Post-Traumatic Stress Disorder Comparison Between Fire and EMS Personnel

An ambulance at night waits outside a hospital with its lights flashing. — File Photo

This study evaluates post-traumatic stress disorder trends and resource utilization in York County, Pennsylvania.

Abstract: First responders, both fire and EMS personnel, have higher rates of post-traumatic stress disorder (PTSD) than the general population. This study evaluates for any differences in PTSD rates between fire and EMS, years of service, urban and rural, as well as volunteer and paid responders. Surveys were completed by personnel across the county and analyzed. The survey also included details about “worst calls” and availability of incident debriefing and mental health resources There does not appear to be any significant difference in PTSD rates across all the areas evaluated. Additionally, the study found limited access to resources. This study evaluates trends that have not been well cited in the literature regarding PTSD and first responders.

Introduction

Post-Traumatic Stress Disorder (PTSD) has become a hot topic in emergency services over the past several years. The National PTSD rate of the U.S. is estimated at 6.8%.¹ The rate for firefighters has been estimated anywhere from 7%-37%.² Unfortunately, not as much research on PTSD and emergency medical service (EMS) providers has been performed. Generally, fire and EMS are grouped together as “first responders.” While these groups frequently respond together, each job description is markedly different. Past studies estimated the rate for PTSD in EMS workers to be 19%.³ While this study result is comparable to the PTSD rates seen in firefighters, it leaves one to question how similar (or dissimilar) the rates in a similar population.

Related

The purpose of this study is to evaluate PTSD trends and resource utilization in York County, Pennsylvania. York County is in South Central Pennsylvania. In 911 square miles, over 430,000 residents span over a mix of urban and rural landscapes.⁴ This area is served by 27 EMS agencies and 58 fire departments. In both services, there is a mix of volunteer, career and combination departments. Currently, the only resource available to all departments is the Critical Incident Stress Debriefing team.

This study will examine PTSD rates and trends between both fire and EMS services as well as career and volunteer departments. Trends among years of service, as well prehospital emergency medical care certifications, will be examined to see if a certification level puts one at higher risk for PTSD development. Resource utilization trends will also be examined to see if one category of first responders is more likely to seek help. Finally, a comparison of resources available and used will be performed both from an administrative perspective and from the personnel’s perspective.

Methods

Procedure

Two separate surveys were created through the website Survey Monkey. The first survey was designed for personnel to answer; the second for one representative of each department’s administration to answer. The surveys were distributed through email from the York County Fire Chief’s Association, as well as through the Eastern Health Services Federation to the fire chiefs and EMS managers, respectively. There are an estimated 1,400 emergency responders in the county. With these two sources, all services within York County could be reached. The email included the purpose of the study, a request to have all of their active members complete the survey for personnel, as well as a representative from the administrative side to complete the administrative survey. All data was then collected through the survey website.

Survey Design

Personnel survey: This survey contained questions regarding the following: demographics, medical training certifications, years of service, and what type emergency service they identify with the most. Participants were also asked to identify the “most disturbing call” or the call that affected them the most. Questions regarding use as well as access to mental health resources provided by their department were also included and their personal utilization of those services. Finally, the DMS-V criteria for PTSD was listed and participants were asked if they believed they met criteria or have been formally diagnosed with PTSD.

Administration survey: This survey contained questions regarding mental health services available to their members, how they market those services to their department and any specific protocols or guidelines for mandatory use of those services or the CSID team.

The survey was made to be 100% anonymous to promote honesty within the answers. No recording of IP addresses or questions relating to their station number or service were included.

Statistical Analysis

The categorical variables as percentages were analyzed via the Chi-square test. The Fisher exact test was used when any of the expected frequencies were five or less. All of the analyses were performed by the SAS 9.4 (SAS Institute, Cary NC).

Results

Personnel survey: There were a total of 387 responses for a response rate of 27%. Eighty were removed secondary to being incomplete and four were removed as the respondents were minors. This left 303 surveys available for analysis. The average age was 38.02±11.98 years with an average of 17.97±11.04 years of service. The male to female ratio was 224:79. The largest group of responders was in the EMS-career full time with 111 responses (36.51%) (See Figure 1).

Figure 1. Response Categories

Figure 1 notes the demographics of each of the categories. Most of the responders were either EMT-B (50.33%) or EMT-P (25.99%). A total of 201 responders knew that they had access to resources for mental health, but only 36.82% used those services. Seventy responders did not know if they even had access to resources (Figure 2).

Figure 2. Categories and Access to Care

Another 20.40% of those that knew they had services felt as if there were barriers to accessing them. Figure 3 details the categories of barriers to care with the highest being the stigma of fire/EMS and the inability to express that they were having problems emotionally with the event.

Figure 3. Barriers to Accessing care

Note responders could free text their answers and could identify multiple barriers. Each responder gave a description of their “worst call” and it was manually entered into the categories listed in Figure 4.

Figure 4. Categories of “Worst Call”

The highest frequency was seen in pediatric traumas, followed by adult trauma, and then knowing the person/persons involved.

For this analysis, if a responder indicated that they met PTSD criteria, they were assumed to have PTSD. Additionally, those that indicated PTSD from another source, other than fire/EMS, were not included in the PTSD category for analysis. Placing all categories together, having a particular certification did not put one at a higher risk of PTSD (p=0.5228) (Figure 5).

There is no correlation (p=0.1950) between PTSD and years of service, comparing in five-year intervals. Finally, for those that did not seek help after their “worst call”, responders did not have a higher incidence of PTSD (p=0.4702)

Between all six categories, there was no statistically significant difference in PTSD rates (p=0.5917). Responders were equally likely to seek help between all six categories (p=0.5107). Overall, when comparing fire and EMS responses, there were no difference in PTSD rates (p=0.3487) and no difference in those seeking help (p=0.2173). Next, those categories of volunteer were compared against those that were career. Again, no difference was found between PTSD rates (p=0.0901) and those seeking help (p=0.7697).

Administrator Survey: There was a total of 39 responses. Career EMS made up the largest group of responders with 17 responses (43.59%) followed by volunteer fire with 15 responses (38.46%) (Figure 6).

Overall, 38% (n=15) of company administrators have resources available to their providers; 12.8% (n=5) did not know if they had resources available. Only seven organizations identified mandatory CSID or debriefings (17.95%).

Discussion

Overall, 33% of personnel were diagnosed with PTSD or met PTSD criteria. 35% of EMS responders and 30% of firefighters were diagnosed or met criteria. Unfortunately, there is not a lot of data regarding PTSD rates for EMS providers; however, studies suggest around 20%.^3,5 Rates for firefighters are highly variable as well ranging anywhere from 17% to 57%.^6,7

No significant statistical difference between all variables is intriguing. The responses were all recorded from the same geographical area, and one would assume that they would have similar traumatic exposures. Although the exposure is the same, the roles between fire and EMS are very different. Several other studies have found higher incidence of PTSD in ambulance personnel in comparison to fire and police.^8,9 One study theorized that this was due to more exposure to critical or significant incidents.¹⁰

Very few studies had compared career and volunteer emergency responders. Typically, rural units are volunteer and urban units are career. Crampton evaluated urban and rural EMS providers.¹⁰ This study also found no significant difference between PTSD rates and was replicated in further studies by Probst.⁵ These studies did note that urban EMS felt as if they had more resources and felt less negative criticism regarding their negative feelings.

Correlation of PTSD rates with years of services has yielded mixed results. Several authors have found no relationship with the length of career.^5,11 In contrast, one study noted decreased rates of PTSD with higher numbers of years of service.¹² They suggested this was due to learning coping mechanisms throughout the years. These authors also noted that those who started their careers at a younger age had higher rates of PTSD, independent of their years of service overall. Those with more years of service are likely to hold rank or a line officer position. Another study found that rank, but not years of service, was a predictor for PTSD.¹¹ Rank was not evaluated in this study.

Certification level assessments have been limited. There was one large study with comparisons of the certification levels.⁵ This also concluded no statistical differences between the certification levels. They did note that EMTs had an overall higher post-traumatic stress severity scores. The authors theorized this may be related to feelings of lack of the control as the EMT is assisting the paramedic in patient care for many of these critical patients. This author also did a comparison a comparison similar to this study evaluating rural and urban access to EAP and other structured services. Rural correlates in York County to more of the volunteer aspects and urban more to the career aspect. They found that rural had less access to EAP services and relied more on peer support groups. This study did not show any statistical difference between urban and rural.

Analysis is of the “worst call” is somewhat as expected. The most common is pediatric victim followed by adult victim. The third most common is friend/family member involved or the responder knowing the victim. This is very similar to what has been seen in other studies.^12,13 Del Ben also reported “near misses,” or own providers feeling of eminent danger or death, was also high on the questionnaire. Interestingly, no responders in this study reported this as one of their worst calls.¹²

Overall, there seems to be a disconnect between management and first responders on access to mental health resources. In this area, more career fire responders were aware of their options and management is proactive on disbursing this information. For both fire and EMS for volunteer services, less than 50% of responders knew if they had resources. Their administrator surveys also suggest that management is not aware of the resources. This could be a potential barrier to access which can be easily addressed from a company level. Many responders did note that stigmata, ease of access and management are the top reasons that they did not access care. Speaking about the subject more openly and frequently may help to encourage emergency responders to access care. Given the consistency of fatalities having higher rates of PTSD, one would expect better utilization of the mental health resources supplied by their organization for these types of events. Very few companies in this study have mandatory debriefings; however, for those that do, fatality is a triggering event.

Early intervention may also play a key role in prevention. For the 100 responders that were diagnosed with PTSD or met criteria, only 17 had initially sought help after their “worst call.” Given this, it appears that early debriefing can be beneficial. One study that followed firefighters from the start of their career through the first two years noted a large increase in PTSD and symptoms between 6 and 12 months of service.¹⁴ Through their analysis, they agreed that early intervention is key, even if the event does not seem that significant or is relatively minor. Others also commented that it may be beneficial to teach adaptive behaviors before the traumatic event in an effort of primary prevention.¹⁵

Prevention is a key aspect in the medical field. Early intervention appears to be a key component for mitigating PTSD in all types of first responders. Based on this study, I would recommend for increased lines of communication between management and responders as well as a protocolized system for incident debriefing, especially if the call involved a critical pediatric patient/arrest, any house fire with victims, especially if children are involved, as well as when the person is known to the crew.

Limitations: Inherently with a survey type model, there will be a self-selection bias. Additionally, PTSD is assumed if the responder reported that they met criteria for PTSD based on the DSM-IV definition. There also may be a selection bias as it could not be confirmed that all services in the York County region received the survey.

Conclusion

PTSD is more prevalent in emergency responders than the general population. There does not appear to be a different between service area, paid status, years of service, or between fire and EMS responders. Early intervention is key for preventing and mitigating PTSD in first responders. This may be streamlined with protocol based CSID for specific call types such as pediatric arrests and fires with fatalities.

Acknowledgements

The author would like to thank Chief Daniel Hoff of York Area United Fire and Rescue for his guidance, project development and support. A special thanks to Retired Chief Chad Deardorff of the York City Fire Department for his input and assisting in growth of the project.

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