Assessment of wildland firefighter opinions and experiences related to incident medical providers

Introduction

Wildland fire suppression is an arduous activity posing significant work hazards such as heat stress (West et al. 2020), smoke exposure (Semmens et al. 2021) and orthopedic injuries (Moody et al. 2019), and illnesses such as camp crud (Rapid Lesson Sharing 2017) and COVID-19 (Belval et al. 2022). Wildland fire epidemiological injury and illness data are somewhat limited and the most commonly cited study on the subject reports only injuries and illnesses significant enough to generate worker’s compensation claims (Britton et al. 2013a), likely resulting in under-reporting of events. With the potential catastrophic consequences of injury combined with employers’ high cost of caring for occupational injuries (Thrift and von Winterfeldt 2021) and the significant threat of time lost working on the fireline, it is imperative that the wildland firefighter (WLFF) has access to high quality medical care and is comfortable seeking services when needed. During most state and federal wildfires, medical services are arranged by the fire’s management team according to guidelines provided by the National Wildfire Coordination Group (NWCG) (NWCG 2010).

Medical providers are available on the fireline and in fire camps, which range in size from hundreds to thousands of personnel, to provide medical services to incident staff. In larger camps, the medical unit can sometimes exceed 50 emergency medical providers at the Emergency Medical Technician (EMT) or paramedic level (NWCG 2010). The providers are a combination of employees from the federal agencies and private contract companies who specialise in Emergency Medical Services (EMS) in remote environments.

While medical services are provided on fire incidents, it is not well understood how WLFFs utilise these services or if there are potential barriers that affect them seeking care. Anecdotal accounts suggest some WLFFs are reluctant to seek care out of a concern of being perceived as weak or possibly being sent off an incident (demobilised or ‘demobbed’) for a minor medical issue. Both of these reasons for not seeking care are potentially related to the firefighter’s level of trust and respect for the providers and may be a barrier to care. There are no published reports ascertaining whether these anecdotes reflect widespread opinions, and if so, whether they have basis in actual practice. If so, steps should be taken to ensure WLFFs have confidence in their medical providers to act in the best interest of all incident personnel. Without an initial exploratory study of this type, the wildland fire community has no evidence to investigate a narrative based on anecdotes and cannot determine whether change is needed, and if so, whether the appropriate change is clarification of existing policies or actual changes in practice. Therefore, the current exploratory study was conducted to examine the WLFFs’ attitudes, opinions towards and experiences with the medical services provided while on fire assignments.

Materials and methods

The study was approved by the Oregon State University (OSU) institutional review board for human subjects research. A web-based Qualtrics (Qualtrics, Provo, UT, Seattle, WA) survey was made available to potential participants via email invitation to National Wildfire Suppression Agency (NWSA) member companies and via links posted on several wildland firefighting-related Facebook groups. The NWSA represents more than 300 private companies, most of which are located in the Pacific Northwest. Survey participants were required to be at least 18 years of age and have been employed as a WLFF for at least one season within the past 10 years. For this analysis, respondents had to complete the demographic, employment, and attitudes and beliefs items on the survey. Survey respondents could indicate that they had worked for a government agency, a private contractor, or both. Of note, in 2018, approximately one quarter of the more than 40 000 WLFFs in the US were from private companies (US News 2019). Respondents who indicated they had worked in both settings were excluded from the present analysis to facilitate comparisons.

To our knowledge, no studies have explored WLFF beliefs and attitudes towards medical services provided on the fire line or in camp. The WLFF Attitude and Beliefs about Medical Services (WLFF ABMS) survey consisted of 26 questions and had four sections: (1) demographics and wildland fire experience; (2) history and description of injuries sustained during firefighting; (3) respect and trust toward fire line and fire camp medical personnel; and (4) perceived impact of injury and injury treatment on personal and crew deployment ability. The survey was developed from existing literature focused on WLFF injuries (Britton et al. 2013a, 2013b; Moody et al. 2019; Sondag et al. 2019) as well as the authors’ experiences in wildland medical services provision, and on discussions with both line firefighters and supervisors. Because this was an exploratory survey, we did not conduct traditional scale development activities prior to this pilot study. The WLFF ABMS contained 23 closed-ended questions and three open-ended questions to allow for further explanation or clarification regarding previous injury history and treatment as well as experience with medical services on fire deployments. To assess our primary aims, we analysed those items assessing trust, respect, discouragement to seek medical services and injury impact on deployment (Table 1). These items were assessed on a seven-point ordinal scale, anchored at ‘strongly agree’ and ‘strongly disagree.’

Results

A total of 177 individuals started the survey. Four failed to indicate consent to take part and were excluded without further review. A further 50 did not complete the required survey items, 31 indicated they had worked for both government agencies and private contractors, and one did not indicate an affiliation. The final analysis dataset included responses from 91 individuals. The majority of respondents were male, white and worked for government agencies; nearly half had worked 10 or more fire seasons, and approximately 40% reported an injury (Table 2).

Access to medical services

The results indicate significant differences in the agreement between respondents regarding perceived access to medical services provided on wildland fires. Agreement with the statement ‘private contracting firefighters have the same access to medical services compared with agency crews’ was similar across agency and contract firefighters, but disagreement with this statement was much higher among contract firefighters compared with agency firefighters (Table 3, Fig. 1a).

Table 3. Statistical results.

	Disagree	Neither	Agree
Access: Private contracting firefighters have the same access to medical services compared with agency crews
Agency	4/6.6	24/39.3	33/54.1
Private	13/43.3	3/10.0	14/46.7
Chi-square = 20.6, P < 0.001
Trust: Most WLFFs have a high level of trust for the medical personnel on fires
Agency	7/11.5	6/9.8	48/78.7
Private	4/13.3	2/6.7	24/80.0
Chi-square = 0.292, P = 0.864
Respect: Most WLFF have a high level of respect for the medical personnel on fires
Agency	8/13.1	8/13.1	45/73.8
Private	3/10.0	1/3.3	26/86.7
Chi-square = 2.5, P = 0.281
Encouraged against: At any point during my career as a WLFF, I have been encouraged not to seek the medical services provided on wildfire incidents
Agency	44/72.1	4/6.6	13/21.3
Private	11/36.7	4/13.3	15/50.0
Chi-square = 10.6, P = 0.005
Witnessed discouragement: I have witnessed a WLFF being encouraged to avoid the medical services provided on wildfire incidents
Agency	40/65.6	6/9.8	15/24.6
Private	7/23.3	5/16.7	18/60.0
Chi-square = 14.7, P = 0.001
Affect demobilisation: I feel that seeking medical attention from incident medical personnel can potentially affect a crew’s demobilisation order
Agency	27/44.3	9/14.8	25/41.0
Private	3/10.0	2/6.7	25/83.3
Chi-square = 14.8, P = 0.001

Fig. 1. 

Comparisons of responses from agency vs private firefighters in the 6 areas of interest (a–f).

Discussion

Wildland firefighting is a dangerous occupation that can lead to injuries ranging from minor to serious to fatal (Britton et al. 2013a). To the extent firefighters perceive that accessing healthcare can jeopardise their income and careers and that of their team, they may not seek timely care, increasing the potential that a given injury could have long-lasting consequences. The purpose of this exploratory study was to examine the WLFFs’ attitudes, opinions towards and experiences with the medical services provided while on fire assignments. The results suggest WLFFs have generally high levels of trust and respect for onsite medical professionals, although there are clear differences between agency and private firefighters in their perceived access to and utilisation of medical services, and in their perceptions of the impact of seeking care on themselves and their crew.

Trust and respect are critical factors in a patient’s decision to seek medical attention (Birkhäuer et al. 2017). A patient’s respect for a provider is linked to their perceived competence of the provider and the attitude the provider displays toward the patient (Gilson et al. 2005). This is a particularly important note for providers on wildland fires, as the attitude displayed toward the WLFFs can impact the level of trust and respect the patient has for them (Gilson et al. 2005). Given the anecdotal accounts of WLFFs not seeking medical attention owing to concerns of being perceived as weak or out of fear of being demobbed, knowing that in general the WLFFs trust and respect the emergency medical providers is an important finding. Specifically, these findings suggest that if individuals are choosing to not seek medical attention, it is likely unrelated to the firefighter’s trust and respect for the medical personnel.

Over the course of the COVID-19 pandemic, a lot of popular press commented on trust in the US medical system. It is important to note that this survey was deployed just prior to the COVID-19 pandemic shut-down and, therefore, the results presented were not directly affected by the pandemic. Regarding trust in the US medical system, evidence from a Gallup poll on the topic indicates that confidence in the US medical system has actually increased as of July 2020 compared with pre-pandemic data (Baker 2020).

Access to community medical services is usually discussed in relation to constructs such as socioeconomic status (Levesque et al. 2013), race (Brown et al. 2000; Richardson and Norris 2010) and health insurance (Brown et al. 2000). However, in the context of wildland firefighting, medical services are provided by a medical unit and are available to everyone assigned to an incident – barriers seen in community settings (e.g. insurance, co-payments, transportation) are absent in the medical unit in the wildland firefighting setting. Consistent with this, the results from this study indicate similar percentages of agency (54.1%) and private (46.7%) firefighters agree that access to care on incidents is the same for both groups. However, when the responses for ‘disagree’ are considered, there is a much larger and concerning percentage of private firefighters (43.3%) who disagree with this statement compared with agency respondents (6.6%). In practice, private and agency firefighters are on the same incidents, camped in the same locations, with the same physical and administrative access to the medical personnel and facilities; yet, private firefighters report a much larger level of disagreement related to equal access to care. To our knowledge, there are no standing medical unit practices that prescribe differential treatment for agency and private firefighters. Although our data do not explain the perceived differences in access, it is likely that several factors contribute, including not understanding the logistics of receiving care, fear of being demobilised from the incident, uncertainty in payment requirements for treatment and tension between private and agency resources.

It remains unknown why some firefighters report perceived lower levels of access to fire provided medical services and it is likely a complex and multifactorial issue. Future work is needed to determine whether firefighters who report decreased access to medical services feel this was due to their supervisor functioning as a gatekeeper, other firefighters discouraging the use of medical services, or other real or perceived barriers. It is important to understand whether firefighters who report decreased access to medical services provided by the incident are receiving care from other sources such as within their own crew or outside of the fire operation, or are self-treating.

The trends seen in the data regarding discouragement of firefighters to seek medical attention are also troublesome. Of the private firefighters responding to this survey, 50% report they were discouraged from seeking medical attention and 60% report having seen others being discouraged from seeking medical attention. The design of the current survey did not investigate the potential sources of discouragement. One possible contributing factor, although not able to be determined from this study, is the effect of firefighter fear of reprisal or negative consequences for seeking care (TriData 1996). Some firefighters have reported the concern of being demobilised from an incident if medical services are utilised for even minor medical issues. Being demobilised for a medical issue does not ensure that private firefighters will be compensated with paid time off or sick leave as is more common for agency firefighters. Our findings support this concern: 83.3% of the private firefighters perceive that seeking medical attention can impact or result in early demobilisation of their crew. For private firefighters, many of whom are seasonal, being demobilised from an incident can have a significant financial impact and this is magnified if an entire crew is removed from an incident because they can no longer maintain a minimum level of staffing.

If WLFFs are not seeking care for injuries and illness for any reason, it is a concern for the wildland fire community for several reasons, many of which have been discussed. However, a potential hidden consequence for individuals not seeking care is the significant under-counting of injuries and illnesses happening in this environment. Without good injury epidemiological data, it is difficult to gain complete understanding of the problems and develop effective change.

In conclusion, wildland firefighting is a physically demanding profession that places the WLFFs at risk for a variety of injuries and illnesses, and providing adequate emergency medical services to fire personnel is an integral part of the incident. Prior to this exploratory study, little was understood about how WLFFs perceived the medical personnel on fire. The results indicate that both agency and private WLFFs have high levels of trust and respect for medical personnel working on incidents, whereas private firefighters more often disagree that access to medical services is similar for both agency and private firefighters. This perceived difference in access to medical services is a substantial concern. Furthermore, private firefighters report a concerning higher rate of either being discouraged themselves or witnessing others being discouraged from seeking medical attention despite having similar access to medical services as agency firefighters.

Although this was the initial exploratory attempt to understand some of the constructs around WLFF health and wellness, several limitations must be acknowledged. We were unable to calculate a response rate based on the sampling technique used in this study and acknowledge the sample size is relatively small compared with the thousands of wildland firefighters in the United States. Although the survey was distributed via nationwide social media in order to reach a geographically broad sample, we do not have demographic information sufficient to document the extent to which respondents represent the national wildland firefighter community. Furthermore, a large number of respondents opened but did not complete the survey. Although the survey did not undergo external validation, it was developed by experts, including the study team, who have considerable experience in survey‐designed research and are familiar with wildland fire incidents and the related literature. Lastly, it should be noted that individuals other than the patient, such as crew members and supervisors, may influence a WLFF seeking medical care and these factors were not directly assessed in this study.

Further study is imperative to better understand why some WLFFs perceive a lack of access to medical services in fire camp, despite the long-standing policy-driven practice of having similar resources available (NWCG 2012). If there is an element of mis-information that contributes to this perception, information efforts and campaigns may be a useful tool to address the problem. Additionally, it would be helpful to gain insight as to why WLFFs report being discouraged from seeking out medical services while working on a fire. With the rigours of working in wildland fire suppression, it is essential that the health and safety of the WLFF are prioritised and that the WLFFs seek out timely and appropriate care for any injuries or illnesses. Lastly, it would be helpful to understand if WLFFs are seeking out other sources of care or are self-treating their injuries or illnesses to mitigate the perceived risk of demobilisation. Understanding and addressing actual or perceived barriers to wildland fire camp medical care is likely to benefit individual firefighters and their employers, and contribute to incident success.

Data availability

The data that support this study will be shared on reasonable request to the corresponding author.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Declaration of funding

This research did not receive any specific funding.