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Stress: The Silent Killer of the EMS Career
Stress is detrimental to any person’s health, but general stress and the stress of an emergency responder are obviously very different. There is stress from having an unpaid bill or too much homework due in too little time; then there’s the stress of working a cardiac arrest where the patient can’t be resuscitated.
When extremely emotional situations are mixed with common everyday emotions, it can be hard to juggle solutions and cope. On a daily basis firefighters, police, and emergency medical workers are all exposed to the risks of seeing death and destruction.
Suicide rates are high in the public safety professions. Divorce rates are growing. Burnout must be addressed, as well as long hours. New solutions must be proposed and evaluated.
Young Personnel
Paramedics as young as 19 years old work on advanced life support ambulances. Studies have shown the human brain does not fully mature until age 25.1 A crew on an EMS shift may run multiple calls during a single shift, where they may be responsible for pronouncing patients deceased.
A 19-year-old provider could respond to a decapitated body on a roadway or enter a home in which an infant is dead in its crib. After making the pronouncement and breaking the news to the family, their next call may be for someone who claims to have back pain but just wants to be medicated. This is where the stress begins.
After a young provider earns his or her license, those initial calls are fueled with adrenaline, making the new provider proud to be who they are. But after three years of those calls, the stress and pressure that accompany the job can begin to weigh on them. That bright 19-year-old is now 22 and still three years away from reaching average brain maturity level.
Shift Hours
A 2009 survey indicated more than 54% of EMS services still use 24-hour shifts, around 29% use 12-hour shifts, and only 7% report using either 8- or 10-hour shifts.2 Coupled with stress, shift hours can be very detrimental to workers’ mental and emotional well-being.
According to Lt. Keith Ellis, Tennessee’s Washington County-Johnson City EMS uses both 12- and 24-hour shifts. It’s recently begun working some crews on 12-hour shifts due to the danger of employee fatigue. The service’s average call volume is 32,000 annually, or 10–20 calls per day per ambulance. Each call can take anywhere from 1–3 hours to clear, depending on its nature.
Do this math, and you’ll find some crews may not stop during their entire 24-hour shift. Half of EMS personnel sleep only six hours every 24, with more than half reporting poor sleep quality and 70% reporting some problems with sleep.3 Loss of sleep, stressful situations, and not eating on a regular schedule could push an already-stressed employee close to the edge.
Insufficient sleep has been linked to cardiovascular disease, obesity, metabolic disorders, gastrointestinal conditions, hunger/appetite, and changes in emotion.3 Research has found higher levels of negative behavior correlating to sleep deprivation and that a person going without sleep for 24 hours experiences impairment equivalent to a blood alcohol level of 0.10%.2
The Dangers of the Job
The high potential for serious injury in EMS is also a stressor. In 2014 the Bureau of Labor Statistics reported the overall injury rate for EMTs and paramedics was 333 injuries per 10,000 workers—more than three times higher than the average rate of 107 for all occupational groups in the U.S.4
Occupational hazards for EMS professionals include emergency vehicle accidents or being struck by an oncoming vehicle while working a motor vehicle accident; issues of exposure to communicable diseases due to working with needles and blood in the back of a moving vehicle; and patients who become combative due to drug use, seizures, or even blood sugar issues. Furthermore, obesity continues to skyrocket, increasing our risk of neck and back injuries.
AIDS: Ambulance-Induced Divorce Syndrome
After working a long, dangerous shift, taking your work home is problematic. Employees may need a way to vent their emotions, and often they turn to family. Some spouses may be able to withstand the pressure, but others prefer not to hear about a dead child or someone being decapitated. The provider is unable to share their emotions with the person they rely on most for support.
A 2015 look at firefighters’ divorce rates found 77% of male firefighters married and 11.8% divorced.5 The U.S. population averages are 57.5% married and 9.4% divorced. Among female firefighters, 42.6% were married and 32.1% divorced. The U.S. averages for women are 55.4% and 10.4% respectively.
For an already-stressed emergency responder, divorce could be the turning point for a potential emotional breakdown.
What Is EMS Burnout?
Currently the average career span of an EMT or paramedic is only five years.6 This is due in part to burnout and stress and in part to the job’s physical toll.
Burnout is typically described as a pattern of negative affective responses that further reduce job satisfaction, productivity, and performance, and that is known to increase absenteeism and turnover.7 Along with this come decreased social engagement, poor bedside manner, trouble at home due to negative emotions after shifts, and possibly suicidal ideations.
At this point it’s time for solutions and for supervisory staff to see the importance of stress management before devastating life-changing decisions are made.
Burnout, no sleep, low nutrition, and fatigue comprise a recipe for post-traumatic stress disorder, prevalent in the emergency services. PTSD is characterized by an initial state of numbness while the individual attempts to assimilate the traumatic experience.8 When an emergency responder runs a bad call, they must clear the call, clean the ambulance, and prepare for whatever’s next. Getting another bad call right away is a strong possibility and departments should weigh preventive and proactive policies.
The national average for suicide contemplation, per the CDC, is about 3.7%. A 2015 survey of emergency personnel found their rate to be 37%. The national average for suicide attempts is 0.5%; among emergency personnel it’s 6.6%.9
Solutions to Stress
Unfortunately it’s impossible to unsee what’s seen or undo what’s done. Emergency services must find better ways to help their employees cope.
Call-in crews—One solution could be “call-in crews.” These crews could be stocked with part-time employees who can replace full-time employees in the event they run a defined “bad call.” If a crew works a call with a dead or seriously injured child or other troubling stressor, they should be able to come off shift immediately if they feel the need. Some employees have their “outlet person” at work; being off duty will provide time to express feelings to this person without the interruption of the radio.
Critical incident stress debriefings—Many services implement critical incident stress debriefings. These are aimed at helping individuals contextualize their experience of trauma at an early stage, thus preventing the development of PTSD.8 CISD is for all services and is recommended to be held no longer than 72 hours after the incident.10 This meeting will allow each person on scene to discuss their feelings openly with no judgment. There is a professional present for reassurance of skills performed on scene and general handling of the situation.
CISD attendance should be not mandatory. Some crew members may not feel comfortable discussing their feelings with others. Some may have attended stress debriefings they felt were unorganized or unprofessional.
The organization and effectiveness of meetings should be given a closer look. There have been reports of spouses and boyfriends or girlfriends being involved, or others in the department who weren’t on the call. Only those involved with the tragic event should attend.
A CISD should not be a show; it should be a neutral setting where those who have difficulty expelling their feelings have a common, comfortable outlet. In one study of duty-related stress among police officers, 63% of respondents found CISDs beneficial.8
Psychological first aid (PFA)—PFA is similar to CISD in offering immediate mental care for those who’ve just experienced a traumatic event, but it uses more of a “laid-back” approach. While CISD is more protocol-driven, PFA is built more for enhancing one’s natural resilience to the traumatic events.11 PFA is also focused more toward individual needs than being a group practice.
Emergency services have come a long way in a short time in this country. However, many issues still need to be worked out, particularly concerning the well-being of our caregivers. Sometimes it’s the heroes who need to be saved.
References
1. University of Rochester Medical Center. Understanding the Teen Brain, www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=1&ContentID=3051.
2. Cotter S. Seeking Shift Work Solutions. EMS World, www.emsworld.com/article/10231867/seeking-shift-work-solutions.
3. Patterson D. Evidence-based guidelines for combatting fatigue in EMS. J Emerg Med Serv, 2018 Feb; 43(2).
4. Maguire BJ, O’Neill BJ. Emergency medical service personnel’s risk from violence while serving the community. Am J Public Health, 2017 Nov; 107(11): 1,770–5.
5. Jahnke S. Firefighter divorce: 3 important facts. FireRescue1, www.firerescue1.com/fire-rehab/articles/2181154-Firefighter-divorce-3-important-facts/.
6. Grayson K. Joining EMS? Here’s what you’re really getting into… EMS1, www.ems1.com/ems-education/articles/894089-Joining-EMS-Heres-what-youre-really-getting-into/.
7. Collopy KT, Kivlehan SM, Snyder SR. Are You Under Stress in EMS? EMS World, www.emsworld.com/article/10776875/are-you-under-stress-ems.
8. Irving P, Long A. Critical incident stress debriefing following traumatic life experiences. J Psychiatr Ment Health Nurs, 2001 Aug; 8(4): 307–14.
9. Newland C, Barber E, Rose M, Young A. Survey reveals alarming rates of EMS provider stress and thoughts of suicide. J Emerg Med Serv, 2015; 40(10).
10. Schottke D. Workforce Safety and Wellness. In: Pollak A (ed.), Emergency Medical Responder: Your First Response in Emergency Care. Burlington, MA: Jones and Bartlett, 2018.
11. Siarnicki RJ. Understanding Psychological First Aid for First Responders. My Firefighter Nation, https://my.firefighternation.com/profiles/blogs/understanding-psychological.
Hollie Backberg, NRP, AAS, is a health science/EMR instructor at David Crockett High School in Jonesborough, Tenn.
Comments
I think the article was good. It gave statistics on the percentages of suicide, divorce, and the percentage of people who find the CSID beneficial. I have actually taken a CSID and it was pretty good. I do however agree that there should be some kind of plan in place for every
First responder. That if u ran a bad call that u come off the truck and go to a CSID if you would like to.
—Tommy Hunter