EMS providers deserve better mental health education

Protecting first responders from psychological stress begins in the classroom


By Nancy Magee

I recently taught a two-day EMR recertification class for a group of government employees who work as park rangers and game wardens. Many also have years of experience as wildland firefighters or in law enforcement.

They told me that they really enjoyed their initial boot camp-style class, but rarely used the skills, and confessed to not remembering much else, especially “all the numbers.” Each of the class members brought the fully stocked gear bag they carry on-duty, and a genuine concern about not knowing exactly what some of the products in the bags were for, or if they would remember during an emergency when and how to use the ones that did look familiar.

There is little or no warning about how often EMS providers will become a default grief sponge for those left behind and even less direction is given about how to cope with the toll that repeated exposure to bad outcomes, intense grief, guilt, fear and anger will eventually have on them. (Photo/Getty Images)
There is little or no warning about how often EMS providers will become a default grief sponge for those left behind and even less direction is given about how to cope with the toll that repeated exposure to bad outcomes, intense grief, guilt, fear and anger will eventually have on them. (Photo/Getty Images)

Challenges of rural responders

In Louisiana, the scope of practice for an EMR is almost identical to a National Registry certified EMT. These rural first responders are often tasked with the care of seriously ill and injured victims for extensive periods of time before ALS by ground or air ambulance arrives on scene. Our second day of class began with special populations and patient advocacy, and the importance of understanding the need for both awareness and compassion when considering how isolation, lack of access to basic healthcare, and especially mental health resources affect rural patients.

This touched off a discussion about the rising rate of suicide in the general population, and statistics related to suicide, post-traumatic stress disorder and depression among law enforcement, firefighters, EMS and military veterans. Almost everyone had a story about a friend or colleague lost to the demons, and I became increasingly concerned when it struck me that more than a few of the class participants fit into all four categories.

Mental health education should be proactive

I provided contact information for mental health programs, resources available specific to our professions, and some research designed to help identify people at risk. An older man raised his hand. Before he asked his question, he leaned back in his chair and crossed his arms. He had a striking resemblance to actor Tommy Lee Jones and spoke in the same kind of deliberate, thoughtful drawl.

“Ma’am, I think it’s great that there are all these new groups and hotlines and all for people in public safety who might be messed up, or even thinkin’ of takin their own life.

What I don’t understand is why y’all don’t teach us how to not get broken in the first place. Seems like that would make a lot more sense.”

“Not enough time” is not an acceptable answer

I was stunned – and he was right. Why is this critical information taught reactively at conferences and in continuing education sessions, instead of proactively during initial education?

As educators, are we so busy filling our student’s heads with numbers and acronyms, anatomy and obscure pathophysiology “zebras” that we forget their vulnerability to the aftermath of human tragedy? How many instructors still teach students that they must put their feelings in a box and subvert their humanity to do this job well? Or that saltiness and dark humor are somehow effective coping mechanisms?

Are we sowing seeds of self-doubt?

I asked the class to share what it is about their EMS experience that kept them up at night.

“I’ve been a cop for 25 years. I’m good at it. I’ve seen a lot of nasty things, but I always know what is expected of me, and I know I do a good job. This is different. I’m not sure if I’m doing enough or doing things right.”

A common thread in their stories was response to hunting accidents – accidental gunshot wounds, falls from tree stands, crush injuries from 4-wheeler accidents. In almost every instance that bothered them, the patient was still breathing or had a pulse when the rangers arrived. And they still died.

“What else should I have done? I thought we learned this stuff to save people. What do I say when a 14-year-old kid is lying in a pool of blood and his daddy is crying and shouting at me to “Do something man, help him, he’s still breathing!”?

Patients die

Accidents happen, and people die from their injuries. But we don’t talk much about that in a 48-hour EMR class. Additionally, in our EMT class scenarios, the only patients who die do so because the student did something wrong. In four hours of AHA CPR video instruction, we don’t learn if the man who collapsed at the airport survives or if the choking baby who arrested recovers. And there is virtually no reference to CPR in traumatic arrests.

The unspoken message to our students is, “If you do this exactly right, you will save lives; if you don’t, people will die.”

Practice real-life scenarios – not zebras

The rest of the day’s lesson plan went out the window; reading assignments would replace the rest of the day’s lectures. Instead, reassurance and confidence building became the priority. For the next several hours, we worked through scenarios; scene size-up, rapid assessment, treatment of life threats, airway management and treatment for shock. Recognizing when injuries are incompatible with life. Understanding what is achievable, and what is not, and accepting those limitations. Role-playing the transition from rescuer to grief counselor.

Students are ill-prepared for EMS realities

“A subtle but important difference distinguishes mentors and teachers. A teacher has greater knowledge than a student; a mentor has greater perspective.”Paula Marantz Cohen, dean of the Pennoni Honors College and distinguished professor of English at Drexel University

EMS initial education often allows new providers to enter the field with unrealistic expectations. There is little or no warning about how often they will become a default grief sponge for those left behind. And even less direction is given about how to cope with the toll that repeated exposure to bad outcomes, intense grief, guilt, fear and anger will eventually have on them.

We pride ourselves on successfully getting students through their testing – and then we forget them. But what if we are subliminally planting seeds of self-doubt? Are we as teachers potentially complicit in the emotional and psychological damage our students may suffer later?

This is the question that keeps me awake at night.

[Read next: Use the RESPOND method to assess EMS provider PTSD]

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