NEXT STOP, EMT Certified!For my senior Project I decided to become certified as an Emergency Medical Technician. Therefore, I took an EMT class at Southwest Colorado Community College last semester. In this class we had to read over the most recent prehospital care textbook, take several tests including written and practical, as well as collect 10-15 Patient Care Reports on Clinicals in the Mercy Emergency Room as well as on the ambulance with the Durango Fire Department. Once I passed the class I began to study to take the National Registry Test which is scheduled on May 30th.
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Why I chose to do this project was because Junior year we had the opportunity to do a month long internship and I chose to be on the ambulance for a month. So I was able to tag along on all the 911 calls, participate in the trainings, and just hang around the station with the firefighters. It was awesome, truly an eye opening experience and one I will always hold dear. This internship made me fall in love with the first responder field and lead me to want to become an EMT. Therefore I got accomplish my goal through this senior project and fulfill my dreams.
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TED TalkIn this TED talk I spoke to mental health illnesses commonly found in Emergency Medical System personnel and how it effects their lives.
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Senior thesis paper
What are the mental health effects of trauma experienced by EMS workers and how can they be effectively addressed?
Introduction:
How do they do it? How does one deal with chaos, trauma, and violence on such a regular basis? We see Paramedics and EMTs as superheroes. They are vigorous in dealing with consistent calls that require them to haul equipment up stairs or visit patients in the middle of the night; they defy death on a daily basis dealing with infectious diseases and hazardous situations such as chemical spills or gas leaks; they deal with all around traumatic situations where danger constantly surrounds them, as well as potentially violent situations where cries of pain and desperation surround them, all while being confident, friendly and keeping their cool. Their job is no picnic. In a speech for new recruits in a paramedics class by David Givot he stated:
“The only people paid less than you are preschool teachers, dishwashers and meatpackers….And none of those people are required to make life-or-death decisions. You will….It is a profession whose divorce, suicide and substance abuse rates soar far higher than the general population. The average career expectancy of an EMT is five years...” (qtd. in Grayson)
The general population sees them as invincible, Godsends even, but what is often forgotten is that they are just people like us. We do not think enough about the mental health of these people, as we do with soldiers or rape victims, but the reality is they deal with trauma everyday. “A 2015 survey by Fitch & Associates’ Ambulance Service Manager Program suggested that mental health struggles and depression among fire and EMS professionals are widespread. In the survey, 37 percent reported contemplating suicide, nearly 10 times the rate of American adults, while 6.6 percent reported having attempted suicide. That’s compared to just 0.5 percent of all adults” (NAEMT 4). Unfortunately, many EMTs and paramedics experience symptoms of mental health disorders, such a PTSD, due to their first-hand trauma encounters which results in affecting their personal life.
Part II: Historical Context/Background Knowledge:
EMTs and Paramedics fall into the first responder category of Emergency Medical Services (EMS), which is the treatment and transport of people in crisis health situations that may be life threatening. “EMS practices can be dated back to the Civil War, but it was not until 1865 that the first United States civilian ambulance was put into service in Cincinnati at Cincinnati General Hospital” (Montclair Ambulance Unit). The first practice of emergency medical services started in the military when they began to realize that in order to increase their soldiers’ survival rate, they needed quick medical attention, interventions, and transport. These practices quickly became routine in the military, which then spread into the soldiers’ life after war. As civilians, they used the medical practices from their service in their hometowns. Later on:
In December of 1869, the first month of operation of the ambulance service of the Free Hospital of New York (Bellevue) ran 74 calls. A total of 1466 calls were run in 1870. The dispatch system was different from that used today. The hospital ran a bess, which triggered a weight to fall, lighting the gas lamp to wake the physician and the driver. It also caused the harness, saddle, and collar to drop on the horse and opened the stable doors. (Montclair Ambulance Unit)
However, at the time, these services were limited to large cities and were still quite underdeveloped compared to the system they had in the military. Originally, patients would be transported in a hearse due to the fact that the hearse was the only transport that was big enough to fit bodies. It would pick up the wounded and rush them to the hospital where they could get the life saving treatment they needed. As transport was the primary focus, there were no medical interventions en route to the hospital, such as providing medications, oxygen, or even cardiopulmonary resuscitation (CPR) which was not introduced until the early 1970s. The patients were alone in the “patient compartment” aside from potentially a family member. After a while, the general population began to question the effectiveness of the current system and began to express their discomfort with the transportation. Then, a paper titled "Accidental Death and Disability: The Neglected Disease of Modern Society", written by the National Academy of Sciences and the National Research Council in 1966, came out describing the need for an improvement in the EMS system. It touched on the need to create treatment protocols, come up with better standardized training for staff, more efficient transportation, better communication methods and equipment, and the importance of doing more research on prehospital care. After the publication of this paper, immediate actions were taken in the improvement of the EMS system, unfortunately it did not come fast enough, thus began the first steps into a wide spread EMS program.
Once the EMS system was organized, put in place and on a good path, it was easier to see the toll that the EMS line of work had on their personnel. It was then possible to notice that mental health services was one of the things that had gotten forgotten in the scurry to improve the EMS system, and it still had a long way to come. An anonymous writer expressed his frustration in an EMS subscription’s article called EMS1’s Breaking the Silence in attempt to bring light to the problem that was being ignored, “But I am pissed. I’m F*#*ING PISSED AT EMS/FIRE FOR HOW IT HANDLES ITS OWN WHEN IT COMES TO OUR OWN MENTAL HEALTH!... I refuse to be silent when I know there are people on ambulances and engines going through exactly what I’m going through. Because, brothers and sisters, we have failed. I have failed. You have failed. We let our system become this broken. Now is time for fixing it” (EMS1). And they are right, mental health illnesses are very prevalent in the EMS community, and it is time to fix it. Yet in order to begin we must explore the roots of the problem. Which can be classified as the stress experienced by trauma.
Trauma is defined as either a deeply distressing or disturbing experience (mental trauma), or physical injury (physical trauma). Trauma can be classified under two categories: primary trauma and secondary trauma. Primary trauma is when a traumatic experience is experienced, witnessed or confronted first hand that caused intense fear, helplessness, or horror such as sexual assault, combat, abuse, terrorism, mass violence and even things like accidents and natural disasters. Secondary trauma is the trauma one gets from indirect means of exposure to trauma through a firsthand account or narrative of a traumatic event. This is the trauma that first responders frequently experience. “Secondary traumatization is also referred to as compassion fatigue and vicarious traumatization” (qtd. in Zimering) “Exposure to patients or clients experiencing trauma or distress can negatively impact professional’s mental and physical health, safety and wellbeing, as well as that of their families, the people they care for, and their employing organizations.” (Cocker)
Part III: Research and Analysis:
As a result of exposure to traumatic experiences, first responders can develop Post-Traumatic Stress Disorder (PTSD). PTSD is a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock. This typically involves disturbance of sleep and constant vivid recall of the experience, with dulled responses to others and to the outside world. Samantha Dutton, PhD, MSW, of the University of Phoenix, spoke on a recent study conducted by the university which surveyed first responders on their experiences with mental health issues, “Some of the more pertinent findings were that 85% of the first responders had experienced symptoms related to mental health issues,” says Dutton. “One third of them were formally diagnosed with either depression or PTSD...”(qtd. in Amato) Formally. There is no way to account for those who have not been diagnosed with PTSD. Even those who have been diagnosed have a hard time admitting to it or even wrapping their heads around it. As Benjamin Vernon, a San Diego paramedic humbly stated, “It’s hard to even write the acronym. I’ve always placed PTSD with our military veterans, and I’m reluctant to use the term because I feel like when I use it for myself, I’m taking away from the men and women in the armed services who’ve truly struggled to heal from life-altering physical and emotional wounds” (Vernon). Yet, PTSD can happen to anyone who is exposed to a life threatening situation. “Symptoms usually start soon after the traumatic event but may not appear until months or years later” (US Department of Veteran Affairs). It is treatable, but how effective the treatment is varies on the person. With PTSD, one can develop anxiety, depression, unhealthy coping mechanisms such as drinking and drugs, and so on. PTSD is a serious disorder and it is even more troubling to believe that it exists in our Paramedics and EMTs.
EMS personnel experience both primary and secondary trauma. However, they deal mostly with secondary trauma. EMS providers see all the “blood and guts”; they see all of the crying and pain that people experience and it takes a severe toll on them. Keep in mind that these EMS personnel see people on their worst day; they do not get called for the people who are healthy and laughing. Seeing people at their worst can be quite traumatic. There was an instance with Tim Casey, a Colorado Springs firefighter when he came upon a scene where a mother had accidentally backed over the head of her toddler. He recalled the hysterical mother running up to him and thrusting her toddler into his arms as its brain left a trail behind her, crying “Save my baby!” in the mist of tears. Casey stated, “It was still breathing, but there was nothing that could be done” (Casey). As a result of this secondary trauma, Casey sadly ended up committing suicide. These scenes are the things that haunt a person for the rest of their life. Other examples of secondary trauma are when the EMS providers feel like they could have saved a person if they had gotten there a little faster or tried a little harder. Or in the same instance, when they cannot enter the scene due to a safety hazard that has not been cleared by the police but can hear the cries of anguish just out of their reach and cannot do anything to help. An anonymous writer on an EMS1’s subscription article called Breaking the Silence experienced this on a call she went on where a 3 year old girl was thrown out of the back window of a car as her drunk mother took a turn too sharp, “I ran the entire call through my mind again and again, critiquing everything I had done, everything I hadn’t done. I questioned myself if there was anything I missed, anything I could have done differently. I knew that I had done everything I could and had given her every chance I could to live, but I still couldn’t make a difference” (EMS1). It is hard not take ‘it personal’ as the EMS provider when the lives of their patients are in their hands, even if nothing could have been done. EMS personnel also experience trauma when they experience encounter stress during calls every day without much of a break in between. In Raymond B. Flannery’s paper, “Treating Psychological Trauma in First Responders: A Multi-Modal Paradigm,” he recognized that, “Even if counselling were sought, the reality of the work would leave limited time for processing one critical incident before a second call for assistance at the next critical incident is received.” This causes them to not have time to correctly process each incident before another happens, which is not an effective way to begin healing. Their job requires them to be constantly ready for the next call and consistently be at the top of their game. This constant state of readiness is called hyperarousal and results in not having time to process and move on from a traumatic experience they have witnessed in their previous call before they get called out again. Virgina J. Duffy, the author of “Behavioral First Aid: Managing Emotions During Emergencies”, elaborates, “Hyperarousal is a natural response to stress and causes significant anxiety. It makes communication extremely difficult, and often compromises the ability to listen and understand and to make decisions” (Duffy). This secondary trauma then ends up affecting their personal lives and relationships, as they are always looking for the next potential danger and can never fully relax. The primary and secondary trauma EMS personnel experience greatly affect their lives and the lives of their loved ones.
Each traumatic experience is unique for every EMT. Not everyone is affected the same by a traumatic experience and not everyone considers the same things to be traumatic. For example, some are triggered by the gore seen on the job while others find the emotions and reactions of patients to be even more traumatizing. Glen Gillies, an Ontario paramedic, describes what significantly bothers him is when he has to let loved ones know that their loved one has passed, “that’s what bothers me most. Especially if it’s a child. Telling a child that their parents have died, or a telling parent that their child has died. I could stare at gunshots, eviscerations, decapitations all day long – they don’t get under my skin” (qtd. in Cameron). Everyone is affected by difference circumstances. Furthermore, not only is there an initial response to trauma, but the potential of being triggered by previous events worsens the impact. The sound of a crying baby which can remind one of a call where a child was abused or the sound of fireworks bringing up memories of explosions and perhaps a multi-casualty incident.
Being in the EMS field can furthermore put significant stress on family life. In a study for “Bringing The Trauma Home: Spouses Of Paramedics.” by Cheryl Regehr, they spoke to how concerned family members were, as the work of EMS personnel involves potentially dangerous situations such as violent patients and harmful infections and diseases:
“Family members in this study worried about the risks associated with violent patients and risks associated with travel on roads at high speeds, often in dangerous weather conditions. These family members also experienced real threats to safety from HIV infection, flesh eating disease, and SARS. When these threats were encountered, family members remained separate from one another and were quarantined, and all members had their activities significantly curtailed” (qtd. in Regehr)
Not only were the family members painfully aware of the dangers of being in EMS, they have to watch their loved ones go through the trauma they experience. “Jaideep Bains, PhD, and his team at the Hotchkiss Brain Institute in the Cumming School of Medicine have discovered that stress transmitted from others can change the brain in the same way as real stress does” (Cumming School of Medicine Staff). Experiencing the stress from their EMS family members can in turn causes more stress to the family members and they can experience symptoms of secondary trauma. The loved ones may also feel helpless to help their EMS spouse as they may not be a mental health professional thus may not have the skills to support them. Being an EMS worker also complicates things when there are small children involved; their unique schedule is hard to explain. How does one explain to a 3 year old that their parent is going to be almost non-existent for a full 48 hours of each week? and how does one explain that they may not be able to touch their parent because they may be infected with some harmful sickness? As a mother of young child expressed in the study for “Bringing The Trauma Home: Spouses Of Paramedics.” by Cheryl Regehr:
“He came home wearing a mask because he was going to be quarantined for five days. Our daughter hadn't seen him for five days and she came running around the corner and headed straight for him and I had to stop her and then all three of us started ball. I tried to explain to her why she couldn't touch him and then as I was explaining, I just went to pieces all the sudden.” (qtd. in Regehr)
It is difficult for the spouse of an EMS personnel as they almost become a single parent, dealing with kids all on their own while the significant other is working, having to resort to extra help among extended family or getting a part time job. Working in EMS can also take a toll on the relationship between partners. When your spouse comes home from a shift they may be physically and mentally exhausted and just want to be alone, when all their partner wants is to be with them. A participant in the above study stated, “We don't really get a chance to spend time together” while another stated, “one of the jokes we have is that were married for 28 years but it only feels like 10 because of the time we had apart.” (qtd. in Regehr) This can put strain on the relationship especially if their EMS partner is withdrawing and irritable. This can cause family members to be inclined to put their needs or problems “on the back burner” in order to care for their EMS spouse as their spouses problems seem to be more significant than theirs. One spouse in a study stated that though she might have been going through a rough day she always puts it aside to help her partner because her problems seemed insignificant compared to his, “ I know when it's been a bad day or bad call, most of my problems get put to the back burner. That's my choice for fear of triggering or making things worse. So if I had a bad day at work, I suck it up.” Jobs in the EMS field are harmful to the health of not only the personnel but to the people that surround them as well, and they will continue to be without bringing attention to mental health illnesses in the field.
Clearly, EMS personnel experience trauma that affects them and their lives, thus need mental health services to cope with it. There are two possible ways to improve mental health services within the EMS system. One is to change the stigma around getting help. There is a negative stigma, within the EMS community, associated with seeking help for oneself which causes EMS personnel to refrain from reaching out and getting treatment. This is due to the fear of being seen as weak by their co-workers or worse, being seen as unfit for their job thus unsuitable for a promotion and given less respect. Therefore, EMS personnel do not seek help as much as they should which is one of the reasons why mental health illnesses are such a big problem in the first responder community. In a 2016 survey conducted by the National Association of Emergency Medical Technicians (NAEMT) 2,200 EMTs, paramedics, EMS managers and medical directors were asked to rate the statement, “My agency considers mental health important.” “55% of participants agreed or strongly agreed, while 45% disagreed or strongly disagreed” (NAEMT 5). While there was a slight lean in agreement with this statement, the polls were almost 50/50 where there should be many more people agreeing with the statement and many less disagreeing with it. There were also many comments of high dismay and even disgust in response to how their agencies feel about mental health. One participant exclaimed, “The agency I work for sees mental health as a weakness. If you ask for help you become verbally abused by co-workers, supervisors and station managers. I needed help and was told, ‘that’s why women don’t belong in EMS. They’re overly emotional…’” (NAEMT 10) This describes a common relationship EMS personnel have with each other and how dismissive coworkers can be towards the impact of trauma on EMS personnel. Other participants also repeatedly expressed that their agencies did not take mental health seriously as well. One participant offered, “Mental health is a joke to management. They still operate on the philosophy that if you can’t handle it, you’re in the wrong line of work” (NAEMT 12). Obviously, the issue of mental health is more complex than this outdated philosophy. It is important to make people in this profession aware that mental illness in the EMS system is very real and even normal, because even EMS providers forget that they are human at times. Yet, it is also important to note that not all agencies are this way and that there was a significant amount of positive feedback in the survey as well, saying things such as, “My company takes mental health seriously...I am proud of my agency.” and “I had to use mental health resources after a pediatric trauma code. It took a few months for me to fully deal with it, but the services provided helped greatly” (NAEMT 10). Even though there are agencies that are working to improve the culture around mental health, there are still some improvements that need to be made. Another way to help improve mental health services for EMS staff is to have specialized counsellors who understand the EMS life available to help EMTs process their on-the-job experiences. One survey participant said, “The only mental health resource we have is our EAP. They are not used to talking to EMS. Word on the street is that if you talk to them regarding work issues, you’ll be counseled to leave EMS. We’d like to talk to someone that understands EMS issues.” (NAEMT 13) Overall, the general EMS community wants help, “If I can’t take care of myself, I am unable to take care of others. I have found ways of coping with the stress that I acquire on the job but many of my coworkers have not. Let’s face it, we don’t get called because someone is having a great day. It would be extremely beneficial to have a functioning, non-biased mental health service within our EMS system to help lighten the load and help us take care of ourselves first” (NAEMT 13).
Part IV: Discussion and Conclusions:
EMS personnel are ordinary people who risk their lives everyday to help us when we are in the most need. When coming to a victim’s rescue, EMS personnel can experience primary and secondary trauma which can often result in mental health issues. These mental health issues, such as PTSD, are very real issues within the EMS community that affect not only the EMTs and paramedics but also their families. The effect on families can take the form of family members taking on the EMTs’ stress, watching them struggle with depression and other symptoms of mental illnesses that can result in them drifting away from their families. Currently, there isn’t much mental health support available and often, when support is sought, EMS personnel is ridiculed by their peers which prevents the pursuit of further support. This lack of seeking support often lead to coping through addiction of harmful substances or attempting suicide. “A 2015 survey by Fitch & Associates’ Ambulance Service Manager Program suggested that mental health struggles and depression among fire and EMS professionals are widespread. In the survey, 37 percent reported contemplating suicide, nearly 10 times the rate of American adults, while 6.6 percent reported having attempted suicide. That’s compared to just 0.5 percent of all adults” (NAEMT 4). As the knowledge of mental illnesses in EMS personnel grows, more support programs need to be put in place to help EMS personnel cope.
In order to prevent further loss in EMS personnel we must continue to raise awareness and dissolve the stigma of weakness that comes with seeking mental health support, because these are just signs that we are human. This may come in the form of more education, increasing access to employee assistance programs and other support services such as therapy, and continuing the important dialogue started by organization like the Code Green Campaign and the #IVEGOTYOURBACK911. EMS personnel have always been there in our times of most need, is it not time to return the favor by helping them overcome the darkness of mental health illnesses that constantly looms over their heads?
Works Cited:
“About.” The Code Green Campaign, www.codegreencampaign.org/.
Amato, Valerie. “Survey Shows High Rates of Depression, PTSD Among First Responders.” EMS World, 9 May 2017, www.emsworld.com/article/12333043/survey-shows-high-rates-of-depression-ptsd-among-first-responders.
Cameron, Trevor. “PARAMEDICS & MENTAL HEALTH TRAUMA .” #SickNotWeak, 9 Aug. 2016, www.sicknotweak.com/2016/08/paramedics-mental-health-trauma/.
Casey, Tim, director. Firefighter/Paramedic. Youtube, 12 Mar. 2015, www.youtube.com/watch?v=D_-e91ipHTE&t=2s.
Cocker, Fiona, and Nerida Joss. "Compassion Fatigue Among Healthcare, Emergency And Community Service Workers: A Systematic Review." International Journal of Environmental Research and Public Health 13.6 (2016): 618. Web. 27 Mar. 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924075/
Duffy, Virginia J. “Managing Emotions During Stressful Events.” EMS World, 28 July 2011, www.emsworld.com/article/10318643/managing-emotions-during-stressful-events.
Grayson, Kelly. “Joining EMS? Here's What You're Really Getting into...” EMS1, 13 Oct. 2010, www.ems1.com/ems-advocacy/articles/894089-Joining-EMS-Heres-what-youre-really-getting-into/.
“History of Emergency Medical Services.” Montclair Ambulance Unit, www.mvau.org/ems-history.html.
“'I'm Pissed:' How EMS Handles It's Own with Mental Health Issues.” EMS1, 2 July 2015, www.ems1.com/ems-products/fitness-health/articles/2230890-Im-pissed-How-EMS-handles-its-own-with-mental-health-issues/.
Interagencyboard.org. N. p., 2018. Web. 5 Mar. 2018. https://www.interagencyboard.org/system/files/resources/2016-naemt-mental-health-report-8-14-16.pdf
Songer, Pat. “Mental Health and Stress in Emergency Medical Services.” National EMS Management Association, Feb. 2016, https://gallery.mailchimp.com/4fc16bc3cc5a64732265e3bca/files/NEMSMA_Mental_Health_and_Stress.pdf?utm_source=Fitch+%26+Assoc+Master+List&utm_campaign=9ffeeaf32a-New+Report+Addresses+Caregiver+Stress+and+Suicide&utm_medium=email&utm_term=0_3141ab550e-9ffeeaf32a-113007385.
“Post-Traumatic Stress Disorder.” Mental Health America, www.mentalhealthamerica.net/conditions/post-traumatic-stress-disorder.
Regehr, Cheryl. “Bringing The Trauma Home: Spouses Of Paramedics.” Journal of Loss and Trauma, vol. 10, no. 2, 2005, pp. 97–114., doi:10.1080/15325020590908812.
Shah, Manish N. “The Formation of the Emergency Medical Services System.” US National Library of Medicine: National Institutes of Health , Mar. 2006, www.bing.com/cr?IG=B8AAE89A6CF841FEBE2802A66B4BD370&CID=1D23BC76E8C06BFF0F27B7DFE96F6A00&rd=1&h=4HNP4UdzfhFfi9RuXSBlrp5F8QzbihKUlxOxSi4b1HM&v=1&r=http%3a%2f%2fwww.mvau.org%2fems-history.html&p=DevEx,5067.1.
Vernon, Benjamin. “How One Paramedic Is Recovering from PTSD.” Jems.com, 15 Jan. 2016, www.jems.com/articles/print/volume-41/issue-2/features/how-one-paramedic-is-recovering-from-ptsd.html.
“What Is PTSD?” US Department of Veteran Affairs , 15 Sept. 2017, www.ptsd.va.gov/public/PTSD-overview/basics/what-is-ptsd.asp.
“Why the Ghost of a Little Girl Now Comforts Instead of Haunts.” EMS1, 28 Apr. 2015, www.ems1.com/health-and-wellness/articles/2164279-Why-the-ghost-of-a-little-girl-now-comforts-instead-of-haunts/.
"Your Stress Is Now My Stress: Research Study Explains How." UToday | University of Calgary. N. p., 2018. Web. 28 Mar. 2018. https://www.ucalgary.ca/utoday/issue/2018-02-13/your-stress-now-my-stress-research-study-explains-how
Zimering, Rose, and Suzy Bird Gulliver. “Secondary Traumatization in Mental Health Care Providers.” Psychiatric Times, 1 Apr. 2003, www.psychiatrictimes.com/ptsd/secondary-traumatization-mental-health-care-providers.
“2016 NATIONAL SURVEY ON EMS MENTAL HEALTH SERVICES.” JEMS, 2016, pp. 4–15, www.interagencyboard.org/system/files/resources/2016-naemt-mental-health-report-8-14-16.pdf.
How do they do it? How does one deal with chaos, trauma, and violence on such a regular basis? We see Paramedics and EMTs as superheroes. They are vigorous in dealing with consistent calls that require them to haul equipment up stairs or visit patients in the middle of the night; they defy death on a daily basis dealing with infectious diseases and hazardous situations such as chemical spills or gas leaks; they deal with all around traumatic situations where danger constantly surrounds them, as well as potentially violent situations where cries of pain and desperation surround them, all while being confident, friendly and keeping their cool. Their job is no picnic. In a speech for new recruits in a paramedics class by David Givot he stated:
“The only people paid less than you are preschool teachers, dishwashers and meatpackers….And none of those people are required to make life-or-death decisions. You will….It is a profession whose divorce, suicide and substance abuse rates soar far higher than the general population. The average career expectancy of an EMT is five years...” (qtd. in Grayson)
The general population sees them as invincible, Godsends even, but what is often forgotten is that they are just people like us. We do not think enough about the mental health of these people, as we do with soldiers or rape victims, but the reality is they deal with trauma everyday. “A 2015 survey by Fitch & Associates’ Ambulance Service Manager Program suggested that mental health struggles and depression among fire and EMS professionals are widespread. In the survey, 37 percent reported contemplating suicide, nearly 10 times the rate of American adults, while 6.6 percent reported having attempted suicide. That’s compared to just 0.5 percent of all adults” (NAEMT 4). Unfortunately, many EMTs and paramedics experience symptoms of mental health disorders, such a PTSD, due to their first-hand trauma encounters which results in affecting their personal life.
Part II: Historical Context/Background Knowledge:
EMTs and Paramedics fall into the first responder category of Emergency Medical Services (EMS), which is the treatment and transport of people in crisis health situations that may be life threatening. “EMS practices can be dated back to the Civil War, but it was not until 1865 that the first United States civilian ambulance was put into service in Cincinnati at Cincinnati General Hospital” (Montclair Ambulance Unit). The first practice of emergency medical services started in the military when they began to realize that in order to increase their soldiers’ survival rate, they needed quick medical attention, interventions, and transport. These practices quickly became routine in the military, which then spread into the soldiers’ life after war. As civilians, they used the medical practices from their service in their hometowns. Later on:
In December of 1869, the first month of operation of the ambulance service of the Free Hospital of New York (Bellevue) ran 74 calls. A total of 1466 calls were run in 1870. The dispatch system was different from that used today. The hospital ran a bess, which triggered a weight to fall, lighting the gas lamp to wake the physician and the driver. It also caused the harness, saddle, and collar to drop on the horse and opened the stable doors. (Montclair Ambulance Unit)
However, at the time, these services were limited to large cities and were still quite underdeveloped compared to the system they had in the military. Originally, patients would be transported in a hearse due to the fact that the hearse was the only transport that was big enough to fit bodies. It would pick up the wounded and rush them to the hospital where they could get the life saving treatment they needed. As transport was the primary focus, there were no medical interventions en route to the hospital, such as providing medications, oxygen, or even cardiopulmonary resuscitation (CPR) which was not introduced until the early 1970s. The patients were alone in the “patient compartment” aside from potentially a family member. After a while, the general population began to question the effectiveness of the current system and began to express their discomfort with the transportation. Then, a paper titled "Accidental Death and Disability: The Neglected Disease of Modern Society", written by the National Academy of Sciences and the National Research Council in 1966, came out describing the need for an improvement in the EMS system. It touched on the need to create treatment protocols, come up with better standardized training for staff, more efficient transportation, better communication methods and equipment, and the importance of doing more research on prehospital care. After the publication of this paper, immediate actions were taken in the improvement of the EMS system, unfortunately it did not come fast enough, thus began the first steps into a wide spread EMS program.
Once the EMS system was organized, put in place and on a good path, it was easier to see the toll that the EMS line of work had on their personnel. It was then possible to notice that mental health services was one of the things that had gotten forgotten in the scurry to improve the EMS system, and it still had a long way to come. An anonymous writer expressed his frustration in an EMS subscription’s article called EMS1’s Breaking the Silence in attempt to bring light to the problem that was being ignored, “But I am pissed. I’m F*#*ING PISSED AT EMS/FIRE FOR HOW IT HANDLES ITS OWN WHEN IT COMES TO OUR OWN MENTAL HEALTH!... I refuse to be silent when I know there are people on ambulances and engines going through exactly what I’m going through. Because, brothers and sisters, we have failed. I have failed. You have failed. We let our system become this broken. Now is time for fixing it” (EMS1). And they are right, mental health illnesses are very prevalent in the EMS community, and it is time to fix it. Yet in order to begin we must explore the roots of the problem. Which can be classified as the stress experienced by trauma.
Trauma is defined as either a deeply distressing or disturbing experience (mental trauma), or physical injury (physical trauma). Trauma can be classified under two categories: primary trauma and secondary trauma. Primary trauma is when a traumatic experience is experienced, witnessed or confronted first hand that caused intense fear, helplessness, or horror such as sexual assault, combat, abuse, terrorism, mass violence and even things like accidents and natural disasters. Secondary trauma is the trauma one gets from indirect means of exposure to trauma through a firsthand account or narrative of a traumatic event. This is the trauma that first responders frequently experience. “Secondary traumatization is also referred to as compassion fatigue and vicarious traumatization” (qtd. in Zimering) “Exposure to patients or clients experiencing trauma or distress can negatively impact professional’s mental and physical health, safety and wellbeing, as well as that of their families, the people they care for, and their employing organizations.” (Cocker)
Part III: Research and Analysis:
As a result of exposure to traumatic experiences, first responders can develop Post-Traumatic Stress Disorder (PTSD). PTSD is a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock. This typically involves disturbance of sleep and constant vivid recall of the experience, with dulled responses to others and to the outside world. Samantha Dutton, PhD, MSW, of the University of Phoenix, spoke on a recent study conducted by the university which surveyed first responders on their experiences with mental health issues, “Some of the more pertinent findings were that 85% of the first responders had experienced symptoms related to mental health issues,” says Dutton. “One third of them were formally diagnosed with either depression or PTSD...”(qtd. in Amato) Formally. There is no way to account for those who have not been diagnosed with PTSD. Even those who have been diagnosed have a hard time admitting to it or even wrapping their heads around it. As Benjamin Vernon, a San Diego paramedic humbly stated, “It’s hard to even write the acronym. I’ve always placed PTSD with our military veterans, and I’m reluctant to use the term because I feel like when I use it for myself, I’m taking away from the men and women in the armed services who’ve truly struggled to heal from life-altering physical and emotional wounds” (Vernon). Yet, PTSD can happen to anyone who is exposed to a life threatening situation. “Symptoms usually start soon after the traumatic event but may not appear until months or years later” (US Department of Veteran Affairs). It is treatable, but how effective the treatment is varies on the person. With PTSD, one can develop anxiety, depression, unhealthy coping mechanisms such as drinking and drugs, and so on. PTSD is a serious disorder and it is even more troubling to believe that it exists in our Paramedics and EMTs.
EMS personnel experience both primary and secondary trauma. However, they deal mostly with secondary trauma. EMS providers see all the “blood and guts”; they see all of the crying and pain that people experience and it takes a severe toll on them. Keep in mind that these EMS personnel see people on their worst day; they do not get called for the people who are healthy and laughing. Seeing people at their worst can be quite traumatic. There was an instance with Tim Casey, a Colorado Springs firefighter when he came upon a scene where a mother had accidentally backed over the head of her toddler. He recalled the hysterical mother running up to him and thrusting her toddler into his arms as its brain left a trail behind her, crying “Save my baby!” in the mist of tears. Casey stated, “It was still breathing, but there was nothing that could be done” (Casey). As a result of this secondary trauma, Casey sadly ended up committing suicide. These scenes are the things that haunt a person for the rest of their life. Other examples of secondary trauma are when the EMS providers feel like they could have saved a person if they had gotten there a little faster or tried a little harder. Or in the same instance, when they cannot enter the scene due to a safety hazard that has not been cleared by the police but can hear the cries of anguish just out of their reach and cannot do anything to help. An anonymous writer on an EMS1’s subscription article called Breaking the Silence experienced this on a call she went on where a 3 year old girl was thrown out of the back window of a car as her drunk mother took a turn too sharp, “I ran the entire call through my mind again and again, critiquing everything I had done, everything I hadn’t done. I questioned myself if there was anything I missed, anything I could have done differently. I knew that I had done everything I could and had given her every chance I could to live, but I still couldn’t make a difference” (EMS1). It is hard not take ‘it personal’ as the EMS provider when the lives of their patients are in their hands, even if nothing could have been done. EMS personnel also experience trauma when they experience encounter stress during calls every day without much of a break in between. In Raymond B. Flannery’s paper, “Treating Psychological Trauma in First Responders: A Multi-Modal Paradigm,” he recognized that, “Even if counselling were sought, the reality of the work would leave limited time for processing one critical incident before a second call for assistance at the next critical incident is received.” This causes them to not have time to correctly process each incident before another happens, which is not an effective way to begin healing. Their job requires them to be constantly ready for the next call and consistently be at the top of their game. This constant state of readiness is called hyperarousal and results in not having time to process and move on from a traumatic experience they have witnessed in their previous call before they get called out again. Virgina J. Duffy, the author of “Behavioral First Aid: Managing Emotions During Emergencies”, elaborates, “Hyperarousal is a natural response to stress and causes significant anxiety. It makes communication extremely difficult, and often compromises the ability to listen and understand and to make decisions” (Duffy). This secondary trauma then ends up affecting their personal lives and relationships, as they are always looking for the next potential danger and can never fully relax. The primary and secondary trauma EMS personnel experience greatly affect their lives and the lives of their loved ones.
Each traumatic experience is unique for every EMT. Not everyone is affected the same by a traumatic experience and not everyone considers the same things to be traumatic. For example, some are triggered by the gore seen on the job while others find the emotions and reactions of patients to be even more traumatizing. Glen Gillies, an Ontario paramedic, describes what significantly bothers him is when he has to let loved ones know that their loved one has passed, “that’s what bothers me most. Especially if it’s a child. Telling a child that their parents have died, or a telling parent that their child has died. I could stare at gunshots, eviscerations, decapitations all day long – they don’t get under my skin” (qtd. in Cameron). Everyone is affected by difference circumstances. Furthermore, not only is there an initial response to trauma, but the potential of being triggered by previous events worsens the impact. The sound of a crying baby which can remind one of a call where a child was abused or the sound of fireworks bringing up memories of explosions and perhaps a multi-casualty incident.
Being in the EMS field can furthermore put significant stress on family life. In a study for “Bringing The Trauma Home: Spouses Of Paramedics.” by Cheryl Regehr, they spoke to how concerned family members were, as the work of EMS personnel involves potentially dangerous situations such as violent patients and harmful infections and diseases:
“Family members in this study worried about the risks associated with violent patients and risks associated with travel on roads at high speeds, often in dangerous weather conditions. These family members also experienced real threats to safety from HIV infection, flesh eating disease, and SARS. When these threats were encountered, family members remained separate from one another and were quarantined, and all members had their activities significantly curtailed” (qtd. in Regehr)
Not only were the family members painfully aware of the dangers of being in EMS, they have to watch their loved ones go through the trauma they experience. “Jaideep Bains, PhD, and his team at the Hotchkiss Brain Institute in the Cumming School of Medicine have discovered that stress transmitted from others can change the brain in the same way as real stress does” (Cumming School of Medicine Staff). Experiencing the stress from their EMS family members can in turn causes more stress to the family members and they can experience symptoms of secondary trauma. The loved ones may also feel helpless to help their EMS spouse as they may not be a mental health professional thus may not have the skills to support them. Being an EMS worker also complicates things when there are small children involved; their unique schedule is hard to explain. How does one explain to a 3 year old that their parent is going to be almost non-existent for a full 48 hours of each week? and how does one explain that they may not be able to touch their parent because they may be infected with some harmful sickness? As a mother of young child expressed in the study for “Bringing The Trauma Home: Spouses Of Paramedics.” by Cheryl Regehr:
“He came home wearing a mask because he was going to be quarantined for five days. Our daughter hadn't seen him for five days and she came running around the corner and headed straight for him and I had to stop her and then all three of us started ball. I tried to explain to her why she couldn't touch him and then as I was explaining, I just went to pieces all the sudden.” (qtd. in Regehr)
It is difficult for the spouse of an EMS personnel as they almost become a single parent, dealing with kids all on their own while the significant other is working, having to resort to extra help among extended family or getting a part time job. Working in EMS can also take a toll on the relationship between partners. When your spouse comes home from a shift they may be physically and mentally exhausted and just want to be alone, when all their partner wants is to be with them. A participant in the above study stated, “We don't really get a chance to spend time together” while another stated, “one of the jokes we have is that were married for 28 years but it only feels like 10 because of the time we had apart.” (qtd. in Regehr) This can put strain on the relationship especially if their EMS partner is withdrawing and irritable. This can cause family members to be inclined to put their needs or problems “on the back burner” in order to care for their EMS spouse as their spouses problems seem to be more significant than theirs. One spouse in a study stated that though she might have been going through a rough day she always puts it aside to help her partner because her problems seemed insignificant compared to his, “ I know when it's been a bad day or bad call, most of my problems get put to the back burner. That's my choice for fear of triggering or making things worse. So if I had a bad day at work, I suck it up.” Jobs in the EMS field are harmful to the health of not only the personnel but to the people that surround them as well, and they will continue to be without bringing attention to mental health illnesses in the field.
Clearly, EMS personnel experience trauma that affects them and their lives, thus need mental health services to cope with it. There are two possible ways to improve mental health services within the EMS system. One is to change the stigma around getting help. There is a negative stigma, within the EMS community, associated with seeking help for oneself which causes EMS personnel to refrain from reaching out and getting treatment. This is due to the fear of being seen as weak by their co-workers or worse, being seen as unfit for their job thus unsuitable for a promotion and given less respect. Therefore, EMS personnel do not seek help as much as they should which is one of the reasons why mental health illnesses are such a big problem in the first responder community. In a 2016 survey conducted by the National Association of Emergency Medical Technicians (NAEMT) 2,200 EMTs, paramedics, EMS managers and medical directors were asked to rate the statement, “My agency considers mental health important.” “55% of participants agreed or strongly agreed, while 45% disagreed or strongly disagreed” (NAEMT 5). While there was a slight lean in agreement with this statement, the polls were almost 50/50 where there should be many more people agreeing with the statement and many less disagreeing with it. There were also many comments of high dismay and even disgust in response to how their agencies feel about mental health. One participant exclaimed, “The agency I work for sees mental health as a weakness. If you ask for help you become verbally abused by co-workers, supervisors and station managers. I needed help and was told, ‘that’s why women don’t belong in EMS. They’re overly emotional…’” (NAEMT 10) This describes a common relationship EMS personnel have with each other and how dismissive coworkers can be towards the impact of trauma on EMS personnel. Other participants also repeatedly expressed that their agencies did not take mental health seriously as well. One participant offered, “Mental health is a joke to management. They still operate on the philosophy that if you can’t handle it, you’re in the wrong line of work” (NAEMT 12). Obviously, the issue of mental health is more complex than this outdated philosophy. It is important to make people in this profession aware that mental illness in the EMS system is very real and even normal, because even EMS providers forget that they are human at times. Yet, it is also important to note that not all agencies are this way and that there was a significant amount of positive feedback in the survey as well, saying things such as, “My company takes mental health seriously...I am proud of my agency.” and “I had to use mental health resources after a pediatric trauma code. It took a few months for me to fully deal with it, but the services provided helped greatly” (NAEMT 10). Even though there are agencies that are working to improve the culture around mental health, there are still some improvements that need to be made. Another way to help improve mental health services for EMS staff is to have specialized counsellors who understand the EMS life available to help EMTs process their on-the-job experiences. One survey participant said, “The only mental health resource we have is our EAP. They are not used to talking to EMS. Word on the street is that if you talk to them regarding work issues, you’ll be counseled to leave EMS. We’d like to talk to someone that understands EMS issues.” (NAEMT 13) Overall, the general EMS community wants help, “If I can’t take care of myself, I am unable to take care of others. I have found ways of coping with the stress that I acquire on the job but many of my coworkers have not. Let’s face it, we don’t get called because someone is having a great day. It would be extremely beneficial to have a functioning, non-biased mental health service within our EMS system to help lighten the load and help us take care of ourselves first” (NAEMT 13).
Part IV: Discussion and Conclusions:
EMS personnel are ordinary people who risk their lives everyday to help us when we are in the most need. When coming to a victim’s rescue, EMS personnel can experience primary and secondary trauma which can often result in mental health issues. These mental health issues, such as PTSD, are very real issues within the EMS community that affect not only the EMTs and paramedics but also their families. The effect on families can take the form of family members taking on the EMTs’ stress, watching them struggle with depression and other symptoms of mental illnesses that can result in them drifting away from their families. Currently, there isn’t much mental health support available and often, when support is sought, EMS personnel is ridiculed by their peers which prevents the pursuit of further support. This lack of seeking support often lead to coping through addiction of harmful substances or attempting suicide. “A 2015 survey by Fitch & Associates’ Ambulance Service Manager Program suggested that mental health struggles and depression among fire and EMS professionals are widespread. In the survey, 37 percent reported contemplating suicide, nearly 10 times the rate of American adults, while 6.6 percent reported having attempted suicide. That’s compared to just 0.5 percent of all adults” (NAEMT 4). As the knowledge of mental illnesses in EMS personnel grows, more support programs need to be put in place to help EMS personnel cope.
In order to prevent further loss in EMS personnel we must continue to raise awareness and dissolve the stigma of weakness that comes with seeking mental health support, because these are just signs that we are human. This may come in the form of more education, increasing access to employee assistance programs and other support services such as therapy, and continuing the important dialogue started by organization like the Code Green Campaign and the #IVEGOTYOURBACK911. EMS personnel have always been there in our times of most need, is it not time to return the favor by helping them overcome the darkness of mental health illnesses that constantly looms over their heads?
Works Cited:
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