Stress for first responders during the pandemic

The fact that EMS is a stressful field has been documented for years. A 2016 survey of EMS professionals revealed that 37% contemplated suicide. The national average is 3.7%. An astounding 6.6% of the respondents actually attempted suicide. The national average is 0.5%. A 2018 review of traumatic stress in First Responders used a “conservative estimate calculation” to conclude that at any given time 87,000 law enforcement officers (LEOs), 804,000 firefighters and 21,000 EMT/paramedics suffer from Post Traumatic Stress Disorder, PTSD. These are indeed estimates. Study results vary considerably. The incidence of PTSD for LEOs range from 6%-32%, for firefighters 17%-32%, and for EMT/paramedics from 9% to 22%. The estimate for the general adult population ranges from 7%-12%. Independent of the study result variability, it is clear that first responders are a population at increased relative risk of PTSD. This baseline level of stress makes us more vulnerable to the impact of current events.

Pandemic

A New York Times article ““I can’t turn my brain off” PTSD and Burnout Threaten Medical Workers” highlights the devastation created in dealing with COVID-19. A renowned Emergency Department physician and a rookie EMT committed suicide. The article made no cause and effect relationship between the suicides and the pandemic, but the well-described stressors inherent to the pandemic may be the tipping point that overwhelms compensatory mechanisms in the experienced individual or devastates those without adequate experience to develop such safeguards. The psychological effects of the pandemic will not subside when the spread of the pathogen ends. Acute stressors can have chronic effects, such as the development of PTSD.

PTSD

PTSD, a delayed reaction to stress, has both non-occupational and occupational risk factors. There are three types of non-occupational risk factors: historical, peritraumatic and posttraumatic.  Historical risk factors are related to what has been described as social determinants of health. A family history of psychiatric disorders, level of intelligence, education, early conduct problems, childhood adversity and childhood abuse play a role. Peritraumatic items such as the severity of the event, the perception of the event as life-threatening, and actual injury or assault increase the likelihood of PTSD. When these occurrences are accompanied by dissociation, the negative effects are magnified. Dissociation occurs when the individual experiences a disconnection that disrupts the continuity between thoughts, memories, actions and identity. People experiencing dissociation use involuntary and unhealthy ways to escape reality, which can cause dysfunction in daily living. Symptoms of dissociation include; amnesia, emotional detachment, distorted perception of people and things, blurred sense of identity, problems in work, relationships and significant life areas, decreased coping skills, and mental health problems such as depression, anxiety and suicidal ideation. Posttraumatic risk factors are the absence of social support, limited access to healthy coping skills or mental health resources, and other stressors (social, physical, spiritual, emotional and economic). Occupational risk factors include: the cumulative nature of job-related trauma, the types of trauma, job stress that becomes routine, the perception of inadequate support, and concurrent gender, ethnic or other discrimination, and stigmatization. The occupational environment of exposure to the elements, fire, smoke, repeated risk for physical injury and erratic sleep patterns compound the risk. Hyperarousal, anger/irritability, sadness, numbing, nightmares and intrusive thought may occur as acute responses to the traumatic event.

Prepare the workforce

The Healthcare Resilience Task Force Behavioral Health Workgroup offers general concepts to protect workers’ psychological health. Organize peer support to address tangible needs of daily living such as childcare, dependent care, pet care and access to food and medication. Plan for boarding at or near work to accommodate staff with travel concerns or fear of infecting loved ones. Give staff resources to create a personal stress management plan. Pre-identify and establish relationships with local behavioral health resources.

Support the workforce

These concepts should be employed on a routine basis, not just during a crisis. Maximize the availability of effective sleep. Connect with mindfulness techniques. https://www.ptsd.va.gov/appvid/mobile/mindfulcoach_app.asp is a free, publicly available app. Encourage stress reduction activities during the workday. Have regular breaks. Limit overtime. Move workers from high stress to low stress functions. Monitor fatigue. Create communication systems so staff can stay connected with loved ones. Supply healthy food, water, snacks, hygiene supplies and comfort items which are accessible without leaving the worksite. When staff is required to shelter in place have adequately equipped facilities to ensure that physical and psychological needs are met.

Self-care

Take a break from the news and social media to avoid pandemic overkill. Take care of your body. Employ relaxation techniques, deep breathe, stretch, or meditate. Eat well. Exercise. Get plenty of sleep. Avoid alcohol and drugs. Don’t forget to have fun. Try and do something you enjoy every day. Don’t be afraid to ask for help. The 988 Suicide & Crisis Lifeline can be reached at 1-800-273-8255 or 988lifeline.org. The Disaster Distress Helpline is available at 1-800-985-5990. To reach a Crisis Counselor at the Crisis Text Line text FRONTLINE to 741741. Don’t forget about your local or internal resources.

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References

• Gist R, Taylor VH, Raak S White paper: Suicide surveillance, prevention and interventions measures for the US Fire Service Presented at: The Suicide and Depression Summit hosted by the National Fallen Firefighter Foundation. July 11 to 12, 2011, Baltimore, Maryland.
• Marshall, J. Beyond Suicide Prevention: Building Caregiver Resilience. Presented at: The Pinnacle Conference, Hosted by Fitch and Associates, July 20, 2016, San Antonio, Texas.
• Federal Healthcare Resilience Task Force EMS/Prehospital Team, “Tips for Self-Care during the COVID-19 Epidemic”, Baltimore, Maryland, 2020.
• Federal Healthcare Resilience Task Force Behavioral Health Workgroup, “Mitigate Absenteeism by Protecting EMS Clinicians’ Psychological Health and Wellbeing during the COVID-19 Pandemic”, Baltimore, Maryland, 2020.
• Lewis-Schroeder, NF, Kieran K, et al, “Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues” Harvard Review of Psychiatry. 2018 Jul-Aug. 26(4): 216-227.
• Hoffman, J “”I can’t turn my brain off.” PTSD and Burnout Threaten Medical Workers.” NY Times, May 16, 2020