Work-Related Injuries Among EMTs and Paramedics in Western Turkey
EMTs and paramedics are at risk for serious injuries during work hours and have higher work-related injury (WRI) rates according to the literature data.1
Among all kinds of frequently encountered work-related injuries, motor vehicle accidents (MVA) comprise a special category for their potentially fatal outcomes. MVA rates have been noted to increase by 40% in Turkey, while the share of ambulances increased by 83% in the meantime.2 However, it is difficult to obtain reliable information on WRI affecting EMTs and paramedics in Turkey, similar to many other countries. Only a minority of the WRIs are public and recorded properly.
Chaotic working environment, unpredictability of the nature of “the next case,” anxiety regarding difficulties in communication with patients and families, and extended stressful working hours lead to burnout and lower job satisfaction of healthcare personnel in EMS.
This study is designed to investigate causes and characteristics of WRI involving EMTs and paramedics staffed in a big city in western Turkey.
Methods
The present study was conducted in the developed city of Denizli in western Turkey, with a population near 1 million. Thirty EMS bases with 36 ambulances staffed by 303 personnel—238 EMTs, 65 paramedics—comprise EMS in the city.
The approval for the study was issued by the municipal health authority. All healthcare personnel staffed in EMS in the city were interviewed face-to-face in their off-duty hours to inform them about the study. The personnel were told not to write their names on the sheets and were notified that data which would be collected from the study would not be used anywhere apart from the scientific analyses. Excluded from the study were those who declined to participate in the study, those who were not on duty during the two-month study period and those who had been working in EMS for shorter than a year.
The subjects were asked to answer 23 multiple-choice questions, mostly involved with WRI that can be encountered in EMS work environment.
Results
A total of 303 EMS personnel were identified—238 EMTs and 65 paramedics. Of these, 93 (30.6%) were excluded for having work experience in EMS for shorter than a year, 37 (12.2%) for being on vacation or out-of-duty during the study period, and 10 (3.3%) for declining from the study. Finally, a total of 163 personnel—117 EMTs, 46 paramedics—comprised the study sample. It took an average of 7 to 10 minutes to fill out the answer sheet by the respondents.
Eighty-three personnel (50.9%) were female and mean age was 29.7±8.4. The most common causes of WRI as reported by the personnel were MVAs (31.9%), needlestick injuries (16%), ocular exposure to blood and other bodily fluids (15.4%) and sharp injuries (i.e., injuries by sharps other than needlestick) (9.8%), respectively. Table 1 demonstrates the incidences of different mechanisms of WRI as reported by EMTs and paramedics during the last two years. Only 11.9% (n=8) of the personnel subjected to WRI such as needlestick injuries, penetrating injuries and eye contact with bodily fluids (n=67) had reported the WRI to the authorities following the event.
Data regarding the detailed mechanisms and location of the injuries are depicted in Table 2. MVAs mostly occurred as collisions with other vehicle and with other object (39.4% and 20.6%, respectively). Needlestick injuries commonly occurred during IV line procedures (59.4%) and inside the cruising ambulance (62.5%). Similarly, sharp injuries mostly occur during the ambulance cruises (50%).
In case of MVA, the subjects were asked if they were injured individually or witnessed a member of the crew or third parties in the accident. Six persons (one healthcare personnel and five others) died and 18 were injured (eight personnel and 10 others) in these accidents.
Personnel who reported to have needlestick injuries (n=32) were asked if the needle had been used previously or not. Thirteen (40.6%) answered positively. Follow-up investigations revealed there were no bloodborne infections on the personnel after the event. None of the respondents noted a flu-like syndrome or other airborne infections in the last year.
Personnel were asked about their procedures following the WRI, such as needlestick injuries, penetrating injuries and eye contact with bodily fluids (n=93) (Table 3). Washing with soap and water was the most common measure taken by personnel (78.5%) and working inside the cruising ambulance was the most commonly stated cause of the WRI (41.3%). Possible causes of the WRI were also posed to personnel and responses are depicted in Table 4.
Only 11.9% (n=8) of the personnel subjected to WRI, such as needlestick injuries, penetrating injuries and eye contact with bodily fluids (n=67) had reported the WRI to the authorities following the event. Of note, 104 (63.8%) of the respondents reported they had undergone a training program specially designed to cover possible WRIs related to EMS working environment before or after they started working on the field.
Discussion
The results of this descriptive study show that EMT and paramedics are exposed to substantial risk in regard to WRI and MVA inherent to EMS work environment. The incidence of injuries was 10.9% and mortality rate was 1.4% in the 73 MVAs reported with the one-year study period.
MVAs are known to constitute the most fatal cause of WRI for the personnel staffed in EMS.3 Ambulance MVAs cause a death toll four times greater than that of other occupations.4 Many studies have focused on the safety of ambulances in the last four decades. Studnek, et al. found the incidence of MVA for EMS personnel at 8.6% in a broad-based study in the U.S. They also reported that sleep deprivation and inexperienced drivers had a major impact in these events.5 The corresponding figure found in the present study is nearly four times greater than this result, which also supports the hypothesis that EMS personnel in the region are under substantially higher risk when compared to developed countries. The total number of vehicles in Turkey have doubled in the last decade. The number of registered vehicles in the city is 315,000 in 2013 and have been increasing by 5% to 7% every year.2 The soaring inner-city traffic deliberately renders it difficult to operate as EMS personnel.
Nearly two-fifths of the MVAs were found to occur as two-vehicle collisions in this study. Studies published on the ambulance crashes so far have agreed upon that most MVAs occur in the crossroads as two-vehicle collisions whose outcomes are commonly mortal.3.6 They suggested that traffic signals be strictly heeded at crossroads and speed limits in urban settings be obeyed.
Of note, although many studies indulged in improvement of occupant protection in passenger vehicles by the industry, the occupant safety of ambulance vehicles has never been addressed adequately.7,8
Needlestick injuries were found to occur commonly in the cruising ambulances during vascular procedures in this study. El Sayed, et al. studied the risks of contagious diseases in ambulance workers and showed that needlestick injuries decline following protective measures while exposures to viral airborne diseases prevail within this group.9 The results of this study did not reveal any patient with airborne diseases and therefore do not support the relevant literature data. This result may be attributed to lack of safety needle devices, while gloves, masks, etc. are used prevalently in the EMS system that hosted the project. Safety needle devices are known to alleviate the incidences of this kind of WRI remarkably in ambulances.10 Broad and population-based studies need to be designed and necessary measures taken to prevent needlestick injuries in the country, regardless of the cost of the measures.
Ocular exposures to blood and other bodily fluids were reported to have an incidence of 5.9 to 10.3% in EMS personnel.9,11 This figure was found to be 15.4%, which is much higher than literature findings.
The findings showed that only about two-fifths of the personnel who were subjected to WRIs, such as needlestick injuries, ocular exposures to bodily fluids or injuries with sharps had washed the contamination site with antiseptic solutions, and only about one-tenth had referred to the infectious diseases clinic. More interestingly, one-fifth did virtually nothing after these exposures. Personnel reported only around 12% of the WRI properly, a more dramatic finding shown in the study.
The results indicate only a small part of the WRI toll are reported to authorities and thus the reported injuries do not represent the whole picture. The percentage of reported injuries may have been reduced by the fact that paramedic and EMTs blame themselves for the injuries. The personnel reported factors defined as “hurrying up” and “carelessness” were the most common causes for the injuries.
Limitations
This is a descriptive study with a limited size, thus the findings cannot be extrapolated to the population as a whole. In addition, this study lacks an investigation of data related to the scene of the WRI and use of protective measures.
Conclusions
Paramedic personnel and EMTs are apparently under high risk of WRI. The mobile nature of the work environment poses a substantial risk in EMS. Given the fact that ambulances should be mobile, strict measures need to be taken to restructure the interior design to protect personnel from all kinds of WRI.
References
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- Social Security Statistics, Turkish Statistical Institute (TURKSTAT), www.turkstat.gov.tr/PreTablo.do?alt_id=1051.
- Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency medical services: a hidden crisis. Ann Emerg Med, 2002; 40: 625–32.
- Levick NR, Swanson J. An optimal solution for enhancing ambulance safety: implementing a driver performance feedback and monitoring device in ground emergency medical service vehicles. Annu Proc Assoc Adv Automot Med, 2005; 49: 35–50.
- Studnek JR, Fernandez AR. Characteristics of emergency medical technicians involved in ambulance crashes. Prehosp Disaster Med, 2008; 23: 432–7.
- Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis. Prehosp Emerg Care, 2001; 5: 261–9.
- Fournier M, Chenaitia H, Masson C, Michelet P, Behr M, Auffray JP. Crew and patient safety in ambulances: results of a personnel survey and experimental side impact crash test. Prehosp Disaster Med, 2013; 28: 370–5.
- Erich J. An ambulance-safety how-to. Federal partners plan guidebook, demo truck to share best ideas. EMS World, 2014; 43: 39–40.
- El Sayed M, Kue R, McNeil C, Dyer KS. A descriptive analysis of occupational health exposures in an urban emergency medical services system: 2007-2009. Prehosp Emerg Care, 2011; 15: 506–10.
- Ford J, Phillips P. An evaluation of sharp safety intravenous cannula devices. Nurs Stand, 2011; 26: 42–9.
- Reed E, Daya MR, Jui J, Grellman K, Gerber L, Loveless MO. Occupational infectious disease exposures in EMS personnel. J Emerg Med, 1993; 11: 9–16.
Atakan Yilmaz, MD, is assistant professor of emergency medicine at Pamukkale University Hospital, Department of Emergency Medicine in Denizli, Turkey. dr_atakanyilmaz@yahoo.com
Mustafa Serinken, MD, is professor of emergency medicine at Pamukkale University Hospital, Department of Emergency Medicine in Denizli, Turkey. mserinken@hotmail.com
Onur Dal, MD, is assistant professor of emergency medicine at Adnan Menderes University Hospital, Department of Emergency Medicine, in Aydın, Turkey. onurdal99@hotmail.com
Serpil Yaylacı, MD, is assistant professor of emergency medicine at Acibadem University Hospital, Department of Emergency Medicine, in İstanbul, Turkey. syaylacı@hotmail.com
Ozgur Karcioglu, MD, is professor of emergency medicine at Acibadem University Hospital, Department of Emergency Medicine, in İstanbul, Turkey. okarcioglu@gmail.com
