Threats to New York City’s EMS personnel are significant and have changed over time.

During 2022, New York City saw a paramedicine clinician brutally stabbed to death, the 100^th paramedicine clinician to die as a result of the September 11, 2001, terrorist attack, and the 147^th ambulance service provider to suffer an occupational fatality. Over the past five years alone, 34 paramedicine clinicians, including 23 members of the FDNY Bureau of Emergency Medical Services, died in service to the citizens of New York City.

Introduction

A horrible tragedy occurred in New York City (NYC) on September 29, 2022. NYC Fire department (FDNY) Bureau of Emergency Medical Service (BEMS) Lt. Alison Russo-Elling, was fatally stabbed while on duty.¹ The lieutenant had worked for a quarter of a century with the BEMS, including as a responder to the September 11, 2001, attack on the city.² It was a brutal, senseless murder. Her attacker was quickly apprehended³ and was reported as having a history of mental health conditions.⁴ She was laid to rest on October 5, 2022.⁵ Her tragedy evoked memories of Yadira Arroyo, a woman brutally murdered in 2017,⁶ and of the many other dedicated ambulance service professionals who died in service to the citizens of NYC. 

In the hope that these tragedies can lead to some positive change, this paper highlights the many dangers faced by emergency medical services (EMS) personnel in NYC. Recognizing and quantifying the risks are necessary precursors to efforts to develop, test and implement risk reduction initiatives.

The first research to document occupational fatalities among EMS personnel in the U.S. determined that they have a fatality rate that is about three times higher than the rate for all U.S. workers and is comparable to the rates for firefighters and police.⁷ The researchers calculated that the homicide rate for paramedicine clinicians was seven times higher than the rate for healthcare workers, about twice as high as the rate for firefighters, and about 40% higher than the average rate for all workers in the U.S.⁷ About 8% of fatal injuries among U.S. paramedicine clinicians are homicides.⁸ International research has found that paramedicine clinicians in other countries have high risks of violence.^9,10 Women working in EMS have a disproportionately greater risk of violence-related injuries.¹¹

The COVID-19 pandemic also contributed to the risks faced by paramedicine clinicians. Between January and August 2020, four paramedicine clinicians in BEMS died of COVID-19.¹² Nationwide, 36 paramedicine clinicians died of COVID between March and early September 2020; the calculated rate of COVID deaths for paramedicine clinicians was higher than the rates for police, firefighters, nurses and physicians.¹³

The NYC EMS system is an appropriate study site since it is the largest and busiest EMS system in the U.S.¹⁴ The NYC EMS system is somewhat unique in that it includes over 70 independent agencies that provide EMS in the city;¹⁵ the FDNY BEMS is one of the over 70 agencies. The BEMS paramedicine clinicians, along with the paramedicine clinicians employed by about 13 hospital-based ambulance agencies, together responded to 1,862,159 emergency medical calls in NYC in 2018: an average of 5,100 calls a day.¹⁶ During COVID, the call volume at times rocketed to over 7,000 calls per day.^17,18

In recognition that the roles and training of ambulance personnel in NYC (and around the world) have been evolving since the 1800s, we use the term ambulance personnel mostly to refer to earlier generations, and the term paramedicine clinicians to describe the more contemporary emergency medical technicians and paramedics who have staffed the ambulances in NYC for about the last half century. The names of the deceased are included to honor them and their service to the citizens of New York City.

The objectives of this article are to: provide a historical perspective on the fatalities among persons working in New York City ambulance services from 1893 to present; determine the rates of fatality for paramedicine clinicians in BEMS; and to compare the calculated rates to the national average for all workers in the U.S.

Methods

Study design

This was an open cohort study.

Setting

The analyses focused on personnel who worked in New York City from 1893 to 2022.

Population

The population was defined as those individuals who met the following criteria: 1) employed by, or a volunteer for, an agency providing ambulance or emergency medical services, 2) died since 1893 from a work-related cause, and 3) worked in New York City.

Variables

The research focused on occupational fatalities.

Data sources/measurement

Co-author Scot Phelps collected the fatality data. Searching was performed over several years as part of the New York Ambulance History Project to identify ambulance worker deaths and submit their names to the National EMS Memorial; it was usually performed by year, covering 1869 through 1990.

Deaths of ambulance personnel were obtained from a thorough search of several newspaper databases, including newspapers.com (which included over 65 New York City-based newspapers covering various periods from the advent of ambulance service in NYC in 1869 to the present day), The New York Times, and FultonHistory.com, with additional searches done through the New York Public Library databases.

A variety of search terms were used. The search term referencing the vehicle was “ambulance” and sometimes “hospital ambulance” because emergency ambulances were operated by both municipal hospitals and voluntary hospitals across most of the period.

Search terms referencing the workers included: “Ambulance Surgeons;” “Ambulance Doctors;” “Ambulance Drivers;” “Ambulance Attendants;” “Motor Vehicle Operators (MVOs);” “Corpsmen;” “Emergency Medical Technician;” and “Paramedic.” The terms “Ambulance Surgeons;” and “Ambulance Doctors” were used through the later 1940s until physicians generally came off the ambulance in the aftermath of World War II, with “Ambulance Attendants” and “Ambulance Drivers” staffing ambulances through the early 1960s. Then they were replaced by the terms “Motor Vehicle Operators (MVOs)” and “Corpsmen,” followed later by the terms “Emergency Medical Technician” and “Paramedic” from the mid-1970s through today.

Search terms referencing the event included: “Crash;” “Accident;” “Flu;” “Shot;” “Stabbed;” “Fall.” Search terms referencing the outcome included: “Hurt;” “Killed;” “Dead;” and “Died.”

Since ambulance workers respond to these types of events, and the outcomes were frequently related to their everyday work, it was often necessary to tie together either the vehicle and the event (e.g., “hospital ambulance crash”) or the worker and the event (e.g., “ambulance attendant shot”), or the worker and the outcome (e.g., “ambulance surgeon killed”) in Boolean quotes to limit an overwhelming number of results. Searches were generally performed in a matrix format with each combination being searched. World War One-era searches were particularly hard to filter because of the number of volunteer ambulance companies organized and staffed by colleges, businesses, and government to serve in France prior to the U.S. entering the war.

After 1990, the New York Ambulance History Project team had either firsthand knowledge of all deaths or obtained them from social media queries of senior staff working in the NYC Emergency Medical Service System at the time. More recent deaths, particularly 9/11 and COVID-related deaths were obtained from contemporaneous media, searches, and admission into the National EMS Memorial and the New York State EMS Memorial.

Bias

The risk of bias was minimized by using all of the relevant data found during the searches. Although it is likely that these searches resulted in a significant proportion of all workplace related deaths of ambulance workers in NYC, it is probable that gaps exist especially related to exposure to infectious disease in general and specifically related to pandemic flu, environmental health deaths, and work-related suicides. Infectious disease deaths and environmental health deaths of ambulance workers may not have all been reported consistently. For example, 1918 flu and pre-1920 heat wave deaths were reported by name in the newspaper daily, but not later pandemic or heat-related deaths. In addition, ambulance workers who were not physicians were of a social standing such that their deaths may not have been reported in the newspaper, and there is a significant difference in the levels of coverage between the deaths of ambulance surgeons and the deaths of ambulance drivers.

Statistical methods

We used a formula described by the U.S. Department of Labor (DOL), Bureau of Labor Statistics: N/W*100,000 to calculate the fatality rate. In the formula, N = number of fatally injured workers, W equals the total number of workers and 100,000 is used to calculate a standard rate per 100,000 workers.¹⁹

For the ambulance service half-century homicide rate in Figure 1, the rate per half-century was estimated by taking the number of homicides in the time period, dividing by the number of years in the time period and then multiplying by 50.

For one subset of the population, during one time period, there was a reliable denominator. That allowed a calculation of the rates for fatalities among the paramedicine clinicians who were employed by the BEMS. We compared the calculated BEMS rates to the rates for all U.S. workers for 2020 (the last year available).

The paper follows the STROBE guidelines for structure.²⁰

Results

Table 1 shows all ambulance service personnel who died in service to the people of New York City since 1893.

Table 1. Date of death, person’s name, employer, and position with cause of death and notes per case. 1893 to 2022. Note that over the decades, ambulance personnel have had many job titles including diver, surgeon, attendant, technician and paramedic.

Date	Name	Hospital/Employer	Position	Cause	Notes
05/15/1893	Dennis J. Ward	Riverside Hospital	Ambulance Driver	Typhus	First Ambulance Worker Death, First Infectious Disease Death
09/04/1898	John Gerry	Bellevue Hospital	Ambulance Driver	Heat Exhaustion	First Environmental Death
07/07/1901	Paddy Travers	Bellevue Hospital	Ambulance Driver	MVC-firetruck	First MVC Death
08/09/1905	John Wallace	St Johns LIC	Ambulance Driver	Pneumonia	First Voluntary Hospital Death
11/27/1905	Clarence W. Barrow	Roosevelt Hospital	Ambulance Surgeon	MVC	First Ambulance Surgeon Death
11/14/1916	Thomas Kress	Bellevue Hospital	Ambulance Attendant	MVC
10/24/1918	Margaret Deneve	Red Cross Motor Corps	Ambulance Driver	Spanish Flu	First Volunteer Ambulance Worker Death, First Female Ambulance Worker Death
02/13/1919	Mrs Charles Meyer	Women’s Motor Corps of America	Ambulance Driver	MVC-trolley
07/29/1919	John Leddy	LICH	Ambulance Attendant	MVC
07/24/1927	Roger W. Ogburn	Bellevue Hospital	Ambulance Surgeon	MVC
03/13/1938	Harry T. Mesh	Harbor Hospital	Ambulance Surgeon	MVC
04/11/1938	Robert Morton, Jr.	St Vincent’s Staten Island	Ambulance Surgeon	MVC
08/24/1943	Morris Linker	Reception Hospital	Ambulance Driver	MVC into water
08/13/1944	John F. Houy	Fort Hamilton Army Hospital	Ambulance Driver	MVC	First Military Ambulance Worker Death
12/25/1945	Abraham Millman	ABC Ambulance	Ambulance Driver	Stabbed by EDP IFO Ambulance Hq Building	First Private Ambulance Worker Death
07/29/1946	Nathan Rabison	Unity Hospital	Ambulance Surgeon	MVC-trolley
02/06/1953	Peter J. Kelly	Methodist Hospital	Ambulance Driver	CVA
12/03/1954	Hannah Callahan	Kings County Hospital	Ambulance Attendant	GSW
08/23/1975	Frank Libraro	Glendale VAC	Ambulance Attendant	MVC into building
12/09/1985	David T. Hoover	Astoria Volunteer Ambulance	EMT	MVC into subway support
04/25/1987	Kirby McElhern	NYC*EMS	EMS Lieutenant	MI	First Paramedic Death
06/17/1994	Christopher Prescott	NYC*EMS	EMT	MVC/homicide
06/09/1996	James Lawrence	Little Neck-Douglaston VAC	EMT	Heart Attack
09/24/1997	Tracy Allen Lee	NYC*EMS	EMT	AIDS
01/21/2001	Barbara Poppo	FDNY	EMS Lieutenant	MI
07/13/2001	Gaylette Drummond	Midwood Ambulance Company	Paramedic	MVC into subway support
09/11/2001	Andre Fletcher	FDNY	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Bob Cirri	PAPD/Hackensack Medical Center	Paramedic	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Brian Bilcher	FDNY	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Carlos Lillo	FDNY	Paramedic	Terrorism/homicide
09/11/2001	Charles Laurencin	US Air Force	Paramedic	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Clive Thompson	Summit VAC	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Cynthia Mahoney	No Affiliation	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	David Lemange	PAPD/Jersey City Medical Center	Paramedic	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Frank Spinelli	Short Hills VAC	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	George Howard	PAPD	Paramedic	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Glenn Winuk	Jericho Fire Department	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Hector Tirado	FDNY	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	James Coyle	FDNY	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Je Jung	No Affiliation	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Jean Peterson	Madison Ambulance Squad	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Jeff Simpson	Triangle Resc Sqd	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Joe Henry	FDNY	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Joe Lovero	Jersey City FD/JCMC	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	John D’Allara	NYPD	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	John Skala	PAPD/ Clifton Passaic MICU	Paramedic	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Karl Joseph EMT	FDNY	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Kathy Mazza	PAPD	RN	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Keith Fairben	NY Presbyterian Hospital	Paramedic	Terrorism/homicide
09/11/2001	Kenneth Swenson	Chatham Emerg Squad	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Kevin Pfeifer	FDNY	Paramedic	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Lauren Grandcolas	No Affiliation	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Linda Gronlund	No Affiliation	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Marc Sullins	Cabrini Medical Center	EMT	Terrorism/homicide
09/11/2001	Mario Santoro	NY Presbyterian Hospital	Paramedic	Terrorism/homicide
09/11/2001	Mark Schwartz	Hunter Ambulance	EMT	Terrorism/homicide	(Mutual Aid Response System)
09/11/2001	Maurice Barry	PAPD/ Rutherford, NJ Amb Corp	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Michael Kiefer	FDNY	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Mitchel Wallace	NYS Courts/Bayside VAC	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Ricardo Quinn	FDNY	Paramedic	Terrorism/homicide
09/11/2001	Richard Pearlman	Forest Hills VAC	EMT	Terrorism/homicide	(Mutual Aid Response System)
09/11/2001	Richard Rodriguez	PAPD	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Rodney Gillis	NYPD ESU	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Sean Tallon	FDNY	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Stephen Huczko	PAPD	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Thomas Jurgens	No Affiliation	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Vincent Danz	NYPD	EMT	Terrorism/homicide	Not working in primary 911 EMS role
09/11/2001	Yamel Merino	Montefiore Medical Center/Metrocare Ambulance	Paramedic	Terrorism/homicide
09/11/2001	Zhe Zeng	Brighton Amb	EMT	Terrorism/homicide	Not working in primary 911 EMS role
01/08/2002	James Kay	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
04/18/2002	Andre Lahens	FDNY	EMT	MVC
06/07/2002	Daniel Stewart	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
10/23/2005	Felix Hernandez	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
06/23/2005	Timothy Keller	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
08/28/2005	Roisin Coohill	Midwood Ambulance	EMT	Terrorism/homicide	Post-9/11 Death
10/23/2005	Felix Hernandez	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
03/15/2006	Deborah Reeve	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
04/23/2006	Brendan Pearson	FDNY	EMS Lieutenant	Injury with complications of surgery
11/26/2007	Brian Ellicott	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
05/14/2008	Rene Davilla	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
09/26/2008	Ryan McCormack	UMDNJ/Verona Rescue	Paramedic	Terrorism/homicide	Post-9/11 Death
09/26/2008	Ryan McCormick	UMDNJ	EMT	Terrorism/homicide	Post-9/11 Death
04/12/2009	Clyde F Sealey	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
12/22/2009	Carene A. Brown	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
05/30/2010	Paula Rodriguez	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
06/15/2010	Freddie Rosario	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
02/06/2012	John McFarland	FDNY	Dept Asst Comm	Terrorism/homicide	Post-9/11 Death
06/15/2012	Anthony Ficara	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
08/27/2012	David Restuccio	Staten Island University Hospital	Paramedic	MVC
12/09/2012	Joseph V. Schiumo	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
12/10/2012	Ruben Berrios	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
03/07/2013	Tyrone Rogers	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
05/02/2013	Walter J. Nelson	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
05/28/2013	Douglas Mulholland	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
06/01/2014	William C. Olsen	FDNY	Captain	Terrorism/homicide	Post-9/11 Death
06/25/2013	Roland Coyne	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
06/28/2013	Irene Gremmert	Newburgh VAC	Paramedic	Terrorism/homicide	Post-9/11 Death
07/09/2013	Rudy Havelka	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
08/27/2013	Francis Charles	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
09/08/2015	Harold McNeil	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
09/24/2013	John W. Wyatt	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
10/07/2014	Thomas V. Giammarino	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
11/07/2013	Luis de Peña	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
12/02/2013	Michael Cavanagh	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
12/14/2013	Lou Angeli	New Castle County CERT	Paramedic	Terrorism/homicide	Post-9/11 Death
02/17/2014	Linda Ohlsen	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
08/24/14	Steve Skipton	UMDNJ	EMT	Terrorism/homicide	Post-9/11 Death
01/06/2016	Norman Valle	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
02/08/2017	Edith Torres	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
02/15/2017	Rose Scott	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
03/16/2017	Yadira Arroyo	FDNY	EMT	MVC/homicide
04/01/2017	Mario Bastidas	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
05/13/2017	Mark Harris	FDNY	Paramedic Captain	Terrorism/homicide	Post-9/11 Death
10/17/2017	Michael G. Guttenberg	Northwell Health	Physician	Terrorism/homicide	Post-9/11 Death
01/10/2018	Steven Shenkman	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
01/19/2018	Joseph Sanamarina	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
03/05/2018	Joeddy E. Friszell	FDNY	Deputy Chief	Terrorism/homicide	Post-9/11 Death
08/19/2018	William Ryan	Bay Community VAC	EMT	Terrorism/homicide	Post-9/11 Death
10/10/2018	Felipe A. Torre	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
11/18/2018	Martha Stewart	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
11/23/2018	Joseph A. Rodriguez	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
02/26/2020	Joseph Braganza	NYU Langone Hospital	Paramedic	COVID Death
03/24/2020	Yakkov Meltzer	Hatzolah of Queens	PA	COVID Death
03/25/2020	Yitchok Zylberminc	Hatzolah of Far Rockaway	EMT	COVID Death
04/12/2020	Tony Thomas	Lutheran Hospital	Paramedic	COVID Death
04/12/2020	Greg Hodge	FDNY	EMT	COVID Death
04/21/2020	John Redd	FDNY	EMT	COVID Death
04/22/2020	Idris Bey	FDNY	EMT	COVID Death
04/23/2020	Marlene Picone	Maimonides Hospital	Ambulance Dispatcher	COVID Death
04/24/2020	John Mondello	FDNY	EMT	COVID Death
04/26/2020	James Villecco	FDNY	Mechanic	COVID Death
04/27/2020	Richard Seaberry	FDNY	EMT	COVID Death
04/27/2020	Thomas Ward	FDNY	Mechanic	COVID Death
04/30/2020	Paul Cary	Ambulanz	Paramedic	COVID Death	National Ambulance Task Force detailed to NYC
05/08/2020	Brian Saddler	Staten Island University Hospital	Paramedic/RN	COVID Death
08/16/2020	Edward McEvoy	Underwood Memorial Hospital/NJ EMS Task Force	Paramedic	Terrorism/homicide	Post-9/11 Death
09/16/2020	Rene Sanchez	FDNY	Paramedic	COVID Death
11/20/2020	Donnell Ben-Levy Ford	Brookdale Hospital	EMT	Terrorism/homicide	Post-9/11 Death
12/22/2020	Evelyn Ford	FDNY	EMT	COVID Death
02/07/2021	Paige A. Humphries	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
08/16/2021	Stephenson McCoy	FDNY	Paramedic	Terrorism/homicide	Post-9/11 Death
09/23/2021	Mark A Weiner	FDNY	EMT	Terrorism/homicide	Post-9/11 Death
10/23/2021	Charles Harris	FDNY	Captain	Terrorism/homicide	Post-9/11 Death
12/07/2021	Alvin J Suriel	FDNY	Asst Chief	Terrorism/homicide	Post-9/11 Death
12/27/2021	John P Raftery	FDNY	Lieutenant	Terrorism/homicide	Post-9/11 Death
01/27/2022	Michael Early	FDNY	Captain	Terrorism/homicide	Post-9/11 Death
10/29/2022	Alison Russo-Elling	FDNY	Lieutenant	Homicide

Table 1 shows that 147 paramedicine clinicians died due to work-related causes since 1893.

Outcome data

Table 2 illustrates the 147 fatalities arranged by the fatality type and by employer.

Table 2. Fatalities by type and agency. FDNY/ BEMS is the NYC fire department’s bureau of emergency medical service. “NYC*EMS” is the NYC EMS agency before it became BEMS. NYC is other NYC government agencies. Government is other than NYC government (e.g., the FEMA task force). Hospital is those non-government hospitals in NYC. Volunteer is members of volunteer ambulance services providing service to the city. Outside NYC is personnel employed by, or volunteers for, agencies outside NYC. Other includes agencies such as the Red Cross. (N = 147)

	FDNY/ BEMS	NYC* EMS	NYC	Govern-ment	Hospital	Private	Volunteer	Outside NYC	Other	Grand Total
Post-9/11	47			1	2	1	2	3	1	57
9/11	11		3	8	4	1	4	7	5	43
Transportation	1		3		8	1	2		1	16
COVID	9			1	4		2			16
Homicide & Homicide/MVC	2	1	1			1				5
Infectious disease		1			2				1	4
Cardiovascular	1	1			1		1			4
Exposure			1							1
Strain	1									1
Grand Total	72	3	8	10	21	4	11	10	8	147

Figure 1 shows the 147 fatalities arranged by time period and by case type. The homicide rate shows how the number of fatalities estimated per half-century has changed for each of the time periods.

Terrorism

In 2022, the 100^th paramedicine clinician died due to the terrorist attack of September 11, 2001; 43 died on September 11, 2001, and 57 died of post-September 11 illness complications.

Transportation

Sixteen of the 147 (11%) died of transportation related injuries (this does not include the two who were victims of vehicle-related homicides).

COVID

There were 16 COVID-related fatalities in 2020. Of them, nine were employed by BEMS.

Homicide

Five of the paramedicine clinicians were victims of homicide; two of those were vehicle-related homicides.

Other

Twenty died of other causes including: ten died of medical conditions; four of cardiovascular disease; four from (non-COVID) infectious disease; one from surgical complications secondary to an on-the-job hernia; and one due to exposure (heat exhaustion).

Fatality Rate in BEMS

There are no data describing the number of workers at the NYC hospital ambulances or volunteer agencies. However, a precise number of workers has been documented for those employed by BEMS. In addition, the BEMS personnel tend to be full time employees.

To determine the most reliable fatality rate in the FDNY BEMS, we focused on just those deaths occurring over the past five years (October 2017 to October 2022). There were 4,408 paramedicine clinicians employed by the BEMS during the study period.²¹ The data in Table 1 show that there were 23 fatalities among BEMS personnel since October 2017. Three of the 23 clinicians were women.

The occupational fatality rate for BEMS paramedicine clinicians is 104.4 (95% CI = 61.7, 147.0). The fatality rate for all workers in the U.S. in 2020 was 3.4.²²

There was one reported homicide among the 4,408 paramedicine clinicians employed by the BEMS over the past five years; the one case over five-years or 22,040 person-years, equals a homicide rate of 4.5. The DOL reported 392 homicides among approximately 140,117,647 workers in 2020 (the most current year available) for a rate of 0.28.

A total of nine BEMS clinicians died of COVID in 2020. The BEMS COVID fatality rate is 204.2. The annual COVID fatality rate for all workers in the U.S. for 2020 was 35.6.²³

Figure 2 shows the fatality rates of COVID, homicide and overall, for BEMS personnel compared to all U.S. workers in 2020 and the relative risk for BEMS personnel.

Figure 2 shows that the overall fatality rate for BEMS personnel is about 35 times higher than the national average, the COVID fatality rate was about six times the national average and the homicide rate was 16 times higher than the rate for all U.S. workers.

Other EMS Agencies

In addition to the nine members of BEMS, seven other paramedicine clinicians working in NYC died of COVID. They included four clinicians working for hospital-based ambulance services and two who worked for volunteer ambulance services. One additional clinician, Paul Cary, was one of the 500 paramedicine clinicians in the FEMA task force who came to help NYC through the COVID crisis.²⁴

For the approximately 70 other EMS agencies in NYC there are no reliable denominator data, so it is not possible to calculate fatality rates. Table 2 shows that 21 of the 147 fatalities (14%) were members of NYC hospital-based ambulance services, 11 (7%) were members of NYC volunteer ambulance services and 4 (3%) were employed by private ambulance services. Eleven (7%) of the victims were members of agencies outside NYC.

Limitations

The lack of a national data set documenting the fatalities and injuries for paramedicine clinicians means that there is no reliable way to identify all of the many clinicians who are injured or killed in the line of duty. We are confident that these 147 should be included here but we realize that there could be many who should be here but who were not identifiable.

The number of BEMS personnel is accurate for one point during the specified time period but there are no data on how the number may have fluctuated over time.

The calculation of rates based on small numbers of cases must be interpreted with caution. It is a reasonable approach to identifying risks, and often, such as here, the only way to identify risks, but should always be followed up with new calculations as additional cases occur or as time passes between cases.

Discussion

Since 1893, 147 ambulance personnel have died in service to NYC. We honor their service and the sacrifices of them and their loved ones.

The September 11 terrorism attack on New York City continues to claim the lives of paramedicine clinicians. Table 1 shows that 43 paramedicine clinicians died on September 11, 2001, and 57 have died since of 9/11 related diseases. Today, many paramedicine clinicians continue to suffer from the illnesses caused by their response to that event and many have been denied support for the illnesses they now suffer as a result of responding to the attack.²⁵

Since 1893, eleven percent of the fatalities were personnel who died in transportation related events. Nationwide research found that 74% of fatalities among paramedicine clinicians were secondary to transportation events.⁷ In the U.S., the paramedicine clinician’s risk of transport related fatality is about five time higher than the rate for all workers.²⁶ Although it is not always included in occupational risk research, due to the nature of their work, it is appropriate to also evaluate all transportation events that occur coming to or going home from work. Richie Gomez was just one of the possibly many paramedicine clinicians who died on their way home from work.²⁷

Methods to reduce ambulance crashes have been described.²⁸ Recently, the National Highway Transportation Administration announced a goal of zero transportation fatalities nationwide,²⁹ that is a critical goal for paramedicine clinicians in NYC and across the country.

The BEMS has a homicide rate 16 times higher than the national average for all workers. Nationwide, paramedicine clinicians have an occupation homicide rate 30% higher than the rate for all U.S. workers and seven times higher than the average rate for all health care workers.⁷

The homicides in NYC are only the tip of the iceberg when looking at the risks of violence among these personnel.³⁰ Fifty-two BEMS clinicians were assaulted in the first 10 weeks of 2021 alone.³¹ But even this high number is likely much lower than the actual number of assaults since, as the BEMS union president noted: “Many of our assaults go unreported due to our members knowing the prosecutors won’t do anything to the offenders.”³¹ The BEMS president noted that the clinicians “face ‘day-to-day assault,’ but get no safety, self-defense or de-escalation training and are outfitted with 20-year-old bulletproof vests — which expired five years after production.”³⁰

About 400 clinicians a year report attacks in the U.S. and women have a higher risk than men.¹¹ A survey of over 600 paramedicine clinicians who had been victims of assault found that many noted that they had no training to protect themselves from attack.³² The current training for protecting paramedicine clinicians from violent attacks should be evaluated for opportunities to improve it and make it available to all paramedicine clinicians working in NYC. Protective equipment should be tested for efficacy, deployed to all personnel and maintained. Much more must be done to protect paramedicine clinicians from violent attacks.

Suicide is often not considered an occupational fatality and is not included in this study. However, it should not be overlooked when evaluating occupational risks for paramedicine clinicians. The CDC wrote a report in 2018 that stated that the occupational suicide rate in the U.S. in 2016 was 17.3 per 100,000 workers.³³ Although there is no systematic collection of EMS suicides, there were at least three suicides documented among BEMS personnel in 2020 alone.¹² The resulting rate of 68.1 for BEMS personnel is a rate about four times higher than the national average for all U.S. workers. The facts that at least three employees committed suicide in one year and that the rate is so much higher than the national average, indicate an urgent need for suicide prevention interventions. Capturing suicides should include off-duty events.³⁴ A successful intervention by the Department of Defense may provide insights to potential methods that could help to reduce risks in NYC and for paramedicine clinicians worldwide.³⁵

The research highlights the critical importance of a national database dedicated to capturing and documenting occupational injuries and fatalities among paramedicine clinicians. Although we applaud the efforts of the U.S. DOL Bureau of Labor Statistics, and are very grateful for the important data they do provide, a critical precursor to any reliable risk reduction interventions will be a much more robust and tailored dataset than the DOL provides. Such a dataset must be able to capture and link data from medical records, personnel files and ambulance service operational records. A working database that could be used as a model is the Defense Medical Epidemiology Database.³⁶

As noted, the NYC EMS system does vary in considerable ways from other EMS systems in the U.S. and internationally. However, we expect that many of the risks are common to all personnel and that the findings are largely generalizable to paramedicine clinicians worldwide.

Conclusions

In total, one hundred and forty-seven dedicated personnel died in performance of their mission to provide ambulance services to the citizens of New York City. Over the past five years alone, 23 paramedicine clinicians employed by the BEMS and 11 paramedicine clinicians from other EMS agencies providing services to NYC, have suffered occupational fatalities. The occupational fatality rate for paramedicine clinicians employed by the FDNY BEMS is 35 times higher than the national average for all workers in the U.S. and their rate of homicides is 16 times higher than the national average.

Call them ambulance workers, EMS professionals or paramedicine clinicians, the title does not matter. What matters is that they dedicated themselves to providing a critical service, they died committed to saving the lives of others, and we must do more to protect these valued emergency medical services professionals.

The research shows that the threats to our personnel are significant and have been changing over time. Although ambulance designs have been improving, we still have a high threat of transportation related fatality, we face new threats from terrorism and contagious disease, and the homicide rate may be rising dramatically. The research also highlights the critical importance of having a national database that tracks occupational injuries and fatalities among paramedicine clinicians; such a database is an essential precursor to any efforts to reduce the risks of occupational fatality and injury.

Immediate efforts are needed to protect these clinicians from the many hazards they face every day in their service to the citizens of New York City.

It will take a dedicated effort to ensure that Alison Russo-Elling is the last paramedicine clinician who dies in service to New York City.

—

Disclaimer: The views expressed in this paper are those of 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.

Conflicts: The authors have no conflicts of interest. Funding: There was no funding for this project.

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