Stress Under Fire

It’s 3 a.m., and you are enduring one of the busiest nights you’ve seen in a long time. Enjoying the first opportunity you’ve had the entire shift to put your feet up and relax, you hope to coast through the rest of your 12-hour rotation. Your eyes get heavy and you slowly begin to slump further and further into your chair as you simultaneously and desperately try to decompress from tonight’s proverbial bends. A feeling of unsettled anxiety sets in that gradually feels more like a wet blanket that makes it difficult for you to get comfortable.

Suddenly, the inevitable happens and the emergency tones blare from your radio like a bullhorn straight into your eardrum. Your body is instantly catapulted into a “fight or flight” response, and your sympathetic nervous system fires into action. Your heart and respiratory rate instantly skyrocket. Your bronchioles dilate to give you better O2 exchange in the lungs, pupils dilate allowing more light to enter, muscles tense up as blood is being drawn away from less useful areas of your body and for an instant, it felt like your stomach was turned inside out. The hypothalamus gland goes to work immediately by coordinating the necessary nerve cell, firing sequences as well as the catecholamine release of epinephrine, nor-epinephrine and dopamine into the brain required to bring pull you into high alert.

What you have just experienced only takes a fraction of a second while your body initiates nearly 1,400 various physiological responses. Like it or not, these natural defense mechanisms against stress and danger will happen with or without your consent. You rely on this response in times of life or death, and you will need it the next time your patient crashes. You thrive on it in times of emergency when the outcomes of quick thinking and split second decisions are decided by how you respond under acute stress. Without question, the human body has an amazing way of dealing with all of this without a single voluntary action. Also called eustress (good stress), it allows you to wake up, think and triage your next move when you may otherwise tend to draw a blank in the face of crisis. This response also allows you to manage and even eliminate certain autonomic reactions that you feel are unnecessary for the task at hand. If you allowed yourself to completely succumb to all of its effects, you might find yourself emptying your bladder and unable to move.

In the business we have chosen, there a few “givens” that we have simply just come to terms with:

  1. We eat when we can, not when we want;
  2. Back pain is a bad thing; and
  3. We will experience some form of stress today, tomorrow and most likely forever.

The good news is you have a choice with how to manage these three issues. For the sake of this article, we’ll examine No. 3 by pointing out some of the biggest factors that stress contributes to the daily life of an EMS provider, the possible outcomes of subjecting your body to this kind of physiological pounding day after day and how it is directly related to the unique nature of our job.

When your body initiates a “fight or flight” response, you may be overcome with sensations that mimic superhuman abilities. You hear stories about people who are given the strength to lift an entire car off someone who’s trapped or others who are able to fight off an attacker twice their size because they are certain that their lives are in danger. The chemicals emitted in the body of those individuals are the same ones that infiltrate your body when you are brought to the sudden attention of a critical situation.

While the acute symptoms are more easily noticed, chronic stress remains the most difficult to identify, since its symptoms tend to be more subtle and gradual. The medical consensus seems to be that this doesn’t come without consequence if left completely unchecked over time. I am talking about heart disease and chronic sleep deprivation. That’s why learning how to take some sort of control over the symptoms can be beneficial. Not only will it improve your psychological and physical well-being, but it will become crucial if you want to ensure any kind of longevity in this business.

Heart Disease
You hear a lot about the three high-profile contributors that precipitate heart disease: poor diet, lack of exercise and smoking. But one that isn’t talked about that much is stress. Why is that? Well we all experience some sort of stress from day to day, be it money matters, family issues, etc. But according to the American College of Occupational and Environmental Medicine, there is evidence that the daily seesaw-like stress delivered to the body of the EMS worker has a higher potential for heart attack or stroke, due to an activation of fibrinogen in plasma, which induces blood clotting. This is the first real scientific indication suggesting that stress increases the risk of a myocardial infarction.

Another major factor is the hormone cortisol, which is secreted by the adrenal gland and mainly used to help turn food into energy under stress. Like most things in life, this is only good in small, short doses, and cortisol is meant to be a short-term acute stress manager. Prolonged amounts of time under acute stress will also prolong the amount of time cortisol stays in the body outside of its intended purpose. Over time, this can lead to weight gain, hypertension and heart disease.

Sleep Deprivation
After a long day, you may find yourself lying in bed unable to disconnect from the events of the day. You have bills on the table that need to be paid. You haven’t spent a quality night with your spouse in two weeks. The lawn needs to be mowed. You ask yourself, will you have enough money to pay for a desperately needed vacation? Not to mention that the screams of a 7-year-old girl with third degree burns on her hands still echo through your head. You will be lucky to get four hours of sleep tonight before your next shift, where it all starts over again. Sometimes, the ability to just snap out of it and go to sleep at the end of the day seems impossible. You are not alone. Chronic sleep deprivation has been shown to have a profound effect on some very key areas that EMS providers count on to do their job effectively, such as decreased alertness, cognitive and memory impairment and even injury.

Tips for Managing Stress
Talk to co-workers: There may always be support figures in your life like family, friends or a spouse that will be there for you, but there are few that will understand your difficulties at work like a fellow employee. Find one that you trust, and ask them if you can confide in them. Chances are you will find that you’re not alone.

Breathing: The average adult human takes approximately 23,000 breaths in a single day. If you stop to concentrate on just a few of them during a stressful situation, you help to lower your blood pressure, heart rate and potentially the risk of an acute heart attack. It sounds strange, but hey, no one will ever have to know what you’re doing. Remember, you’re no good to the patient if you’re worse off than they are. Stop and take some deep breaths-in through the nose and out through the mouth just like you tell your patients. Each repetition should take about eight seconds. It will help to relax your vascular system and divert O to areas that need it most, like your brain.

Sleep habits: Stress is one of the most universally recognized prohibitor of sleep. There are of course medications available for those with severe sleep disorders, and only a doctor can tell you if it’s right for you. However, I will tell you what I have done to help with this dilemma, and maybe you will find some help with it, too.

When you’re lying in bed trying to fall asleep, there seems to be what can only be described as a radio that constantly changes stations. Those stations are your stressors, and they won’t let you sleep without first being heard.

First, try something that creates ambient noise like a sound or some classical music from your alarm clock/radio. Turn it on low, so it does not to disturb you after you fall asleep. By doing this, it should concentrate a large portion of your focus to that noise, but not too much to prevent you from falling asleep. Think of your body as a lead weight, and focus your attention on relaxing every muscle in your body from head to toe. Any deviation from thinking about stress in your life could be a step closer to falling asleep.

Exercise: I know, “exercise is recommended for everything,” but hear me out. Imagine there was a pill that gave you tons of natural energy, a stronger heart, better metabolism, longer life and even helped you sleep by reducing your overall stress level. The only way it would work is if that pill got you off the couch and onto a treadmill. There are few things that could be more beneficial to you than 30 minutes of exercise a day, and its effects tend to reciprocate to other areas of well-being. That makes it a one-task option for a multiple of potential problems.

Since there is no telling what a new day will bring us, we need to come to work physically and mentally prepared for the worst everyday. We don’t get to start the shift with an agenda, except that of what we need to do when the moment comes. For this reason, EMS will simultaneously remain one of high respect and high demand for our public. It’s also yet another reason why caring for our patients must parallel caring for ourselves.

Reviewed by: Dr. Bradley Barth Medical Director/ER Physician for St. Joseph’s hospital, St. Paul, MN.


  1. Clays E, De Bacquer D, Delanghe J, et al: “Associations Between Dimensions of Job Stress and Biomarkers of Inflammation and Infection” Journal of Occupational & Environmental Medicine. 47(9):878-883, 2005.
  2. Michael Breus: “Chronic Sleep Deprivation Man Harm Health.”
  3. Lawson W: “Eat Right To Fight Stress.”
  4. The American Psychological Association: “Mind/Body Health:Stress.”

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