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Decision making and mental health in EMS

Recognizing three common patient care decisions that contribute to cumulative stress in EMS providers

By Lindsey Stein, MS, NRP, FP-C

As EMTs and paramedics, we’re intimately familiar with the prevalence of PTSD among first responders. We’re called to tragedies that can be visually disturbing, emotionally distressing and that require immediate compartmentalization in order to get the job done.

More and more, we’re discovering the effects of cumulative PTSD: symptoms of PTSD that arise from continuous exposure to stressful situations rather than from one traumatic event. Repeated exposure to death, trauma and emotionally charged calls can all contribute to this stress, but what effect does our daily responsibility to make the right decisions at the right times have on our mental health?

Every job requires decision-making, but in EMS, that requirement is unique. We must make decisions about resources, treatment, priority and transport that all have the potential to affect whether someone lives, dies or has a permanent disability. These decisions are “just part of the job,” but over time, the constant responsibility and subsequent consequences can begin to weigh on our minds.

Here are three decisions that EMTs and paramedics make daily:

  1. What’s killing (or not killing) our patient. Sometimes, this isn’t as clear-cut as we would hope. CHF that’s progressed to cardiogenic shock and ARDS can look identical during primary assessment. Anxiety attacks and pulmonary embolisms have a matching list of early signs and symptoms. Atypical MIs in women, the elderly and diabetics often don’t look like MIs at all. A thorough assessment, detailed history and erring on the side of caution all inform our decisions about these patients, but determining what’s wrong with a critical patient quickly and with limited information is a sometimes challenging necessity.
  2. The best course of action. Protocols and algorithms exist as guidelines for treatment, but not every patient fits perfectly into a protocol, and not every treatment is appropriate for every patient. Understanding the pathophysiology of disease processes and trauma, as well as the pharmacology behind the drugs we use, adds a complex level to our assessments and treatments. Consider a trauma patient who has a herniating head injury but is also in hypovolemic shock: should you increase their pressure to perfuse their brain and bleed them out faster, or keep their blood pressure low to slow the hemorrhage but starve the brain? What are the best medications for a respiratory patient who also has a sick heart? Do you fly the trauma patient who is likely “just drunk?” Not every decision is a big one, and rarely is there one right answer, but they all play a role in patient outcomes.
  3. What to do differently next time. For many, this is the most stressful part of the job. When we take pride in our work, we’re constantly looking for ways to improve, but this process can manifest in a critical, self-deprecating way. Even when we have the utmost confidence in our training, our knowledge and our skills, the personal after-action review can take its toll, especially under circumstances where we’re left wondering if different actions could have resulted in a better outcome.

EMS providers are charged with the weighty task of immediately identifying and addressing life threats, developing a differential diagnosis and carrying out treatment based on our findings. Sometimes it’s easy, and sometimes it’s not. We’ve all seen patients (both trauma and medical) who present in complex, vague and contradicting ways that make forming a general impression and differential diagnosis difficult.

We have our knowledge, our physical assessments and an increasing number of assessment tools to inform our treatment decisions and justify why we did or did not do something, but that doesn’t mean we’re always right. While often, we did everything exactly as we should have on the call, how many times do we find out that our general impression was off? How often do we never find out at all?

Recognizing the symptoms of PTSD

Our jobs revolve around making decisions that may impact whether or not a patient lives or what type of long-term outcome they’ll have, and we sometimes evaluate our own self-worth as a provider based on how right our decisions were. Re-evaluation and reflection after any call is an unavoidable and necessary process because it gives us a chance to improve and understand what can be done better next time. But it’s also exhausting and, for some of us, a deeply personal and critical process. Our career involves making life-altering decisions with limited information under time constraints and extreme stress. Finding healthy ways to cope with the effects that has on us over time – and recognizing that is has effects at all – should become a priority.

Symptoms of PTSD from a single event or long-term exposure are similar:

  • Sleeplessness.
  • Nightmares.
  • Difficulty managing emotions.
  • Uncharacteristic temper.
  • Irritability.
  • Substance abuse and addiction.
  • Flashbacks.
  • Depression.
  • Difficulty concentrating.
  • Suicidal thoughts and actions.

If you or someone you know needs help, visit the Code Green Campaign for a list of crisis resources.

About the author

Lindsey works full-time as a paramedic for Culpeper County, Va. and is a long-time volunteer with the Harrisonburg Rescue Squad. She works part-time as a paramedic instructor and EMS educator for Associates in Emergency Care and for Rockingham County Fire and Rescue. Lindsey is a graduate of James Madison University in Virginia and recently received her Master’s in Emergency Management from Jacksonville State University in Alabama.