Minding the Mind of EMS—Part I

If I can stop one heart from breaking,

I shall not live in vain;

If I can ease one life the aching,

Or cool one pain,

Or help one fainting robin

Unto his nest again,

I shall not live in vain.

—Emily Dickinson

In this two-part series, the authors will shed a refocused light on crisis coping and the emotional challenges faced by EMS every day even prior to the psychologically fatiguing COVID-19 pandemic. They will share examples of new, realistically sustainable initiatives that can better support the psychological well-being of our EMS and other public safety families on the frontlines worldwide now and going forward. 

The impact of EMS responses on the mental well-being of public safety personnel was appreciated long before the COVID-19 pandemic, but frank discussion about best practices in mitigation and interventions were largely lacking.^1,2 Although more recent attempts to address compassion fatigue and cultural diversity have helped refocus considerations of psychological wellness in the EMS workforce, many gaps remain in identifying best practices.^3–7 

Even during the most routine lights-and-sirens responses, EMS personnel not only contend with uncertain and often unsafe situations, we concurrently bear witness to the ravages of violence and deep irrevocable pain of families realizing a loved one’s demise. Be it to protect our own psyche from these unfixable tragedies or to avoid giving off any sign of human weakness when we feel the need to be strong for others, the overall public safety culture has been to be professionally stoic—i.e., “just suck it up and move on.”⁸ These events are an expected part of the profession we chose.

Despite this pervasive mantra, a day for EMS is not a typical day at the office. It is indeed human to have mixed feelings about what we routinely experience. As the next alarm comes in, realistically there is often no time to pause, process, or grieve what we’ve just witnessed. There’s no time to reflect upon our own internal fears that such tragedies could also occur to ourselves or our loved ones. This time is especially needed when it comes to the unfair deaths of vulnerable persons. 

One of the most powerful emotions to emerge in humans after tragedy is a sense of “guilt.”^9,10 In EMS it may manifest as feeling guilty about letting someone down, even when it wasn’t our fault. This may occur when we call the time of death for a young woman fatally injured while trying to cross the street. It may arise when we try to objectively triage dozens of victims in a mass shooting or as we still hope to find a survivor after an aircraft crash. Despite our best efforts, we largely cannot be the miracle-working superheroes we always wish to be in these tragedies. We may try to rationalize away these cases as simply “futile,” but it is still human nature to second-guess ourselves and question, almost subconsciously, what we could have done better or differently.

Crisis Coping

The message to appreciate here is that second-guessing (i.e., the human sense of guilt or feeling like we let someone down) should be recognized as an expected, normal human reaction. It’s actually a good thing that we always have the thoughtful concern, Could I have done anything better? That’s good quality assurance, good quality improvement, and, most important, good human behavior. This remains true even when we expand these questions to what’s outside our individual control and wonder what as a society we could do differently to prevent drunk driving, child abuse, or mass shootings.

In that respect, another source of “moral suffering,” usually leading to morale suffering, is a sense of betrayal.¹¹ EMS professionals in many locales have sensed this, be it real or perceived, from their chain of command, their municipal or state leaders, members of their medical community, and even coworkers or the public. Beyond the person driving under the influence or the active assailant’s avoidable path to slaughter, lack of adequate personal protective supplies in the setting of the current COVID-19 pandemic may be another source of this sense of betrayal. Such societal and professional betrayals have been shown to lead to emotions ranging from shame to rage. In turn, these emotions can lead to self-harm and destructive behavior.¹¹

These all-too-normal and mixed human reactions need to be recognized and appreciated for what they are, and then we must allow ourselves to be “forgiven,” either on a personal insight level or by the reassurance of our peers. This need not be a protracted and unrelenting process, and it’s important to remember it’s OK to lean on others and allow them to help us through the process. This reassurance and support may come from a mental health professional, sage mentor, or even trusted peer, but an external source is usually pivotal.¹² 

And now in 2020, with so much communitywide tragedy and fear being witnessed daily, there is no better time to emphasize this humanity towards ourselves. As the response to patients with COVID-19 (and other, yet-to-be-confronted challenges) evolves and the pandemic continues to linger unpredictably, maintaining intense vigilance becomes more and more difficult. We must be proactive in finding ways to support this need for sustained physical and psychological resilience, also referred to by some as crisis coping.^13–17 

Admittedly, most EMS responders grow familiar and reasonably comfortable with the risk of daily responses and unpredictability of the circumstances they encounter. The possibility of contracting diseases at work has always existed, but, in the era of COVID-19, history-taking and physical exam skills have their limitations. We ourselves, not to mention patients and bystanders, could be asymptomatic carriers. The real possibility of unknowingly and unintentionally spreading the virus adds a subliminal fear to EMS response and undoubtedly is a source of more “guilt” and additional stress (note the common observation of EMS personnel sleeping in their vehicles to avoid potential contamination of those at home).

At the same time, personnel sent home to quarantine may feel like they’re letting others down as their coworkers are left to fill their absence. Adding to this, the nature and march of COVID-19 remain difficult to predict. There is still so much to learn while awaiting an effective remedy, vaccination, or well-proven treatment. It all seems elusive at this time, compounding the dilemmas. 

Within months, the deaths attributed to COVID-19 in New York state, for example, far surpassed the deaths attributed to the 9/11 World Trade Center attack.¹⁸ This realization had a particular impact on the New York EMS community, whose collective consciousness still weighs heavy with the deaths of colleagues from 9/11-related illnesses, even decades later.¹² Those in many other jurisdictions now dealing with the impact of COVID-19 deaths may have also experienced their own prior mass-casualty tragedies or other horrific events, reigniting those emotions.

While various media numbingly report statistics day after day about those who have died from COVID-19, EMS responders have personal, individual memories of the dying and dead—images of their faces and the sights, sounds, and smells of their homes. Standing in a living room, surrounded by a lifetime of memorabilia, and delivering the worst imaginable news, absent the support systems and resources usually available to in-hospital providers, can be a traumatic event in itself. Doing this over and over, day in and day out, will no doubt have lasting psychological consequence.^8,19 

Adding to this emotional burden is the burden of responsibility for understanding and carrying out the evolving directives for crisis standards of care and modified operational guidelines—and the fear of not getting it right or not performing as optimally as we expected. Lacking familiarity with these modifications, the concomitant loss of the comfort zone provided by well-established routines, and the growing barriers to social support have undoubtedly begun to take their toll on all of us. 

Kick In the Door

EMS providers are used to being the resolute ones, trained to exude seamless competence to patients and their families to, so appropriately, gain their trust and confidence. We routinely work in dark highways or cramped bedrooms. Sometimes we duck under spinning helicopter rotor blades to reach the critically injured or go into unsecured locations to assist the child in danger. 

Armed with our bags of gear, we’re ready to kick in a door and do whatever necessary to fight back against the angel of death. But what if it’s we who are “aching”? Could we be so weary, physically and psychologically, that we don’t even know we need to call for help? The question is, should we now be kicking in the mental well-being door for ourselves and others, and should we not clearly articulate that it’s OK not to always feel so OK? 

While it takes courage to respond to others in dire conditions, it also takes courage and great personal strength to reach out and give ourselves permission to be vulnerable, open, and, quite frankly, human. It is true that various strategies have been shown to be effective in addressing the physical well-being of healthcare providers, such as better attention to sleep habits, exercise, nutrition, and personal hygiene. But while these physical well-being strategies can also improve mental well-being, the universal establishment of wellness committees, debriefing sessions, and a focus on life outside work have not been implemented so well in EMS as in other disciplines.²⁰

Public safety personnel work in a culture where expressing vulnerability or a sense of dilemma (conflicting feelings) can be perceived as a sign of weakness, when the opposite may be true. That stoic culture must evolve, both now and going forward. Needing help and reassurance from others is human. Advocating for our own health must be seen as an intrinsic part of our duties to ourselves—and to others. This is not a call for nonproductive criticizing and complaining, but rather more reflecting and confiding. 

In the next part the authors provide examples of programs and experiences that have already begun to produce positive results.  

References

1. National Association of Emergency Medical Technicians. Guide to Building an Effective EMS Wellness and Resilience Program, www.naemt.org/docs/default-source/ems-preparedness/naemt-resilience-guide-01-15-2019-final.pdf. 

2. National Association of Emergency Medical Technicians. 2016 National Survey on EMS Mental Health Services, www.naemt.org/docs/default-source/ems-health-and-safety-documents/mental-health-grid/2016-naemt-mental-health-report-8-14-16.pdf. 

3. Crowe RP, Fernandez AR, Pepe PE, et al. The association of job demands and resources with burnout among emergency medical services professionals. JACEP Open, 2020; 1(1): 6–16. 

4. Donnelly E, Siebert D. Occupational risk factors in the emergency medical services. Prehosp Disaster Med, 2009; 24(5): 422–9. 

5. Donnelly E. Work-related stress and posttraumatic stress in emergency medical services. Prehosp Emerg Care, 2012; 16(1): 76–85. 

6. Musso M, Tatum D, Hamer D, Hammarlund R, Son L, McMahon P. The Relationship Between Grit and Resilience in Emergency Medical Service Personnel. Ochsner J, 2019; 19(3): 199–203. 

7. Brueggemeyer MT, Riddle M, Kellermann AL. Health Protection: Military Concepts Applied to the Civilian World. Amer J Public Health, 2018 Sep; 108(9): 1,155.

8. Almojera A. Heroes, right? Washington Post, 2020 Jun 21; www.washingtonpost.com/nation/2020/06/21/paramedic-new-york-city-coronavirus/?arc404=true. 

9. Mandell F, McClain M, Reece RM. Sudden and unexpected death. The pediatrician’s response. Amer J Dis Children, 1987; 141(7): 748–50. 

10. Pepe PE. It ain’t over till it’s over: the unfortunate evolving experience with active shooters. J Emerg Med Serv, 2018; 43: 43–8. 

11. Shay J. Moral injury. Psychoanalytic Psychology, 2014; 31: 182–91. 

12. Smith E, Walker T, Burkle FM. Lessons in Post-Disaster Self-Care From 9/11 Paramedics and Emergency Medical Technicians. Prehosp Disaster Med, 2019; 34(3): 335–9. 

13. Poland S. Coping With Crisis—Lessons Learned: A Resource for Schools, Parents, and Communities. Longmont, CO: Sopris West Publishers, 1999; https://nsuworks.nova.edu/cps_facbooks/182. 

14. Jin Y. The effects of public’s cognitive appraisal of emotions in crises on crisis coping and strategy assessment. Public Relations Review, 2009; 35: 310–3. 

15. Kolier PA. Family needs and coping strategies during illness crisis. AACN Adv Crit Care, 1991; 2: 338–45. 

16. Persh J. Coping with tragedy: a fieldwork student’s experience with FEMA crisis counseling. Occup Therapy Mental Health, 2004: 19: 129–43. 

17. Abraham LJ, Thom O, Greenslade JH, et al. Morale, stress and coping strategies of staff working in the emergency department: A comparison of two different-sized departments. Emer Med Australasia, 2018; 30: 375–81. 

18. Perrett C. New York City’s coronavirus death toll officially passed the number of people killed during the 9/11 attacks. Business Insider, 2020 Apr 7; www.businessinsider.com/new-york-city-covid-19-deaths-surpass-deaths-on-911-2020-4. 

19. Campos A, Ernest EV, Cash RE, et al. The association of death notification and related training with burnout among emergency medical services professionals. Prehosp Emerg Care, 2020: 1–14 [epub ahead of print]. 

20. Ross S, Liu EL, Rose C, Chou A, Battaglioli N. Strategies to Enhance Wellness in Emergency Medicine Residency Training Programs. Ann Emerg Med, 2017; 70: 891–7. 

Lauren M. Maloney, MD, NRP, FP-C, NCEE, is assistant professor of emergency medicine at Stony Brook University Hospital, Stony Brook, N.Y.

Jason Hoffman, BS, NRP, CCEMT-P, is a paramedic supervisor at Stony Brook University Hospital, Stony Brook, N.Y.

Paul E. Pepe, MD, MPH, is coordinator of the Metropolitan EMS Medical Directors (aka “Eagles”) Global Alliance, Dallas, TX.

Christopher B. Colwell, MD, is professor and vice chair of emergency medicine at University of California, San Francisco.

Peter M. Antevy, MD, is EMS medical director for the Coral Springs-Parkland Fire Department and Davie Fire Rescue, Broward County, Fla. 

Remle P. Crowe, PhD, is the National Research Scientist and Performance Improvement Manager for ESO, Austin, TX.

Bryan L. Doerries, MFA, is artistic director for Theater of War Productions, New York, N.Y.

Sandra M. Schneider, MD, is associate executive director for clinical affairs for the American College of Emergency Physicians, Dallas, TX.