A HAZMAT instructor (left) adjusts the respirator mask being used by one of two area emergency medical technician team members who are preparing to respond to a simulated rescue operation to a chemical spill. All first responders cleaning up the toxic conditions caused by Hurricanes Katrina and Rita have undergone similar training. © Win Henderson / FEMA, 2005 Baton Rouge LA.
THE SPANISH FLU pandemic of 1918-1919 infected one third of the world’s population and killed an astonishing 50 million people. Since this pandemic, the deadliest in recorded history, several other disease outbreaks have swept through the world, including Severe Acute Respiratory Syndrome (SARS) in 2003 and Ebola in 2014.
Among those who became ill or lost their lives during these more recent disease outbreaks were a disproportionate number of healthcare providers. For instance, 21 percent of SARS victims were healthcare workers, and some of them transmitted the disease to their family members (Smith et al. 2009). Moreover, during the SARS outbreak in Toronto, Canada, 436 (51 percent), of 850 paramedics involved were exposed to SARS and quarantined for 10 days at home or work. Sixty-two of them developed SARS-like illnesses, and four of them were hospitalized (Silverman, Simor, and Loutfy 2004). When it comes to Ebola, a recent report from the World Health Organization shows that healthcare workers are 21 to 32 times more likely to be infected with Ebola than people from the general population (WHO 2015). This report also shows that about two-thirds of infected healthcare workers died. These recent outbreaks of SARS and Ebola have brought renewed attention to a dilemma that medical professionals face: Should they respond to disease outbreaks if this means risking their own and their family’s health?
It is generally recognized that healthcare workers are willing to prioritize patient needs over their personal needs, interests, and safety, especially during disasters. When it comes to disease outbreaks, however, this isn’t always the case. In fact, research studies show that, except for radiation disasters, healthcare workers are the least willing to work during epidemics (Qureshi et al. 2005). Safety of family and self, uncertainty, and a lack of confidence in an employers’ response to a disease outbreak are all associated with unwillingness to report for duty during such events (Ives et al. 2009; Devnani 2012). Yet these factors are not well elucidated in the literature and they need further investigation (Devnani 2012).
Additionally, research studies that assess healthcare workers’ ability and willingness to report for duty during disasters and public health emergencies focus mainly on physicians, nurses and hospital administrators (Damery et al. 2010). Little research has been conducted on emergency medical service (EMS) providers, despite the fact they are an essential component of the larger healthcare system (Watt et al. 2010). In response to this need for further research, I decided to document and examine EMS providers’ views about working during disease outbreaks compared with during natural disasters, and to discuss the main factors that may influence their decision to keep working during such situations.
What is EMS?
EMS is a system that provides out-of-hospital care for patients with urgent needs. EMS personnel are trained to rescue medical and trauma patients, provide them with emergency care, and transport them to the appropriate care facilities. While there are different levels of certifications and licensing, emergency medical technicians (EMTs) and paramedics are the most common EMS providers, with paramedics being the ones with highest level of training and licensing (NREMT 2015). The organizational structure of EMS varies considerably across the country. Pre-hospital services can be based in a hospital, a fire department, an independent government agency, a nonprofit corporation (such as a Rescue Squad) or be provided for by commercial for-profit companies. (NREMT 2015; NHTSA 2014).
The EMS system is in many ways both similar to and different from the larger healthcare system. Compared with their counterparts in hospitals, EMS providers have a different level of education and training, they have a different work culture and structure, and they work in different and less controlled work environments. Also, since they work in the field, EMS providers are often the first point of contact a person has with the system during an emergency. Therefore, more research is needed that addresses EMS, particularly how its providers report to duty during outbreaks of infectious diseases.
Will EMS providers show up during disease outbreaks?
As I already noted, research studies focusing on EMS reporting for duty during disasters and public health emergencies are scarce. Smith, Burkle, and Archer (2011) assessed the risk perception among Australian paramedics toward different hazards. From the 40 most common disaster scenarios that the authors developed, they found that paramedics ranked nuclear and radiological events and outbreaks of new and highly contagious disease highest for fear and unfamiliarity. In another study, which assessed the willingness of EMS personnel to report for duty during disease outbreaks, Barnett et al. (2010) found that 93 percent of EMS personnel would be willing to report for duty if required. The willingness falls, however, to 48 percent if there is a possibility of disease transmission to a family member. A similar study by Mackler, Wilkerson, and Cinti (2007) found that 91 percent of the respondents would remain on duty if they had been vaccinated and ensured that they were protected from infection. This percentage, however, falls to 38 percent if their families have not received the vaccine, and to only 4 percent if neither vaccine nor protective gear are available.
These research studies underscore that the decision to report for duty during disease outbreaks is highly influenced by many factors, enough to cause EMS workers’ intention to come to work to plunge—from 91 percent to 4 percent. I was surprised that in-depth qualitative studies have not been conducted in the United States. In my research, I have applied a mixed qualitative and quantitative approach to more fully understand this issue. In the qualitative phase of the study, I performed 13 interviews with EMTs and paramedics in the state of Delaware to explore their insights and views about working during both natural disasters and disease outbreaks. I explored the factors that may influence their decision to work or not work during disease outbreaks. The findings of the face-to-face interviews were also used to develop a questionnaire to conduct the second phase of the study, which is in development as this article goes to press.
In this article I offer a preview of the perspectives that EMS providers shared when asked about how working during disease outbreaks compares with working during natural disasters. As was the case in prior studies of other healthcare providers, many factors influence EMS providers’ decisions. Family obligations, workplace culture and organization, training and skills, severity of the disease, and confidence in the employer’ capabilities to respond accurately to an event are the main factors that I discussed in the interviews. I chose to focus on the views of EMS providers about their confidence in their employer; to me these are the most significant and interesting factors. Work on other factors is ongoing and will be presented in future publications and my doctoral dissertation.
Responding to natural disasters vs. disease outbreaks: Is there a difference?
During disasters and public health emergencies, EMS providers are among the frontline first responders to step up and provide service. EMS providers receive intense training in responding to disasters using the Incident Command System (ICS).1 They are trained to provide emergency care, triage, and search-and-rescue operations depending on the type of the disaster. However, during disasters not everybody is able and willing to come to work and provide service. In case of natural disasters, Connor (2014) found that between 83 percent and 90 percent of healthcare providers are willing to respond. There may be some providers who are unable to come to work due to personal injuries or transportation problems caused by the disaster. These are considered barriers for ability, as opposed to barriers for willingness to report for duty.
Natural disasters: thrill seeking
When I asked participants to express their views about working during natural disasters compared with their day-to-day operations, different views and insights emerged. Some said that they have no problems with responding to natural disasters and that they are well trained to work in such situations. Some participants even considered responding to such disasters as the exciting part of their job.
“The huge disaster or terrorist threat that can happen, that is the exciting [part] of the job…it keeps me motivated because this is something that I [was] trained to do. This is ideally what I want to do.”
“Like adrenaline junkies…[EMTs) like the excitement… they want to be there, everybody wants to be there to get that thrill.”
“I think [responding to natural disasters] is little more interesting. It’s just a little bit different than what we do every day.”
Curiously, the respondents’ emphasis on excitement was not found in previous studies on healthcare providers. To understand this attitude, it is important to know the routine work of EMS providers. In day-to-day operations, the majority of the EMS calls are non-emergency, or non-life threatening calls, meaning that patients need minimal care and transport to the appropriate care facilities (Goldstein 2014). To some extent, this type of work is routine and boring to providers. EMS providers prefer to provide care for acute cases of sick and injured victims, which is the kind of work that they like and are trained to do. This may explain why participants described responding during and after natural disasters as the exciting part of their job.
Other participants didn’t share the same enthusiasm to respond during disasters. They voiced concerns about their safety and the safety of their families. It is the unknown-type situations and the lack of experience that concern providers. However, these concerns did not keep them from doing their jobs. This feedback is congruent with a previous study done on EMS in Australia. In this study, Smith et al. (2009) interviewed paramedics in Australia and found that even though paramedics were concerned about working during disasters, they were adamant about fulfilling their professional responsibilities.
A third group of my participants noted that EMS providers find themselves in unsafe situations virtually on a daily basis. For instance, an EMS provider could be dispatched to a routine call and ended up in an active shooting scene. As such they felt that there are no real differences between working in day-to-day operations and working during natural disasters.
“[Responding during] disaster isn’t any different than anything else. It is just the number of people you have in the bad day.”
Disease outbreaks: a little more concerning
When it comes to stress and concern while working during disease outbreaks, participants expressed two views. The first group was more concerned about working during disease outbreaks when compared with normal conditions or natural disasters. Participants who consider working during disease outbreaks as a concern, mentioned the following:
“[EMS providers] could potentially spread [disease] to innocents who are not involved in the situation…So there is some anxiety that comes with that.”
“Natural disasters…we can't really prevent them, you know, they just happen and you deal with it. Disease outbreak–I think a lot of people have a lot of fear, and it's a lot of uneducated fear, …people don't know about it as much, and the less educated they are, the more panicky.”
“With an outbreak, if you don’t completely understand what is causing it, how [a disease] is transferred, or what’s even going on, then that’s where the hesitation probably comes in with EMS people.”
“In disease outbreaks, I think a lot of us are worried about taking it back home to the families.”
Other participants did not see working during disease outbreaks as a concern. This group considered the risk of working during disease outbreaks the same as working in day-to-day operations as long as the EMS provider is aware of the risk and equipped with the appropriate protective gear.2
“It is no different dealing with just a sick person today than it is dealing with someone during disease outbreak.”
“I will not say people are still excited to come, but when it comes to something like that, I mean EMS providers, we are going to [listen to] the warnings, and prepare with any type of protective equipment, gear, we need to carry, and that is all that we need to do about it.”
“If I come across somebody [who exhibits] all the signs and symptoms of Ebola, I’m turning [this patient] over to somebody else to take care of that.”3
While participants expressed varying concerns about working during pandemic conditions, everyone from both groups felt willing and obligated to come to work despite the perceived high risk for some of them. Yet, they were not “excited” to report for duty. Rather, they used less energetic statements like:
“It is kind of your job to continue, even though there is an outbreak.”
“This is what I chose to do, knowing the risk associated with it.”
“I will not wake up in the morning excited to come to work.”
This view contradicts Smith et al. (2009), who found that paramedics were less willing to work in non-conventional disasters like pandemics, mainly due to the unpredictable and invisible nature of such outbreaks.
Nancy Writebol, the second American stricken with the Ebola virus, has arrived at Emory University Hospital in Atlanta for treatment. © Say Donaldson October 2014
Confidence in employer
EMS workers’ confidence in their employer to respond adequately to a disease outbreak and provide them with all the necessary information also seemed to have a significant effect on their decisions whether to come to work or not. Lack of such confidence was associated with less willingness to work during disasters (Trainor and Barsky 2011). Research shows that healthcare employers who adopt risk-mitigation strategies in the workplace increase their workers’ willingness to take some risk as part of their duty to work (Draper et al. 2008; Ives et al. 2009). Namely, healthcare workers might be “willing to take necessary risks, but not unnecessary risks” (Damery et al. 2010). Given that pandemics are associated with a high level of uncertainty in the early stages, employers need to communicate with emergency workers about the emergency plan in place: what is known, what is unknown, and what is expected of workers (Ives et al. 2009). Communication with workers and keeping them abreast of the available information about the evolving outbreak as it unfolds can potentiate workers’ trust in their employer. However, a study by the Australian Centre for Prehospital Research (2008) found that about two-thirds of the ambulance personnel reported low confidence in their employer. Additionally, Ives et al. (2009), who conducted focus group sessions with doctors and nurses, found that “lack of information was a key theme across all groups”. In the aforementioned study by Smith et al. (2009) paramedic participants reported a lack of confidence in their employer with regard to receiving accurate information about an emerging infectious disease. These participants believed that their employer may downplay the situation by providing inaccurate or incomplete information. Paramedics mentioned that “they would seek information from outside of the ambulance services before making their personal risk assessments.”
When I asked participants if they trust their employer to share accurate and the most up-to-date information about a disease outbreak, their views contradict with the above studies. Participants indicated that they do indeed trust their employers not to withhold anything that is pertinent to their work safety. They also believed that employers will share information promptly when they receive it, although a few had some reservations if employers would have access to the most accurate information.
“I think for the most part my employer has my best interest in mind. I think they will give me the best information they have. It is whether or not they've done enough to get the best information, and whether or not the information that has [been] related to them is the best information. But I don't believe they will withhold anything from me intentionally”.
Senior EMTs and paramedics who hold administrative roles that were interviewed confirmed that they always pass whatever information they have down to frontline workers immediately. They stated that hiding information would not do the employer nor the workers any good, given that the truth will come out through the media.
When I asked participants if they look for external resources of information to verify the information they obtain from their employers, all participants said yes. However, they explained that looking for external resources of information does not necessarily signal mistrust. Rather, they do so in order to obtain more information about the disease outbreak. Some of them said they believe it is their duty to learn more about a disease, since it enables them to be better prepared.
Emergency managers, public health officials, and EMS administrators are always concerned about how disease outbreaks can affect a community. EMS providers are among the first responders to step up and help in containing such outbreaks. In this article I discussed their views about working in such situations. Unlike findings of other studies from outside of the United States, I found that EMS providers in this country seem to be more than willing to report for duty when there is a disease outbreak, though they are much more excited to work during natural disasters. These views of EMS providers can put emergency managers, public health officials, and EMS administrators at ease. However, it is difficult to draw a conclusion about the real behavior of EMS providers during disease outbreaks using perception studies (Trainor and Barsky 2011). EMS providers in the state of Delaware, and generally in the United States, have not experienced real epidemics during their career. Although some of them witnessed the 2009 swine flu, this outbreak was not severe in terms of virulence and mortality rate, and in turn, it did not scare healthcare providers, particularly EMS personnel. Therefore, we cannot predict their behavior until such crisis occurs.
Given that EMS providers will look for external resources of information should a disease outbreak occur, it is better that employers provide the most up-to-date information to workers on the frontlines and educate them about reliable resources and where to find them. In other words, when employers disseminate information to the frontline workers, it is recommended that they point workers who like to get more information into the right direction in terms of reliable resources (such as the Centers for Disease Control and Prevention’s official website). By doing this they can strengthen the bonds of trust between employer and employee.
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ICS, the concept that currently prevails in the United States, is a standardized hierarchical approach to the command, control, and coordination of emergency response. ↩
It is important here to mention that during disease outbreaks, EMS agencies are supposed to activate their pandemic protocols, if they have them. This helps frontline workers obtain more resources, increases their awareness of the potential threat of infections, and in turn, helps them to be more protected. ↩
During Ebola outbreak, some EMS agencies had assigned specific units with extensive training and specialized resources to respond to potential cases of Ebola patients. ↩