Minding the Mind of EMS, Part 2

In Part 1 of this series,¹ the authors described many of the mental well-being challenges EMS personnel face day to day and how those difficulties have been amplified during the COVID-19 pandemic. Many psychological observations and typical concerns were described, but mechanisms had yet to be provided to help EMS professionals mitigate moral injury and address feelings of betrayal and guilt in their day-to-day experiences, let alone the COVID-19 crisis. We had to provide tools to facilitate crisis coping during the pandemic and beyond.

In this discussion the authors will begin to annotate existing examples of some resources available to EMS personnel that have worked well in various settings. Not only do all of us need to find better ways to acknowledge and “forgive” ourselves for the human feelings of guilt, fear, betrayal, defeat, and the moral- and morale-injuring moments we experience, we also need to do the same for others and encourage a culture of safe zones among colleagues as we journey together through our challenges, past, present and future. Hopefully the ensuing discussion, despite its intrinsic limitations, is one step forward.

Control and Confidence in Context

We have yet to learn the full impact of COVID-19 on the long-term mental well-being of frontline EMS responders, a workforce already vulnerable to physical and psychological stress. While the COVID-19 pandemic intensified these concerns, it did not change the fact that the mental well-being of EMS personnel has always been an ever-present, yet largely sub-rosa element of the job. In that respect, instead of simply focusing further on the heartbreak and tragedy of COVID-19, perhaps we should think of this ongoing catastrophic event as an opportunity to replace the traditional and stoic EMS culture of “be in control, suck it up, and move on.”

While exuding confidence and situational control remains a critical real-time role during responses and interactions with patients, families, and bystanders, we still need to distinguish that momentary role for what it is and recognize and accept in follow-up reflections that it is indeed humane to be human. We need to take pauses together, not only immediately following tragedy but long afterward. 

Changing our longstanding culture of “keeping to yourself” will take time and likely involve setbacks, but it is also a pivotal evolution for our profession. Ironically, even in an era of physical distancing, many more opportunities have now emerged for “social closening” and creating safe zones for each other. In the following discussion, the authors will touch upon some examples of those opportunities. 

Code Lavender

As a starting point, each EMS team member and their agency needs to create an evolving culture of “all for one and one for all.” We should no longer just expect ourselves or our colleagues to manage job-related trauma and crises alone. Specifically, we proactively encourage open sharing and embrace of human feelings such as expressions of sadness after witnessing horrific scenes or feeling a sense of failure or self-questioning after bad outcomes. The concept is to adopt a collective mentality that it is not a sign of weakness, but rather a sharing of mutual human experience by being open and feeling safe to do so when the moment comes. The three C’s of control, compassion, and confidence are all parts of on-scene skills and professional conduct, but they are not necessarily needed in after-scene reflections and communications. 

One agency’s example is the Code Lavender program. Even prior to COVID-19, Stony Brook University Hospital EMS (SBEMS), a hospital-based 9-1-1 response and critical care transport agency, had initiated a proactive, culture-changing program to support the mental well-being of its EMS responders. 

The name Code Lavender was adopted from a Hawaii-based in-hospital program designed to offer support to caregivers after tragic or unexpected events.^2,3 This initiative often included the use of lavender aromatherapy for the soothing influence it is believed to convey. While aromatherapy explains the roots of that moniker, the true value of therapy is the feeling of safe harbor among a team of colleagues who identify with your experiences and exude empathy.

The SBEMS Code Lavender program therefore has two key components: 1) a proactive team that is alerted and performs follow-up with involved responders after tragic or exceptionally stressful incidents or responses; and 2) a continuous pan-agency emphasis on both individual and group wellness, both physical and mental well-being, creating that safe harbor. 

To reduce the stigma associated with notifying the team of an event, the SBEMS architects of Code Lavender developed a series of criteria for automatic team notification. This approach is similar to how triage criteria have been created to initiate automatic in-hospital trauma team activations that can be deescalated later. When alerted, SBEMS Code Lavender team members determine if they need to respond to the hospital, for example, to meet an EMS crew immediately after a disturbing call, or if following up by phone or text is reasonable. Importantly, this follow-up process extends for several days, if not weeks, beyond the initial call.

Following the onset of COVID-19 and its additional stressors, the SBEMS Code Lavender team found ways to meet the evolving needs of staff members. Providers under quarantine were called or texted on a routine basis. They also experienced social “closening” via regular Friday evening Zoom “happy hour” sessions in which members could enjoy beverages and catch up with teammates, special guests, and even have cameos from family members and pets.

These communications also included discussion of other physical and mental well-being initiatives. The team identified and facilitated access to other resources, including traditional programs such as chaplaincies, AA, NA, and even therapists as indicated. Nevertheless, changing the culture across the agency, especially with visible support from leadership, was central to preventing perceptions of shame or concerns over appearing to be a “weak link.” 

At the same time, while boots-on-ground efforts among colleagues are important to improving mental well-being, there are other external factors, both personal, political and economic, that also can affect it well beyond the individual efforts of team members.

Stress Unit

Most agree the COVID-19 pandemic has amplified existing mental healthcare crises in society as a whole. Beyond being part of that at-risk society, EMS professionals also have increased risks for post-traumatic stress disorder, depression, and even suicide.^4,5 Given their traditional culture of stoicism, EMS agencies must do a more proactive job of quashing the longstanding stigma associated with requesting mental health support, particularly among the most desperate. 

While little has been published on effective prevention of depression and suicide in EMS, there are known options already in place. The evolving mind-sets and cultural changes stemming from initiatives such as Code Lavender have begun to create zones of safety for those who are most vulnerable. Trust and openness with partners, coworkers, supervisors, and/or medical directors about difficult calls and other life stressors can become akin to therapy or addiction groups. As a result, many personal issues involving underlying self-esteem difficulties or personal life challenges may be also assuaged. 

Nevertheless, it is often the most troubled who may be the least comfortable in discussing those feelings, which are largely internalized. Those feelings are often masked by a bravado or indifferent or joking demeanor that hides an unwillingness to be “outed” as overly anxious, lonely, or depressed. Self-denial can be another protective mechanism. Many EMS systems have recognized these factors and trained people not only to help identify concerns but also to be available to speak directly with any affected person who finally comes forward, in person or anonymously, to help such persons through difficult events or mental wellness issues. 

The San Francisco Fire Department (SFFD) has a stress unit that can be accessed 24/7 for any department member in need of assistance. Firefighters who have accessed this resource have said they were reluctant to seek help elsewhere but had greater trust in reaching out to one of their own who could better understand many mutual experiences and difficulties both professional and personal. Issues of gender, race, and other discriminatory experiences are often better addressed within the context of the job.

EMS agencies should also appreciate that most EMS professionals are not aware of the state and national resources available. Organizations such as the Code Green Campaign,⁶ a first responder-oriented mental health advocacy and education organization, and the All Clear Foundation,⁷ dedicated to connecting first responders with crisis support and wellness options, are just some of the resources specifically focused on EMS. Every EMS agency should clearly outline what resources are available to its members, regionally and nationally, to help support them in times of need and encourage their use within a culture of genuine, trusted support. 

Organizational Factors 

While a focus on team members and mutual support of all individual responders and agency leaders are both critical to mental well-being and “minding the mind,” agency-level and related societal and political factors are also pivotal to address. Some of these are inherent discriminatory practices and cultures that just ignore and permit disrespect, microaggressions, and unkindness. At the same time, other organizational factors, including economies and use of resources, also affect the mental well-being of EMS professionals. 
The following research-based bullet points help elucidate this concept.

• The job-demands resources theory, a leading model for the etiology of burnout, emphasizes that burnout results from prolonged imbalances in the work environment where job demands exceed job resources.⁸ 
• Burnout has negative consequences for EMS organizations, including increased turnover and absenteeism, further exacerbating work environment imbalances.⁹  
• A large study of nearly 250 EMS agencies in South Carolina indicated that burnout levels indeed varied across agencies and were likely due to agency organizational factors.¹⁰ For example, having to hurry between calls (continual time pressure factors) was associated with a fourfold increase in the odds of burnout. 
• Likewise, posting in an emergency vehicle frequently and lacking aspects of a more familiar physical environment (where one can have a more relaxed place to eat, sleep, or shower) was also associated with increased burnout.¹⁰ 
• Even before COVID-19, performing death notifications was associated with increased burnout among EMS professionals.¹¹ Appropriate targeted training in death notification procedures can mitigate this effect and may have become particularly important over the past year, with many areas seeing profound increases in unresuscitatable cardiac arrest cases during the pandemic.¹¹ 
• Less-tangible job resources like feedback and frequent interaction from a medical director, a supportive/participatory environment, and adequate, appropriate, and well-targeted training were associated with reduced odds of burnout in EMS.¹⁰ 
• Most important, even in conditions where job demands were high, having high job resources to meet those demands reduced risk of burnout.¹⁰ 

Above all, individuals will have a better sense of identity and self-worth when they enjoy a mutual esprit de corps as part of a team of public servants who sincerely and genuinely are doing their best, from top to bottom, to address both the mission and challenges of 9-1-1 response.

Closing Comments

The scales of compassion and caring can truly fatigue during a pandemic and will likely continue to do so in the post-pandemic era. In Part 3 of this series, we will provide additional considerations that range from proactive training and community-based initiatives to professional society initiatives and theatrical performances aimed at soothing the soul of EMS and its invaluable team of individuals on the front lines. 

References

1. Maloney LM, Hoffman J, Pepe PE, et al. Minding the Mind of EMS—Part I. EMS World, 2020 Nov; 49: 38–40; www.hmpgloballearningnetwork.com/site/emsworld/article/1225094/minding-mind-ems-part-i.

2. Karlamangla S. As health workers deal with mass shootings and fires, more hospitals are looking to help them cope. Los Angeles Times, 2018 Jan 2; www.latimes.com/local/california/la-me-ln-code-compassion-20180102-htmlstory.html.

3. Davidson JE, Graham P, Montross-Thomas L, et al. Code Lavender: Cultivating Intentional Acts of Kindness in Response to Stressful Work Situations. Explore (NY), 2017 May–Jun; 13(3): 181–5.

4. Van Der Ploeg E, Kleber RJ. Acute and chronic job stressors among ambulance personnel: Predictors of health symptoms. Occup Environ Med, 2003; 60(Suppl 1): 40–6.

5. Vigil NH, Beger S, Gochenour KS, et al. Suicide among the Emergency Medical Systems Occupation in the United States. West J Emerg Med, 2021; 22(2): 326–32.

6. The Code Green Campaign. Help & Resources, https://codegreencampaign.org/resources/. 

7. All Clear Foundation. Resources for Responders and their families, https://allclearfoundation.org/resources/.

8. Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Applied Psych, 2001; 86: 499–512.

9. Crowe RP, Bower JK, Cash RE, et al. Association of burnout with workforce-reducing factors among EMS professionals. Prehosp Emerg Care, 2018; 22: 229–36.

10. Crowe RP, Fernandez AR, Pepe PE, et al. The association of job demands and resources with burnout among emergency medical services professionals. JACEP, 2020; 1: 6–16.

11. Campos A, Ernest EV, Cash RE, et al. The association of death notification and related training with burnout among emergency medical services professionals. Prehosp Emerg Care, 2020: 24: 1–14.

Lauren M. Maloney, MD, NRP, FP-C, NCEE, is assistant professor of emergency medicine at Stony Brook University Hospital, Stony Brook, N.Y.

Jason Hoffman, BS, NRP, CCEMT-P, is a paramedic supervisor at Stony Brook University Hospital, Stony Brook, N.Y.

Paul E. Pepe, MD, MPH, is coordinator of the Metropolitan EMS Medical Directors (aka “Eagles”) Global Alliance, Dallas, Tex.

Christopher B. Colwell, MD, is professor and vice chair of emergency medicine at the University of California, San Francisco.

Peter M. Antevy, MD, is EMS medical director for the Coral Springs-Parkland Fire Department and Davie Fire Rescue, Broward County, Fla. 

Remle P. Crowe, PhD, is the National Research Scientist and Performance Improvement Manager for ESO, Austin, Tex.

Bryan L. Doerries, MFA, is artistic director for Theater of War Productions, New York, N.Y.

Stephen H. Anderson, MD, FACEP, is an attending emergency physician at MultiCare Auburn Medical Center in Auburn, Wash. 

Sandra M. Schneider, MD, is associate executive director for clinical affairs for the American College of Emergency Physicians, Dallas, Tex.