Considering the Big Picture
Efforts to address high rates of infection and deaths from COVID and other infectious diseases among paramedicine clinicians will have the best chances of success if there are concurrent efforts to address the larger emergency medical services (EMS) system issues of low salaries, inadequate support for education, EMS-specific research needs and insufficient EMS system funding.
Introduction
Paramedicine clinicians have one of the most dangerous jobs in the United States (U.S.). Their occupational fatality rate is comparable to the rates for police and firefighters,1 their occupational injury rate is three times higher than the national average for all workers,2 and their non-fatal injury rate is higher than the injury rates for police and firefighters.3 The COVID-19 pandemic has brought attention to, and highlighted, the unique dangers they confront each day from infectious diseases. The rate of COVID-related fatalities for paramedicine clinicians in the U.S. was 14 per 100,000 workers compared to 13 for fire-fighters, 12 for police, 5 for nurses and 3 for physicians.4
Paramedicine clinicians typically work in emergency medical services (EMS) agencies, and they have job titles that include emergency medical technician (EMT), advanced EMT, and paramedic. These clinicians enter patient’s homes and workplaces, they operate and perform complex rescue and medical treatment in highly unstable dynamic environments, they transport patients in the small, enclosed, often poorly-ventilated workspace of an ambulance, and they are often exposed to airborne and body fluid transmission throughout the patient encounter. They may have additional exposure to airborne transmission of communicable diseases while performing advanced airway techniques, and aerosol-generating procedures,5 for poorly- or non-breathing patients. Their exposure potential may continue after the patient encounter when, after transferring the patient to the hospital, they return to the possibly-contaminated ambulance.6
This article has been prepared in response to the “Department of Health and Human Services, Agency for Healthcare Research and Quality [AHRQ], Supplemental Evidence and Data Request on Emergency Medical Service/911 Workforce Infection Control and Prevention Issues”.7 The authors commend AHRQ for taking on this critically important issue and have formatted this article to describe what we know about infectious disease among paramedicine clinicians, the research needs and what larger issues must inform efforts to reduce work-related infectious diseases for paramedicine clinicians.
This AHRQ project is an important step in identifying existing knowledge gaps so steps can be undertaken to develop evidence-based practices. However, we expect the overall response to this request will reveal that there is a paucity of reliable and comprehensive information available, despite the daily infectious disease risks faced by paramedicine clinicians. A wider understanding of the current state of the profession will underscore why this is the case and must be considered when developing any possible interventions to address infectious diseases. To assist, we have identified four key areas that need to be considered: Status of the Profession; Investment in EMS; Education Status; and Investment in Research.
Status of the Profession
Of the one million paramedicine clinicians in the U.S.8,9, about 25% are employed;10 most of the rest are volunteers11. The paramedicine clinicians work in over 20,000 EMS agencies, and respond to over 40 million calls for assistance each year.8,9,12 There are several EMS system models in the U.S. including government-run independent agencies, fire department-based agencies, private for-profit agencies, Tribal agencies, volunteer agencies and agencies run by hospitals or others.12 Chart 1 shows that the average salary for paramedicine clinicians in the U.S. is far below the salaries of their health care and emergency services colleagues.13-15 In other countries, paramedics are paid more than nurses, police and firefighters.13
Over the past two decades, EMS professionals in other countries have achieved self- regulation, national registration and degree-to-practice entry standards.16 There they have created systems that are integrated into the local healthcare and public health systems, they provide emergency, urgent and primary care, and they use paramedicine clinicians in both traditional roles (e.g., emergency) and non-traditional clinical roles such as providing scheduled care for elderly, and end-of-life patients. The value of having paramedicine clinicians capable of operating in non-traditional roles was seen, for example, in Germany during the COVID-19 pandemic where paramedicine clinicians were able to treat patients at home and reduce the burden on the hospital system.17
In the U.S., the over 20,000 EMS agencies have little integration with public health and there are only sporadic examples of paramedicine clinicians performing non-traditional clinical roles.18-20 One example shows how paramedics in Florida recognized and addressed a high rate of pediatric drownings in their community. They recognized the problem, researched the problem, discovered the causes, lobbied for pool fence regulations and educated the public around drowning risks. As a result of their efforts, the pediatric drowning rate in their community decreased by 50%.21 However, due to the poor EMS funding practices in the U.S., little has been done to continue that program or replicate public health type programs like that in other communities.
Low salaries, high risks and poor investment in the U.S. EMS system, have resulted in a turnover rate for paramedicine clinicians in excess of 25% in 2019.22 In contrast, the turnover rate for paramedics in Australia in 2018 was 3.3%.23 Among those who remain in U.S. agencies, some clinicians may be reluctant to report an infectious disease exposure, or even an illness, because they may not have health insurance, may have no sick-time benefits, and could lose pay not only from their primary EMS job but also from their other part-time EMS jobs. Paramedicine clinicians in the U.S. often work for more than one agency because their pay is so low.24
The status of the profession in the U.S. reflects the lack of adequate government investment. The inadequate investment has resulted in poor salaries, high turnover rates, a stagnation of clinical development, and high occupational risks, including high rates of COVID-related infections, hospitalizations and deaths.
Prior to the pandemic, some efforts were made to identify infectious disease risks for paramedicine clinicians. A 2016 study reported that swabs taken from emergency medical vehicles found contamination with presumptive methicillin-resistant Staphylococcus aureus (MRSA) and other bacterial colonies.6 Nasal swabs taken from one group of EMS responders showed that 6.4% were positive for MRSA, compared to a 1.5% rate in the community.25 A 2018 study determined that efforts to reduce infectious disease risks for paramedicine clinicians may not only improve workforce safety but may also improve patient outcomes, and community safety.26
The EMS system is now in crisis mode due to inadequate system funding. The decades-long lack of investment has led to a national “crippling workforce shortage” of paramedicine professionals.27-29 Beyond bake sales that some EMS agencies have resorted to in desperate attempts to keep operating,30 many EMS agencies are essentially reliant on government funding (including Medicare). Efforts to reduce infectious disease risks among paramedicine clinicians are critically important, but these efforts must be developed and undertaken concurrently with efforts to ensure sufficient investment in EMS.
Investment in EMS
The EMS system in the U.S. has been struggling for decades. Once envied and emulated around the world, the U.S. EMS system has fallen far behind the standards in other countries. Lack of investment has left EMS agencies unprepared for disasters.31-33 The COVID-19 pandemic exacerbated and highlighted many of the long-term EMS system deficiencies that left EMS agencies ill-prepared to cope with the disaster. Stories of ambulances held together with duct tape,34 EMS agencies struggling to pay bills,35,36 overwhelmed with calls,37,38 and paramedicine clinicians dying and suffering serious, long-term illness from SARS-CoV-24,39-41 provided glimpses into the enormous strains on already limited EMS resources.
Little is known of the characteristics, incidence, prevalence and severity of occupationally-acquired infectious diseases among paramedicine clinicians. There is no single database for collecting this type of information, which hampers identification of the magnitude, nature, and scope of the risks of injury and death. Nor is there a way to determine risks by age, sex, job title, work location, etc. Furthermore, data that are available are often incomplete. As an example, among 36 paramedicine clinicians who died of SARS-CoV-2 in 2020, the age was only known for 21 victims.4 An additional issue arises when individuals from other professions (e.g., police, firefighters, nurses, etc.) who are working in EMS roles on EMS vehicles acquire an infectious disease (or an injury) and the case is listed under their other profession. Any later analysis of the data would show an artificially increased risks for those other professions and an artificially decreased risk for the EMS profession.
A report of COVID-19 infections among employees of the New York City Fire Department (FDNY) documented that the rate of COVID infections for paramedicine clinicians (in the EMS Bureau) was 20% higher than the rate for firefighters.4 In that same department, the COVID-related fatality rate was 249.5 per 100,000 for paramedicine clinicians compared to the rate of 17.8 for firefighters; indicating a relative risk for paramedicine clinicians that is 14 times higher than the risk for firefighters.39 Two paramedicine clinicians in that department were in the ICU for a month, and both have long-terms effects from the coronavirus infection.40-42 Two years into the pandemic, the FDNY EMS Bureau continues to be overwhelmed43,44 and 30% of the workforce was out sick one day alone.45
Although paramedicine clinicians are always on the frontline of any disaster or infectious disease outbreak, during COVID the current system was ill equipped to provide them with the necessary personal protective equipment (PPE).46 PPE that was made available may not have been suitable for the EMS work environment and may not have been properly used due to a lack of PPE training. Addressing the inability of many clinicians to practice and train on PPE will help to protect the EMS workforce and maintain the resilience of both the EMS and U.S. healthcare system.47
The lack of investment in EMS has also led to spiraling emergency care costs for the most vulnerable citizens as 911 ambulance calls have steadily increased over the past several decades. The trickle in funding targeted at directly addressing the need for emergency medical services has been wholly inadequate. The lack of investment is especially baffling considering the cost to fund a professional EMS system. In 1996, a group of experts estimated that the funding to cover “EMS training, communications, ambulance services, quality improvement, data collection, and other aspects of the system”, would cost about $27 per U.S. citizen per year.11 (System Finance)
Rules and regulations for EMS agencies, including infection prevention policies and procedures, differ from state to state and even among EMS agencies in the same state. This fractured, non-system approach is inefficient. Investments in a unified, professional EMS system would result in the development of best-practice standards to be shared among all EMS agencies.
Educational Status
The lack of investment in EMS has resulted in the educational status of the EMS profession in the U.S. falling far behind the levels in other countries. Many other countries have degree-to-practice entry standards.16,48-51 Although many EMS agencies in the U.S. add to the skill set of paramedicine clinicians with skills such as blood administration, point of care ultrasound, and REBOA (resuscitative endovascular balloon occlusion of the aorta – a minimally invasive technique used to support hemorrhage control), the complexity of these procedures ideally require clinicians who are academically prepared.
Currently there is no academic requirement to be a paramedicine clinician within the U.S. Even though paramedic education averages 48 credits in the U.S., while registered nursing education at the same colleges averages 42 credits,52 many paramedics receive no college credit and few pursue undergrad or graduate degrees12. Two factors contribute to limiting the number of paramedicine clinicians who obtain a bachelor’s degree:
1) paramedicine clinicians working three jobs to make ends meet have little time for education; and
2) EMS agencies have few resources to provide tuition reimbursement or to recognize and offer higher pay for any additional educational qualifications their clinicians do achieve.
This gap in education hampers the advancement of the profession in terms of pay but also in evidence-based practices that are researched and developed by PhD-qualified paramedicine clinicians. Many other countries have growing numbers of PhD-qualified paramedicine clinicians. Australia for example, has 30 times the per-capita number of paramedic PhDs as the U.S.53
Nurses have recognized the need for minimum education standards. They recognize that an academic preparation improves their skills in critical thinking, leadership, case management, and health promotion. In countries around the world, nurses are moving to create a more highly educated nursing workforce. Countries that require a four-year undergraduate degree to practice as a registered nurse include Canada, Sweden, Portugal, Brazil, Iceland, Korea, Greece and the Philippines.54
Investment in Research
Historically, little has been known about the risks of infectious disease among paramedicine clinicians. The future research needed to close existing evidence gaps that will help to prevent, recognize, and treat occupationally-acquired infectious diseases in the EMS workforce requires an investment in paramedicine clinician research and researchers. The lack of paramedic PhDs in the U.S. critically limits EMS research, including research on EMS PPE needs, and risks of infectious diseases among paramedicine clinicians.
Other reasons for this paucity of knowledge includes a lack of funding for paramedicine-related research, the lag time between exposure and illness, and the lack of a system to capture infectious disease cases among paramedicine clinicians.
In order to prevent occupationally-acquired infectious diseases among paramedicine clinicians, research is needed to determine:
- The rates of occupationally-acquired infectious diseases for paramedicine clinicians.
- The rates of iatrogenic infectious diseases for EMS patients.
- The risks of contagious EMS personnel infecting other patients in the hospital, community members and family members. Researchers have noted the need for specific research on the risks of disease transmission from first responders to vulnerable patients.55
The essential infectious disease PPE for paramedicine clinicians includes masks, gloves and gowns. However, much of the current PPE options were designed for in-hospital use. Research to determine the future PPE needs for EMS must address use in weather extremes, for example most disposable N95 masks become ineffective if they get wet. The PPE should also be capable of being worn for prolonged periods, and be reusable, while offering the clinician the ability to communicate clearly with patients, other providers and dispatchers.
Research is needed to address the many ethical issues related to EMS and infectious diseases.56
Researchers in a 2018 study published by the American Journal of Infection Control, noted the need to have paramedicine clinicians receive more advanced education related to highly infectious diseases.26 Research is needed to determine what specific education is needed and how best to provide that education.
More from the Authors
- Personal Protective Equipment for Emergency Medical Services; Research and System Needs
- Occupational Fatalities Among EMS Clinicians and Firefighters in the New York City Fire Department; January to August 2020
- The Ethics of PPE and EMS in the COVID-19 Era
Researchers from the Republic of Korea determined that 45% of EMS personnel suffered potentially occupational-related respiratory diseases but only 20% reported the illness. One of the reasons for not reporting an incident was the complexity of the reporting process. In addition, many of the survey respondents did not use PPE appropriately, possibly due to poor training.57
Paramedicine clinicians are exposed to a variety of hostile work settings. The uncontrolled environment can be a barrier to infection prevention efforts.58 For example, alcohol-based hand sanitizers are not effective against some spore-forming pathogens, like potentially-fatal Clostridium difficile,59 yet paramedicine clinicians may rely on them when cleaning their hands in the field if handwashing with soap and water is not available. Clearly, research is needed to develop and test new products that will meet the needs of paramedicine clinicians and will function in the unique EMS environment.
Although emergency medical vehicles have been shown to be contaminated with infectious disease organisms,6 little research has been done on the best practices for cleaning ambulances. In 2018, researchers noted that “developing best practices for disinfecting standards will ensure a cleaner pre-hospital care environment.”60
In the U.S., paramedicine clinicians are typically responsible for cleaning the ambulances. However, that work, and other support functions, should be handled by non-clinicians.61 Research is needed to determine best-practices, cleaning policies and cleaning procedures.60 There is evidence that having a team of trained, dedicated staff to clean and decontaminate emergency medical vehicles — instead of paramedicine clinicians — results in cleaner, safer vehicles.62,63
One of the main reasons so little is known about the occupational risks for paramedicine clinicians in the U.S. is that there are very few U.S. paramedicine clinicians who are doing research. The main reason for that is the lack of funding for EMS research in the U.S. Any future funding for occupationally-acquired infectious diseases among paramedicine clinicians should be required to support paramedicine clinician researchers as a way to seek to not only answer the immediate research questions, but also to grow the field of paramedicine clinicians who are researchers. Only then can we both address immediate emergencies and prepare for future emergencies.
Conclusions
Paramedicine clinicians have had one of the most dangerous jobs in the U.S., and they now also have very high rates of occupational illness and fatality secondary to infection with SARS-Cov-2. Efforts to reduce the rates of occupationally acquired infectious diseases among paramedicine clinicians must include specific research to identify the risks, identify the PPE needs of these clinicians and to develop, test and implement risk reduction interventions. The AHRQ is to be commended for taking on this critical project. However, efforts to address EMS infectious disease risks, will have the best chances of success if there are concurrent efforts to address the larger system issues of low salaries, system needs, education needs and EMS-specific research needs. Only then will our EMS system be able to achieve its goal of providing the most advanced paramedicine clinical care for the citizens of the United States.
Acknowledgements
The authors wish to express our thanks to the HHS Agency for Healthcare Research and Quality (AHRQ), for addressing this critically important topic.
Funding: There was no funding for this project.
Disclaimer: The views expressed in this article reflect the results of research conducted by the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.
Conflict of interest: The authors have no conflicts of interest.
References
1. Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency medical services: A hidden crisis. Ann Emerg Med. 2002;40(6):625-632.
2. Maguire BJ, Smith S. Injuries and fatalities among emergency medical technicians and paramedics in the United States. Prehosp and Disaster Med. 2013;28(4):1-7.
3. Maguire BJ, Hunting KL, Guidotti TL, Smith GS. Occupational injuries among emergency medical services personnel. Prehosp Emerg Care. 2005;9(4):405-411.
4. Maguire BJ, O’Neill BJ, Phelps S, Maniscalco PM, Gerard DR, Handal KA. COVID-19 fatalities among EMS clinicians. EMS1. September 24, 2020. Available at: https://www.ems1.com/ems-products/personal-protective-equipment-ppe/articles/covid-19-fatalities-among-ems-clinicians-BMzHbuegIn1xNLrP/. Accessed 24 Sep 20.
5. U.S. Department of Health & Human Services, Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. Sep 21, 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed 6 Jan 22.
6. Makiela S, Taylor-Robinson AW, Weber A, Maguire BJ. A Preliminary Assessment of Contamination of Emergency Service Helicopters with MRSA and Multi-Resistant Staphylococcus aureus. Emergency Medicine: Open Access. 2016;6:304.
7. Department of Health and Human Services. Supplemental Evidence and Data Request on Emergency Medical Service/911 Workforce Infection Control and Prevention Issues. 2021. Available at: https://www.govinfo.gov/content/pkg/FR-2021-12-09/pdf/2021-26630.pdf. Accessed 18 Dec 21.
8. Maguire BJ, Walz BJ. Current emergency medical services workforce issues in the United States. J Emergency Management. 2004;2(3):17-26.
9. National Association of State EMS Officials. National Emergency Medical Services (EMS) Assessment. 2020. Available at: https://nasemso.org/wp-content/uploads/2020-National-EMS-Assessment_Reduced-File-Size.pdf. Accessed: 6 Jul 20.
10. U.S. Bureau of Labor Statistics. Occupational Employment and Wages, May 2020; 29-2040 Emergency Medical Technicians and Paramedics. 2021. Available at: https://www.bls.gov/oes/current/oes292040.htm#st. Accessed 2 Jan 22.
11. U.S. National Highway Traffic Safety Administration. EMS Agenda for the Future. 1996. Available at: http://www.nhtsa.dot.gov/people/injury/ems/agenda/emsman.html. Accessed 2 May 2008.
12. U.S. National Highway Traffic Safety Administration. National EMS Assessment. 2011. Available at: http://www.ems.gov/pdf/research/Studies-and-Reports/National_EMS_Assessment_2011.pdf. Accessed 26 Jan 15.
13. Maguire BJ, Phelps S, Maniscalco PM, et al. Paramedicine Strategic Planning: Preparing the ‘far forward’ front lines for the second COVID-19 wave. Journal of Emergency Medical Services. May 14, 2020. Available at: https://www.jems.com/2020/05/14/paramedicine-strategic-planning/. Accessed 14 May 20.
14. U.S. Bureau of Labor Statistics. Occupational Outlook Handbook: 2020; EMTs and Paramedics. Sep. 21, 2021. Available at: https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm. Accessed 1 Jan 22.
15. U.S. Bureau of Labor Statistics. Occupational Outlook Handbook, 2020. Sep. 15, 2021. Available at: https://www.bls.gov/ooh/home.htm. Accessed 8 Jan 22.
16. Makrides T, Ross L, Gosling C, Acker J, O’Meara P. Defining two novel sub models of the Anglo-American paramedic system: A Delphi study. Australasian Emergency Care. 2021.
17. Bennhold K. A German Exception? Why the Country’s Coronavirus Death Rate Is Low. New York Times. April 4, 2020. Available at: https://www.nytimes.com/2020/04/04/world/europe/germany-coronavirus-death-rate.html. Accessed: 14 Apr 20.
18. Walz BJ, Bissell RA, Maguire B, Judge JA, 2nd. Vaccine administration by paramedics: a model for bioterrorism and disaster response preparation. Prehosp Disaster Med. 2003;18(4):321-326.
19. Jensen JL, Marshall EG, Carter AJE, Boudreau M, Burge F, Travers AH. Impact of a Novel Collaborative Long-Term Care –EMS Model: A Before-and-After Cohort Analysis of an Extended Care Paramedic Program. Prehosp Emerg Care. 2016;20(1):111-116.
20. van Vuuren J, Thomas B, Agarwal G, et al. Reshaping healthcare delivery for elderly patients: the role of community paramedicine; a systematic review. BMC Health Serv Res. 2021;21(1):1-15.
21. Harrawood D, Gunderson MR, Fravel S, Cartwright K, Ryan JL. Drowning prevention. A case study in EMS epidemiology. Journal of Emergency Medical Services. 1994;19(6):34.
22. AAA/Avesta. Ambulance Industry Employee Turnover Study. 2019. Available at: https://ambulance.org/wp-content/uploads/2019/07/AAA-Avesta-2019-EMS-Employee-Turnover-Study-Final.pdf. Accessed: 19 Apr 20.
23. Reynolds L. EMS Around the World: Australia`s Tyranny of Distance. EMS World. Dec. 27, 2018. Available at: https://www.hmpgloballearningnetwork.com/site/emsworld/article/1221926/ems-around-world-australias-tyranny-distance. Accessed 4 Jan 22.
24. Bahler K. ‘The Pay Is Just Not Enough.’ EMTs Are Working Multiple Jobs Just to Make Ends Meet. Money. Oct. 13, 2018. Available at: https://money.com/the-pay-is-just-not-enough-emts-are-working-multiple-jobs-just-to-make-ends-meet/. Accessed 4 Jan 22.
25. Al Amiry A, Bissell RA, Maguire BJ, Alves DW. Methicillin-resistant Staphylococcus aureus nasal colonization prevalence among emergency medical services personnel. Prehosp Disaster Med. 2013;28(4):348-352.
26. Le AB, Buehler SA, Maniscalco PM, et al. Determining training and education needs pertaining to highly infectious disease preparedness and response: a gap analysis survey of US emergency medical services practitioners. Am J Infect Control. 2018;46(3):246-252.
27. Weixel N. Ambulance, EMT first responders face ‘crippling workforce shortage’. The Hill. Oct. 27, 2021. Available at: https://thehill.com/regulation/labor/577879-ambulance-emt-first-responders-face-crippling-workforce-shortage. Accessed: 8 Jan 22.
28. McCausland P. EMS services warn of ‘crippling labor shortage’ undermining 911 system. NBC News. Oct. 8, 2021. Available at: https://www.nbcnews.com/news/us-news/ems-services-warn-crippling-labor-shortage-undermining-911-system-rcna2677. Accessed: 9 Jan 22.
29. Edwards E. What if you call 911 and no one comes? Inside the collapse of America’s emergency medical services. NBC News. Oct. 22, 2019. Available at: https://www.nbcnews.com/health/health-care/there-s-shortage-volunteer-ems-workers-ambulances-rural-america-n1068556. Accessed: 9 Jan 22.
30. Sable-Smith B. Already Struggling Financially, EMS Providers Ask For Rate Increase To Respond To Coronavirus Pandemic. Wisconsin Public Radio. April 15, 2020. Available at: https://www.wpr.org/already-struggling-financially-ems-providers-ask-rate-increase-respond-coronavirus-pandemic. Accessed: 19 Sep 21.
31. Maguire BJ, Dean S, Bissell RA, Walz BJ, Bumbak AK. Epidemic and bioterrorism preparation among emergency medical services systems. Prehosp and Disaster Med. 2007;22(3):237-242.
32. Mitchell CS, Maguire BJ, Guidotti TL. Worker Health and Safety in Disaster Response. In: Ciottone G, ed. Disaster Medicine. Philadelphia: Elsevier; 2015:192-199.
33. Maguire BJ, O’Neill BJ, Maniscalco PM, Gerard DR, Handal KA. Will an Ambulance Be Available When You Call? Inside Sources. September 10, 2020. Available at: https://www.insidesources.com/will-an-ambulance-be-available-when-you-call/. Accessed 15 Sep 20.
34. Staff. Duct tape mended ambulance fleet under investigation. EMS1. Oct. 15, 2014. Available at: https://www.ems1.com/ambulance-service/videos/duct-tape-mended-ambulance-fleet-under-investigation-48SZvJKlvsbsO9f1/. Accessed 20 Aug 21.
35. Berard Y. Ambulance companies hit hard by COVID costs. The Atlanta Journal-Constitution. July 17, 2020. Available at: https://www.ajc.com/news/georgia-news/ambulance-companies-hit-hard-by-covid-costs/OK4XSUGPFZEUHLH23FS5FPZ3VM/. Accessed: 17 Aug 20.
36. Krans B. Alameda County ambulance services could be disrupted during COVID-19 pandemic. Berkeleyside. April 8, 2020. Available at: https://www.berkeleyside.com/2020/04/08/alameda-county-ambulance-services-could-be-disrupted-during-covid-19-pandemic. Accessed: 15 Apr 20.
37. Watkins A. N.Y.C.’s 911 System Is Overwhelmed. ‘I’m Terrified,’ a Paramedic Says. NY Times. March 28, 2020. Available at: https://www.nytimes.com/2020/03/28/nyregion/nyc-coronavirus-ems.html. Accessed: 26 Jul 20.
38. Al Amiry A, Maguire BJ. Emergency Medical Services (EMS) Calls During COVID-19: Early Lessons Learned for Systems Planning (A Narrative Review). Open Access Emergency Medicine: OAEM. 2021;13:407.
39. Maguire BJ, O’Neill BJ, Gerard DR, Maniscalco PM, Phelps S, Handal KA. Occupational fatalities among EMS clinicians and firefighters in the New York City Fire Department; January to August 2020. J Emergency Medical Services. November 19, 2020. Available at: https://www.jems.com/2020/11/19/occupational-fatalities-among-ems-clinicians-and-firefighters/. Accessed 20 Nov 20.
40. Goldberg N. Hometown Heroes: FDNY EMS captain Hugo Sosa battling back from near-fatal COVID case. NY Daily News. 6 Jul, 2021. Available at: https://www.nydailynews.com/new-york/ny-hometown-hero-fdny-ems-captain-hugo-sosa-20210706-mvtsytxlnfggtlsicsk6isjpva-story.html. Accessed: 20 Dec 21.
41. Goldberg N. NYC paramedic hospitalized with coronavirus sedated, breathing with ventilator as condition worsens, family says. NY Daily News. March 24, 2020. Available at: https://www.nydailynews.com/coronavirus/ny-coronavirus-fdny-paramedic-young-virus-20200324-74tadm2skjb7zeuwb2xhwvtfoi-story.html. Accessed: 26 Jul 20.
42. Goldberg N. ‘I woke up a totally different person’: FDNY paramedic in coronavirus coma for a month wakes up, tells Daily News she has new lease on life. NY Daily News. 3 May, 2020. Available at: https://www.nydailynews.com/coronavirus/ny-coronavirus-recovery-covid-19-coma-christell-cadet-fdny-paramedic-20200503-hvvltwf7frdodhsgoxsq4zfjai-story.html. Accessed: 20 Dec 21.
43. Calder R, Edelman S. NYC’s EMS staff crisis leads to new orders to urge stable patients to stay home. NY Post. 1 Jan, 2022. Available at: https://nypost.com/2022/01/01/stable-patients-urged-to-stay-home-amid-nycs-ems-staffing-crisis/. Accessed: 2 Jan 22.
44. Thomas T, Clayton G. NYC faces shortage of EMS crews on Christmas as omicron wave sickens city. NY Daily News. Dec. 25, 2021. Available at: https://www.nydailynews.com/new-york/ny-ems-crew-shortage-christmas-day-covid-omicron-20211225-kqnnycnke5guzkinzimgke4yhe-story.html. Accessed: 2 Jan 22.
45. Hogan G. NYC EMS Faces Record Staffing Shortage As 911 Calls For COVID-Like Symptoms Surge. Gothamist. Dec. 29, 2021. Available at: https://gothamist.com/news/nyc-ems-faces-record-staffing-shortage-911-calls-covid-symptoms-surge. Accessed: 5 Jan 22.
46. Wedell K. After Six Months of Coronavirus, PPE Still Lacking. EMS World. July 1, 2020. Available at: https://www.emsworld.com/news/1224569/after-six-months-coronavirus-ppe-still-lacking. Accessed 13 Sep 20.
47. Richey TW, Fowler RL, Swienton RE, O’Neal JP, Harris CA. Review of Emergency Medical Services Vulnerability to High Consequence Infectious Disease in the United States. Frontiers in Public Health. 2021:1469.
48. UK National Health Service. Roles in the allied health professions: Paramedic. Available at: https://www.healthcareers.nhs.uk/explore-roles/allied-health-professionals/roles-allied-health-professions/roles-allied-health-professions/paramedic/paramedic. Accessed 5 Jan 22.
49. The Paramedicine Board of Australia. Paramedic Qualifications. 2021. Available at: https://www.paramedicineboard.gov.au/Qualifications.aspx. Accessed: 5 Jan 22.
50. Brooks IA, Cooke M, Spencer C, Archer F. A review of key national reports to describe the development of paramedic education in England (1966–2014). Emerg Med J. 2016;33(12):876-881.
51. NZ Government. Paramedic: About the job. Nov. 8, 2021. Available at: https://www.careers.govt.nz/jobs-database/health-and-community/health/paramedic/. Accessed 9 Jan 22.
52. Phelps S. Credits granted for professional education of paramedics and nurses at at US colleges with paired programmes. International Paramedic Practice. 2016;6(1):6-12.
53. Maguire BJ, O’Neill BJ, Maniscalco P, et al. Personal Protective Equipment for Emergency Medical Services; Research and System Needs. Journal of Emergency Medical Services. 2021;21 Sept.
54. The American Association of Colleges of Nursing (AACN). The Impact of Education on Nursing Practice. 2019. Available at: https://www.aacnnursing.org/news-information/fact-sheets/impact-of-education. Accessed: 4 Jan 22.
55. Tarabichi Y, Watts B, Collins T, et al. SARS-CoV-2 Infection Among Serially Tested Emergency Medical Services Workers. Prehosp Emerg Care. 2020(just-accepted):1-9.
56. Maguire BJ, Shearer K, McKeown J, et al. The Ethics of PPE and EMS in the COVID-19 Era. Journal of Emergency Medical Services. Apr. 10, 2020. Available at: https://www.jems.com/2020/04/10/ethics-of-ppe-and-ems-in-the-covid-19-era/. Accessed 10 Apr 20.
57. Oh HS, Uhm D. Occupational exposure to infection risk and use of personal protective equipment by emergency medical personnel in the Republic of Korea. Am J Infect Control. 2016;44(6):647-651.
58. Thomas B, O’Meara P, Spelten E. Everyday dangers-the impact infectious disease has on the health of paramedics: a scoping review. Prehosp Disaster Med. 2017;32(2):217.
59. World Health Organization. Appendix 2: Guide to appropriate hand hygiene in connection with Clostridium difficile spread. In: WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. 2009.
60. Makiela S, Taylor-Robinson AW, Weber A, Maguire B. Infection Control Protocols: is it Time to Clean Up our Act? Australasian Journal of Paramedicine 2018.
61. Maguire BJ. COVID-19: Urgent EMS Issues. Journal of Emergency Medical Services. March 23, 2020. Available at: https://www.jems.com/2020/03/23/covid-19-urgent-ems-issues/. Accessed 23 Mar 20.
62. Mackenzie M, Pilbery R. The impact of an ambulance vehicle preparation service on the presence of bacteria: a service evaluation. British Paramedic Journal. 2019;3(4):27.
63. London Ambulance Service. Caring for you in a clean environment. Available at: https://www.londonambulance.nhs.uk/about-us/what-we-do/caring-clean-environment/. Accessed 9 Sep 21.
