After a prolonged time of working in emergency medical services, there comes a time when there is not much left that can fluster you. You have possibly seen a decapitation, maybe some protruding bowels, and smelled every kind of imaginable putrid funk from gangrene to the unmistakable tang of C-Diff. You’ve been to the hoarder houses for a code blue and the public events where you are scrutinized by hundreds of spectators. Putting your knee into an unidentified wet or squishy “something” is part of a regular day.
You’ve most likely experienced multiple supervisors from involved to absent, from inept to overzealous. You have heard the promises of more education and better training, more staffing and upgraded equipment. You’ve sat on the street corners for endless hours waiting for a call. You’ve also been the crew who has the invisible target on your back that doesn’t get a break for the entire shift. I have dealt with ambulances that do not have working heat in winter nor A/C in the summer. I’ve worked in ambulances that have over 450,000 miles on them and dealt with countless equipment failures.
Strong Personalities are Part of EMS
It is part of what makes this type of individual able to perform this type of work well. We’ve all dealt with the medics that walk around with their superiority complex, constantly oozing their ego driven self-idolatry. There are the “Toxic Terry’s” who always find something to complain about and try to force you into their “Negative Nancy” gang. There are low-level supervisors who used to be in the field, that only exist in their glory days and wrap their antiquated thinking around them like a ratty, old quilt and bury their head in the sand to progress. There’s fanatical new guys who think they are the exception to every EMS rule and the veteran that has literally seen it all and remains humble. There’s room to learn from each of these types, even if it’s a lesson in what not to do.
Don’t forget about the never-ending red tape. There is constant recertification for physicals, licenses, accreditations and registries. The constant policy and protocol updates, so just when you have one memorized, a new one appears with dramatic changes. There’s compliance times and an ongoing turnover of base hospital staff that aren’t familiar with local field protocols. Add in the micro-managing of bad managers that feel it is their sole mission to pick apart every choice you make on a call, despite favorable outcomes or difficult circumstances that they can only armchair quarterback. All of this for the same starting wage as the local fast-food joint.
Burdens
Along with the physical and mental burdens that are an ordinary part of the job, there is an emotional weight that each provider must tackle as well. No matter who you are, or how tough you think you may be, there are times when the experiences that you encounter in this field will remain somewhere in the recesses of your psyche for years to come. Not always bad experiences, but most likely the negative weight of those is heavier though. There has been a well-accepted belief in the past that having emotion attached to any part of the job is a weakness. This all adds to the increased likelihood of burnout. One recent study of EMS workers reported burnout rates as high as 56%.1
I remember a distinct time when I was required to attend a very public incident debriefing. First, I had felt that I had already dealt with the incident by confiding in a co-worker and working through it in a manner that felt healthy to me and had alleviated the bad feelings I had about it. Second, it was a week after the incident, and I was ready to put it behind me. Third, the critical incident debriefing manager was a coworker that I did not have a positive relationship with, and I did not feel safe discussing my feelings in their presence.
Another issue was that it turned into a finger pointing session. During the debriefing, I was called out for “being able to show my weaknesses” for attending by the same person who demanded my presence. I walked away not only feeling worse about the incident, but irritated and frustrated about how the entire process was handled. The interesting thing is that I have not heard of them being offered since.
The calls that need to be debriefed have not stopped, there is just a complete lack of accountability to offer any post incident debriefs in many organizations. The field hasn’t changed, but instead of being approached to debrief, you get raked over the coals for a documentation error or misspelled word in an overly scrutinized manner, which for most of us, makes us introvert even farther. Often, the people who should say something after these calls don’t. On top of that, due to the ongoing HIPAA regulations, there is very little communication about the outcome of many patients beyond your care of them. This used to be one of the highlights of a job well done, knowing the outcome was positive, and in instances when it wasn’t, it was a good source of learning to improve our care.
The Hardest Type of Call
For me, there is nothing more personally traumatizing than handling a pediatric code. Like many paramedics and EMTs, they are my bugaboos. In the past 25 years, I have responded to more than a person should be able to remember. They are always in my mind, easily recalled. They are the calls that have given me nightmares, kicked my insomnia into high gear, and keep me ever vigilant with pediatric protocols. It’s the reason that I carry my own First 5 book and Breslow tape. They are the calls that you try not to relate to and do whatever you can to not personalize.
Despite this, there has only been the single incident mentioned previously. And that single debriefing has left as many scars as the code itself. Every EMS provider has their own bugaboo. Add to that, personal issues that we all deal with in our daily lives, and you have a recipe for burnout, not to mention higher rates of divorce, suicide, addiction issues and unhealthy behaviors.
These factors lead to feelings of being overwhelmed, frustrated, disappointed, exhausted, and isolated. It’s also commonly referred to as compassion fatigue, vicarious trauma, emergency responder exhaustion or burnout. These emotions can then relate to poor patient care with a lack of empathy and subpar attention which can lead to missing important signs and symptoms, as well as medical errors. The amount of stress a person can deal with can be described as a metaphorical “resiliency bucket.”
Each of us has one that we fill with a lot of different things. On a perfect day, in a perfect world, the bucket never gets close to full. We have an unpleasant experience and then we manage it, put it behind us, and move on. This is not realistic, however. One must consider that before we even start our shift, our bucket has some residual contents from our intimate life outside of the job. When you show up for your shift, it may already be nearly filled.
Even stress that comes from positive sources can add to the fullness of your resiliency bucket. Whether positive or negative, every stress adds to the load we carry. Everyone’s bucket is a unique size. Some people handle stress well and keep their bucket empty, while others struggle to keep it from spilling over infinitely.
Long-Term Effects
Recently, I read an article about the long-term effects of chronic stress from jobs like EMS, and realized how detrimental it was on my long-term health.2 One of the easiest suggestions that I have found to combat the cortisol dump after a stressful event was to take a short walk. After incidents that I felt were the most nerve-wracking, I would grab my partner and take a quick, five-minute walk. Usually around the campus of the hospital where we had left the patient.
We will rehash the call, take some deep breaths, look for something good to focus on, and then return to service. It was short enough that dispatch and the field supervisors were usually OK with it, but long enough for us to reset our sympathetic nervous system and focus on the next patient. I noticed right away that my patient care and reports improved along with my overall attitude and positivity for the remainder of the shift. In the past, I would rush to the ambulance, put my head down, and start hammering out my patient care report. This led to the retention of stress and emotions for the remainder of the shift and well into my home life, also.
Self-care in theory is great, but the realities of long shifts and off duty responsibilities tend to leave a mark of exhaustion for responders that can make prioritizing oneself a nearly impossible task. Here are some ways that may help you manage stress and burnout. Get plenty of sleep, take your vitamins and minerals, exercise, meditate, read a book, pray, listen to music, go for a walk, avoid toxicity, practice gratitude, try not to drink alcohol, etc.
While these are all great pieces of advice, they are not continuously the ones that seem realistic when you start to spiral into dark thoughts and feelings. More practically, do the best you can by prioritizing your health, your mind and your soul. Talk to someone, anyone, when the burden starts to feel like too much. Better yet, talk to someone as the stress comes, rather than wait for it to be too heavy. After you deal with the hard call, the difficult patient, the one you couldn’t save, talk to someone.
Lean on a coworker or friend to work through these things. Call your employee assistance program to see what resources you have available. Find a therapist who understands first responder stress. Be willing to open up and deal with the hard stuff so that later on you aren’t dealing with the fallout.
Conclusion
Ultimately, burnout is bad for everyone. It’s bad for the employer who has spent time and money on training and wants to retain employees long term. It’s bad for patients when they deal with increased complacency of care, reduced empathy, and lack of focus from their provider.
It’s bad for our families, friends and real-world relationships by putting strain on them. Most of all, it’s bad for us, the providers. We need to protect our mental and physical health to the best of our ability. Not only to be able to remain in the field and serve our communities, but to be the best version of ourselves in and out of the uniform. Never be afraid to ask for or to offer help. Be courageous enough to make your health a priority in whichever way works best for you.
Editor’s Note: This commentary reflects the opinion of the author and does not necessarily reflect the opinions of JEMS.
Signs of Burnout3,4
- Feeling exhausted even after sleeping; change in sleep patterns
- Getting sick more often than normal; lowered immunity
- Headaches, backaches, joint pain
- Lack of motivation to do normal things
- Anxiety about returning to your next shift
- Irritability, lack of patience, cynicism, easy to anger
- Overall sense of hopelessness, more pronounced when at work
- Procrastinating, putting off getting things done on and off shift
- Change in eating habits
Resources
- Employee Assistance Program
- American College of Emergency Physicians (ACEP) Wellness Guide acepwellnessguide.pdf
- Safe Call Now 206-459-3020
- National Alliance on Mental Health 800-950-6264
- The Code 9 Project | You Are Not Alone
- First Responder Response Network https://www.frsn.org/
- First Responders’ Bridge (firstrespondersbridge.org)
- HERO Project — Fairhaven Ministries — Retreat for emergency responders (fairhaven-ministries.org)
Recommended Reading
- Mental Health Intervention and Treatment of First Responders and Emergency Workers by Clint A. Bowers, Deborah C. Beidel, and Madeline R. Marks
- Self-Care for Healthcare: Creating Resilience in the Workplace by Kenzie Wilcox-Ingebrand
- The Body Keeps Score by Bessel Van Der Kolk, MD
- Stress into Strength by Nick Arnett
- Toxic Stress: A Step-by-step guide to managing stress by Dr. Harry Barry
- The Essential Guide to Burnout: Overcoming Excess Stress by Andrew and Elizabeth Procter
References
- Reardon, M., Abrahams, R., Thyer, L., & Simpson, P. (2020). Review article: Prevalence of burnout in paramedics: A systematic review of prevalence studies. Emergency medicine Australasia : EMA, 32(2), 182–189. https://doi.org/10.1111/1742-6723.13478
- Robinson, B. (2022, May 2). How Chronic Work Stress Can Damage Your Brain and 10 Things You Can Do. (forbes.com)
- Weber, A., & Jaekel-Reinhard, A. (2000). Burnout syndrome: a disease of modern societies? Occupational medicine (Oxford, England), 50(7), 512–517. https://doi.org/10.1093/occmed/50.7.512
- Bianchi, R., Boffy, C., Hingray, C., Truchot, D., & Laurent, E. (2013). Comparative symptomatology of burnout and depression. Journal of health psychology, 18(6), 782–787. https://doi.org/10.1177/1359105313481079
