Allostatic Load is the Quiet Hazard in Fire/EMS

The most prevalent hazard I experienced in my former position as a professional firefighter/paramedic was prolonged exposure to high call volumes working in a dual-response system. During a shift (24hrs - 38hrs), firefighter/paramedics could respond continuously to medical emergencies, fires, vehicle accidents, overdoses, traumatic injuries, and other high-stress situations. Although each individual emergency presented its own hazards, I believe the cumulative exposure created one of the greatest risks to employee health and safety. 

Repeated emergency responses can expose responders to physical fatigue, interrupted sleep, psychological stress, infectious diseases, hazardous environments, and traumatic events. When Call volume remains high for an extended period, there may be very little opportunity for personnel to physically or mentally recover between incidents. Fatigue can also affect concentration, reaction time, communication, and decision-making, potentially increasing the likelihood of injuries or errors. 

The primary hazard control used to address this type of risk would be considered an administrative control. Examples include adequate staffing, rotating personnel between high-demand assignments, providing rehabilitation after major incidents, allowing sufficient recovery periods, and distributing emergency calls among available crews. Employee assistant programs, peer-support programs; and mental health resources can also help address the cumulative psychological effects of emergency response.

In my experience, some of these controls existed, but high call volumes could make them difficult to consistently apply. An administrative action that was meant to alleviate one issue created another. A seniority rule was put in place to shield senior members from working in the dual EMS/Fire role. While this reduced exposure for senior personnel, it placed additional strain on junior members who often had little relief from the workload. From a safety-management perspective, recognizing cumulative workload and exposure as an occupational hazard is important because protecting first responders involves more than protecting them during a single emergency. It also requires managing how often, how long, and under what conditions employees are exposed to those hazards over the course of their careers. 

Hierarchy of Controls

The primary control used to reduce the risks associated with high call volume and prolonged exposure in the fire and EMS service is an administrative control. Administrative controls are policies, procedures, staffing practices, scheduling methods, and work rules designed to reduce how often or how long an employee is exposed to a hazard. 

In a FIre/EMS setting, administrative controls can include maintaining adequate staffing, rotating personnel between high-demand assignments, using additional units to distribute call volume, requiring rehabilitation after physically demanding incidents, allowing recovery time between calls when possible, and providing access to peer support or mental health resources following traumatic events. These controls do not remove the hazard itself, but they can reduce the amount and duration of exposure experienced by individual employees. 

Administrative controls are located below elimination, substitution, and engineering controls within the hierarchy of controls. Elimination is considered the most effective because it removes the hazard completely, while substitution replaces the hazard with something less dangerous. Engineering controls physically separate the employee from the hazard. In emergency response work, however, many hazards cannot realistically be eliminated or substituted because responding to emergencies is the essential function of the job. A fire/medic cannot eliminate exposure to medical emergencies, structure fires, traumatic injuries, or other critical incidents while still performing the required duties.

Because of this, administrative controls become especially important. For example, increasing staffing or rotating crews can reduce the number of consecutive emergency calls handled by one crew. Formal rehab procedures can help ensure that firefighters are medically evaluated, hydrated, cooled or warmed as necessary, and given time to recover after strenuous operations. Limiting excessive overtime and monitoring fatigue can also reduce the risk of errors, injuries, and impaired decision-making. 

Although administrative controls are not as effective as eliminating a hazard, they can significantly reduce risk when they are properly designed and consistently enforced. In a high-call-volume fire and EMS system, effective administrative controls can reduce cumulative physical and psychological exposure and help prevent fatigue, burnout, injury, and mistakes during emergency operations. 

Effectiveness and Additional Control

The administrative controls used to address high call volumes and prolonged exposure were only partially successful at reducing risk. Policies related to staffing, rehabilitation, crew rotation, and recovery periods can be effective when they are consistently applied. However, in a busy fire and EMS system, Operational demands can limit how effective those controls are. When call volume remains high and staffing is limited, crews may be sent from one emergency directly to another with little time to recover physically or mentally. In those situations. The control may exist, but the conditions of the job can prevent it from fully reducing the risk.

One additional control I would recommend is a formal fatigue-management and crew-rotation policy. This would also fall under administrative controls. The policy could track factors such as the number of consecutive calls, hours worked, missed rest periods, and exposure to especially demanding incidents. Once certain limits are reached, a crew could be rotated to a lower-demand assignment or temporarily taken out of service for rehabilitation and recovery. 

This would not eliminate the hazards associated with emergency response. But it could reduce cumulative fatigue and prolonged exposure. It could also help decrease the risk of impaired judgment, slower reaction time, communication errors, and injuries. In a profession where many hazards cannot be eliminated, managing the amount of exposure an employee experiences is an important way to improve overall safety.