Mental Health and Burnout

Introduction

  • Trigger warning
  • Importance of mental health
  • Brain Anatomy and Physiology
  • Fight or Flight Response
  • Memory storage
  • Brain integration of traumatic memories
  • What is a traumatic event?
  • High-stress calls
  • Trauma response
  • Effects on mental health after trauma
  • Anxiety
  • Depression
  • Emotional dysregulation
  • Chronic fatigue
  • PTSD
  • PTSD in EMS
    1. Evidence shows that EMS providers suffer PTSD rate up to 8 times that of the general population
    2. 25.5% of EMS providers will develop a diagnosis of PTSD during their career.
    3. 55.6% of EMS providers display some sort of symptoms of PTSD.
    4. Being exposed to a traumatic event including
      1. patient death, massive bleeding, open surgical wounds, trauma related injuries, and performing futile care to critically or terminally ill patients.
    5. There has been linking to factors that also increase the likelihood of developing PTSD when working in EMS including age, sex, being unmarried and earlier experience of violence.
  • Burnout
    1. Definition: A combination of emotional exhaustion, depersonalization, and reduced personal accomplishment caused by chronic work stress.
    2. S&S: Overwhelming fatigue, loss of motivation, a cynical view of one’s job, and a sense of ineffectiveness and failure.
    3. Burnout and PTSD are closely linked and often underreported in EMS
  • Burnout in EMS
    1. Educational programs do not effectively prepare providers for the inherent emotional stresses.
    2. Triggered by many of the same stresses that lead to symptoms of PTSD.
    3. With high levels of emotional exhaustion and depersonalization and low levels of personal achievement.
    4. Working long hours at multiple jobs and enduring frequent exposure to traumatic events. The stressors inherent to the prehospital setting may increase the likelihood of experiencing burnout and lead providers to exit the profession, representing a serious workforce and public health concern.
    5. Burnout Statistics in EMS
      1. More prevalent among Paramedics than EMTs
        1. Personal: 38.3% vs. 24.9%
        2. Work-related: 301% vs. 19.1%
        3. Patient-related: 14.4% vs. 5.5%
      2. Variables Associated with increased burnout
        1. Certification at the Paramedic Level
        2. 5-15 years of EMS experience.
        3. Increased weekly call volume.
    6. Burnout was associated with over a two-fold increase in odds of reporting ten or more days of sickness absence in the past year.
  • Suicide
    1. Definition:
      1. Suicide: Death caused by injuring onseself with the intent to die.
      2. Suicide Attempt: When one harms themselves with any intent to end their life, but do not die as a result of their actions.
      3. Suicidal Behavior (ideation): A behavioral or psychological syndrome or pattern that occurs in an individual associated with clinically significant distress or disability that is diagnostically valid, clinically useful, and reflective of an underlying psycho-biological disturbance.
        1. It is clinically well-described, associated with biological markers, amenable to a strict differential diagnosis, confirmed in follow-up studies to occur at higher rates in those with a past diagnosis
        2. May come and go.
    2. S&S: Hopelessness, despair, isolation, sleep changes, emotional changes, easily angered, depression, anxiety, thoughts or feelings of self harm
    3. Causes may vary and are different for each. Common causes include stressors and health issues. Conditions like depression, anxiety, and substance problems (especially when unaddressed) increase risk for suicide.
    4. Takes over a million lives worldwide every year.
    5. Non-fatal suicidal behavior is estimated to be 25-50 times more common.
  • Suicide in EMS
    1. Suicide rates are significantly higher in EMS than the general public.
    2. High levels of acute and chronic stress as well as high rates of depression and substance abuse, which increase the risk of suicide.
    3. EMS providers have been shown to have suicide rates of 17.2 to 30.5 suicides per 100,000.
    4. Additional risk factors are post-traumatic stress disorder (PTSD), alcohol abuse, and access to lethal means.
  • Preventing Burnout
    1. Person-directed interventions reduce burnout for a short term of 6 months or less.
      1. Emotional Regulation, self-care workshop, yoga, massage, mindfulness, meditation, stress management skills, and communication skills training.
    2. Organization-directed Interventions
      1. Workload or schedule-rotation, stress management training programs, group face-to-face delivery/discussions, teamwork training, Balint training, debriefing sessions and focus groups.
    3. With a combination of both Person- and Organization-directed interventions have longer effective prevention and growth of 12 months plus.
      1. Snoezelen (sensory stimulation rooms), stress management and resiliency training, stress management workshops, and improving interactions with colleagues through personal training.
    4. View Points to help you work through Burnout
      1. Accept what your job isn’t
        1. Life and death emergency calls are a small part of our job and you should not rely on them for job satisfaction.
      2. Accept you are there to help people
        1. We are there to make situations better, not necessarily saving lives. This can be as simple as education of the public, providing simple medications or interventions to make a situation less uncomfortable.
      3. Appreciate the small victories.
        1. When we direct our focus on making a situation better it increases the satisfaction, indeed of relying on the rare big victories.
      4. Don’t expect others to know what you do.
        1. Not everyone has the same knowledge, experiences, and resources. Getting frustrated about situations that you deem is inappropriate can add to burnout.
  • Help with suicidal ideations
    1. Although suicide is difficult to predict, a large proportion of those who eventually kill themselves will give more or less clear warning signs of their suicidal intentions in the weeks or months prior to their death.
    2. Warming Signs
      1. Withdrawn and unable to relate, talking about feeling isolated and lonely, expressing feelings of failure/uselessness/hopelessness/self-hatred, dwelling on solutionless problems, relaying plans of tidying up lose ends, or suicide plans.
    3. Steps to help
      1. Never assume that the person is doing so for attention or to manipulate.
      2. Keep yourself and others safe.
      3. Give physical space until invited in by the person. Sudden movements, attempts to make physical touch, or introduction of multiple people into the space may create a misunderstanding and could escalate the situation.
      4. Express acceptance and concern without arguing, problem-solving, or giving advice.
      5. Engage in actively listening to the person. This will create a starting point for a solution. Asking about the suicidal ideations, plan, means, and access will not tip them over the edge. This can create a sense of relief and show genuine concern.
      6. Remove access to all lethal means.
      7. Get the person the appropriate mental health care. If you are comfortable you can be an active part in helping the person's treatment.
      8. Never leave a suicidal individual alone. Regardless of their promise to visit a mental care facility or program. Ensure family members or other important individuals to the person help in getting the appropriate care.
  • Positive Coping Mechanisms
    1. Positive Coping Mechanisms are those that are constructive, beneficial and useful in producing a good outcome.
    2. Examples Include
      1. Emotional Growth
        1. Confronting your fears, Recognising your emotional responses, Expression of your emotions,
      2.  Positive Habits
        1. Eat healthily, exercise in moderation, setting boundaries, get enough sleep, develop a good routine, limit caffeine, and set up time for yourself. Use Humor, spending time with friends or family, serve someone in need, prioritize
      3. Positive Hobbies that can be used to help process.
        1. Diversions-write, draw, paint, photography, play an instrument, sing, dance, act, take a shower or bath, garden, take a walk or go for a drive, watch TV or a movie, play a game, clear or organize your environment, read, take a break or vacation, journaling, meditation.
      4. Asking for help
        1. Consulting with a healthcare professional for therapy or medication as a way to help with the emotional turmoil.
  • Negative Coping Mechanisms
    1. Negative Coping Mechanisms are those that are harmful or unhealthy in nature.
    2. The reason that a lot of people go to using negative coping mechanisms is because they provide immediate effects when it comes to reducing stressful feelings.
    3. Although they mask or stop you from feeling awful they actually increase the dysfunction by strengthening and maintaining it.
    4. Examples include
      1. Anxious Avoidance (avoiding the problem)
      2. Smoking
      3. Compulsive Spending
      4. Drinking too much caffeine
      5. Escaping
      6. Binge Drinking
      7. Sleeping all day
      8. Promiscuity with negative behaviors
      9. Stop eating or start over-eating
      10. Emotional Eating
  • Effects of Mental health on Quality of Life
    1. Mental health can cause a variety of different effects on one's personal lives. Causing a wide variety of negative or positive outcomes dependent on one’s own mental state.
    2. Important Quality of Life Areas
      1. Health
      2. Material Comforts
      3. Personal Safety
      4. Relationships
      5. Learning
      6. Creative Expression
      7. Opportunity to help and encourage others
      8. Participation in public affairs
      9. Socializing
      10. Leisure
    3. Pour mental health could create large changes and shifts that could create devastating defecates or deterioration in your QOL. Unfortunately, there are no studies out there to fully look at and identify QOL changes and areas of impact in First Responders.
  • Management and Treatment
    1. There is no one treatment that works for everyone. Each person may need to find the right fit for them. There are multiple options out there.
      1. Psychotherapy explores thoughts, feelings, and behaviors and seeks to improve an individual's well-being.
      2. Medication- does not cure mental illness, but can help with the management of symptoms.
      3. Hospitalization may be needed so one can be closely monitored, accurately diagnosed, or have medication adjustments when one mental illness worsens.
      4. Group Support-made up of peers who suffer from similar experiences. Can create growth and a feeling of not being alone.
      5. Complementary & Alternative Medicine-treatment and practices that are not associated with a standard of care.
      6. Self Help Plan-where one addresses their own condition by implementing a plan to help with wellness, recovery, triggers, or warning signs.
      7. Case Management- can help coordinate assessment, planning, and implement a strategic recovery.
  • Preventing and Managing Stress
    1. Slow, deep breaths can lower BP and HR. Can also help relieve anxiety
    2. Listen to music-classical music can be especially relaxing right before bedtime.
    3. Take a Quick Walk-This provides physical activity and time alone to gather your thoughts.
    4. Find the Sun-Bright light can improve depression and improve mood.
    5. Give yourself a Hand Massage-can calm a pounding heart due to reducing tension. The hands carry a lot of tension.
    6. Count Backward-this provides distraction and a way to focus, calming a racing mind.
    7. Stretch can relieve muscle tension.
    8. Rub your feet over a Golf ball-the feet and legs can carry a lot of tension and strain from being on your feet all day.
    9. Close your eyes-an an easy way to regain calm and focus.
    10. Stress balls-is an easy, portable, and non-violent way to relieve frustration and tension.
    11. Try progressive relaxation-by using this technique one can become calm and is a great way to help one fall asleep.
    12. Be Alone-this provides you time to collect your thoughts and clear your head.
    13. Get Organized-clutter can contribute to stress.
    14. Do some positive coping mechanisms to help reduce the overall stress and provide relaxation.
    15. Eat some Chocolate-1.4oz of chocolate has been shown to calm your nerves. Dark chocolate can regulate levels of cortisol and stabilize metabolism.
    16. Meditate-two quick five minutes of meditation a day can relieve stress and depression.
    17. Cuddle with a pet or significant other
    18. Chew gum can reduce anxiety and cortisol levels.
    19. Sip Green Tea- L-Theanine found in green tea can relieve anger
    20. Laugh- Can increase blood flow and boost immunity that can reduce stress and anxiety.
    21. Drip cold water on your wrists- applying a cool source to your wrists and behind your earlobes where major arteries lie that can help calm the whole body.
    22. Crease a Zen-Zone-this can give you a place where you can center yourself and reduce the overall stress
    23. Slurp some honey- honey contains compounds that reduce inflammation in the brain that can reduce depression and anxiety.
    24. Talk to a Friend.- sharing your feelings or venting can create a feeling of openness and overall calm.
  • Scenario
    1. Sam has been working for the past 5 years in a busy 911 system as a firefighter and transporting provider. Same has been on countless horrific calls including a pediatric arrest, multiple trauma arrests, several unsuccessful cardiac arrests, and even had to take care of a friend from high school who unfortunately did not make it.
      1. Sam over time has become distant from friends and family. Feels apathy towards patients. Is avoiding home life issues by working overtime, drinks beyond the recommended amount of caffeine while on shift, and alcohol off shift.
      2. This is your first shift working with Sam in about a year. While catching up with Sam, you start to recognize that Sam is displaying negative coping mechanisms.
        1. While going on a depressing pt, Sam takes primary. While transporting the pt to the closest appropriate facility you overhear the conversation between Sam and the pt. Sam and the pt are both talking about how difficult life is and all the bad things that have happened to both the pt and Sam. At first, you don’t think too much of it.
        2. After the pt is dropped off at the ED, on the drive back to the station, you ask Sam about the conversation. Sam explains that the home life is not good, the calls that have caused nightmares, and the overall exhaustion and lack of caring about helping the community.
        3. Sam jokingly made the comment “It is okay, I’ll be fine. Just go home and drink me unconscious. Maybe that will fix the issue.”
      3. After all of this information and the interaction between Sam and the pt along with the conversation after. It causes you to be concerned about his mental health along with feeling he is experiencing Burnout. You also are concerned that he is using negative coping mechanisms.
      4. You decide that you should talk to Sam about mental health and you concern. Sam and yourself have a good rapport and have been in some crazy stressful situations before. Sam is receptive to the conversation. As you both talk, Sam relays that there has been a few times that self-harm and suicidal thoughts have been going through their head.
        1. You relay to Sam that you want to be there to help through this difficult time. You also relay to Sam that talking to a therapist may be helpful. Sam also says that he is concerned that his drinking may be getting out of control. Sam relays that there is concern that getting into a mental health specialist is going to be difficult. You relay that therapists are definitely pretty thin right now, but that the local hospital has mental health resources. Sam asks you to take him to the local hospital after shift.
      5. Throughout the rest of the shift, you offer to take the calls and give Sam a break. Sam sees how you show empathy and compassion towards pts. Sam relays that he misses being able to do that and is not sure if he can. You relay to Sam that this mental illness can be overcome.
      6. At the end of the shift, Sam calls their partner and explains what is going on. Sam lets you take them to the hospital for evaluation. As you pull up to the hospital, Sam confides in you, that without your help the pit of depression and despair would have consumed them. You accompany Sam in to speak with intake along with speaking to the mental health evaluator. The practitioner diagnosis Sam with depression, anxiety, suicidal ideations, and PTSD. The provider suggests that Sam stay here for mental health care.
      7. Two months later you see Sam on shift. Sam relays that since going in, they have been seeing a therapist, have received alcohol abuse assistance, are using positive coping mechanisms to help reduce anxiety and depression, are no longer suicidal, and are taking an SSRI. Sam relays that the once extreme burnout, lack of empathy and compassion, along with the PTSD has diminished significantly.  Sam also relays that relationships and homelife are getting better as well.
        1. Sam asks if you want to catch up and go out for a meal to say thank you for everything you have done.
  • Opportunities for Growth
    1. NAEMT.org has resources for awareness and training opportunities.
    2. The First Resiliency Curriculum
      1. Focuses on goal setting, nutrition, exercise, sleep, relaxation, self-defeating thoughts, empathy, wins and losses, reaching out, and social support to help with coping skills and reduce stressful events.
    3. Code Green Campaign
      1. Deals with depression, substance abuse, anxiety, and suicide.
      2. Provides information and help that is available.
  • Self Assessment
    1. With mental health affecting each person in their own way, it can be difficult to say that all signs and symptoms will be the same. In reality, one person may experience all the typical symptoms, while another may only experience a few. That is why it is important to self-assess if you are experiencing these symptoms.
      1. Signs & Symptoms include
        1. Sleep or appetite changes
        2. Mood changes
        3. Withdrawal
        4. Drop-in functioning
        5. Problems thinking
        6. Increased Sensitivity
        7. Apathy
        8. Illogical thinking
        9. Nervousness
        10. Unusual behavior
    2. It is important to remember that this is only a shortlist of signs and symptoms. One or two of these alone cannot predict a mental illness but may suggest that you should seek counsel or assistance from a mental health professional.
  • Key takeaway points.
    1. Mental Health can be a difficult conversation. But understanding it better along with your own mental health is very important.
    2. Mental illness affects more people than you realize and negative mental health has consequences.
    3. Our Brains regulate our memory integration, emotional regulation, and our perception of the world around us. No two brains respond to events or store memories exactly the same.
    4. Emotions and mental illness can be caused or driven by multiple different things. EMS is an industry that we expose ourselves to a high level of high stress or emotional situations for the sake of helping others. We see a multitude of traumatic events that the general public does not.
    5. If you or someone you know is struggling with the conditions described above or other mental health issues. It is very important to seek help and take care of yourself along with others.

Content Creator: Tanner Wick
CAPCE Course Number: 21-EMTP-F3-4320
Total CE Hours: 1
Level: Basic
EMT-CE uses the NEMSES guidelines as the foundation for every course outline.