Paramedic 1.15 – Workforce Safety and Wellness: Wellness Principles

In this, our last module on workforce safety
and wellness, we will explore some workplace wellness principles as applied to the paramedic. Once completed with this module, you should
be able to discuss wellness principles that can be employed to enhance the physical and
mental wellbeing of the paramedic. In recognizing the importance of paramedic
wellbeing, there are two major categories that must be addressed: physical wellbeing,
as well as mental or psychological wellbeing. First, we will focus on principles of physical
wellbeing. As already discussed in previous modules,
the United States in general is suffering from an obesity problem. While the numbers are old, the CDC reported
that the estimated annual medical cost of obesity in the United States as of 2008 was
$147 billion, with obese people having a per capita medical spending rate in 2006 that
was 42% higher than non-obese individuals. As rates of obesity have only increased since
that time, as has inflation and the cost of living, the cost of obesity to the United
States has probably only increased since that time. Unfortunately, these rates and statistics
cross over into the realm of EMS with a 2009 study published in the American Journal of
Hypertension finding that three out of every four active emergency responders nationwide
are overweight or obese. Of those overweight or obese responders, 75
percent of them were determined to be hypertensive or prehypertensive. Another 2009 study out of Boston published
in Obesity (a research journal) found that 44 percent of all new fire and EMS recruits
were overweight, with an additional 33 percent classified as obese. As EMS providers, we know that being overweight
increases an individual’s likelihood of developing or having diabetes, hypertension,
heart disease, stroke, some cancers, and numerous other health conditions. The Annals of Emergency Medicine reported
all the way back in 2002 that cardiovascular disease was the number three on-the-job killer
of EMS providers, accounting for 11 percent of on-duty deaths. While not all firefighters are EMS providers,
there is a strong relationship between the two professions in many areas, Wisconsin included,
and the NFPA reported in June of 2018 that 53 percent of reported on-duty firefighter
deaths for the previous year were due to overexertion, stress, or some type of medical incident. 48 percent of all on-duty deaths were as a
result of sudden cardiac death and 3 percent were due to stroke. U.S. Fire Administration data is similar with
59.8 percent of 2017 on-duty firefighter deaths occurring due to stress or overexertion. Heart attacks were responsible for 57.7 percent
of the 2017 recorded on-duty firefighter deaths, and strokes accounted for 2.3 percent. Needless to say, emergency service workers
need to take a serious look at their own health and wellness and begin practicing what we
preach to work on reducing these numbers. One of the first components to reversing these
trends is for EMS providers to increase or improve their overall physical fitness. While there are numerous resources available
that support the need for physical fitness, the CDC summarizes it well within its 2014
State Indicator Report on Physical Activity. Simply stated, people who are physically active
generally live longer and have lower risk for heart disease, stroke, type 2 diabetes,
depression, some cancers, and obesity. The World Health Organization states that
adults should participate in at least 150 minutes of moderate-intensity aerobic physical
activity every week, and encourages people to participate in 300 minutes of aerobic physical
activity every week for additional health benefits. Beyond simple aerobic activity, however, it
is also important to maintain muscular strength and flexibility as well. An article published in Biogerentology in
2016 took a close look at muscle mass, aging, and the negative impacts of musculoskeletal
deterioration on an individual’s overall health. Past the age of 25, men will typically lose
about 4.7 percent of peak muscle mass per decade and women will lose about 3.7 percent
per decade. Given this loss of skeletal muscle mass, about
17 percent of women and 9 percent of men over the age of 65 cannot lift a 10 pound weight
or kneel down. Further data showed that individuals over
the age of 60 within the lowest third classification group for overall strength were 50 percent
more likely to die of all causes of mortality than those in the upper third group for strength. Those with higher cardio-respiratory fitness
have a greater life expectancy and there is even an inverse correlation between muscular
strength as we age and rates of cancer (having more muscle mass seems to reduce the incidence
of cancer). We previously talked about the prevalence
of injury within the EMS profession, and maintaining strong muscles can help prevent injury. The third component of maintaining a healthy
level of physical fitness is stretching and flexibility. While this component is easily and often overlooked,
the Harvard Health Letter published an article in 2013 that recognized building muscle and
maintaining aerobic fitness is not enough to maintain a healthy lifestyle as we age. In brief, stretching keeps muscles flexible,
strong, and healthy. This maintains a healthy range of motion in
our joints, without which muscles shorten and become tight, which can then lead to pain,
strains, muscle damage, and other injury when the muscles are finally called upon to do
work. With all that being said, think of your physical
fitness needs as being a three-legged stool. You need to maintain aerobic capacity, muscular
strength, and overall flexibility to maximize your personal health, reduce the risk of injury,
and hopefully extend your life expectancy. Being physically fit can be very challenging,
however, if you are not providing your body and cells with proper nutrition. It has also been said that you cannot exercise
your way out of a bad diet. So what does this mean for EMS providers? The U.S. Office of Disease Prevention and
Health Promotion publishes dietary guidelines and the most recent edition at the time the
presentation was produced, which covers the span of time from 2015 to 2020, recognizes
the important and critical link between nutrition and health. Data shows that healthy eating patterns, in
conjunction with regular physical activity, can help people achieve and maintain good
health while reducing the risk of chronic disease. To summarize the recommendations, people should
consume a healthy eating pattern that accounts for all foods and beverages within an appropriate
calorie level (which, for most people, is somewhere within the neighborhood of 1,800
to 2,200 calories per day, although that number can vary by age, activity level, and gender). Such a healthy pattern includes a variety
of vegetables, fruits (especially whole fruits), grains (at least half of which are whole grains),
fat-free or low-fat dairy, a variety of protein foods, and oils. Additionally, people should attempt to limit
intake of saturated fats, trans fats, added sugars, and sodium. If alcohol is consumed, it should be consumed
in moderation, which means no more than one drink per day for women and two drinks per
day for men. If you have an opportunity, it is well worth
checking out the dietary guidelines published on With that nutrition information in mind, think
about the typical work day for an average EMS provider. More than likely, it may include a lot of
sedentary activity (or, more appropriately, lack of activity) along with quite a bit of
caffeine consumption and eating of fast food (which includes unhealthy additives and excessive
calories). There may be a lot of snacking during the
shift, which definitely adds up over the course of a day. Maintaining physical fitness and eating healthy
while at work can be challenging, especially for an EMS provider where the prevalence of
emergency calls and other associated duties make it difficult to plan time for physical
fitness and eating well-balanced meals. For the sake of longevity, however, EMS providers
must make concerted efforts to improve their physical fitness and nutritional practices. Along similar lines, EMS is notorious for
its long hours and anyone who has been involved in EMS for even a short period of time can
tell stories of those late night or early morning calls that disturbed an otherwise
restful sleep. Thus, another important facet of physical
wellbeing is the need to obtain enough sleep. As stated by the National Heart, Lung, and
Blood Institute, sleep plays a vital role in good health and well-being. Sleep helps the brain work properly and a
good night’s sleep even improves learning. On the flip side, sleep deprivation or deficiency
actually alters some parts of the brain, resulting in difficulty making decisions, solving problems,
controlling emotions and behavior, and coping with change. Sleep is involved in the healing and repair
of the heart and blood vessels, and ongoing sleep deficiency is linked to increased risk
of obesity, heart disease, kidney disease, high blood pressure, diabetes, stroke, and
immune system compromise. Those suffering from sleep deprivation are
less productive at work, they take longer to finish tasks, have slower reaction times,
make more mistakes (which is obviously not good for someone expected to provide emergency
medical care to others), and are more likely to experience career or professional burnout. Those who lose sleep several nights in a row,
even if only a loss of just one or two hours per night, have functional impairments equivalent
to not having slept at all for a day or two. This can even cause something known as “microsleep,”
where the sleep-deprived person experiences brief moments of sleep that occur when he
or she is normally awake, which further impacts the individual’s routine functioning. If you are driving an ambulance while sleep
deprived, you may be just as dangerous as a drunk driver as research has shown that
sleep deficiency can harm an individual’s driving ability as much as, or more than,
being legally drunk. It has been estimated that driver sleepiness
is a factor in about 100,000 car accidents each year, resulting in approximately 1,500
deaths annually. Beyond all this, sleep deficiency has also
been linked to depression, suicide, and risk-taking behavior. Unfortunately, despite considerable evidence
related to sleep deprivation, resulting medical errors, and the impact on the sleep-deprived
individual, many EMS systems still insist on maintaining 12 or 24 hour shifts. So long as call volume is low and the likelihood
of a full night’s sleep is high, these shifts may not be extraordinarily problematic. As a system’s call volume increases and
the likelihood of a full, uninterrupted sleep cycle is reduced, however, the cumulative
negative impacts of sleep deprivation become more pronounced on the EMS provider and the
level of care he or she can deliver to patients. As recognized by the Agency for Healthcare
Research and Quality in their 2019 Fatigue, Sleep Deprivation, and Patient Safety article,
sleep is very important for healthcare providers as both acute and chronic sleep deprivation
results in cumulative deficits in executive function and mood, as well as heightened irritability
that can impair communication and coordination within health care teams. Needless to say, this is bad for the providers
as well as their patients. As part of the EMS Agenda 2050: A People-Centered
Vision for the Future of Emergency Medical Services, EMS agencies of the future must
be inherently safe and effective. One part of that goal is to ensure the overall
health and wellness of the EMS providers themselves, which must include evidence-based methods
of preventing EMS personnel fatigue from impacting the safety of the workforce, their patients,
and the public. Such methods could include regulations to
limit the number of consecutive hours worked by EMS personnel, adequate breaks and rest
during shifts, sufficient pay and staffing to avoid the need for working extensive overtime
or multiple jobs, and physiological or other types of testing to objectively measure an
EMS workers’ level of fatigue before, during, and after shifts. Until EMS as a profession reaches that lofty
goal, however, it is up to you, as an individual EMS provider, to take steps to ensure you
obtain adequate sleep on a regular basis. Another important facet of maintaining EMS
provider wellbeing is to take appropriate steps to prevent the spread of disease to
EMS providers. This typically means ensuring EMS providers
have access to routine vaccinations as well as prophylactic measures when a suspected
exposure occurs. While many employers will pay for flu shots
and other vaccinations, not all do. EMS agencies need to recognize the importance
of disease prevention in maintaining an EMS provider’s physical wellbeing and adequately
support efforts to reduce and prevent the transmission of disease from sick patients
and others to their EMS providers. In addition to ensuring your immunizations
are all current, additional steps you can take to prevent disease transmission include
taking standard precautions when delivering patient care, which typically includes the
wearing of gloves and possibly a gown, mask, or eye protection when necessary. As mentioned earlier, sleep deprivation can
also have a negative impact on your body’s immune system and its ability to ward off
and fight infection. Obtaining adequate sleep is also an important
component in preventing illness and disease. The last key component in EMS provider physical
wellbeing is injury prevention and related activities. We already discussed EMS provider injuries
in a previous module, so we will not delve into too much additional detail here. If you remember our previous discussion, the
CDC and NIOSH indicated that EMS providers suffered 21,900 injuries in 2016 that required
treatment at a hospital emergency department. The most common diagnosis (34 percent) was
sprains and strains. 11 percent were punctures or lacerations,
and eight percent were contusions or abrasions. The most common events that gave rise to the
injuries included overexertion and bodily reaction (36 percent); harmful exposures (19
percent); violence (16 percent); contact with objects and equipment (11 percent), and falls,
slips, and trips (8 percent). Believe it or not, injury prevention begins
with physical fitness as physically fit workers are less likely to sustain injury than those
who are not physically fit. Given a high incidence of sprains, strains,
and overexertion injuries, utilizing proper lifting and moving techniques, along with
assistive equipment and technology is also critical for EMS providers. As previously discussed in another module,
a NHTSA study of data from 1992 through 2011 found that ambulances are involved in approximately
4,500 crashes per year within the United States; 34 percent of which resulted in injuries with
33 people killed each year. Data also shows a significant increase in
the risk of injury or death to EMS providers who are not wearing seatbelts. Therefore, another simple and easy injury
prevention activity is to ensure EMS providers are wearing seatbelts in the ambulance at
all times, even in the patient compartment. Maintaining a safe workplace free from hazards
is important, especially within the context of slips, trips, and falls. Slippery surfaces should be addressed as quickly
as possible. When out in the field, EMS providers should
be wearing proper footwear that provides good traction and reduces slipping. According to a 2014 NFPA report, approximately
four to five firefighters are killed each year due to being struck by motor vehicles. When working on an accident scene, use equipment
and apparatus to create a safe zone in which to work and also ensure you are wearing high-visibility
apparel so other drivers can see you. Be aware of your surroundings and try to avoid
tunnel vision. If possible or necessary, have a safety officer
on scene who is not involved in patient care and can monitor the scene to specifically
identify safety hazards or concerns. Violence is also becoming an increasing concern
for EMS providers. In a 2016 study published in the American
Journal of Industrial Medicine, it was noted that healthcare workers are exposed to the
highest rate of workplace violence compared to all other industries and EMS workers were
more likely to be assaulted by patients than firefighters. In 2012, it was determined by the CDC that
approximately 2,400 EMS workers visited hospital emergency departments for treatment of work-related
violence injuries. Unfortunately, it is also suspected that instances
of violence against EMS providers are severely underreported. As a paramedic, it is important for you to
heed the “scene safety” mantra you learned as an EMT and constantly maintain situational
awareness while keeping an eye out for circumstances that could escalate into a violent encounter. If a scene is unsafe, do not proceed. Wait for law enforcement or other assistance. In other cases, it may be prudent to consider
physical or chemical restraint of the patient as permitted by your protocols if the patient
presents a risk of harm to himself, herself, you, or others. If an initially safe scene deteriorates to
one in which your safety is threatened, retreat from the area to a safe space and call for
assistance (if it is not already there or on its way). There are even courses on self defense for
EMS providers and firefighters (one of which is available online through the Firefighters
Support Foundation and Fire Engineering). Ultimately, your own physical safety, health,
and wellbeing begins with you. Maintain your physical fitness, eat healthy,
get plenty of sleep, and take steps to ward off diseases and prevent injuries. Following these guidelines can definitely
have a significant, long-term, positive impact on your overall health, personal life expectancy,
and longevity within the profession. As if that was not enough to think about,
we must also remember the other critical component of overall EMS provider wellbeing, psychological
health. To put this need into perspective, we know
that firefighting and EMS can be inherently risky and dangerous professions. In 2017, however, the number one cause of
emergency responder deaths was not one of the other causes that we discussed previously,
like a heart attack, a motor vehicle collision, or cancer. Rather, as identified by a Ruderman Family
Foundation report, at least 103 firefighters and 140 police officers committed suicide. (By comparison, 93 firefighters and 129 police
officers died in the line of duty that year.) This mental health study cited post-traumatic
stress and depression stemming from chronic exposure to psychological trauma as factors
that contributed to higher than usual suicide rates within the protective services professions. To go a step further, the Firefighter Behavioral
Health Alliance estimates that only 40 percent of firefighter suicides are actually reported,
which would mean this 2017 number would be closer to 257. That is almost three times the number of firefighters
who died in the line of duty due to other causes. Regardless of what the actual numbers are,
one suicide within the EMS profession is one too many. It is time for the profession to come to grips
with the psychological stressors associated with the job and develop mechanisms for helping
providers cope with post traumatic stress injuries and other psychological factors. Another area in which emergency responders
need help is in dealing with the vestiges of addiction. While the statistics may vary depending upon
the resource, the numbers are always jarring. The Cincinnati National Institute for Occupational
Safety and Health has reported that 29 percent of firefighter engage in alcohol abuse and
the U.S. Firefighters Association suspects that as many as 10 percent of all firefighters
may be struggling with drug addiction. EMS providers in particular are at significant
risk and the U.S. National Library of Medicine has reported that as many as 40 percent of
EMS providers engage in high-risk alcohol and drug use and more than 20 percent suffer
from post-traumatic stress disorder. The Addiction Center estimates that 30 percent
of all first responders develop behavioral health conditions during their time of service,
including depression, anxiety, and post-traumatic stress disorder. An underlying cultural stigma against seeking
help for psychological stressors is often recognized as part of the problem within the
profession. To go a step further, the Substance Abuse
and Mental Health Services Administration has reported that 36 percent of all EMS workers
suffer from depression, 72 percent suffer from sleep deprivation, and more than 20 percent
suffer from post-traumatic stress disorder; all of which puts them at increased risk for
substance abuse. Some very legal substances are also often
abused by emergency responders to help them cope with physical and psychological stressors
of their jobs. Sleeping aids, stimulants (such as caffeine),
and tobacco are just some examples. By now, we are all familiar with the risks
associated with tobacco use and many employers are taking active steps to encourage employees
to quit. Unfortunately, we are now seeing vaping filling
that particular void under the guise of being a healthier alternative to smoking. Emerging data, however, is starting to reveal
that many e-cigarettes contain more nicotine than traditional cigarettes, the long-term
effects of vaping is relatively unknown, and second-hand vapor may contain lead, other
heavy metals, and chemicals that have been linked to lung disease. Steering away from these legal substances
can be very important to supporting an emergency responder’s psychological and physical wellbeing. It probably goes without saying, but EMS is
a stressful profession. There are long shifts and odd hours, it can
be difficult to exercise enough or eat a proper and healthy diet, providers are constantly
having to respond at a moment’s notice to unknown scenarios that are often literally
matters of life and death, fiscal troubles can be common as first responders are often
not paid what they are worth, and mental illness is prevalent within the profession given the
other aspects we already discussed. Stress is a constant factor in the EMS provider’s
life that must be routinely and effectively mitigated, otherwise things can ultimately
spiral out of control for the provider. EMS providers and other emergency responders
must often develop a tough exterior and coping mechanisms to remain calm, focused, and in-control
when disaster and catastrophe strikes (which it does on a frequent basis). Some develop medalists syndrome, where they
feel as though no one understands what they are going through, others experience survivor’s
guilt where they struggle to understand how they have avoided some of the traumas and
tragedies they see others suffering from on a regular basis, and the list goes on. Sometimes the provider withdraws from others;
other times he or she may lash out. Regardless, this can have a significant impact
on interpersonal relationships for the EMS provider. An attempt to protect or shield loved ones
from the horrors he or she has seen can actually drive a wedge between the provider and a loved
one. Some of the other behaviors already discussed
can also take a toll on relationships. Ultimately, the culture within EMS must change
to recognize that it is not weakness to seek help. Rather, it is important for providers to recognize
when they are struggling and they should be encouraged to seek help. The International Association of Firefighters,
for example, has been working to remove the occupational stigma associated with psychological
challenges and have developed a behavioral health program that includes peer support,
an online behavioral health awareness course, and a physical in-patient residential behavioral
health treatment and recovery facility. Peer support networks have proven to be very
effective in helping mitigate psychological crisis for emergency providers. There are courses available (such as QPR training)
to help responders recognize the warning signs that someone may be considering suicide and
what to do to help that person. Many employers provide employee assistance
services that can also assist providers who are in crisis. Critical incident stress management teams
are also becoming more common to allow providers to talk about things they have seen on critical
incidents, normalize those experiences with other peers, and move forward without having
to bear the trauma and stress of the incident internally on their own. Some insurance plans will even cover costs
associated with counseling and therapy. We are also seeing some states now passing
laws that recognize post-traumatic stress injury as a compensable injury under the state’s
workers’ compensation system. Unfortunately, though, many of these efforts
and resources fail to capture or support volunteers who are exposed to the very same stressors
as paid EMS providers. As an individual EMS provider, it is important
for you to be ever mindful of your own psychological health and wellbeing. If you need assistance, reach out for it sooner
rather than later. It is not weakness to seek help when you need
it. Actually, the inverse is true in that it takes
a truly strong person to recognize when he or she is drowning emotionally, so to speak,
and seek out assistance. People enter the EMS profession to help others,
yet you cannot be fully effective in your job as a paramedic if you are not healthy
yourself, which includes both your physical health as well as your psychological and mental
wellbeing. It should be a goal of every EMS provider
to have a long, fruitful, productive, and enjoyable career. If the psychological stressors of the job
are such that you are struggling, it is important to seek help. Your health… your life, is important. Remember that, and never hesitate to not only
help others, but be sure to seek help yourself when needed. Again, to be able to effectively help others,
you must be healthy yourself. Hopefully, this module helped reiterate the
importance of taking care of yourself both physically as well as emotionally, and provided
you with some tips and resources to assist you in the pursuit of maintaining your personal
health and wellbeing. Given your completion of this module, you
should now be able to discuss wellness principles that can be employed by the paramedic to enhance
his or her personal physical and mental wellbeing. This presentation was prepared by Waukesha
County Technical College in Pewaukee, Wisconsin and is distributed with an attribution, non-commercial,
share alike 4.0 international Creative Commons license. Copyright 2019, Waukesha County Technical
College. For information on WCTC’s numerous fire
and EMS educational offerings, please visit us online at

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