Administration and Leadership, Columns, Operations

EMS Agencies Need to Have EAP Resources to Address Stress and Reduce Suicides

Issue 1 and Volume 41.

We battle a lot of demons in EMS. We battle cardiac arrhythmias in an attempt to reverse their negative effects on the heart. We battle infections by taking preventive actions to ensure we, and our patients, don’t succumb to its predictable damage. And we battle time with trauma patients, taking rapid action to prevent irreversible shock. But yet, we’re a stubborn, proud breed that does very little to help ourselves battle one of our worst demons: stress.

EMS, fire, rescue and law enforcement attracts compassionate and physically strong people. But some responders feel that admitting to suffering stress because of what they’ve seen or experienced in the field is somehow a show of weakness. It’s not.

By the nature of what we do, we’re often labeled as “adrenaline junkies.” That’s not a bad thing because adrenaline, a natural hormone in our body, increases our rates of blood circulation, breathing and carbohydrate metabolism, and prepares our muscles for exertion. These are all very important in stressful and demanding situations and help us get through them.

But adrenaline, like all hormones or chemicals, has a limited strength and effective time period. Therefore, soon after a stressful event occurs, so too does our adrenaline level and its compensatory mechanism.

That’s when we begin to feel the physical and emotional aftermath of an incident and stress builds. It becomes greatly accelerated if we have a second or third stressful call on the same shift, often referred to as “cumulative stress.”

When this occurs and we lack proper coping mechanisms or time to defuse or dissipate our emotions, we can become an emotional time bomb and victims of depression. Depression, defined as feelings of severe despondency, can get worse if not addressed.1

I got a phone call recently informing me that one of my star students at a two-day mass casualty incident (MCI) workshop—21-yearold Katie Broeker, a paramedic student in Gloucester County, N.J.—took her own life. She was a wonderful, vivacious EMT who stepped forward to lead a complex MCI drill. She did a great job and I left New Jersey happy to see such a young EMT do so well.

But she had several stressors in her life including paramedic class, which took their cumulative toll. Her mom and dad are allowing me to tell her story so others realize that cumulative stress, depression and suicide are not age-dependent, can creep up on you or your co-workers and must be recognized and addressed.

Katie Broeker was a bright, young paramedic student who left us all too soon.

Katie Broeker was a bright, young paramedic student who left us all too soon. Photo A.J. Heightman



The word “residual” means “something that remains after the greater part or quantity has gone.” Synonyms of residual include: enduring, remaining, leftover, lingering, unused and unconsumed. Residual stress can hit you at any time after a major incident.

I suffered an attack of residual stress years after I helped locate, sort and place the amputated legs, arms and torsos of small children in the appropriate body bags after a mid-air collision of two airplanes in Allentown, Pa.

It hit me hard and without warning one evening as I watched the 1992 made-for-TV movie Crash Landing: The Rescue of Flight 232, a realistic depiction of the crash of United Airlines flight 232 during an emergency landing at Iowa’s Sioux City Gateway Airport on July 19, 1989.

Although 185 of the 296 people on board survived that horrible crash, 111 didn’t.2 And even though dead bodies weren’t shown during the movie, there was a very short but impactful scene that hit me like a ton of bricks and triggered a deep emotional release.

The scene showed a group of responders and investigators matching the little limbs and sneakers of children in the body bags.

Even though it was a movie and not real footage, it took me right back to my stressful experience and opened an emotional log jam that never left the deep recesses of my mind.

You see, the brain is the most advanced and complex image retention mechanism ever created. It’s like a camera that doesn’t lose images due to battery failure and doesn’t have an SD or sim card that you can remove or easily alter.

Chemical imbalances and physical trauma such as concussions and traumatic brain injuries have almost the same effect as a damaged computer hard drive or faltering central processing unit (CPU).

And, like your computer CPU or hard drive, your ability to forget or delete traumatic or stressful experiences from your memory is seriously impacted and it takes an educated “technician” or psychologist to find and fix bad “data sectors,” or redirect or recover lost (or repressed) images and memories.


Stress is recognized and unavoidable as part of the job in public safety and military roles. But it’s also one of the least-discussed problems addressed by individuals and their agencies.

Length of service, ego, fear and shame are common reasons personnel avoid discussing the crippling stress, nightmares or depression they’re experiencing.

However, with the increasing number of reported suicides in public safety agencies, we have to pay closer attention to the debilitating effects of stress, particularly in the aftermath of a critical incident.

And it’s not just the stress of EMS that’s causing problems for emergency responders. Failed relationships, alcohol abuse, financial problems, work harassment, obesity and a loss of self-esteem can compound stress and cause people to spiral out of emotional control.

Jeff Mitchell, PhD, noted psychologist and founder of the International Critical Incident Stress Foundation (ICISF) program, reminded me recently that when people are overly stressed and lose their self-esteem, it often transfers to self-loathing, which can put them in a dangerous and fragile state of mind. If they begin to think the pain of dying is less than the pain of continuing to live, they may contemplate taking their own lives. If they feel there’s no hope for the future, their situation becomes even more personally threatening.

In the October 2015 issue of JEMS, an epic study by Reviving Responders, a group of EMS personnel born out of a research assignment at Fitch & Associates’ Ambulance Service Manager Program, pointed out the prevalence and severity of EMS provider stress in the workplace.

In the study, critical stress (CS) was defined as: “The stress we undergo either as a result of a single critical incident that had a significant impact upon you, or the accumulation of stress over a period of time.”3

This study included responses from 4,022 emergency responders, showed that stress has a strong emotional impact on providers, regardless of their years of service. It also showed that 86% of the respondents experienced CS. More shocking, 37% reported they had contemplated suicide, and 6.6% said they had actually attempted to take their own life—an act that probably went unnoticed.3

Most distressing to the researchers and others was the fact that, while 40% of the respondents reported they had either contemplated or attempted suicide and had access to support, they didn’t seek help because they were concerned about how they’d be viewed or treated at work if they had.

However, for those who had the support of their service managers and peers, and were encouraged to utilize the formal support institutions in place, the suicide contemplation rate dropped by 66%!3

There’s a critical message in this study: Every agency needs to ensure their staff (paid or volunteer) has access to group critical incident stress management (CISM) sessions and an effective employee assistance program (EAP) so they can obtain counseling in a rapid and confidential manner. And they should be encouraged to participate in them.

The fact is, however, that many agencies, particularly volunteer agencies, either don’t have an EAP or the one they have isn’t effective because the affiliated counselors don’t understand the complexities and stressors involved in EMS. But there are solutions for that. Mitchell notes that services seeking a therapist who truly understands the demands and stressors in public safety can usually find one who is closely involved with their CISM program—therapists and psychologists who have learned over time and through extensive training and experience to understand and appreciate our problems.

Many agencies now have stress recognition and management as a high priority. The National Association of EMTs (NAEMT), the American Ambulance Association (AAA) and the International Association of Fire Fighters (IAFF) all have programs designed or under development to address this silent, apolitical epidemic.

The IAFF has pilot programs underway offering advice to emergency responders on how to react to stress, such as an online, interactive behavioral health awareness course to help address the stigma surrounding these issues in the fire service.4,5 The course provides a basic overview of common behavioral health problems and available treatment options, information on balancing work and life stressors, and information on how to improve the behavioral health services offered in local departments.

In addition, the IAFF will soon launch a new peer support training program that gives members the knowledge and skills they need to implement and sustain an effective peer support team in their department.

In addition to excellence in advocacy, AAA membership now offers benefits never before available to many volunteer and moderate call volume EMS agencies. The AAA has expanded its membership categories (and rates), to enable volunteer agencies, municipal agencies, manufacturers, state associations and international services to join and receive important benefits such as CISM and an EAP.

These benefits include:

  • Free access to a Ceridian LifeWorks EAP for EMS staff, including up to three free in-person counseling sessions per employee/volunteer member;
  • Free CISD counseling should a traumatic event, active shooter, or staff death occur and a member service needs a team(s) from outside their region;
  • Human Resources and operations toolkits covering workplace violence, suicide prevention, intercultural communication, and more;6

For information on AAA membership categories and rates, visit

NAEMT is also taking an active role in this area, bringing mental health resources to members to help them or their coworkers get the assistance they need, and supporting the Code Green Campaign.

Two weeks after the March 2014 suicide of a 25-year-old co-worker’s death, Ann Marie Farina, EMT-P, and a group of concerned EMS practitioners from Spokane, Wash., and around the country launched the Code Green Campaign to raise awareness and let those struggling with mental health issues know they aren’t alone. Code Green allows EMS practitioners to anonymously share their struggles with depression, substance abuse and anxiety.

NAEMT reports in their fall 2015 newsletter that their efforts and the nonjudgmental, supportive environment offered by Code Green are already having a positive impact. Last fall, a 20-year-old EMT wrote to Code Green about the horror of doing CPR on a 1-month-old baby who didn’t survive.

“I was struck with an indescribable emotional cocktail of helplessness, anger, and sadness … It took everything out of me,” he wrote. “I feel as though I’m at the breaking point.”

Six months later, he shared an update. His new posting talked about him seeking help, being diagnosed with PTSD, depression and anxiety, and the changes it meant for his life.

“Today I look back, in awe that I could ever get to such a low point … This website, my therapist, my doctor, and my support system saved my life … If you are struggling, you can’t do it alone. Be vocal, lose your pride and get some help.”

NAEMT is calling on EMS agencies to ensure they establish an environment that supports their EMS practitioners in reporting problems, seeking help and providing training to help them cope and build resiliency.

NAEMT’S EMS Workforce Committee has compiled a valuable collection of mental health resources that practitioners and agencies can turn to for information about suicide prevention, depression, anxiety and how to prevent mental health issues from developing by improving their resiliency.

The NAEMT listing of helpful articles, treatment and prevention programs, hotlines and websites is available at and via links attached to the Web version of this article.


Don’t let the demons of stress defeat you or your co-workers. Recognize that we all experience stress and that some of us receive higher doses than other.

Talk about your stress with trusted confidants and take the steps necessary to get professional counseling when you feel stress is winning.

With emergency service suicides 10 times that of the general populace,6 it’s critical we all address this area so we don’t lose our most valuable resource: our personnel. Please make this one of your top priorities in 2016; JEMS and PennWell Corp. are, by offering multiple expert sessions at our 2016 EMS Today Conference and Exposition and follow-up articles in JEMS.


1. Clinical depression. (2015.) Retrieved Nov. 17, 2015, from

2. Thompson P. How the crash of United Flight 232 changed the way we fly. (July 19, 2014.) Flight Club. Retrieved Nov. 17, 2015,from

3. Newland C, Barber E, Rose M, et al. Critical stress: Survey reveals alarming rates of EMS provider stress & thoughts of suicide. JEMS. 2015;40(10):30–35.

4. Reactions to traumatic stress. (n.d.) IAFF. Retrieved Nov. 17, 2015, from

5. Morrison P, Leto F. Behavioral health and suicide awareness. (n.d.) IAFC. Retrieved Nov. 17, 2015, from

6. EMS mental health. (n.d.) NAEMT. Retrieved Nov. 17, 2015,

Hear more from A.J. Heightman and about important stress and suicide prevention topics at the EMS Today Conference & Expo in Baltimore, Md., February 25–27, 2016.

More on Provider Wellness & Safety at