Faced with a rising on-the-job injury rate and workers’ compensation claims, Scott Strufe, program manager at Nash County EMS in North Carolina, decided to get serious about improving the physical fitness of his 78 full-time and 30 part-time paramedics and EMTs. “You look at the physical state of the staff and you realize the culture and the environment—the nature of being on shift—is not conducive to healthy habits, conditioning and wellness,” he says.
Five years ago, Strufe began beefing up his agency’s fitness program. He already had weights and a treadmill or elliptical trainer in each of his 10 stations; to make sure the equipment actually got used, his department required employees to exercise three days a week for 30 minutes at the start of a shift. He and his staff rewrote their standard operating guidelines to allow responders to come to work wearing department-issued shorts and T-shirts for workouts, and to slip on jumpsuits—previously permitted only during night runs—over their workout gear if they had to respond to a call mid-workout.
Last year, they also hired a fitness consultant—Bryan Fass, a paramedic and athletic trainer—who recommended adding resistance bands and foam rollers to increase core strength (strength in the muscles of the torso) and flexibility. With Fass’ help, Nash County EMS trainers also assessed each medic and EMT to create individual fitness plans, and they went over proper lifting technique and how to safely maneuver patients in cramped spaces such as bathrooms.
“Up until we hired Bryan, it was a cookie-cutter workout: Do 15 minutes on the treadmill, 10 minutes of weights, then push-ups and sit-ups,” Strufe says. “But doing the same thing over and over again had become too much of a routine. Now we have what the staff really wanted, which is individualized workouts to address specific weaknesses.”
Providing support and resources for EMS workers to maintain their physical fitness while on the job (and on the clock) has paid off for Nash County. In 2006, they had about $200,000 in workers’ comp claims. That fell to $50,000 in 2011, a rate that seems to be holding steady. “The frequency of injuries hasn’t changed, but they tend to be less severe,” Strufe says. “There are far fewer days out of work, fewer specialty physician visits, fewer surgeries and less physical therapy.”
Questions of ethics and legality
Given the physical demands of the job of an EMT or paramedic, there seems to be little question that EMS agencies are better off having physically fit workers than those who are out of shape. Yet experts say fitness in EMS is actually a thorny issue that raises a host of legal and practical questions. For instance, should responders have to maintain a minimum fitness level? What should be done if someone isn’t meeting those requirements? And what physical abilities should be tested for in the first place? For example, lifting ability seems an obvious skill that EMS workers need to have. But what about flexibility or cardiovascular fitness? Should there be weigh-ins for overweight and obese employees?
There are no easy answers, says Glenn Jones, physical fitness coordinator for the Charlotte-Mecklenburg Police Department and the Charlotte Fire Department in North Carolina. Police and fire have been grappling with the issue of physical fitness among their workforce for years, prompting those departments to implement minimum fitness standards for police and firefighters.
“It sounds great: If they can’t do the job, get rid of them,” Jones says. “But we ended up spending 90 percent of our efforts trying to get a small percentage of the population to meet the minimum standard.”
There were also legal issues, including that it was nearly impossible to fire someone who failed the fitness test but was otherwise a good employee—and questionable whether that’s the right thing to do anyway, he says. One of their best homicide detectives, for example, was never able to pass the fitness test. “If we took that to a civil service board, they would never fire him,” Jones says. “And does firing somebody who is very good at their job in other ways solve your problem? I don’t think so.”
Jones admits he didn’t always have this point of view. “When I was younger, my attitude was, If they can’t do the job, get rid of them. It seemed very black and white,” he says. “But as you’re around it longer, you realize there will always be some people who slip through the cracks and who won’t be in as good of shape as you hope they’d be. Your efforts are better spent trying to keep everyone else from slipping down.”
According to Charlotte Fire Department’s policy, firefighters who can’t pass the minimum fitness standards test could be put on light duty or even potentially lose their job, but Jones says the test is relatively easy and he doesn’t expect that to ever become an issue. To pass the test, firefighters have to do various exercises while carrying a hose pack (100 feet of 1.75-inch hose) and drag a 165-pound dummy 25 feet in eight minutes, 40 seconds or less.
Police officers have a different test, which includes two repetitions of running 200 yards, doing 15 push-ups and 15 sit-ups, and stepping onto and down from an 8-inch step 20 times in six minutes, 18 seconds or less. Officers who can’t make the time are given remedial counseling, but there are no penalties for those who don’t improve, he says.
Cures for an epidemic?
One thing that’s sure: Injuries in EMS are all too common. A 2002 study found that 27 percent of paramedics and 16 percent of EMTs responding to the Longitudinal Emergency Medical Technician Attribute and Demographic Study had experienced a “back problem.” And in 2005, a groundbreaking study in Prehospital Emergency Care led by Brian Maguire, a clinical associate professor of emergency health studies at the University of Maryland, Baltimore County, reviewed four years of injury records on EMS providers at two urban agencies and compared them to U.S. Department of Labor injury statistics for other industries. Their research found that the occupational injury rate was higher for EMS workers than any other U.S. industry. The back was the most common site of injury; “sprains, strains, and tears” was the most common type of injury; and the most common cause of injury was lifting. Of the 489 injuries, 277 (57 percent) resulted in lost workdays.
“The injury rates in EMS are reaching near catastrophic levels, and one of the only ways to combat that high injury rate is to have a fit workforce,” says Fass, who writes a blog on EMS and fitness issues, Fit Responder.
To avoid hiring EMTs or paramedics who are either unable to do the job or prone to injuries, some EMS agencies screen job applicants with physical ability tests. Huntsville Emergency Medical Services Inc., a nonprofit that serves Alabama’s Huntsville and Madison Counties, is one of those agencies.
After hiring a few responders whose physical capabilities were problematic, the agency developed a pre-employment fitness test in which job applicants had to carry a weighted stretcher up a short flight of stairs and crawl through a window, among other tasks. “We had a physical test we created on our own, without much science behind it,” says Huntsville CEO Jon Howell. “It was basically, We think this is what our folks should be able to do. But we weren’t confident that if it was challenged, it would hold up in the realm of public scrutiny.”
So Huntsville EMS, along with five other EMS agencies (LifeNet EMS in Texarkana, Texas; LifeStar Response in Halethorpe, Md.; MedStar in Fort Worth, Texas; SeniorCare EMS in Bronx, N.Y.; and City of Hudson EMS in Hudson, Ohio) each provided funding to Avesta Systems Inc., a Hudson, Ohio-based consulting and EMS recruiting firm, to develop a “validated test.”
“We were approached by clients who said, ‘We’ve looked at a lot of tests out there, but we can’t seem to find any that have actually gone through a validation process, or that were developed through the use of data to prove and predict that the candidate is likely to perform on the job,’” says Greg Lawton, Avesta’s president.
The test, which was released in September 2012, was developed using data on responses from the six EMS agencies and by having organizational psychologists interview and observe responders at work. Other EMS agencies can license the test for use for three years; it costs $12,000 for those with fewer than 500 people and includes training staff to administer it and evaluate the results.
It takes about 11 to 13 minutes for a job candidate to get through a series of exercises to measure strength, muscular flexibility and stamina. Specific abilities tested include dragging a 150-pound mannequin, carrying a weighted stretcher up and down stairs and loading it into an ambulance, and performing good-quality CPR compressions for three minutes uninterrupted.
Huntsville’s Howell says it’s not all that different from the test they used to do, but that it brings an added benefit: consistency. “The new test has very similar components to the old test, but I believe the new test is better structured and designed so we can more consistently administer it,” he says. “It has very clear stations they go through to demonstrate their physical abilities, and it’s pass/fail, so either you can do it or you can’t. There is no grading that could be subjective.”
A “validated test” such as the one offered by Avesta may appeal to human resources or legal departments, which may be concerned that the test could be challenged in court by someone not hired, or that someone could be injured while taking the test and open the agency to liability, says Strufe. In Nash County, he uses a pre-employment screening known as the Medical Physical Ability Test, which was developed by Charlotte-Mecklenburg County EMS and includes 10 timed skills done one after another, such as lifting an 85-pound curl bar while walking backward, pushing or pulling a stretcher across a carpet and dragging a 150-pound “patient.”
Before taking the test, applicants have to sign an injury waiver; have a physician attest that they are capable of performing the test; and sign a form that says they have read the instructions and understand what’s involved. EMS trainers also check applicants’ vital signs just before they take the test.
A goal, not a mandate
No matter how much pre- or post-employment testing or assessing you do, eliminating injuries in EMS likely isn’t possible, Strufe says, given the nature of the job. But that’s no reason to ignore it. In Nash County, EMTs and medics will have their fitness reassessed annually to track progress. As of now, there are no plans to penalize responders who don’t show improvement, although it will be noted on their job evaluations.
“It’s a fact of the world of EMS that there are going to be injuries, but we feel like we are starting to get a handle on reducing the severity of injuries by improving overall employee health and teaching or re-teaching some basic skills such as lifting; proper stance; how to plant your feet, brace the abs, keep your head up and lift with your legs—things we are not focused on during initial training,” he says.
Legal and human resources issues aside, Jones from Charlotte-Mecklenburg says tests that try to focus on specific, job-related tasks may not be necessary. Though the public perception is that police officers are often scaling fences and chasing down bad guys, or that firefighters are climbing down ladders with a fire victim over their shoulder, that doesn’t happen all that often, he says.
The fitness program he recommends for police and firefighters doesn’t look much different from what he’d recommend to any office worker. “It’s what I recommend to anybody: Maintain a healthy blood pressure. Keep your weight in a healthy range to avoid diabetes. Maintain cardiovascular fitness,” Jones says. “For the most part, the fitness programs I do with police and firefighters don’t look that much different than if I were designing programs in a corporate fitness field.”
