Earlier this year, a falling object struck a worker’s head at an Amazon fulfillment center in Robbinsville, New Jersey. The worker visited Amcare, the company’s on-site medical unit, and told the emergency medical technicians on staff there that they had a headache and blurred vision — classic symptoms of a concussion. According to company protocol, Amazon’s medical staff should have sent the worker to a hospital or doctor’s office for further evaluation, or at least called a physician for advice. They did neither.

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In various instances, OSHA investigators found that Amcare medical staff decided to treat the employees in-house, rather than referring them to doctors or hospitals — decisions that potentially violated New Jersey state law and federal regulations, such as OSHA’s “general duty” clause requiring employers to maintain workplaces free of hazards that put workers in danger.

This wasn’t the first time OSHA had investigated Amcare, nor was it the first time the agency alerted Amazon to problems at the clinics. “The current OSHA inspection again revealed instances indicating that the EMTs and Athletic Trainers (ATs) at AMCARE are working outside their scope of practice, without proper supervision,” regulators wrote in a warning letter to Amazon, reported here for the first time. “New Jersey state laws do not allow EMTs and ATs to practice medicine independently; a physician must supervise their work.”

An investigation by The Intercept and Type Investigations — drawing on previously unreported documents, an interview with a former OSHA medical expert, and interviews with 15 current and former Amcare employees — found multiple instances in which clinic staffers violated Amazon’s own rules as well as government regulations. The investigation found that Amcare employees nationwide were pressured to sweep injuries and medical issues under the rug at the expense of employee health.

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The strenuous nature of the work at Amazon’s warehouses can take its toll on the human body: As Reveal and The Atlantic reported last week, the rates of serious injury at 23 fulfillment centers from which data could be obtained were more than double the industry average in 2018. The company’s Amcare clinics are intended to address the many minor aches and pains workers experience on the job. The company claims that this care falls under the category of “first aid,” which, according to an OSHA letter to Amazon, is defined as “emergency care provided for injury or sudden illness before emergency medical treatment is available.” These clinics operate in most, if not all, of the company’s warehouses, and they are staffed by EMTs and supervised by safety managers. According to a former OSHA medical officer and multiple former Amazon employees interviewed for this story, safety managers are not required to have extensive medical training. (Amazon declined to answer specific questions about its safety managers’ training as well as other details reported in this story.)

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Since 2015, Amazon workers have filed at least 10 complaints about problems at Amcare — all of which OSHA deemed “valid” — according to previously unreported documents obtained through a Freedom of Information Act request. These 10 complaints represent a small fraction of the hundreds of general health and safety complaints filed by Amazon workers in the last seven years. The complaints alleged that employees were being sent back to work with no medical care after requesting treatment, that injured employees were being told they must wait two weeks to see if their conditions worsened before being seen by doctors, and that Amcare staffers were not adequately trained. One complaint, made by phone in December 2017 from Tracy, California, alleged that Amcare simply refused to treat an injury. Though the complaints were determined to be valid, the agency did not follow up with an inspection in every case; OSHA is a small agency that employs about one inspector for every 59,000 U.S. workers.

Still, in response to these complaints and others, OSHA has investigated Amcare clinics at least three times: beginning from summer 2015 at an Amazon fulfillment center in Robbinsville, New Jersey; from fall 2017 to spring 2018 at a fulfillment center in Florence, New Jersey; and again at the Robbinsville warehouse in an investigation that concluded in September 2019. Each time, the federal agency found that EMTs were providing care beyond first aid. Twice, OSHA recommended that they be supervised by on-site physicians. Twice, in Florence and during the first Robbinsville investigation, the agency also found evidence that Amazon was underreporting injuries on federally mandated logs. The results of the Florence investigation and the 2019 Robbinsville investigation are being reported here for the first time.

Accounts from Amcare employees across the country reveal that problems identified by OSHA are likely not confined to the warehouses it inspected. In interviews with The Intercept and Type Investigations, 15 current and former on-site medical representatives — Amazon’s term for the EMTs who staff Amcare — from fulfillment centers in 11 states bolster OSHA’s findings. Ten of the medical technicians said their bosses pressured them to send injured employees back to the warehouse floor when they likely needed additional medical attention. Eight felt like there was a conflict of interest between their manager’s priorities and their duties as medical professionals. Four said they were pressured to underreport or misclassify injuries. Some Amcare staff members described a positive experience with Amazon; even so, they expressed concerns about tensions between the company’s bottom line and injured employees’ best interests.