Article Text

Occupational injury among paramedics: a systematic review
  1. Jason Kearney1,
  2. Carlyn Muir1,
  3. Karen Smith2
  1. 1 Monash University Accident Research Centre, Monash University, Clayton, Victoria, Australia
  2. 2 Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
  1. Correspondence to Jason Kearney, Monash University Accident Research Centre, Monash University, Clayton, VIC 3800, Australia; jason.kearney{at}


Introduction Paramedics are frequently exposed to acute and/or chronic environmental, operational and patient-related factors that increase their risk of physical and psychological injury. However, there has been wide variation in reported paramedic injury rates. This systematic review aims to synthesise the evidence to examine the incidence and nature of occupational injury among paramedics.

Methods This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO 2020: CRD42020164556). A systematic search of four electronic databases was conducted for the years 2004–2019. Peer-reviewed studies examining the incidence and proportions of paramedic occupational injury within civilian emergency medical services (EMS) were included. Injury types, mechanisms, contributing factors and incidence of injury were synthesised narratively.

Results Twelve studies met the inclusion criteria. The incidence of injury ranged from 29.7 to 345.6 injuries per 1000 workers per year. Sprains and strains were the most reported injury types, and the trunk and upper limbs were the main sites. Body motion was the most frequently reported mechanism of injury, accounting for 35%–55% of all injuries. Female paramedics had a proportionally higher rate of injury compared with male paramedics. Paramedics aged 25–34 years accounted for the majority of fatal (mean 34.0%) and non-fatal (mean 51.7%) injuries.

Conclusion This review highlights the increased risk of occupational injury among paramedics and provides further insight into their overall injury profile.

  • occupational injury
  • prehospital
  • workplace
  • systematic review

Data availability statement

Data are available upon request.

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Paramedics (inclusive of ambulance officers, emergency medical responders, emergency medical technicians and paramedics) provide emergency medical assessment, treatment and care to patients in the prehospital setting.1–5 The nature of work within the emergency medical services (EMS) occurs in a dynamic and unpredictable environment which frequently exposes paramedics to a variety of acute and/or chronic risk factors for injury. These may include working in unfamiliar and uncontrolled environments; shift work; driving under lights and sirens conditions; the carrying of heavy equipment and transferring of patients; and the frequent exposure to trauma, violence, human suffering, death and dying.5 6 This exposure increases the risk of occupational physical and psychological injury above that of the general population.6 7 Paramedics injured at work often miss workdays, have higher rates of anxiety and depression and experience lower levels of career satisfaction.4 8 9 Paramedic perceptions of decreased workplace safety have been found to negatively impact the manner in which they are able to provide care to their patients and contribute to increased rates of absenteeism.10 This has a direct financial impact on ambulance services and more importantly, reduces the ability of ambulance services to respond to the emergency demands of the community.9 11

In Australia, the overall paramedic injury compensation claim rate for physical and psychological injuries combined, is more than 5 times greater than the general population and more than 1.5 times greater than police and firefighters.12 Similarly, in the USA, physical injury rates among paramedics are higher than private industry and similar to, or above, the injury rates found in police and firefighters.13 The focus of paramedic injury research is often on specific injury types (eg, musculoskeletal injuries) or specific situations (eg, occupational violence and aggression) rather than taking a holistic perspective on injury. In addition, rates and proportions of injury can vary dramatically between studies, even within similar populations, due to varying data sources and definitions of injury. This creates difficulty when attempting to understand the magnitude of the problem and the overall burden of injury. This review seeks to address this by broadly quantifying paramedic occupational injury and providing insight into the burden of injury through systematic review of the literature.

The aim of this review is to examine the incidence of occupational injury among paramedics. Specifically, this review aims to synthesise the incidence, commonly reported injury types and mechanisms and the factors that influence the risk of occupational injury among paramedics.


Protocol and registration

This systematic review was performed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.14 The protocol for this review was registered with PROSPERO prior to commencement of data extraction. PROSPERO registration number CRD42020164556. Submitted 12 February 2020, registered 28 April 2020.

Eligibility criteria

All studies were assessed for eligibility against predefined inclusion and exclusion criteria. These criteria are outlined in table 1. For the purpose of this review, the term paramedic was used to collectively describe ambulance officers, emergency medical responders, emergency medical technicians (EMTs) and paramedics due to the global variability in terminology. We defined injury as any physical or psychological injury excluding exposure to, or the acquirement of, acute and/or chronic diseases.

Table 1

Eligibility criteria

Information sources and search

A search of the literature was conducted on the 18 November 2019 using four electronic databases: MEDLINE (online supplemental material 1), Embase, CINAHL and PsycINFO. Each of the database searches were limited to articles published between 1 January 2004 and 18 November 2019.

Indexed terms and keywords were identified for three concepts, (1) an occupational-type concept (ambulance/paramedic/emergency medical technicians), (2) an injury-type concept (physical injury/psychological injury/fatality) and (3) a work-related concept (work/occupation/workplace). Terms within the three concepts were combined with the Boolean operator ‘OR’ and the final search conducted by combining the search results of the occupational type, injury-type and work-related concepts with the Boolean operator ‘AND’.

Additionally, we hand searched the reference lists of all included articles and related systematic reviews for studies that met the eligibility criteria for this review that were not found using the outlined search strategy.

Study selection

The results identified from each of the database searches were combined, and duplicate studies were removed. Title and abstracts were screened independently by one author (JK) and one researcher outside of the research team. Studies that were deemed to be potentially eligible for inclusion in this review progressed to full-text review. Full-text review was conducted by the same two independent researchers. Each of the full-text articles were reviewed against the inclusion and exclusion criteria to determine eligibility. Discrepancies that arose in both title and abstract and full-text screening were resolved in a consensus meeting adjudicated by an independent reviewer (CM).

Data collection process and data items

Data were systematically extracted by two independent researchers. The primary author (JK) extracted data from each of the included studies. In order to validate the accuracy of the primary author’s extraction, a second researcher extracted data from a random selection of six (50%) of the included studies. Discrepancies were resolved in a consensus meeting and adjudicated by a third independent researcher, if required (CM). If any data were missing, the primary author (JK) was to contact the corresponding author to gain additional results. The following data were extracted from each of the studies: author; year of publication; title; aims/objectives; study setting; study population; study design; data source; injury definition; injury type; type of claim or injury report; injury rate; demographics; and main study findings. Where studies did not report the incidence of injury, the injury rate was estimated by the authors using the information provided. Unless specified in the study, total hours worked were calculated by multiplying the overall workforce population by 2000 hours per year. The injury rate was calculated by multiplying the total number of incidents by 2 000 000 (equivalent to the hours worked by 1000 workers in a year) divided by the total worked hours, giving an estimated injury rate per 1000 full-time equivalent (FTE) workers per year. Cases of disease exposure were removed from the total number of incidents. The calculation used in this review to determine the injury rate has been previously applied to EMS populations, however, 2000 work hours per year may not be reflective of all ambulance services globally.1 3–5 7 15

Risk of bias in individual studies

Each of the included studies were assessed for methodological quality by the primary author (JK) using the Joanna Briggs Institute (JBI) Critical Appraisal Tool for Studies Reporting Prevalence Data.16 The studies were then independently reviewed by a second researcher outside of the research team and discussed to reach consensus. The JBI prevalence data appraisal tool assesses methodological quality using a nine-point questionnaire comprised of ‘yes/no/unclear/not applicable’ fields. ‘Unclear’ answers were treated the same as ‘no’ responses and ‘not applicable’ responses were removed from the overall appraisal score. The nine questions covered six main areas: (1) methods of population sampling; (2) description of the setting; (3) coverage of data analysis; (4) reliability of the methods used for identifying and measuring the condition; (5) appropriateness of statistical analysis; and (6) response rate. The studies were classified as being either of poor (≤3 ‘yes’ answers), fair (4–6 ‘yes’ answers) or good (7–9 ‘yes’ answers) methodological quality.

Summary measures

The primary outcome measure for incidence of injury was number of injuries per 1000 workers per year.

Synthesis of results

The findings of the included studies were synthesised qualitatively to identify the incidence of injury and the most prevalent injury types, mechanisms and influencing factors. In circumstances where different articles sampled the same study population across overlapping time periods, the study with the largest population was selected and used as the primary source of data for the narrative synthesis. The additional studies were included in the narrative synthesis if they presented unique findings or analysed different variables to the larger study. All statistical analyses were conducted using Stata V.15.0 (StataCorp).


Study selection

The search strategy initially identified 6008 citations (figure 1). An additional study was identified through the hand searching of reference lists. Following the removal of duplicates and title and abstract screening, 154 studies were identified as being potentially eligible for inclusion. Of these, a further 142 studies were excluded (online supplemental material 2). A total of 12 studies met the selection criteria and were included in this review.

Figure 1

Results of search strategy.

Study characteristics

Of the 12 included studies, 9 were conducted in the USA,2–5 13 17–20 2 in Australia1 12 and 1 in Poland21 (table 2). The year of publication ranged from 2005 to 2018. Eleven of the included studies were retrospective cohort studies1–3 5 12 13 17–21 and the remaining study was of a combined retrospective cohort and descriptive surveillance design.4

Table 2

Summary of included studies

The majority of studies obtained their data from national injury surveillance systems,3 13 17 18 20 one used data from a national compensation database,12 two used data from nationally regulated injury databases,1 2 three used organisational level injury data5 19 21 and one used self-reported data from participants treated in hospital emergency departments (EDs) and recruited via a national injury surveillance system4 (table 3). The cohort sizes ranged from 3001 to a weighted estimate of 99 400.20

Table 3

Injury definitions, data characteristics and injury rates of included studies

Ten studies specified the level of clinical practice of the study population. Six of these included both EMTs and paramedics1 2 12 17 20 22; two included medical first responders, EMTs and paramedics3 4; and of the remaining two, one only included EMTs18 and the other only paramedics.21

Eight of the included studies provided some information based on employment type of the study population. Four studies noted their included populations were comprised of both private industry and local government EMS agency workers.2 17 18 22 Two studies provided a proportional comparison of fatal injury data between private industry and local government EMS workers.17 22 No studies provided an estimate of total workforce size based municipal and private sectors.

Five studies reported the employment status of their included populations.3 4 18–20 Of these, three differentiated compensated employees (full-time or part-time) from voluntary workers when reporting population characteristics.4 18 20 One study reported an aggregate population comprised of compensated employees and volunteers,3 and the remaining study only included full-time EMS workers.19 Only one study provided estimates of the compensated and voluntary workforce sizes.4

Six studies included occupational diseases in addition to injuries.3–5 12 18 20 In each of these studies, the occupational disease data were able to be removed from the total figures and incidence rates and proportions re-calculated.

Risk of bias within studies

The quality of the included studies ranged from poor to good. Two studies achieved a high-quality rating of ‘good’,3 20 nine studies were rated as being of ‘fair’ methodological quality1 2 4 12 13 17–19 21 and the remaining study was rated as ‘poor’.5 The detailed methodological quality assessment for each of the included studies is shown in online supplemental material 3.

Incidence of injury

The mean incidence of generalised paramedic injury ranged from 29.7 to 345.6 injuries per 1000 FTE workers.1–5 12 17–22 There was variation in the incidence of injury when comparing organisational injury data sources to national injury surveillance and compensation data. The incidence of injury for studies using organisational occupational health and safety (OHS) injury data ranged from 115.8 to 345.6 injuries per 1000 FTE workers,5 19 and studies using data sourced from a compensation and national injury surveillance databases, reported incidences ranging from 29.7 to 141.7 per 1000 FTE workers.3 4 12 18 20 22

Injury type and sites

Types of injury

Musculoskeletal injuries were the most frequently reported of all injury classifications,2–5 12 18–20 of which, sprains and strains were the most commonly reported injury type with the proportion of injury ranging from 35.0% to 79.2% (mean 55.0%—excluding disease exposures).2–5 17–20

Surface wounds, contusions and abrasions were the second most commonly reported injury type, accounting for 11.9%—21.2% (mean 15.9%) of all injuries.2–5 17 20 Fractures were associated with just 2.1%—5.9% (mean 4.1%) of injury cases.1 4 17 19 Sharp injuries were reported and delineated from generalised disease exposure in three studies,5 20 21 and accounted for 2.1%5—37.3%21 of all injuries in these studies. Psychological injuries were only reported in two studies. The mean rate for psychological injury claims was 7.8/1000 covered workers.12 A total of 10.8% of all violence-related cases resulting in lost work days were due to psychological injury.1

Fatal injuries were reported in four studies.17 18 20 22 The fatality rate for EMTs working in a paid position was 6.3 per 100 000 FTE workers (95% CI: 4.0 to 8.7).

Site of injury

Four studies reported the specific location of injury with disease exposure data removed.1 2 12 13 17 19 The upper extremities and trunk were the two most commonly reported sites of injury. The proportion of trunk injuries ranged from 18.9% to 34.2% (mean 25.2%) and upper extremity injuries from 7.7% to 35.1% (mean 20.7%) of all injuries.1 2 17 19 Injuries attributed to violence affected the upper extremities in most cases.1 2 In six studies, multiple regions of the body were injured in a single event, with the proportion of injury ranging from 12.7% to 35.6% (mean 20.7%).1 2 17 19

Mechanism of injury

Body motion related injuries

Body motion was the main precipitating factor of injury in six of the studies.3–5 18–20 The proportion of injuries attributed to body motion ranged from 35% to 59% of all reported injuries. Most body motion related injuries were caused by repetition, poor posture, excessive physical effort or the lifting, moving or transferring of patients and equipment. Lifting related overexertion injuries resulting in lost workdays occurred at rates between 12.813 and 58.019 per 1000 FTE workers per year.

Loss of balance injuries

Loss of balance injuries were characterised as slips, trips or falls. This mechanism of injury was attributed to 10%—20% of all injuries in four studies.3 4 18 19 The rate of loss of balance injuries ranged from 5.213 to 15.44 per 1000 FTE workers per year.

Transport-related injuries

Transport-related incidents were identified as the primary cause of injury in 8%—12% of all reports.3 4 18 19 The rate of transportation-related injury resulting in lost workdays or ED presentation ranged from 2.6 to 24.0 per 1000 workers per year.4 13 17 19 Most injuries were evenly distributed between the front (46.0%) and rear (41.9%) compartments.4 Approximately half of incidents had compliance with seat belt use, with almost all occupants in the front compartment wearing a seat belt at the time of the incident.4 Transport-related incidents were the leading cause of death accounting for 77.8%18–87.7%20 of all workplace fatalities mostly due to collisions with other vehicles, mobile or stationary equipment or stationary objects.18 20 One study20 reported failure to yield to another vehicle, loss of traction on wet or icy roads and a lack of seat belt use as factors involved in fatal highway incidents.

Violence-related injuries

The proportion of injury resulting from a violence-related incident ranged from 3% to 9% of all injuries.3 4 19 The rate of violence-related injury resulting in lost workdays or serious injury ranged from 0.52 to 6.0 per 1000 FTE workers per year.1 2 13 19 The rate was higher (7.0 per 1000 FTE workers per year) for injuries that resulted in an ED presentation.4 Assault-related fatalities accounted for 8.5% of all paramedic fatalities.13 The patient was identified as the source of violence in 77%2–95.3%4 of cases. Most cases (55.8%) were reported as unintentional or of unknown intent, 31.9% of which, occurred while restraining or subduing a person and 26.4% while moving a person.2 Intentional injury by a person occurred in 35.0% of all violence-related cases, of which, 64.9% of these injuries were attributed to either hitting, kicking, beating or shoving.2

Contributing factors to injury


The rate of injury per 1000 workers ranged from 315.2 (277–354) for men to 382.7 (333–432) for women19 and for injuries resulting in claims, 129.2 for men to 214.2 for women (RR: 1.47; 1.41–1.52).12 Male paramedics accounted for the majority of fatalities (74.5%).18 Male paramedics were also non-fatally injured more than female paramedics in all but one of the included studies. In this study, 53% of transport-related injuries involved a female paramedic, despite comprising of 27% of the EMS workforce.17 A further three studies found female paramedics to be at disproportionately higher risk of injury based on workforce composition. In one study, female paramedics accounted for 43% of all injuries and yet comprised 30% of the total workforce.18 In two violence-related studies, female paramedics accounted for 39%–41% of violence-related injuries yet comprised 32%–33% of the total workforce.1 2

The greatest proportion of fatal (26.1%–39.0%; mean 34.0%)13 18 20 and non-fatal injuries (39.4%–64.0%; mean 51.7%)3 18 occurred in those aged 25–34 years. The rate of non-fatal injury in this age group ranged from 155.612–388.619 per 1000 workers for all injuries. The highest rate of non-fatal injury claim was in paramedics aged 45–54 years.12 Workers aged 40 years and older had the highest rate of body motion related injury treated in a hospital ED.4 The rate of fatality was highest in those aged ≥45 years.20

Worker characteristics

Three studies identified specific worker characteristics that may contribute to risk of injury.2 4 17 Only two studies reported the proportion of injury based on level of experience.4 17 One study found most (52.0%) transport-related injuries occurred among paramedics with 1–5 years of experience.17 The remaining study4 found no significant variation in the proportion of body motion injuries among paramedics of varying levels of experience.4 In the single study to compare the population level of clinical practice, EMTs accounted for a greater proportion (55%) of injuries related to body motion compared with paramedics (27%).4

Employment and shift characteristics

EMS personnel employed in the private sector accounted for a greater proportion of fatal injuries compared with their counterparts employed by local governments. In one study, private sector EMS personnel accounted for two-thirds of all fatalities.22 For transport-related fatalities specifically, 57% of fatally injured workers were employed in the private industry and 40% by local governments.17 The majority (60%) of violence-related injuries involved private sector EMS workers.2 In comparison to voluntary workers, compensated EMS personnel accounted for most of the reported workplace fatalities (66%–86%).18 20

Two studies reported the specific time of injury separately from disease exposure.2 17 In these studies, most assaults (50.0%) occurred between 16:00 and 00:00 hours2 and most transport-related injuries (24.0%) between 16:01 and 21:00 hours.17 The greatest proportion of transport-related injuries occurred 8–10 hours (18.6%) after the commencement of the shift and on either a Monday (19.0%) or a Thursday (19.0%).17


This systematic review sought to describe the incidence, characteristics and contributing factors of occupational injury among paramedics working within EMS. Through the qualitative synthesis of data from three different countries, this review has provided further insight into the extent of the occupational injury problem in this cohort.

Incidence of occupational injury among paramedics

In Australia, the average occupational injury rate of the entire working population is 43.3 injuries per 1000 workers, and in the USA, this rate is 29.0 injuries per 1000 workers.23 24 The incidence of paramedic injury in this review ranged from 29.7 to 345.6 injuries per 1000 FTE workers. There was considerable variation in the reported incidence of injury based on data source classification. Data collected directly from EMS organisations typically reported higher worker injury rates than data sourced from national injury surveillance systems and compensation databases.

The variation between these two groups is a likely reflection of the inclusion criteria and definitions of injury used by these sources. While hospital injury records, nationally mandated injury report data and compensation claim data provide pertinent information, the cases that meet the threshold for inclusion in these data sources typically represent injuries of a more serious nature and therefore, are likely not to be a true representation of the full injury spectrum and the overall extent of the problem. Organisational OHS data has the advantage of capturing more cases spanning the entire spectrum of injury due to less restrictive case inclusion criteria and broader definitions of injury. However, these systems also have limitations. Under-reporting is often an issue in these systems, particularly when the processes involved in injury and near-miss reporting are time consuming or where there is fear of disciplinary action and unfavourable reactions from management and colleagues.25 The variation in incidence between data sources observed in this review, also highlights that direct comparison between rates of injury may not be appropriate where there is variability in injury definition.

Injury type and mechanism

In this review, work-related musculoskeletal disorders manifesting as sprains and strains were the most frequently reported injury type, predominantly affecting the upper limbs and the trunk. This finding is consistent with the injury profile seen in other emergency service workers, such as police and firefighters.3 12 26–28 Paramedics, like other emergency service workers, encounter unique physical challenges associated with their work that often require moments of dynamic, and physically strenuous activity in high stress and uncontrolled environments. These periods of high physical activity are often followed by prolonged sedentary periods.29 Given this, it is unsurprising that the primary precipitating event to musculoskeletal injury in this review was body motion.

This review also highlighted the significant impact of transport-related incidents on paramedic health. Four studies identified fatigue as a possible contributor to fatal and non-fatal transport-related injuries.4 5 17 20 Fatigue diminishes the ability of paramedics to focus on complex tasks such driving under lights and sirens conditions.30 Impaired focus increases the risk of error while driving, ultimately increasing the risk of crash and serious injury.31 Paramedics are not only at risk of vehicle-related injury due to crashes. Injuries were also reported when caring for a patient in the rear compartment of an ambulance32 due to loss of balance, cabin designs that are not conducive to ergonomic practice and poor rear-compartment seat belt compliance.4 33 Further research is required to explore paramedic transport-related safety culture, fatigue management and the efficacy of paramedic driver training programmes to better understand and manage fleet safety among paramedics.

Although occupational violence emerged as one of the least common mechanisms of paramedic injury, the rate of violence-related injury resulting in lost work days or serious injury was more than 2.5–28.5 times greater than all other occupations in the USA.34 The significant variation in injury rate may be attributed to differences between the typically more comprehensive organisational OHS data versus national data, geographical variation, community perceptions of ambulance, under-reporting and organisational incident reporting culture.11 35

In this review, the patient was identified as the source of violence in the majority of cases irrespective of intent. This finding is consistent with those of a recent systematic review examining violence exposure against paramedics.11 The routine exposure to violence, whether intentional or not, perpetuates a common perception among many paramedics that violence is a part of their job.35 36 This perception is problematic, as it limits progress in mitigating violence against paramedics. With the physical and psychological consequences of violence and aggression exposure being so great,9 35 36 further research is required to systematically examine occupational violence and aggression among paramedics in order to understand the nature and drivers of this problem.

Factors contributing to injury

In this review, just one study provided a comparison of injury proportions based on the level of clinical practice and training. Given that most of the studies included in this review were conducted in the USA, where municipalities tend to have a defined, but segmented training class structure among their EMS personnel,37 pertinent factors that may influence the occurrence of paramedic injury may have been inadvertently overlooked. There is a need for future studies to consider the influence of often under-represented population characteristics and their influence on the EMS personnel injury profile such as practitioner role, practitioner level of training, employment type, public or private sector work and years of experience.38 39

This review has highlighted a possible increase in injury risk among female paramedics irrespective of mechanism. Although, these findings reflect those reported in other violence-related EMS studies,36 40 the causative factors are still unclear and further exploration in future studies is needed, particularly as female paramedic numbers continue to increase.

The greatest proportion of injuries occurred to those aged 25–34 years. As 9 of the 12 included studies were set in the USA, this finding is possibly a reflection of the demographic composition of US EMS workforces rather than an increased risk of injury among younger paramedics. In the USA, the median age of paramedics is 33.0 years with the majority of the workforce (56%) being comprised of paramedics aged 34 years or less.24 This is in contrast to EMS organisations in Australia, where 64% of paramedics are aged 35 years or older41 and account for the majority of injuries.12 This variation may not only be attributed to differences in workforce demographical composition but rather, the complexity of paramedic injury risk and the multitude of different factors that may influence that risk. Such factors may include, level of experience, training (eg, de-escalation techniques and identifying behaviours of concern), organisational support and safety culture.


This review has a number of limitations. First, this review is limited by the data sources of the included studies. Only three studies used data collected directly from EMS organisations, while the remaining studies used data from national sources based on compensation claims, serious reportable injuries, lost work time or hospital-treated injuries. These sources typically only include injuries that represent the most serious cases on the injury spectrum, therefore the incidence and proportions presented in this review may not reflect the true burden of the problem. Second, 9 of the 12 included studies were set in the USA which may limit the global generalisability of injury proportions and rates presented in this review. Third, the exclusion of studies reporting psychological injuries that were not based on worker compensation, hospital or organisational OHS data is likely to have greatly under-represented the magnitude and impact of psychological injury among paramedics. Finally, a primary focus of this review was to examine the incidence of occupational injury among paramedics, we excluded studies that did not report the overall workforce size or injury rate based on FTE workload. This is likely to have diminished the size of the proportional data. In addition, it should be noted that paramedics often work more than 40 hours a week due to incidental overtime and long shift duration, therefore calculating incidence of injury based on 2000 work hours per year may not accurately reflect the workload of all paramedic populations.

Conclusions and further research

This is the first systematic review to examine the incidence, types and contributing factors of occupational injury among paramedics working within EMS. The findings of this review highlight the inherent risks to personal safety that paramedics encounter when at work.

There is a need for future studies to explore injury among paramedics using organisational level data. Exploration of this data will allow for greater capture of injury cases encompassing a larger proportion of the injury spectrum rather than a reliance of serious injury cases and claim data. It is also important to triangulate with data captured directly from paramedics, to get a true understanding of under-reporting. This will assist in providing more accurate representations of the incidence and prevalence of paramedic injury. The exploration of EMS organisational level data can also provide greater context to injury cases by allowing for the concurrent examination of specific organisational information. Such information includes, workforce demographics, shift characteristics, organisational safety culture and evaluation of the efficacy of current training programmes for high-risk skills, such as emergency driving, manual handling and violence-avoidance. This information may contribute to a better understanding of the underlying drivers to paramedic injury and help to inform meaningful injury prevention and risk mitigation strategies and initiatives at the organisational, regulatory and parliamentary levels.

What is already known on the subject

  • Paramedics are at an increased risk of occupational injury.

  • Due to the significant variation in reported injury rates in the literature, it is difficult to accurately quantify the overall size and burden of the problem.

What this study adds

  • Most reported injury rates and proportions are sourced from national injury surveillance and compensation databases rather than from emergency medical services (EMS) organisations.

  • The incidence of paramedic injury using EMS organisational injury data is significantly higher than those reported by studies using national injury surveillance data.

Data availability statement

Data are available upon request.

Ethics statements

Patient consent for publication

Ethics approval

This study does not involve human participants.


The authors thank Sarah Petering for her assistance with the quality assessment of the included studies, and David Christiansz and Nelfio Di Marco for their contribution to study selection and data extraction. The authors also wish to thank Associate Professor Lyndal Bugeja for providing feedback on the draft version of this manuscript.


Supplementary materials


  • Contributors All authors were involved in the planning of the study. JK conducted the search and CM reviewed it. Data extraction was initially performed by JK and discussed with CM in order to reach consensus. The quality of each study was assessed by JK. The qualitative data synthesis was completed by JK and discussed and validated by CM and KS. JK drafted the manuscript, and all authors contributed to its revisions. JK is the guarantor of this review.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.