Caring for the Caregiver

The bay door rumbles open, a diesel engine starts and a siren's sound fades into the distance as an ambulance clears an intersection and makes its way down the street toward another call. Over the course of their duty shift, the crew will be subjected to a number of tests of physical will: frequent lifting and moving of equipment and patients in imperfect conditions, hunger, inadequate recovery times, temperature extremes, critical events and a higher risk of being involved in a motor vehicle crash. And this is just the first shift of the week.

     EMS work places personnel at risk of frequent injury and can potentially contribute to long-term health concerns. In the case of injuries, one recent study found that the overall rate for EMS workers was six times higher than the national occupational average reported by the Bureau of Labor Statistics and almost double that of firefighters. These injuries resulted in lost work days equal to almost three times the national average.1 Repeated strain and injury to ankles, knees and backs far too often contribute to early career changes and lifelong impairment.

     Complicating our resilience to defend ourselves against injuries and illness are a culture and work environment that enable a whole host of health issues resulting from poor eating habits, lack of adequate exercise and excessive use of alcohol and tobacco, which virtually guarantee our place as future patients of our own EMS systems. In addition, continuous exposure to calls stretches our coping abilities.

Lifestyle: It's a Choice
     Watch between breaks at a conference, or stand outside a busy emergency department during peak hours, and you will witness a whole host of poor lifestyle habits that plague our industry. Just a few are discussed here.

     America is probably growing faster than any other civilized society on the planet; however, the growth is not in population, but in waistlines. Our overly busy lifestyles, coupled with a lack of exercise and poor eating habits, are making obesity a public health crisis resulting in seven of 10 American deaths each year.2

     In the movie Super Size Me, documentary filmmaker Morgan Spurlock shocked America when he revealed the health risks of eating every meal at McDonald's for a month. He gained weight, his cholesterol went through the roof and his doctor cautioned him repeatedly to stop. Eric Schlosser raised similar concerns in his book about the fast food industry, when he traced the rise in obesity in America to the increased consumption of processed food and fast-food restaurants.3

     Unlike other emergency service partners, EMS workers tend to have higher productivity levels and no dedicated meal time. This often means that being able to heat up a homemade meal is not predictable, leaving many to rely on restaurants, often fast food.

     When it comes to relative health risks, smoking is a close second to obesity. Thankfully, communities are making it less socially acceptable to smoke, taxes have raised the price point per pack, and we are seeing fewer smokers in the field. While it's not an easy habit to kick, doing so instantly improves life expectancy by years.4

     Finally, in spite of all of the physical work we do, how prone we are to injury and how poorly we eat, we still fail to get enough exercise. This can result in difficulty managing weight, increased injury and longer injury recovery times, and poor stress management.

     Making a conscious choice to change bad habits is tough and doesn't happen overnight. It takes at least 21 days of continuous practice to replace a bad habit with a new one.5 Easier said than done, but it's necessary. Table I shows how lifestyle is associated with the leading causes of death in America.

It's the Job, Right?
     To this point, we have focused on individual lifestyle issues, but what risks are there in the work that we do? Shift work and calls can also have an impact on our well-being and need to be understood.

     Everyone needs an optimal amount of sleep to feel rested and ready for the day. For most people, this falls between seven and 10 hours per night, although it varies by person. The EMS profession is notorious for grueling shifts, which can contribute to sleep deprivation. A recent survey of urban EMS systems in America found 24-hour shifts continue to be the most common practice.6 EMS personnel frequently deny that they are tired and work many long, sleepless hours. When they do rest, they may not be getting the maximum benefit from their sleep, simply because they are so exhausted.

     In our fast-paced society, people are getting less sleep than ever, and we fail to appreciate that it does have an effect on our performance. In their book On Combat, Dave Grossman and Loren W. Christensen cite a sleep study conducted by the U.S. Army on an artillery battalion.7 The battalion was divided into four batteries, and each battery conducted fire missions for 20 days. Each group was allowed certain amounts of sleep per night ranging from only four hours to as much as seven. At the study's conclusion, group performance was easily correlated to the amount of sleep each group received. While the dropoff in performance was dramatic from group to group, the one with the least amount of sleep became ineffective and almost dangerous. The soldiers' sacrifice leaves important lessons for us all to consider.

Self-Care & Stress Management
     Self-care and stress management involve a whole host of activities that impact our health and wellness. Following is a foundation for building self-care and stress management into your life.

Get active
     A trauma surgeon (with the worst bedside manner ever seen) leaned over a motor vehicle accident victim and said, "You know, if you were in shape you would recover a lot faster from this accident!" While his delivery left a lot to be desired, his point rang true-people who are in shape are stronger, healthier, more resilient, and recover from injuries faster. If you are in emergency services, there is no reason not to work out-your life could depend on it!

     One simple start is to walk. Try setting a goal of 10,000 steps a day. This gets you to the 30 minutes of daily activity recommended by the surgeon general. Walking can be done anytime and anywhere, can be low or high impact, and is cheap.

     The added bonus of exercise is that it is a great way to relieve tension and stress. After a critical incident, those who work out frequently report that exercise helps with both the physical and emotional strain associated with the incident. If you are not currently exercising, consult with your physician and get started. This investment in yourself will give you the most bang for your buck, and you will soon start to look and feel better.

Eat well
     When it comes to the foods you eat, healthy habits can dramatically change how you feel on a daily basis. Healthy, balanced meals, as opposed to fast food or, worse, skipping meals, will help you stay energized and fit. While it can be difficult to plan for healthy meals or bring your own for a shift that may be nonstop, the trick is to eat well as often as possible and use the fast, unhealthy food when it is the only option. Remember, every restaurant offers a "healthier choice."

Stay hydrated
     There are conflicting reports about how much water you should drink daily, as well as whether or not caffeinated beverages count. The old standby of drinking eight 8-ounce servings of water a day is a good rule of thumb. If you work out, you should drink more. If you are drinking caffeine, be sure to offset each serving with water or a sports drink. If you feel thirsty, you are behind the power curve and need to catch up. If assigned to an extended call, be sure to alternate between water and a sports drink to replenish your electrolytes.

Rest up
     When it comes to sleep and rest, the challenge is to listen to your body's physical and emotional signals when you are tired, and allow time for restoration, repair and preparation for the next day. A good way to ensure that you rest well is to limit caffeine late in the day and stick to a routine as much as possible with regard to the times that you go to sleep and wake up.

Relax
     In many ways, the EMS profession is more like a lifestyle than a job. When a career is also a way of life, it is sometimes hard to get away from the work that you do. Additionally, EMS personnel tend to socialize in the same small circles. The outcome of all of this is a fun and exciting way of life, but also one that is out of balance.

     It is imperative to take personal days off, take vacations and find ways to relax. A balanced life means keeping your hobbies, maintaining healthy familial relationships and having friends outside of the tight EMS circle. These outside activities will help keep you from getting burned out and will also keep you engaged in your life outside of work. This is important, because, when the day comes to retire, you can either be ready to start your new life, or you can be caught off guard and find yourself struggling with transition into your new life.

Drink in moderation
     Having a drink with a friend and sharing a few war stories is a common way to relax and stay connected. The thing to remember when it comes to alcohol is to consume in moderation. The USDA Dietary Guidelines for Americans recommend no more than one drink for women and two for men per day.8 Frequently exceeding this can be unhealthy and is possibly an indication that something else is going on.

Talk it out
     Whether you share stories with a fellow EMS professional, talk to friends or family, or even seek the help of a professional, talking about your experiences is a great way to come to grips with your reactions to an incident. Talking and journaling are how our minds process information and figure out how to interpret and store events as memories. It is important to have an outlet. Find someone you trust and talk about it!

Laugh a little
     Humor is an important part of emergency services. Finding humor in what others would not consider funny allows us to get the job done. Sometimes it is important to laugh in order to mitigate the effect of something that may otherwise have a very negative impact. Laughing is a great stress reliever. Just be sure you do it away from the media and bystanders.

Take a deep breath
     It is human nature to hold your breath when you are stressed. This does absolutely nothing for you except deplete your brain and body of oxygen. Learning to breathe during stressful times can not only improve your performance by sharpening your focus, it can also help you remain calm. Learn to monitor your breathing and focus on taking long, deep, slow breaths, even when things are hectic.

How Employers Can Help
     EMS organizations have been behind other types of workplaces in appreciating the need to assist their employees in living healthy lives. Many companies whose employees work long hours with increased stress have realized that not addressing it head-on results in added lost work days, higher turnover and decreased productivity. While EMS organizations are not likely to offer prepared meal service or personal trainers to their staff, there are a lot of lower-end things managers can do to contribute to helping their staff improve their overall health.

Educate
     Information empowers people to act. Many providers may not know how to access the right information on healthy living or appreciate the ramifications associated with poor life habits. By tapping into Internet resources and local health and fitness experts, organizations can produce and distribute important information that can make it easier for their staff to access the right information to take action on.

Enable fitness
     In a perfect world, every EMS station would be equipped with a variety of fitness equipment for working out at the station, but this is often not feasible. Dedicated large fitness equipment is not the only answer. Here are a few easy solutions:

• Resistance cords, jump ropes, grip trainers and basic free weights are all safe, cheap and compact items that can be purchased for every station and easily stored. Many of these can even be stored away in the ambulance and pulled out by the crew anytime they have a free moment.
• Many fitness clubs and YMCAs will offer group membership rates. Some may provide added incentives for public safety personnel. Connecting with these centers and doing the leg work may facilitate these discounts for your staff.
• Walking is easy exercise, and most can do it. Buy everyone a pedometer and start an organization-wide step program. It can even be a charity event. The goal is to get everyone excited and motivated to push toward a walking goal together.

Manage stress
     Obviously, organizations can't manage individual staff members' stress, but they sure can make it easier for the employees to manage. Ensure shift schedules allow for adequate daily sleep and recovery; don't over-schedule staff activities; be prepared to intervene if personnel are working too much or showing signs of stress; make human needs a priority by allowing them to take a few extra minutes of recovery; and be supportive and proactive if your staff needs help dealing with a large event.

     These are just a few ways organizations can take care of their human capital. There are many more. The most important thing is to listen to your staff and figure out what they need to be healthy, happy and productive. A little investment at the front end will save you the big expense that could occur from lost employee work time. Plus, it's just the human thing to do.

Conclusion
     EMS is not an easy job, but it's a great one. If we're not careful, however, we can give and give of ourselves until we have nothing left to give, and that is not good for each other or our patients. We all have to work together to take care of the people who take care of others, and everyone will benefit. Be aware, be proactive, and be healthy and safe.

References

Maguire BJ. The epidemiology of occupational injuries and illness among emergency medical services personnel. Doctoral dissertation, The George Washington University, 2004.
1. United States Surgeon General. Public health priorities. www.surgeongeneral.gov/publichealthpriorities.html.
2. Schlosser E. Fast-Food Nation: The Dark Side of the American Meal. Boston: Houghton Mifflin Company, 2001.
3. American Lung Association. Quitting smoking. www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=33567.
4. Maltz M. Psycho-Cybernetics. Chatsworth, CA: Wilshire Book Co., 1967.
5. Williams DM. 2005 JEMS 200-city survey: A benchmark for the EMS industry. JEMS 31(2):44-61, 100-101, 2006.
6. Grossman D, Christensen LW. On Combat. Belleville, IL: PPCT Research Publications, 2004.
7. United States Department of Agriculture. Nutrition and your health: Dietary guidelines for Americans. Washington, DC, 2000.

Tania Glenn McIntosh, PsyD, LCSW, CTS, is president of T. McIntosh and Associates, PA, a clinical practice in Austin, TX, focusing on public safety and military individuals, couples and families. She specializes in trauma and is a Certified Trauma Specialist. Dr. McIntosh is also a managing partner of Readiness Group International (www.readinessgroup.com), where she provides trauma-based consulting services. Contact her via e-mail at taniag@readinessgroup.com.

David M. Williams, MS, is a senior associate with the international EMS/public safety consulting firm Fitch & Associates LLC (www.fitchassoc.com). An experienced paramedic, trainer, quality manager, author, researcher and consultant, he assists clients with leadership and organization development, quality management, research and system issues. Contact him via e-mail at dwilliams@fitchassoc.com.