On October 6, 2020, the Fire Department of the City of New York (FDNY) conducted a memorial service for department members who had recently died. It was a somber ceremony for the many fallen personnel. The ceremony was very inclusive and noted the passing of emergency responders, FDNY civilians and mechanics as well as a paramedic who had come to NYC on a FEMA deployment to assist during the pandemic.1 The information on the notice also provided an opportunity for a preliminary agency-level epidemiology analyses to develop a better understanding of the risks faced by FDNY personnel in 2020.
New York City is both the most populous and most densely populated major city in the U.S.; over eight million people live in 302 square miles.2 FDNY covers this entire area and employs 11,230 firefighters and 4,408 emergency medical services (EMS) clinicians (including paramedics and emergency medical technicians).3 In 2018, there were 1.8 million “ambulance runs” in NYC; FDNY firefighters responded to 619,378 calls.4 EMS crews in NYC typically respond to about 4,000 emergency calls a day; at times during the pandemic, demand swelled to over 7,000 calls a day.5,6 Of almost 1.5 million people tested in NYC by August 20, 27% had antibodies to the coronavirus.7
Some of the Lives Lost to COVID-19
Prior research has shown that EMS clinicians face high risks and have occupational fatality rates similar to police and fire and non-fatal injury rates higher than police and fire.8-10 The purpose of this analyses was to both document current fatalities among FDNY personnel and to compare risks between two occupational groups in FDNY.
We used the information posted by FDNY to calculate the rates of occupational fatalities and COVID-19 related fatalities among firefighters and EMS clinicians in the agency.
- Organizations such as the U.S. Department of Labor (DOL), Bureau of Labor Statistics, use the occupational fatality rate to measure and compare risks among different occupations. We used standard formulas to calculate rates. For example, the occupational fatality rate formula is the number of deaths in a population during a time period such as a year, divided by the number of individuals in the population during that time period, multiplied by 100,000.
- To calculate an annual fatality rate for this study, we divided the number of cases in the first eight months by eight and multiplied that number by 12 to get the equivalent number of cases per year. To determine the population size equivalent for one year, we divided the number of personnel by eight and multiplied by 12.
- The relative risk is used to show how much more (or less) dangerous one occupation is compared to another. We used the formula of the fatality rate for Group 1 (EMS) divided by the rate for Group 2 (fire).
The posted notice included a list of the names and job titles of the FDNY emergency responders who died in 2020. Among them were 11 EMS clinicians and two firefighters. Sex and age were not included but all had male sounding names. All the 2020 FDNY cases occurred prior to the end of August 2020. EMS clinicians and firefighters employed by FDNY are full time employees.
Figure 1 illustrates the occupational fatality rate per 100,000 personnel for FDNY firefighters is ((3/16,845) * 100,000 =) 17.8, while the rate for FDNY EMS clinicians is ((16.5/6,612) * 100,000 =) 249.5.
The fatality rate for Group 1 (EMS) divided by the rate for Group 2 (fire) shows the relative risk for EMS compared to Fire is 249.5/17.8 = 14.
This shows that in FDNY during the first eight months of 2020, the risk of occupational fatality for EMS clinicians was 14 times higher than the risk for firefighters.
Four of the EMS clinicians were categorized as “Died of COVID-19;” neither of the two firefighters were classified as having died from COVID-19.1 The four EMS COVID-19 fatalities were also noted on another website.11 That site noted that the ages of the four individuals were 59, 60 and two who were 63; all were described as male.
Using the fatality rate formula above, we determined that the COVID-19 fatality rate in FDNY EMS is 90.7.
Tragically, three FDNY EMS clinicians took their lives between January and August 2020. The names of three EMS clinicians on the FDNY list were the same names noted in newspaper reports indicating that the clinicians died of suicide.12-14 All three were males. None of these three were categorized as “Died of COVID-19.”
Calculating the FDNY EMS suicide rate using the DOL formula described above ((4.5/6,612) *100,000), the rate for FDNY EMS clinicians is 68 per year.
A primary limitation is that this analysis covers a relatively small population over a relatively short period of time. Focusing on one organization also limits the generalizability of the findings. However, reports with such limitations can serve an important function of being an early indicator of a growing risk. The DOL, for example, publishes relative risks for occupational groups with as few as five fatalities as a way to highlight areas of potential concern.15
The DOL reports that the civilian occupation with the highest fatality rate in the U.S. in 2018 was “Logging” with a rate of 97.6.16 The FDNY EMS clinicians have a rate of occupational fatality that is 2.5 times higher.
Regrettably, as of October 2020, little is known about the pandemic related fatality rates among different professions. We know that the pandemic fatality rate for the U.S. population as of October 17 (217,918 deaths) is 66.4 per 100,000 persons. Using the formula from above we see that the relative risk for FDNY EMS is about 36% higher than the national rate.
A recent study found that the national COVID-19-related mortality for EMS clinicians was 14 cases per 100,000 personnel, compared to 13 for firefighters, 12 for police, five for nurses and three for physicians; the risk for EMS clinicians was about three times higher than nurses and almost five times higher than physicians.17
One study documented that, at the end of March in New York City, 573 of 4,408 FDNY EMS clinicians had confirmed cases of COVID-19 compared to 1,198 cases among the 11,230 firefighters.3 The risk for EMS clinicians was 130 cases per 1,000 persons compared to 107 for firefighters; the relative risk of infection was 20% higher for EMS than for firefighters.
A study of 260 EMS clinicians in Cleveland found that 16 (5.4%) had a COVID positive serologic test; of those, eight had no symptoms and only one sought healthcare.18
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A 2020 report by the U.S. Centers for Disease Control and Prevention (CDC) found that the occupational group with the highest suicide rate in the U.S. was “Mining, Quarrying, and Oil and Gas Extraction.”19 The suicide rate for males in that group was 54.2. The suicide rate for males in “Healthcare Practitioners and Technical” and “Healthcare Support” is 23.6 for both groups.
The relative risk of suicide for all EMS clinicians in FDNY in 2020 is about 25% higher than for males in mining and about three times higher than for all male healthcare workers in the U.S. If half of the FDNY EMS clinicians are male, the rate for male EMS clinicians would be twice as high as the rate for all EMS clinicians.
The EMS suicide risk in the U.S., as measured by the percent of all fatalities, is about twice as high as the national average20 and twice as high as the risk for firefighters.21
In Australia, the rate of suicide among paramedics was estimated to be 20 times higher than the rate for all Australians.22
The findings show that for the first eight months of 2020, EMS clinicians in FDNY had a risk of fatality that was 14 times higher than for firefighters in the same department.
As of October 2020, there are limited data available that describe the range of occupational risks for EMS clinicians. The data that are available indicate that EMS clinicians are at higher overall risk of death, pandemic-related mortality and suicide than other emergency services and health professions. These findings reinforce how important it is to test all EMS clinicians on a regular basis and to note the percent positive and the health outcomes associated with the virus.
In the U.S., as of October 2020, there are no government data reported that document pandemic related fatality, illnesses, long-term health effects and employee turnover among EMS or any other occupational groups. Although this study has a relatively small sample size, the very high fatality rates demonstrate an urgent need to do these analyses on additional EMS populations and for longer periods of time. Only when we identify the risks can we hope to develop and implement reliable risk-reduction interventions.
Our analyses, and these referenced studies, indicate that the rate for suicide appears to be very high in the EMS profession and is a risk that must be studied in order to develop and implement profession-wide risk reduction interventions.
The findings highlight both the risks and the paucity of data. For example, we still have essentially no idea how many EMS clinicians have been diagnosed with work related mental health issues, attempted suicide or completed an act of self-harm resulting in their death.
Reducing employee occupational injury and death has been a mainstay of the risk management divisions of fire and law enforcement. Emergency medical services agencies, faced with increasing demands for service and with less money to accomplish their tasks, have been largely unable to pursue meaningful risk reduction. The data provided underscores the need for EMS research and risk management.
The profession is in dire need of both comprehensive data and funding for research. With those resources, coupled with a commitment to change from both EMS leaders and clinicians, risk-reduction and occupational health improvement can be achieved.
The authors share our heartfelt condolences to all our colleagues in FDNY, and to the families and friends of the FDNY EMS clinicians and firefighters who lost their lives while serving NYC.
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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