Building Paramedic Resilience

If for some cruel reason you were tasked with creating a job description for a role that would almost certainly break an individual physically and psychologically you would probably include the following criteria:

• Work must be performed in complex, unpredictable environments, by day and night
• Essential information provided prior to attending work should be incomplete and often inaccurate
• Every job must be time-pressured to meet unrealistic organisational Key Performance Indicators
• Ensure that resources and budgets are limited to maximise stress on the workforce
• Ensure an organisational culture of stigmatising mental health and physical injuries
• Promote a culture of underreporting injuries and incidents
• Ensure that there is a constant risk of being assaulted physically, verbally, and sexually every day at work
• Regular lifting of heavy items in awkward and often confined spaces to maximise potential for lower back and other physical injuries
• Exposure to constant trauma including death, dismemberment, and human suffering across a spectrum of age ranges from infants to geriatrics
• Ensure all individuals that the employee interacts with are having one of, if not, the worst day of their lives
• Ensure a high percentage of individuals that the employee interacts with are affected by alcohol, drugs, or are suffering from acute mental health disturbances
• Don’t facilitate debriefing following critical incidents, rather send the employee immediately back to work
• Ensure shift work to minimise employee time with family and friends
• Don’t provide any situational awareness training to identify possible threats in the workplace, or training to deescalate threats or respond to physical violence
• Minimise acknowledgement of the stress of the role and the contribution that the employee makes to the wellbeing of the community served 

Sounds terrible doesn’t it, and who in their right mind would sign up for such a role? The answer – hundreds of thousands of paramedics worldwide. I suspect there’s more than a few paramedics reading this article who are nodding their heads in agreement already. These certainly aren’t my thoughts; all the above-mentioned job stressors are cited widely in the international literature on paramedicine. The goal of this article is not to get bogged down in the academic references but rather touch on the wavetops of the stressors of paramedicine and offer some tools to help start turning the tide of the global epidemic of paramedic psychophysiological health issues that stem from their unique and extraordinarily stressful professional role. The key references used to compile this article are cited at the end and I strongly encourage anyone with an interest in the area to look them up and read them in their entirety.

The statistics on paramedic health

There is an abundance of international literature, including some very recent and powerful scientific studies, demonstrating that paramedics have significantly higher rates of mental and physical health issues than the general public. Statistics suggest that among paramedics a prevalence of PTSD of 11%, depression 15%, anxiety 15%, and general psychological distress 27% with an assumption that a culture of underreporting means that the actual rates are much higher. These numbers are up to four times higher than the general public, and double those of other health professionals. Concerningly, studies suggest that 10% of paramedics have suicidal ideation, which is once again likely underreported. Compounding these mental health statistics are the high rates of physical injuries sustained in the line of paramedical work, owing to the frequent requirements to lift patients and equipment, as well as perform duties in awkward and often confined spaces.

Why do paramedics have such high rates of health issues?

The mental and physical health statistics seen in paramedics are a result of the unique work environment in which they operate. Many / all the job descriptors listed in the introduction paragraph of this article are at play daily. The result is a constant low-level activation of a paramedic’s stress response systems, compounded by periodic acute stress responses to jobs and work situations, leading longer-term to compassion fatigue, anxiety, depression, PTSD, burn out, and worst-case suicidal ideation and completed suicides. Surveys of paramedics cited in the literature suggest that they receive little to no education on dealing with the unique stressors of the role during their training, and once on the job often receive no opportunity for debriefing after critical incidents. Mental health issues can often be stigmatised in what has been described as a “…military-like or macho culture that discourages emotional displays of distress” (Lawn et al. 2020) leading to paramedics adopting maladaptive coping strategies such as alcohol and other drugs, anxious avoidance, and sensitising behaviours. Employee Assistance Programs are often structured in a manner that exists only to intervene when problems are detected. Basically, the system waits for the paramedic to break before offering assistance to fix them.

This situation can be diagrammatically represented with resilience and stress sitting on opposite ends of a set of scales, and tipped in the favour of stress[1].

 

The problem with this approach is that by the time the system steps in to offer support there has already been a mental and/or physical health injury and the paramedic is likely already on sick or stress leave from the job, and potentially on WorkCover or other forms of compensation. This is a disastrous outcome for not only the paramedic, but for the organisation, which now must pay the paramedic while they recover, as well as fill the deficit in the roster. All too often these roster gaps will be filled by existing paramedics working extra shifts, increasing their stress levels and occupational exposures, and making them more likely to suffer a mental or physical health injury themselves! Furthermore, the goal of any intervention for the affected paramedic is simply to just balance their scales again in order to bring them back to a functional state to return to the very same work that broke them in the first instance. There is generally no ongoing intervention to positively build resilience to minimise the chance of a further occurrence.

What’s the solution? 

It’s easy to throw our hands up in the air and declare the situation hopeless, but that doesn’t get us any closer to a solution, and it certainly doesn’t provide the paramedic at the coalface with any tools to deal with their stress. It’s tempting to externalise the responsibility to the organisation that a paramedic works for, and certainly some of the responsibility in solving the problem does lie with them, however having such an external locus of control tends to create a victim mentality and not lead to solutions. The opposite to an external locus of control is an internal locus of control, where individuals take ownership over a problem and in the empowering words of the great Stoic Marcus Aurelius…

“…get active in your own rescue…”

Instead of waiting for a stress event, or the culmination of years of chronic stress, overwhelm the paramedic, The Resilience Shield model proposes strategies that are consciously implemented to build resilience to the stressors of the role on a day-to-day basis to strengthen defences against physical and mental health illnesses. Let’s look at the following downward spiral that the literature tells us can happen to a high percentage of paramedics during their careers, with a view to potential resilience interventions along the way before things hit crisis point.

Figure 2. The downward spiral of paramedic mental and physical health.

By the time this downward spiral gains momentum it can be difficult to reverse. In the worst case the patient suffers a poor clinical outcome as well, owing to the stressed paramedic not being in their optimal state to care for them, which of course serves to increase the stress load on the paramedic! The following list is not designed to be exhaustive; it is simply aimed at seeding thoughts in paramedic’s minds about resilience-building strategies to stop the downward spiral in its tracks and start to reverse it.

Building paramedic resilience

There’s not a whole heap you can do to change the nature of the callouts that you’re required to attend in your work. Ultimately people will continue to crash their cars, hurt themselves, and have heart attacks! What you can control is the way that you react to the stress of these situations. Here’s some tips on how to get started:

• Acknowledge that you’re being exposed to trauma. This one seems a bit ridiculous, however I bet that most paramedics out there wouldn’t fully consciously register the amount of trauma they are exposed to in their work. Through repeated exposure to the routine trauma of paramedicine it is normal to recalibrate to a new level of normal. For most of us the first dead body, very sick child, or amputated limb we see will probably be a bit of a shock, but by the time you see your tenth or twentieth it’s unlikely to even register on the radar as traumatic at all. The problem is that while it doesn’t register consciously as trauma, your subconscious is taking it all in, and a psychological bucket within you is slowly filling. Through a process of what I call traumatic adaptation, the huge trauma load just seems normal. Compounding this issue is the fact that every other paramedic on the job is being equally exposed, and recalibrating as well, so it’s easy to lose perspective on what should and shouldn’t be traumatic when talking with workmates. A useful question to ask yourself is: “Are my experiences unusually traumatic or stressful when compared to the average person?” For the “average person” in this scenario picture the avatar of a middle-aged accountant, who has a comfortable middle-class existence, who has never been in a fist fight, and has never seen a dead body up close other than the open casket at his grandmother’s funeral. If the answer is yes, and I bet it will be for most paramedics, then it’s probably worth touching base with a psychologist for some preventative sessions long before your psychological bucket starts to overflow.

• Train and study continuously! Ever notice how when you’re new to a skill such as IV cannulation it seems terribly stressful, however by the time you’ve racked up a few dozen cannulations on the job it becomes second nature, and you can almost do it on autopilot. What has occurred in that setting is a stress inoculation, where you become desensitised to the stress of the procedure through experience and competence. The stress of any situation can be significantly reduced if you feel you have some control over it and can react to it in a positive manner. Ongoing study and training empower you with this feeling of control and reduces stress. If you encounter a situation on a job that you weren’t prepared for then make a note of it and ensure that you go away and educate yourself on how to confidently approach the situation next time.

• Don’t Sensitising is summed up nicely by a famous quote from Mark Twain:

“I’ve had a lot of worries in my life, most of which never happened”

It’s human nature to worry and it’s easy to get caught up in sensitising behaviour. While a little stress can be a good thing to prime you for optimal performance when required, constant worry about what might occur on the next job, or on the next shift sets off a chronic stress response within our systems. If this is not consciously identified, and strategies implemented to address it, it can lead to all manner of physical and psychological ill health effects. Try to start being mindful of any sensitising thoughts you might be having, and when you detect them attempt to block and replace them. Tell yourself that you’ll worry about the situation if or when it occurs and not before! Sounds silly but it works.

• Meditate. If there’s one habit that I urge you to take up after reading this article, it’s meditation. The evidence is now definitive and overwhelming that a regular meditation practice not only reduces chronic stress responses, but it also enhances the ability to operate well in stressful environments and has a whole raft of other positive benefits to prevent the downward spiral illustrated in figure As icing on the cake for any paramedics out there who suffer from chronic pain such as back pain, meditation has been demonstrated to significantly reduce pain perception in chronic pain sufferers. It doesn’t take hours a day for years to reap the benefits, as little as ten minutes a few times a week has been demonstrated to have significant effects on stress reduction. So, download one of the many guided meditation apps and get started today – most have a ten-minute daily meditation that could potentially even be crammed in between jobs at work!

• Journal. There’s some really interesting scientific literature demonstrating the benefits of journaling, especially when capturing things you’re grateful for on a regular basis. It doesn’t need to be much, and it certainly doesn’t need to be neat or grammatically correct! The goal is to simply scribble down your thoughts from time to time as a tool for capturing information, formalising thoughts into words, and ideally documenting little things in your day-to-day life that you’re grateful for. Paramedicine provides exposure to lots of traumatic and sad events, and simply being grateful for things like returning safely from a shift when patients you’ve treated have had to go to hospital, or suffered a significant illness or injury, is a good start. At Resilience Shield we recommend debriefing your life in your Resilience Journal. This means capturing the good and bad points of your day as a starting point for working out strategies to reinforce the good and improve on the bad.

• Breathe. In the military we were taught the art of combat breathing to settle down an acute stress response when in the combat environment. Martial artists and elite athletes alike get trained in similar breathing techniques, and it’s highly applicable to paramedics. In a nutshell, consciously taking control and slowing your breathing when stressed can reduce your sympathetic stress hormone release and decrease your fight and flight response. This is ideal for use before stepping into a high-stress environment, or for use during an incident when you mindfully become aware that your stress response is escalating. The simple art of combat breathing, also referred to as box breathing, involves breathing in for four seconds, holding for four seconds, breathing out for four seconds, and holding for four seconds. Repeated for just a few cycles, it will have a remarkable effect on reducing your stress response and helping optimise your performance. Practice it regularly both at work and at home and you’ll be more likely to think of doing it when you’re actually under duress.

• Take a self-defence course. The statistics on paramedic assault are damning, and the harsh reality is that every paramedic will encounter at a minimum verbal assault, and very likely physical and sexual assault during their careers. If your organisation doesn’t offer any form of Occupational Violence training to learn the situational awareness to identify threats, de-escalation techniques for situations that might arise, or basic techniques to defend yourself in the worst case of physical or sexual assault, then get active in your own rescue and seek out some training yourself. Even a basic training in situational awareness and de-escalation could make an exponential difference in your awareness of the threat of an environment and defusing situations, allowing for a potential crisis to be averted.

For a deeper dive into resilience, check out www.resilienceshield.com or have a read of The Resilience Shield book, which is available in hard copy, audio, and eBook formats through all major book Australian and New Zealand book distributors.

As always, comments, discussion, and criticism are welcomed! Let’s just start the discussion!

About the Author

References

Abbaspour S, Tajik R, Atif K, Eshghi H, Teimori G, Ghodrati-Torbati A, Zandi A. Prevalence and Correlates of Mental Health Status Among Pre-Hospital Healthcare Staff. Clin Pract Epidemiol Ment Health. 2020 Mar 25;16:17-23.  

Lawn S, Roberts L, Willis E, Couzner L, Mohammadi L, Goble E. The effects of emergency medical service work on the psychological, physical, and social well-being of ambulance personnel: a systematic review of qualitative research. BMC Psychiatry. 2020 Jul 3;20(1):348.

Pararamedics Australasia, 2018. The high rates of mental health conditions experienced by first responders, emergency service workers and volunteers Submission 57. (Online) www.paramedics.org (Accessed 9 August 2021).

Petrie K, Milligan-Saville J, Gayed A, Deady M, Phelps A, Dell L, Forbes D, Bryant RA, Calvo RA, Glozier N, Harvey SB. Prevalence of PTSD and common mental disorders amongst ambulance personnel: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2018 Sep;53(9):897-909.

Pronk, D, Pronk, B, Curtis, T (2021) The Resilience Shield. SAS resilience techniques to master your mindset and overcome adversity. Pan MacMillan Australia, Sydney.

Pyper Z, Paterson JL. Fatigue and mental health in Australian rural and regional ambulance personnel. Emerg Med Australas. 2016 Feb;28(1):62-6.

Shakespeare-Finch. (2007) Building resilience in emergency service personnel through organisational structures. In Proceedings 42^nd Annual Australian Psychological Society conference: Making an impact, pages pp. 362-365, Brisbane.

[1] This concept was developed through another project that I’m involved in, being The Resilience Shield, where myself and two other SAS veterans have taken a deep dive into resilience, presenting it as a dynamic, multifactorial, and most importantly modifiable construct. Much of the discussion in this article is framed around our evidence-based Resilience Shield model, which is elaborated on in great detail in our book titled The Resilience Shield.