Minding the Mind of EMS, Part 3

In Part 1 of this series,¹ the authors described many of the mental well-being challenges EMS personnel face day to day and how those difficulties have been amplified during the COVID-19 pandemic. Many psychological observations and typical concerns were described, but mechanisms had yet to be provided to help EMS professionals mitigate moral injury and address feelings of betrayal and guilt in their day-to-day experiences, let alone the COVID-19 crisis. We had to provide tools to facilitate crisis coping during the pandemic and beyond. 

We began that mitigation discussion in Part 2 of this series, addressing the mutual efforts of partners, teams, and agencies.² In this discussion the authors continue to annotate existing examples of resources available to EMS personnel that have worked well in settings that include proactive training, communitywide programs, and professional society activities. We recognize there are many other successful programs not listed here, and one size does not fit all. Also, in some cases, multiple avenues of mitigation and crisis coping should be considered in parallel. 

Not only do all of us need to find better ways to acknowledge and “forgive” ourselves for the human feelings of guilt, fear, betrayal, defeat, and the moral- and morale-injuring moments we experience, we must do the same for others and encourage a culture of safe zones among colleagues as we journey together through our challenges, past, present, and future. Hopefully this discussion, despite its intrinsic limitations, is one step forward.

Proactive Initiatives for High-Stress Calls

The scales of compassion and caring can truly fatigue during a pandemic and continue to do so in the postpandemic era as well. However, even one tragic response can trigger a psychological impasse that may persist indefinitely, particularly when it involves a child or other vulnerable person. Sub rosa residual stress can remain within many of our colleagues throughout their days of duty, even before the 9-1-1 alarm tones and reinduces a fear response. 

One approach to mitigate such persistent psychological challenges is the strategy of preemptive crisis coping. This strategy involves understanding that the stress of treating a child in the EMS setting begins long before making contact, especially among those responders with a prior history of experiencing bad outcomes. For decades many EMS professionals have rationalized their anxiety-laden responses to children with “kids are just different.” This ongoing negative feedback loop can perpetuate psychological trauma. Coupled with a lack of recognition of the root cause, damage to mental well-being is perpetuated.

However, there are now evidence-based strategies that can help us to unravel the accumulating ball of anxiety yarn. These strategies not only improve our ability to provide better care but also facilitate emotional healing and wellness. For example, many agencies now teach EMS professionals to conduct prearrival discussions en route to every pediatric call. These could include scene assignments to deal with family directly or preparations that will avoid on-scene drama. For example, in a possible cardiac arrest case, the responders can use the child’s age to quickly ascertain, prior to arrival, three related details: 1) epinephrine dose; 2) airway size; and 3) joule determination. 

With those interventional decisions made, arriving crews are already ahead of the typically chaotic on-scene situation. Knowing ahead of time that the 1-year-old to whom one is responding will simply need to receive 0.1 mg of epinephrine avoids the on-scene calculations, time they take, and potential errors they introduce.³ 

Despite preparations and professional performance of medical skills, distraught families, understandably, still can create tremendous emotional pressures. There now exist training programs that can help with “verbal judo” and de-escalation techniques. Such techniques and associated training are part of the inventory of EMS agencies that have diminished the psychological impact of these tragedies. They have improved outcomes dramatically using both “system one” thinking techniques (fast and intuitive), improved pit crew approaches, and a renewed systemwide focus on teamwork and support from colleagues, supervisors, and medical directors.^3,4 Despite the eventual outcome in individual cases, a renewed sense of confidence and feeling of agency support generally extends to other types of pediatric and adult responses. 

With such training, procedures, and systemwide support, human communication is better enabled during difficult calls, and this has proven to save many more lives, including the lives of our own brothers and sisters. The bottom line: It supports the well-being of our colleagues.

Lay Training and Professional Well-Being 

In western Washington state the READY program (Real Emergency Aid Depends on You) originated as a communitywide effort to offer a one-hour basic “CPR for mental health” course. The inspiration was that if one could teach the public CPR with a one-hour class, why not train them within an hour’s time in another out-of-hospital emergency that occurs with much higher frequency? Many daily responses by EMS professionals involve some aspect of mental health or behavioral crisis, and often they can involve highly emotional mental health confrontations.

READY is both an in-person and online instruction that became an overlapping effort of local government, hospital partners, EMS, and law enforcement. The primary premise is to teach 1) the fundamentals of recognizing a person in a mental health crisis; 2) how to best notify 9-1-1; and 3) how to keep the scene safe before and after the emergency lights and sirens arrive. Like CPR, it is an asset that can make the EMS professional’s job a little easier.

The team that created this exemplary course eventually came to understand they were not only helping others but also helping themselves. By having trained bystanders helping set the tone and de-escalate incidents prior to arrival, there was a better sense of teamwork with loved ones and bystanders. Moreover, they felt renewed that EMS professionals were being provided with better insight and comfort levels when dealing with the disturbing challenges of managing mental health crisis incidents. This additional skill set has better prepared them and enhanced their crisis coping both at home and at work. READY was deemed to be highly effective and honored with the Innovation in Suicide Prevention Award by the American Foundation for Suicide Prevention and American College of Emergency Physicians.⁵ 

Online and Theatrical Readings 

Numerous professional societies ranging from the National Association of Emergency Medical Technicians (NAEMT) and International Association of Fire Fighters (IAFF) to the National Association of EMS Physicians (NAEMSP) and American College of Emergency Physicians (ACEP) have developed a myriad of online and print resources that address mental well-being for their members. Some of these initiatives have been quite creative and effective.

One such resource that has achieved much acclaim this past year among the EMS and emergency medicine communities has been the latest series of Theater of War productions. Theater of War for Frontline Medical Providers (aka Theater of War Frontline) is a webinar-based event that presents dramatic readings from Greek tragedies, usually delivered on a Zoom platform during the COVID-19 era but traditionally set in live stage performances.

For more than a decade, the classic readings have been routinely provided in real time by acclaimed actors such as Frances McDormand, Frankie Faison, Jesse Eisenberg, Bill Camp, Taylor Schilling, David Strathairn, and many other dedicated performers. Those thought-provoking readings taken from ancient Greek tragedies have proven a catalyst for powerful and healing discussions about the ethical and emotional challenges faced by frontline medical responders and practitioners, particularly during the COVID-19 pandemic.⁶ Based on a theory that ancient Greek drama arose to meet the needs of a highly militarized democracy often challenged by its own plagues during the 5th century B.C., the plays created a place and a process for communalizing combat stress and invisible wounds. Similarly, Theater of War Frontline uses scenes from ancient Greek plays to engage EMS professionals in crucial dialogue about difficult subjects and discomforting experiences.^7,8 

The dramatic readings of scenes from Sophocles’ Ajax, Philoctetes, and Women of Trachis—ancient plays depicting the struggles of chronically and terminally ill patients and conflicted caregivers—have served as an effective point of departure for guided conversations, generating a shared vocabulary for discussing themes such as personal risk, deviations from standards of care, abandonment, betrayal, isolation, and deferred grief.⁹ Participants are not asked to narrate their own struggles or share anything they feel uncomfortable discussing, but rather to offer their own reactions and interpretations of the ancient plays. In this way the project frames challenging discussions about mental well-being, job-related stress, moral injury, and psychological trauma, but without using offputting medical or psychological jargon.

The project, recently written about in The Lancet, Forbes, and The New Yorker, is a collaboration between the social impact company Theater of War Productions, the Johns Hopkins Berman Institute of Bioethics, and the Johns Hopkins Program in Arts, Humanities, and Health.^10–12 After a virtual presentation of the project for New York City-based EMS professionals early in the pandemic, more than 90% of respondents to a post-performance survey said viewing Theater of War for Frontline Medical Providers made it easier for them to talk about difficult topics. 

In addition, 88% said participating in the session reduced their sense of isolation, and 97% said they would recommend the project to a colleague or a friend. The project has now been formally rolled out for frontline health workers nationwide and continues in live-stream formats. Frequently cited at the conclusion of these performances is a quote from BG Loree Sutton, MD, who reflected, “I think Sophocles wrote these plays to comfort the afflicted and to afflict the comfortable.” For more information and dates, visit www.theaterofwar.com. 

Closing Reflections

Beyond the need imposed by the COVID-19 pandemic, initiatives to improve mental well-being for EMS professionals are timely. We know many existing programs have limitations. One must understand that one size does not fit all and that, in some cases, multiple interventions may be applicable. 

Nevertheless, as a starting point and stimulus for changing the status quo, we offer these examples as seedlings of what we believe should be a growing initiative in the world of EMS and public safety, especially as new societal challenges evolve. 

Sidebar: Additional Resources

• American College of Emergency Physicians: Peer Support Project
• American College of Emergency Physicians: Physician Suicide
• Centers for Disease Control and Prevention: Violence Prevention 
• Dean W, Jacobs B, Manfredi RA. Moral injury: the invisible epidemic in COVID health care workers. Ann Emerg Med, 2020 Oct; 76: 385–6. 
• Kiser SB, Bernacki RE. When the dust settles: preventing a mental health crisis in COVID-19 clinicians. Ann Intern Med, 2020 Oct; 173: 578. 
• Lahr J, Taylor A. Create a Culture of Caring. EMS World, 2021 May. 
• National Association of Emergency Medical Technicians: EMS Mental Health
• Wong AH, et al. Healing the healer: Protecting emergency health care workers’ mental health during COVID-19. Ann Emerg Med, 2020 Oct; 76: 379–80. 

References

1. Maloney LM, Hoffman J, Pepe PE, et al. Minding the Mind of EMS—Part I. EMS World, 2020 Nov; 49(11): 38–40.

2. Maloney LM, Hoffman J, Pepe PE, et al. Minding the Mind of EMS—Part 2. EMS World, 2021 Sep; 50(9): 36–38.

3. 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: 24: 1–14.

4. Pepe P, Banerjee P, Vittone RA, Singh A, Roka A, Ganti L. Effecting neurologically-intact survival for children following out-of-hospital cardiac arrest (Phase 2). Crit Care Med, 2019; abstract #1544.

5. City of Auburn, Washington. Healthy Auburn for Life, www.auburnwa.gov/city_hall/mayor/healthy_auburn_for_life.

6. Theater of War Production. Theater of War Frontline, https://theaterofwar.com/projects/theater-of-war-for-medical-communities.

7. Shay J. Features: Ancient Stagecraft. Didaskalia, 1995; 2(2); www.didaskalia.net/issues/vol2no2/shay.html.

8. Doerries B. The Theater of War: What Ancient Greek Tragedies Can Teach Us Today. New York: Knopf-Doubleday, 2016.

9. Doerries B. All That You’ve Seen Here Is God: New Versions of Four Greek Tragedies. New York: Vintage, 2015.

10. Rushton C, Doerries B, Green J, Geller G. Dramatic Interventions in the Tragedy of the COVID-19 Pandemic. Lancet, 2020; (396): 305–6.

11. Gladder R. Theater of War: Using Tragedy to Help Frontline Medical Workers Cope During Covid-19. Forbes, 2020 Aug 4; www.forbes.com/sites/robertglatter/2020/08/04/theater-of-war-using-greek-tragedy-to-help-frontline-medical-workers-cope-during-covid-19/#35355b2f2211.

12. Batuman E. Can Greek Tragedy Get Us Through the Pandemic? New Yorker, 2020 Sep 1; www.newyorker.com/culture/culture-desk/can-greek-tragedy-get-us-through-the-pandemic.

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, Tex.

Christopher B. Colwell, MD, is professor and vice chair of emergency medicine at the 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, Tex.

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

Stephen H. Anderson, MD, FACEP, is an attending emergency physician at MultiCare Auburn Medical Center in Auburn, Wash. 

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