This essay is this year's winning entry for the Tema Conter Memorial Trust Scholarship Award. To learn more, visit www.tema.ca/Scholarships

Stress in Emergency Services

Megan McDonald

February 2012

Emergency service workers, firefighters, police officers, and other first responders are exposed to situations that the average civilian may rarely or never be exposed to in their lifetime.  These workers encounter individuals who are sick or dying; who are violent offenders or victimized innocents.  They come into contact with those who have suffered tragic accidents.  The personnel of these services fight for the well-being of others.  Although these occupations may be viewed as rewarding careers, these individuals can struggle for their own welfare behind closed doors.  Studies have shown that paramedics and other health care workers who have experienced or witnessed trauma are more prone to Post Traumatic Stress Disorder (PTSD) (Alden, Regambal & Laposa, 2008).  The cumulative stress of witnessing or experiencing direct traumatic events can have a profound negative impact on the emergency service worker’s well-being.  This paper discusses the symptoms and residual effects of Acute Stress Disorder (ASD), Critical Incident Stress (CIS), Cumulative Stress and PTSD.  These topics have not been impregnable to controversy and criticism has surrounded the Diagnostic Statistical Manual’s definition of PTSD and ASD as well as various treatments currently used to treat the disorders.  In regards to PTSD and emergency health care workers, it is important to recognize that experiencing symptoms of these disorders is often not reported and therefore left untreated (de Boer et al., 2011).  Present-day organizations, such as the Tema Conter Memorial Trust exist solely for the purpose of educating and researching CIS and PTSD.  This paper will also focus on the role these organizations have propose improvements for identifying and combating the stigma associated with PTSD.  In addition, David Whitley, who is a paramedic and member of the Critical Incident Stress Management (CISM) team for York Region EMS, will share his knowledge and experience regarding PTSD in emergency services. 

We must clearly define “abnormal” or “maladaptive” reactions are after experiencing a traumatic event.  Before PTSD was a diagnosis in the Diagnostic Statistical Manual, the now-defined symptoms were believed to be a normal response to such events (Pratchet et al., 2011).  However, when the DSM-III introduced PTSD as a disorder in 1980, a breadth of research and writings were produced regarding the effects of trauma (Foa, et al., 2009).  More than 30 years later, the definition has changed to its present state in the DSM-IV-TR.  After being exposed to a traumatic event, the person must experience a variety of different symptoms to be diagnosed.  According to the latest edition, these symptoms are grouped into several categories:

• The re-experiencing of the event (in ways such as dreams, recollections, or extreme distressed when reminders of the event are present
• The avoidance of situations and objects that relate to the traumatic experience as well as emotional flattening or decreased involvement in activities that were part of life before the exposure
• Increased arousal, which includes sleep disturbances or problems concentrating
• These symptoms must be present for more than one month in duration
•  These disruptive symptoms must cause a marked deficiency in various aspects of life, such as social or work-related functions.
• (DSM-IV-TR, 2000)

Although the DSM-IV-TR seems to have clearly outlined characteristics for the disorder, there is still a shortage of clarity on some issues, such as the definition of “trauma”.  This concern will be discussed later along with other controversies.  PTSD can have varying degrees of severity and there is high incidence of comorbid disorders.  Pratchett et al. (2011), state that an “estimated 79% of women and 88% of men diagnosed with PTSD have at least one other psychiatric disorder…particularly depression and substance use disorders”.  Whitley, who has been in the emergency services field for over two decades, states that alcoholism is an abundant concern for paramedics (personal communication, December 21, 2011).  Alcohol misuse or other drug addictions may also lead to maladaptive behaviour and the correlate subsequent disorders.  Frequency of comorbidity may cause misrepresentation in the prevalence of PTSD, as symptoms of certain disorders can overlap causing under or misdiagnosis.  Statistically, it is reported that “8% of Canadians suffer from PTSD” and “research indicates that this number is two to three times higher in the emergency services sector” (Tema Conter Memorial Trust website, 2010, “Home”, para. 1).  Despite these estimations regarding PTSD in emergency services, there is still a high frequency of underreporting symptoms of the disorder.  Stigmas centered on stress disorders and why underreporting may occur will be conversed further into the paper.   To be diagnosed with PTSD, the symptoms must be present four weeks after being exposed to the trauma (Nolen-Hoeksema & Rector, 2008).  Since the PTSD diagnosis does not describe post-trauma symptoms that are experienced in the first month after exposure, the diagnosis of Acute Stress Disorder (ASD) was introduced in the DSM-IV.  Both ASD and PTSD are designated under the grouping of Anxiety Disorders in the DSM.  Although closely related, the two disorders differ on the length and time period the symptoms are experienced.  Harvey & Bryant (2002), state that the ASD diagnosis “was driven by the notion that dissociative reactions are a crucial mechanism in posttraumatic adjustment” and that an individual’s recovery may be impaired “if their dissociative responses impede access to affect and memories about their traumatic experience.”  These dissociative symptoms include emotional numbing, detachment, decreased awareness of surroundings, disconnection of mind and body or being unable to remember aspects of the trauma (Nolen-Hoeksema & Rector, 2008).  Aside from the time and duration of ASD, another reason the diagnosis was first introduced was for the assistance of identifying individuals at risk of developing PTSD (Grey, 2009).   By communicating with and evaluating individuals who are exposed to major stressors on the job, making an early diagnosis of ASD can help determine the prognosis for PTSD.  Researchers have estimated that of those diagnosed with ASD, between 72% to 83% developed PTSD six months after their traumatic exposure.  After two years of the exposure and initial ASD diagnosis this statistic slightly decreases, yet between 63% and 80% are still inclined to develop PTSD (Harvey & Bryant, 2002).  This predictability of the development of PTSD is essential for the research of better treatments and long-term outcomes of traumatic experiences.

In terms of traumatic stressors that may lead to the development of ASD and PTSD, we must define Critical Incident Stress (CIS) and Cumulative Stress.  Critical incidents are unpredicted and abrupt occurrences that significantly impact the emotional and psychological well-being and coping mechanisms of the individual experiencing the event (de Boer et al., 2011).  Recovery from these events may vary and in the period of reclamation symptoms of ASD or PTSD may arise.  Emergency service workers may experience one or more critical incidents, such as the death of a child, the traumatic death of an individual, or even making the association of a certain patient or patient condition with a friend or family member.  Cumulative stress is defined as sustained exposure to stress factors (Managing stress in the field, 2009).  Cumulative stress in the field of emergency services may lead to work exhaustion, or ‘burn out’.  Since medics have a high exposure to illness, death and human suffering, one can assume the correlation of these stressors to the prevalence of PTSD, which is estimated to be 16-24% or higher within the field (Tema Conter Memorial Trust website, 2010, “Home”, para. 1).  Due to the high incidence of stressful occurrences encountered in emergency services, it is important that appropriate preventative measues are available so that effective coping can take place.

Controversy surrounding PTSD

Since the inclusion of PTSD into the DSM over 30 years ago, it has not been immune to controversy. The lack of clarity of what constitutes “trauma” and the diagnostic criteria of PTSD have both been criticized.  Other criticisms has revolved around whether or not PTSD should be considered a diagnosis on its own or rather be seen under the diagnostic criteria of other disorders like depression or anxiety, which have overlapping symptoms (Rosen, 2004).

Although some of these symptoms may overlap with varying disorders, we must look at what we are defining: post-traumatic stress disorder.   The DSM has struggled with the definition of trauma for the PTSD diagnosis since it was introduced.  In 1980, the DSM-III defined a traumatic stressor as an event that would induce a considerable amount of distress in any person (Alden, Regambal & Laposa, 2008).  This vague definition left the diagnostic criteria rather open-ended and it would seem that most individuals would have been exposed to such a stressor at some point in their life.  Why would some individuals react adversely to such “trauma” while the majority of the population did not?  A new definition of trauma was necessary to help better recognize true PTSD and to add credibility to the DSM’s newly added diagnosis.  The definition of trauma was re-worded in the DSM-III-R and again subsequently in the DSM-IV and DSM-IV-TR.  The most recent edition of the DSM defines trauma as an extremely traumatic event where one is at risk of death, injury or physical harm; where any of the previous events are witnessed having done to another individual; the exposure of such traumatic events having happened already (such as an unexpected death); or the threat of substantial harm to someone within the individual’s family or social circle (DSM-IV-TR, 2000).   The continuous change in the definition and the lack of clarity throughout the years has forced critics to raise speculation as to the credibility and consistency of the diagnosis.
Another aspect of the diagnosis that has been critiqued is that the symptoms of PTSD coincide with other anxiety disorders, sometimes making a solitary diagnosis difficult.  Grey (2009) confirms this statement, suggesting that it is “unsurprising that there is high comorbidity because many symptoms overlap with other diagnoses”.  That there is any doubt or difficulty forming a diagnosis enhances critics’ argument that the definition is too broad and open-ended.  Since individuals with true PTSD may not fit into the formal diagnosis because of other symptoms or the presence of comorbid disorders, the DSM is considering a new subtype for ASD and PTSD.  Although tentative, a new diagnosis would purpose to serve those who do not meet all diagnostic criteria “but who are clearly exhibiting a clinically significant assortment of posttraumatic re-experiencing, dissociative, avoidance and/or arousal symptoms” (Bryant et al., 2011).  This would assist in the proper recognition of individuals who suffer from various symptoms, yet to do receive appropriate care because they do not fit into the current diagnosis.

Treatment

Rosen (2004) writes “if most people show resilience after traumatic events, but a minority go on to develop significant posttraumatic problems, how should professionals and communities best respond in the aftermath of trauma?”  Many different treatments and management techniques have been proposed and used for ASD and PTSD over the years.  These include critical incident stress debriefing (CISD), cognitive-behavioural therapy (CBT), and eye movement desensitization and reprocessing (EMDR) and the use of medications for symptom relief. 
As discussed earlier, Critical Incidence Stress (CIS) is an occurrence of an event that may be physically, emotionally or psychologically traumatic to an individual.  Due to the high exposure of traumatic events emergency workers face, Critical Incident Stress Debriefing (CISD) was designed to support this population. CISD is “generally conducted within 24-72 hours of a trauma experience and involves a seven-step process” which includes reassuring confidentiality; discussion of what occurred and how the individuals interpreted it; recognition of one’s reactions to the event and subsequent distress; education of how the body normally responds to stress; and a final review of the entire situation (Pratchett et al., 2011).  Despite some reports of CISD being beneficial to emergency workers, there is considerable controversy regarding its effectiveness.  Khai & Nkansah (2010) report that cumulative evidence proposes that “debriefing could impede natural recovery from acute PTSD symptoms”.  Feldner, Monson, & Friedman (2007) support this statement, suggesting that CISD may cause over-stimulation in the individual post-event, leading to intensification of memories relating to the traumatic event.  Since this prompt intervention technique has sufficient evidence of risk involved, how are emergency workers being affected?  In a recent study conducted by Halpern et al. (2009), numerous EMS workers and supervisors were interviewed and asked to share their opinions on different ways to intervene after a critical incident.  The conclusion was drawn that CISD was viewed as impersonal, as the person conducting the interview was often an external mental health worker rather than someone from within the EMS organization.  Conclusively, the formality of the debriefing was thought also to cause a possible hindering of the healing process (Halpern et al., 2009).  However, different factors contribute to the overall atmosphere and experience of CISD.  Whitley states that the supervisor or the emergency personnel overseeing the debriefing process has great impact on the outcome (personal communication, December 21, 2011).  Some supervisors may facilitate the healing process and be regarded as supportive by their peers, while others may contribute to negative ideologies about the debriefing.  Supervisor support will be discussed in further detail later in the paper.  Overall, it appears that although CISD may be beneficial to some individuals, evidence suggests there may be significant risk involved in this form of treatment.  This data is important to note as new studies are now in the process of discovering more progressive ways of rapid intervention for individuals exposed to traumatic events.

Cognitive behaviour therapy (CBT) is not a specifically defined treatment, but rather a group of interventions that typically focus on “trauma education, exposure-based exercises and cognitive restructuring” (Pratchett et al., 2011).  These therapies put emphasis on challenging patients’ detrimental thinking about a traumatic event and replace these with more beneficial ways of coping.  Problem-solving techniques for wider-scale issues are also developed between the therapist and patient (Nolen-Hoeksema & Rector, 2008).  This method of therapy has shown great efficacy towards a variety of disorders, yet data may be insufficient as many patients still fail to respond to treatment or drop out before treatment is complete (Henny et al., 2011).  In terms of defining CBT’s efficacy, this may be difficult to do as there are various ways to implement the treatment.  Rakovshik & McManus, 2010, state that there is an “ongoing debate about what makes CBT effective” and that it is necessary to “identify what CBT therapists do (or don’t do)”.  Although there have been studies that show the effectiveness of CBT, it is evident that more research is necessary to determine which part of the treatment is causing beneficial outcomes.

EMDR is a non-CBT treatment of PTSD that has a controversial evidence base. Some studies show the efficacy of the treatment (Pratchett et al., 2011) while others have “growing skepticism…regarding the value of the eye movements in achieving the outcomes” (Keane, Marshall & Taft, 2006).  The individual undergoing treatment is asked to focus on an image of a distressing memory and is then asked to use their eyes to follow the therapist’s finger across their visual field (Bandelow et al., 2008).  Due to the nature of the traumatic memory, negative thoughts are provoked naturally and the patient is instructed to focus on thoughts that are more positive.  This continues repeatedly until distress is no longer reported by the patient (Keane, Marshall & Taft, 2006).  One study conducted looked in depth at scholarly articles written on the effectiveness of EMDR in treating PTSD.  Rubin (2003) found that this therapy was beneficial to individuals who had experienced a single “civilian” traumatic event.  However, the evidence for individuals who had undergone multiple traumas, children exposed to trauma, or those involved in combat trauma was less persuasive.  This research suggests that treatment for PTSD should be subjective rather than objective, reflecting the differing needs of the individual involved.

Lastly, specific medications have been found to be useful in the treatment of PTSD.  In the past decade, numerous clinical trials for the use of medications in treating PTSD have significantly increased (Keane, Marshall & Taft, 2006).  Selective serotonin reuptake inhibitors (SSRIs) have been found to be highly beneficial in managing the symptoms associated with the disorder (Bandelow et al., 2008).  Pratchett et al.,(2001) propose that some evidence regarding the efficacy of SSRIs in treating PTSD has shown that “up to 30% of PTSD patients…may achieve full remission after three months and 55% after a more prolonged treatment course”.  However, SSRIs are not the only medications used for PTSD treatment.  Tricyclic Antidepressants (TCAs) are also used, although it is suggested that the effectiveness was only reported in regards to symptoms of depression associated with PTSD, not the specific symptoms associated with PTSD itself (Bandelow et al., 2008).  As noted above, it is clear that SSRI’s are moderately effective for many patients, yet research suggests that the medication does not have beneficial effects for up to 40% of individuals with PTSD (Baker, Nievergelt, & Risbroug, 2009).   Although there are numerous studies being conducted regarding other potential pharmacological treatments of PTSD, no conclusive evidence illustrates other medications that are more beneficial than the current SSRI treatment. It is evident that there is a distinct necessity for a wider selection of effective pharmacological treatments for PTSD and the residual symptoms associated with the disorder.

PTSD and Emergency Personnel

Rates for PTSD within the general population are reported to be approximately 8% (Keane, Marshall & Taft, 2006), yet the statistic for the disorder is estimated to be between 16% and 24% in emergency service personnel (Tema Conter Memorial Trust website, 2010, “Home”, para. 1).  There are various concerns regarding this staggering statistic of emergency workers who may be suffering from stress disorders, including the shame and stigma surrounding the diagnosis, compassion fatigue, and ensuring appropriate treatment and interventions post-trauma. 
Personal and professional concerns over the stigma of recognizing one’s symptoms and seeking treatment may hinder an individual from identifying the need for help.  Kaloupek et al., 2010 confirm this, stating that “stigma and other barriers have been implicated as potential contributors to avoidance of care for PTSD”.  The stigma surrounding stress disorders may relate to several factors: the individual’s own personal beliefs about mental illness or treatment for such disorders; their previous experience with mental health care, if any; how the social circles of these individuals react to and perceive mental illness; and certain institution’s (ie. the military’s) role in encouragement or hindering of treatment seeking (Spoont et al., 2009).  Whitley discusses that although he feels the stigma still exists in emergency services, the magnitude has diminished in recent years.  However, he states that paramedics are still “under-supported” in their jobs and that more people need to admit to needing help (personal communication, December 21, 2011).  Education of these disorders is necessary on an individual as well as wide-scale level to dissipate the maladaptive ideologies of mental illness and treatment.  It is also important that employers and supervisors of emergency workers are advised when a critical incident has occurred and to ensure that the staff has proper accessibility to treatment and work leave if necessary.  One article recognized the importance of supervisor support following a critical incident.  Dobson (2010) found that emergency personnel “appreciate when supervisors acknowledge an incident, express concern about the well-being of the EMT, are willing to listen…value his work and offer material help”.  When talking to an individual who had experienced a critical incident earlier this year, the issue that most bothered them was the lack of support immediately following the event.  Despite nearly a year having past, this individual was still more upset about how their feelings were disregarded then the actual event itself (which had caused these initial feelings).  Dobson (2010) suggests that talking about a critical incident and subsequent emotions may be difficult to do between paramedic and supervisor.  In regards to obtaining help from a Critical Incident Stress Management (CISM) team, Whitley suggests that a supervisor can detriment the post-traumatic outcome for the medic if they leave the option for help open and not mandatory.  He states that since the need for help may not be immediately recognized, a medic with the option to forego CISD could possibly make that decision, deterring them from potentially vital treatment (personal communication, December 21, 2011).  Since supervisors play a large role in the transition of traumatic exposure to the healing process, it is important that proper education (for the supervisor) is mandated to better ease this phase.  In addition, proper monitoring of care for individuals who have experienced a critical incident is vital for an emergency service.  Ensuring that these individuals have proper treatment and recovery time is essential for the worker’s well-being, as well as ensuring confidence in the organization.

Negative ideologies and feelings regarding treatment can not only deter an emergency worker from seeking appropriate help, but it can also impede their work morale.  Health care workers who deal with multiple patients over a prolonged period may experience symptoms of compassion fatigue or burn out.  Adams et al. 2006 define compassion fatigue as the worker’s “reduced capacity or interest in being empathetic” and is a “consequence of working with traumatized individuals”.  Compassion fatigue and burn out are detrimental not only to the organization and workers providing the care, but to the patient on the receiving end.  If emergency services are aware that burnout rates are high in their profession, what is being done to avert it?  Preventative measures like stress education and teamwork-building skills are important to ensure a trusted support system is in place when an individual recognizes the need to ask for help.

The Tema Conter Memorial Trust

Organizations exist that strive to raise awareness and educate individuals about PTSD and its residual effects.   Some, like the Tema Conter Memorial Trust, are in place to “call attention to the psychological trauma encountered by emergency services and military personnel” (Tema Conter Memorial Trust website, 2010, About us).  The Tema Conter Memorial Trust’s Advisory Board is comprised of individuals in the medical field, paramedics, fire personnel and police officers (The Tema Conter Memorial Trust website, 2010, Advisory Board and Trustees).  Since these members have been a part or currently play active roles in their respective fields, it is likely that they have all been exposed to trauma at one time in their careers.  I believe that this is a strength of this organization, as these members would have a better understanding of such traumatic exposures and the effects that are linger post-trauma. The past experiences of these individuals can help the organization determine how to deliver appropriate care and support to those suffering after traumatic events.  Their input is also vital for education, preventative measures and prospective research studies.

The Tema Conter Memorial Trust educates emergency personnel as well as members of the community through training sessions, education days, media advertisements to bring attention PTSD and the organization and large events with guest speakers pertaining to such issues (Tema Conter Memorial Trust website, 2010, “Upcoming Events” and “Welcome to Common Threads”).  Holding such events encourages employers and employees of emergency services to participate in expanding their knowledge of PTSD.  Getting involved as an individual or a group creates an awareness of how prevalent these disorders really are and steps toward proper recovery.

The Tema Conter Memorial Trust is also currently sponsoring and promoting various research studies relating to critical incident stress and PTSD.  These include, but are not limited to, the controversy surrounding CISD in emergency services and the role of supervisor support as an early intervention post-trauma.  As discussed above, it is evident that large amounts of research discredit CISD and proclaim it as potentially detrimental to the natural healing process.

Current research on PTSD and related topics is essential.  Bringing attention to these issues and educating emergency workers and the general public is aiding in the destruction of the negative ideologies surrounding PTSD and allowing individuals to acquire the proper treatment they require.  Together, with organizations like the Tema Conter Memorial Trust, emergency services have an abundance of resources for education, research and a common goal of breaking the stigma associated with PTSD.

My Own Learning Experience

Before researching PTSD and trauma-related stress, I had little idea how complex and life-encompassing these symptoms could be.  What I learned most was how important prevention is and how essential one’s own protective factors are in coping with critical incident stress.  For this paper, I researched numerous databases searching for facts and statistics regarding stress in emergency services.  However, my conversation with David Whitley was what fully opened my eyes to how debilitating and life-altering stressors experienced in emergency services can be. Although I believe that there are organizations like the Tema Conter Memorial Trust who strive to educate and promote research for these debilitating disorders, it is vitally important for individual emergency services to provide the proper support and education to their workers.  There here are staggering reports of diagnostic underrepresentation in the emergency service field, yet progress can be made to ensure that those in need of help can attain the proper treatment.  I spoke with a retired emergency room (ER) nurse regarding her experience with post-traumatic stress.  What confounded me was not that she acknowledged high prevalence of PTSD in her profession, but that nothing was being done about it.  The nurse stated that ER nurses were simply “supposed to be tough and thick-skinned” and that PTSD was recognized, yet “no one talked about it” (personal communication, November 9, 2011).  With these domineering stereotypes of how individuals in such careers should act or feel, how do we break these stigmas and attack the problem in a progressive way?  First, I believe that mandatory attendance to educational sessions regarding PTSD and CIS should be in place.  I also believe that supervisors for all services should have an abundance of training regarding these issues and have additional training in communications and recognizing work-related stress.  I understand that some services, such as Toronto EMS, have an acute care psychologist as well as a peer support team in place when critical incidents occur or cumulative stress is overbearing (Toronto EMS website, “Psychological Services”, 2010).  This is a great asset to the service and its employees.  Although many services are much smaller than Toronto EMS and such resources may be limited, having access to staff and psychological support can be quite beneficial to employees.  Being acquainted with the individual offering support can be more beneficial to those receiving treatment than if that person were an external heath care worker (Halpern et al., 2009).  Calling awareness of PTSD to the general public is also imperative to terminate the stigma.  Anything from public awareness campaigns or community education sessions to a simple radio advertisement are all ways to bring attention to the debilitating effects stress has on emergency personnel.  Within emergency services, it must not be assumed that the employee is knowledgeable of and prepared for traumatic events.  It should be a group effort that creates reassuring bonds between paramedic, supervisor and support team.  I believe a supportive framework within emergency services is essential to ensure that emergency personnel feel comfortable and appreciated in times of need.

It is evident that PTSD, ASD and the stressful events that lead to these disorders are largely present in the emergency services field.  There is considerable controversy surrounding these topics, including the efficacy of certain treatments, the stigma surrounding the disorder and how critical incident stress should be managed immediately following a traumatic exposure.  Organizations that raise awareness about PTSD are essential to creating a progressive approach to the disorder.  Along with these external groups, emergency services can work together to ensure proper education and social support is in place.  Numerous studies are in place regarding current issues of PTSD in the emergency field, which will further add to the advancement of proper care and stress management in the field.

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