Paid and Volunteer EMS Services: How Do Their Resources Differ?

by Rebecca Heick, PhD

There was always that moment, right before the tones dropped on the pager, that the “air” around it seemed to open up – rousing my mind even if my body still seemed to be sleeping. I never knew what the next minute would hold or what I might be called to do.  What I did know was that whatever the call, whatever the weather, whatever else I might have been doing, I would go.  I was a volunteer, a key piece of the EMS puzzle in my community.  An important link in the chain of survival for neighbors, friends, and even family.  There were nights when it seemed that I would never get to sleep, the pager a constant interruption too much needed rest – and the reason I was dragging when it was time to head to work in the morning.  Other times, our service might go a week without a single call.  The years I spent as an EMS provider (both volunteer and paid) helped to shape me in so many ways – and ignited a passion for ensuring that all EMS providers were as safe and healthy as possible.

Rebecca Heick,PhD
Rebecca Heick,PhD

EMS is considered to be the intersection of public safety, public health, and healthcare – a critical component of saving lives from injury and illness.  If EMS providers are being injured on the job, they aren’t available to respond when that call comes in to 911.  In the case of volunteer providers, if they are injured, not only are they unavailable to respond to calls for help in their communities, they are likely unable to report to their “day job” as well, impacting both the safety of their communities and their ability to put food on the family table.  In addition, workers’ compensation coverage varies greatly for volunteers in the US – potentially leaving them unable to work and with unpaid medical bills.  

The work of EMS volunteers is the same as that of paid providers, except that the call volume is normally far less, additional help is often further away, and most volunteers have a “day job” they have to go after the call ends.  The skills required, the training needed, the equipment used, and the hazards faced, physical, emotional, and psychological, are the same.  But what happens when those hazards result in an injury for an EMS provider?  What happens when they can’t be there to help the community?  In the fall of 2005, after nearly 10 years as a member of the EMS community, I decided it was time to learn more about the injury experiences of paid and volunteer EMS providers – and to look for ways to keep all of our providers healthy and on the job.

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In order to learn more about the injury experiences of my fellow EMS providers, I contacted the National Registry of Emergency Medical Technicians (NREMT) and requested their assistance in compiling a mailing list of 2100 EMS providers across the country, chosen randomly from the more than 200,000 individuals in their system.  On the heels of Hurricane Katrina, I sent out a survey to each person on the list, asking (among other things) about their service in EMS, the occurrence of physical injuries on the job, and their exposure to violence and aggression while working.  Even with the massive disruptions in the aftermath of Katrina, more than 700 providers returned their surveys (a 34% response rate), giving me great data to begin my exploration of these issues.

Paid providers made up nearly 80% of the respondents with volunteers making up the remaining 20%.  While more paid providers responded, there was still a good representation of volunteers in the sample, allowing me to compare their experiences.  

Nearly 30% of the respondents reported having had an injury on the job in the last 12 months and 64% of those reported more than one injury.  These injuries included motor vehicle crashes (MVCs), back injury, assaults, and slips/trips/falls.  

While paid providers were at greater risk for injury, the likelihood of injury increased with increasing number of calls responded to per week (more calls equal more exposure to hazards).  Survey respondents reported a total of 50 motor vehicle crashes in the prior 12 months, with the risk of being in a crash equal for paid and volunteer providers.  Fortunately, reports of injuries from MVCs were quite low in the respondent group (10%).  

The study also examined experiences with on-the-job physical and verbal assaults.  A total of 267 physical assaults were reported by respondents in the prior 12 months, with 26 (10%) resulting in injury.  While assaults were more frequently reported by paid providers, the likelihood of being injured was the same across paid and volunteer responders.  A majority of assaults against providers were perpetrated by the patient, most frequently a patient who was under the influence of drugs and/or alcohol.  In addition, more than 50% of respondents reported having been verbally assaulted while in the last 12 months, most more than once.  For those with experience in EMS (or other public safety fields), verbal assault is fairly common and may include threats or insults to your heritage, your family, and your intelligence (if you get my drift).  

So what did this study tell us?  

Injuries are fairly common in EMS – whether you are a paid provider or a volunteer, the more calls you go on, the more likely you are to be injured.  EMS providers are at risk of assault by the very nature of the work – up close and personal with individuals who may be intoxicated, hypoglycemic, mentally ill, or who may simply not like us!  

Why do these findings matter?  I think most of us understand why being safe on the job matters – whether we are talking about an EMS provider, a firefighter, or a police officer.  Each of us has the goal of returning home safe and well at the end of the shift and living to fight another day.  Knowing how and why we get hurt opens the door to developing strategies to prevent those injuries.  We know that paid and volunteer providers have a different occupational injury experience (in general, fewer injuries), but it is also important to understand how prevention strategies may need to be different as well.    

Consider for a moment the responses of two EMS crews – one paid, one volunteer.  It is 0200 hours on a cold, windy night and the tones drop for a serious motor vehicle crash on the highway.  The paid crew has been sleeping in quarters and needs only to pull on their boots and jackets and head out the door to the waiting ambulance.  The volunteer crew has been sleeping in their beds at their respective homes and will need to trade pajamas for clothes, grab the car keys, and head to the station to meet the rest of the team before responding – or perhaps they respond directly to the scene if it’s closer than the station.  The two crews are equal in their skills and knowledge and in the equipment they carry, but in what important ways might they differ – and how might that raise their risk of injury?

Picture in your mind the differences in how these crews are dressed:  A paid crew in uniform with pants, shirt, coat, and boots prescribed (and likely provided) by their agency and a volunteer crew in jeans, t-shirts, jackets, and tennis shoes (maybe they have department identified shirts or jackets if the budget exists or they could afford to buy it themselves).  How might these differences impact the safety of the crews?  Limited visibility alongside the road?  Greater risk of slips/trips/falls?  Increased chance of a blood or body fluid exposure?  Mandating uniform clothing would seem like the best option to protect these responders, but is that truly feasible?  Given the limited budgets of most of our volunteer services and the tight budgets in many families these days, requiring specific clothing or footwear, while potentially improving responder safety, may do nothing more than force a committed responder to stop volunteering because they simply can’t afford it.  If you had to choose between feeding your family this week or buying those new boots they EMS Headlines Photo.jpgsaid you had to have, which would you choose?  This is a concrete example of how prevention strategies need to be adaptable and sensitive to the needs of both populations of providers – those with employer-mandated standards and those that are doing their best with potentially limited personal or departmental resources. 

We know that these differences in paid and volunteer experiences very likely extend beyond physical injury risks – involving their mental health as well.  Do volunteers have the same access to mental health services as paid providers?  I honestly don’t know from a “data” perspective, but from personal experience, I can say no, they don’t.  What we do know is that protecting mental health is just as important as protecting physical health – and in many instances is a tougher job.

In some areas of the country, responders and leadership have come to the table and the conversation about helping our EMS providers be safe and stay well on the job, both physically and mentally, is well underway.  What seems to be missing from the conversation in many locations is an open, honest discussion of how our paid and volunteer services – and their resources – differ and how that impacts occupational injury prevention.  How can we adapt prevention strategies to help our responders achieve the greatest level of health and safety, whether they respond to 10 calls a month or 10 calls a year?  I encourage you to reach out to fellow providers and leadership – invite them to the table and begin the conversation.  Every day that passes without improved strategies to protect responders’ health and safety brings us one day closer to another tragic loss.

Heick, R.J., Young, T., and Peek-Asa, C. (2009). Occupational injuries among emergency medical services providers in the United States.  Journal of Occupational Environmental Health, 51(8), 963-968.

About the Author: Rebecca J. Heick earned her PhD in Public Health/Occupational Injury Epidemiology at the University of Iowa in 2006 and currently works as an Assistant Professor of Public Health at Massachusetts College of Pharmacy and Health Sciences University.  Dr. Heick has teaching and mentoring experience in both online and face-to-face settings, having spent four years as a faculty member in the Walden University PhD Public Health Program and has taught numerous face-to-face courses in the life sciences as well as pre-hospital emergency care.  Dr. Heick has worked as an occupational injury researcher, health educator, and pre-hospital care provider for more than 15 years.  She has first-hand experience in disaster preparedness and response through both paid and volunteer work with the American Red Cross and the local Medical Reserve Corps.  Dr. Heick is currently engaged in research to reduce motor vehicle crash injuries and fatalities in law enforcement officers and serves as chairperson of the Joint CDC/ARC Committee for Epidemiologic Surveillance during Disasters.  On a personal note, Dr. Heick is married to her high school sweetheart (a former paramedic and now police officer of 9 years) and mother to 7 year old twins (son and daughter).