Under a cloak of darkness

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Michael Gill Via Wikimedia Commons

Responding to stabbings, blunt force trauma, compound fractures, attempted suicides and domestic violence is just another day at the office for Emergency Medical Service (EMS) crews. In fact, charging headlong into strange and seriously stressful circumstances isn’t just part of the job, it is the job.

In his two years working for American Medical Response (AMR) on an ambulance crew in Boulder, Reilly Capps saw all of that and more. He says nothing he’s encountered on the job so far has been heavy enough to haunt his dreams, but many of his coworkers haven’t been so lucky.

Capps describes one friend from his ambulance crew who has been tormented endlessly after responding to a fatal car accident involving two parents and their young child. While the EMT attempted to save the couple in the front, their baby cried helplessly in a car seat in the back, watching as her parents slipped away.

“Every time he closes his eyes he sees that scene,” Capps says. It is far from an uncommon story. “Babies seem to get to people a lot.”

EMS providers, paramedics and EMTs, like Capps and his friend, deal with some intensely stressful situations on a daily, even hourly basis. Work on an ambulance long enough and eventually a person is bound to encounter some traumatic scenes that can (and often do) scar the psyche.

“People are calling you on their worst day,” Capps says. “You try to do what you can for them, but sometimes you can’t do anything.”

Post-traumatic stress disorder (PTSD) is regularly talked about in regards to the military, police officers and firemen, but paramedics and EMTs are often left out of the discussion. Regardless of the inherently stressful nature of their work, support services for those in the EMS community suffering from PTSD are lacking.

According to a 2016 industry survey of 40,000 EMTs, paramedics and EMS managers from the National Association of Emergency Medical Technicians (NAEMT), less than half of EMS agencies provide any kind of mental health services for their employees. This, despite the fact that 37 percent of those surveyed reported having contemplated suicide (10 times the rate for average adults in the U.S.) and 6.6 percent reported having actually tried to commit suicide (13.2 times the average rate). 

Devastating statistics such as these were the motivating factor behind Senator Leroy Garcia’s (D-Pueblo) recent Peer Assistance Medical Service Provider bill (SB19-065), which passed unanimously through the Colorado State Senate on Thursday, March 14. The bill has since been introduced in the House where it is being reviewed and amended before it heads to Governor Polis’ desk.

A former paramedic himself, Senator Garcia has seen the effects of PTSD in the EMS industry firsthand. He recognizes the clear need for a more comprehensive support system — something that could aid EMS providers who are suffering emotionally, psychologically or physically. It’s especially important for those providers who don’t have access to support services through their employer.

Some EMS agencies provide Employee Assistance Programs (EAPs), which usually include access to therapists and are specifically designed to support first responders and their families. But not all agencies offer such programs. In many rural areas and for many volunteer EMTs and paramedics, there is no such support system.

“We have had 196 deaths in Colorado over the last 10 years from [first responders] who just couldn’t cope with it anymore,” Senator Garcia says. This includes police, corrections and security officers, as well as dispatchers and firemen; 11 of those suicides were EMS providers. Garcia adds that unaddressed PTSD is also a huge contributor to the high turnover rate in the EMS industry. “This is a real thing that’s impacting providers in the EMS realm,” Garcia says. “And we know that a lot of these rural counties and a lot of agencies don’t have services available for them to access.”

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SB19-065 will provide counseling and support for EMS providers across the state, as well as education and assistance for physical, emotional and psychological injuries, and evaluating and referring EMS providers for further treatment if needed. It’s like an EAP for the entire state. So now, even if an EMS provider is working in an extremely rural region of Colorado, on a small volunteer ambulance crew, they’ll still have access to help if they need it.

All it’s going to take is an additional $2.55 tagged on to Colorado’s EMS certification and re-certification fees. According to Garcia, that’s the “peer-assisted” part. He likens it to the Colorado Search and Rescue fund that comes with a fishing and hunting license in this state. Every hunting and fishing license contributes a small amount to an “insurance pool,” which covers the cost of search and rescue operations should one of those fishermen or hunters get lost or stranded in the wilderness.

In the case of EMS, “Practitioners of all levels are going to pay this $2.50 every year and that will help provide services for someone who needs them,” Garcia explains.

It’s certainly not a cure-all, but it’s a step in the right direction; a flotation device that can be thrown to anyone who cries out for help.

But it won’t do much for those who are struggling silently. Even in cities like Boulder and Denver, where EMS crews have access to EAPs through their agencies, many emergency workers choose to bury their trauma and move on, Capps says.

“I think it goes back to the fact that a lot of these guys are from military backgrounds and they have this attitude of ‘we should be tough and nothing should get to us,’” Capps continues.

He describes how, after shifts, crews will hang out and exchange stories about the day, what they saw and how they dealt with it. But they generally don’t debrief or decompress from something traumatic. Capps says it’s more like they’re trying to impress or one-up each other. “I don’t know if I ever heard the discussion drift toward ‘are you OK?’” Capps says.

It seems to be a widespread pattern: 48 percent of the NAEMT survey respondents said that they do not feel comfortable talking about mental health issues with their colleagues. It’s a trend that Chris Williams, AMR’s regional director for northern Colorado and Wyoming, has also observed.

“Historically, the people that you see coming into this career field often are those that don’t talk,” he says.

This presents a real challenge when getting these services to the people who need them most, since addressing PTSD among EMS providers relies largely on self-diagnosis. According to Williams, it’s really up to the individual to reach out and ask for help.

Williams’ duty is to provide these support services for his employees if requested, he says, but not to determine who needs them. AMR Boulder has an EAP and their EMS providers also have access to Building Warriors, a nonprofit specialty group that offers direct services and training for emergency responders.

“If people come to us with problems, we can push them in the direction to find the help that they need depending on what level of issue they’re having,” Williams says. “But it’s a fine line, right? We want to respect their privacy but we also want to make sure they’re OK.”

Joel Dyer

However, according to Thom Dunn, a clinical psychologist, statistics professor and paramedic field-instructor for Denver Health, self-diagnosis is a challenging way of addressing mental health issues.

“Just like any other mental illness, there’s sort of a stigma around [PTSD] and a lot of people don’t like talking about it, a lot of people don’t like admitting it,” Dunn says. “Instead, it will pop out in things like drinking too much and depression and problems at home.”

And even for EMS providers who have access to an EAP or something like Senator Garcia’s peer assistance bill, people are often reluctant to access those services on their own. Dunn says that sometimes a person’s peers will suggest they get help if they notice out-of-character behavior like repeatedly showing up late to work or smelling like alcohol on the job. Other times significant others will suggest a person seeks help if they notice problems at home. Rarely, though, do EMS providers recognize the symptoms of PTSD in themselves and take steps to get better without any external encouragement — often for fear of repercussions at work.

As one respondent in the NAEMT survey put it, “Initiating mental health services through the EAP is an invitation for mandatory competency evaluation, grounds for dismissal.”

Another said, “Most of the people in my organization do not feel comfortable using any service provided by the organization for fear that the information will come back and be used against them in the future.”

Around 20 percent of EMTs and paramedics suffer from some level of PTSD, according to research published in the Emergency Medical Journal. And Dunn says even those numbers might underestimate the problem.

“It’s hard to do research in this area,” he explains. Ideally, researchers would round up a sample of EMS providers who had quit the job and ask why they left. That might provide a more accurate number of how many are actually suffering from PTSD, Dunn says. “But most of our current research is with people who are in the profession, who are still hanging in there and still able to go to their jobs, do a great job and who are able to be resilient.”

So, how can the issue be addressed when trauma and stress are inseparable aspects of the job?  What options, outside of programs like the one funded by Senator Garcia’s Peer Assistance bill, can be implemented to confront this issue?

On the front end, Dunn suggests screening people more thoroughly to make sure that those who are hired as EMS providers are mentally stable, resilient and cut from the right cloth to handle the inevitable stress of the job. “If I had my way we would screen everybody,” he says.

There’s also the option for more resiliency training, like what Building Warriors offers. This type of training teaches EMS providers how to deal with stress, how to reach out for help, and how to recover from a traumatic event. Most EMS agencies provide some level of resiliency training, although for many it’s not enough to combat the horrors they encounter on the job.

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On the back end, things are trickier. Counseling and therapy are usually the most effective response treatments for PTSD, which EAPs provide in some areas, and the peer-assisted program aims to expands services throughout the state. Unfortunately, though, there’s no easy remedy for EMS providers experiencing PTSD, no panacea that could more effectively treat the problem.

But there might be something close.

“I told so many people, ‘You need to try some MDMA therapy,’” says Capps, who has benefited from the treatment himself. “MDMA therapy could make a huge difference in EMS, because they can’t talk about it. Even if they had counselors to talk them through seeing a kid surviving, who watched its parents die in a car, most people will really have a hard time talking through that.”

It’s an intriguing idea, especially considering that the Food and Drug Administration recently designated MDMA-assisted psychotherapy for PTSD as a “breakthrough therapy.” In clinical trials sponsored by the Multidisciplinary Association for Psychedelic Studies (MAPS), 68 percent of the study participants were relieved of their treatment-resistant PTSD after only their second session of MDMA therapy. Of the 26 study participants 22 were veterans, three were firefighters and one was a police officer.

However, MDMA-assisted psychotherapy is still very much in its infancy as a treatment. Studies have only just begun and the drug itself still carries a stigma. To many, MDMA is just a party drug with little-to-no application outside of nightclubs and raves. It may be a while yet before this is an easily-accessible and culturally acceptable option for suffering EMS providers.

Whatever treatments or services are pursued, it’s clear there’s a lot of room for improvement when it comes to mental health services for EMS providers. Dunn, Williams, Garcia and Capps all seem to agree on that. Fortunately, steps are being taken to fill the gaps.

“In our field, it’s been under a cloak of darkness for a long time,” Williams says. “And now it’s kind of moving to the forefront of, ‘let’s help people before they start to have issues.’”

The need for skilled, mentally healthy EMS providers isn’t going anywhere, and the nature of their work is never going to be less intense. The only real hope for lifting the psychological burden is creating a better support system for those who risk their mental and physical well-being to help their communities on a daily basis.

“I still think we have a long way to go but I think we’re getting better as an industry,” Dunn says. “It’s not a pandemic but it’s something that has rightfully needed a lot more attention than it’s been getting.”