Looking Over The Edge: Moral Injury in EMS
We have entered the second year. COVID-19 has continued to slash through the population. Aided by a perfect storm of factors, we seem to be no further ahead in moving past this pandemic. Just like in a prolonged conflict, each victory is temporary; with setbacks occurring almost every time we turn on the news.
When I think of what’s happened since last January, I find myself using war metaphors, because it’s easier for me to sort it out in my head. I grew up listening to stories my elders told me about the Second World War. My grandfather losing his helmet under fire on the Remagen Bridge. My Uncle Hank losing his arm in the Pacific and overcoming it. My father, holding his draft card and waiting for his draft number to come up, to see if he would go to Vietnam.
Dad didn’t go. His number was 359. But I remember on a rare trip with him to Washington DC, and seeing him at The Wall fervently looking for the names of people he knew who didn’t return.
He didn’t tell me much more about it.
My grandmother, not to be outdone, would tell me about what it was like being at home. Your husband leaves one day on a boat; and doesn’t return for three years.
No video chat. No cell phones. Maybe a letter. And then, if you’re really lucky; they show up on the front porch when you get home from work.
No one is shooting at us. But the randomness of you, your partner, or a co-worker getting sick from COVID is no less dangerous than a piece of shrapnel. The failings of those in charge; who should have had our best interests first, are no less damaging than an incompetent or egotistic commander who puts their own glory ahead of their troops. And the uncertainty of what will follow once time passes and this is actually over won’t be any different than our grandparents.
And us? The “frontline heroes”?
The calls don’t stop. The second wave is different here, more younger people. They’re sicker, and we have very limited interventions to help. Some we know have little chance of survival; but we still have to treat and transport them.
We tell them they’ll be OK. Even when they won’t.
We remind them to take their phone and a charger, so they can still talk to their family. Hopefully.
Talbot and Dean define the term “moral injury” as, “perpetrating, failing to prevent, bearing witness, or learning about acts that transgress our moral beliefs and expectations”.
They were talking about combat veterans, of course; but there is a parallel to what we as clinicians are going through right now.
As Talbot and Dean state in their article; our moral injury is from not being able to provide high-quality care. It comes from frustration with the factors we deal with daily, the challenges we are constantly tasked with, and the realization that what we do may not be enough.
Our profession doesn’t help. EMS has modified very little since we started this. For the most part, we handle 911 calls the same way, our policies are the same, and our working conditions are the same.
But everything is different.
Our leaders think that if they just “thank us for our service”, maybe hang a couple “hero” signs, that we’ll soldier on and get the job done. They think this is just a phase, and that this will pass.
But it’s not going to work.
We need to acknowledge the ten thousand ton tiger in the room; that none of us will be the same after this. We need to understand the fact that we’re just not going to be able to do the job the same way now as before, and be able to keep our clinicians functional.
The stats are starting to show, and it’s a matter of time before we start seeing the effects.
Almost 70% of EMS providers in one study say they don’t get enough time to recover from a traumatic event.
Another study reports that female EMS clinicians have higher rates of substance abuse almost three times the general population. It’s not a stretch to think that male clinicians aren’t at higher risk as well. Overall, levels of alcohol use are skyrocketing during the pandemic, as locked down people try to cope with the reality of living right now. We are no different.
Clinicians are stressed out from the fear of getting sick from a patient, the rapid changes in our work environment, seeing and hearing of colleagues and friends who get sick or test positive, and watching a hell of a lot more people dying in front of them on a daily basis. Add in the fact that the majority of EMS clinicians work multiple jobs and/or overtime shifts regularly, and you have a toxic combination of factors that is ominous.
I know at least two colleagues who left EMS in the last year because of the stress from COVID. A couple who got flat out fired, and didn’t seem to care. I know of at least two more who are wrestling with the idea of getting out, either because of the pandemic or because they just don’t want to do the job anymore.
How many more are there? And what happens then?
I doubt we’re replacing clinicians at the rate we’re losing them. Add in substance abuse and underreported mental illness; and we’re looking at a future staffing crisis.
The result of which will be the absolute opposite of what we need. The survivors will be tasked with more shifts, more overruns, more calls. More sick and dying people.
And less time to recover from it.
Lather, rinse, repeat.
We’re not an army. We can’t draft enough people into EMS to overcome our losses. But, we need to worry that we won’t attract people into the profession in the current state. When you can make more money in less draining jobs; people will pick those jobs.
What needs to happen? Plainly, EMS needs to realize the precarious situation it is in. Start by valuing the job their clinicians do, and the health and welfare of those people. The time of looking at your employees as replaceable “cannon fodder” is over. Guess what, suits? Soon you won’t have an endless supply of rubes to con with promises of heroic stuff, lights and sirens, and saving lives. And then you’re over a barrel.
We need to educate students and trainees about the real role of our job; that we will have rare opportunities to truly save lives, but that we will always be there to help people. For every “rock and roll” hot call, there will be 10 where you simply hold someone’s hand or listen to their story. For every tourniquet you’ll use, there will be 100 warm blankets.
EMS needs to embrace staffing and reducing call volume on crews. Yes, I know that’s not profitable. None of this industry is, and this is what you’ve been saying to us for years. Calls per shift are increasing and expecting your people to continue that forever is madness. It should be the exception; but it’s more the rule for too many units. Our current model values bare minimums, and that’s part of what got us into this mess.
We need to realize that not every 911 call for EMS needs an ambulance or a paramedic. Our dispatch guidelines need to stop utilizing algorithms and embrace actual call screening by clinicians who can figure out the best resources to send for the right reasons. The “You call, we haul” mentality needs to be drowned in a bucket. EMS Dispatch needs to change its mission to getting the right resources to the patient.
Let’s realize that System Status Management will not work for the majority of agencies, save a small amount of agencies that fit very narrow parameters and placing two clinicians in an ambulance and sitting them on a street corner for 12 hours is abusive and dangerous. Crews need to have a place to rest, eat and drink something not from a fast food joint, care for their personal needs, and sleep, especially on longer shifts.
When a crew has a critical patient or call, they need time to not only decontaminate or restock, but they need time to decompress and debrief. Not be sent on another call because the system depends on them clearing up.
We need regular occupational mental health care, and we need to be encouraged to look after our mental health as well as physical health. We need to stop stigmatizing clinicians who ask for help as weak or unfit. Maybe, just maybe, they’re exactly the people we need, because they actively seek health instead of damaging behaviors.
We are standing on the edge of a cliff. We can back up, or keep moving forward. The choice will tell whether we move forward as a viable profession; or crash and burn.
References:
Simon G. Talbot and Wendy Dean, Talbot, S., Dean, W., About the Authors Reprints Simon G. Talbot sgtalbotmd@gmail.com Wendy Dean wdean@moralinjury.healthcare @WDeanMD, Talbot sgtalbotmd@gmail.com, S., Dean wdean@moralinjury.healthcare @WDeanMD, W., . . . Says:, W. (2020, April 30). Physicians aren't 'burning out.' They're suffering from moral injury. Retrieved February 01, 2021, from https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/
Silver, D. (2011, September 01). Beyond PTSD: Soldiers Have Injured Souls. Retrieved February 01, 2021, from https://psmag.com/books-and-culture/beyond-ptsd-soldiers-have-injured-souls-34293
Langabeer, J., -, & Staff, J. (2020, December 12). Recognizing and Supporting EMS Providers with Mental Health and Substance Use Disorders. Retrieved February 01, 2021, from https://www.jems.com/best-practices/spotlight/recognizing-and-supporting-ems-providers-with-mental-health-and-substance-use-disorders/
Dean, W., Talbot, S., & Dean, A. (2019, September). Reframing Clinician Distress: Moral Injury Not Burnout. Retrieved February 01, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752815/
