The EMS system of the United States is one built to ensure that the pre-hospital needs of the public are met and to accomplish this goal, the system is structured with four levels of emergency provider certification, recognized at the national level: Emergency Medical Responders (EMR), Emergency Medical Technicians (EMT), Advanced Emergency Medical Technicians (A-EMT) and lastly Paramedics. These providers are the initial contact that patients from all kinds of backgrounds may have with the healthcare system on a day, that for some, may be their worst. To ensure that these providers are capable of providing the best care they must learn skills that ensure they are up to the important task of providing pre-hospital care to patients of all backgrounds. One of the topics covered nationwide in EMT courses, as recommended by the National Highway Transit Safety Administration’s (NHTSA) Office of EMS, all of which fall under the United States Dept. of Transportation, is mental health care.
This research paper focuses on how the Emergency Medical Services (EMS) system approaches mental health for both EMS providers and patients suffering from mental health emergencies. The paper has been divided into two parts, the first focuses on current and potential future methods used by EMS providers when faced with treating patients who are suffering from mental health emergencies, commonly described as a patient with an altered mental status (AMS) and begins on page 3. The second part of this paper focuses on the mental health of EMS providers due to the intense, and occasionally traumatic, work environment can cause significant mental health issues, such as PTSD and burnout, and what the EMS system is doing to combat these issues and begins on page 7. In addition, a table can be found on page 2 of this paper consisting of all abbreviations and explanations found throughout the paper.
ABBREVIATION TABLE
Abbreviation
Explanation
AMS
Altered Mental Status
Burnout
a condition involving extreme physical and emotional demand that can be caused by a specific area of one’s life (CROWE 230 & ADDITIONAL CITATIONS)
CISD
Critical Incident Stress Debriefing
ED
Hospital Emergency Department
EMS
Emergency Medical Services
GCS
Glascow-coma Scale, a numeric system used to standardize a patient’s mental status
PCP
Primary Care Provider
PCR
Patient care reports → Reports are completed by EMS providers after completing patient contact with details on all events that occurred.
PTSD
Post-traumatic stress disorder
PART ONE
On a yearly-average, EMS personnel across the United States respond to approximately 2.2 million calls for service involving patients with an altered mental status (AMS). (Trivedi 1). Similar to the mental health studies on EMS providers (see Part Two), studies designed to assess the pre-hospital treatment of patients with an AMS has not been well-documented anywhere in the world. A 2018 study, by the Los Angeles County Emergency Medical Services Agency and the UCLA Geffen School of Medicine, which has been cited as the Sanello study, did however use this finding to develop baseline recommendations for all EMS providers to use when a patient presents with some form of AMS. (Sanello 527). The L.A. County/UCLA study analyzed the protocols for EMTs in thirty-three different EMS agencies across the State of California for treating AMS patients.
After reviewing the protocols of the thirty-three agencies, the Sanello study found several key components that are believed to be crucial for all EMS providers to complete to provide the best possible treatment to patients with an AMS. The first component states that providers that take time to interview family and bystanders as well as examine the surrounding environment for clues on what may have caused the AMS are more likely to begin adequate treatment to help return the patient’s mental status to “normal.” While this is a skill taught across the nation to EMTs, it has been found that many providers neglect to truly ask bystanders for additional information.
The additional components recommended in the study fall under what the Sanello study calls “point-of-care” testing. “Point-of-care” testing is basic diagnostic testing that occurs at the time of patient assessment by EMS providers (Sanello 530) which could then allow for the patients to receive on-scene care and not require transport or further treatment at an Emergency Department (ED) thereby reducing overall stress on the EMS system (Trivedi 3). The recommended “point-of-care” testing includes testing blood glucose levels for any patient with a suspected AMS, administering naloxone and beginning oxygen therapy. These recommendations come after reviewing patient care reports (PCRs) and finding that hypoglycemia was the most common cause of an AMS followed by drug & alcohol intoxication and carbon monoxide poisoning.
Point-of-care testing allows for several new transport options to arise. With blood glucose testing allows for the confirmation or negation of hypoglycemia as a cause for an AMS. If hypoglycemia is confirmed to be the cause of an AMS, the patient to be treated on scene with oral glucose and then elect to refuse transport to an ED. While some may feel that a patient who has just suffered from such a dramatic drop in glucose levels, requiring EMS response, mounts an immediate need for ED care, but in cases where diabetic patients got distracted and forgot to eat a meal, for instance, once EMS assists with returning the patient’s glucose levels to normal, the patient can chose to meet with their primary care provider (PCP) at a later date. Patients under the influence of drugs and alcohol often present with an AMS, and in some cases, even present with a Glascow Coma Scale (GCS) score of less than 9. (Sanello 533). When this information is combined with examining the environment where the patient was found and speaking with bystanders, providers may chose to administer naloxone, a medication that reverses the effects of narcotics and is often referred to as Narcan, one of the brands that produces naloxone. Naloxone can even be administered by EMS providers without fear of further injury to the patient if they are later found to not be under the influence of narcotics. (Wermeling 22) and then transport to an ED may occur. Oxygen therapy can reverse the effects of carbon monoxide poisoning, a common finding in patients suffering from an AMS. (Sanello 530). After treatment, the patient can elect to refuse transport to an ED, similar to the patients mentioned above with blood glucose testing.
One of the key takeaways from the 2018 Sanello study is that in a review of thirty-three EMS agencies which all fall under the California Emergency Medical Medical Services Authority there are several different treatment protocols. And while some of the protocols are a result of different community environments, Los Angeles versus Napa Valley, many of the protocols were found to be capable of becoming standardized across the nation. In addition, the point-of-care testing recommended in the study are basic skills nationally taught to EMTs, yet upon review of the thirty-three California agencies protocols, the study found a range of instructions for providers. Using the findings of the Sanello study to create standardized protocols can aid in ensuring AMS patients receive adequate treatment before irreversible effects take place. It is also important to note that it is understandable that due to the fact that less than 10% of the annual calls for service EMS personnel respond to involve AMS patients, (Sanello 527) some basic training regarding AMS care may be forgotten but with standardized protocols, it becomes easier to understand to refer and recall this information.
One of the newest transport options that is sure to provide serious AMS patients with the fastest care is direct transport to a psychiatric treatment facility, instead of an ED which are often lacking in enough inpatient psychiatric bed. (Trivedi 1). In addition, almost all care levels of the ED have said psychiatric patients often experience stays much longer than treatment in a dedicated psychiatric hospitals. (Trivedi 2). This new method of directing AMS patients directly to a psychiatric facility, after meeting certain criteria, has been in place for some time in Alameda County, California. A study analyzed all EMS calls that involved AMS patients between 2011 and 2016 and found that about 10% (53,887 patients) of all calls handled by EMS in Alameda County, 41% (22,074 patients) met criteria for going straight to a psychiatric emergency care facility rather than an ED. The success of this new concept has found that only 0.3% (60 patients) of those sent directly to a psychiatric facility required retransporting to an ED for further care, over a five year period. (Trivedi 9).
With these new transport decisions available, EMS providers are able to provide better care to their patients by giving them access to the quickest and most useful treatment facilities. In addition, directing certain patients to specific care facilities, such as a psychiatric emergency hospital rather than an ED, may alleviate the overall stress on the hospital systems. This can be seen here in the State of Connecticut where four psychiatric treatment facilities are operated by the Connecticut Department of Mental Health and Addiction Services, providing 154 in-patient beds to the public (Note: this does not take into consideration non-profit and private hospital facilities that have inpatient psychiatric beds). (Connecticut). If AMS patients are transported directly to these facilities, after meeting criteria similar to that used in Alameda County, adequate treatment can begin.
PART TWO
Annually, the nation-wide EMS system responds to over 28 million calls for service and when these calls are paired with high-risk environments and exposure to traumatic events the wellbeing of the prehospital providers is put at a significant risk for burnout. (Crowe 229). Burnout as defined by the Maslach Burnout Inventory is a condition involving extreme physical and emotional demand that can be caused by a specific area of one’s life. (Crowe 230, Maslach 191). In fact, roughly 80% of U.S. EMS personnel experience some form of moderate to high levels of stress at some point while a part of the EMS system. (Ebadi 1).
A 2018 study at Ohio State University, which has been cited as the Crowe study, highlights the fact that while burnout has been well studied in many healthcare professions, very few studies have actually focused on the pre-hospital/EMS field and as a result, sought to create a baseline assessment of burnout in the EMS field by surveying a little over 1,100 EMTs and 1,482 paramedics. It should be noted that these EMTs and paramedics mentioned above are among those who chose to respond to the survey request, a little over 10,500 EMTs and 10,600 paramedics were sent the survey using the contact information listed in the National Registry of EMTs. The Crowe study found that there are three factors that can determine how likely one is to leave the EMS field: certification level, years of EMS experience and weekly call-volume. (Crowe 235). These all go hand-in-hand, which the study acknowledges, as a someone is not likely to spend time earning higher certification if they are already feeling the effects of burnout which is found to increase in EMS providers that have a high-call volume, such as those that cover urban communities.
The effects of burnout can create safety concerns for the “burnt” provider, their partner and the patients they care for. As a result of the limited pre-hospital field research available, it became necessary to include studies from other parts of the world. In a study completed in Germany, it was found that in a survey of over 1,000 EMS workers 73.7% of the workers had admitted to “compromising behavior” when it came to patient care, the highest behavior being not checking the blood glucose level of patients with an AMS. (Baier 4). This finding in the study reinforces the recommendations found in the Sanello study of Part One of this paper.
Another concern of EMS-related stress is its long-term effects on a person. In fact, it has been found that when a provider fails to manage the feelings of burnout they are experiencing within a few weeks, it can lead to long-term post-traumatic stress disorder (PTSD) (Collopy), have serious effects on family life (Roth 462), and in the worst cases, substance abuse. (Vettor 219).
PTSD is in most cases preventable, “early detection allows for early intervention.” (Mishra 710). Preventing PTSD takes place at many levels in the EMS field, right down to the co-workers. One preventative measure that is highly debated among researchers and EMS personnel, alike, is the Critical Incident Stress Debriefing (CISD). (Mishra 710). CISD is designed to provide peer counseling after a large-scale traumatic event. However, there are other pieces to preventing PTSD that are extremely hard to debate against, one of which, is the EMS managers or supervisors being aware and inquiring about the mental state of their personnel, ensuring that they receive access to all available resources. (Mishra 710). Several other systems have also been shown to “prevent or moderate the creation of burnout and encourage coping” (Mishra 710-711) such as the peer-support “buddy system” that pairs personnel with someone who is able to listen and help providers cope with stress and trauma. In addition, providing access to professionals, not just peers as seen in the previous systems, such as psychologists and local mental health centers have been shown to also prevent PTSD and burnout.
When a family member enters the EMS work-force, the remaining family members have to adjust to a life that is different from the societal-norms, which in itself can be stressful. One study, interviewing family members of EMS workers, found three common themes: the impact of family members working on a shift, coping with the EMS lifestyle and concerns for the EMS workers safety. (Roth 464). But it has been found that EMS families are capable at negotiation and giving providers “space,” and support. (Roth 468). In EMS personnel who become stressed and potentially on the path towards mental-health issues, the family become huge in identifying the provider’s stress and the provider’s biggest supporters.
Overall, burnout and PTSD are highly preventable in the EMS field. When co-workers, supervisors and family members come together to form a support network for providers suffering from traumatic events caused by the work-place environment, they are clearly more likely to come out stronger with a network behind them. By supervisors checking in on their staff and providing access to professional counseling, peers becoming an outlet to “vent” serious stress and discuss ways to move past the trauma and family members noticing changes in providers, the EMS system becomes stronger as whole and is able to provide the very best care to its patients.
AUTHOR’S NOTE
This paper has been written to fulfill the project requirements for the University of Connecticut’s Honors Program course credit conversion. The course this paper was written for is the UConn/Hartford Hospital EMT Certification Course, taught by Mr. Michael Zacchera.
The paper began with the idea of studying the emotional treatment of patients suffering from mental health diseases and disorders, such as schizophrenia and the mental health of EMS providers. But upon review of current literature on treatment of patients with mental health disorders this paper evolved into a review of current and potential future methods that can be used by EMS providers to provide the best care to patients with an altered mental status, thereby providing proper treatment faster and ensuring that EMS providers receive adequate support after going through traumatic events.
Bibliography
Baier, N., Roth, K., Felgner, S., Henschke, C. (2018). Burnout and safety outcomes – a cross-sectional nationwide survey of EMS-workers in Germany. BMC Emergency Medicine. DOI: 10.1186/s12873-018-0177-2
California Emergency Medical Medical Services Authority. (2018). Retrieved on 2018, November 1. https://emsa.ca.gov
Crowe, R., Bower, J., Cash, R., Panchal, A., Rodriguez, S., Olivo-Marston, S. (2018). Association of Burnout with Workforce-Reducing Factors among EMS Professionals. Prehospital Emergency Care, 22:2, 229-236. DOI: 10.1080/10903127.2017.1356411
Collopy, K.T., Kivlehan, S.M., Snyder, S.R. (2012). Are you under stress in EMS? Understanding the slippery slope of burnout and PTSD. EMS World. 41:10, 47-50. PMID: 23097838
Connecticut Department of Mental Health and Addiction Services. (2018, May 1). State-Operated Inpatient Treatment Facilities. Retrieved on 2018, November 20. https://www.ct.gov/dmhas/cwp/view.asp?a=2902&q=335192
Durant, E., & Sporer, K. A. (2011). Characteristics of patients with an abnormal glasgow coma scale score in the prehospital setting. The western journal of emergency medicine, 12(1), 30-6. PMCID: PMC3088371
Ebadi, A., Froutan, R., Malekzadeh, J. (2018). The design and psychometric evaluation of the emergency medicals services resilience scale (EMSRS). International Emergency Nursing. DOI: 10.1016/j.ienj.2018.09.002
Maslach C., Jackson S.E., Leiter MP. (1981). Maslach Burnout Inventory: MBI (3rd ed.). Consulting Psychologists Press.
Mishra S., Goebert D., Char E. (2010). Trauma exposure and symptoms of post-traumatic stress disorder in emergency medical services personnel in Hawaii. Emergency Medicine Journal; 27:708-711. DOI: 10.1136/emj.2009.080622
Mistovich, J. J., & Karren, K. J. (2014). Prehospital Emergency Care (10th ed.). Pearson Education.
National Highway Safety Transit Administration (NHTSA). 2018. About the Office of EMS. Retrieved on 2018, October 17. https://www.ems.gov/officeofOEMS.html
Roth, S.G., & Moore, C.D. (2009). Work-Family Fit: The Impact of Emergency Medical Services Work on the Family System. Prehospital Emergency Care. 13:4, 462-468, DOI: 10.1080/10903120903144791
Sanello, A., Gausche-Hill, M., Mulkerin, W., Sporer, K. A., Brown, J. F., Koenig, K. L., Rudnick, E. M., Salvucci, A. A., … Gilbert, G. H. (2018). Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care. The Western Journal of Emergency Medicine, 19(3), 527-541. DOI: 10.5811/westjem.2018.1.36559
Trivedi, T., Glenn, M., Hern, G., Schriger, D., Sporer, K. (2018). Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to “Medically Clear” Psychiatric Emergencies in the Field, 2011 to 2016. Annals of Emergency Medicine. DOI: 10.1016/j.annemergmed.2018.08.422
Wermeling, D. (2015). Review of naloxone safety for opioid overdose: practical considerations for new technology and expanded public access. Therapeutic advances in drug safety, 6(1), 20-31. DOI: 10.1177/2042098614564776
Vettor, S. M. & Kosinski, F. A. (2000). Work‐Stress Burnout in Emergency Medical Technicians and the Use of Early Recollections. Journal of Employment Counseling, 37: 216-228. doi:10.1002/j.2161-1920.2000.tb01028.x