Establishing a Personal Protective Technology Center of Excellence to Address Unique Research Needs of Paramedicine Clinicians

The proposed NIOSH Centers of Excellence for personal protective technology project is an important step toward identifying and reducing occupational risks for the million paramedicine clinicians in the U.S.

Introduction

A Federal Register notice on November 02, 2021, announced that “The National Institute for Occupational Safety and Health (NIOSH), within the Centers for Disease Control and Prevention (CDC), is soliciting public comment on the need to establish centers of excellence to address research and practice needs in the area of personal protective technology (PPT), including personal protective equipment.” Docket number CDC-2021-0115; NIOSH-343.1 The purpose of this article is to address the questions asked by NIOSH in that notice.

The proposed personal protective technology (PPT) center of excellence (CoE) is critically important for paramedicine clinicians working in emergency medical services (EMS) because this occupational group has one of the most dangerous jobs in the U.S. Even before the COVID-19 pandemic, research documented their unique risks and showed that their occupational fatality rates and occupational injury rates were much higher than the national average.2-7 Two years into the pandemic, when their exposure to potential infection escalated, it is clear that the paramedicine clinicians have had very high rates of COVID-related occupational fatality, illness and long-term disability.8-15

There are many reasons why the occupational risks for this occupational group are so high. However, one overarching reason is that there has been a paucity of national funding and support in the U.S. for the EMS industry, especially for paramedicine clinician-related safety research and the development of innovative safety technologies.

More from the Authors

The lack of adequate funding for EMS research has led to a dearth of paramedicine clinician researchers in the U.S.13,16 This is not the case in other countries, for example, Australia has about 30 times the per-capita number of doctoral-level paramedics as the U.S.17 The inadequate number of graduate-level paramedicine clinicians in the U.S. has left the profession ill-equipped to anticipate and address the current crises and unprepared to address future crises. 

The poor overall funding for EMS in the U.S. has resulted in salaries for paramedicine clinicians that are well below the average for all workers and far below the salaries received by their emergency services and health profession colleagues.13 In other countries, paramedics are paid more than nurses, firefighters and police officers.16 The high occupational risks and low salaries contribute to a turnover rate of 25% for paramedicine clinicians in the U.S. in 2019.18

Paramedicine clinicians need, and would substantially benefit from, a personal protective technology (PPT) center of excellence (CoE). Such a CoE would have far-reaching impact on the health and safety of all Americans by reducing EMS workplace hazards and helping to reinforce the currently fraying safety net of emergency medical care. The authors appreciate the task that NIOSH is undertaking and have prepared this paper to respond to the NIOSH questions and to emphasize the value that the proposed CoE could have for reducing risks for paramedicine clinicians.

We also note the value of, and advocate for, an EMS-specific CoE with funding and support to address immediate worker safety needs and to support the development of paramedicine clinician graduate-level researchers who can address the current crisis and help prepare for future crises.

Specific questions from NIOSH:

1. What are the perceived needs for and benefits of establishing centers of excellence to advance PPT [personal protective technology] research and practice as it relates to your organization or for you personally?

We expect that a CoE investigating the unique needs of paramedicine clinicians could assemble a multi-disciplinary team of researchers, clinicians and educators to identify, quantify, and qualify the full range of occupational risks – and then select those risks that could be mitigated by PPT. The scope of the paramedicine clinician’s operational environment includes daily threats ranging from, but not limited to: infectious disease; hazardous materials incidents; highway crashes; violence; building collapses; conflagrations; terrorism; and active shooters. In addition, they are exposed to a myriad of risks associated with their frequent response to disasters.

The CoE would develop new research projects aimed at identifying the PPT needs of the paramedicine clinicians. The CoE could determine evidence-based best practices, write and present EMS-specific training and develop operational policy recommendations that could be made available to all paramedicine clinicians. The benefit of such a CoE could be a dramatic reduction in the number of infectious diseases, illnesses, injuries and occupational fatalities among paramedicine clinicians. This, in turn, could help improve care for the over 40 million people who call paramedicine clinicians for help every year in the U.S.19-2

2. Are there specific PPT research and practice needs for certain industry sectors and/or occupations?

Yes. Paramedicine clinicians operate in environments different from any other occupational group. They face unique risks and need research that is focused on their risks and their needs.

The extent of the hazardous environments faced by these professionals cannot be overstated. They crawl into overturned vehicles or under trains to treat trapped patients, they wade through flood waters to get to and remove their patients, they operate in blizzards, monsoons and heat waves. While performing their duties they can be faced with a gunman,22 shot23 or murdered.24 On any day they could be on a boat, plane or helicopter to get to and remove their patients. They are among the first on the scene for terrorism, active-shooters and every type of disaster. They must be prepared for large-scale threats including terrorist attacks, for example, with explosives to deliver nerve agents, anthrax, and radiological material over a large area.25-27 Their unique responsibilities result in unique risks.

In order to understand their occupational risks, it is necessary to know how emergency medical services are provided by the approximately one million paramedicine clinicians working in over 20,000 EMS agencies in the U.S.19,20 In communities across the U.S., the agency responsible for providing emergency medical care might be:

  • independent “third-service” government-based EMS agencies,
  • fire-department based agencies (some with firefighters working as clinicians and some with non-firefighter, civilian employees of the department who provide clinical care),
  • hospital based agencies,
  • private for-profit agencies,
  • Tribal agencies,
  • volunteer agencies and
  • others.16,19

Agencies typically provide basic life support care by emergency medical technicians (EMTs), or advanced life support by paramedics, or both. Across the many agency types, these paramedicine clinicians provide medical care in a variety of settings. Each setting presents unique occupational hazards. The settings include:

  • Mobile Care (non-emergency transport, which is a critical part of moving patients between different parts of the health care system to ensure they get the specific care they need),
  • Mobile Emergency Care (EMT-level emergency response, the backbone of emergency medical response in the U.S.),
  • Mobile Intensive Care (paramedic response, with advanced invasive procedures),
  • Mobile Specialized Care (advanced inter facility transport, often for critically ill patients vulnerable to infection), and
  • Mobile Aeromedical Care (with the vulnerability of transporting patients in a limited number of aircraft, usually reserved for the most seriously ill or for conditions that are the most time-dependent).

A recent Medicare change allowing paramedicine clinicians to transport to alternate destinations and to treat on site28 may also alter the hazards in some of these settings. In addition to these settings, some paramedicine clinicians work as community paramedics with public health, primary healthcare and preventive services to provide care for underserved populations in the community.29 Some are integrated with health, aged care and social services.30 Community paramedicine clinicians work to reduce both overcrowding of emergency departments and healthcare costs.31 In other countries, community paramedics are becoming integrated into both community health and primary care programs.32

The capabilities and duties of these providers are not interchangeable. The settings and the services they provide in those particular settings each present unique hazards. Although as yet unstudied, it is likely that these settings and patient interactions may create risks that are different from the risks faced by paramedicine clinicians in other roles.

Table 1 illustrates some of what we know about how the risks for paramedicine clinicians compare to other occupational groups. These are just some of the many examples of how the occupational risks for paramedicine clinicians are very different from the risks for workers in other occupations.

Table 1. How the risks for paramedicine clinicians compare to other occupational groups.

RiskRisks for paramedicine clinicians compared to other occupations
Overall occupational fatalities– More than twice the national average for all workers
– Comparable to the rates for police and firefighters2
Transportation related fatalities– 57% higher than police officers
– 68% higher than firefighters5 times higher than the national average2
Homicides– 1.4 times higher than the national average
– 1.8 times higher than firefighters
– 7 times higher than the rate for all healthcare workers
– U.S., police officers have a homicide rate more than 6 times higher than the national average2
Occupational injury rate– 1.5 times higher than firefighters
– 5.8 times higher that health services workers
– 7 times higher than the national average3
Violence related injury– 22 times higher than the national average33
– According to data from the Bureau of Labor Statistics, the average rate of violence related injuries from 2011 to 2020 was 5.7 for firefighters compared to 20.1 for paramedicine clinicians34
Exposure to harmful substances or environments– According to data from the Bureau of Labor Statistics, the average rate for all U.S. workers from 2011 to 2020 was 8.3, compared to a rate of 32.7 for paramedicine clinicians35
COVID (fatal and non-fatal)– COVID-related fatality rates in the U.S. were 13 per 100,000 workers for firefighters, 12 for police, 5 for nurses and 3 for physicians, compared to 14 for paramedicine clinicians9
– Among the 11,230 firefighters and 4,408 paramedicine clinicians in the New York City Fire Department (FDNY), the COVID-related fatality rate per 100,000 workers was 17.8 for firefighters and 249.5 for paramedicine clinicians (the COVID-related occupational fatality rate was 14 times higher for the paramedicine clinicians)8
– The rate of non-fatal COVID cases in FDNY was 20% higher for paramedicine clinicians compared to firefighters12
Back injuries– According to data from the Bureau of Labor Statistics, in 2015 the rate of back injuries per 10,000 equivalent full-time workers for all workers was 17.3,36 in 2015 the rate of back injuries for paramedicine clinicians was 104.837
Shoulder injuries– According to data from the Bureau of Labor Statistics, in 2015 the rate of shoulder injuries per 10,000 equivalent full-time workers for all workers was 8.4,36 the same year the rate for paramedicine clinicians was 32.38

3. Are there specific PPT research and practice needs for different types of hazards (e.g., biological, chemical, gas and vapor, thermal, physical)?

Yes. Paramedicine clinician respond on an regular basis to disasters, fires, patients’ homes and other requests for help that present environments where a variety of hazards may exist.39 Paramedicine clinicians are regularly exposed to all categories of work hazards as outlined by Occupational Safety and Health Administration (OSHA)40 and seen in Figure 1.

Figure 1. OSHA hazards seen in EMS
Figure 1. OSHA hazards seen in EMS

The hazards for paramedicine clinicians include:

  • Chemical and Dust Hazards, including from decontamination cleaning products,
  • Ergonomic Hazards, including carrying heavy patients up or down many flights of stairs, extricating patients from crushed vehicles or other confined spaces, carrying equipment and supplies,
  • Safety Hazards, such as slips, trips and fall hazards and needlestick injuries,
  • Work Organization Hazards, like workplace violence,41
  • Physical Hazards, including temperature extremes, fires and transportation related injuries and deaths for paramedicine clinicians, including from air and ground ambulance crashes and being struck by a vehicle while caring for a patient,42-47 and
  • Biological Hazards, such as infectious disease48 and hazards that are present when the paramedicine clinician enters the home of a patient with a communicable disease, during a potentially long ride in a relatively small, enclosed, poorly-ventilated patient compartment, when the paramedicine clinician performs aerosol-generating procedures,49 for patients with breathing problems and when the paramedicine clinician returns to a potentially contaminated ambulance.50-52

Large knowledge gaps remain in what we know about the full range of hazards among paramedicine clinicians. For example, for biological hazards and infectious diseases we know little about the rate of illnesses among these clinicians or how these hazards may lead to occupational death, long-term illness or early career termination. Nor do we know how these occupational risks for paramedicine clinicians may result in risks for other workers or civilians including iatrogenic infections. We do know that all of these hazards for paramedicine clinician could potentially be mitigated by PPT.

We also know that female paramedicine clinicians have a disproportionately greater risk than male paramedicine clinicians for violence related injuries.41 This finding suggests that even beyond the need to develop PPT for paramedicine clinicians in general, there is a need to look at sex-specific PPT needs within the profession. In addition, since violence is such a grave hazard to paramedicine clinicians, that research beyond PPT is needed to determine if multiple types of violence prevention interventions might need to be integrated in order to reduce risks.53

There is a need not only for research focused on outcomes such as violence related injury and death, but also on potential mitigations strategies. For example, researchers have noted the importance of situational awareness for paramedicine clinicians and that it must be increased to improve their performance in many different situations.54 The CoE could examine how PPT might improve situational awareness.

A harsh example of another type of hazard faced by paramedicine clinicians is illustrated by the suicides of three paramedicine clinicians over seven months during the pandemic in New York City.8 Mental health related hazards, including disaster related, have been an ongoing threat for these clinicians.55 Research is needed to determine ways that PPT might help mitigate mental health hazards.

4. Are there specific PPT research and practice needs for certain anatomical categories of protection (e.g., dermal, vision, hearing, respiratory)?

Yes. As noted in Table 1, we know that paramedicine clinicians have very high rates for back and shoulder injuries. The COVID research noted in Table 1, as well as their frequent responses to hazardous environments, clearly indicates a dire need for PPT research focused on respiratory protection for paramedicine clinician. An underexplored area where PPT research is needed is in relation to dermal and eye injuries. The authors of one study described a high proportion of paramedicine clinician with hearing deficits and clearly showed the need for PPT research focused on the hearing needs of paramedicine clinician.56

5. Which particular academic disciplines, research domains, or technical expertise should contribute to addressing PPT research and practice needs? Describe multi- or inter-disciplinary needs to most effectively advance research and practice.

One of the reasons that occupational illness, injury and fatality rates are so high for paramedicine clinicians is that there has been insufficient funding for paramedicine clinician-directed research. This in turn has resulted in a very small number of graduate- and doctoral-level paramedicine clinician researchers in the U.S.

Optimally, graduate- and doctoral-level paramedic researchers would contribute to addressing PPT research and practice. However, because they are so scarce in the U.S., one of the main benefits of this NIOSH CoE program could be to provide a center where paramedicine clinicians could conduct research and collaborate with other safety professionals. That way, they can help to not only solve these immediate problems but will also be available and prepared to solve the problems of the future.

In addition to graduate-level paramedicine clinicians, other academic disciplines that could make a valuable contribution to this injury prevention research include epidemiology, engineering, medicine, psychology, public health, emergency management, physiology, ergonomics and artificial intelligence.

6. Describe emerging or novel technologies that can be investigated with respect to increasing the effectiveness of PPT.

There are a myriad of potential new technologies that could help reduce risks for paramedicine clinicians. They could result in improved patient and worker safety while also promoting comprehensive systems of safety within the profession. For example, wearable devices could warn of potential overexertion or fatigue and could help predict risks and automatically report injuries and location. Google-glass-type technology could provide new means of communication and enhanced situational awareness. Ergonomic research could reduce lifting injuries through identifying equipment and methods. Artificial intelligence (AI) research could focus, for example, on reducing fatigue-related risks. Exoskeleton research may seem like science-fiction today, but research now could make them a reality. Augmented reality technology could help train paramedicine clinician on how to reduce risks for themselves and their patients. Drones could reduce risks by first entering potentially hazardous environments and reporting conditions before the paramedicine clinician enters. A recent study demonstrated that drones could be beneficial and cost effective in the EMS environment.57

There is an urgent need for PPT to reduce risks from physical attacks.22 A survey of 1,172 paramedicine clinicians who had been physically attacked on-duty found that in 10% of the assaults, the perpetrator used a weapon.58 However, issuing paramedicine clinicians with off the shelf bullet-proof vests designed for police, could potentially increase the risks for paramedicine clinicians. Instead, novel technologies are needed that will meet the unique needs of these clinicians. These novel technologies must include not only vest-type technologies but also new technologies to restrain violent patients.59,60

Novel technologies might include ways to make the clinicians more visible on highways to reduce their risks of being struck or improve ambulance restraints to reduce the risks of the clinicians (and their patients) dying in an ambulance crash. Even simple solutions like regular use of slide boards and use of semi-automatic stair chairs and stretchers could significantly reduce risks for members of the profession. Turning these ideas into a reduction in risks requires funding for research, publications of best practices, training and policy development.

7. How well do the three broad focus areas described above identify critical needs? Are there alternate or additional needs that have not been identified in this notice?

The three broad objectives represent a giant step toward occupational risk reduction for paramedicine clinicians. We especially applaud the recognition that there are occupation-specific needs that are not met with general workforce safety programs. Paramedicine clinicians are an occupational group that faces unique hazards and have injury and illness risks that are different from any other occupational group.

Additional needs include a multi-domain evaluation of the reasons that PPT might not be utilized and how those reasons might vary by demographics, geographical location and other factors. Such an evaluation could help maximize use of current and future PPT.

For example, prior to the pandemic, experience with the utilization of PPE for paramedicine clinicians was limited to events where the clinicians may have donned protection for a few hours at a time. In addition, there was adequate staff to allow clinicians the ability to step back from the incident, to rehab and to decompress. During the pandemic, PPE has been necessary during the entire shift, for every patient encounter, during breaks and in the station, for 8, 10, 12 or more hours at a time. These lessons and experiences must be considered during any PPT research.

8. NIOSH anticipates that future PPT centers of excellence will include at least three functional core areas:

planning and evaluation, which includes center of excellence administration; research, which can be comprised of pilot projects, small projects, and large projects; and outreach, which can include communication and dissemination activities, education activities, and implementation activities. An academic training functional core area is optional. How important are the different core areas and activities within core areas to the ability of centers of excellence to advance PPT research and practice?

The three functional areas are important. An academic training functional core that would support development of domestic graduate programs for paramedicine clinicians, coupled with increased federal attention with a dedicated funding stream, would jump-start research in this field, leading to healthier clinicians, safer communities, and long-term savings through improved EMS systems across the U.S.

The newly created CoE could also promote interprofessional education and awareness that healthcare and public health is best accomplished with a team approach. Paramedicine clinicians could draw from their front-line experiences and apply them to research and policy initiatives that would potentially be of benefit to many occupational groups. 

Discussion

Having a CoE addressing risks among paramedicine clinicians could also benefit other occupations and other centers of excellence. Research on a group with such very high injury rates and exposure to a broad range of hazards could yield data on intervention effectiveness much sooner than research using groups with lower rates.

In addition, we suggest and advocate for a paramedicine clinician specific CoE. Paramedicine clinicians have unique occupational risks and risk-reduction research needs that are exclusive from police, firefighters, nurses and other emergency and health care personnel. Any risk-reduction efforts that conjoins paramedicine clinicians with other occupational group(s) creates the risk that the unique needs of paramedicine clinicians will be diluted or overlooked in efforts to meet the needs of the other group(s). At the same time, research focused on paramedicine clinicians could ultimately help to reduce risks for professionals in those other occupation.

We strongly support the establishment of the NIOSH CoE and note that they would benefit not only the million paramedicine clinicians and their patients; such CoE would benefit many other occupational groups in the U.S.

Conclusions

Each day paramedicine clinicians are exposed to a wide variety of hazards which results in them having one of the most dangerous jobs in the U.S. At the same time, research into those specific hazards has been marginalized. This has led us to the current crisis where the emergency medical services system is fraying to the point that EMS organizations cannot staff their ambulances because of illness, injury and vacancies, response times are increasing to unacceptable levels across the country, and paramedicine clinicians have died of COVID-related illness in the past two years, at higher rates than their firefighter and law enforcement partners in emergency response.

A NIOSH CoE addressing the unique needs of paramedicine clinicians will help reduce occupational hazards for the million paramedicine clinicians in the U.S. and that will in turn, help those clinicians to provide the best possible care for the millions of Americans who call for their help every year.

Acknowledgements

The authors wish to express our thanks to the National Institute for Occupational Safety and Health (NIOSH), for addressing this critically important topic.

Funding: The authors had 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.

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