Having been in EMS for more than two decades, I—like many of you—have grown up in an ambulance. The difference between me and you—or maybe not—is that the monster, called suicide, stalked and killed my wife, brother and 10 of my EMS colleagues.
Psychological trauma can be fatal and EMS would do well to realize it. It should come as no surprise that we in EMS are routinely exposed to stress and psychological trauma significantly more than the general public.1
One-fourth of U.S. adults are diagnosed with a mental illness,2 while it’s estimated that 50% have a mental illness, but have not been—or will not be—diagnosed.3 I have been diagnosed with, and have been successfully treated for, posttraumatic stress disorder (PTSD), depression and anxiety.
Given that anywhere from 4.34–30% of paramedics—depending on which study you read—have developed PTSD, I’m far from alone.4–12 In comparison, 8.7% of the U.S. population has a diagnosis of PTSD.13
Depression and anxiety are also frequently associated with PTSD. Researchers who surveyed 34,340 EMS providers, discovered roughly 6% of us are experiencing mild to extreme depression, anxiety and stress.14
Unspecified trauma and stressor-related disorder is diagnosed when a person meets some, but not all, criteria for PTSD that exerts a negative effect on their life. Acute stress disorder may happen shortly after a trauma and last up to a month, after which time PTSD is diagnosed.13
Many responders don’t reveal their mental health difficulties, with 55% saying supervisors would treat them differently, 45% saying co-workers would think them weak, and 34% believing they wouldn’t get promotional opportunities.15
I would rather have the EMT or paramedic in the ambulance, the firefighter in the engine, or the police officer in a patrol vehicle, who has been successfully treated for a mental illness, rather than depending on a partner who’s “sucking it up” and not getting any help. There’s a reason the flight attendants tell us, “if there’s an emergency, put your own oxygen mask on before helping others.”
Psychological trauma results from exposure to death, serious trauma or sexual violence. These traumas may have occurred to us personally, been witnessed happening to others, or been heard of in an unexpected and violent situation. This trauma may happen after one event or repeated exposures.13
Not everyone exposed to trauma will develop a psychiatric disorder. Three EMTs can respond to the same incident, with one unscathed, one profoundly impacted, and another not immediately affected, but having added to his later cumulative trauma.
Often, the factor that tips the balance is personal identification with a victim—like a responder dispatched to assist a victim the same age as her own child. The diathesis-stress model holds that a genetic predisposition, which only manifests when the exposure to a stressful event has the right “ingredients” to unlock the mental health condition, occurs.16.17
Burnout is characterized as work overload, lack of development in one’s role, and feeling “worn out.”19 Compassion fatigue occurs in people who have been traumatized themselves or work with people who have been traumatized. 20
Are you frustrated by patients who are intoxicated or those who you think could drive themselves to the hospital? If those feelings become frequent and persistent, you may have compassion fatigue.
Young EMS Providers
Younger EMS providers are at risk as well. On average, the human brain doesn’t fully develop until the mid-20s.21 Because of this delay, the younger EMS provider may be more impulsive, have impaired emotional management, and may be more susceptible to psychological trauma.22
With psychological trauma, the hippocampus, which regulates storing and retrieving of memories, often shrinks, as well as the emotion-regulating prefrontal cortex. This allows the amygdala to take over—unchecked—putting the responder into a difficult to control fight, flight or freeze reaction.
With evidenced-based therapy, such as cognitive processing therapy,23 prolonged exposure24 therapy, or eye movement desensitization and reprocessing (EMDR) therapy,25 the hippocampus may build up again, allowing trauma to become manageable and for one to function well again.
EMDR therapy is an integrative psychotherapy approach that’s been extensively researched and proven to be effective for the treatment of trauma. It uses standardized protocols that incorporate elements from many different treatment approaches.
After receiving EMDR for three months, I moved from constant intrusive thoughts and suicidal ideation to having none. Results may vary, and others may need different types of treatment. It amazes me how many people with PTSD haven’t received a proven treatment.
Trauma can also have a positive outcome, known as post-traumatic growth (PTG).26 PTG generally co-exists with PTSD and results when one takes the sum of their experiences and feels rewarded by using them to help others.27
PTG may provide a source of meaning and purpose in life—important for suicide prevention—and result in emotional growth.28,29
Another phenomenon is called compassion satisfaction. As opposed to burnout or compassion fatigue, those with compassion satisfaction report positive feelings from helping others, whether that’s helping those we respond to, contributing to the betterment of the agency, or serving the broader society.30
The worst-case outcome of trauma is suicide. In my review of the 1994–2016 death records from Minnesota, over 80 responding agencies have had at least one responder die by suicide. The four most common illnesses attributed to suicide are major depressive disorder, borderline personality disorder, nicotine dependence and PTSD.31–33
Cultural factors may also contribute to the toxic ingredients necessary for an EMS provider to die by suicide. Cowboy and EMS culture have an amazingly common set of beliefs and values. When conducting research in the “suicide belt” of the U.S.—the Intermountain West—I found cowboy culture is a major factor that discourages help-seeking behavior, makes one feel alone in their pain, and encourages dangerous coping skills, like use of alcohol and risk-taking behavior.34 Culture can shape stigma and stigma can reshape culture—a vicious cycle noted in research.35
People who are suicidal often feel they cannot be helped, and empathy is our best tool to render care.36 Without enough empathy to understand our patients, how can we evaluate our own psychological state, baggage-free?
Empathy is often stuffed into EMS education in the ethics unit, but the reality is that opportunities to infuse it into scenario-based learning are often missed—but that’s not the only deficiency.37
The required EMS education on mental illness, suicide and the danger of psychological trauma to the responder comes up short. The National Continued Competency Program topics to be covered under behavioral and psychological health emergencies—mental status examination, restraint techniques, agitated/excited delirium, suicide/depression and verbal de-escalation/soft restraint.38
If we divide the allotted time by six, assuming we give each category equal time, it is hardly adequate to provide knowledge to treat ourselves, much less others. (See Table 1.)
We must take steps to recognize psychological trauma among our partners and ourselves, establish a supportive culture of understanding and help seeking, and realize that we are ineffective in caring for others if we do not first help ourselves. Highly effective treatments are available.
- Boffa JW, Stanley IH1, Hom MA. PTSD symptoms and suicidal thoughts and behaviors among firefighters. J Psychiatr Res. 2017;84:277–283.
- Substance Abuse and Mental Health Services Administration. (Sept. 4, 2014.) Substance use and mental health estimates from the 2013 National Survey on Drug Use and Health: Overview of findings. Retrieved Sept. 10, 2018, from www.samhsa.gov/data/sites/default/files/NSDUH-SR200-RecoveryMonth-2014/NSDUH-SR200-RecoveryMonth-2014.htm
- Centers for Disease Control and Prevention. (n.d.) CDC mental illness surveillance. Retrieved Sept. 10, 2018, from www.cdc.gov/mentalhealthsurveillance/fact_sheet.html .
- Alexander DA, Klein S. Ambulance personnel and critical incidents. Br J Psychiatry. 2001;178(1):76–81.
- Bennett P, Williams Y, Page N, et al. Levels of mental health problems among UK emergency ambulance workers. Emerg Med J. 2004;21(2):235–236.
- Clohessy S, Ehlers A. PTSD symptoms, response to intrusive memories and coping in ambulance service workers. Br J Clin Psychol. 1999;38 (Pt 3):251–265.
- Fjeldheim CB, Nöthling J, Pretorius K, et al. Trauma exposure, posttraumatic stress disorder, and the effect of explanatory variables in paramedic trainees. BMC Emerg Med. 2014;14:11
- Grevin F. Posttraumatic stress disorder, ego defense, and empathy among urban paramedics. Psychol Rep. 1996;79(2):483–495.
- Jonsson A, Segesten K, Mattsson B. Post-traumatic stress among Swedish ambulance personnel. Emerg Med J. 2003;20(1):79–84.
- Streb M, Häller P. PTSD in paramedics: Direct versus indirect threats, posttraumatic cognitions, and dealing with intrusions.
- Regehr C, Goldberg G, Hughes J. Exposure to human tragedy, empathy, and trauma in ambulance paramedics. Am J Orthopsychiatry. 2002;72(4):505–513.
- Streb M, Häller P, Michael T. PTSD in paramedics: Resilience and sense of coherence. Behav Cogn Psychother. 2014;42(4):452–463.
- American Psychiatric Association. Diagnostic and statistical manual for the mental disorders, fifth edition. American Psychiatric Association: Washington, D.C., 2013.
- Bentley MA, Crawford JM, Wilkins JR, et al. (2013). An assessment of depression, anxiety, and stress among nationally certified EMS professionals. Prehosp Emerg Care. 2013;17(3):330–338.
- University of Phoenix. (April 18, 2017.) Majority of first responders face mental health challenges in the workplace. Retrieved Sept. 10, 2018, from www.phoenix.edu/about_us/media-center/news/uopx-releases-first-responder-mental-health-survey-results.html.
- McKeever VM, Huff ME. A diathesis-stress model of posttraumatic stress disorder: Ecological, biological, and residual stress pathways. Review of General Psychology. 2003;7(3):237–250.
- Tiegel IM: Diathesis-stress models for understanding physiological and psychological effects of stress. In S. Wadhwa (Ed.), Stress in the modern world: Understanding science. Greenwood: Santa Barbara, Calif, pp. 36–44, 2017.
- Wadhw S. (2017). Burnout. In S. Wadhwa (Ed.), Stress in the modern world: Understanding science and society. Greenwood: Santa Barbara, Calif, pp. 451–458, 2017.
- Montero-Marín J, García-Campayo J. A newer and broader definition of burnout: Validation of the “Burnout Clinical Subtype Questionnaire (BCSQ-36)”. BMC Public Health. 2010;10(1):302–310.
- Zeidner M, Hadar D, Matthews G, et al. Personal factors related to compassion fatigue in health professionals. Anxiety Stress Coping. 2013;26(6):595–609.
- Pujol J, Vendrell P, Junqué C, et al. When does brain development end? Evidence of corpus callosum growth up to adulthood. Ann Neurol. 1993;34(1):71–75.
- Yurgelun-Todd D. Emotional and cognitive changes during adolescence. Curr Opin Neurobiol. 2007;17(2):251–257.
- Forbes D, Lloyd D, Nixon RD, et al. A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder. J Anxiety Disord. 2012;26(3):442–452.
- Powers MB, Halpern JM, Ferenschak MP, et al. A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clin Psychol Rev. 2010;30(6):635–641.
- Davidson PR, Parker KC. Eye movement desensitization and reprocessing (EMDR): A meta-analysis. J Consult Clin Psychol. 2001;69(2):305–316.
- Tedeschi RG, Calhoun LG. The posttraumatic growth inventory: Measuring the positive legacy of trauma. J Trauma Stress. 1996;9(3):455–471.
- Tedeschi RG, Calhoun LG. Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry. 2004;15(1):1–18.
- Berman AL. Psychological autopsy certification program participant manual. American Association of Suicidology: Washington, D.C, 2013.
- Frankl VE: Man’s search for meaning. Beacon Press: Boston, 1959/2006.
- Stamm BH: The concise ProQOL manual, 2nd edition. ProQOL.org: Pocatello, Idaho, 2010.
- Bolton JM, Robinson J. (2010). Population-attributable fractions of axis I and axis II mental disorders for suicide attempts: findings from a representative sample of the adult, noninstitutionalized US population. Am J Public Health. 2010;100(12):2473–2480.
- Goldsmith SK, Pellmar TC, Kleinman AM, et al (eds.): Reducing suicide: A national imperative. National Academies Press: Washington, D.C., 2002.
- Richard-Devantoy S, Olié E, Guillaume S, et al. Distinct alterations in value-based decision-making and cognitive control in suicide attempters: Toward a dual neurocognitive model. J Affect Disord. 2013;151(3):1120–1124.
- Caulkins CG. (2014). Suicide in the Intermountain West: A Syndemic in Park County Wyoming? (Master’s thesis.] Retrieved Sept. 17, 2018, from ProQuest Dissertations and Thesis Database Open. (UMI No. 1528221.)
- Caulkins CG. Bridge over troubled discourse: The influence of the Golden Gate Bridge on community discourse and suicide. Journal of Aggression, Conflict and Peace Research. 2015;7(1):47–56.
- Pompili M. Our empathetic brain and suicidal individuals. Crisis. 2013;36(4): 227–230.
- Bramer K. (2013.) The sufficiency of ethics education in paramedic curricula. (Unpublished master’s thesis). Bethel University: Roseville, Minn.
- National Registry of Emergency Medical Technicians. (2016.) National continued competency program. Retrieved Sept. 17, 2018, from www.nremt.org/rwd/public/document/nccp.