Being Repeatedly Exposed

In a most career fields there is a certain level of stress that comes with the job and most of those stressors will work themselves out over time. However, there are a handful of professions that have stressors that will stick with someone for a lifetime and in some cases, end his or her life. These professions are comprised of our military members and our emergency medical services (EMS) workers which include but are not limited to first responders, paramedics, emergency medical technicians (EMTs), police officers and firefighters. The brave men and women who choose these professions are exposed to traumatic tragedies day in and day out, so it is not surprising that over time there is a high potential that one can develop and suffer from compassion fatigue (CF) which can later lead to a mental condition known as post-traumatic stress disorder (PTSD).

Being repeatedly exposed to the trauma of others can lead to secondary traumatic stress (STS) and burnout (BO), when coupled together, EMS workers can potentially develop CF (Cocker & Joss, 2016). This is characterized by, but not limited to exhaustion, anger, depression, anxiety, poor judgement, negative coping behaviors and a reduced ability to feel sympathy and empathy. In 2009 64 emergency department nurses from three different hospitals were surveyed and 85% experienced at least one symptom of CF. In another case study conducted in 2010, 138 nurses were surveyed to assess their levels of CF; 86% of those working in the emergency department reported moderate to high levels of CF (GW School of Medicine & Health Sciences, 2013). Developing CF can jeopardize patient safety, impact the quality of patient care as well as negatively impacting professional and personal relationships. The worst outcome could be developing PTSD.

Post-traumatic stress disorder or PTSD is defined as a disabling anxiety disorder that people may develop after experiencing one of more traumatic events (PSTD and the Ambulance Service, 2017). 1 in every 10 EMS workers have PTSD however, ambulance personnel suffer the brunt of it being 1 in every 5 meeting criteria (Emergency Public Health, 2014).

Being an EMS worker, witnessing and/or being exposed to a traumatic event is embedded in the nature of the job and according to paramedic Benjamin Vernon, EMS personnel share a common characteristicwe have the ability to shut off our emotionto stop feeling and start thinkingwe shut off the emotional side of our brains (Vernon, 2016). However having that ability is a double-edged sword. It is absolutely vital to the patient that EMS workers are able to fully focus on the situation at hand; however, after that is all said and done at the end of the day what those EMS workers have essentially done is just suppressed all the natural emotions associated to that traumatic event without ever dealing with it and over time doing that repeatedly will begin to take its toll on them emotionally, physically and mentally.

People react and process various traumatic events/tragedies differently. There will be EMS workers who are able to respond to certain events that will not really affect them but may hit home for their co-workers and sometimes all it takes is that one situation to resonate with the responding personnel that can push them over the edge and lead them into downward spiral. For example, if there is a call that involves a child it may negatively impact responding personnel who are parents themselves or it may be a situation in general is relatable on a personal level. That was the case for former paramedic, Vince Savoia. He responded to the murder of Tema Conter. Savoia and his partner found Tema deceased in her Toronto apartment bound, gagged and nude. She was beaten, stabbed 11 times and raped (Erich, 2014). What really shook Savoia up about this particular call was that Tema was a spitting image of his fianc©e, so much so that his partner said 'Oh, my God, is this your fianc©e?' (Erich, 2014). This would become the one incident that haunted Savoia for the next 12 years, leading to his diagnosis of PTSD.

Post-traumatic stress disorder is a diagnosis that is often associated with military members and/or veterans because of events that are usually witnessed in a war zone. Events where soldiers watch their brothers and sisters in arms getting killed and blown into pieces in front of their eyes will no doubt be detrimental to their mental health; even more so for the medics that work in the trauma bays and must race against time to save what is left. Being exposed to such horrific traumas will affect an individual over time because those are things that cannot be unseen. Our soldiers who deploy are usually in the war zone for as short as a month to as long as a year and on a good deployment traumatic events do not occur on a daily basis.

On the other side, our civilian EMS workers are actually exposed to traumatic events at a much higher rate than military members who are not in a deployed setting. If we were to take a non-deployed military paramedic and compare their traumatic exposure to a civilian paramedic, it would be vastly different. Having some experience working in a military emergency department, the most common encounters we have are urgent care cases (fever, vomiting, diarrhea, lacerations and maybe a broken bone here and there). On very rare occasions we will receive a truly traumatic event in the nature of a suicide, homicide, infant/child death and or motor vehicle fatalities. I think our exposure is limited because we are responsible for a smaller, healthier population versus that of the civilian sector which is exposed to all sorts of different encounters.

Between the two professions (military and EMS workers) there is a shared mentality of the stigma associated with seeking professional help and PTSD. However, I have learned there is an enormous difference when it comes to awareness and available resources for the prevention and treatment of the disorder. In both professions there is a fear of seeking help because its viewed as a sign of weakness and there is also the fear of being diagnosed with PTSD for the sole reason that is it presumed to have a high potential of being a career-ender. There are several symptoms that are associated with PTSD such as depression, anxiety, chronic stress and substance abuse; however, not all will lead to the diagnosis.

Thus far in my tenure within the military I have crossed paths with many people who refuse to take advantage of the mental health resources for any of the aforementioned symptoms because of the fear of getting kicked out or seen as a weakling; this mentality is also found in the EMS world. There are few cases in which people have fallen victim to that stigma like Ross Beckley, former fire fighter and deputy captain of 21 years and a former police officer (who was asked not to be identified). They are perfect examples as to why people are so hesitant to seek help. They were forced to leave a career that they loved because of their PTSD diagnosis; Beckley resigned from his position and the police officer was relieved of his duties (Knowles, 2015).

Another commonality between these professions is the culture that is fostered. There is a perceived notion that those who are in these career fields are unbreakable, that they do not require help from anyone and can handle anything, but this is not the case. In time, an individual will reach their breaking point but the question is, are they equipped with the resources they need to help them through that hard time? This is where I found a difference between the military and EMS workers.

In the military, whether we are preparing to deploy or not it is mandated that we received various trainings and are aware of our resources to help us when a life crisis occurs. These preventative trainings include but are not limited to resiliency training, mental health awareness and suicide awareness. Through resiliency training we learn to cope emotionally, mentally, physically and spiritually with drastic life changes and/or traumatic events we may come across. We are taught to recognize the different symptoms that are associated with depression, anxiety and stress. Through suicide awareness we are taught to identify behaviors and mood changes within others that may often lead to suicide; we are also equipped with different ways we can intervene and be a good Wingman to potentially save a life. In recent years, the military (specifically the Air Force) has taken an active approach in ensuring that we are fully aware of our resources and the different avenues we can take to make sure we receive the help we need.

They have even dedicated an entire day and set up workshops to foot stomp and talk about mental health and the importance of being mentally resilient. Leadership will disseminate information of the numerous resources available to us in different forums such as Commander's Calls, award ceremonies, promotion ceremonies, squadron picnics; you name it and they will take full advantage of the opportunity to guarantee each Airman knows where to turn during tough times. Some of these resources include the mental health clinic, Military OneSource (which is free undocumented counseling sessions with a civilian therapist), access to military life counselors, chaplains, first sergeants and our very own peers. Although we have all these resources available to us, it doesn't make us a suicide-free force, but it does serve as a reminder that we are not alone and that our mental health is of importance. The annual trainings at times start to feel redundant but in reality, because we receive it so often when a life crisis does occur it serves us like muscle memory and we are able to tap into those resources without any second thoughts.

On the civilian EMS side of the house, just based on my research it was hard to actually find any resources or trainings that were easily available. If anything, most of my research was consistent with the inadequacy and unavailability of resources to combat or prevent PTSD. This is an issue that spans across the world among the EMS profession. A study that was conducted in Iran revealed that paramedics and hospital emergency personnel had a high incidence (94%) of PTSD, and because the paramedic service is fairly new to the Iranian healthcare system, paramedics do not receive training or awareness regarding PTSD (Iranmenesh, Tigari, & Bardsiri, 2013). In another study conducted in South Africa among paramedic trainees it was found that 94% of trainees were exposed to direct traumas and 16% of them met the PTSD criteria (Fjedheim et al., 2014).

In the UK a study revealed that 22% of their emergency medical care workers met the criteria for PTSD (Fjedheim et al., 2014). One of the predictors for the development of PTSD Fjeldheim et al. found was the lack or peer and management support. In another report, PTSD was never talked about in the healthcare providers' years of employment within the ambulance service and they were never taught to be aware of mental health issues (PSTD and the Ambulance Service, 2017). There were limited resources available such as fellow colleagues that could be contacted (with possibly limited counseling qualifications) to discuss any issues or concerns. They also offered debriefs in which they mostly ensured procedures and protocols were done correctly versus checking on the wellbeing of the responders. Outside of those resources they cannot recall any other available support (PSTD and the Ambulance Service, 2017).

Another case of inadequate support would be that of Joanne Trofaneko, a former ambulance paramedic from Canada. She was one of the first responders on scene to respond to an accident in which an ambulance plunged over a cliff into Lake Kennedy in 2010 killing both paramedics inside, one of them being her close friend (DeRosa, 2014). She was diagnosed with PTSD in 2013 and filed a claim for compensation because it was caused by her line of work; however, her claim was denied because it was not filed within a year of the incident (DeRosa, 2014). This left her with feelings of helplessness, depression and thoughts of suicide (DeRosa, 2014).

Here in the US there was survey that was pushed out to EMS workers to research the prevalence and severity of critical stress (CS) in the workplace. Critical stress was defined as a single incident that had a significant impact on the individual or the accumulation of stress over time. The survey asked a series of questions such as if the participants have experienced CS and if so, did they ever contemplate suicide, or had they attempted suicide. Were there available support programs offered by their employer, if so was it effective? Lastly, did they find support among their peers and management team. There was a total of 4,022 participants from all 50 states (Newland, Barber, Rose & Young, 2015).

The results yielded that 86% experienced CS, 37% contemplated suicide and 6.6% attempted suicide (Newland et al., 2015). These suicide statistics are 10 times greater than the national average for adults in America based on a study conducted by the Centers of Disease and Control and Prevention in 2012 (Newland et al., 2015). There were various support programs offered by employers and 43-47% of the participants found them very helpful (Newland et al., 2015). The data also reflected the positive impact that peer and managerial support had based on the suicide statistic; the more support participants had the lower the suicide statistic (for both contemplation and attempts).

All these studies around the world fully support the fact that EMS workers are highly susceptible to PTSD because of the nature of their job. But It seems that there is a common theme of the lack of awareness of PTSD among EMS workers in the civilian sector, not just based on the research I have found but also how difficult it was to find studies and/or resources that covered this topic. There are programs that are slowly coming around that provide support for EMS workers. One program that has been implemented in the UK is known as TRiM (Traumatic Risk Management).

It was originally only being utilized by the Royal Marines but has been adopted by many at risk organizations such as their National Health Service (NHS) emergency care workers (PSTD and the Ambulance Service, 2017). TRiM is a trauma-focused peer support system that promotes resilience and is offered to employees who have witnessed a traumatic incident. There are also practitioners that are TRiM trained to help individuals cope and also to serve as a counselor for anyone that needs to speak to someone in confidence regarding the traumatic event (PSTD and the Ambulance Service, 2017).

In Australia, they have published guidelines of evidence-based treatments that are specific to treating emergency workers with PTSD (McNaught & Wheelahan, 2015). In the US there are a handful of agencies that are dedicated to helping EMS workers who struggling with what they are exposed to day in and day out. One of the organizations is The Tema Conter Memorial Trust which was founded by Vince Savoia (Erich, 2014). The organization provides help, peer support, family assistance, referral services, training and resources (Erich, 2014). There are also resiliency programs that are offered for emergency personnel in Arizona and Colorado that aim to prevent the development of PTSD (Erich, 2014).

It is vital that EMS workers receive preventative training just as the military does especially because they are faced with trauma and tragedies every single day. Those who do not receive any type of training for their profession have a higher risk of developing PTSD (Skogstad et al., 2013). The limited data and statistics that I have found proves that there is a desperate need for training, support and resources that need to be made easily available for our first responders. Being equipped with the tools to manage life crises makes a huge difference as supported by paramedic and Marine veteran, whom I have interviewed, Adam Rodriguez. He expressed that he is more resilient and is able to cope with the traumas he sees because of his military background.

Also, former Air Force Independent Medical Technician Mariane Tolentino, who now works and interns in three different Las Vegas emergency departments; one being a pediatric trauma center. Tolentino says that the resiliency training she has received from the Air Force has helped her tremendously to cope with the traumas she witnesses daily because it is not something she is used to seeing, especially transitioning from a military emergency department.

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