Burnout, Mental Health and the First Responder Compassion Crisis

By Athena Ryals

Health care first responders in the United States are often the first ones to tell you that we as a profession are experiencing a compassion crisis. Fire and EMS systems were already stretched to the breaking point as the metaphorical safety net for many communities before COVID struck in 2020. Now, fire and EMS systems everywhere are veritably crumbling¹–especially EMS, which, in many states, is not considered an “essential service,” and therefore does not receive federal and state assistance like fire and police departments do.²

The burden then falls on the individual EMS agencies and, more specifically, the individual EMS workers, to provide what is often the only access to health care many communities can access.³ This responsibility comes at great personal cost to the individuals doing the work of patient care. With rampant understaffing,⁴ increased violence against EMS workers,⁵ and stagnant wages,⁶ burnout among EMS workers is anecdotally reported to be at an all-time high–and where burnout is found, compassion is often one of the first things to deteriorate.

Burnout can be exacerbated by moral distress. With increased budget challenges, lack of support from agency leadership, and rising pressure to “turn and burn” or run calls as fast as possible to bring as many (hopefully insured) patients to the emergency room as possible,^1,7 many first responders feel they are unable to provide ethical patient care.

This is one of the leading causes of moral distress among first responders,⁸ a form of psychological pain that can have a “crescendo effect.”⁹ This buildup of moral distress into “moral residue”⁹ can have a hardening effect on the first responder’s emotions and stifle their ability to express–or even experience–compassion.

In 2008, a 48-year-old man died in the emergency room after the EMTs who responded to his 911 call forced him to walk down three flights of stairs rather than using non-exertional methods to get him downstairs while he was experiencing a heart attack. A malpractice suit against the defendants was settled in 2012 for $1 million.¹⁰

In 2018, an EMT was seen on a police body camera repeatedly punching a restrained 17-year-old patient in the face after he allegedly spat on her.¹¹ More recently, in 2023, two EMS providers were charged with first-degree murder after they strapped a patient down to their cot face-first and he asphyxiated, following long bodycam footage of them treating the patient disrespectfully.¹² These are just a selected few examples of the growing number of incidents of EMS workers experiencing critical failures of compassion.

These occurrences are not just isolated incidents indicative of a few “bad apples;” they are sentinel events indicating the stress being placed on a system that can no longer take the weight. Unfortunately, very few studies have been done that examine the correlation between burnout and patient safety events.

A study performed in Germany in 2018 indicated that burnout may be highly associated with safety outcomes, but more studies are necessary.¹³ Interventions must be taken–both for the sake of the mental health of our nation’s first responders, and for the safety of the patients they serve.

There is a financial cost of burnout as well, which–sometimes–gets the attention of business leaders. While the cost of EMS burnout has not been studied, the wider cost of health care burnout has; according to O.C. Tanner’s Global Culture Report, health care employee burnout costs $190 billion and 120,000 lives per year.¹⁴ On an individual level, the cost of attrition per employee is quite high–$6,780 per EMT and $9,113 per paramedic¹⁵–and considering that EMS is currently experiencing a 23-26% turnover in its patient care workforce, those costs add up.¹⁶

The burnout data for first responders that is available paints a grim picture. A study was performed in South Carolina and published in 2020 that indicated that 19% of EMTs and 30% of paramedics met criteria for burnout. ¹⁷ Some studies show burnout rates as high as 60%.¹⁸ The results of a nation-wide study were published in 2021 indicated that first responders reported high scores of lack of Personal Accomplishment (22.1%), Emotional Exhaustion (40%), and Depersonalization (50%), which are all components of the Maslach Burnout Inventory (MBI).¹⁹

Another nation-wide study published in 2023 focused on the compounding results of the COVID-19 pandemic and the substance use disorder (SUD) crisis on first responder burnout, and the moral injury and compassion fatigue that has resulted.²⁰ This was study was qualitative and therefore did not focus on hard data, but a notable figure is that 93.9% of the study participants had observed fellow first responders exhibiting a lack of compassion towards not just overdose patients; all patients suffered from first responders’ compassion fatigue.

Key Definitions

Empathy: the ability to perceive the feelings of others, often leading to the transference of suffering between the one in pain and the one perceiving it, sometimes leading to empathic distress, decreased helping behavior, and burnout

Compassion: a feeling of concern for the suffering of others, often associated with increased helping behavior, likely mediated by oxytocin and dopamine release

While empathy and compassion are often used interchangeably in everyday speech, the two functions serve fundamentally different purposes and create fundamentally different outcomes. Empathy increases activity in the anterior insula and anterior midcingulate cortex (parts of the brain associated with empathizing with physical pain when it’s perceived in others) and creates a negative effect in the viewer.²¹ This internal experience of other people’s pain is called “empathic distress” and can actually decrease helping behavior–the exact opposite of the behavior we want to exhibit as first responders.

Compassion, on the other hand, occurs at an activation of the orbitofrontal cortex, putamen, pallidum, and ventral tegmental area, which are associated with the reward system in the brain.²¹ These areas are likely mediated by oxytocin and dopamine release, further emphasizing compassion’s importance in forging connections between first responders and their patients–and providing a protective measure for the first responders’ mental health as well.

Therefore, when developing support and training for first responders, it’s best to focus on how we can experience concern for others without necessarily taking on their pain.

The impact of compassion training in EMS is difficult to overstate. There is no federal requirement for compassion training in initial or continuing education for any level of first responders–or, indeed, any requirement for any training in mental health at all.

The continuing education requirement for recertification for emergency medical responders (EMR), emergency medical technicians (EMT), advanced emergency medical technicians (AEMT) and paramedic first responders offers “psychiatric and behavioral emergencies” as a possible topic in the “medical” section of the education.²² This pathologization of mental health divorces behavior from its context and places the patient and the provider at odds with each other before the interaction even begins–a dynamic which can, and often does, lead to violence.

A recent scoping review of the non-technical skills in paramedicine named empathy (for our purposes we could interchange this with compassion) as one of the top five identified skills. Ethics was also identified,23 which is arguably an aspect of compassion and is definitely an aspect of moral distress, an extension of compassion.

What is there to be done? Burnout, compassionate fatigue, and overworked first responders are all topics that have received much more attention in the past few years than they ever have before. With those conversations have come resources.

The Substance Abuse and Mental Health Services Administration has a resource portal specifically for first responders,²⁴ with offerings on stress management, compassion fatigue, and grief. Social Work License Map has a webpage with a mental health action plan for first responders, guides for workplaces to support first responders, advice for friends and family to help their first responder loved ones and an impressive list of talk and text hotlines, mental health apps, factsheets, and more.²⁵ JEMS has an entire archive for their mental health and wellness articles.²⁶

And yet the crisis wears on. It’s hard to know what else to do, when it feels there is so much being done–but when faced when the enormity of first responder burnout and compassion fatigue, it feels like anything we do is only a drop in the bucket. As long as there are first responders suffering, though, I know there will be fellow first responders on deck to support each other. Until a massive overhaul of our entire industry comes to pass, I fear that that is all we have to battle compassion fatigue–each other.

About the Author

Athena Ryals is a paramedic of almost ten years. She has worked in urban and rural systems and has served on a special operations and rescue team alongside SWAT, SAR, and dive teams. Currently, she works in Illinois as a paramedic with Carle Arrow Ambulance Service. She has a bachelor’s degree in mining engineering and also works as a simulation operations specialist.

References

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