Trauma exposure and symptoms of post-traumatic stress disorder in emergency medical services personnel in Hawaii

Evaluation of Posttraumatic Stress Disorder Screening Measures of Emergency Medical Services Clinicians in Urban and Suburban New York During the Coronavirus Disease 2019 Pandemic

OBJECTIVE

The objective of this study was to assess the psychological impact of the coronavirus disease 2019 (COVID-19) pandemic on the self-reported rates of posttraumatic stress disorder (PTSD) among emergency medical services (EMS) clinicians in urban and suburban settings that were one of the primary epicenters during the first wave of the COVID-19 pandemic.

METHODS

Anonymous surveys containing the PTSD Checklist-Specific (PCL-S) were sent electronically between November 2020 and April 2021 to EMS clinicians working in 2 EMS agencies. A threshold score ≥ 36 was considered a positive screen for PTSD symptomology; a score ≥ 44 was considered a presumptive PTSD diagnosis.

RESULTS

Of the 214 surveys sent, 107 responses were returned. The total PCL-S scores suggested PTSD symptoms were present in 33% of responding EMS clinicians (95% confidence interval [CI], 24.1%-42.5%), and 25% (95% CI, 17.6%-34.7%) met the criteria for a presumptive diagnosis of PTSD. Regression revealed increasing PCL-S scores were associated with thoughts of job resignation (+3.8; 95% CI, 1.1-6.4; P = .006), whereas lower PCL-S scores were related to the degree that respondents believed emotional support was available at their institution (-3.6; 95% CI, -6.8 to -0.4; P = .03).

CONCLUSION

Sixth months after the first wave of the COVID-19 pandemic, one third of participating EMS clinicians screened positive for PTSD symptoms. Pandemic planning must address the mental health of EMS clinicians to reduce subsequent burnout and maintain a healthy workforce.

Duty-related trauma and PTSD symptoms in US urban firefighters

BACKGROUND

Little is known about the multi-dimensional nature of traumatic duty-related events encountered by firefighters in relation to their post-traumatic stress disorder (PTSD) risk.

AIMS

To describe the types of duty-related events encountered by career firefighters and explore if years in the fire service or total event load moderated the association of trauma exposure to PTSD symptoms.

METHODS

Participants included 755 career, male firefighters (19% of the department's firefighters and 76% of those who accessed the electronic anonymous survey). The Duty-Related Incident Stressors scale was used to assess exposure to 25 potentially traumatic events (event load) and self-appraisal of the stress associated with these events, grouped by type of event (indirect, direct and colleague-related). The Post-Traumatic Stress Disorder Checklist was used to assess PTSD symptoms.

RESULTS

Firefighters rated colleague-related events as the most stressful, followed by indirect and direct events. Event load (r = 0.25) and indirect, direct and colleague-related events stress (r = 0.32-0.35) were positively associated with PTSD symptoms. Results of moderation analyses indicated that event load served as a risk factor in the relation of indirect events stress to PTSD symptoms, and as a buffer in the relation of direct events stress to PTSD symptoms. Years in the fire service were not associated with PTSD symptoms nor moderated the relation of event stress to PTSD symptoms.

CONCLUSIONS

Findings underscored the importance of considering the differential effects that types of duty-related traumatic events and cumulative exposure to trauma may have on firefighters' PTSD symptoms.

Implementation and evaluation of a palliative care training unit for EMS providers

Background

The prevalence of children with life-limiting conditions (LLCs) is rising. It is characteristic for these children to require 24/7 care. In emergencies, families must decide to call the emergency medical service (EMS) or a palliative care team (PCT)-if available. For EMS teams, an emergency in a child with an LLC is a rare event. Therefore, EMS providers asked for a training unit (TU) to improve their knowledge and skills in pediatric palliative care.

Aim of the study

The questions were as follows: whether a TU is feasible, whether its integration into the EMS training program was accepted, and whether an improvement of knowledge can be achieved.

Methods

We designed and implemented a brief TU based on findings of a previous study that included 1,005 EMS providers. The topics covered were: (1) basics in palliative home care, (2) theoretical aspects, and (3) practical aspects. After participating in the TU, the participants were given a questionnaire to re-evaluate their learning gains and self-confidence in dealing with emergencies in pediatric patients with LLC.

Results

782 (77.8%) of 1,005 participants of the previous study responded to the questionnaire. The average age was 34.9 years (±10.7 years SD), and 75.3% were male. The average work experience was 11.4 years (±9.5 years SD), and 15.2% were medical doctors. We found an increase in theoretical knowledge and enhanced self-confidence in dealing with emergencies in patients with LLC (confidence: before training: 3.3 ± 2.0 SD; after training: 5.7 ± 2.1 SD; min.: 1; max.: 10; p < 0.001). The participants changed their approaches to a fictitious case report from more invasive to less invasive treatment. Most participants wanted to communicate directly with PCTs and demanded a standard operating procedure (SOP) for treating patients with LLC. We discussed a proposal for an SOP with the participants.

Conclusion

EMS providers want to be prepared for emergencies in children with LLCs. A brief TU can improve their knowledge and confidence to handle these situations adequately. This TU is the first step to improve collaboration between PCTs and EMS teams.

Inhibitory control as possible risk and/or resilience factor for the development of trauma related symptoms-a study of the Utøya terror attack survivors

PTSD symptomatology is known to be associated with executive dysfunction. Inhibitory control is a core component of executive functioning, and inhibitory skills are essential both for adequate functioning in everyday life and important in situations following trauma. The aim of the present study was to examine the relationship between trauma exposure, inhibitory control and PTSD symptomatology in adolescent survivors of the terror attack at Utøya, Norway on the 22nd of July, 2011. In this cross-sectional case-control study, 20 trauma exposed adolescents and 20 healthy controls matched in age and gender were compared on a neuropsychological test of cognitive inhibition (Color-Word Interference Test) and a self-report measure of inhibition ability (BRIEF-A). Our analyses revealed that the trauma exposed group differed significantly on the self-reported measure of inhibitory control compared to the control group, but there were no differences between groups on the objective measures of cognitive inhibition. Follow-up analyses with subgroups in the trauma exposed group based on PTSD symptomatology (PTSD + and PTSD-) and the control group revealed that the PTSD- group showed significantly better results than both the PTSD + and the control group on the measures of inhibitory control. Moreover, the follow-up analyses showed that the PTSD + group showed significantly poorer results from the other two groups on the measures of inhibitory control and self-reported inhibition. We conclude that impaired inhibitory control, measured both objectively and by self-reported questionnaire, is related to PTSD symptomatology. Findings suggest that inhibitory dysfunctions may be a vulnerability factor for the development of PTSD symptomatology in trauma exposed adolescents, and thus it seems that the ability to exhibit inhibitory control could be a possible resilience factor to prevent the development of PTSD symptoms.

Work-related posttraumatic stress disorder in paramedics in comparison to data from the general population of working age. A systematic review and meta-analysis

Objective

Paramedics are at particularly high risk for developing posttraumatic stress disorders (PTSD). Hitherto, evidence for higher prevalence rates in paramedics compared to the general population is vague. We aimed to determine and compare 12-month prevalence of PTSD in paramedics and general population from high-income countries.

Methods

We conducted systematic review processes to identify relevant studies for inclusion. For paramedics, we searched relevant databases, reference lists, and did citation tracking. Inclusion criteria were applied according to PICO. Quality of the studies was assessed using a validated methodological rating tool. Twelve-month prevalence data from all studies were pooled using random effects model. Subgroup analyses were performed to identify sources of heterogeneity.

Results

In total, we found 41 distinct samples with 17,045 paramedics, 55 samples with 311,547 individuals from non-exposed general population, 39 samples with 118,806 individuals from populations affected by natural disasters, and 22 samples with 99,222 individuals from populations affected by human-made disasters. Pooled 12-month prevalence estimates of PTSD were 20.0, 3.1, 15.6, and 12.0%, respectively. Prevalence estimates in paramedics varied with methodological quality and measurement instrument. Paramedics reporting distinct critical incidences had lower pooled prevalence than paramedics reporting indistinct types of exposure.

Conclusion

Paramedics have a pooled prevalence of PTSD that is considerably higher than rates of unexposed general population and populations affected by human-made disasters. Chronic exposure to low-threshold traumatic events during daily routine work is a risk factor for developing PTSD. Strategies to ensure long working lifetime are strongly needed.

Ambulance personnel's perceptions on their workplace well-being: A descriptive interpretative study

BACKGROUND

Ambulance personnel face numerous challenges during their working hours. Exposure to stressful situations and other factors in the outpatient emergency medical service can affect the health of ambulance personnel as well as their well-being.

OBJECTIVE

The main objective of this study was to explore the perceptions of ambulance personnel regarding their physical and mental well-being at the workplace.

METHODS

A qualitative descriptive-interpretative research design was used. Individual face-to-face and online interviews were conducted between February and April 2022. A total of 26 interviews were conducted to explore employees' perceptions regarding the impact of work on their health and well-being.

RESULTS

Ambulance personnel described in detail their perceptions of the impact of work on their physical and mental health and well-being. Three main themes emerged from our data: 1) the impact of work on the psychophysical condition of ambulance personnel; 2) the impact of work on the lifestyle of ambulance personnel; 3) the impact of work and the work environment on the lives of ambulance personnel.

CONCLUSION

Long-term work in emergency medical services affects the health and well-being of ambulance personnel. As demonstrated by this study, raising awareness on the importance of preventive and health promotion programmes, understanding employees' problems by considering their opinions, and providing relevant training are extremely important tools for preventing such problems among employees.

Prehospital emergency medicine for children receiving palliative home care in Germany-a cross-sectional, exploratory study of EMS providers

BACKGROUND

The prevalence of children with life-limiting conditions is rising, and since the amendment of the social insurance code in Germany, palliative home care teams have treated an increasing number of children. These teams provide 24/7 readiness, yet some parents still call the general emergency medical service (EMS) for various reasons. EMS is exposed to complex medical problems in rare diseases. Questions arose about the experiences of EMS and whether they felt prepared for emergencies involving children treated by a palliative care team.

METHODS

This study used a mixed methods approach to focus on the interface between palliative care and EMS. First, open interviews were conducted, and a questionnaire was developed based on the results. The variables included demographic items and individual experiences with patients. Second, a case report of a child with respiratory insufficiency was presented to assess the spontaneous treatment intentions of EMS providers. Finally, the need, relevant topics, and duration of specific training in palliative care for EMS providers were evaluated.

RESULTS

In total, 1,005 EMS providers responded to the questionnaire. The average age was 34.5 years (±10.94SD), 74.6% were male. The average work experience was 11.8 years (±9.7), 21.4% were medical doctors. Experience with a call of a life-threatening emergency involving a child was reported by 61.5% and severe psychological distress during such a call was reported by 60.4%. The equivalent distress frequency for adult patient calls was 38.3%. (p < 0.001). After review of the case report, the EMS respondents suggested invasive treatment options and rapid transport to the hospital. Most (93.7%) respondents welcomed the consideration of special training in pediatric palliative care. This training should include basic information about palliative care, an analysis of cases involving palliatively treated children, an ethical perspective, practical recommendations, and available (24/7) local contact for further guidance and support.

CONCLUSION

Emergencies in pediatric palliatively treated patients were more common than expected. EMS providers perceived the situations as stressful, and there is a need for specific training with practical aspects.

Diversity, Equity, and Inclusion in the United States Emergency Medical Services Workforce: A Scoping Review

OBJECTIVE

Emergency medical services (EMS) workforce demographics in the United States do not reflect the diversity of the population served. Despite some efforts by professional organizations to create a more representative workforce, little has changed in the last decade. This scoping review aims to summarize existing literature on the demographic composition, recruitment, retention, and workplace experience of underrepresented groups within EMS.

METHODS

Peer-reviewed studies were obtained from a search of PubMed, CINAHL, Web of Science, ProQuest Thesis and Dissertations, and non-peer-reviewed ("gray") literature from 1960 to present. Abstracts and included full-text articles were screened by two independent reviewers trained on inclusion/exclusion criteria. Studies were included if they pertained to the demographics, training, hiring, retention, promotion, compensation, or workplace experience of underrepresented groups in United States EMS by race, ethnicity, sexual orientation, or gender. Studies of non-EMS fire department activities were excluded. Disputes were resolved by two authors. A single reviewer screened the gray literature. Data extraction was performed using a standardized electronic form. Results were summarized qualitatively.

RESULTS

We identified 87 relevant full-text articles from the peer-reviewed literature and 250 items of gray literature. Primary themes emerging from peer-reviewed literature included workplace experience (n = 48), demographics (n = 12), workforce entry and exit (n = 8), education and testing (n = 7), compensation and benefits (n = 5), and leadership, mentorship, and promotion (n = 4). Most articles focused on sex/gender comparisons (65/87, 75%), followed by race/ethnicity comparisons (42/87, 48%). Few articles examined sexual orientation (3/87, 3%). One study focused on telecommunicators and three included EMS physicians. Most studies (n = 60, 69%) were published in the last decade. In the gray literature, media articles (216/250, 86%) demonstrated significant industry discourse surrounding these primary themes.

CONCLUSIONS

Existing EMS workforce research demonstrates continued underrepresentation of women and non-White personnel. Additionally, these studies raise concerns for pervasive negative workplace experiences including sexual harassment and factors that negatively affect recruitment and retention, including bias in candidate testing, a gender pay gap, and unequal promotion opportunities. Additional research is needed to elucidate recruitment and retention program efficacy, the demographic composition of EMS leadership, and the prevalence of racial harassment and discrimination in this workforce.

Analysis of Work Related Factors, Behavior, Well-Being Outcome, and Job Satisfaction of Workers of Emergency Medical Service: A Systematic Review

Background: The workloads of emergency medical service personnel (EMS) are varied. In the absence of recovery, health consequences can result. The aim of this review was to analyze the literature on the associations between psychosocial or physical work factors on one hand and the well-being outcomes and job satisfaction on the other hand. Methods: A systematic literature review examining the workloads, behavior, and well-being of EMS including emergency physicians, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement for the reporting systematic reviews, was performed. The PubMed, Ovid Medline, Cochrane Library, Scopus, Web of Science, PsycINFO, Psyndex, and Embase electronic databases were used. Results: Thirty-three studies were included. These were divided into studies that predominantly focused on the behavior (6), stress and strain (22), and well-being (5) of EMS. Only four studies also examined emergency physicians. The studies indicated a high prevalence of psychological and physical stress factors. Burnout and posttraumatic stress disorders have been the most studied consequences of mismatched stress. The health status variable performs better in conjunction with higher qualifications. Age is not a protective variable in some studies. Conclusions: EMS workloads are varied and must be assessed on an individual basis. Studies on emergency physicians are needed. Organizational and personal measures must become the focus of health promotion and prevention in the workplace.

The impact of critical incidents on nurses and midwives: A systematic review

AIMS

To synthesise the existing literature, which focuses on the impact of critical incidents on nurses and midwives, and to explore their experiences related to the support they received in the current healthcare environment to move on from the event.

DESIGN

Systematic review and qualitative synthesis.

DATA SOURCES

The electronic databases CINAHL, MEDLINE, PsycINFO, PubMed, Embase and Nursing and Allied Health (ProQuest) were systematically searched from 2013-2018, and core authors and journals identified in the literature were manually investigated.

REVIEW METHODS

Qualitative studies of all research design types written in English were included according to the PRISMA reporting guidelines. The methodological quality of included studies was evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research.

RESULTS

A total of 7,520 potential publications were identified. After removal of duplicate citations, study selection and appraisal process, 11 qualitative primary research papers progressed to the meta-synthesis by meta-aggregation. The 179 findings and sub-findings from the included studies were extracted, combined and synthesised into three statements addressing three different aspects within the context of critical incidents: the experiences of the impact, the perceptions of support and the ability to move on.

CONCLUSION

This review illuminated that moving-on after critical incidents is a complex and wearisome journey for nurses and midwives. More attention should to be drawn to second victims within general nursing and midwifery practice to strengthen their ability to navigate the aftermath of critical incidents and reclaim the professional confidence indispensable to remain in the workforce.

Post-traumatic stress disorder symptoms in healthcare workers: a ten-year systematic review

Background and aims:

Healthcare workers (HCWs) employed in hospital settings frequently experience many occupational stressors leading to post-traumatic stress disorder (PTSD) symptoms. Literature has increasingly highlighted PTSD as a major issue that involves both staff and healthcare organizations; the consequences of PTSD may include medication errors and lower standards of care. The current COVID-19 pandemic poses the need for preventing PTSD in HCWs working closely with COVID-19 patients. The purpose of this systematic review was to analyze the latest developments in assessing and managing the occupational risk of PTSD symptoms in hospital HCWs.

Methods:

We searched for publications in MEDLINE/Pubmed using selected keywords. Each article was reviewed and categorized into one or more of the following four categories based on its subject matter: risk assessment, risk management and occurrence rates.

Results:

Our search resulted in a total of 32 publications that matched our inclusion criteria. Increased years of service, older age, previous year exposure to violence, personality traits (i.e. neuroticism), history of mental disorders, being non-graduates, were found to be workers’ pre-trauma factors predicting PTSD symptoms.

Conclusions:

The findings suggest the need to prioritize preventative interventions aimed to anticipate the effects of traumatic exposure by training HCWs in evidence based anticipatory methods of coping with stressful events. With regard to the current COVID-19 pandemic, we found evidence of the need to strength social support and training targeted at psychological skills of medical staff who treated COVID-19 patients. (www.actabiomedica.it)

An Intervention Framework to Facilitate Psychological Trauma Management in High-Risk Occupations

Various psychological trauma management programs (PTMPs) are offered to assist employees who have been exposed to a traumatic event in the workplace. There is, however, limited literature available on how employees in high-risk occupations experience these programs. This study qualitatively explored the experiences of PTMPs from the perspective of employees working in three high-risk occupations. The purpose of this study was to explore the experiences of the participants in order to compile a framework that could help support and improve the productivity and wellbeing of employees affected by work-related trauma. The study used a qualitative research design based on an approach informed by interpretivism and social constructivism. A multiple-case study was used as research strategy to incorporate three sectors in South Africa, namely mining, policing, and emergency medical services. Data were gathered through semi-structured interviews and focus groups, and analyzed using thematic analysis. The findings across the three sectors showed effective strategies considered by participants to manage psychological trauma. These strategies include multiple counseling sessions, face-to-face counseling, regaining control, and receiving support. Strategies that were viewed as ineffective include inability of counselors to relate to the participants' work environments, lack of involvement, lack of supervisor support, unavailability of counseling and specialized skills, premature resuming of duties, and a single-dimension approach. Based on the findings, an intervention framework is proposed to address psychological trauma in high-risk occupations.

Risks of post-traumatic stress disorder among emergency medical technicians who responded to the 2016 Taiwan earthquake

BACKGROUND

Few studies have explored the field experiences and risk factors related to post-traumatic stress disorder (PTSD) among disaster rescue workers.

METHODS

A 6.4-magnitude earthquake struck southern Taiwan on February 6, 2016. A standardized, paper-based, self-administered survey questionnaire including demographic information, field experiences and the Post-Traumatic Stress Disorder Checklist (PCL) was conducted among emergency medical technicians (EMTs) one month after the earthquake. A multivariate regression model was used to analyze the associations between risk factors and the PCL. A two-sided p value less than 0.05 was considered statistically significant.

RESULTS

The survey response rate was 86.1% (447/519). The respondents who exceeded the cut-off points for the re-experience, avoidance, or hyperarousal domains were 11.8%, 2.7%, or 4.7%, respectively. A proportion of 12.7% of respondents met partial PTSD. The personality characteristics of anxiety (p < 0.001), perfectionism (p = 0.023) and introvert tendency (p = 0.002) were significantly correlated with partial PTSD. Emergency medical services (EMS) were significantly associated with partial PTSD than other main tasks (p < 0.001). The prevalence of partial PTSD was higher but was not significantly different in the groups of lower educational level, longer EMT careers, earlier arrival date, fewer field working hours, or managing dead people. Both univariate and multivariate logistic regression analyses showed that an anxious personality and EMS as the main task during the missions were significantly associated with PTSD risk.

CONCLUSION

Not only personality characteristics but also the task components could alter the PTSD risks in disasters. A broad realization of these risks may improve the mental outcomes of disaster rescuers.

The Relationship Between Grit and Resilience in Emergency Medical Service Personnel

Background: Emergency medical service (EMS) personnel are regularly exposed to traumatic incidents and experience higher rates of symptoms of posttraumatic stress disorder (PTSD) than the general population. Grit is a construct proposed to be associated with achievement, but it has demonstrated preliminary evidence of an association with resilience. The current study examined the relationship between grit and resilience among EMS workers. Methods: A link to an online survey was sent to East Baton Rouge Parish Emergency Medical Services personnel via an email distribution list. Demographic variables and the following self-report measures were assessed: the PTSD Checklist for DSM-5 (PCL-5), the Grit Scale, the Brief COPE scale, and the Professional Exposure to Traumatic Experiences scale (modified from the Life Events Checklist). Results: PCL-5 scores were significantly and negatively correlated with the Grit Scale score (r=-0.57, P<0.01). Hierarchical regression revealed that grit and coping mechanisms were predictive of self-reported PTSD symptoms (adjusted R²=68.7%, F(15,67)=9.81, P<0.001). Examination of the coefficients revealed that lower total Grit Scale scores and higher scores on the following Brief COPE scales were significant predictors of PCL-5 scores: denial, substance abuse, disengagement, and self-blame. Conclusion: This study examined the relationship between grit and resilience, measured by self-reported PTSD symptoms. Our results demonstrate a significant relationship between grit and resilience. Grit is related to, but distinct from, other constructs that predict resilience, such as coping mechanisms. Large prospective studies could have significant implications for hiring practices and building grit in existing personnel to bolster resilience.

Well-being and PTSD in German emergency medical services - A nationwide cross-sectional survey

Background

Emergency medical service (EMS) can be a burdensome occupational field, and employees can be confronted with traumatizing events. Posttraumatic stress disorder (PTSD) and depression rates among paramedics are considered higher than those in the general population. In the German setting of a physician-based EMS system, the literature provides little data on PTSD or non-PTSD-related mental health or on the correlation between PTSD and well-being.

Methods

The study collected data through a nationwide cross-sectional questionnaire survey of the German EMS. Next to gathering sociodemographic data, it used the 5-item World Health Organization Well-Being Index (WHO-5) and the Short Screening Scale for the DSM-IV-PTSD to assess well-being and identify indicators of depression and PTSD.

Results

A total of 2,731 paramedics and emergency physicians participated in the survey; 2,684 questionnaires were submitted to analysis. The average WHO-5 score was 53.15%. A total of 43.4% of participants screened positive for possible depression, as indicated by a WHO-5 score below 50%. Female gender, older age, higher total years spent working in EMS and increased body mass index were significantly correlated with lower well-being. A total of 5.4% of respondents had a positive PTSD screening result. In particular, older employees were significantly more likely to test positive for PTSD (12.2% of those over 50 years, compared to 2.8% of those under 30 years). Positive PTSD screening results were associated with significantly lower well-being. Over an average period of 1 year, the paramedics reported perceiving a median of 2 emergency missions as mentally distressing.

Conclusion

Low well-being and PTSD seem to be relevant experiences among German EMS despite their perception of low numbers of emergency responses as mentally distressing. Paramedics who have been diagnosed with PTSD should be investigated for depression and vice versa, as correlations in both directions exist. Special attention should be paid to older employees, who have significantly lower well-being and higher PTSD rates compared to younger employees.

Social Support Outside the Workplace, Coping Styles, and Burnout in a Cohort of EMS Providers From Minnesota

Occupational burnout has been linked to the delivery of lower quality of care in some health care professions, including with turnover intentions and absenteeism in emergency medical services (EMS) workers. Thus, studies that identify factors associated with burnout may be integral to optimizing quality and workforce engagement among EMS professionals. A survey was conducted to assess social support outside the workplace, coping styles, and occupational burnout in a cohort of EMS providers from Minnesota. Surveys were returned by 217 providers (54% response), of which 167 had provided data on burnout, social support, and coping styles and were included in the analysis. The mean age was 41 years, 62% were male, and the prevalence of burnout was 17%. After adjustment for age and EMS tenure, the odds of burnout was higher among those characterized as socially isolated as compared with providers who were integrated socially or moderately integrated (odds ratio = 3.52; 95% confidence interval = [1.13, 10.98]). Common coping responses included planning, positive reframing, and active coping, while behavioral disengagement and denial were rarely used. Lack of social networks outside the workplace and frequent use of self-blame, food, or substance use as coping strategies were associated with burnout. Conversely, social integration and use of religion and instrumental support to cope with stressors were associated with reduced burnout.

Massage Therapy in Management of Occupational Stress in Emergency Medical Services Staffs: a Randomized Controlled Trial

BACKGROUND

Results of various studies indicate that emergency medical service (EMS) staff suffer from occupational stress that adversely affects their quality of life and their care quality.

PURPOSE

This study aimed at determining the effect of massage on occupational stress experienced by emergency medical service staff.

SETTING

Prehospital emergency medical services stations of a city in the southwest of Iran.

PARTICIPANTS

A total of 58 members of staff of the emergency medical services, working in prehospital emergency medical services stations.

RESEARCH DESIGN

In this randomized controlled trial, a total of 58 EMS staff were selected from prehospital EMS stations, according to inclusion and exclusion criteria, and then assigned in two groups (29 in massage and 29 in control group) randomly by the minimization method. The intervention group received Swedish massage, twice a week for four weeks in the morning after the end of the work shift. Each massage session lasted 20-25 minutes. Subjects in the control group received no intervention. The level of occupational stress of the two groups was measured under the same conditions before and after the intervention by using the expanded nurses' occupational stress scale (ENSS). Data were analyzed with the SPSS16 software by using the chi-squared test, paired and independent-sample t tests, one-way ANCOVA. P value < .05 was considered as the level of significance.

RESULTS

The mean and SD of total occupational stress scores in the control group was 114.41±30.11 in pretest and reach to 112.58± 30.62 in posttest stage. Also the mean and SD of total occupational stress scores in the intervention group was 130.20±26.45 in pretest and reach to 110.41±21.75 in posttest stage. A one-way ANCOVA showed that there is a significant effect of massage on EMS staff's occupational stress level after controlling for pretest score (p = .001).

CONCLUSIONS

The training and the application of massage therapy can serve as an effective method in reducing occupational stress in emergency medical centers.

Emergency Medical Services Provider Perspectives on Pediatric Calls: A Qualitative Study

Objective: Previous research indicates that 9-1-1 response to incidents involving children is particularly distressing for emergency medical services (EMS) clinicians. This qualitative study was conducted to increase understanding about the difficulties of responding to pediatric calls and to obtain information about how organizations can better support EMS providers in managing potentially difficult calls. Methods: Paramedics and emergency medical technicians from a single U.S. ambulance service were invited to participate in focus groups about responding to 9-1-1 calls involving pediatric patients. A total of 17 providers from both rural and metro service regions participated in six focus groups held in community meeting spaces. A semi-structured focus group guide was used to explore (1) elements that make pediatric calls difficult, (2) pre-arrival preparation practices, (3) experiences with coping after difficult pediatric calls, and (4) perspectives about offered and desired resources or support. Focus groups were audio recorded and transcripts were analyzed using standard coding, memoing, and content analysis methods in qualitative analysis software (NVivo). Results: Responses about elements that make pediatric calls difficult were organized into the following themes: (1) special social value of children, (2) clinical difficulties with pediatric patients, (3) added acuity to already challenging calls, (4) caregivers as secondary patient, and (5) identifying with patient or patient's family. Pre-arrival preparation methods included mental or verbal review of hypothetical scenarios and refocusing nerves or emotions back to the technical aspect of the job. Participants described using available resources that largely took the form of social support. Suggestions for additional resources included: increased opportunities for external feedback; more frequent pediatric clinical training; institutionalization of recovery time after difficult calls; and improved storage and labeling of pediatric equipment. Conclusions: This study provides qualitative data about the difficulties of responding to pediatric calls and resources needed to support clinicians. Findings from this study can be used to guide EMS leaders in designing and implementing institutional initiatives to enhance training and support for prehospital clinicians providing care to children.

Burnout and Exposure to Critical Incidents in a Cohort of Emergency Medical Services Workers from Minnesota

Introduction

Very little quantitative data on occupational burnout and exposure to critical incidents are available from contemporary United States emergency medical services (EMS) cohorts. Given that burnout has been associated positively with turnover intentions and absenteeism in EMS workers, studies that uncover correlates of burnout may be integral to combating growing concerns around retention in the profession.

Methods

We administered a 167-item electronic survey that included the Maslach Burnout Inventory (MBI) and a modified version of the Critical Incident History Questionnaire (n=29 incident types) to paramedics, emergency medical technicians (EMTs), and dispatchers of a single ambulance service. We defined the presence of burnout as a high score on either the emotional exhaustion or depersonalization subscales of the MBI.

Results

Survey respondents who provided regular 911 response at the time of the survey and completed the MBI portion of the survey were included in our analysis (190 paramedics/EMTs, 19 dispatchers; 54% response). The overall prevalence of burnout was 18%, with prevalence reaching 32% among dispatchers. The seven pediatric critical incident types presented in the survey accounted for seven of the top eight rated most difficult to cope with, and severity ratings for pediatric critical incidents did not differ by parental status (all p>0.30). A significant number of respondents reported that they had been threatened with a gun/weapon (43%) or assaulted by a patient (68%) at least once while on duty. Being over the age of 50, a parent, or in a committed relationship was associated with reduced odds of burnout in unadjusted models; however, these associations did not remain statistically significant in multivariate analysis. Increasing tertile of career exposure to critical incidents was not associated with burnout.

Conclusion

Medical dispatchers may be an EMS subgroup particularly susceptible to burnout. These data also demonstrate quantitatively that in this EMS agency, responders find pediatric critical incidents especially distressing and that violence against responders is commonplace. In this study, a simple measure of career exposure to potentially critical incidents was not associated with burnout; however, individual reactions to incidents are heterogeneous, and assessment tools that more accurately enumerate encounters that result in distress are needed.

Post-traumatic stress disorder and its predictors in emergency medical service personnel: a cross-sectional study from Karachi, Pakistan

BACKGROUND

Emergency medical service (EMS) personnel who work to provide emergency medical care at the scene and during transportation are exposed to various kinds of stressors and are particularly susceptible to developing stress-reactions. This study assesses symptoms of post-traumatic stress disorder and its predictors among the personnel of a selected EMS in Karachi, Pakistan.

METHODS

Data were gathered from 518 personnel working in an EMS setting from February to May 2014. Participants were screened for post-traumatic stress symptoms using the Impact of Event Scale-Revised (IES-R). Demographic and work-related characteristics, coping styles and the social support systems of the participants were assessed. Linear regression was used on the IES-R to identify predictors of post-traumatic stress symptoms.

RESULTS

The mean score of the IES-R was 23.9 ± 12.1. EMS personnel with a dysfunctional coping style (β = 0.67 CI 0.39 - 0.95), anxiety, and depression (β = 0.64 CI 0.52 - 0.75) were more likely to have increased severity of post-traumatic stress symptoms. Age was found to have an inverse relationship with stress symptoms (β = -0.17 CI 0.33 - -0.023), indicating the susceptibility of younger EMS personnel to stress.

CONCLUSION

The EMS personnel in this setting were found to have a moderate level of post-traumatic stress symptoms. The significant predictors of post-traumatic stress symptoms in this EMS population were age, coping style, and levels of anxiety and depression. These predicting factors can be a potential avenue for interventions to improve the mental health of these frontline workers.

Association of post-traumatic stress disorder and work performance: A survey from an emergency medical service, Karachi, Pakistan

BACKGROUND

The purpose of the study was to explore the association between post-traumatic stress disorder (PTSD) and work performance of emergency medical services personnel in Karachi, Pakistan.

METHODS

Emergency medical service personnel were screened for potential PTSD using Impact of Event Scale-Revised (IES-R). Work performance was assessed on the basis of five variables: number of late arrivals to work, number of days absent, number of days sick, adherence to protocol, and patient satisfaction over a period of 3 months. In order to model outcomes like the number of late arrivals to work, days absent and days late, negative binomial regression was applied, whereas logistic regression was applied for adherence to protocol and linear for patient satisfaction scores.

RESULTS

Mean scores of PTSD were 24.0±12.2. No association was found between PTSD and work performance measures: number of late arrivals to work (RRadj 0.99; 0.98-1.00), days absent (RRadj 0.98; 0.96-0.99), days sick (RRadj 0.99; 0.98-1.00), adherence to protocol (ORadj 1.01; 0.99-1.04) and patient satisfaction (β 0.001%-0.03%) after adjusting for years of formal schooling, living status, coping mechanism, social support, working hours, years of experience and anxiety or depression.

CONCLUSION

No statistically significant association was found between PTSD and work performance amongst EMS personnel in Karachi, Pakistan.

Predictors of posttraumatic stress and preferred sources of social support among Canadian paramedics

OBJECTIVE

Emergency medical service (EMS) providers are exposed to a variety of stressors endemic to the profession. These exposures may contribute to stress reactions, including posttraumatic stress. The objective of this study was to evaluate the relationship between work-related stressors and posttraumatic stress. The secondary objective was to determine paramedics' preferred sources of support for managing work-related stress.

METHODS

269 paramedics in a county-based EMS service were invited to complete an online survey. Respondents reported their demographic characteristics, levels of chronic stress, critical incident stress, posttraumatic stress symptomatology (PTSS), and preferred sources of support for managing work-related stress.

RESULTS

A total of 145 paramedics completed the survey. PTSS was significantly correlated with operational stress (p<0.001), organizational stress (p<0.001), and critical incident stress (p<0.001). Regression models revealed that chronic operational stress was a significant independent predictor of PTSS (p<0.001) and in combination with critical incident stress (p<0.01). Paramedics reported a higher preference for receiving support from a work partner, friend, or family member than from other sources (p<0.001).

CONCLUSION

Both chronic and critical incident stressors appear to be significant predictors of PTSS. Our findings suggests that holistic health and wellness initiatives that address the impact of both critical incident stress and the chronic stressors associated with day-to-day operations may help mitigate PTSS. Our findings also provide preliminary evidence that interventions may benefit from a focus on peer support and on friends and family members who can support the affected paramedic.

World Trade Center-related physical and mental health burden among New York City Fire Department emergency medical service workers

OBJECTIVES

To describe the health burden among Fire Department of the City of New York (FDNY) emergency medical service (EMS) workers and examine its association with work at the World Trade Center (WTC) disaster site.

METHODS

In this observational cohort study, we used FDNY physician diagnoses to estimate the cumulative incidence of physical health conditions including rhinosinusitis, gastroesophageal reflux disease (GERD), obstructive airways disease (OAD) and cancer among EMS workers and demographically similar firefighters who were active on 11 September 2001 (9/11). Validated screening instruments were used to estimate the prevalence of probable post-traumatic stress disorder (PTSD), probable depression and probable harmful alcohol use. We also analysed the association between health conditions and WTC-exposure.

RESULTS

Among 2281 EMS workers, the 12-year post-9/11 cumulative incidence (11 September 2001 to 31 December 2013) of rhinosinusitis was 10.6%; GERD 12.1%; OAD 11.8%; cancer 3.1%. The prevalence of probable PTSD up to 12 years after exposure was 7%; probable depression 16.7%; and probable harmful alcohol use 3%. Compared with unexposed, EMS workers who arrived earliest at the site had higher adjusted relative risks (aRR) for most conditions, including rhinosinusitis (aRR=3.7; 95% CI 2.2 to 6.0); GERD (aRR=3.8; 95% CI 2.4 to 6.1); OAD (aRR=2.4: 95% CI 1.7 to 3.6); probable PTSD (aRR=7.0; 95% CI 3.6 to 13.5); and, probable depression (aRR=2.3; 95% CI 1.6 to 3.1).

CONCLUSIONS

In this 12-year study, we documented a high burden of health conditions associated with WTC-exposure among FDNY EMS workers. These findings underscore the importance of continued monitoring and treatment of this workforce.

Current state of knowledge of post-traumatic stress, sleeping problems, obesity and cardiovascular disease in paramedics

PURPOSE

The impacts of emergency work on firefighters have been well documented and summarised, but this is not the case for paramedics. This paper explores the literature regarding the impact of work stress on paramedics.

OBJECTIVE

To identify the literature available on the effect of paramedics' jobs on their health status.

METHODS

Electronic database used: MEDLINE (Ovid, PubMed, National Library of Medicine) between 2000 and 2011. Key words used for the computer searches were: paramedics, emergency responders, emergency workers, shift workers, post-traumatic symptoms, obesity, stress, heart rate variability, physiological response, blood pressure, cardiovascular and cortisol. Exclusion criteria were: studies in which participants were not paramedics, participants without occupational exposure, physical fitness assessment in paramedics and epidemiological reports regarding death at work.

RESULTS

The electronic databases cited 42 articles, of which we excluded 17; thus, 25 articles are included in this review. It seems clear that paramedics accumulate a set of risk factors, including acute and chronic stress, which may lead to development of cardiovascular diseases. Post-traumatic disorders, sleeping disorders and obesity are prevalent among emergency workers. Moreover, their employers use no inquiry or control methods to monitor their health status and cardiorespiratory fitness.

CONCLUSIONS

More studies are needed to characterise paramedics' behaviour at work. These studies could allow the development of targeted strategies to prevent health problems reported in paramedics.

Psychiatric Morbidity and Work and Social Adjustment Among Earthquake Survivors Extricated from under the Rubble

OBJECTIVES

This cross-sectional study examined psychiatric co-morbidity and work and social adjustment after a natural disaster among survivors who were extricated from under the rubble.

MATERIALS AND METHODS

Individuals (N=40) belonging to district Muzaffarabad, a severely earthquake affected area on 8(th) October 2005, were interviewed. The examination included the MINI International Neuropsychiatric Interview for DSM-IV Axis I disorders, Work and Social Adjustment Scale, and questions covering background characteristics and disaster exposure.

RESULTS

The most prevalent disorders were posttaumatic stress disorder (32.5%), major depressive disorder (17.5%), dysthymia (15.0%), agoraphobia (25.0%), and panic disorder (20.0%). Moreover, 77% of the respondents have been diagnosed with at least one psychiatric disorder. Work and soical adjustment was found to have an inverse relationship with the psychiatric co-morbidity.

CONCLUSION

Small sample size and lack of comparison group from non-earthquake struck areas may limit the generalizability of the psychatric disorders. Psychiatric disorders other than PTSD, especially depressive and anxiety disorders, are of clinical importance when considering long-term mental health effect of disasters.

Work-related stress and posttraumatic stress in emergency medical services

INTRODUCTION

Recent research efforts in emergency medical services (EMS) has identified variability in the ability of EMS personnel to recognize their level of stress-related impairment. Developing a better understanding of how workplace stress may affect EMS personnel is a key step in the process of increasing awareness of the impact of work-related stress and stress-related impairment.

OBJECTIVE

This paper demonstrates that for those in EMS, exposure to several types of workplace stressors is linked to stress reactions. Stress reactions such as posttraumatic stress symptomatology (PTSS) have the potential to negatively influence the health of EMS providers. This research demonstrates that two different types of work-related stress and alcohol use influence the development of PTSS.

METHODS

A probability sample of nationally registered emergency medical technician (EMT)-Basics and EMT-Paramedics (n = 1,633) completed an Internet-based survey. Respondents reported their levels of operational and organizational types of chronic stress, critical incident stress, alcohol use, and PTSS.

RESULTS

Ordinary least squares regression illustrated that when demographic factors were controlled, organizational and operational forms of chronic stress, critical incident stress, and alcohol use were all significant predictors of PTSS (p < 0.01). Inclusion of an interaction effect between operational stress and critical incident stress (p < 0.01) as well as between operational stress and alcohol use (p < 0.01) created a robust final model with an R(2) of 0.343.

CONCLUSION

These findings indicate that exposure to both chronic and critical incident stressors increases the risk of EMS providers' developing a posttraumatic stress reaction. Higher levels of chronic stress, critical incident stress, and alcohol use significantly related to an increased level of PTSS. Further, for those reporting high levels of alcohol use or critical incident stress, interactions with high levels of chronic operational stress were associated with higher rates of PTSS. For those interested in the impact of work-related stress in EMS, these findings indicate that attention must be paid to levels of stress associated with both critical incident exposure as well as the chronic stress providers experience on a day-to-day basis.