Responding to first-responders

Most of us rarely dial 911. We’re seldom on the scene of a critical accident or sudden illness. But for paramedics, such abnormal events are part of a normal day’s work.

Yet, when every day is physically and mentally demanding, the work can take a heavy toll. Over time, stress can undermine a worker’s ability to cope.

Every call, too, brings physical risks, from back injuries to blood contamination. Today, however, new equipment, innovative training and, most of all, new attitudes are helping reduce some of the health hazards of paramedicine.

Dwayne Forsman, secretary of the Paramedic Association of Canada, says paramedics suffer from a variety of physical injury. Shoulder and knee damage is common, but the most prevalent is back injuries.

“There is a very high incidence of lower back injuries among paramedics, and those can quickly be career-ending,” he says.

The prime cause of musculoskeletal injuries (MSI), he explains, is lifting. Patients are often in hard-to-reach locations — trapped in a car, for example, or wedged between a wall and bed — and paramedics have to put themselves in awkward positions to lift them.

As people have become heavier, too, lifting patients has grown more physically hazardous, Forsman adds. In fact, special equipment, such as larger stretchers and ambulances fitted with lifts or winches, are now being used in some areas.

In addition to lifting patients, paramedics also carry an enormous amount of equipment, including defibrillators, oxygen tanks, suction devices, cots and jump kits (medical supply bags). Over time, these weights can lead to debilitating MSI and joint problems.

Bronwyn Barter, president of Ambulance Paramedics of B.C. and chief paramedic, says paramedics also have to deal with violence in the workplace. A 2011 study by a St. Michael’s Hospital researcher found two-thirds of 1,381 paramedics in Ontario and Nova Scotia reported they had been verbally, physically or sexually abused on the job within the previous year.

Exposure to blood and needle sticks can also result in injury, she says. “If a patient needs a drug, they may struggle. And in that struggle, or if they react to the needle prick, they may move and it can fire back and poke us.”

“We work in uncontrolled environments,” she explains. “It’s not a pristine hospital setting, and patients aren’t always lying still and co-operative. We may be dealing with someone in a dark alley.”

Mental health risks
Paramedics also face serious mental health issues, most stemming from the stress of dealing with traumatic events every day, says Steven Mills, primary care paramedic program manager at the Justice Institute of British Columbia (JIBC). Most workers will have difficulty with some calls — such as those involving children who have been injured, abused or killed.

However, he adds, specific circumstances of a call can also provoke an unexpected stressful reaction in a paramedic. For example, a call might trigger a painful memory, such as a death of a childhood friend or the memory of a traumatic call earlier in the person’s career.

People need time to recover from a stress response, Mills says, but paramedics rarely have time, and sleep deprivation caused by shift work makes coping more difficult.

“You finish the call, the hot phone rings, and you do another call. And so you keep going. You move from call to call with little downtime, little time to reflect or compose yourself,” he says.

“That’s the big struggle. And when you’re sleep deprived, it’s very difficult to manage your emotions, to be mindful of your mental state.”

The effects of stress, Mills says, have been aggravated by a professional culture that discouraged any discussion of feelings. When he started, he says, the attitude was, “This is what you’re going to see. Just get used to it.”

Suppressing feelings, however, has caused many paramedics to develop cumulative critical incident stress, which can evolve into post-traumatic stress disorder (PTSD). They may face such problems as difficulties in personal relationships and alcohol and drug abuse. Moreover, he adds, it can aggravate mental health issues.

“If one already has depressive tendencies, then the build-up of critical incident stress makes that worse. The shelf-life of one’s coping strategies wears out earlier,” he says.

While they have fewer calls, rural paramedics face other pressures, most caused by lack of anonymity. Their patients are their neighbours, friends and acquaintances, and they see them at their most vulnerable, going into their homes, bedrooms and bathrooms.

“As the paramedic, you’re exposed to the inner life of this family, who you may or may not have known anything about. You may be there for a cardiac arrest, or because a child is hurt, because it has been abused and nobody knew,” he says.

In remote areas, too, Barter says, severe weather makes driving more hazardous and increases the chance of falling and slipping with the clot. As well, paramedics in rural areas have far fewer resources than their urban counterparts.

“They may have to do a job that in metropolitan B.C. would have 20 kinds of specialists. They’re basically a one- or two-man show,” she says.

Ergonomic challenges
In recent years, Forsman says, the number of injuries among paramedics has risen, a result of an aging population and consequent increase in call volume. Every worker should be trained in proper lifting techniques, and the introduction of advanced equipment, designed to reduce repetitive lifts, will also reduce injuries.

In April, for example, Manitoba introduced, on a one-year trial basis, new power-loading stretchers in some Winnipeg ambulances. The stretcher lifts the patient, and the ambulance then lifts the stretcher into the ambulance, reducing lifting, lowering and bending.

Michelle Gawronsky, president of the Manitoba Government and General Employees’ Union, says the devices should make an immense difference, significantly reducing back pain. The former paramedic suffered one shattered and two cracked vertebrae — the cumulative effect of 33 years on the job. She required surgery when the shattered vertebra cut into her spinal cord.

“If they had had these [stretchers] 10 years ago, I would still be a paramedic,” she says. “I think they’ll be life-saving for a lot of paramedics. They’ll be able to go home, pick up their kids and not feel any pain.”

New equipment is often better designed ergonomically, says Barter. For example, she and her colleagues are using new jump kits — typically slung over one shoulder — that allow them to spread the heavy weight across their backs.

Barter says the key to managing critical incident stress is to be proactive. In B.C., they have set up an internal peer team that helps colleagues having trouble coping as soon as they return from the call.

But fatigue and lack of downtime are still major obstacles to improved psychological wellbeing, she says. With no scheduled breaks and some paramedics doing 15 calls a night, Ambulance Paramedics of B.C is calling for a reduction in call volume and increased downtime.

“We need more resources for metropolitan B.C. so they can do one call at a time — not have the next two lined up in the back of their heads — and so they have adequate rest time,” she says.

Today, there is a drive to change the professional culture of paramedics, JIBC’s Mills says. During training, students are learning how important their physical and emotional wellbeing is to their ability to avoid injury and cope with stressors.

“There’s a lot more awareness among paramedics that one of the best ways to manage stress is to eat well, to be physically fit, to sleep well and to have good support systems,” he says.

Students also learn the signs of critical incident stress, coping strategies and where to look for help. At JIBC, he adds, they are increasing their emphasis on resiliency.

“We’re teaching students how to change the way they live their lives to become more mindful, to be generous with themselves and to connect with people, instead of withdrawing from people,” he says.

“We’re looking to make a cultural change across the profession, so there isn’t as much suffering as there has been in the past.”