Ambulance Crews Can’t Avoid Violence, But They’re Trying to Change the Culture of Ignoring It

For as long as emergency medicine has existed, being physically assaulted has been part of the job.

Talking about feelings that come after an assault, though? Not so much.

"That’s something that paramedics and others working in emergency medicine are trying to change," said Crystal Eastman, a paramedic instructor and “peer responder” at Denver Health. "The sheer amount of violence discourages paramedics from reporting each time they’re assaulted, and the culture pushes them to act like it doesn’t affect them. Personally, I’ve been kicked in the chest, punched, spat on, and had a knife pulled on me. Our environment is uncontrolled, so we’re frequently out by ourselves, meeting people who are not having their best day.”

Lt. Will Hargreaves, who oversees a team of about 15 paramedics at Denver Health and goes out on some calls, said on most days, an ambulance crew will have to restrain or sedate someone who’s being combative. Often, it’s because the person they need to treat doesn’t want them there or is worried about getting in trouble for their drug use, he said. Other times, people are confused because of their medical condition, especially if they were just revived from an overdose.

"Sometimes, though, even people who aren’t sick or injured will get aggressive from the stress of the situation," Hargreaves said. "The ambulance crew tries to de-escalate the situation, but sometimes there’s no option other than to call police."

“We’ve had family members jump in the back of the ambulance and try to take control of patient care,” he said.

"Traditionally, paramedics didn’t learn tactics for dealing with their emotions about violence, or even techniques to verbally de-escalate a situation with patients and their families," Eastman said. "Now, some schools have started to add that information, and everyone at Denver Health can take in-house training if they want."

Durango emergency medical services Chief Scott Sholes, who is president of the EMS Association of Colorado, said he’s seen a similar shift in agencies across the state over the last decade. Most now offer professional counseling to their employees, and many have trained some staff as peer counselors, he said.

“It took a lot of time for us to get it in terms of resiliency,” he said. “We have come to recognize that it affects people’s jobs, careers, families, relationships.”

Dr. Angie Wright, UCHealth‘s medical director of EMS and prehospital care in the Denver area, said the Anschutz campus’ new paramedic training program weaves discussion about mental health throughout the curriculum. The program launched in May.

The goal isn’t to scare students with the idea that post-traumatic stress is inevitable, but to get across that their well-being is as important as the patient care skills they’re learning, Wright said.

“All of us want to take excellent care of our patients, but to be able to do that, we have to take care of ourselves and each other,” she said.

Peers are key, first responders say.

"Usually, when people think of wellness, they expect to talk about things they can do for themselves, like eating better." she said "But it’s not realistic for people who are dealing with trauma or chronic stress to fix that themselves, Wright said. Individuals need to be able to recognize signs they’re struggling – such as getting angry more easily or withdrawing from loved ones – and know that systems are in place to support them."

Focusing on self-care “kind of puts it back on the individual who’s already stressed,” she said.

"People in management or leadership need to show that mental health is a priority by checking in with their teams and making it clear that it’s okay to ask for whatever support they need, whether it’s a day off, someone to talk to, or even just a few minutes to sit quietly," said Terry Foster, a nurse in Kentucky and president of the Emergency Nurses Association. "It’s tough to give people time off during a workforce shortage, but pushing someone to come back before they’re ready isn’t good for the person who was hurt or the rest of the team."

“I don’t want an emergency nurse to feel alone or abandoned,” he said.

Leigh Foster, a paramedic and coordinator of Denver Health’s peer assault care team, said just knowing that someone is aware of what happened and available to offer support can be helpful. The team’s volunteers reach out immediately after an assault, then again two days and 10 days later, to give people time to start processing it and decide if they want to talk, she said. Some aren’t ready until much later.

"The pervasiveness of violence means that some people who could use help likely aren’t getting it," Foster said.

In April, 64 people working in ambulances at Denver Health said anonymously that there had been violence during one of their shifts that month, but only three went through the process of reporting it with their names. Typically, they only report if an assault causes an injury that forces them to miss work, she said. People who didn’t file a report could still ask the team for support, but the volunteers won’t know to reach out if they don’t.

“We still underreport, and that’s part of the culture we need to work on,” she said.

Other resources at Denver Health include a 24/7 phone line to talk to a peer counselor; a “safe space” where staff can sit and regroup; group support sessions to discuss topics like burnout; groups specifically for people of color and LGBTQ staff; and outreach to specific people or units if a colleague calls with a concern, Eastman explained.

"Talking with other people in the same job and learning healthy ways to deal with stress can be the most helpful things, Hargreaves said. “If you just go to a regular psychiatrist, psychologist, they don’t understand what it’s like to be a first responder."

Foster explained that there's nothing like the current mental health emphasis that existed when she experienced an assault earlier in her career, and while her supervisor and colleagues meant well, asking her to repeatedly talk about what happened meant she kept re-experiencing the trauma. It’s best for a person to talk to someone who’s been trained to focus on the emotions – rather than the details of the trauma itself – and who isn’t their boss.

“My chief asked, ‘Hey, you cool?’ I guess? I’m not cool talking to you about it,” she said she thought at the time.

Stressors aren’t always obvious

Hargreaves explained that people who don’t work in emergency medicine tend to assume that the hardest parts are huge traumas, like mass shootings, and that that’s not the case for everyone — someone might be most affected by a sick person who really reminds them of their dad.

“Different things get different people,” he said. “For me, it’s the grind of the job. Every day you see people at their worst, fighting you and spitting on you and saying they’d kill you if they got the opportunity.”

Eastman said the toll of constant stress became clear to her when she returned to work after nine months off to heal from a back injury. She noticed an odd sensation in her chest when she went out on some calls that hadn’t been there before her time off.

“It took two weeks for me to figure out that was a normal response to stress,” because she’d repressed the sensations before to be able to do the job, she said.

Sometimes, it’s the contrast between the life-and-death demands of the job and what seems important to a first responder’s partner or child that becomes a problem, Sholes said. He tries to periodically discuss steps staff can take to preempt problems, like setting aside some decompression time between work and home, he said.

“At home, it’s picking out a paint color or dealing with a neighbor’s fence issue,” he said. “Everything seems unimportant” compared to what they see at work.

Sholes likened the shift in thinking about mental health to the recognition of how repetitive stress injuries shortened careers. When ambulance services started to realize their people were leaving in a few years because of back problems, they took steps to reduce the amount of heavy lifting, and now they’re doing something similar for psychological injuries, he said.

“What we need to do as EMS leaders is recognize everybody is different and give them the tools they need,” he said.

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