Assessing unsafe behaviors and their relationship with work-related factors among EMS staff in Iran: a cross-sectional study.

BACKGROUND: Emergency Medical Services (EMS) staff often encounter various safety incidents. Work-related factors can lead to unsafe behaviors and safety incidents. This study assessed unsafe behaviors and their relationship with work-related factors among EMS staff. METHODS: This descriptive-correlational study used census sampling method to select 284 EMS staff in Ardabil Province, northwest of Iran, from April to June 2023. The data collection tools were demographic and occupational information form, Mearns Unsafe Behavior Scale, Cohen Perceived Stress Scale, Michielsen Fatigue Scale, and Patterson Teamwork Scale. The data were analyzed using the SPSSv-16, descriptive statistics, Pearson correlation, and multiple linear regression. RESULTS: The mean of unsafe behavior, fatigue, perceived stress, non-conflict of teamwork, and conflict of teamwork were 15.80 (± 4.77), 20.57 (± 6.20), 16.10 (± 6.13), 117.89 (± 17.24), and 40.60 (± 9.59), respectively. Multiple linear regression analysis showed that "partner trust and shared mental models (PTSMM)," "physical fatigue," "age," "type of shift," "employment status," and "overtime hours per month" were predictors of general unsafe behavior (P < 0.001) and "mild task conflict (MTC)," "employment status," "partner trust and shared mental models (PTSMM)" were predictors of unsafe behavior under incentives EMS staff (P < 0.001). CONCLUSION: The present study showed that some work-related factors were predictors of unsafe behaviors. The negative consequences of unsafe behaviors should be considered, and long-term planning should be done to reduce them. Developing specific guidelines for addressing unsafe behaviors, implementing measures to reduce fatigue, managing overtime hours in the workplace, and Establishing a system where novice staff work with experienced staff during their first year can be beneficial in reducing these behaviors among EMS staff.

An important issue of burnout among pre-hospital emergency medical personnel in Chengdu: a cross-sectional study.

OBJECTIVE: This survey aims to comprehensively understand occupational burnout among pre-hospital emergency medical personnel and explore associated risk factors. METHODS: A cross-sectional online survey using a census method was conducted between 15 July, 2023, and ends on 14 August, 2023, in Chengdu, SiChuan province, China. The questionnaire included general demographic information, the Maslach Burnout Inventory-General Survey (MBI-GS) with 15 items, and the Fatigue Scale-14 (FS-14) with 14 items. Univariate analysis was conducted on all variables, followed by multivariate logistic regression models to examine the associations between occupational burnout and the risk factors. RESULTS: A total of 2,299 participants,99.57% completed the survey effectively The participants were from 166 medical institutions in Chengdu, comprising 1,420 nurses (61.50%) and 889 clinical doctors (38.50%). A total of 33.36% participants experienced burnout, predominantly mild (30.27%), followed by moderate (2.78%) and severe (0.3%). Physicians, higher fatigue scores, age, work experience appeared to be related to burnout. Logistic regression models revealed that individuals aged over 50 were less prone to experience burnout compared to medical staff aged 18-30 (OR: 0.269, 95% CI: 0.115-0.627, p = 0.002). Physicians were more prone to experience burnout compared to nursing staff (OR: 0.690, 95% CI: 0.531-0.898, p = 0.006). Those with 0-5 years of experience were more prone to experience burnout compared to those with 6-10 years or over 15 years of experience (OR: 0.734, 95% CI: 0.547-0.986, p = 0.040; OR: 0.559, 95% CI: 0.339-0.924, p = 0.023). Additionally, for each 1-point increase in the fatigue score, the likelihood of burnout in medical staff increased by 1.367 times (OR: 1.367, 95% CI: 1.323-1.412, p < 0.0001). CONCLUSION: Pre-hospital emergency medical personnel demonstrate a notable prevalence of mild job burnout. These results provide a groundwork for future focus on the various stages of job burnout within pre-hospital emergency staff, alerting hospital and departmental managers to promptly address the mental well-being of their personnel and intervene as needed.

Navigating into the unknown: exploring the experience of exposure to prehospital emergency stressors: a sequential explanatory mixed-methods.

INTRODUCTION: The unpredictability of prehospital emergencies combined with constantly changing circumstances can lead to increased stress and mental health issues among Emergency Medical Technicians (EMTs). To accurately determine the stress-inducing factors in the prehospital environment, it is important to first identify the stressful events that occur in this environment. Therefore, this study strives to provide a thorough analysis of the stressors in the prehospital environment. METHODS: Sequential explanatory mixed methods were conducted in Hamadan prehospital emergency centers in 2022. The study included 251 EMTs, who were selected through a method in the quantitative phase. The quantitative part used a questionnaire consisting of basic information and the Posttraumatic Stress Questionnaire (PCL-5). In the qualitative phase, 17 with extensive experience in dealing with prehospital stressors were selected based on their PCL-5 scores (above 33). The qualitative phase analysis was carried out using the contractual content method using the Graneheim and Ladman's approach. Statistical analyzes for the quantitative and qualitative phases were performed using SPSS 21 and maxqda 10, respectively. RESULTS: The study revealed that the EMTs had an average PTSD score of 21. 60 ± 11. 45. Multivariate linear regression analysis showed that the number of shifts had a statistically significant relationship with PTSD scores (t = 26.38, P < 0.001). The qualitative phase of the study included 17 interviews, resulting in 14 subcategories, which consisted of four categories: "the overall impact of the stress crisis on technicians," "missing links in the communication network in incident management," "professional shortcomings in pre-hospital care," and "the complex and multifaceted context of stressful pre-hospital emergencies." Additionally, the study's theme was centered around "surveying the experiences of EMTs in stressful environments." CONCLUSION: As the number of shifts increased, the primary cause of the high prevalence of PTSD in EMTs was revealed. Prehospital emergency stress can be reduced and managed more skillfully by adjusting various factors such as shortening workdays, offering continuous training, augmenting workforce, supplying ambulance equipment insurance, refraining from hiring personnel devoid of clinical training, hiring psychologists, hiring midwives in an emergency, updating prehospital protocols and guidelines, encouraging cooperation between EMTs and other relief groups, and utilizing cutting-edge technologies.

Effect of stachys lavandulifolia on occupational stress in emergency medical technicians.

OBJECTIVE: According to studies, occupational stress is quite prevalent among Emergency Medical Technicians (EMTs). On the other hand, it has been shown that Stachys lavandulifolia, also known as the Mountain Tea in Iran, has anxiolytic properties. Considering the current increasing trend of using remedies based on alternative medicine for stress management, the present clinical trial intended to investigate the effect of Stachys lavandulifolia on occupational stress in EMTs METHODS: The present study included 60 EMTs working in Arak, Markazi province, Iran, who were randomly divided into study and control groups. The study group was treated with tea made of Stachys lavandulifolia (2 g daily) for 2 months, while the control group was treated with black tea. Moreover, the level of occupational stress in the study participants was assessed using the Hospital Stress Scale (HSS-35) before and after the intervention. Data analysis was performed using the SPSS software version 22. RESULTS: According to our results, the mean occupational stress score was significantly decreased in the study group after the intervention (p < 0.05). Moreover, the post-intervention scores were significantly lower in the study group compared to the control group (p < 0.05). However, there was no significant change in occupational stress in the control group after the intervention (p > 0.05). CONCLUSION: In combination with other stress-relieving options, the tea made of Stachys lavandulifolia can be used as a complementary therapy for alleviating occupational stress in EMTs.

Perceived human factors from the perspective of paramedics - a qualitative interview study.

BACKGROUND: The work environment in prehospital emergency medical care setting is dynamic and complex and includes many stressors. However, little is known about the perceived human factors from the perspective of paramedics. In this study, we investigated, from the perspective of paramedics, what are the human factors, and how are they linked to prehospital emergency medical care? METHODS: Data were collected through semi-structured interviews (n = 15) with Finnish paramedics. The material was analyzed using inductive content analysis. RESULTS: Three main categories of human factors were identified. The first main category consisted of factors related to work which were divided into two generic categories: "Challenging organizational work environment" and "Changing external work environment." The second main category comprised factors related to paramedics themselves and were divided into three generic categories: "Issues linked to personality," "Personal experiences", and "Factors resulting from personal features." The third main category described that paramedics have difficulties in understanding and describing human factors. CONCLUSION: This study revealed numerous factors that can affect paramedics' work in the EMS setting. Increased knowledge about human factors in the EMS setting provides organizations with the opportunity to develop procedures that can support paramedics' cognitive and physical work. Human factors in different situations can be addressed to improve occupational and patient safety.

Impact of COVID-19 Pandemic on Stress and Burnout Levels amongst Emergency Medical Technicians: A Cross-Sectional Study in Spain.

BACKGROUND: Emergency medical technicians (EMTs) are essential health care workers (HCWs). Although they play an extraordinary role during the COVID-19 pandemic, they are mostly exposed to various occupational health and safety risks that have significantly impacted their mental health, giving rise to symptoms, such as stress and burnout. AIM: This study aimed to assess the perceived levels of stress and burnout amongst EMTs in relation to their socio-demographic characteristics and to explore the associations between their stress and burnout levels during the COVID-19 pandemic. METHODS: This work is an observational cross-sectional design study conducted between 29 March and 30 April 2021, with a convenience sample of 280 Spanish EMTs yielding a response rate of 28%. The online survey had 42 items that aimed to determine participants' socio-demographic characteristics, the Perceived Stress Scale (PSS) and the Maslach Burnout Inventory (MBI). RESULTS: The results showed that more than half of the EMTs (53%) perceived a moderate stress level, 37% perceived moderate levels of emotional exhaustion (EE) and 40% had moderate levels of depersonalization (DP). Furthermore, 48% had low levels of personal accomplishment (PA). Gender, age, having personal protective equipment (PPE) and experiencing fear of infection were statistically significant areas where participants experienced greater stress (p < 0.05). A positive correlation between stress, EE and DP and a negative correlation between stress and the PA subdimension of burnout were found. CONCLUSIONS: The COVID-19 pandemic had a tremendous impact on the mental health of ambulance EMTs. Further studies building on this study and others on the psychological status of EMTs before the pandemic and follow-up during the pandemic, as well as deeper investigations on their work conditions, are needed to facilitate the implementation of various interventions. Such efforts can mitigate the negative impacts of the pandemic on their mental health, and prepare them for future disasters.KEY MESSAGEThe COVID-19 pandemic has affected the lives of the majority of the world's population. In particular, it has impacted the mental health of various communities, including HCWs. Highly stressful and insecure work conditions have placed frontline HCWs at a high risk of psychological distress, making them victims and service providers simultaneously.

Secondary Traumatic Stress in Emergency Services Systems Project: Quantifying the Effect of Personal Trauma Profiles on Lifetime Prevalence of Suicidality in Emergency Medical Services Personnel.

OBJECTIVE: Within the last 20 years, there has been a 500% increase in public safety suicides, the exact cause of which is unknown. METHODS: This was a cross-sectional survey of emergency medical services (EMS) personnel. Nine EMS agencies were selected to participate based on geography and population. The survey assessed sociodemographic, occupational, and military factors. Childhood adversity and traumatic experiences were evaluated using the Adverse Childhood Experiences Questionnaire and the Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, respectively. Using factors significant in univariate analyses, a logistic regression was conducted to determine predictors of suicidality while controlling for potential confounders. RESULTS: A total of 681 EMS providers participated; 56.1% were male, 12.6% were minorities, and 72.8% were paramedics. Nearly a quarter (24.4%) had considered suicide. Approximately twice as many had received counseling for a stress-related event, and 1.5 times as many identified as currently in counseling. Indigenous populations were 4.76 times more likely to have suicidality (odds ratio [OR] = 4.76; 95% confidence interval [CI], 1.22-18.62). Suicidality was 97% more likely in EMS professionals with prior military service (OR = 1.97; 95% CI, 1.08-3.57) and 2.22 times more likely in sexual minorities (OR = 2.22; 95% CI, 1.16-4.25). Emotional abuse (OR = 1.86; 95% CI, 1.08-3.21) and burnout (OR = 2.88; 95% CI, 1.78-4.66) were also predictive. CONCLUSIONS: Suicidality is an indisputable concern for the EMS profession and represents a multifaceted issue that must be addressed.

Covid-19 phobia in prehospital emergency medical services workers in Turkey.

Background: The COVID-19 (coronavirus disease-2019) outbreak has its social, economic, and political effects on wider society, as well as physical and mental health effects on individuals. The psychological and social impacts are more apparent and common on emergency health care workers who have close contact with patients. Aim: Our study aims to investigate coronaphobia in emergency health care workers. Subjects and Methods: A cross-sectional study was carried out in July 2020 with 253 people working under the Bingöl 112 Provincial Ambulance Service Chief of Staff. The data of the study were collected using a questionnaire including sociodemographic characteristics, working conditions, pandemic process, and the Coronavirus-19 Phobia Scale. P < .05 was considered statistically significant. Results: The mean total score of COVID-19 phobia in 112 employees was 58.03 ± 18.78. The sub-dimension scores are psychological 21.92 ± 6.19, somatic 10.83 ± 5.68, social 15.98 ± 5.60, and economic 9.28 ± 4.18. Psychological and social sub-dimension scores and total COVID-19 phobia score of women, the somatic sub-dimension score of married people, all sub-dimension scores, and total COVID-19 phobia score of those who had contact with COVID-19-positive patients were found to be significantly higher (P < .05). Conclusions: Close contact with patients, working conditions, and the heavy schedule of nightshifts increase psychological and social fear in emergency health care workers. It is important to provide psychosocial support to emergency health care workers during the pandemic period.

Determinants of Stress, Depression, Quality of Life, and Intent to Leave in Washington State Emergency Medical Technicians During COVID-19.

OBJECTIVES: This study characterizes determinants of stress, depression, quality of life, and intent to leave among emergency medical technicians (EMTs) in the Puget Sound region, Washington, during the COVID-19 pandemic and identifies areas for intervention on these outcomes. METHODS: A cross-sectional survey measured stress, depression, quality of life, and intent to leave among EMTs ( N = 123). Regression models were developed for these outcomes. RESULTS: A total of 23.8% of respondents were very likely to leave their position in the next 6 months. Job demands predicted stress and depression, and financial security predicted stress and quality of life. Intent to leave was predicted by stress, manager support, and length of employment. CONCLUSIONS: Increased exposure to hazards has impacted EMT mental health. Emergency medical technicians are vital to healthcare, so improving EMT health and well-being is important, as attrition during a pandemic could impact public health.

The Relationship Between Death Anxiety and Alexithymia in Emergency Medical Technicians.

INTRODUCTION: When confronted with traumatic accidents and events that result in death, people are at risk of developing death anxiety. Due to their stressful job, emergency medical technicians (EMTs) will develop alexithymia and be unable to express and manage their emotions over time. Studies show that alexithymia causes physical and mental disorders in many people. The present study aimed to determine the relationship between death anxiety and alexithymia in EMTs. METHODS: The convenience sampling method was used to select 400 EMTs in southeastern Iran who met the inclusion criteria for this descriptive-analytical study. The Templer Death Anxiety Scale and the Toronto Alexithymia Scale were used to collect data. SPSS version 20 was used to analyze the data, which included descriptive and analytical statistics (Independent t test, ANOVA, Pearson correlation, and regression). RESULTS: The results of the study showed that the mean score of death anxiety in EMTs was 10.26 ± 3.69. It was revealed that 46.7% of the EMTs experienced severe death anxiety. Furthermore, the total mean score of alexithymia in EMTs was 59.65 ± 8.28, indicating the possibility of alexithymia. The Pearson correlation test showed a direct moderate relationship between death anxiety and alexithymia scores (r = .351, p < .001). CONCLUSION: According to the results, there is a direct significant relationship between death anxiety and alexithymia in EMTs. Therefore, it is suggested that EMTs be continuously taught effective methods to deal with death anxiety and reduce the physical and mental disorders caused by this problem.

EMS Experience Caring and Communicating with Patients and Families with a Life-Limiting-Illness.

Introduction: The emergency medical services (EMS) system was designed to reduce death and disability and EMS training focuses on saving lives through resuscitation, aggressive treatment and transportation to the emergency department. EMS providers commonly care for patients who have life-limiting illnesses. The objective was to explore EMS provider challenges, self-perceived roles and training experiences caring for patients and families with life-limiting illness. Methods: Qualitative content analysis of semi-structured interviews with EMS providers (n = 15) in Alameda County, CA. Purposive sampling was used to ensure a variety of perspectives including provider age, years of EMS experience, emergency medical technicians and paramedics, fire-based versus private, transport versus non-transporting. Recorded and transcribed interviews were analyzed using a thematic approach. Results: In their work with patients with life-limiting illness, participating EMS providers were interviewed and reported challenges for which their formal training had not prepared them: responding to grief and emotion expressed by families during traumatic events or death notification, and performing in the moment decision-making to determine the course of action after acute, unexpected, and traumatic events. Many participants reported becoming comfortable with grief counseling and death notification after acquiring some clinical experience. In the moment decision-making was eased when patients and families had had advance care planning discussions, however many patients, especially those from vulnerable and underserved populations, lacked advance care planning. In the face of situations where the course of action was not immediately clear, EMS providers voiced two frames for their role in caring for patients with life-limiting illness: transportation only ("transport people") versus a more "holistic" view, where EMS providers provided counseling and information about available resources. Conclusions: EMS providers interface with patients who have life-limiting illness and their families in the setting of traumatic events where the course of action is often unclear. There is an opportunity to provide formal training to EMS providers around grief counseling as well as how they can assist patients and families in in the moment decision-making to support previously identified goals and align care with patient goals and preferences.

Near-miss incidents owing to fatigue and irregular lifestyles in ambulance personnel.

We aimed to investigate the association between fatigue and near-miss incidents and between irregular lifestyles and fatigue in ambulance personnel. In this cross-sectional study, we used a self-administered questionnaire and ambulance dispatch records during November 2017. We performed multiple logistic regression; in total, 254 ambulance staff were eligible for inclusion in the analysis. The adjusted odds of near-miss incidents were 3.19 times higher for participants with higher fatigue than for those with normal fatigue, with statistical significance. Fatigue was significantly associated with the monthly number of ambulance dispatches, office working hours, mealtimes, daytime napping hours, and napping hours during a night shift. In this study, we demonstrated a positive association between fatigue and near-miss incidents among ambulance personnel. Additionally, our results suggest that irregular lifestyles are a root cause of fatigue in ambulance personnel.

Prevalence of pain, analgesic self-medication and mental health in German pre-hospital emergency medical service personnel: a nationwide survey pilot-study.

PURPOSE: The aim of this study was to estimate the prevalence of pain, the extent of analgesics intake and the mental health status of German pre-hospital emergency medical service (EMS) personnel. METHODS: We conducted a nationwide online survey, which consisted of sociodemographic and job-related items, questions on pain and analgesics intake and the short-version of the validated Depression-Anxiety-Stress Scale (DASS-21). RESULTS: A total of 774 EMS personnel with a mean age of 33.03 (standard error [SE] 0.37) years were included into the final analysis of which 23.77% were female. Pain was reported by 58.64% (454 of 774) of the study participants with 10.72% (95% confidence interval [CI] 8.54%; 13.29%) suffering from chronic, 1.68% (95% CI 0.89%; 2.87%) from acute and 46.25% (95% CI 41.49%; 51.30%) from recurrent pain, respectively. Most frequent location of pain was lumbar spine. Analgesics were used by 52.76% (239 of 454) of pre-hospital EMS personnel with pain (acute 76.92% / chronic 69.88% / recurrent 47.90%). Moreover, participants with chronic and recurrent pain indicated significantly higher depression (p ≤ 0.001), anxiety (p ≤ 0.001), and stress (p ≤ 0.001) levels compared to those without pain, respectively. CONCLUSION: This study indicates a high prevalence of pain and analgesics usage in participating German pre-hospital EMS personnel and a poorer mental health in those with chronic and recurrent pain. Therefore, disease prevention and health promotion measures are needed to preserve health of pre-hospital EMS personnel.

Impact of COVID-19 on paramedicine students: A mixed methods study.

BACKGROUND: Viral epidemics have negative and sometimes extreme impacts on psychological well-being, particularly in health care workers. Studies have reported higher levels of depression, anxiety, insomnia, stress, distress, fear, burnout, and post-traumatic symptoms. OBJECTIVE: This research aimed to explore the psychological impacts of COVID 19 on paramedicine students. METHODS: A convergent mixed method design study was undertaken using self-reporting instruments and qualitative interviews. RESULTS: Responses were received from 151 students (38.3% responses rate). Most students experienced some level of anxiety (62%), although severe levels were only reported by 6% of respondents. Students had significantly greater odds (OR = 2.05, p = 0.045, 95% CI: 1.02, 4.12) of higher anxiety levels if they were female. Thematic analysis of the interviews largely supported these results, with themes focused on changing approaches to study, financial situation, social support, University adaptation, acceptance and career pathway choice. CONCLUSIONS: This study identified and explored the anxiety and coping strategies in an undergraduate paramedicine cohort when faced with a viral epidemic. Although most of the responding paramedic students reported above normal levels of anxiety in the initial stages of the COVID-19 outbreak, many students, with the help of learning, financial and social support, and a range of positive coping strategies, have adapted well to the impact of the pandemic and associated lockdown period.

COVID-19 Vaccine Acceptability Among US Firefighters and Emergency Medical Services Workers: A Cross-Sectional Study.

OBJECTIVES: Estimate the point prevalence of COVID-19 vaccine acceptability among US firefighters and Emergency Medical Services (EMS) workers. METHODS: A cross-sectional study design was used to administer an anonymous online survey to a national non-probabilistic sample of firefighter and EMS workers. RESULTS: Among the 3169 respondents, 48.2% expressed high acceptability of the COVID-19 vaccine when it becomes available, while 24.2% were unsure and 27.6% reported low acceptability. Using the "high COVID-19 vaccine acceptability" group as the reference category, the groups with greater odds of reporting low acceptability included those: 30 to 39 years of age (odds ratio = 3.62 [95% confidence interval = 2.00 to 6.55]), Black race (3.60 [1.12 to 11.53]), Hispanic/Latinx ethnicity (2.39 [1.45 to 3.92]), with some college education (2.06 [1.29 to 3.27]), married (1.65 [1.03 to 2.65]), of current rank firefighter/EMS (2.21 [1.60 to 3.08]). CONCLUSIONS: Over half of US firefighters and EMS workers were uncertain or reported low acceptability of the COVID-19 vaccine when it becomes available.

Paramedics in pandemics: protecting the mental wellness of those behind enemy lines.

Besides a global health crisis, the COVID-19 pandemic has potential to have a severe and long-lasting psychological impact on frontline healthcare workers such as paramedics. It is imperative to shed light on these mental health issues and employ interventions to protect the mental wellness of this vulnerable group of healthcare workers.

Exploring stress coping strategies of frontline emergency health workers dealing Covid-19 in Pakistan: A qualitative inquiry.

BACKGROUND: The COVID-19 outbreak has gravely impacted the physical and psychological health of people. As the outbreak is ongoing, it is crucial to equip the emergency healthcare workers (HCWs) to be medically and psychologically prepared. OBJECTIVE: To examine the psychological impact of COVID-19 on emergency HCWs and to understand how they are dealing with COVID-19 pandemic, their stress coping strategies or protective factors, and challenges while dealing with COVID-19 patients. METHODS: Using a framework thematic analysis approach, 15 frontline emergency HCWs directly dealing with COVID-19 patients from April 2, 2020 to April 25, 2020. The semi-structured interviews were conducted face-to-face or by telephone. Data were analyzed using thematic analysis. RESULTS: Findings highlighted first major theme of stress coping, including, limiting media exposure, limited sharing of Covid-19 duty details, religious coping, just another emergency approach, altruism, and second major theme of Challenges includes, psychological response and noncompliance of public/denial by religious scholar. CONCLUSIONS: Participants practiced and recommended various coping strategies to deal with stress and anxiety emerging from COVID-19 pandemic. Media was reported to be a principal source of raising stress and anxiety among the public. Religious coping as well as their passion to serve humanity and country were the commonly employed coping strategies.

Exploring the need for and application of human factors and ergonomics in ambulance design: Overcoming the barriers with technical standards.

Ergonomic risk factors, such as excessive physical effort, awkward postures or repetitive movements, were the leading causes of injuries amongst EMS workers in the United States, of which 90% were attributed to lifting, carrying, or transferring a patient and/or equipment. Although the essential tasks of patient handling, transport, and care cannot be eliminated, the design of ambulances and associated equipment is modifiable. Our aims were to identify the extent of Human Factors and Ergonomic (HFE) considerations in existing ambulance design standards/regulations, and describe how HFE and the standards/regulations were applied in the EMS system. Through an extensive environmental scan of jurisdictionally relevant standards/regulations and key informant interviews, our findings demonstrated that existing standards/regulations had limited considerations for HFE. As a result, HFE principles continue to be considered reactively through retrofit rather than proactively in upstream design. We recommend that performance-based HFE requirements be integrated directly into ambulance design standards.