Expo ICYMI: Mitigating Psychological Trauma

We know not everyone can make it to EMS World Expo every year. For that reason we are pleased to offer a new series, Expo ICYMI (that’s In Case You Missed It, if you’re not hip to social media acronyms), in which Expo speakers summarize their presentations into short print articles. 

Responders performing emergency medical care are at higher risk for psychological trauma and suicide than the general population.^1–3 We must practice prevention, intervention, and postvention to mitigate trauma and suicide most effectively. This article concentrates on the prevention piece as it pertains to response. Changing even a couple of response policies and practices may be an effective method of reducing mental health casualties among responders. These ideas are “low-hanging fruit” that will complement a multifaceted approach to psychological trauma reduction.

Psychological Trauma

EMS personnel are subject to calls that may evoke psychological trauma on a frequent, if not regular, basis. When we think of emotional trauma, we often think of mass-casualty incidents or responses to loss of life or limb. What we often do not consider are the seemingly benign calls. These calls may become malignant if the responder identifies with or knows the victim, stripping us of our protective mechanisms. The malignancy grows if the provider suffers from burnout or compassion fatigue—the foundation upon which other trauma may be built (see Figure 1).

The worst-case outcome is a nonarrested malignancy that results in suicide. It is important to recognize that suicide is rarely the result of one thing. Risk factors from outside emergency response work may also serve as magnifiers of trauma incurred on the job. These factors may include personal or family history of suicide or mental illness, adverse childhood events, psychological trauma from non-EMS sources, physical pain or injury, etc.^4–9

I frame the mitigation of trauma by drawing on two theories. The first is the diathesis-stress model, and the second is Swiss cheese theory. Understanding both is critical to the understanding and prevention of psychological trauma.

The diathesis-stress model holds that mental health problems occur when the right—or wrong—set of circumstances occurs and unlocks a latent mental health issue.^10,11 Think of this as a lock (latent mental health issue)-and-key (situation) phenomenon. Our goal is to prevent the key from entering the keyhole.

Swiss cheese theory posits that a negative outcome—psychological trauma—is the result of several circumstances aligning. Imagine each risk factor as a slice of Swiss cheese. If the holes in each piece of cheese line up, an object can pass through the entire stack and cause a negative event, such as suicide and/or trauma.¹² A prudent strategy is to pull a slice of cheese out of alignment before the object falls through the holes (see Figure 2).

The Identification Hook

Twice I assisted with care in the back of an ambulance during the transport of a family member who was in critical condition. While I desperately wanted to help, I’m not sure whether I was more of a help or a hindrance. The memories of those calls fester. I realize that not playing the part of the EMS provider for a family member or friend may not be feasible, especially in a rural environment, but we should make a good faith effort to avoid this situation.

Sometimes we come upon a call that, while we do not personally know the patient, reminds us of someone we know and causes us to identify too strongly with that person. A couple of decades back I responded to a motor vehicle collision where the driver—the sister of the patient—was dead and impaled on a pole. Our patient—a 5-year-old boy—was head-injured, combative, and had bilateral femur fractures. My partner—the mother of a 5-year-old boy of her own—was next up for patient care, while it was my turn to drive. To the credit of my fellow paramedic, she recognized that patient care would be too difficult for her and asked if I would render care while she drove—effectively averting a larger exposure to psychological trauma than she needed. Of course, what may cause a provider to identify with a patient is a highly subjective; we must rely on ourselves to recognize when potential triggers may occur. A culture that is accepting of healthy self-awareness of limitations is crucial for this to be effective.

Two other researchers and I are conducting a study to determine what exacerbates trauma among paramedics. We have preliminarily found that the arrival of the loved ones of a critically ill or injured patient may be additive to our own trauma. I hypothesize this is because the presence of a loved one repersonalizes the situation and defeats our defense mechanism. Limiting responder exposure to family members to only those needing to interact may prevent unnecessary trauma.

We build up a psychological wall of depersonalization to avoid becoming nonfunctional at scenes. My recommendation is to go ahead and build your wall but remember to take a few bricks out now and then (debriefs, counseling, personal fitness, etc.). Those who build their walls so high they can’t see over them are at risk for serious mental health ramifications. We must be able to experience some emotions, lest we end up robotic. Serial killers, after all, use depersonalization to carry out their crimes.¹³

The EMS Gawker

We’re all familiar with the phenomenon whereby motorists slow down to get a glimpse of what’s going on with an accident. This gawker effect not only slows down traffic but also often causes secondary collisions. Hence, the gawkers become additional victims.

Perhaps the call involves a fatality or particularly gruesome scene. I have been on many of these calls where the errant gawker gets an eyeful of something they’re ill-equipped to process. I would guess this often results in psychological trauma. True, there has been talk of quick administration of midazolam for victims of psychological trauma in hopes of benefiting from its retrograde amnesic effects—but there is not sufficient empirical evidence to support the treatment at this time.¹⁴

EMS providers are not so different. We have been educated and conditioned to respond to emergencies and want to be a part of the action. We have difficulty resisting the urge to see the carnage, even when we have no practical need or anything to contribute. We can be a group of ghoulish scene gawkers—and I am not exempt. We, like the public, can’t unsee what traumatizes us. I use see liberally in that it includes the sights, sounds, feels, and smells of the scene. Add to this a newer EMS responder whose brain is still physically developing—often in the 25- to 30-year-old range—and emotional trauma is more likely.^15,16

To thwart the diathesis-stress model from coming to fruition and prevent the Swiss cheese slices from aligning in a detrimental way, it is important that we limit the number of responders exposed to the sensory input of potentially traumatizing scenes to only those necessary. This is the responsibility of every first-arriving crew, supervisor, or first-response agency. We may want to run in and see the scene, but undoing what we’ve experienced is not possible. Not everyone needs to see the victim who fell in the meat grinder at the rendering plant.

Conclusion

Psychological trauma and suicide are all too prevalent among EMS providers. Taking steps to eliminate or reduce unnecessary exposure to potentially traumatizing events is key. These steps entail restriction of personnel, when possible, from scenes and situations where they may identify with a patient. Even when the identification hook is not anticipated, allowing scene access to only the minimum number of responders needed to render effective care is a prudent precaution. Exposure to the loved ones of the patient should be similarly controlled. Because how a responder perceives a patient or scene is highly subjective, it is incumbent on the provider themselves to recognize—as best as possible—what may trigger trauma for them.

For more great content, start planning now for EMS World Expo 2019, Oct. 14–18 in New Orleans.

References

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2. Donnelly EA. Secondary Trauma Among First Responders In: Figley CR, ed. Encyclopedia of Trauma. Thousand Oaks, CA: Sage Publications, 2012.

3. Caulkins CG, Wolman D. Emergency Responder Suicidality: An Analysis by Field and Emergency Medical Services Credential. Manuscript submitted for publication, 2018.

4. Roy A, Janal M. Family history of suicide, female sex, and childhood trauma: separate or interacting risk factors for attempts at suicide? Acta Psychiatrica Scandinavica, 2005; 112(5): 367–71.

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6. Janiri D, Rossi PD, Kotzalidis, GD, et al. Psychopathological characteristics and adverse childhood events are differentially associated with suicidal ideation and suicidal acts in mood disorders. Eur Psych, 2018; 53(2018): 31–6.

7. Thompson MP, Kingree JB, Lamis D. Associations of adverse childhood experiences and suicidal behaviors in adulthood in a U.S. nationally representative sample. Child: Care, Health & Development, 2019; 45(1): 121–8.

8. Fishbain D, Lewis J, Gao J. (2014). The pain suicidality association: A narrative review. Pain Med, 2014; 15(11): 1,835–49.

9. Tang NK, Crane K. Suicidality in chronic pain: A review of the prevalence, risk factors and psychological links. Psych Med, 2006; 36(5): 575–86.

10. McKeever VM, Huff ME. A diathesis-stress model of posttraumatic stress disorder: Ecological, biological, and residual stress pathways. Review Gen Psych, 2013; 7(3): 237–50.

11. Tiegel IM. Diathesis-Stress Models for Understanding Physiological and Psychological effects of Stress. In: Wadhwa S., ed. Stress in the Modern World: Understanding Science. Santa Barbara, CA: Greenwood, 2017.

12. Reason J. Human error: Models and management. BMJ, 2000; 320(7,237): 768–70.

13. Winter DA. Construing the construction processes of serial killers and other violent offenders: The limits of credulity. J Constructivist Psych, 2007; 20(3): 247–75.

14. Starcevic V. No role for benzodiazepines in posttraumatic stress disorder? A surplus of certainty despite scarce evidence. Austral Psych, 2017; 25(4): 339–341.

15. Pujol J, Vendrell P, Junqué C, et al. When does human brain development end? Evidence of corpus callosum growth up to adulthood. Ann Neurology, 1993; 34(1): 71–75.

16. Yurgelun-Todd D. Emotional and cognitive changes during adolescence. Curr Opin Neurobiology, 2007; 17(2): 251–7.Chris Caulkins, EdD, MPH, MA, NRP, is executive director of the Strub Caulkins Center for Suicide Research (SCCSR), the EMS program director for Minnesota’s Century College, and a paramedic with the Woodbury, Minn. Public Safety Department. He has researched and presented on suicide and related phenomena at the state, national, and international levels. Reach him at c.caulkins@suicideresearch.org.