experienced on the job, and 42 percent stated that violence had an overall effect on their attitudes about their job, 26 suggesting that despite the lack of abundant evidence, there is a concerning relationship between burnout, violence, and quality of patient care.

EMS Responder-Level Characteristics

Age was found to be a significant indicator for increased risk of violence in three selected studies. 22 , 44 , 53 Conversely, one study of Canadian paramedics found age to be a protective factor and described that with each incremental increase in age, medics were less likely to be exposed to verbal violence. 22 In a nationally representative sample of EMTs in the United States, responders who experienced physical violence from a patient were 1.9 years younger than those who did not experience violence in the last twelve months. 44 In Mechem et al.’s 53 study detailing intentional and unintentional assault, the average age of victims was 37.0 ± 8.2 years and 33.8 ± 8.4 years, respectively, marking no difference in age. Therefore, we find the evidence supporting age to be inconclusive.

While some studies indicated with statistical significance that men were more likely to experience violence, 25 , 28 , 38 , 53 others found women were more at risk. 22 , 39 Not until Gormley et al. 44 and Oliver and Levine 45 utilized longitudinal cohort designs was this risk factor studied under more rigorous conditions. They found that among nationally registered EMTs, women had an increased risk for physical violence, 44 while men had an increased risk for verbal violence. 44 , 45 Other research found the female gender to be a predictor only for cases of sexual assault and sexual harassment, 23 while another study found women at significant risk with regard to sexual assault, sexual harassment, and verbal violence. 29 In a review of three fatality databases, women were found to be the majority of EMS assault-related fatalities. 13 We found conflicting evidence of gender as a risk factor for EMS responders.

Years of experience.

Some research shows that work experience is not a significant risk factor for encountering violence. 22 , 47 Gormley et al. 44 found that personnel who had experienced violent patient encounters had more than double the median years of experience in a longitudinal cohort study of nationally registered EMTs. Likewise, Oliver and Levine 45 found that EMTs or their partners with more than ten years of work experience were more likely to experience violence in the form of being punched, slapped, or scratched compared to less experienced EMTs. These findings present inconclusive evidence supporting years of experience as a risk factor for EMS responders.

Occupational role.

In Philadelphia, one study analyzed all injuries reported between January 1996 and December 1998. Of 1,100 injury reports related to violent incidents, 93.2 percent of documented assaults occurred during patient care activities, suggesting that EMS calls pose more risk compared to fire calls. 53 All other selected research yielded results showing provider level to be significantly associated with increased risk of violent interactions. Robust evidence points to paramedics being at increased risk for violence compared to firefighters. 11 , 44 , 53 Responders who spent more time providing direct patient care were at increased risk for violence. 29 In one fire department, the odds of paramedics being assaulted compared to their firefighter counterparts were fourteen-fold higher. 11 Thus, these findings present robust evidence of occupational role as a strong characteristic associated with WPV.

Characteristics of Perpetrators of Violence

The literature identifies several patient characteristics associated with violent events including age, gender, mental status, substance abuse, and underlying health condition. No data exist describing which of these characteristics is the most frequent. We describe what is known from the extant literature included in this review.

A large body of evidence points to patients as the most common perpetrator of violence. 5 , 13 , 22 , 25 , 26 , 28 , 34 , 38 , 42 , 44 , 46 , 47 , 50 It is worthwhile to consider the environment associated with providing pre-hospital care, as violent behaviors may be exacerbated by the confined space of an ambulance. Another consideration to note is the limited translation and transferability of policies, procedures, and practices that provide important institutional mechanisms to protect the safety and health of workers in the “bricks and mortar” fixed environment to that of the mobile EMS environment. These findings strongly suggest the patient as the primary contributor of violence against EMS providers.

Patient’s family, friend, or bystanders.

Patients are not the only perpetrators of violence. Violence is also initiated by nonpatients such as family members of patients and bystanders. 25 , 26 , 44 , 46 , 47 , 50 , 53 , 71 In a prospective, observational case-series study of 297 EMS runs conducted over 737 hours of observation, the violent person was not the patient in as many as one third (five out of sixteen) of violent calls. 25 A separate observational case-series found “others” to be the cause of violence in 10.3 percent (19 out of 184) of violent calls. 28 Studies were uniform in their findings that in addition to patient-initiated violence, family, friends, and bystanders also frequently engage in violence against EMS.

Mental status, substance abuse, and underlying health conditions.

In a study of violent patients in the ED, those who demonstrated violent behaviors were more likely to be suffering from an altered mental capacity, compared to violent patients committing violence against EMS responders. 49 In the prehospital setting, Bernaldode-Quiros et al. 49 found that a majority (55.2%) of violent patients had no known altered mental capacity, and fewer than half of violent perpetrators had a psychiatric disorder or were under the influence of drugs and alcohol. Conversely, a prospective case-series study found that a suspected psychiatric disorder was significantly associated with violence against EMS responders. 28 Further, industry perspectives were uniform that three of the major patient characteristics associated with violence are intoxication, drugs, and altered mental status. 16 , 72 Several academic studies support this claim. 22 , 25 , 39 , 46 , 47 Additional research suggests that any medical condition that causes an altered mental status or consciousness, such as trauma and diabetes, may lead to patients committing violent acts. 16 , 21 , 22 , 39 , 47 , 53 , 72 – 74 For instance, insulin-dependent diabetics experiencing hypoglycemic episodes were the cause of 9 percent of violent incidents in a retrospective review of ambulance call reports over a six-month study period. 21 In the larger healthcare context, altered mental status associated with dementia, delirium, and substance intoxication were the most common characteristics of violence perpetrators against healthcare workers. 75 – 80 These studies provide strong support that the patient’s medical status is a potential indicator for violent behavior.

Weapon possession.

In studies measuring weapon possession, weapons were present on scene in less than 12 percent of violence-related patient cases. 21 , 25 , 26 Although these studies suggest a relatively low incidence of weapons possessed by violent or combative patients, other research shows that many EMS responders may not be equipped or prepared to deal with the issue. As many as 42 percent of study participants comprised of EMS responders from the Boston and Los Angeles metropolitan areas indicated that they did not regularly search their patient for weapons, yet 62 percent had found a weapon on a patient in the course of their careers. 48 Another study showed that as many as 79 percent of respondents reported having “ever seen or found” a weapon on a patient. 27 More years of experience and those trained at the paramedic level were significantly associated with finding weapons on patients. 49 Likewise, EMS responders who had received weapons-specific training were more likely to report weapons found. 49 These studies suggest the need for more robust research to understand the role of a patient’s possession of a weapons.

Violent call type.

Violent call type, a call that comes into dispatch as violence-related, is an understudied characteristic of the occupation that may be predictive of exposures to violence. One study found that while only 5 percent of calls (297 EMS runs over 737 hours of observation) involved a violent situation directed at EMS responders, an additional 14 percent of calls were flagged as locations where violence was mentioned to have occurred prior to the arrival of EMS responders (i.e., “postviolent” runs). 25 The 14 percent indicates a potentially hostile environment for responders upon arrival. Consequently, Mock et al. 25 suggest that 5 to 20 percent of sampled EMS calls in the urban EMS system were related to either physical or verbal violence. However, dispatch codes intended to alert responders to potentially violent scenes were not used in almost 40 percent of violent calls. 25 An analysis of responder narratives from the near-miss and injury events reported to the National Fire Fighter Near-Miss Reporting System revealed that violence may not be anticipated by responders in many cases, as violence can often erupt instantaneously. 42 Evidence supporting violent call type is inconclusive and future studies should continue to evaluate this variable in relation to WPV experienced in EMS.

Other factors.

Other potential contributing factors for violent patient behaviors include dissatisfaction with response time 49 ; lack of understanding of treatment and care needs 49 ; feelings of helplessness, frustration, and anger in the face of an emergency 47 ; wishes to refuse transport 25 ; culture clash 47 ; and communication or language inadequacies. 47 , 49 Similar factors have been indicated in the larger healthcare context. 81 Unlike other fields which have found a history of violence to be a precursor to committing interpersonal violence, 82 , 83 the relationship between history of violence and resulting violent acts against healthcare workers has not yet been found. 84 Additional research on factors that contribute to and presage violent patient behaviors in healthcare and EMS is needed.

Reporting/Underreporting

One of the limitations that is frequently mentioned in both academic and industrial publications is the perception that violence is inherent to the profession and reporting violent incidents implies an inability to provide patient care and perform job duties competently. 27 Such attitudes might lead to significant underreporting of violence in the field. 26 A study of 1,500 medical providers in New Mexico found that 56 percent of EMS survey respondents stated that violence is “just a part of the job.” 85 And although a large percentage believe violence is a part of the job, 40 percent believed that if no one was injured during the incident then there was no need to report. 85 Reasons for not reporting violent encounters include the fear of punitive actions such as being fired. 85 Other studies show higher frequencies, with as many as 71 percent believing that violence is a part of their job, and 84 percent believing that their personal safety was at risk as a direct result of violence. 26 In a Canadian study, 62 percent of participants stated that no actions were taken by most paramedics in response to the violent events, 61 percent did not report the violence to a superior or authority, and 81 percent did not formally document the occurrence in the patient care report narratives. 22 Regarding proper documentation of violent encounters, one study found that only 31 percent of all violent encounters were properly mentioned in the paramedic narrative. 25 This indicates that while the rates of violence from the literature are concerning, there is reason to believe that violence is vastly underreported and ill-documented in EMS. Therefore, any retrospective reviews of ambulance calls or paramedic narratives are likely to be missing the true prevalence of violence experienced by responders. 25 These research studies provide strong evidence that the issue of WPV in EMS is vastly underreported.

Industry Best Practices, Policies, and Procedures

To date, there exist no evidence-based interventions in the academic literature that prepare EMS responders for violence. Therefore, EMS has relied heavily on industrial publications to disseminate best practices, policies, and procedures. Industrial literature primarily highlights the use of prevention strategies to keep EMS providers from entering a potentially violent situation, such as scene safety. 86 – 96 If scene safety precautions indicate potential violence, or if there is a known history of violence for that patient or location, current recommendations largely suggest requesting police backup; however, it is also cautioned that police do not guarantee responder safety and are not always available to respond to EMS requests for backup. 86 – 89 , 91 , 97 – 101 While dispatch is integral to EMS operations, patient information received by EMS from dispatch is often unclear, incorrect, or incomplete, thus contributing to EMS responders feeling unsupported and placed unnecessarily in dangerous situations. 11 The industrial literature recognizes these fractures within the EMS system and heavily emphasizes the need to build and maintain supportive relationships between EMS and other organizational entities such as police and dispatch 86 – 89 , 91 , 97 – 100 , 102 and is supported in academia as well. 71 , 103 , 104

The industrial literature also emphasized the need for significant improvements to the quantity and quality of trainings provided to EMS responders, inclusive of de-escalation trainings to confer professional command and control in the event of unexpectedly violent persons. 97 , 105 , 106 The industrial literature is particularly helpful in identifying specific call types and situations most likely to be associated with violence, such as alcohol or drug use, gang violence, homicides, domestic violence, mental health and psychiatric calls, suspected suicides and suicidal ideation, active shootings, bombings, terrorist events, and other events that pose threats of mass casualties. 16 , 102 , 107 , 108 It is a lack of training that leads individuals to use excessive force or “pick the wrong tool to solve the problem” in many of these scenarios. 97 , 109

Discussions regarding self-defense have become highly controversial, due to some attempts or requests by EMS organizations or EMS responders to arm personnel with weapons such as guns, tasers, mace, and pepper spray as additional forms of protection. 11 , 91 The industrial literature provides warning that protective measures designed to arm EMS responders should be considered only as a last resort, and others argue whether their implementation is needed at all. 91 , 100 , 110 No standards or evaluations on effectiveness exist for departments considering this protective measure. Furthermore, it has been posited in the academic literature that protocols to increase the safety of communities, in addition to training to provide confidence and competency in the face of violence, might supplant the need for EMS personnel to carry weapons for personal protection. 27 While providing body armor is less controversial than providing armament to EMS responders, it remains heavily debated. 87 , 100 , 111

Intervention and Policy Opportunities

Currently, violence prevention training that exists consists of generic programs that are not tailored to the prehospital patient care provider and unique EMS mobile environment. 112 Available trainings also tend to focus primarily on self-defense techniques rather than prevention. 112 Infantino 34 suggests the following considerations for an EMS violence intervention program: environmental considerations, self-assessment, prevention, verbal intervention (calming/defusing techniques), escape and release procedures, control and restraint procedures, staff anxiety decompression, and postincident follow-up. Additional considerations include increasing (1) communication skills with patients and/or relatives and bystanders, (2) the ability to identify high-risk situations, (3) the ability to effectively implement safety measures, (4) support for mental health, and (5) the availability of resources to professionals who have suffered from WPV. 51

In 1998, the United States Department of Transportation developed a new paramedic-training curriculum that included expanded topics of abuse, assault, and violence. The curriculum is noted to have included learning objectives concerning how to handle victims, diffuse violent situations, and ensure personal safety. 113 However, since authority over EMS initiatives is held by state jurisdictions, individual states can choose not to adopt certain training interventions or curriculums. 71 , 113 There have been calls for development of protocols at the national level in response to violent incidents through initiatives such as the National Fallen Firefighters Foundation Firefighter Life Safety Initiative 12, which states the need for development and implementation of practices and policies to reduce the likelihood that EMS responders will encounter violence, to standardize response protocols, and to increase survivability for fire and EMS personnel when violent situations are unavoidable. 92 , 114 Other entities that advocate for safety and health in EMS include labor organizations, such as the International Association of Fire Fighters, the International Association of EMTs and Paramedics, EMS Workers United/American Federation of State, County and Municipal Employees, and many others. These labor organizations are dedicated and committed advocates that lobby for increased safety and health protections for the EMS work force. In fact, in 2016, the United States Fire Administration subcontracted a study on violence against EMS responders to the International Association of Fire Fighters because of their strong advocacy and commitment to improving responder safety. 115 Labor unions in healthcare and related industries have long called for increased research and protective regulations on the issue. 84 Within fire departments, local labor unions are successful champions of safety and health and advocates of policy change, resource installation, and safe reporting environments. 116 At individual workplaces, union advocacy can bring about changes in policies and in the availability of protective equipment even between contract negotiations. Unions can have an impact on underreporting by advocating for the elimination of disincentives to reporting. All of these can be strengthened further by getting them written into collective bargaining agreements. The ability to build solutions from the bottom up workplace by workplace and demonstrate their feasibility produces immediate gains for the represented workplaces and can ultimately lead to the adoption of similar solutions as best practices, guidelines, and/or enforceable standards. No other kind of advocacy organization can have that kind of direct impact on individual workplaces.

Other active initiatives to address WPV in EMS include the Center for Leadership, Innovation, and Research in EMS (CLIR), which has launched the EMS Voluntary Event Notification Tool to assist in data collection of exposures to violence. 117 In 2010, CLIR partnered with the National EMS Management Association and the End Violence Against Paramedics initiative to include violence in their data collection processes, which can be used to inform the development of interventions. 118 One such intervention that exists is Defensive Tactics 4 Escaping Mitigating Surviving Violence. 119 While this intervention has been developed specifically for the EMS industry, it has not been evaluated to determine its reach and effectiveness. In response to the growing issue of violence, some departments have taken it upon themselves to investigate causes of violence and respond proactively.

While NIOSH has not developed an EMS-specific intervention, they have recommended several best practices for fire departments as a way to prevent and mitigate violence at both the organizational and employee level. 120 In 2004, NIOSH released recommendations on methods to best mitigate violence following the investigation into the death of a female firefighter who responded to the scene of a civilian shooting. 121 While the recommendations have been disseminated, no formal intervention program has been developed nor has a formal evaluation of the recommendations been conducted. NIOSH has also recommended that employers establish a zero-tolerance policy for all incidents of violence, train workers on recognizing and preventing WPV, investigate all reports of violence, and work with police to identify dangerous neighborhoods where special precautions need to be taken and provide that information to employees. From the employee’s standpoint, NIOSH recommends that employees should participate in violence prevention training and report all incidents of violence, no matter how minor. 122

Supplemental to NIOSH’s recommendations are the guidelines proffered by OSHA in their updated 2015 “ Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers .” 75 These guidelines offer critical recommendations on effective approaches to eliminate violence in the workplace, including the essential components to an effective WPV prevention program. While the guidelines are not regulatory in nature, several states including New York and California have adopted these guidelines as policy. 123 , 124 In fact, in 1993, Cal OSHA (the California state OSHA program) was the first entity to establish WPV guidelines, which was a result of the persistent pressuring done by a multiunion task force on WPV. 84 This union-led initiative ultimately informed the creation of the federal OSHA guidelines, 84 further demonstrating the union’s fortified commitment to health and safety, especially as it relates to influencing the local, state, and federal policy arena of WPV. Components of OSHA’s guidelines that are relevant to EMS include their identified risk factors, of which eight out of ten, apply to EMS. 75 In addition, the components to an effective violence prevention program are highly adaptable to the EMS work environment and include management commitment and employee participation, worksite analysis, hazard prevention and control, safety and health training, and record-keeping and program evaluation. 75

While the EMS literature notes that the guidelines developed for violence reduction specific to ED settings do not generalize well to the EMS industry, 27 there is great utility in evaluating educational initiatives in the hospital setting for goodness of fit in the prehospital setting. Interventions such as the “Workplace Violence Prevention for Nurses” online training program have been designed and evaluated as a method to help healthcare workers recognize violence in the workplace and may be useful to consider when developing EMS-specific interventions and policy initiatives that focus on primary prevention. 125

WPV is a concerning and complex issue facing much of the healthcare industry, including EMS. Most of our knowledge on the issue of WPV in healthcare stems from EDs and psychiatric facilities. Indeed, many research findings on WPV in EMS are not unique and have been indicated in the larger healthcare context. 81 , 84 , 126 – 131 However, research on the issue of WPV in EMS is still lacking, with little to offer in terms of prevention programs and policy. This literature review sought to compile what is currently known so that effective interventions and policies aimed at increasing the safety and health of emergency responders can develop.

To date, two systematic reviews have been conducted regarding violence against EMS responders. 132 , 133 Each employed a systematic process: Pourshaikhian’s review included eighteen articles in their analysis, and Maguire’s included twenty-five articles. There are six total articles between the two literature reviews absent from our analysis. This is likely due to their scope and case inclusion criteria, in which Maguire included literature pertaining to military ambulance officers and air ambulances, and Pourshaikhian included articles published in English and Persian. We believe these differences to be insignificant due to the immense return of our literature search which led to a total of sixty-eight academic publications included in our analysis.

Moreover, our case inclusion criteria and review of the literature led to the inclusion of thirty-six industrial publications. The industrial literature provided the unique perspective of how the industry perceives the issue of violence, its ideas for training opportunities, and its attempts at interventions to best mitigate and reduce violence exposures. It is our opinion that academic researchers should source from these publications to the same degree they do the peer-reviewed literature. In particular, the industrial literature gives unique credence to practices already utilized in the fire and rescue service that could be further buttressed by the academic community in terms of intervention development and evaluation. For example, the industrial literature expounds on a variety of best practices used during the multiple phases of emergency response. Fields such as public health and organizational science could bring their considerable prevention acumen to this process. With an approximately 20 percent increase in call volume each year, it is imperative to begin thinking about interventions that focus not on the individual EMS responders by making them do more with less 11 but by shifting the onus of safety and health from the individual to the organization. By utilizing the counsel of the industrial literature, multiple training, policy, and environmental interventions could be developed to better protect the safety, health, and well-being of EMS responders from stress and violence. Such interventions have the potential to impact organizational and safety outcomes in this profession. 134

The academic literature focused on incidence and prevalence estimates. Research conducted through 2016 used cross-sectional designs with small convenience samples. As such, there are very few studies that employed strong scientific design. Other limitations identified include (1) the lack of a standardized definition of violence, (2) variation in study design, (3) depth of data available, (4) insufficient studies using nationally representative data, and (5) wide-ranging estimates. There is a great need for rigorously designed, nationally representative examinations of occupational exposures in order to better understand the temporal associations of violence, cumulative occupational stressors, and the outcomes of physical and psychosocial injuries that are occurring as a result of exposures to violence. Based on current studies, it is not possible to discuss causality among violence risk factors and reported outcomes. Noticeably absent from both industry and academic literature is intervention evaluation to assess the effectiveness of best practices, training programs, and policies mentioned in both literatures. Research in the larger healthcare sector also shows that studies are typically designed to quantify the problem, with little mention or focus on methods designed to prevent violence from occurring. 81 Issues reminiscent of our findings—especially WPV being poorly defined and underreported—complicate the design of evidence-based policy. 81 , 84 , 128 , 129

In the United States, there have been no widely applicable, efficacious interventions to address WPV in healthcare. 81 Due to the high prevalence of occupational violence compared to other industries, healthcare is often the subject of WPV research and initiatives, yet EMS is often absent from these national efforts. While numerous states have enacted felony assault statutes that include first responders, these policies are tertiary in nature and do not offer much in terms of prevention. 135 In order to prevent WPV in EMS from happening, we must focus our policy efforts on primary prevention strategies. The first step in doing so is to have national support advocating for the inclusion of EMS in forums and policy discussions on WPV. We can look to OSHA’s Guidelines for Preventing Workplace Violence to develop strong and effective prevention programs and policies. 75 In 2017, the Department of Labor and OSHA issued a “Request For Information” on the prevention of WPV in healthcare and social assistance (Docket No. OSHA-2016–0014). 136 In response, coauthors of this manuscript submitted an executive summary on WPV in EMS advocating for the inclusion of emergency medical responders in OSHA’s development of standards and policies to prevent violence in the workplace. 137 This level of inclusion is important to ensure that EMS providers are not left out of crucial legislation and prevention opportunities. However, policy at the national-level is not the only way to affect positive changes in the safety and health of EMS providers. By focusing policy efforts at the local-level, we may be able to affect more immediate change by creating EMS-specific solutions to violence. The SAVER Systems-level Checklist, part of a current research study exploring the efficacy of policy and training to prevent WPV in fire-based EMS, holds promise for primary prevention. 138 , 139 It was created as a checklist for the system (department and union leadership teams), as opposed to an individual-level checklist that would put more burden on already overstretched EMS responders. The checklist contains training, policy, and environmental modification interventions organized by phases of EMS response. It has “pause points” which are feedback mechanisms for the individual responder. The pause points redistribute traditional hierarchical power by giving the individual EMS responder the authority to pause an EMS encounter based on perceived risks to their safety. The checklist creates organizational support that can positively impact burnout, morale, and work engagement while decreasing the number of assaults and injuries experienced by EMS personnel. While too early in its implementation to have evaluation results, the SAVER Systems-level Checklist is already inspiring policy and program development within fire departments such as the creation of standard operating procedures for supporting members assaulted on duty (Philadelphia) 140 , 141 and the creation of resilience programs to reduce occupational burnout (Dallas). 142

We undertook this comprehensive literature review to more deeply understand the incidence and prevalence of violence against EMS responders, but in so doing, we uncovered additional stressors that emanate from the organizational culture. Such stressors may be duration of shift for busy EMS responders, the skill mix of personnel on EMS runs, the ability to rest and recover after traumatic or compelling events, and the busyness of responders visiting the community. Also important to consider is the sometimes sensitive nature of this research topic. Sharing sensitive and traumatic details associated with violent exposures can impact an individual’s willingness to report. Academic and industry publications equally posit the notion that violence is an expectation of the work, and the high frequency of violence occurring in the profession has caused it to be internalized as “part of the job.” 26 , 27 , 85 , 98 This perception is validated by the almost nonexistent reporting by EMS responders Thus, it is imperative for leadership in EMS to support and champion consistent and mandatory reporting and follow-up with responders who have experienced violence during the course of their duty. The sharp rise in community demand is an increasing stressor for departments and agencies providing EMS. For example, the top five busiest medic units in the United States run between seventeen and twenty-four calls per day. 143 In a twenty-four-hour period, this gives little or no time to “eat, sleep, or pee.” These added occupational stressors can increase the level of job dissatisfaction that responders experience. 6 Exposures to WPV, especially cumulative exposures, in concert with these added stressors, may result in mental health outcomes such as anxiety, depression, and posttraumatic stress disorder. Poor work environments and deficient social networks, in combination with anxiety, depression, and posttraumatic stress disorder, have been known to lead to suicidal ideation and, in some cases, suicide completion. 59 Future research should systematically measure and understand the degree to which the stress of increasing community demand intersects with the stress of insufficient resources in fire and rescue organizations. Finally, the psychological impact of experiencing violence on the job can change the way EMS responders approach the occupation and has implications for quality of patient care and patient outcomes. 11

We found that from 1978 to 1992, the issue of WPV in EMS is only discussed within industrial trade journals which addressed the risks of the job long before the first peer-reviewed research was published in 1993. While prevalence estimates fluctuate slightly from 1993 to 2016, authors are discussing the same issues forty years later, highlighting the fact that little progress has been made to protect EMS responders against violence in the field. Today, literature on the issue of violence has been bolstered by intensified efforts of EMS organizations and officials to decrease the prevalence of violence in the industry, yet violence remains poorly defined and assessed. This systematic review warrants further rigorous scientific inquiry to better identify risk factors for violence, circumstances surrounding violence, and methods to best mitigate violence so that resources can be properly allocated to protect the health, safety, and well-being of EMS responders. As public health researchers, we are compelled to advocate for increased research and development of interventions and policies to reduce and prevent the occurrence of WPV in EMS. In order to ensure that EMS remains a vital community resource, we must protect the safety and well-being of responders against all harm, starting with the harm caused by the very people they are seeking to help. We have identified the following content areas for future inquiry for EMS-focused research and practice related to OSHA’s Guidelines for Preventing Workplace Violence. These content areas include (1) standardizing the definition of violence used in EMS research; (2) creating reliable and consistent epidemiological surveillance on violence against EMS responders through data system development and recurring surveys; (3) securing sufficient funding for scientific research on EMS violence that uses rigorous scientific designs; (4) identifying and quantifying risk factors of providers, patients, and communities inclusive of stress, trauma, and mental health outcomes; (5) understanding the roles of coping, resilience, and social support in EMS; (6) developing practices, procedures, and policies that support EMS responders; (7) training all responders to recognize and respond to violence on the job; (8) conducting evaluations of existing trainings to measure their effectiveness; (9) developing new trainings as needed and evaluating their effectiveness; (10) conducting economic analyses on the psychosocial impact of violence in EMS; and (11) assessing the impact of violence on patient care and quality.

Supplementary Material

New893388 1, new893388 2, new893388 3, new893388 4, acknowledgments.

The authors would like to thank the following colleagues for their contributions to this manuscript: Kathleen Turner, the Liaison Librarian for the Dornsife School of Public Health at Drexel University, and previous affiliates of the Center for Firefighter Injury Research and Safety Trends: Shannon Widman, Cydney McGuire, Shachi Mistry, and Cecelia Harrison. The authors also thank Dr. Darius Sivin for his contribution in deepening the explanation of how labor unions are uniquely positioned to advocate on the issue of workplace violence.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a subcontract from the International Association of Fire Fighters under their contract with the Department of Homeland Security/Federal Emergency Management Agency/United States Fire Administration contract number: HSFE20-15-Q-0053 and the Federal Emergency Management Agency (FEMA) FY 2016 Assistance to Firefighters Grant Program, Fire Prevention and Safety Grants (Research & Development) Grant number: EMW-2016-FP-00277.

Author Biographies

Regan M. Murray is a project manager and certified emergency medical technician at the Center for Firefighter Injury Research and Safety Trends (FIRST) at the Drexel University Dornsife School of Public Health. She provides oversight to the project funded by the Federal Emergency Management Agency: “Stress and Violence in fire-based EMS Responders (SAVER).” Ms. Murray received her Bachelor of Arts degree from St. Lawrence University and her Master of Public Health degree, concentrating in Community Health and Prevention, from Drexel University.

Andrea L. Davis , MPH, CPH is the senior project manager at the FIRST Center. She earned her Master of Public Health degree from Drexel University in 2012 and holds the designation of Certified in Public Health from the National Board of Public Health Examiners. Ms. Davis holds a Master of Liberal Arts degree from the Harvard University Extension School and Bachelor of Art from the University of Delaware.

Lauren J. Shepler , MPH, is the outreach and communications manager at the FIRST Center. She received her Bachelor of Science degree from North Carolina State University in 2012 and her Master in Public Health degree, concentrating in Environmental and Occupational Health, from Drexel University in 2015.

Lori Moore-Merrell , DrPH, is the president and CEO of the International Public Safety Data Institute. She serves as a senior executive with the International Association of Fire Fighters, responsible for frontline interaction with elected officers; executive board members; state, provincial, and local chapter leaders and individual members throughout the United States and Canada. Dr. Moore-Merrell is an expert in emergency response system evaluation, data collection and analysis, costs and benefits analysis, strategic planning, advocacy, consensus building, and policy development and implementation.

William J. Troup has served at the United States Fire Administration for over twenty-nine years, as the Chief of the National Fire Data Center managing the National Fire Incident Reporting System, On-Duty Firefighter Fatality Reporting Program, the National Fire Department Registry, and other data reporting programs. He oversees United States Fire Administration research programs in Firefighter and Emergency Responder Health and Safety and serves on the DHS Science and Technology First Responders Resource Group.

Joseph A. Allen , PhD, is a professor in Industrial and Organizational Psychology and the Director for the Center for Meeting Effectiveness at the University of Utah. He completed his doctorate in Organizational Science at the University of North Carolina at Charlotte in 2010 and received his Master of Arts degree in Industrial and Organizational Psychology at the UNCC in 2008. Dr. Allen’s research focuses on three major areas of inquiry including the study of workplace meetings, nonprofit organizational effectiveness, and emotional labor in various service-related contexts.

Jennifer A. Taylor , PhD, MPH, CPPS, is an injury epidemiologist and the Arthur L. and Joanne B. Frank Professor of Environmental and Occupational Health at the Drexel University Dornsife School of Public Health in Philadelphia, PA. Dr. Taylor is the founding director of the FIRST Center at Drexel University. She received her doctorate from Johns Hopkins Bloomberg School of Public Health, specializing in Injury Prevention and Control, where she received the Haddon Fellowship and the ERC-NIOSH Training Fellowship in Occupational Injury. Dr. Taylor’s research investigates the impact of safety climate on occupational injury and related psychosocial outcomes among first responders.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

What Is EMS?

Emergency Medical Services, more commonly known as EMS, is a system that responds to emergencies in need of highly skilled pre-hospital clinicians.

But EMS clinicians aren’t just the first healthcare practitioner on the scene; they’re often the first to identify a healthcare crisis in a community and act as a critical component of emergency management and, increasingly, a practitioner of community healthcare.

EMS is most recognizable by its vehicles, helicopters and workforce, which respond to emergency incidents. But far from being simply a ride to the emergency department (ED), this system of coordinated response and emergency medical care involves numerous people and agencies. A comprehensive EMS system is ready every day for every kind of emergency, whether or not that includes going to the hospital.

Despite a robust ecosystem of its own, EMS does not exist in isolation. It integrates with other services and systems intended to enhance the community's health and safety. As seen in the graphic below, EMS operates at the crossroads of healthcare, public health, emergency management and public safety.

The principles and resources of each field are employed in EMS systems. As noted above, the emergence of a significant health problem is often heralded by its arrival in the ED. Because EMS clinicians respond to all kinds of emergencies, hazards and natural and man-made disasters, they often work side-by-side with public safety colleagues in law enforcement and the fire service, with the primary mission of providing emergency medical care.

EMS also plays a role in non-emergent medical care. Community Paramedicine (CP), also known as Mobile Integrated Healthcare (MIH), is a patient-centered healthcare model in which EMS clinicians provide care outside the emergency response system, frequently through scheduled visits in the patient’s home.

These patients are often from underserved populations without ready access to healthcare or health insurance. Community paramedics work closely with primary care physicians, social services and other preventive services, resulting in patients making fewer emergency calls for help and experiencing better health outcomes.

EMS clinicians also play an important role in mental health and behavioral health crisis services. The ideal crisis response model is an integrated service involving EMS, mental health professionals and sometimes law enforcement to provide caring, high-quality support to individuals experiencing a mental health crisis. The goal of crisis services is to increase access to quality mental and behavioral healthcare for those in need.

The organizational structure of EMS, including service providers and financing, varies significantly from community to community. Prehospital services may be based in any number of settings or facilities. Regardless of the provider, the essential components of an EMS system include agencies and organizations, life-saving data , communication and transportation networks, centers and facilities, and highly trained personnel. Data is critical to informing the profession’s national commitment to evidence-based practices . In order to be ready every day for every kind of emergency, an EMS system must be comprehensive, too. Developing and maintaining such a system requires thoughtful planning, preparation and dedication from EMS stakeholders at the local, State and Federal levels.

Learn More About EMS

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EMTALA: Ensuring Emergency Medical Care for all

This essay about the Emergency Medical Treatment and Labor Act (EMTALA) explains its role in ensuring public access to emergency medical services regardless of an individual’s ability to pay. Enacted in 1986, EMTALA was a response to “patient dumping” practices and mandates that hospitals provide medical screening, stabilization, and necessary transfers for all emergency patients, including women in labor. The law aims to guarantee that all individuals receive essential emergency care, preventing discrimination based on financial status. Despite challenges such as financial strain on hospitals and overcrowded emergency rooms, EMTALA remains a crucial element of the U.S. healthcare system, promoting equity and access to emergency treatment for all.

How it works

The Urgent Medical Assistance and Labor Regulation (UMALR) stands as a pivotal enactment in the United States, ensuring universal access to critical emergency services irrespective of an individual’s financial standing. Enacted in 1986, UMALR was formulated to counteract instances of “patient dumping,” where medical facilities, particularly those equipped with emergency departments, would turn away patients due to their inability to afford medical care. This federal statute plays a crucial role in guaranteeing that all individuals receive appropriate emergency medical treatment, fostering a sense of fairness within the healthcare framework.

UMALR emerged as a response to widespread reports of “patient dumping,” an egregious practice where hospitals, predominantly those housing emergency units, would transfer, discharge, or neglect patients based on their financial incapacity to remunerate medical expenses. This practice not only jeopardized the lives of many but also underscored the systemic disparities within the healthcare sector. To address this issue, UMALR mandates hospitals to conduct a comprehensive medical assessment for anyone seeking treatment for a medical condition, regardless of their financial or insurance status.

In accordance with UMALR, hospitals are obligated to stabilize any patient presenting with an emergency medical condition. Stabilization entails administering the requisite medical intervention to ensure that no significant deterioration in the patient’s condition occurs during the transfer or discharge process. If the hospital is incapable of providing the necessary care, they are mandated to facilitate a suitable transfer to a facility capable of delivering the required treatment. This provision ensures that all patients receive a basic level of emergency care and are not deprived of essential medical attention.

UMALR’s purview extends beyond emergency scenarios to encompass women in labor, who must receive treatment and stabilization before undergoing transfer or discharge. This provision recognizes the critical nature of childbirth and ensures that pregnant women receive adequate care during labor, irrespective of their financial means. By incorporating labor into its provisions, UMALR safeguards one of the most vulnerable segments within the healthcare domain.

Compliance with UMALR is enforced through penalties levied against hospitals and physicians found to contravene its provisions. These penalties may include fines and exclusion from federal healthcare programs such as Medicare and Medicaid, which serve as significant sources of financial support for many medical institutions. Oversight of UMALR’s enforcement falls under the purview of the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG), which conduct investigations and impose sanctions as necessary. This regulatory oversight ensures that hospitals adhere to UMALR and uphold a standard of care for all patients.

Despite its noble objectives, UMALR has encountered criticism and obstacles over the years. One of the primary concerns revolves around the financial strain it imposes on hospitals, particularly those situated in underserved or economically disadvantaged areas. Providing emergency care without guaranteed reimbursement can strain hospital resources, leading to financial hardships and, in some instances, closures. Additionally, UMALR has been criticized for creating a “safety net” that may result in overcrowded emergency departments as individuals lacking access to routine healthcare services may turn to emergency rooms for non-urgent medical needs.

Nonetheless, UMALR remains a cornerstone of the American healthcare landscape, embodying the principle that emergency medical care should be accessible to all individuals, irrespective of their financial circumstances. It epitomizes a commitment to medical ethics and human rights, ensuring that no one is deprived of potentially life-saving treatment due to an inability to pay. The statute’s impact on patient care and hospital protocols has been profound, fostering a more inclusive and equitable healthcare milieu.

In conclusion, the Urgent Medical Assistance and Labor Regulation represents a pivotal legislative measure addressing the ethical and practical imperative of providing emergency medical care to all individuals. By mandating medical assessment, stabilization, and appropriate transfer or discharge, UMALR safeguards patients against denial of critical healthcare services based on their financial status. While presenting certain challenges and burdens, UMALR’s role in promoting equitable access to emergency medical treatment underscores its enduring significance within the U.S. healthcare system. Through UMALR, the principle that every individual deserves immediate and essential medical attention during emergencies is upheld, reflecting a fundamental tenet of medical care in a just society.

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• Research article
• Open access
• Published: 03 July 2020

The effects of emergency medical service work on the psychological, physical, and social well-being of ambulance personnel: a systematic review of qualitative research

• Sharon Lawn   ORCID: orcid.org/0000-0002-5464-8887 1 ,
• Louise Roberts 1 ,
• Eileen Willis 2 ,
• Leah Couzner 1 ,
• Leila Mohammadi 1 &
• Elizabeth Goble 2  

BMC Psychiatry volume  20 , Article number:  348 ( 2020 ) Cite this article

75k Accesses

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Metrics details

High rates of mental distress, mental illness, and the associated physical effects of psychological injury experienced by ambulance personnel has been widely reported in quantitative research. However, there is limited understanding of how the nature of ambulance work contributes to this problem, the significant large toll that emergency medical response takes on the individual, and particularly about late and cumulative development of work-related distress among this first responder workforce.

This study examined peer-reviewed qualitative research published from 2000 to 2018 to outline the effect of emergency medical response work on the psychological, psychosocial, and physical health of paramedics, ambulance officers, ambulance volunteers, and call-takers. Databases searched included: Ovid Medline, CINAHL, Ovid EMcare, PsychInfo and Scopus. The systematic review was organised around five key areas: impact of the work on psychological wellbeing; impact of psychological stress on physical wellbeing; how work-related well-being needs were articulated; effects of workflow and the nature of the work on well-being; and, effects of organisational structures on psychological and physical well-being.

Thirty-nine articles met the eligibility criteria. Several factors present in the day-to-day work of ambulance personnel, and in how organisational management acknowledge and respond, were identified as being significant and contributing to mental health and well-being, or increasing the risk for developing conditions such as PTSD, depression, and anxiety. Ambulance personnel articulated their well-being needs across four key areas: organisational support; informal support; use of humour; and individual mechanisms to cope such as detachment and external supports.

Conclusions

Interactions between critical incidents and workplace culture and demands have an overwhelming impact on the psychological, physical and social well-being of ambulance personnel. These include day-to-day managerial actions and responses, the impact of shift work, poorly-managed rosters, and long hours of work with little time between for recovery. Mental health issues result from exposure to traumatic events, and the way managers and peers respond to worker distress. Ambulance personnel suffering from work-related stress feel abandoned by peers, management, and the service, during illness, in return-to-work, and post-retirement. Policy, programmes and interventions, and education need to occur at an individual, peer, organisational, and government level.

Peer Review reports

Ambulance personnel are essential first responders in the community. Across different countries and jurisdictions, they are known by a variety of terms such as paramedics, emergency medical technician, emergency medical personnel, emergency dispatch personnel and call-takers. Their role is to directly provide or coordinate the communication of response for out-of-hospital or pre-hospital emergency medical care in the community. However, they are arguably ‘the forgotten profession’ within the healthcare system. Their contribution to the health and wellbeing of the community and to healthcare is overshadowed by more dominant dialogues and debates about community services, acute care and hospital emergency department tensions and resource demands [ 1 , 2 , 3 , 4 ].

In Australia, the nature of ambulance work, the uncontrolled and often unpredictable environments, the everyday experience of trauma, and the cumulative nature of that trauma all play a key role in the development and impact of mental distress and psychological injury [ 3 , 4 , 5 ]. In addition to the nature of the work, organisational and occupational factors such as workload, work demands, shift work, limited time for debriefing or downtime, the hierarchical nature of supervision, and the lack of recognition are clearly shown to have effects on the well-being of ambulance personnel that are as significant as, if not greater than, the nature of the work itself [ 3 , 5 , 6 ]. This paper examines the peer-reviewed qualitative research to outline the effect of emergency medical response work on the psychological, psychosocial, and physical health of paramedics, ambulance officers, ambulance volunteers, and call-takers.

A recent systematic review of 27 international studies [ 7 ] reported on 30,878 ambulance personnel and found estimated prevalence rates of 11% for post-traumatic stress (PTS), 15% for depression, 15% for anxiety, and 27% for general psychological distress among ambulance personnel. A broader Canadian study [ 8 ] of emergency response and correctional workers (5813 correctional workers, dispatchers, firefighters, paramedics, and police officers) showed that 44.5% screened positive for clinically significant symptoms of one or more diagnosable mental disorders; approximately four times higher than diagnosed rates for the general population at 10.1%. Of concern, these rates were noted to be higher than earlier studies and suggested the rate of anxiety among paramedics to be as high as 22%, with depression and suicidal ideation both at 10% [ 8 ]. Of added concern, under-reporting is thought to be a pervasive feature of this healthcare workforce [ 2 , 5 ]. Apart from psychological impacts, a range of physical impacts resulting from the nature of ambulance work and exposure to occupational stress have also been reported. These include headaches, sleep disruption, muscular skeletal injuries, fatigue, dietary problems, weight gain and, in some cases, exposure to dangerous pathogens [ 9 , 10 , 11 ]. The research therefore suggests that rates of mental distress, mental illness, and the associated physical effects of psychological injury experienced by ambulance personnel demonstrate the large toll that emergency medical response takes on the individual.

Safe Work Australia [ 12 ], the Australian government statutory body established to develop national policy for work health and safety and workers’ compensation, reports that, although serious mental disorder claims from first responders account for only around 10% of all claims, they have significantly more impact on the individual than other claims. These impacts included extended time off work and significant compensation for ongoing care and support. Claims were almost five times longer than for other serious claims for all types of injuries and illnesses, and monetary payouts for serious mental disorder for first responders was almost double that of all payments [ 12 ]. These statistics demonstrate the high cost in monetary value, lost productivity, and lost personnel which is experienced by Ambulance Services personnel and other first responders due to the effect of mental distress and psychological injury [ 12 ].

The predominant use of measures of stress and psychological injury which focus on current symptoms make the longitudinal screening of personal mental health and wellbeing difficult and potentially miss important information about late and cumulative development of work-related distress. This mismatch may result in failure to recognise and address adverse longer-term impacts of the work itself. It may also result in failure to identify effective evidence-based prevention measures or to intervene early to prevent potentially higher rates and prevalence of psychological distress in this group [ 6 ].

Granter et al’s [ 13 ] recent study with ambulance services in England explored how emergency workers respond to the varied and multidimensional nature of their work and how this influences resilience and vulnerability to distress. Their study highlighted a cross-section of intense, high energy, and time-critical aspects of the work intermixed with a mundane, operational, and bureaucratic work life [ 13 ]. This mixture of high intensity and mundane work often created a difficult shift for paramedics’ mindset, with little respite or time for debriefing and dealing with administrative requirements during periods of intense emotions [ 13 ].

In Australia, and internationally, there has been extensive measurement of prevalence of this problem and increasing focus on policy development, service-based strategies, and programs for promoting mental health and wellbeing among ambulance personnel and other first responder groups. To date, quantitative study designs have provided the basis for these developments but with limited focus on the lived experience and qualitative evidence. Despite these initiatives and the existence of a broad range of organisational support services and programs, concern for the mental health of ambulance personnel continues to grow. This review aims to provide a stronger spotlight on the lived experience of ambulance personnel to identify the gaps in provision of support and care, and the challenges faced by those who experience psychological distress as a consequence of their everyday work.

Aim and research questions

The aim of this study is to provide a comprehensive review of relevant international peer-reviewed qualitative literature on the effects of emergency medical service work on the psychological, physical, and social well-being of ambulance personnel (paramedics, ambulance officers, ambulance volunteers, and call-takers). The Ambulance Employees Association of South Australia (AEASA) which commissioned this review were aware of the extensive quantitative research in this area but wanted to see what the qualitative research showed that might help to expand our understanding and better explain potential contributors to psychological, physical and social well-being status in ambulance personnel. In this sense, they were interested in answers to the following three broad research questions: What is the problem? What causes the problem? What is needed to address the problem?

The following questions guided this systematic review:

What impact does emergency service work have on the psychological well-being, and psycho-social health of paramedics, ambulance officers, ambulance volunteers, and ambulance call-takers?

What impact does the psychological stress linked to the workplace have on physical well-being for paramedics, ambulance officers, ambulance volunteers, and call-takers?

How do paramedics, ambulance officers, ambulance volunteers, and call-takers articulate their work-related well-being needs?

How are paramedics’, ambulance officers’, ambulance volunteers’, and call-takers’ mental health and well-being effected by workflow, the nature of work, and their changing roles?

What effect do organisational structures addressing respite, debriefing (both formal and informal) and workload have on paramedic, ambulance officers, and ambulance volunteers’ psychological and physical well-being?

Further questions about perceived stigma, help-seeking behaviours and how ambulance personnel identify and report signs of psychological distress related to their work were also explored for this systematic review. However, dedicated examination of these specific issues will be reported elsewhere.

Search methods and screening

A systematic literature search was conducted to identify the relevant peer-reviewed literature using the PICO tool for qualitative research to identify key concepts pertinent to ‘participant problem (or population)’, ‘intervention’, ‘comparison or control’ and ‘outcome’ [ 14 ]. Research on the topic of this review is relatively young and has proliferated predominantly in the last two decades, with widespread professionalisation of the paramedic workforce via transfer of paramedic education to the university section in Australia, New Zealand and the UK around 2000, resulting in an increase in paramedic academics and subsequent research being conducted by them; therefore, only studies published since 2000 were included [ 15 ]. The main search was conducted in the Ovid Medline database, and incorporated both Subject headings (MeSH: Medical subject headings) and text words, and then translated into the PsycInfo, Ovid EMcare, CINAHL, and Scopus databases (executed in October 2018; see Appendix 1 ). Retrieved results of the database searches were then exported into Endnote for collation. A PRISMA diagram was used to report the search results and screening process. The titles and abstracts of all results were screened independently by two reviewers with a third reviewing any discrepancies, based on inclusion and exclusion criteria shown in Table  1 . Full texts deemed eligible for inclusion based on their title and abstract were obtained for further screening.

The review was registered with PROSPERO (Registration No.CRD42019117397).

Data extraction and synthesis

The following data was extracted from each study: aim and methodology; sample characteristics; data collection methods; data analysis methods; and study limitations (see Appendix 2 ). The findings of each study were extracted and collated according to the focus questions (see Appendix 3 and 4 ). This enabled a thematic narrative synthesis to be undertaken in which commonalities and discrepancies between the findings of the studies were identified [ 16 ]. To perform this step, two reviewers read and re-read the data extracted for each study, noting patterns within and across the data. Tentative themes were then discussed within the broader research team over a series of formative meetings to reach consensus on the most pertinent themes arising from the data.

In the case of the literature reviews, only the data from relevant studies were included, and each qualitative study included within the systematic reviews was screened for inclusion as a primary study. Where studies included other groups of first responders in addition to paramedics, ambulance officers, ambulance volunteers, or call-takers, only the data relating to ambulance personnel was extracted and included. The quality of each included study was evaluated using the Critical Appraisal Skills Program (CASP) checklist for qualitative research, with quality of systematic literature reviews determined using the CASP tool of systematic reviews [ 17 , 18 ]. The CASP checklists entail 10 questions related to various aspects of quality including whether aims were clearly stated, methodology, design, recruitment and sampling, ethical clearance, and rigor of data analysis. We determined high quality study were those that met eight or more of the 10 criteria, reasonable quality studies met 6–7 of the 10 criteria, and poorer quality studies met five or less of the 10 criteria. Where the reviewer assessing a study was unsure if the criteria had been met, input was sought from a second reviewer.

A total of 6154 documents were retrieved from all searches, from which 1086 duplicates were removed. The remaining 5068 titles/abstracts were screened based on the agreed inclusion and exclusion criteria, with 4976 titles/abstracts removed because they did not meet the eligibility criteria. The remaining 92 full texts were reviewed, with 39 articles deemed to meet the eligibility criteria (see Table  2 and Fig.  1 ).

PRISMA 2009 Flow Diagram

The studies were conducted in a range of countries including the United States of America ( n  = 9) [ 9 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ], Australia ( n  = 8) [ 10 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ], Canada ( n  = 6) [ 34 , 35 , 36 , 37 , 38 , 39 ], Sweden ( n  = 5) [ 40 , 41 , 42 , 43 , 44 ], the England ( n  = 4) [ 44 , 45 , 46 , 47 , 48 ], Ireland ( n  = 2) [ 49 , 50 ], Norway (n = 2) [ 11 , 51 ], Saudi Arabia ( n  = 1) [ 52 ], and Israel (n = 1) [ 53 ]. Another study was conducted in both Australia and the United Kingdom [ 54 ]. Of the 39 articles, the majority were deemed to be primary research articles ( n  = 26) [ 20 , 21 , 25 , 26 , 27 , 28 , 29 , 30 , 34 , 35 , 37 , 38 , 39 , 40 , 41 , 42 , 44 , 45 , 46 , 48 , 49 , 50 , 52 , 53 , 54 ] with the remainder being either non-systematic literature reviews (n = 9) [ 9 , 19 , 20 , 22 , 23 , 24 , 31 , 32 , 36 , 43 ] or systematic literature reviews ( n  = 4) [ 11 , 43 , 47 , 51 ]. Of the primary research studies, the most common data collection method was semi-structured interviews ( n  = 11) [ 26 , 27 , 40 , 41 , 42 , 44 , 45 , 46 , 49 , 51 , 53 ]. Four studies used a combination of semi-structured interviews and focus groups [ 21 , 34 , 35 , 54 ], while another four utilised questionnaires with at least one open-ended question [ 10 , 20 , 29 , 37 ]. Six studies used a mixed methods approach, combining qualitative and quantitative approaches. These methods included a questionnaire and interviews (n = 4) [ 28 , 30 , 38 , 39 ], conducting both interviews and focus groups, attending organisational management meetings and examining information available on the public record ( n  = 1) [ 48 ], and brainstorming, flow chart analysis, and examination of health service usage records (n = 1) [ 52 ]. Additionally, one study reported on the outcome of a court case pertaining to a paramedic who developed PTS as a result of his employment [ 25 ].

Of the 39 included studies, no studies focused explicitly on unpaid volunteers within ambulance services. Their views may have been captures within individual study samples; however, their status as volunteers was not distinguished from other participants. Hence, their views and experiences in relation to the review questions remains unknown. Only one study focused explicitly on retirement. This study from Ireland explored policies and procedures for retirement within ambulance and fire services, with a primary focus on managers aged 42–73 years [ 49 ]. One US study explored how EMS work impacts upon family life, with a convenience sample of 11 spouses and one parent of EMS providers [ 26 ]. The remaining 37 included studies related to ambulance personnel on active duty.

Summary of quality evaluation

The majority of articles were generally of high quality, with all but one clearly stating the research aim and all using an appropriate research design. However, a qualitative methodology was not considered appropriate for one of the studies, and the appropriateness could not be determined for a further two studies. Recruitment strategies were deemed appropriate, except for three studies where insufficient details were reported. We were unable to determine if one study collected data in a way that addressed the research question; however, the remainder of the studies were deemed to have achieved this. Rigour of data analysis was considered acceptable in most cases except for one study, and five for which this could not be determined. Eight studies did not report on ethical issues and one did not provide sufficient information to determine this. The relationship between the researcher and the participants was adequately described in 12 studies; however, there was not enough detail to determine this in three studies. All studies concluded with a clear statement of findings (see Appendix 5). The four systematic literature reviews were deemed to be of high quality, with all stating a clearly focused question, and all considered to have adequately assessed the quality of included studies (see Appendix 6).

The results are summarised in two main sections, with each section addressing the specific research questions identified for this review:

Impacts and work-related psychological and physical well-being needs (Questions 1, 2 and 3)

Impacts or organisational and systems parameters (Questions 4 and 5)

Section 1: impacts and work-related psychological and physical well-being needs

This section describes the psychological and physical effects of frontline emergency medical work on ambulance personnel. It addresses factors recognised by individuals and organisational management as being significant and contributing to mental health and well-being, or increasing the risk for developing conditions such as PTSD, depression, and anxiety. It also describes how work-related psychological and physical well-being needs were articulated and framed by ambulance personnel. Findings of the studies discussed in Section 1 are summarised in Appendix 3 .

Q1: impacts on psychological well-being

Psychological effects were framed within five themes: 1) Recognised reactions and associated signs and symptoms; 2) Effects on relationships with others; 3) Observations from “above” (e.g., the influence of organisational structures, policy, and support); 4) Perceived control versus real control and the nature of the event; and, 5) Protective and coping mechanisms employed.

Recognised reactions, associated signs and symptoms, and causes

A number of key commonly-recognised responses to trauma and the associated signs and symptoms of adverse impacts of that trauma on ambulance personnels’ psychological well-being were identified. These responses included angry outbursts and changes in tolerance to everyday interactions, sleep disturbances and deficits, irritability, decreased social life, and an increased sense of isolation. An increase in vigilance and fear of doing the required role, and recognition of associated triggers, unwanted and unpredictable flashbacks or intrusive thoughts, fatigue, stress, high rates of sickness and days absent, and difficulty switching off were significant [ 9 , 11 , 24 , 25 , 27 , 31 , 34 , 36 , 39 , 46 , 50 ]. The high and increasing rates of depression and anxiety, and associated development of PTS and suicidal ideation [ 9 , 11 , 19 , 20 , 22 , 23 , 25 , 34 , 40 , 41 , 47 , 52 ] were clearly outlined as current and systemic issues faced by paramedics and call-takers, with rates estimated as being twice as high as other health professionals [ 24 , 25 , 28 , 30 , 36 , 39 , 46 , 47 ].

The nature of the work, including routine ‘everyday’ call-outs, and those that generated associated secondary or vicarious trauma, had a cumulative effect on ambulance personnel. This left them with feelings of frustration, helplessness, trepidation, and emotions of being overwhelmed during and after the event. The cumulative build-up of emotions and continued exposure to stress led to compassion fatigue and self-blame [ 39 , 41 , 45 , 53 ]. The literature notes rates of substance use (e.g., alcohol and other drugs) by ambulance personnel accelerated following exposure to critical incidents as a means to mitigate and manage these lived experiences [ 9 , 24 , 34 , 39 ].

One paper specifically outlined how attending critical incidents or traumatic events has six distinct stages related to the experience [ 42 ]. The initial stage involves anticipation of the event characterised as the (1) pre-trauma and preparation for the unknown. Early in the management of the event, there is a keen sense of (2) feelings of responsibility and the associated anxiety and fear of mistakes. As the event progresses, paramedics recognise intense feelings of being (3) insufficient and worthless, even though they have done everything possible accompanied by the challenges of (4) containing emotions and putting on the ‘professional face’. After the event, feelings of (5) confusion, exhaustion, and of being in chaos were dominant. Other more subtle feelings included being (6) rejected by relatives or fellow workers, feelings of anger, frustration, resentment, and bitterness, betrayal and rejection, self-loathing, guilt and humiliation, being out of control, trapped, and feelings of helplessness [ 42 ].

Effects of relationships with others

The effects of workplace stress on the psychosocial well-being of ambulance personnel profoundly influenced how they interacted with others. Social withdrawal and the above-mentioned signs and symptoms created an environment which negatively affected personal relationships, exacerbated the sense of isolation and withdrawal, and what they described as a debilitating loss of compassion. To manage this, paramedics specifically found themselves projecting difficult feelings and blame onto others, especially those close to them. This enabled them to distance themselves from their negative emotions and alleviate their emotional distress. Paramedics also found themselves being hyper-alert and over-protective of family and friends because they knew and saw worst-case scenarios as part of their everyday work [ 26 , 34 , 50 , 53 ].

The effects of shift work added to the psychological stress due to the continuous negotiation between their role and identity at work and their personal life. Shift work specifically reduced the time for recovery and quality individual and family time with limits on their social life. Rosters, over-time, and other work commitments such as training and professional development often affected social and family gatherings at significant times of the year, and operating in a “9 to 5 world” was viewed as being potentially problematic. Paramedics described shift work as having a negative effect on family roles and intimacy, and disrupting the structure and rhythm of home life with concerns about family safety and the risks of the job [ 26 ].

Observations from “above”: Occupational oversight and the operational environment

The occupational environment and nature of the work performed by ambulance personnel was well recognised as being a significant contributor to stress, with a range of impacts on their mental and physical health. Prolonged and high exposure to excessive occupational demands and lack of crisis support led to poor physical and mental health, increased sick leave, and lower productivity [ 19 , 26 , 41 , 50 , 51 ], and was associated with increased overall morbidity, and physical and mental illnesses [ 19 , 30 ]. Along with a challenging occupational environment, operational factors (such as key performance indicators, quotas, operational standards, response times, and expectations) also contributed to psychological stress [ 32 , 45 ]. Another significant aspect was the feeling of a ‘big brother’ environment in which everything is observed and taped leading to call-takers being ‘on-edge’ [ 27 ]. The increased risk of potential aggression and violence that paramedics faced, particularly verbal abuse, added to the sense of work-related uncertainty and vulnerability. This was compounded if reports were not taken seriously or were under-reported, as culturally, potential agression and violence was seen as a ‘normal part of the job’ [ 28 ].

Perceived control, real control, and nature of event/trauma

The nature of the critical incident, and the perceived or real sense of control were identified as factors that either mediated or increased the incidence of psychological injury. Key events and case types that contributed to signficant distress for ambulance personnel included the death of a baby or child, neglect, abuse or harm, burns, assault, family violence, drownings, harm to colleagues [ 20 ], suicide, grotesque mutilation, and those cases that had a personal significance ascribed to them (e.g., personally knowing the patient, working with children or the critically ill, and the death of patients) [ 29 , 38 , 39 , 43 , 44 , 50 , 51 ]. Adding to the burden was the need to complete administrative and documentation requirements and to remain professional in further interactions with others following a critical incident.

Lack of control, whether perceived or real, particularly a lack of control over work, their environment, and work demands [ 28 , 40 , 47 ], increased the incidence and severity of psychological distress, and were triggers for the development, or exacerbation, of existing mental illness. Associated with the lack of control was the immediate knowledge of outcomes during the critical incident, or lack of clinical feedback after the event, which influenced how the critical incident was perceived and processed by ambulance personnel [ 24 , 39 , 47 ]. Other prominent issues in relation to feelings of loss of control and safety were workplace bullying, actual assaults by others (patients, colleagues), loss of control through verbal and physical threats, remoteness and isolation felt if subjected to these behaviours, lack of back-up support and reports of incidents not being taken seriously or not being followed-up by supervisors or the service.

Protective and coping mechanisms

Ambulance personnel used a number of strategies to cope with the nature of the work they face; some that contributed to the delayed nature of mental illness presentations. One strategy used was compartmentalising the event and associated emotions to manage the immediate demands and to be able to provide care which was protective in the short-term, but which may be detrimental in the longer-term, or they distanced themselves emotionally from the patient to protect themselves. Avoidant strategies and information searching were often used to try to regain a sense of control and manage the demands they faced [ 39 , 45 , 48 ].

The nature of the work, although complex and challenging for mental health, also offered individuals a sense of identity and status, affiliation and camaraderie, structure and routine, direction and meaning, and intellectual stimulation and challenge which together enhanced personal satisfaction and resilience. Social support, mainly emotional support, was also crucial and protective against the development of PTSD [ 51 ]. These protective aspects of the work are significant, but were often minimised or disrupted if a critical incident challenged their sense of role and connection to the service, especially if re-tasked or forced to medically retire due to mental health concerns or illness.

Q2: impacts on physical well-being

Physical side-effects of continued exposure to occupational stress manifested in predominantly somatic symptoms such as headaches, gastrointestinal distress, sleep disruption, fatigue, and their associated effects on work performance [ 9 , 11 , 24 , 34 ]. The fast-paced nature of the work and the psychological demands of the job did not allow for physical rest and processing of incidents [ 38 , 44 ], which created a vicious cycle for ambulance personnel, and contributed to a difficult work-life balance and poor post-shift recovery [ 27 , 30 , 36 , 46 ].

Due to the nature of the work, the major physical concerns experienced by paramedics were reported as musculoskeletal injuries, specifically back problems, associated with the weight of patients and manual handling requirements in challenging environments. Other risks to physical health were blood-borne pathogens and needle-stick injuries which occurred mostly with inexperienced clinicians [ 22 , 30 , 44 ]. Critical incident stress particularly affected physical health due to associated weight gain, back problems, and changes in appetite and diet. It was difficult for paramedics to maintain or improve their general levels of fitness and maintain diet because of shift work and the lack of on-site exercise facilities [ 30 , 50 ].

Sleep and disrupted sleep patterns are of interest as a key to understanding physical fatigue and psychological effects of work in this area. Inadequate or disrupted sleep has been associated with cardiovascular disease (CVD), metabolic disease, depression, impairment in immune function, and hormone secretion fluctuations which can instigate adverse psychological changes [ 33 ].

Both increases and decreases in cortisol levels have been found following stress exposure and indicate strain on the endocrine system [ 33 ]. The literature indicates that pro-inflammatory cytokines significantly increased or decreased from baseline following single as well as multiple nights of complete and partial sleep restriction [ 33 ]. Elevated levels of sleep regulating cytokines have been associated CVD, metabolic syndrome and depression; higher, flatter diurnal cortisol patterns are related to depression and elevated morning cortisol levels are positively associated with CVD and metabolic syndrome [ 33 ].

Q3: articulation of well-being needs

Ambulance personnel articulated their well-being needs in terms of occupational safety and in relation to their lived experience, across four key areas: organisational support; informal support; use of humour; and individual mechanisms to cope such as detachment and external supports [ 26 , 43 , 44 , 47 ].

Organisational and informal support:

Ambulance personnel reported a need for broader recognition of incidents that may be viewed as routine and yet have personal significance, or were cumulative in nature and caused significant distress, thus becoming a critical incident [ 20 ]. To adequately address critical incidents, the literature highlighted the needs for structured recovery time after the event, active moves to address stigma surrounding mental health at all levels, ease of access to care, and supported case review in a non-judgemental environment with the focus on feedback and learning.

Both paramedics and call-takers identified a need for quality supervision, positive working relationships with managers and colleagues, and for workplace conflict to be taken seriously and addressed through education and training [ 34 , 47 ]. Call-takers, in particular, identified that workplace conflict existed when their roles were not acknowledged. On occasion, they felt that paramedics did not value them and that they were seen as ‘punching bags’ in an ‘us and them culture’ [ 27 , 46 ].

Paramedics particularly identified that workplace violence and threats were a significant and common issue and played a major role in their feelings of vulnerability and poor mental well-being. These issues need to be taken seriously by the organisation, with continued prevention and occupational safety measures implemented (e.g. duress alarms, recognition of dangerous addresses, increasing training and knowledge of staff of minimisation strategies and how to deal with violent patients) [ 20 , 28 ].

Individual mechanisms to cope

Ambulance personnel described experiencing emotional pain arising from the work they do, with associated feelings of helplessness during and after extreme events. They described feelings of emotional and cognitive detachment from patients and their families during more routine events. They coped by focusing on the technical and clinical aspects of the job and the immediacy of the activity. More broadly, they expressed a need to maintain a sense of purpose and frame their work as meaningful [ 53 ]. They saw themselves as advocates and accustomed to using problem-solving and emotion-focused efforts to manage situations. These skills were considered essential to protecting oneself, as feeling useful and managing people and incidents was a positive and protective aspect of the role and contributed to their sense of identity. They also used advocacy skills as a means of addressing workplace stress and in attempts to get better resourcing (e.g. more personnel, equipment, and recognition) from management and the organisation to be able to perform their role effectively [ 43 ].

Ambulance personnel and their significant others employed cognitive strategies to manage not only the effects of their work environment, but also their relationships and life outside of work. These strategies included trying to go with the flow and realising that you can only control what you can, and to consider and allow yourself to look at the worst possible scenario as a means of cognitively and emotionally preparing for the demands of the role. During and after the event, it was essential to recognise early signs of distress and to know when to seek social support and how to cultivate those friendships and networks of support as essential preventative and positive means to reduce isolation. Negotiating family role responsibilities and learning how to balance relationships were identified as being crucial for personal well-being. As part of the balance of work and life outside of work, establishing and developing one’s own interests created a sense of meaning and assisted in delineating work and home life [ 26 ].

If illness, either psychological or physical or both, became evident, it forced a change in personal views of the self and highlighted the concept of striking a balance with the experience of wellness and illness. The sub-themes to this experience focused on the idea of attaining and maintaining wellness through personal nurturing, encountering illness as an experience and a threat, and accepting and managing illness. Wellness was nurtured by the experiences of being excited and challenged by the work they did or could still do; having freedom and flexibility and a sense of autonomy in their work and life; being “someone” and having a sense of making a difference; and being one of the gang [ 44 ]. If injury was severe, the positive and protective nature of being a contributing member was challenged and often created a sense of frustration, anger, and worthlessness. As part of framing wellness and illness, there was a distinct narrative of encountering illness as an experience and a threat. The illness experience had a psychological, physical and social dimension which was encapsulated by the concepts that “the body makes itself heard; one can get worn out; and one can become too vulnerable or hardened” [ 44 ].

Section 2 impacts of organisational and systems parameters

The findings of the studies discussed in Section 2 are summarised in Appendix 4.

Q4: effects of workflow and nature of the work on mental health and well-being

The nature of the work performed by all first responders is distinguished from other occupations by exposure to human distress and tragedy, referred to in the literature as critical incidents [ 11 , 20 , 31 , 35 ]. However, ambulance personnel share with all other professions and occupations issues to do with how work is organised, the industrial relations and human resources factors that have an impact on the job, the skills and qualities of managers who organise the work, and the personalities and experience of their immediate supervisors. Several studies note problems under this category of workflow [ 9 , 10 , 11 , 19 , 20 , 21 , 23 , 27 , 31 , 32 , 33 , 34 , 37 , 38 , 40 , 44 , 45 , 46 , 47 , 48 , 50 , 54 ].

The type of work performed by ambulance personnel

Ambulance personnel made a distinction between specific traumatic events that produce an emotional toll, such as attending the death of a child or a suicide of a young person [ 9 , 20 , 27 , 41 ], and a patient who may present a range of problematic or difficult responses such as someone with a mental health issue [ 9 ], or domestic violence, a drug and alcohol incident, or road rage [ 37 ]. A further distinction was made under the broad heading of uncertainty or lack of control [ 38 , 40 , 47 , 48 , 55 ], for situations in which they must proceed to a job without adequate knowledge, unsure of what they will find or how to prepare themselves [ 37 ], or where they may be exposed to pathogens and it is difficult to ensure universal precautions [ 20 , 27 , 40 , 47 ]. Any incident may therefore prove to be critical. The event does not need to be traumatic; it merely needs to evoke a strong emotional response in the individual [ 11 , 41 ]. It may have an immediate impact on their sense of well-being, or in some cases, many months or years later, even beyond retirement, or precipitate early retirement [ 11 , 49 ]. Small or major events had a cumulative effect on stress levels [ 11 , 27 , 31 , 34 ], particularly if there was little time between jobs and shifts to switch off from the trauma of a previous incident [ 48 , 54 ].

The way the work is organised

The organisation of work can be examined from the perspective of the strength of the industrial protections in place, and the expertise of the human relations and managerial systems within the organisation [ 38 ]. The research is almost universal in reporting that both are problematic for ambulance personnel. In dealing with industrial relationships arrangements, they report that given the workload pressures and performance metrics governing their jobs, they had no time to deal with, or digest, the effects of critical events [ 23 , 27 , 29 , 33 , 34 , 45 , 46 , 47 ]. Other factors noted were lack of resources including a lack of available ambulances to send to a job [ 37 , 38 , 45 ], too few staff [ 10 ], and in the case of the USA, low salary requiring a second job [ 9 ], long shifts, lack of sleep linked to shift work, fatigue as a result of long drives in rural areas, and failure to have the required breaks or meals as a result of work intensification resulting in poor eating habits and weight gain [ 10 , 20 , 29 , 31 , 32 , 33 , 34 , 48 , 54 ]. Added to this were the unreasonable metrics governing the speed required to get to a job, the time allowed ‘on-scene’ and later at the hospital before management radio in expecting the paramedic team to respond to the next case [ 23 , 33 , 45 , 46 , 50 ], and the erosion of team work and skills mix through the appointment of single responders, or lower grades of workers who lack the necessary skills [ 37 , 45 , 46 ]. For call-takers, stressful issues included working alone during weekends and at night, the intensity of the work that made it difficult to take breaks, and the antagonism of paramedics towards them [ 46 , 50 ].

The general view reported is one of alienation between management and supervisors and on-road paramedics, ambulance officers, and volunteers [ 9 , 34 , 35 , 48 , 50 , 54 ]. Managers were seen to lack empathy or consideration towards paramedic work, to downplay the impact of critical incidents, or the pace of the work [ 33 , 46 , 53 ], to stigmatise those seeking help [ 34 , 35 , 39 ], and to lack the skills and training to deal with workplace bullying [ 34 , 35 , 54 ]. Ambulance personnel reported not being supported in legal and audit cases and to consistently have their skill-base ignored through either a failure to be promoted, to access higher level roles, or unable to make their own clinical decisions [ 38 , 48 , 55 ]. A further frustration was the constant restructuring of the organisation [ 44 ].

Q5: effects of organisational structures on psychological and physical well-being

The organisational response to ambulance personnel’s psychological and physical well-being was influenced by the structure and culture of the organisation [ 38 , 43 ] along with the personal attributes of the paramedic such as their age, gender, years of experience, and psychological factors such as internal locus of control and the capacity to ensure a work-life balance [ 9 , 20 ]. In Australia, historically, these services had their origins in paramilitary culture, with a strong hierarchical chain of command, which in-turn prizes stoicism in the face of adversity, and compliance, with little sense of worker control or clinical autonomy [ 48 , 54 ], but also a high level of teamwork, camaraderie, and public service [ 20 , 38 ]. Paramedicine has moved from being a vocationally-trained, male-dominated, blue-collar occupation to a university-trained and registered profession with an increasing number of women and younger recruits who appear to be more comfortable with contemporary methods of stress management [ 34 , 35 ]. Providing a comprehensive duty-of-care service to ambulance personnel along with meeting performance metrics during a time of cultural transition can prove difficult for any organisation [ 27 , 46 , 49 ].

Managerial response to paramedic well-being and workplace stressors

Managerial responses can be examined through the way managers respond to on-road or call-taker distress and to the type of welfare services provided [ 27 , 34 , 35 , 45 , 46 , 48 , 50 , 54 ]. A number of studies noted that on-road staff report that managers universally failed to understand, appreciate, or respond to the distress of critical incidents [ 27 , 30 , 38 , 41 , 45 , 48 , 54 ]. The alienation of call-takers is particularly marked [ 46 ]. They reported that the only contact they had with management was when something went wrong, or the organisation wished them to implement an unpopular directive, leaving them to negotiate the ire of on-road staff [ 27 , 46 , 50 ]. Importantly, management’s lack of capacity to deal with organisational stressors such as bullying, workplace conflict, management of rosters and sleep deprivation, and promotion was also seen as a stressor that, in turn, exacerbated ambulance personnel’s reactions to traumatic incidents [ 9 , 20 , 29 , 30 , 38 , 50 ].

Managers could assist through more thoughtful organisation of rosters to reduce fatigue and lack of sleep, along with ensuring adequate staffing to fill rosters and reduce overtime, and ensuring that rosters followed a clock-wise rotation [ 29 , 31 ]. Managers benefitted from doing occasional shifts to keep themselves abreast of on-road circumstances [ 46 ], and for the need for adequate equipment [ 21 ]. Including call-takers in debriefing sessions along with paramedics was also seen as a positive strategy for managers to employ [ 27 ].

Types of welfare services provided

The type of welfare services provided to ambulance personnel, including those who have retired, and the evidence-base, is also complex, with reported ambiguity around the usefulness or otherwise of critical incident debriefing or mandatory crisis meetings [ 20 , 23 , 35 , 41 , 49 ], as well as cognitive behavioural therapy [ 22 , 34 , 47 ]. There was also debate about the time when management should offer services and what exactly should be provided [ 22 , 41 , 52 ]. Prevailing strategies promoted were pre-employment testing, peer support programs, and psychological first aid along with adequate training of front-line staff as well as managers and team leaders in order to recognise symptoms in individuals at risk [ 19 , 34 , 35 , 46 , 51 ]. In severe cases of PTSD, there was a recognition that pharmaceutical responses may be required until the individual gained emotional control [ 51 ]. There is limited research on pre-employment testing [ 32 , 51 ]. Peer support can be as simple as time out between jobs, but time scarcity is a factor [ 34 , 35 , 44 ], and for younger personnel, time to learn to trust colleagues [ 34 , 50 ]. One of the most important principles reported was to ensure confidentiality of counselling services [ 34 , 35 , 52 ] given the highly competitive nature of the contemporary workplace [ 35 , 54 ], and that counselling staff be formally trained and experienced in understanding the issues faced by ambulance personnel [ 22 , 35 , 36 ]. Stress surrounding access to workers compensation was explored in the US context [ 25 ].

Training in stress management for managers was seen as essential, and for on-road staff was part of their personal armoury strengthening internal locus of control [ 9 , 20 ]. The research suggested the cumulative impact of critical incidents made years of experience a negative factor in well-being, but also notes that experience was a positive factor [ 9 , 20 , 34 , 48 , 54 ]. While the individual was seen as primarily being responsible for maintaining their occupational well-being, the peer-reviewed literature also points to the responsibility of the employer to provide both welfare services and a working environment conducive to health [ 9 , 20 , 22 , 38 , 50 ].

This paper has provided a comprehensive overview of the qualitative peer-reviewed literature dealing with the impact of emergency medical service work on the psychological, physical, and social well-being of ambulance personnel. In synthesizing the literature, three key themes emerged which align with the three key areas of enquiry: What is the problem? What causes the problem? What is needed to address the problem?

Theme 1 - mental health issues result from exposure to traumatic events, but also to the way personnel in the workplace respond (managers, peers) to worker distress

The peer-reviewed literature reported on the negative impact of continuous and cumulative exposure to critical incidents. There was strong agreement on the types of incidents that paramedics find particularly distressing; for example, those reported by Donnelly and Bennett [ 20 ]. There was also evidence to suggest that, on occasion, mundane jobs that may appear routine for one paramedic can trigger anxiety or distress for another, making exposure to stress an individual response. Recovery is made difficult by the nature of shift-work, over-time, the physical demands of the job, and fatigue. The way the work is organised matters and needs to be addressed with physical and emotional well-being in mind.

Both the Australian and international literature confirms that the incidence of psychological distress in ambulance personnel is not just a matter of exposure to traumatic incidents, but also arises from the way the organisation responds, at the managerial and organisational level. For example, at the managerial level, when paramedics experience work-related stress and require access to formal avenues of care, many managers are unsympathetic and lack personal empathy. This is often assumed to have its origins in the military-like or macho culture that discourages emotional displays of distress [ 48 , 54 ].

Further to the above contributing factors, in several studies ambulance personnel reported that their access to appropriate care is made difficult through failure to acknowledge the stress, lack of confidentiality, use of inappropriate therapies, poor return-to-work mechanisms, isolation, and stigmatisation, concerted efforts to obstruct access to Worker’s Compensation provisions, and the lack of support post-retirement.

The interactional impact between exposure to traumatic events and workplace culture goes beyond the lack of support or open hostility shown by some managers within paramedic organisations, to the negative outcomes associated with New Public Management principles. This is best summed up by Hamling, in relation to the New Zealand experience [ 55 , 56 ], who argued that the productivity and efficiency targets set by governments and, of necessity, implemented by management, prevent on-road paramedics from achieving their vocation to care . She suggested that the culture of metrics (key performance indicators used by managers) means that on-road staff become more concerned about the speed in which a job is performed, than caring for the patient. This creates tension and stress in on-road paramedics and underpins their response to critical incidents and much of the workplace stress they experience. This view is supported by a number of other researchers in South Australia, the UK, and the USA, and was evident across the literature [ 9 , 34 , 35 , 48 , 50 , 54 , 56 , 57 ]. Regehr and Millar encapsulate these issues within a framework of Demand and Control as factors affecting the individual’s sense of support. Where these factors are perceived to be or are absent, it leads to work stress and depression [ 38 ] (see Fig.  2 ).

Conceptual model of paramedics’ work-related stress

Theme 2 – ambulance personnel suffering from work-related stress feel abandoned by peers, management, and service, during illness, in return-to-work, and post-retirement

The research reported overwhelmingly that ambulance personnel perceive that they receive little support from the organisation when they are suffering from workplace stress, burnout, anxiety, and/or PTSD. They view mental illness as highly stigmatised within ambulance organisations, making them loathe to seek professional help. They report that informal helpful debriefing occurs largely outside of the service, with family or friends, despite most organisations providing peer support programs. Relying on outside support is not always satisfactory given the possibility that family and friends may experience vicarious trauma [ 58 ]. Strategies such as black humour are used, but this is increasingly seen as politically inappropriate, with paramedics on edge as to where and how it can be exercised [ 59 ].

Given the recognition that stress is cumulative, it is surprising that support for well-being does not extend to those personnel who are forced to retire due to illness or at the end of their career. There was little research reporting on support programs for retired personnel, or recognition that they may be able to assist those currently in the service in need of care. As noted, despite many services providing support mechanisms, at all points in their career, the individual is seen as responsible, with management and the organisation being unable or unwilling to assist. Some research suggests that the failure of management to respond to paramedic stress does not arise from a lack of empathy, but a failure in appropriate skills in managing bullying, conflict, and confidentiality which ‘boils over’ into workplace management [ 9 , 20 , 29 , 30 , 38 , 50 ]. The overwhelming alienation between management and front-line ambulance personnel is a key finding emerging from a significant number of papers across the peer-reviewed literature.

Theme 3 - policy, programmes and interventions, and education need to occur at an individual, peer, organisational, and government level (Programmes and resources)

Research exploring how the issues highlighted above can be addressed takes a holistic approach moving from the individual through to the organisation. The organisation can assist through a number of strategies and processes that can be divided between cultural shifts and organisational re-design. Cultural action is required to remove the stigma associated with seeking help for work-related stress. This is a difficult task and is probably only achieved when actions speak louder than any rhetoric on the topic. Actions taken up by the organisation will in turn shift cultural perceptions and include recognising that workplace stress is cumulative and that it can manifest following routine incidents. This may mean that the service needs to organise staffing and rosters to allow paramedics with structured recovery time between jobs so that fatigue and emotional processes can be addressed. This will invariably have an impact on budgets along with the need for a more concerted focus on the training and education of leaders and managers in all aspects of their role, from designing rosters that safeguard well-being, to recognising colleagues in distress, to the management of workplace tensions.

A number of studies reported mixed results from the support programs currently used within Ambulance Services. For example, there was considerable discussion on the use of Critical Incident De-briefing with claims that it lacked an evidence base. There was support for providing robust peer-support programs and independent counselling services that extended to ambulance personnel’s families and to those who have retired. Although the current recommendation is for psychological first-aid support programs, there is currently only limited evidence establishing efficacy of both peer support programs and psychological first aid in the emergency service context.

A number of studies suggested pre-employment testing, although there was insufficient evidence to support the recommendation [ 21 , 51 ]. There is also recognition that younger employees may respond to different approaches, particularly if the organisation uses the internship period to demonstrate its commitment to workplace well-being. Researchers noted that counselling staff needed to be highly trained in the area, and to have greater knowledge of the day-to-day work performed by ambulance personnel [ 22 , 35 , 36 ].

Related to the above, it is clear from the research literature that the problems require ongoing education about mental health and wellbeing across the continuum from initial training to post-retirement. However, there was a notable absence within the literature on preparing student paramedics and other ambulance personnel for the potential psychological stresses associated with the role.

In response to the increasing need to care for those providing emergency medical responses, a number of national and international initiatives have been proposed and implemented. For example, in 2018, the Paramedic Association of Canada in partnership with other key organisations launched a new standard for developing and maintaining a psychologically healthy and safe workplace [ 60 ]. The standard specifically aims to assist ambulance organisations to: raise awareness of stigma, self-stigma and harassment; systematically identify potential sources of stress and hazards to psychological wellbeing; and identify measures that can be implemented to address those hazards. Naylor et al. [ 61 ] suggests there needs to be a concerted effort to integrate mental health into new models of care for frontline service personnel as part of efforts to increase mental health literacy and to support education and training.

A range of broad steps for policy are suggested by the findings of this review. For example, policies may be required to regulate the role and skills of counsellors working in this space, to ensure that they understand the unique nature of ambulance work are specialised in addressing the needs of this group who are routinely exposed to critical incidents. Policies should also consider how ambulance services’ support for injured ambulance personnel is funded. For example, this could include policies that provide members and their families (employed and retired) with financial support to seek their own confidential psychological well-being counselling outside of the organisation, with no financial cap put on resource use. Also, given the cumulative nature of psychological and physical impacts on this population, Workers Compensation claims systems and processes should be streamlined and accepted for conditions that are often chronic in nature and which require long-term support.

Limitations

This systematic review had several limitations. There were few studies about retirement issues, none devoted to volunteers, and none that examined potential gender differences. Most studies involved mixed samples; however, experiences and needs may vary across gender, role, education level, urban and rural location, availability of supports, experience and seniority level. Research on the potential differences between various groups, such as those on active duty versus call takers, is still limited, and many of the included studies did not distinguish between groups when reporting study findings. To help address this problem, we recently examined all the included research on issues specific to call-takers [ 62 ]. Exposure to critical incidents and toll of shift work and full-time roster rotations may vary also across different groups within the population of ambulance personnel.

Other limitations include exclusion of research published prior to 2000, the exclusion of non-English literature, and terms used in some countries that may have been overlooked in the search strategy. There are also limits associated with qualitative research which relies on self-report, often involving sample sizes and single organisations for recruitment, which may have led to recruitment bias and problems with generalising the findings to other contexts and other countries. Further limitations included the inclusion of all available studies regardless of their quality which may have affected the trustworthiness of conclusions drawn and validity of themes.

The research literature suggests that strategies to address psychological wellbeing of ambulance personnel are of two kinds: specific programs to assist them to manage the distress that comes with attending to critical incidents; and secondly, programs that deal with organisational issues. There is, however, insufficient evidence for generalising specific beneficial strategies programs across ambulance service systems and countries, more broadly; that is, to know whether one country is doing better or worse than others, and why. Further comparative research is needed. Despite the limitations noted, the research literature reported in this review points overwhelmingly to an interactional effect between critical incidents and workplace culture and demands. This culture includes day-to-day managerial actions and responses, but also the impact of shift work, poorly managed rosters, and long hours of work with little time between for recovery. Coupled with work-flow issues are the negative consequences of New Public Management productivity and efficiency targets, now part of many ambulance services that require the job to be done within particular time limits. There is sufficient evidence within the research literature to suggest that these metrics are detrimental to the mental and physical health and well-being of ambulance personnel.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Abbreviations

Ambulance Employees Association of South Australia

Cardio-Vascular Disease

Emergency dispatch centre

Emergency medical service

Emergency medical dispatcher

Emergency medical technician

Post-traumatic stress

Post-traumatic stress disorder

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Acknowledgements

We would like to thank the AEASA for supporting us to undertake this important work. We would also like to acknowledge Jeremy Stevenson’s assistance in populating draft material for some of the tables developed for this review.

This research was funded by the Ambulance Employees Association of South Australia (AEASA). The five key questions guiding this systematic review design were established by the AEASA. The funding body were not involved in the collection, analysis, or interpretation of data, or in the writing of the manuscript.

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SL led the project. All authors contributed to refining the inclusion and exclusion criteria. LM provided expert librarian input to the structure of the search and selection of databases and conducted the searches in consultation with SL and the research team. LR, with support from LC and EG, applied these criteria to establish the final included articles, and the extraction and drafting of results. LR and EW led the analysis, applying their expert knowledge of the ambulance sector. SL drafted the article with all members of the research team’s review and input. All authors have read and approved the manuscript.

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Supplementary information

Additional file 1: appendix 1..

. Systematic literature review search strategies

Additional file 2: Appendix 2.

Description of studies included in systematic literature review

Additional file 3: Appendix 3.

Impacts and work-related psychological and physical well-being needs

Additional file 4: Appendix 4.

Impacts of organisational and systems parameters

Additional file 5: Appendix 5.

CASP quality ratings of primary research and non-systematic literature reviews

Additional file 6: Appendix 6.

CASP quality ratings of systematic review

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Lawn, S., Roberts, L., Willis, E. et al. The effects of emergency medical service work on the psychological, physical, and social well-being of ambulance personnel: a systematic review of qualitative research. BMC Psychiatry 20 , 348 (2020). https://doi.org/10.1186/s12888-020-02752-4

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Pathophysiology for Emergency Medical Services Essay

Individual health is substantially defined by the ability of different body systems to function well. In fact, the body systems do not work in isolation, and the processes taking place within them are interrelated with each other. Considering that it is impossible to study pathophysiology in significant detail during one semester, I expect the course “Pathophysiology for Emergency Medical Services” to be a solid starting point in the research of the given area of knowledge.

First of all, I would like to complete an overview of key pathophysiological mechanisms in all body systems, paying attention to the ones associated with the most common diseases posing the greatest threat to public health. They include heart diseases and stroke, neurological conditions such as Alzheimer’s disease, various infections, obesity, diabetes, and others. Secondly, I expect to learn about the links among various pathophysiological processes that take place in different body systems. The given knowledge is essential to understand comorbidity and polymorbidity. Thirdly, since the course explores pathophysiology in the context of emergency medical services, I would like to develop skills in quick recognition of signs of acute health problems. Along with this, I expect to understand how to select appropriate solutions for their alleviation and prevention of health aggravations. For this reason, practical work (namely, analysis of case studies and synthesis of evidence, et cetera) would be of tremendous help.

To sum up, the present course meets my objective of learning about pathophysiological alterations and creating a base for further exploration of the subject. My specific expectations are as follows: the overview of primary pathophysiological mechanisms, the exploration of links among them, and the development of critical thinking skills needed to detect distinct pathophysiological symptoms and choose the best health interventions. By fulfilling them, I will progress in my academic and professional development.

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IvyPanda. (2021, June 22). Pathophysiology for Emergency Medical Services. https://ivypanda.com/essays/pathophysiology-for-emergency-medical-services/

"Pathophysiology for Emergency Medical Services." IvyPanda , 22 June 2021, ivypanda.com/essays/pathophysiology-for-emergency-medical-services/.

IvyPanda . (2021) 'Pathophysiology for Emergency Medical Services'. 22 June.

IvyPanda . 2021. "Pathophysiology for Emergency Medical Services." June 22, 2021. https://ivypanda.com/essays/pathophysiology-for-emergency-medical-services/.

1. IvyPanda . "Pathophysiology for Emergency Medical Services." June 22, 2021. https://ivypanda.com/essays/pathophysiology-for-emergency-medical-services/.

Bibliography

IvyPanda . "Pathophysiology for Emergency Medical Services." June 22, 2021. https://ivypanda.com/essays/pathophysiology-for-emergency-medical-services/.

EMS Week at 50: Honoring the Past While Looking at the Future

This year, we celebrate EMS Week by honoring our past.

Via the American College of Emergency Physicians

Editor’s note :  JEMS  is a strategic media partner with the American College of Emergency Physicians and EMS Week.

Half a century ago, a presidential proclamation called on the nation to support efforts to improve emergency medical care across the country. It also established the first national EMS Week, a tradition we proudly continue today. Much has changed since 1974, yet there is still much we can learn from those trailblazing professionals who helped EMS evolve into the sophisticated branch of medicine it is today. Their dedication, commitment and sacrifice inspire us to take bold steps of our own, to continue to seek out ways to better serve our patients and our communities.

This year, we celebrate EMS Week by honoring our past—by taking a pause to recognize the contributions of each generation, the people who dreamed that we could save more lives and have less suffering, and then found ways to make it happen. EMS Week is never just about the past, however. It’s also about inspiring the EMS professionals just starting out and the young people who haven’t even discovered EMS yet. It’s about learning from the challenges and building on the successes of the last five decades. It’s about forging our future—a future in which the next generation has the tools they need to deliver compassionate care and alleviate suffering in communities everywhere.

The History of EMS Week

In 1974, President Gerald Ford authorized EMS Week to celebrate EMS professionals and the important work they do in our nation’s communities. National Emergency Medical Services Week brings together local communities and medical personnel to honor the dedication of those who provide the day-to-day lifesaving services of medicine’s frontline. EMS Week is presented by the American College of Emergency Physicians (ACEP) in partnership with the National Associations of Emergency Medical Technicians (NAEMT). Together, NAEMT and ACEP lead annual EMS Week activities. These organizations are working to ensure that the important contributions of EMS professionals in safeguarding the health, safety and well-being of their communities are fully celebrated and recognized.

May 22nd: EMS Day at Museum

https://americanhistory.si.edu/press/releases/May-2024-calendar

Wednesday, May 22; Noon – 4 p.m.

First Floor West & Warner Bros. Theater

The National Museum of American History will explore the history of Emergency Medical Services (EMS) in the U.S. during the 50th Anniversary of EMS Week with a special day of events. The roots of today’s Emergency Medical Services go back to the chaotic field care during wartime battles, including the Revolutionary and Civil Wars. Over time, it developed into today’s EMS with specialists trained to respond to accidents and disasters, from heart attacks and home fires to hurricanes, earthquakes, and terror attacks. Pittsburgh’s Freedom House Ambulance Service, founded in 1967, was staffed by Black paramedics and was one of the first ambulance services to offer emergency medical services in the U.S. The afternoon events will include a panel discussion with John Moon, one of the Freedom House paramedics, and others. Representatives from the American College of Emergency Physicians (ACEP), the National Highway Traffic Safety Administration Office of Emergency Medical Services (NHTSA OEMS), the National Association of Emergency Medical Technicians (NAEMT), and DC Fire and EMS (DCFEMS) will be on hand to talk about the history of saving lives in an emergency Visitors will also be able to see related objects from the museum’s collection and vintage ambulances.

May 23rd:  EMS Week on the National Mall

Location: National Mall, 9th Street, between Madison and Jefferson

Time: 11:30 am – 4:00 pm Eastern Time

Antique and Modern Ambulances on display

Hands-on Heart CPR and AED Training

Stop the Bleed and Tourniquet Training

Guest speakers to include:

ACEP President

NAEMT President

ACS Executive Director

NHTSA Office of EMS

Federal Interagency Committee on EMS

And more……..

EMS Week Theme Days

Having special theme days during EMS Week helps to structure the week in terms of planning special events, conducting training and hosting celebrations. Remember all the days of EMS Week when planning your agency’s activities.

Sunday is Health, Wellness, and Resilience Day

To promote the health, wellness, and resilience of EMS professionals and patients. Health, Wellness, and Resilience Day highlights the need to recognize and care for the health and wellness of EMS professionals and patients and share ideas on strengthening resilience. It is an opportunity to step back and take care of ourselves through self-care and care for our fellow EMS professionals and the patients in our care every day.

Monday is Education Day

Highlighting public education programs and EMS professionals’ education.

Education Day seeks to highlight community educational programs and the importance of continuing education for EMS professionals. This is the ideal day to plan a community injury or illness prevention program and a special CE course for your agency. Consider in-person or online community education programs related to the prevention of falls, burns, poisoning, or drowning.

Tuesday is EMS Safety Day

To promote Safety for the EMS professional, the patient, and the public, Safety Day encourages first responders to focus on risk and prevention rather than possible negative outcomes and aims to advance safety measures for both the community and the profession. This is a great day to highlight stress reduction, self-care, and mental health awareness programs. Other options for programs include improved situational awareness, driving and roadway safety, vehicle and device maintenance, proper lifting techniques, or violence awareness.

Wednesday is EMS for Children Day

To highlight the special needs of caring for children EMS for Children Day highlights the distinctive physiological and psychological aspects of caring for children and serves as an opportunity to raise awareness about improving specialized care for children in pre-hospital and acute care settings. Consider planning a pediatric care educational event for your clinicians and a community program related to first aid, emergency preparedness, car seats or bicycle safety.

EMSC Day Promotional Toolkit

EMSC Day & EMS Week

Thursday is Save-A-Life Day

To promote Stop the Bleed, public CPR programs and other programs It doesn’t matter how quickly EMS professionals get to a scene—bystanders will almost always be there first. Save-A-Life Day empowers the general public to learn and apply steps that can be taken to help save a life. This is an ideal day to schedule community CPR and Stop the Bleed educational courses. Take advantage of the many programs and toolkits available that make it easier to coordinate these programs.

Thursday is also STOP THE BLEED® Day!

Please check out the STOP THE BLEED® Project website and all of the programs for STOP THE BLEED® Day including:

STOP THE BLEED® Day (Save the date! May 23, 2024!)

STOP THE BLEED® Day Scholarships – over $175,000 awarded to date! Available for high school and college students. Applications now open!

STOP THE BLEED® Day Grants – Grants from $1,000 to $100,000! Applications now open!

The fast growing STOP THE BLEED® Day Ambassador program (now in 75+ countries).

Friday is EMS Recognition Day

To recognize your local EMS heroes and those who save lives through the EMS system. On EMS Recognition Day, we honor members of the EMS community who regularly go above and beyond what’s expected. It’s a day to give gratitude to first responders for their unwavering commitment to serving their communities. Plan an awards event, a special meal, a gift-giving event, and other honors for EMS Recognition Day.

Saturday is EMS Remembrance Day

To honor emergency medical services personnel who have died in the line-of-duty and to recognize the ultimate sacrifice they made for their communities. We thank them for their service to EMS and for bringing comfort and lifesaving care to their patients. They leave us with the proud memory of their commitment and dedication to EMS. This day is set aside to recognize those fallen EMS professionals and their families. Some ideas for this day include: Plan a memorial ceremony, hold a moment of silence event, create a Wall of Honor, host a ceremony to recognize families or establish a memorial scholarship.

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Walter Reed Celebrates 50th Anniversary of Emergency Medical Services Week

Photo By Harvey Duze | How would Walter Reed National Military Medical Center (WRNMMC), the flagship of... ... read more read more

Photo By Harvey Duze | How would Walter Reed National Military Medical Center (WRNMMC), the flagship of military medicine, respond if a multi-vehicle accident resulting in numerous mass casualties occurred on the Capital Beltway near the medical center? Emergency Management and hospital staff at Walter Reed National Military Medical Center (WRNMMC) tested its readiness posture for such an event, or anything similar, during a Code Green exercise November 3, 2022. A Code Green is activated during a mass casualty (MASCAL) event, and the recent WRNMMC’s MASCAL exercise simulated an accident involving an overturned tractor trailer catching fire causing multiple crashes and injuries on the I-495 Inner Loop. More than 150 people are hurt, and many of them brought to WRNMMC for care. WRNMMC’s Simulation Center staff also participated in this exercise, conducting a training scenario using its high-fidelity manikin. The life-like manikin reacts physiologically as if it is alive with human responses, and it can recreate realistic emergency medical situations to provide learners with an opportunity to practice and refine their clinical skills. The Code Green exercise didn’t impact patient care, the emergency department or other clinical areas in the hospital, and all services operated at normal. (DoD Photographs by Harvey A. Duze – Office of Command Communications, WRNMMC)   see less | View Image Page

BETHESDA, MD, UNITED STATES

Story by james black  , walter reed national military medical center.

Emergency Medical Services Week, May 19-25 this year, celebrates the physicians, nurses, corpsmen, medics and other EMS professionals who care for patients in Walter Reed National Military Medical Center's emergency department (ED). Emergency medical services (EMS) system consists of “first responders, emergency medical technicians, paramedics, emergency medical dispatchers, firefighters, police officers, educators, administrators, pre-hospital nurses, emergency nurses, emergency physicians, trained members of the public, and other out of hospital medical care providers,” according to National Association of Emergency Medical Technicians, an organizer for EMS Week. The ED at Walter Reed treats a number of patients arriving to the emergency room, including those who have experienced trauma, falls, motor vehicle collisions (MVC), work-related injuries, chest pain, shortness of breath, headache, abdominal pain and other injuries and illnesses, according to Dr. Juan-Maria Sanfuentes, a staff physician in the ED. "Members of the ED at Walter Reed are ready to provide lifesaving care to those in need 24 hours a day, seven days a week," Sanfuentes added. Walter Reed serves as one of the pinnacle hospitals for trauma care in the Military Health System, according to the Defense Health Agency. The institution has taken care of complex war casualties since before World War I and is the site of groundbreaking innovations in the care of wounded warriors. Both Walter Reed and DHA leadership are supporting efforts to integrate the military capabilities with the civilian EMS system in part by achieving American College of Surgeons (ACS) verified trauma center status. According to Navy Cmdr. (Dr.) John Maddox, Walter Reed Trauma Medical Director and Trauma Surgeon, “Walter Reed is uniquely positioned to take care of severely injured service members and beneficiaries arriving from around the world. Our efforts to meet the ACS verification standards assures we have the administrative processes in place that align with civilian EMS systems. The focus on civilian partnership will help keep Walter Reed ready to care for combat patients during this interwar period.” Code Green Exercises: Preparing for a Potential Mass Casualty Event Each year, Walter Reed conducts at least one “Code Green” exercise simulating a mass casualty event. The Code Green assists hospital managers in evaluating the emergency notification system, staff response, creation of mass casualty receiving stations and ensuring those areas were equipped with the appropriate personnel, supplies and personal protective equipment (PPE). Become a Lifesaver: Enroll in CPR Classes and Stop the Bleed Trainings Sanfuentes explained the public can become part of the EMS team by learning CPR and the Heimlich maneuver in order to help save a life when a victim’s heart stops beating, or when they are choking. In addition, the Walter Reed Trauma program aligns with the national STOP THE BLEED awareness campaign which trains bystanders to provide simple lifesaving first aid in a bleeding emergency. STOP THE BLEED and CPR trainings are offered at Walter Reed throughout the year. For more information about Walter Reed trainings contact: [email protected] or [email protected]. For more information about CPR, visit: https://medlineplus.gov/cpr.html. For information about the Heimlich maneuver, visit: https://medlineplus.gov/choking.html. For information concerning STOP THE BLEED, visit: https://www.stopthebleed.org/. Hot Weather Safety Also, with warmer weather fast approaching, Sanfuentes offers the following information to help people avoid heat injuries, which lead many people to emergency rooms during the summer. • Always stay well hydrated, especially if outdoors in the heat. • Always wear sunscreen and reapply often. • Use insect repellent (permethrin on clothing and DEET on skin).

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MAY 17, 2024

Enhancing Emergency Medical Services Dispatch and Operations

Emergency Medical Services (EMS) play a critical role in public health, responding to urgent medical situations and saving lives daily. However, EMS operations face numerous challenges that can hinder their efficiency and effectiveness.

High call volumes, limited resources, complex logistical demands and the need for rapid coordination across various agencies and jurisdictions all contribute to the complexity of EMS work. These challenges necessitate robust and efficient systems to ensure that emergency services can deliver timely and effective care.

Effective dispatch systems are crucial to overcoming these challenges and improving EMS outcomes. Dispatchers must manage a multitude of tasks, from triaging calls and determining the severity of incidents to coordinating the deployment of ambulances and ensuring that the closest and most appropriate units respond to emergencies. 

Effective dispatch systems are crucial to overcoming these challenges and improving EMS outcomes. In this article, we will explore the complexities of EMS operations, the vital role of dispatch, and how advanced technologies like CentralSquare Unify™ (CAD-to-CAD) can enhance these systems.

Challenges in EMS Operations

EMS providers face a myriad of challenges that can affect their ability to deliver timely and effective care. One of the primary issues is the increasing demand for services, driven by a growing population and the rising prevalence of chronic diseases. 

This surge in demand often leads to overburdened EMS systems, where limited resources must be stretched to meet the needs of many patients.

Geographical and jurisdictional boundaries further complicate EMS operations. Emergencies do not respect borders, yet EMS providers often have to navigate through different jurisdictions, each with its protocols and systems. 

This lack of interoperability can cause delays in response times, as emergency vehicles may not always be dispatched from the nearest location due to jurisdictional constraints.

Additionally, communication barriers pose significant challenges. Traditional dispatch systems often rely heavily on phone calls for coordination, leading to potential miscommunication and time delays.

In high-stress situations, the accuracy and timeliness of information exchange are crucial, and any lapse can result in life-threatening consequences.

Extreme Interoperability Across Borders

Emergencies don’t adhere to jurisdictional lines, often complicating EMS operations. CentralSquare® Unify™ (CAD-to-CAD) addresses this challenge by enabling seamless interoperability across borders. This technology allows 911 communication centers to create a virtual network, integrating their systems with other Public Safety Answering Points (PSAPs) and coordinating agencies . 

This integration ensures that resources can be shared effectively, allowing EMS providers to dispatch the closest and most appropriate unit to every call, regardless of jurisdictional boundaries. 

Interoperability also enhances situational awareness and operational coordination. When multiple agencies respond to the same incident, having access to a shared, real-time information platform is crucial. 

Unify enables two-way data sharing through mobile and handheld devices, ensuring that all responders have the latest updates. This real-time communication allows for more effective on-scene coordination, as agencies can quickly adapt to changing conditions and make informed decisions.

Faster Response Times

Time is of the essence, especially in life-threatening scenarios such as cardiac arrests, severe trauma, and respiratory distress, where every second counts. Reducing response times can greatly enhance the chances of survival and positive outcomes for patients.

Unify leverages rule-driven data mediation to optimize resource and asset sharing across multiple jurisdictions. This sophisticated approach ensures that the closest and most suitable emergency units are dispatched, regardless of jurisdictional boundaries.

Traditional dispatch systems often face delays due to the need to coordinate across different communication systems and protocols. Unify streamlines this process, creating a seamless network that enables swift and efficient allocation of resources.

Agencies using CentralSquare Unify have reported a significant reduction in call processing times, with average decreases ranging from 30 seconds to 2 minutes. In emergency medical situations, this reduction can be the difference between life and death. 

For example, during a heart attack, brain cells begin to die within minutes due to lack of oxygen. A faster response can mean quicker administration of life-saving interventions such as defibrillation or CPR, drastically improving the patient’s chances of recovery without severe complications.

Reducing Communication Barriers

Traditional dispatch systems often rely heavily on voice calls for coordination, which can lead to potential delays and miscommunication. When an emergency occurs, dispatchers must often make multiple phone calls to coordinate with various agencies and units. 

This manual process is not only time-consuming but also prone to errors and misinterpretations. In the high-stakes environment of emergency response, these inefficiencies can have serious consequences, potentially delaying critical interventions.

Unify addresses these challenges by eliminating the need for back-and-forth phone calls in joint responses. Instead of relying on voice communication, Unify utilizes an intelligent network to streamline and automate the coordination process. 

The system can identify and communicate with the appropriate units directly within the Computer-Aided Dispatch (CAD) system, bypassing the traditional phone call method. This direct communication significantly reduces the time wasted on manual coordination and ensures that information is transmitted quickly and accurately.

The intelligent network allows for controlled messages and notifications to be sent seamlessly to partner agencies and organizations. For example, when a multi-vehicle accident occurs, the CAD system can automatically notify relevant parties such as towing companies, ambulance services, hospitals and state Department of Transportation (DOT) road crews. 

This automated notification system ensures that all necessary responders are informed and mobilized promptly, facilitating a more coordinated and efficient response.

Additionally, the use of controlled messages within the CAD system enhances the clarity and efficiency of communication. Dispatchers can send precise, structured messages that contain all relevant details about the emergency situation, reducing the risk of miscommunication.

Optimized Resource Allocation

Effective allocation ensures that the right resources are deployed to the right place at the right time, ultimately saving lives and enhancing service delivery. Unify plays a pivotal role in optimizing this process by leveraging advanced technology to enable full interoperability and real-time mobile data sharing among responders.

The system facilitates a seamless integration of various emergency response units across jurisdictions, which ensures that the most appropriate and closest unit is dispatched to every call. 

This capability is crucial in emergencies where every second counts. For instance, in a scenario where multiple emergencies occur simultaneously, the system can quickly assess the availability and proximity of units from different jurisdictions, selecting the best-suited responders based on real-time data. 

This dynamic allocation reduces response times and enhances the efficiency of EMS operations, ensuring that help arrives as swiftly as possible.

The interoperability feature means that it can integrate various public safety and emergency management systems into a cohesive network. This networked approach allows for a more comprehensive overview of resource availability, making it possible to allocate resources more strategically.

Trusted Technology Integration

Unify is a tested, trusted, and patented technology that works with any CAD system. This compatibility ensures that EMS providers can integrate it seamlessly into their existing infrastructure without the need for extensive overhauls or additional investments. 

The technology supports full interoperability, allowing different systems to communicate effectively and share crucial information in real-time. This integration is essential for modern EMS operations, where quick access to accurate information can significantly impact outcomes.

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Addressing these challenges requires a multifaceted approach, including increased funding, improved inter-jurisdictional cooperation, advanced communication systems, better resource allocation and the integration of modern technology. 

By tackling these issues, EMS systems can enhance their responsiveness, improve patient outcomes, and better meet the growing demands of their communities.

Watch our webinar featuring Doug Workman, 911 Center Manager at the Town of Cary, North Carolina, as we discuss the benefits of a seamless integration between CentralSquare’s ONESolution public safety suite and the Unify to drive true interoperability. 

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• State of International Emergency Medicine
• Open access
• Published: 25 November 2015

An update on emergency care and emergency medicine in Russia

• Anthony Rodigin 1  

International Journal of Emergency Medicine volume  8 , Article number:  42 ( 2015 ) Cite this article

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Russia’s national healthcare system is undergoing significant changes. Those changes which affect healthcare financing are particularly vital. As has often been the case in other nations, the emergency care field is at the forefront of such reforms. The ongoing challenges constitute the environment in which the hospital-based specialty of emergency medicine needs to develop as part of a larger system. Emergency care has to evolve in order to match true needs of the population existing today. New federal regulations recently adopted have recognized emergency departments as the new in-hospital component of emergency care, providing the long-needed legal foundation upon which the new specialty can advance. General knowledge of Western-style emergency departments in terms of their basic setup and function has been widespread among Russia’s medical professionals for some time. Several emergency departments are functioning in select regions as pilots. Preliminary data stemming from their operation have supported a positive effect on efficiency of hospital bed utilization and on appropriate use of specialists and specialized hospital departments. In the pre-hospital domain, there has been a reduction of specialized ambulance types and of the number of physicians staffing all ambulances in favor of midlevel providers. Still, a debate continues at all levels of the medical hierarchy regarding the correct future path for emergency care in Russia with regard to adaptation and sustainability of any foreign models in the context of the country’s unique national features.

Very few articles describing the state of emergency medicine and emergency care in Russia are available in English [ 1 , 2 ]. This paper reviews select topics pertaining to prospects for emergency medicine development in the Russian Federation (Fig.  1 ). It aims to generate further interest on the subject among providers who practice emergency medicine or are otherwise involved in emergency care in other nations.

Russian Federation—location on the world map and the surrounding states

Private sector versus public sector

No different from many other nations, the private sector of Russian healthcare exists in parallel with the government-run national system which predominates. What is less typical is the lack of any significant or uniform integration between the two components in terms of emergency care services. For instance, while private ambulance companies have been plentiful [ 3 ] since the 1990s (working for upfront or pre-arranged fees, while contracted with similarly private hospitals and clinics), such enterprises are found largely in the cities and, more importantly, are affordable for a small segment of the population. In addition, these companies do not participate in the public emergency ambulance dispatch telephone networks (“03” or “103”). Thus, government-controlled services, organized and funded at the federal level, continue to constitute the bulk of emergency care available to the average person—in principle, guaranteed to all citizens free of charge [ 4 ].

Outsourcing and for-pay EMS divisions

In some areas of the country, for instance the cities of Perm, Kirov, Ufa, and a few others (Western Russia), contract-based government outsourcing of ambulance services has recently been attempted with variable success [ 5 ]. However, such experimental handovers of operational ownership so far have not included the actual ambulance personnel. Ambulance crew members have remained government employees now staffing ambulances owned, supplied with equipment and maintained by private entities.

As a somewhat different approach, for some years many official EMS services at the municipal level have been running their so-called for-pay divisions, providing alternatives to using mainstream “03” crews for various needs (for instance, medical support for public events), albeit no longer for free [ 6 ]. While for-pay services generate funds for local agencies, it has been controversial and a matter of debate whether such fee-for-service options and add-ons ought to remain a part of the government’s emergency ambulance care specifically.

Volunteer workforce

Unlike countries where volunteers make up a substantial component of healthcare organizations and services, volunteerism is neither common nor popular in today’s Russia. Undoubtedly, this has more to do with the harsh and enduring economic realities than with some inherent cultural trait. Still, the two factors are not independent, as the former will often shape the latter if given enough continuity in time. Some progress is occurring, as can be discerned from videos describing community “paramedics” (more correctly—volunteers) being trained from among lay persons in rural areas [ 7 ].

Emergency departments

At present, a small number of Western-style emergency departments (ED) exist, including ones at the Dzhanelidze Emergency Care Institute in St. Petersburg, at select hospitals in the republic of Tatarstan and few other locations [ 8 ]. Still, within such EDs there remains a tendency for the sickest patients (“red designation”—those needing immediate resuscitation and/or surgical interventions) to be treated by specialists rather than emergency care physicians very early and/or to bypass the geographic ED altogether. While their total number is negligible, viewed against the nation’s territorial spread, these first contemporary-style EDs represent important conceptual and physical constructs integral to the overall strategy of modernizing Russia’s emergency care system.

In the last few years, several publications have surfaced in Russian emergency care journals describing the new conceptual model of the ED. Preliminary data from the abovementioned pilot EDs has also been presented describing specific outcomes sought and monitored, such as the ED’s effect on reducing unjustified hospitalizations [ 9 , 10 ].

Paradoxically, the idea of the modern ED in terms of its basic mission and functions is not as novel to the Russian medical community as it may appear at first glance.

Since the nineteenth century, the majority of Russian hospitals (or their individual specialty departments at large facilities) have had admission wards (AWs; sometimes translated “receiving bays”) intended for the initial reception, triage (surgical/medical), and sanitary screening of patients. The gradual evolution of such units in Russia has been described in some detail in a recent English language article [ 11 ] and will not be repeated here.

It suffices to say that prior to the 1960s, the Russian AWs were not altogether different in terms of physical space and basic capabilities from many ERs of the same era in the USA—for example, the “basement ED,” as described by John McDade on page 35 of Brian Zink’s Anyone, Anything, Anytime: A History of Emergency Medicine [ 12 ].

In 1963, the USSR Ministry of Health introduced the concept of hospitals of emergency medical care (HEMC), which became the preferred receiving facilities for ambulance traffic in urban and other populated areas. The new requirement for more coordinated emergency care at HEMCs placed new demands on AWs. In response, over the subsequent 20 years and into the 1980s, AWs evolved into what became known as the “receiving diagnostic departments” (RDs) of HEMCs. While not matching all capabilities of a true ED, an HEMC’s RD typically has examination gurneys and procedural areas, a resuscitation “room,” and access to EKG, laboratory services, and radiography.

The old-fashioned AWs (still common at rural and small hospitals) and the more modernized RDs (HEMCs and large central facilities) are the most common “ER” setups found in Russian hospitals today. Thus, while neither type is a full service emergency department, they both fulfill a similar function.

One can thus argue that it is not the ED itself that is truly novel for the Russian healthcare system today but rather the role of the emergency physician as a key player within the in-hospital domain of emergency care. In Russia, no such role has existed or entered discussion until most recently.

Attempts to introduce the ED model and the emergency physician role (starting with select locations in large cities) undertaken by the Russian Society of Emergency Medical Care [ 13 ] and by few other entities have been met with mixed attitudes, including frank skepticism and resistance [ 14 ]. In part, the latter views can be attributed to factors outside of the immediate emergency care reform, e.g., the overall decline of the post-Soviet infrastructure coinciding with the shrinking healthcare workforce due to aging. Other reasons for such reactions stem from difficulties encountered during the ongoing transition to the government’s newly adopted way of financing healthcare (the Mandatory Medical Insurance system). There may also be the perception that many existing physician jobs are being threatened—including positions on the ambulance services.

Emergency physicians

It is true that historically and until today, in Russia there have never been “emergency physicians” in the Western sense of doctors primarily working at designated emergency departments. What is not true is that no physicians exist whose professional practices are restricted to emergency care.

One of such specialties is anesthesia - reanimation , better translated as anesthesia-resuscitation. Such providers are involved in both in-hospital and pre-hospital care. In the in-hospital, they run resuscitation departments (ICUs specializing in resuscitation), and in the pre-hospital setting, they are the most common type of a physician in charge of a resuscitation crew (the classic reanimation yellow ambulance one may see on the street). Arguably, this cohort of physicians represents one group of existing specialists whose required skills closely match those of emergency physicians.

Second, the often encountered claim regarding “generalists” without specific training working on the majority of ambulance units is not accurate in reference to the three most recent decades. While such a situation existed through the 1970s, one must recall that it was during the same time period that the majority of EDs in countries with the so-called Anglo-American model were also staffed by an incidental assortment of doctors. By 1982, emergency medical care ( skoraya meditzinskaya pomosch , SMP) in USSR became a certifiable specialty, albeit one constrained to pre-hospital field work [ 15 ]. One-year internships in “SMP” and longer clinical ordinaturas (residencies) became available to students graduating medical schools as internists, surgeons, or pediatricians (at that time, such basic specialization was granted upon completion of all 6 years of medical education following high school).

Finally, while any point of view is by definition subjective, to the majority of emergency care providers in Russia, including the current career ambulance physicians, the model of emergency care they have inherited and are hoping to improve is not and has never been “Franco-German.” Rather, it is considered to be fully Russia’s own, shaped by the nation’s own medical leaders over the last two centuries, and one that has paid daily tribute to the country’s unique features—even as simple as climate and territory.

Pre-hospital care

The basics of the European model’s general approach to pre-hospital care, as well as the Soviet two-tier system of ambulances (basic vs. specialized), have been well described elsewhere [ 1 , 16 , 17 ].

However, it is often overlooked that while physicians have always worked and continue to work on the Russian ambulances now, they have never been the predominant ambulance workforce. By some estimates, the Russian midlevel providers, known as feldshers , make up as much as 80 % of the crews in total. In remote and rural areas, this percentage may often approach 100 %. This unique profession, tracing its name to German military field medics, is once again at the forefront of pre-hospital emergency care today, as efforts are underway to gradually reduce both the variety of specialized ambulance units and the number of physicians staffing them. Still, challenging questions remain—for instance, what is the continued need for pre-hospital thrombolysis capabilities (and thus, questionably, physician supervision), given that the country’s geography limits access to hospitals in vast areas of land?

Paramedics (implying the established profession and not simply a label for any pre-hospital provider) do not exist nor are they envisioned in Russia as of now. But surrounding issues do arise.

One topic of ongoing debates is the future of Russian ambulance drivers. Traditionally, the drivers have not received any medical training. They were instead responsible for monitoring a vehicle’s operational condition and performed the frequently needed on-the-spot repairs. They also provided navigation skills based on memory and knowledge of the local streets. In the Soviet times the need for a separate driver was dictated, in part, by the fact that relatively few persons owned automobiles and hence held driver’s licenses—almost none among women, who made up (and continue to make up) the majority of the pre-hospital workforce.

In today’s changing environment of car ownership, satellite tracking, and online maps, many have proposed the replacement (or up-training) of the mere driver with a medical person of sorts: a medical technician or perhaps another midlevel provider. Yet, others have pointed out that while professional driving skills are at least helpful in city traffic, in the peripheral areas filled with unlit and unpaved roads such skills remain a necessity.

Overall, in the near future, one is likely to observe a shrinking number of categories of specialized ambulance units [ 18 ] and a gradual replacement of ambulance physicians with midlevel providers. Even now, very few basic-level emergency ambulances are routinely staffed by physicians.

Separation of emergent and urgent ambulance services

In USSR, a multi-specialty ambulatory care center, the polyclinic , was assigned to a specific city district or rural area. An average primary care provider, such as a pediatrician, would split their work week between having clinic hours and making house calls within an assigned zone covering several blocks. While in theory many polyclinic services and specialists were available on a first come first serve basis, the “03” ambulance system quickly became overused by the so-called “non-profile” patients (those without emergent conditions). Such patients would primarily rely on the ambulance personnel for their various medical needs [ 19 ]. Of note, this trend continues until today, adversely affecting ambulance response times and crew burnout rates.

In order to at least partially compensate for the undue demand on ambulances, walk-in urgent care centers have been set up within the polyclinic structure. More importantly, separate ambulance services termed “urgent” as opposed to “emergent” have been split away from main EMS to augment such centers. Based immediately adjacent to the polyclinics, the urgent ambulances are also staffed by urgent care or primary care personnel. Calls are re-directed to these units by the main dispatch depending on specific criteria. Examples include fever alone or uncontrolled hypertension without other symptoms. Unlike the commonly accepted goal of arrival within 20 min for “03” EMS, response times of up to 2 hours may be acceptable for the urgent units. This separation of the two ambulance services is not new—it has been attempted in the past at various times of USSR history. Proponents and opponents of this dual system continue their debate until today.

Two other types of urgent care facilities have existed traditionally. These are the travmpunkt (literally “trauma point”) providing basic minor trauma care services for walk-ins and the rural feldsher-obstetrical “point” staffed, as its name implies, by midlevel providers. The future need for these facilities and the way of integrating them into the envisioned new system, one containing modern emergency departments, remain unclear.

Emergency care professional societies

Several national organizations best described as emergency care professional societies have been created since the turn of the twenty-first century. The National Scientific and Practical Society of Emergency Medical Care, founded at a medical university in Moscow, has worked on cadre development and improvements for the existing system. It has also focused on increasing research efforts and evidence-based practice within EMS, urgent care, and primary care practice settings [ 20 ]. Another organization founded more recently and based at the renowned Sklifosovsky Institute of Emergency Care in Moscow has chosen as its mission “uniting [all] specialists (resuscitation specialists, emergency care physicians, surgeons, cardiologists…) working in the area of medicine of emergency conditions” [ 21 ]. Finally, the Russian Society of Emergency Medical Care mentioned above is perhaps the most forward organization, attempting to not only improve but also shape the future of emergency care in Russia. All three organizations display their respective journals online, with abstracts available in English.

Limitations

This brief overview does not aim to be comprehensive or to replace the few works on this topic published in English. Important themes not covered included systems of trauma care, pediatric emergency care, plans for creating or improving inter-facility and inter-regional relationships among entities participating in emergency services, and financial and legislative support of the emergency care system as a whole, among many others. The main goal of this paper has been to expose the reader to select but key issues faced by Russia’s emergency care community at present and to hint at the spectrum of viewpoints which abound.

Undoubtedly, all of the topics discussed above point to the two main issues at hand. The first has to do with the future well-being of Russia’s emergency care providers—a characteristic directly affecting their ability to consistently carry out their vital role. The second rests on the question—how well will the new system, however constructed, match the real needs of the Russian society at large in terms of its demand for emergency care services?

Presented with a combination of challenges that are both universal and country-specific, the Russian medical community is facing tough choices along the road towards a more modernized healthcare system. Emergency medical care is widely recognized as imperative for the overall health of the nation. The need for a hospital-based physician practice focused solely on emergency care is slowly coming into recognition, immersed in a pool of diverging professional and public opinions held at a time of substantial economic hardships.

In the near future, it would be of interest and value for the world’s emergency medicine community to see more papers by Russian authors come out describing the operation of the planned EDs and the proposed pathways for training (or re-training) the new ED-based emergency care providers. While the Russian emergency care system is likely to take on a unique shape, not exactly matching that in other nations, ultimately its effectiveness will be measured using a number of universally accepted metrics—for instance, any reduction in mortality of victims of motor vehicle accidents.

Abbreviations

admission ward

emergency department

emergency medical services

hospitals of emergency medical care

intensive care unit

receiving diagnostic department

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The author would like to thank Vicken Totten, M.D., for her review of and comments on an earlier draft.

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Anthony Rodigin, M.D., FACEP, FAAEM, is an attending physician and an assistant ED medical director at the Sutter Delta Medical Center in Antioch, California. He has been a member of the international section of the American College of Emergency Physicians (ACEP) since residency at UCSF-Fresno and is the ACEP Lead Ambassador to the Russian Federation. Dr. Rodigin’s non-clinical and research interests include education, EMS administration, and comparative studies of emergency care and EM development internationally, with a focus on Eastern Europe and Russia.

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Rodigin, A. An update on emergency care and emergency medicine in Russia. Int J Emerg Med 8 , 42 (2015). https://doi.org/10.1186/s12245-015-0092-1

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Opinion columnists | national emergency medical services week is a time to celebrate and advocate | commentary.

This year holds particular significance as we commemorate the 50th anniversary of President Gerald Ford’s establishment of EMS Week. Now, more than ever, amidst unprecedented challenges, we honor the dedication of medical personnel who provide around-the-clock lifesaving services — first responders, emergency medical technicians, physicians, nurses and countless others.

During EMS Week, May 19-25, let’s recognize the invaluable contributions of these individuals who save lives and provide critical care when every second counts.

Luminis Health Anne Arundel Medical Center, with more than 120 years of proud history, has one of the busiest EDs in the country and is one of the few hospitals in the state with a pediatric ED. With nearly 95,000 ED visits each year, it takes a dedicated team of doctors, nurses, receptionists, other hospital staff and volunteers to give you the care you need as quickly as possible.

Knowing emergency rooms can feel frightening for young patients, we have a dedicated space with kids in mind. At our pediatrics ED, children receive tailored attention from a specialized team ready to treat their unique needs.

For all patients, we use a process called triage to carefully prioritize who needs care first. Treatment is administered based on the severity of their condition, with those facing life-threatening illness or injury receiving immediate attention. This means someone who arrives after you might receive care before you.

At Luminis Health, we believe in a culture of mutual caring: We provide the best care possible in a healing environment and we always treat each other with respect and dignity. Caring for and protecting patients, families, employees and our community is important to us.

Dealing with an emergency is stressful, particularly when waiting in an Emergency Department. We try to minimize this stress by initiating care in our waiting room and keeping our patients informed while waiting.

Luminis Health has also made significant investments to offer more expansive care programs for mental health, substance use and domestic violence in our ED. Additionally, Maryland lawmakers recently provided funds to enhance security for staff and patients, creating de-escalation spaces in the pediatrics ED.

During EMS Week, it’s also important to recognize the challenges some of our ED staff face from time to time. According to the American College of Emergency Physicians, two out of three Emergency Department physicians reported being assaulted in 2022. One-quarter of them reported being assaulted multiple times a week.

That’s why Luminis Health supports the Safety from Violence for Healthcare Employees (SAVE) Act. If enacted by Congress, the law would provide protections similar to those that exist for flight crews, flight attendants and airport workers.

As we continue to improve ED wait times, we also ask for your help to ensure you receive timely care, by taking these steps:

Make sure you bring everything you need for emergency care. Your time in the Emergency Department will be more efficient if you bring essential items for your care team, such as the following:

• Driver’s license or identification card;
• For individuals covered by a health insurance plan, your insurance card;
• List of medical history, medications and allergies, primary physician, and specialists.

Urgent care is another option

There are many situations in which the ED is the best place to go for care, such as life-threatening injuries or conditions. In other cases, urgent care centers are a convenient option for minor issues such as cough and cold symptoms, minor cuts, sprains and strains, etc.

Telehealth visits are refreshingly easy

If your situation is not a true emergency, Luminis Health offers CareConnectNow, a virtual urgent care service for ages 13 and up. We provide expert care for many conditions that need immediate, but not emergency, attention.

With the availability of after-hours and weekend virtual visits, we aim to accommodate your schedule. You can also access this convenient service by calling (443) 951-4270.

At Luminis Health we continue to evaluate and explore ways to ensure a positive patient experience. That is our commitment to our community. We thank you for your patience, support, and your own efforts as we strive to improve emergency care for every patient.

Let us carry forward the appreciation and recognition for the dedication of our Emergency Department personnel during EMS Week and throughout the year.

Dr. Michael Kent is emergency department medical director at Luminis Health Anne Arundel Medical Center.

Dr. Lauren Fitzpatrick is medical director of pediatrics at Luminis Health Anne Arundel Medical Center.

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Patients being hit with costly ambulances and emergency medical bills. This must stop.

• The high cost of ambulances is a major barrier to healthcare for many Americans.
• The No Surprises Act, which went into effect in 2022, does not protect patients from surprise bills for ground ambulances.
• A federal-level modification of the No Surprises Act to include ground ambulances would result in a more equitable healthcare system.

Ryan Elaoud is a third-year student at the Ohio State University, majoring in biomedical science.

In the current U.S. healthcare landscape, there are glaring obstacles that impede many Americans in obtaining appropriate healthcare.

One such obstacle may even result in the difference between life or death: the exorbitant cost of ambulances and emergency medical services. As critical life-saving services become increasingly financially out of reach for many, it's time to scrutinize the economic barriers preventing swift and lifesaving access to healthcare for all.

Currently, escalating costs of ambulance services create an insurmountable barrier, deterring many individuals from seeking timely medical assistance.

Healthcare system has dangerous flaws

In 2017, one in four American families had to turn down medical care that they needed purely because of cost. This figure is exacerbated among older millennials (ages 34-42) with 32% turning away from medical care because they couldn’t afford it in the past year.

However, this issue extends beyond mere financial burden; it is a systemic flaw that hampers the very essence of accessible and equitable healthcare. The financial barrier to ambulances affects the vulnerable—the poor—the hardest, resulting in adverse health outcomes and an ethically strained healthcare system.

In 2022, 12.2% of Americans did not have health insurance; in that same year, the average charge for an ambulance before health insurance coverage and discounts was $1,277 — a debilitating charge for many people of lower socioeconomic status. This cost barrier to ambulance services exacerbates health disparities, perpetuates inequality, and jeopardizes public health by impeding swift critical care delivery.

Ambulance companies state that large costs of round-the-clock staffing, limited insurance reimbursements and expensive equipment are the predominant reasons for elevated consumer bills. Furthermore, some argue that high ambulance costs are justified by the complex, highly trained personnel providing care and the life-saving nature of emergency medical services.

While the high costs of said staffing and the complex technology involved may be understandable in certain cases, it is nonetheless crucial to recognize that these same large costs commonly result in insurmountable financial barriers to potentially life-saving care for many Americans.

What is the solution?

While the No Surprises Act, established on January 1, 2022, helped overcome many of the financial barriers to healthcare for vulnerable populations, it is not close to exhaustive, or even to what is required to create equitable healthcare for all.

The No Surprises Act aimed to prohibit healthcare services from billing patients with “surprise” charges for out-of-network fees. This meant that for various emergency services and for select non-emergency services from out-of-network providers, patients could not be billed more than their in-network rates.

However, No Surprises Act’s protections do not extend to ground ambulances, meaning that patients can still be hit with crippling surprise out-of-network fees for critical, life-saving care. A more expansive NSA that includes traditional ground ambulances would alleviate this problem.

Not only would it result in more transparent pricing and lower ambulance costs for patients on average, but it would also lessen the financial burden facing Americans for critical healthcare services. This solution has already been implemented in multiple states with legislation such as House Bill 388 , wherein protections like the No Surprises Act are extended to ground ambulances.

A federal-level modification of the No Surprises Act to include ground ambulances would result in a more equitable healthcare system, reduced financial disparities and improved overall public health.

Failure to address this issue will perpetuate a cycle of delayed or denied emergency care, with consequences echoing across American communities.

Now is the time for collective action

To produce change necessary for health equity for all Americans, we—as upstanding citizens—must advocate for policy changes, engage in community discussions and support initiatives that champion affordable and timely access to emergency medical services.

By calling on our local and federal lawmakers to amend the NSA, we can help to dismantle financial barriers preventing access to ambulances and ensure that every individual, regardless of financial standing, can seek emergency medical assistance without hesitation.

Our health and the well-being of all American communities depend on our actions.

The Key Points at the top of this article were created with the assistance of Artificial Intelligence (AI) and reviewed by a journalist before publication. No other parts of the article were generated using AI. Learn more .