Courtney Smith, 54, drove to a desolate country road on a cold winter morning. It was three hours from the city where she worked as a medic for 28 years. Courtney pulled to the side of the road and sent a text to her three children. She told them she was proud of them and that she loved them. She then walked out into the field beside the road, pulled out a pistol and succumbed to the memories that had been nagging her for years of shift work, responding to countless horrific calls. The flashbacks of a mother’s wail when she’s told her child has died, the vision of bodies mangled in a vicious car wreck, and the memories of all the suicides—the smells and the sounds—would plague her no more.
Courtney always seemed to be able to manage the stress that accompanies the critical calls—the type of calls that haunt most people. It was all a facade. Courtney was able to hide the pain and subdue the effects of the nightmares and flashbacks she had almost every day. She knew if she showed any weakness, she would be pulled off the truck and possibly lose her job. The thought that she would lose the respect of her partner, her boss and her co-workers was more intimidating than addressing her issues. The idea that she may need counseling was even scarier.
Courtney’s co-workers, friends and family were surprised by her suicide. They said everything in her life seemed fine. She was happy, vibrant and excited about her future. They said she loved her job, loved her children and loved her husband. She was the person they could all count on when they needed help.
Others saw something—a shift in her outlook, her mannerisms, her attitude—but didn’t know what to do or what to say. Their concerns for appearing too nosy or breaching some unknown boundary into Courtney’s personal life seemingly outweighed what was really important. They were unable to see the depth of her pain and her need for help. They felt guilty for not speaking up and talking to her about their concerns and now there was nothing they could do except support her family and each other.
It’s stories like these that led us to form the group Reviving Responders. This began as a research assignment from Fitch & Associates’ Ambulance Service Manager Program, which is designed to provide new leaders and managers with an up-to-date curriculum of the industry’s best practices and foremost challenges.
We chose to research the prevalence and severity of EMS provider stress in the workplace. We created a survey to address something we termed "critical stress" (CS) and also looked at providers who’ve either contemplated or attempted suicide. Additionally, we attempted to measure how effective current support mechanisms are from the provider’s point of view, and what can be improved through these support institutions. Lastly, we took a snapshot of the various cultures of EMS throughout the country as they pertain to provider support for mental health and looked for any connections between an EMS provider’s stress level and the associated culture in which they are immersed.
PREVALENCE & SEVERITY OF CRITICAL STRESS
A group at Ambulance Service Manager, which consisted of seven individuals from Missouri, Texas, Oregon, Colorado, California and Nevada, created the survey questions. This survey, hosted by SurveyMonkey, was then sent to all employees of each member’s EMS system as well as continuing education classmates, the Trauma Regional Advisory Council, the National EMS Management Association and other contacts from the medical field. Many recipients then shared the survey via social media, allowing the survey to spread to providers and organizations across the country.
In the survey, we defined CS 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. This stress has a strong emotional impact on providers, regardless of their years of service." Some of the questions asked respondents if they’ve ever experienced CS, if they’ve ever contemplated suicide and if they’ve ever attempted suicide. The survey went on to ask if support was available and if it was used.
The survey then explored the different types of support, such as employee assistance programs (EAP) and critical incident stress management (CISM) teams, with the intent of finding how effective EMS providers found the help, and what they felt would have made the support more effective. Finally, the survey asked questions about whether the provider felt supported by their peers and management team with respect to their mental wellness, and asked whether or not an employee was encouraged by their peers and management team to use the formal support services available.
Figure 1: Comparison of suicide contemplation and attempt rates: survey respondents vs. national average (n = 4,022)
We didn’t know how many responses we would receive, but we knew that our project hinged on getting enough data to make the study statistically valid. So it was with a considerable amount of trepidation that we pressed the "send" button and initially distributed the survey. We initially thought that something could be put together with 100 responses, but we were really hoping to get something closer to 500 by the time the survey was closed.
Within one hour there were 100 responses, and within one week there were over 1,000. The survey quickly had respondents from all 50 states and we wound up with a total of 4,022 responses.
That many responses in such a short time was nothing short of amazing, but we surely weren’t ready for what came next. The results showed that 3,447 (86%) of the 4,022 respondents experienced CS, but the shocking discovery was that 1,383 (37%) of the respondents had contemplated suicide and 225 (6.6%) had actually tried to take their own life. (See Figure 1.) These statistics are roughly 10 times greater than the national average for adults in America, according to a study done by the Centers for Disease Control and Prevention in 2012.1 Even taking into account inherent survey bias, these figures were mindblowing. This information concretely establishes the fact that EMS provider stress is prevalent in our nation and is extreme, to say the least.
THE EFFECTIVENESS OF FORMAL SUPPORT INSTITUTIONS
Most people have heard a story (or been a part of one) about a caregiver who goes to a CISM debriefing and believes it to be a colossal waste of time, or an EAP counselor who knows absolutely nothing about the EMS industry and spends the sessions in horror, learning about events providers are routinely exposed to.
Figure 2: Effectiveness of formal support institutions
We’ve heard those same stories as well, and we expected the survey results to show that formal support institutions such as EAP and CISM are ineffective or mediocre at best in dealing with provider CS. We were surprised to find that these institutions received higher ratings than we expected.
Of the 86% of respondents who experienced critical stress, 18% (614) attended CISMtype programs and 63% (388) of them found the sessions very helpful or extremely helpful.
Of the 11% (394) who attended EAP sessions, 53% (210) found them very or extremely helpful. (See Figure 2.)
This isn’t to say that the support couldn’t be improved, or that the stories we’ve all heard aren’t real. Indeed, 51% of the people who used EAP for support stated that the support would have been more helpful if the therapist was experienced in dealing with people in the EMS industry or with post-traumatic stress disorder. One respondent summarized the EAP interaction as such: "I described the call that I was having trouble with only to have the psychologist look at me and say, ‘How do you guys do what you do?’ She was clueless and ill-equipped to help me."
There were other common themes in the critiques of formal support institutions. Some people who used CISM teams stated they received the CISM support too late or that they didn’t feel comfortable sitting in a room full of people to talk about how they felt, and were horrified to have to "relive the call."
There were two critiques prevalent in the responses, regardless of what type of support they utilized: the support was either not accessible or the provider felt discouraged from using the support. Some comments from the survey that illustrate these critiques include:
- "Fear of being fired. We’re not allowed CISM at our service."
- "I asked for help and ended up losing my 22-year career."
- "Asked for help and was laughed at."
- "Was told to get back to work. Was told I signed up for it so deal with it."
- "It wasn’t offered even though we all thought it should be. One co-worker stated it didn’t even bother him. A different co-worker who heard about it made comments about me being ‘mentally fit enough to be on a truck’ because the kid’s death bothered me."
The survey results revealed that 1,592 (40%) of the respondents had access to support but didn’t seek help. Roughly a quarter of these respondents who didn’t seek help for their CS were concerned about how they’d be viewed at work if they had sought support. Over 40% of those who had either contemplated or attempted suicide and didn’t get help also listed scrutiny from others as the reason why they didn’t seek support.
CRITICAL STRESS & EMS CULTURE
Indeed, another shocking revelation was this notion that EMS culture is a huge barrier to providers getting relief for their sleepless nights or relived nightmares. As an industry, how we support our EMTs and paramedics when they’re feeling overwhelmed varies from one department to the next.
A portion of the survey gathered data about the different EMS cultures around the country. Four prominent cultures dominated the data, but didn’t represent the results in their entirety. They were cultures where:
- A field provider doesn’t experience mental wellness support from their peers or management team. This field provider is also not encouraged to engage in formal support institutions like EAP or CISM;
- A field provider experiences support from their peers regarding their mental wellness, but doesn’t feel supported by the management team. This field provider isn’t encouraged to engage in formal support institutions like EAP or CISM;
- A field provider experiences support from their peers and management team, but there’s no encouragement for a field provider to utilize CISM or EAP; and
- A field provider is supported by both peers and the management team. This field provider is also encouraged to utilize the formal support institutions like EAP and CISM.
The survey results show that presence of CS is roughly the same in all of these cultures (see Figure 3), but the rates of suicide contemplation and suicide attempts (see Figure 4) significantly decrease when a field provider has the support of their peers and is encouraged to utilize the formal support institutions in place: A supportive and encouraging environment cut suicide contemplation rates in half and attempt rates by 66%.
Figure 3: EMS cultures and the presence of critical stress
When it comes to a provider seeking help for CS from either a CISM or EAP program, the data suggests that being in a supportive environments isn’t enough. The major factor increasing the likelihood that a respondent would seek help is if he or she was encouraged to seek said help by either their peers of management. (See Figure 5, below.)
Furthermore, the perceived effectiveness of the formal support institutions is greater when a field provider is supported by peers and management with respect to mental wellness, and is encouraged to utilize formal support. (See Figure 6, below.) Also worthy of note here is that the support effectiveness was greater when the provider attended on a voluntary basis versus instances where a field provider was mandated to attend.
Stories like Courtney’s are becoming all too common. If we’re really looking, we can walk through the operations building or sit on the tailboard of a truck with some of the crews and see the haunted look in so many eyes. We can even tell when somebody is less engaged, despondent or is having trouble coping with the burdens that come with helping unconditionally whenever asked.
Suicide contemplation and attempt rates among EMS practitioners are significantly higher than the general population. There may be a variety of factors that contribute to CS beyond the things we see throughout our careers. Sleep deprivation, feeling underappreciated, poor nutrition and exercise are just a few of many issues that may contribute to poor mental health in this field. More research is forthcoming to look at how those issues affect our well-being.
Figure 4: Suicide contemplation and attempts in EMS cultures
Figure 5: EMS providers who sought help for stress in various EMS cultures
There’s one thing we can all do, right now, to make an impact on rates of suicide contemplation and attempts in EMS workers. A conscious decision is needed to make a positive change in the culture surrounding mental health. Nobody needs special training to support their co-workers. Ask them how they’re doing, and be honest when others ask you how you’re doing. Support each other, support yourself and take care of yourself. Talk and listen to each other. If you feel like one of your peers needs more advanced help, there are several resources out there.
Figure 6: The effectiveness of formal support in different EMS cultures
You need to decide to be part of the solution, and not tolerate the behavior of those who are part of the problem. Confront the behavior of those who promote a negative culture at your workplace. Support those who promote a positive culture. Together we all can work to make a change in the culture to help improve the well-being of our profession.
1. Centers for Disease Control and Prevention. (2012). Suicide Facts at a Glance. Retrieved Aug. 7, 2015, fromwww.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf.