Comfort, convenience, and safety features of the climate controlled hospital with a multitude of staff members, limited access entry, bright lighting, 24-hour housekeeping, and wheelchair and stretcher access scarcely apply to the prehospital setting. Field medicine many times is initiated in austere environments. Specific, unique, and many times, predictable dangers are faced by prehospital practitioners on a regular basis. Dangers that killed emergency medical services can be tracked and have been reported by the National Emergency Medical Services Memorial Service.3 These statistics do not include the numerous injuries that occur daily in the provision of emergency medical services, but rather specifically fatalities. Physicians practicing in the field are subject to the same risks.
Routine occupational hazards of emergency medical services most often are related to the physical nature of the work: lifting and carrying bulky equipment and patients over uneven terrain. Analysis of the National Electronic Injury Surveillance System (NEISS-Work) revealed that for emergency medical services workers during the period of 2003 to 2007 the most common nonfatal injury diagnosis was sprains and strains, comprising 38% of all injuries.4 The most recent year for which NEISS-Work data are available is 2009, with 57% of injuries diagnosed as sprains, strains, contusions, or abrasions. Arm injuries were less prevalent (9%) than injuries of the leg and foot, hand and fingers, upper trunk, and lower trunk which each comprise approximately 20% of injuries. The most common mechanism for these injuries was bodily exertion and motion during the care of a patient.
Bureau of Labor Statistics (BLS) Census of Fatal Occupational Injuries for 2003 to 2007 indicate that 45% of emergency medical services on duty injury-related fatalities were from motor vehicle incidents, and 31% were related to medical aircraft crashes, with these two causes alone accounting for 76% of injury-related fatalities.4 Analysis of Emergency Medical Services Memorial Service data reveals that over a 10-year period that these two causes account for 77% of all on duty fatalities, with twice as many fatalities accounted by air medical crashes compared to ground motor vehicle crashes. Twenty percent of all on duty fatalities are accounted for by nontraumatic cardiac arrest.3 The latter may be related to the physical nature of providing emergency medical services, coupled with exposure to night shifts and unhealthy nutritional options that have been linked to increased coronary artery disease, diabetes, and cerebrovascular disease.5 The stereotypical lifestyle of the emergency medical services provider which involves high levels of stress, sleep deprivation, poor availability of quality nourishment, and night shift work may be as dangerous as any hazard on the scene. The general wellness, lifestyle, and behaviors of the EMS physician are as important in the lifetime before the call as they are during it.
Most fatalities occur getting to and from a scene. Safe travel, due regard, and judicious use of air medical services are crucial. Entering or exiting the response vehicle is a vulnerable time as well, and passersby may be distracted by the flashing lights and not drive cautiously and attentively through a scene: the so-called “rubber necking” phenomenon. Even with traffic control in place, some drivers will navigate around the measures, or fail to slow down at all. Motor vehicle crash scenes are among the most dangerous encountered in routine emergency medical services operations. Traffic remains a major concern, but there is also the risk of fire, exploding fuel, smoke, and toxic fumes.
Care equipment placed on the ground can become a trip point at any scene. The electrical systems of hybrid and electric propulsion vehicles are volatile and a risk to rescuers. Tanker trucks, tractor trailers and trains are prone to their own fuel exploding along with dispersal or incineration of their cargo which may be toxic. Dust from airbags may be irritating to the skin and respiratory tract, and the debris, including shattered glass and the vehicle itself are typically jagged and capable of inflicting injury. Debris itself and uneven or slippery surfaces from precipitation or spilled liquids present a danger of fall as well. Many crashes involve damage and dangers from utilities such as broken fire hydrants and downed electrical wires. Trees or other structures struck in a motor vehicle crash can be unstable following a crash and prone to falling unexpectedly. Response vehicles themselves may become a threat when their undercarriages, hot from a priority response, touch off dry grasses or spilled liquids adjacent to the vehicle.
Absent the calamities of a motor vehicle crash, domestic calls also present risks to the EMS physician. By virtue of medical or mental illness, many homes are not well maintained: cluttered passageways may become trip points, stairs and entrances may not have proper snow and ice removal, and in some cases the structure may be in disrepair to the point that there are sink holes in the flooring or even walls or ceilings that are in danger of collapsing. Stairs are many times steep, uneven, and perhaps not rated for several emergency responders and their heavy equipment. The family dog or other pets may perceive an intruder and attack. Smokers in settings where home oxygen is used, or where supplemental oxygen has been brought to patient by emergency medical services, can become the source of a fire risk and should not be tolerated during emergency medical services operations. Exposure to tobacco smoke second hand is a known health risk, and some scenes may be tainted with elevated levels of carbon monoxide or cyanide, particularly after a fire. Confined spaces such as caves should be considered hazardous spaces that emergency medical services providers without special training and protective equipment should not enter.
Patients themselves and their illnesses present their own dangers to emergency medical services providers. They are by definition, undifferentiated patients, and may expose the provider to communicable disease, or even violence as a result of delirium, intoxication by drug or alcohol, mental illness, or criminal activity. Those in the drug trade often suffer emergencies, and they are associated with large quantities of cash and sometimes weapons. Knives, guns, fists, and any object in reach can be used as weapons. Drug users may carry needles that can cause accidental injury to the emergency medical services provider. EMS physicians are prone to unique dangers. By virtue of a shortage of trained EMS physicians, they often respond alone and can be the first unit arriving on a scene. Their vehicles are typically smaller, less protected, and more prone to roll over than ambulances or fire apparatus. They may have a longer emergency response distance by virtue of covering several ambulance districts, and thus more prone to motor vehicle crashes en route.
First arriving units typically have minimal lighting on scene, and thus there is diminished awareness of hazards. Misrecognition of the EMS physician is of major concern: they typically drive low-profile vehicles that do not resemble an ambulance or fire apparatus, which may appear to be law enforcement vehicles. EMS physicians are not expected on many scenes, and may be mistaken for intruders. Further, many emergency medical services personnel wear uniforms with a badge, double breast pocketed button down uniform shirts, and a name plate that are analogous to law enforcement duty uniforms. This is particularly problematic on violent scenes where law enforcement might be particularly targeted, or where the public may have certain expectations of a public safety person appearing to be a law enforcement officer. There are case reports of the public requesting emergency medical services personnel to intervene in a shooting, mistaking them for law enforcement, perhaps due to their uniforms. Perpetrators of violent acts may still be on scene at the time of arrival, and may mistakenly identify the physician as a law enforcement officer and thus a threat. Also an emergency response vehicle may be thought of as an easy target for carjacking for narcotics, as a hiding spot or as a getaway vehicle. Some may view a physician as a high-value target for hostage taking or a soft target for domestic terrorism or acts of violence.6,7 Some mentally ill persons call in emergencies for the sole purpose of an emergency response and the opportunity to attack public safety personnel, as evidenced by the December 24, 2012, shootings by sniper that occurred on the scene of a home arson, left two firefighters dead, two wounded, and one police officer wounded in the town of Webster, New York. Emergency medical services status does not offer guaranteed protection from violence, although some states have enacted legislation that makes assault of an emergency medical services provider a high-level felony.