Introduction
There can be little doubt that EMS work contains more than its fair share of strain or that certain EMS calls are apt to produce a significant level of stress. This is not a calling well suited for those disposed toward the sedentary or the serene. The emergency side of the enterprise ensures EMTs a ringside seat, if not a central speaking role, in the majority of events listed on the classic Holmes and Rahe checklist of stressful life events [1]. Even the most routine elements of contemporary EMS work (e.g. non-emergency transfers) can bring providers into repeated contact with demanding people in difficult circumstances.
Whether looking from the health care side or the rescue viewpoint, the field provider often perceives himself or herself to have been relegated to a rather lowly position in the overall pecking order. When it comes time to pay the bills, there is no escaping the reality of limited pay for long hours. There probably couldn’t be a better recipe for disenchantment, especially for people who studied hard and competed intently for positions in which they could help others and maybe save lives.
But do EMS workers endure radically greater stress than other health care and public safety workers? Are they grossly unsatisfied with their jobs? Are they falling victim to posttraumatic stress disorder (PTSD), suicide, and depression at epidemic levels? Do their careers “burn out” in just 4 or 5 years? Does unrelenting exposure to life’s most poignant events lead to intractable harm? Can that harm be prevented or ameliorated by patent remedies and “self-help” programs? Does the absence of such programs lead providers to unravel and organizations to fail?
A quick survey of the industry’s folk wisdom could lead one to think so [2–4]. Several years ago, articles in trade magazines and presentations at trade shows and conferences made sweeping claims about the risk of PTSD while a booming cottage industry arose to offer instruction in how to mount stress management programs [5]. It all seemed reasonably simple, straightforward, and intuitively clear.
Human responses to life’s many challenges are anything but simple. Those seemingly straightforward questions posed above are actually multidimensional and layered with nuance. EMS workers report more frequent and proximal involvement with objectively distressing events than do many others but this should be expected, given the nature of their work. Just when their reactions should be considered symptoms of dysfunction rather than signs of exposure poses another, considerably thornier set of questions [6–8]. EMTs are well aware of the limitations their occupation presents but are also uncommonly attuned to its rewards [9]. To whom should they be compared to determine whether their satisfaction with their careers is greater or lesser than one might reasonably expect of workers in any challenging enterprise? Rates claimed for PTSD and depression vary widely between studies, depending on criteria, methods, and assumptions employed [10]. Those looking for high rates of disorder seem to find what they are seeking while those looking for resilience find it as well.
The question of whether prescriptive, prophylactic efforts at prevention and intervention can effectively mitigate these effects is no less complicated. Programs built around “critical incident stress management” (CISM) and its signature intervention, “critical incident stress debriefing” (CISD) permeated the industry and were typically well received as indicators of the organization’s concern for the impact of work-related stressors on EMS personnel [11]. Yet despite years of proclamation from promoters and purveyors regarding the effect of these efforts on job satisfaction, career longevity, and clinically significant sequelae, there is little evidence that these interventions have any appreciable effect on limiting PTSD and a disturbing trend in more extensive studies for debriefing to show paradoxical effects on natural recovery for at least some recipients [12,13]. A number of authoritative guidelines for evidence-based practice now caution against the routine application of debriefing, and some list it as contraindicated [14–19].
This leaves the EMS manager with a troubling conundrum. It seems evident, on the one hand, that EMS workers have chosen to take on a challenging occupation and deserve to receive every effort the organization can muster to assist them in coping with its effects. It is also increasingly clear that what was once widely accepted as a de facto industry standard for addressing this concern has proven less than effective and might even become a complication for some persons in at least some situations.
Even though traditional CISM interventions failed to live up to sweeping promises regarding prevention or mitigation of PTSD, they were generally well received as expressions of organizational support [5]. Such expressions are indeed important, and it is only reasonable that some cogent set of supportive responses continues to be made following distressing events in the field. Fortunately, a widely growing research base containing increasing sophisticated information now offers useful suggestions.
Occupational health approach: organizational systems perspective
Traditional CISM programs were marketed and disseminated as “grass roots” approaches designed to operate in a “peer-driven” structure; the program and its operation were typically insulated from the usual structure and boundaries of daily operation and management. The original dissemination model was centered on two-day “Chautauqua-style” workshops in which dozens of would-be interveners, typically dominated by prospective “peer” providers, received training that was oversimplified with respect to underpinnings and overspecified with respect to intervention [20]. While these teams were to include a mental health professional as “clinical director,” there was no qualification prescribed other than licensure or certification in some field related to counseling and attendance at one of these 2-day workshops.
These programs were ostensibly developed to address risk of occupational injury but have rarely been articulated with or supervised by the agency’s occupational health provider. It is not uncommon, however, to find integration with an organization’s employee assistance program (EAP). EAP programs are typically capitated delivery models, most usually from an external vendor, designed to provide limited basic counseling in areas such as substance abuse, depression, and family issues. “Critical incident response” is often provided as an add-on service.
The limitations of these types of insulation were addressed in recent revisions to National Fire Protection Association Standard No. 1500, Standard on Fire Department Occupational Safety and Health Programs [21]. Changes recommended by a series of consensus groups convened through the National Fallen Firefighters Foundation as a part of its occupational health and safety initiatives included placing the organization’s program for response to atypically stressful occupational events under the supervision of the occupational health physician and integrating elements of basic support into the daily structures and operations of the delivery system; changes were also made to provide more specific standards for EAPs. These consensus groups also adopted guidelines and recommendations for an integrated, stepped care approach to organizational support of employees and competent professional assistance where clinical issues arise, derived from current best practices and published guidelines (e.g. guidelines of the Oxford-based Cochrane Collaboration regarding debriefing following trauma [19], guidelines of the United Kingdom’s National Institute for Clinical Excellence [16], guidelines of the Australian Centre for Posttraumatic Mental Health [14], recommendations of the NIMH/Department of Defense consensus panel on early interventions following terrorism [18], and various refereed reviews [11,12,15,22]). A basic outline of current recommendations is summarized below.
- Immediate assistance should be proximal, non-intrusive, and ecologically intact, using principles of basic stress first aid as indicated by the situation and circumstances. The Combat Operations Stress First Aid program of the US Navy and Marine Corps [23] was identified as a prototype combining evidence-based principles and organizationally integrated implementation.
- Early, reliable, and non-intrusive assessment should be seen as an essential element in the process of resolution. While most EMS providers experience some level of distress following difficult duty, the greatest majority will not see that distress rise to levels that demand clinical treatment. The best approach in the early stages is generally one of practical support, compassion, and watchful waiting, referring any displaying obvious or profound difficulties for professional behavioral health intervention as indicated by their level of impairment. Easily utilized, non-intrusive screening measures are therefore an important element in tracking employee resolution and identifying those for whom more focused intervention is warranted.
- Stepped care entails providing treatment specifically to those who need it at levels that match their clinical needs. While basic supportive assistance is generally appreciated by most who have experienced distressing events, it may not be of universal benefit and can feasibly prove detrimental to some. Indeed, studies of cardiac patients following major coronary events found that a significant minority actually fared better if not enrolled in seemingly benign interventions such as psychoeducational support and symptom education [24,25]. Studies of early interventions based on debriefing techniques have also shown these sorts of paradoxical effects [26,27].
Experienced EMS providers tend to be well acquainted with the transient discomfort that particularly poignant occupational experiences can bring and most have developed methods of regulating their discomfort that keep it from interfering with their lives and careers [5]. Where transient but subsyndromic discomfort proves recalcitrant or troublesome, referral to EAP providers or reliable self-help resources can be beneficial in shoring symptom management skills and in addressing external stressors that may be compounding the provider’s ordinary capacity for self-regulation [28]. Where symptom manifestation reaches clinical thresholds, referral to specialty providers for evidence-based treatment of the clinical conditions manifested is warranted.
- Evidence-based treatment of clinical conditions
