Paramedics often experience some of the worst calls and scenes that life can throw at anyone, from grizzly animal attacks to horrendous motor vehicle accidents to burns and abuse in pediatric patients. They are often the first on scene and must manage their psychological stimulation and the patients, family members, friends, and witnesses’. It certainly never is a textbook situation in the life of a First Responder.
Paramedics can often develop Burnout Syndrome during their career because of the stress that comes from frequent and intense exposure to traumatic situations, complicated work schedules and shift hours, and modified circadian sleep cycles (25). The more experience a Paramedic has, the higher the risk is. (2) But what happens to these health workers when their Burnout is not properly managed or even identified?
By analyzing many articles dealing with Burnout Syndrome and PTSD, this article plans on showing a very tangible relationship between one and the other and will discuss some of the therapeutic options that exist for both phenomena.
The ICD-11 (International Classification of Diseases) does not consider Burnout Syndrome a disease. Its most recent revision defines it as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. […] Burnout refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.” (1)
Based on this definition, Burnout Syndrome is caused by our work environment and the frequent stimulation of our psychological triggers in it. It stands to reason that the more experienced paramedics are at higher risk due to the accumulated stress that is often attributed to working in any Emergency Services. (2)
As mentioned by the ICD-11, Burnout Syndrome is not a disease, and it is not considered a distinct mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (3). This type of classification has caused many agencies and stations to overlook the general warning signs that lead to Burnout Syndrome and its symptoms. Due to Burnout Syndrome’s stigma, many First Responders find it challenging to talk about it and avoid the subject altogether. (4)
Because of the nature of the work done in emergency services, specifically, the violent, traumatic and stressful situations encountered in everyday calls, many first responders prefer not to share their stories or feelings to family members and friends outside of the “community” and avoid doing so with close work partners for fear of being considered weak or less competent in their skills. (4)
Although studies have shown that paramedics and firefighters experiencing Burnout Syndrome are more likely to commit mistakes under pressure in their daily activities, not dealing with it or not seeking help can significantly increase the odds of making a mistake. (5) It is relevant and vital that agencies and stations learn to recognize and treat burnout syndrome in their paramedics (paid and volunteers). (10)
There is a myriad of methods to deal with Burnout Syndrome in and outside of work. Some of these include regular mental health routines such as exercising, reading, doing yoga, mindfulness, and other concentration techniques. (6,7) Agencies and stations that incorporate these mental wellbeing routines in their everyday practice have shown a significantly lower percentage of Burnout than those that have not. (8,9)
Based on these previous recommendations, treating Burnout does not have to be an expensive adventure. Several organizations have begun to offer services across Canada to help create a mental wellness plan that can stimulate healthier actions and lower the probability of Burnout in their station paramedics.
However, not dealing with the obvious signs of Burnout Syndrome and not supporting staff members throughout these ordeals can have catastrophic economic setbacks for stations and agencies. As such, no studies have focused on the cost of Burnout Syndrome on first responders, though a study done in 2019 published in the Annals of Internal Medicine calculated that physicians alone cost the healthcare industry over 4.6 billion American Dollars per year. This number includes costs in malpractice, patient safety, equipment not deemed necessary for the patient and unnecessary workup studies on patients. (11) This study was also applied to nursing sections and showed similar costs and causes.
All this is a preamble to the consequence of not dealing with Burnout Syndrome.
Post Traumatic Stress Disorder
The American Psychiatric Association defines Post Traumatic Stress Disorder (PTSD) as “a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury.” (13)
As mentioned in the introduction of this article, first responders are often witnesses to horrendous scenes, many with victims who succumb to their pre-existing conditions or injuries before paramedics arrive at the scene and many with victims perishing in transit. In a newcomer, these calls can lead to feelings of guilt (“Why couldn’t I save her?”, “Why didn’t we get there sooner?”). In the experienced professional, it is more associated with feelings of anger and frustrations (“Another life lost,” “Why does this keep happening on my shift?”). (2, 12) Can these thoughts slowly desensitize the first responder and lead them down the road to Burnout and the eight criteria for a PTSD diagnosis?
In order to make a PTSD diagnosis, eight criteria must be met, according to the DMS-5. These are shown in Table 1. (14)
As can be seen, by this table, many of these criteria are met by first responders on most violent or shocking calls.
Regarding Burnout Syndrome, the ICD-11 states that it encompasses three dimensions which are (1):
- feelings of energy depletion or exhaustion; (DSM-5 Criterion D)
- increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; (DSM-5 Criterion G)
- reduced professional efficacy. (DSM-5 Criterion G and H)
If left unchecked and with continuous negative psychological stimulation, these three dimensions can lead to fulfilling the eight criteria set forth by the DSM-5. Therefore, it is logical to conclude that unattended Burnout Syndrome in any first responder can be a preamble to Post Traumatic Stress Disorder, even though it is important to note that PTSD is not necessarily related to Burnout Syndrome and that one does not always lead to the other. (15)
Returning to our original question, “Does Burnout Therapy reduce the risk of PTSD?”
As previously mentioned, one of the many therapies available for Burnout Therapy is incorporating mental wellness in stations and bases. There are also multiple psychological approaches to this phenomenon, such as talk therapy, cognitive behavioural therapy, and psychoanalysis. (16) These therapies are also used in the treatment of PTSD. (17)
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT) is when the patient seeks to change learned patterns for reacting in certain ways to specific stimuli. It is based on three core principles (18):
- Psychological problems can be based on faulty ways of thinking
- Psychological problems can be based on learned patterns of behaviours
- Patients can learn a better way to cope with their problems
A 2011 study compared multiple therapies in the treatment of PTSD and concluded that CBT was a very effective treatment method, though other methods, such as EMDR, have also been proved effective. (19) The reason for this can be found in that CBT helps patients restructure their thought patterns so that the negative associations we have with trauma are seen from a different perspective and become associated with more positive relations. It is a type of therapy in which patients frequently remind themselves of the different approaches to any stress factor. (20) For instance, a first responder can either choose to think of a horrific car accident to which he or she responded to or can decide to focus on the grateful patient that survived. Whichever thought brings the most comfort or tranquillity is the one on which that paramedic should focus.
Considering that CBT adjusts specific thought processes and that patients who have PTSD tend to relive their traumatic experience in a heightened state, leading to recurrently disturbing thoughts and, in many cases, harmful attitudes to oneself and others, there is enough evidence to conclude that this type of therapy can lead to a more positive outcome when treating PTSD and Burnout Syndrome. (19, 20)
Eye-Movement Desensitization Reprocessing
Eye-movement desensitization reprocessing, or EMDR for short, is an eight-phase treatment approach consisting of standardized protocols and procedures. These phases can be seen in table 2. (21)
In layman’s terms, EMDR consists of concentrating on specific movements while talking (reliving) a traumatic experience. In many cases, the therapist will move their fingers from side to side while the patient talks. This causes the patient to activate the long-term memory by “loading” it to the short-term. Following the fingers with their eyes causes a slight “overload” of the brain and desensitizes part of that memory. (23)
A study from 2018 focusing on the efficacy of EMDR therapy specifically in PTSD concluded that there is “robust evidence that EMDR therapy is an effective treatment to improve diagnosis of PTSD and reduce symptoms of PTSD, and other trauma-related symptoms.” (22)
Furthermore, a specific study done in Sonora, Mexico, on First Responders in 2013 shows that EMDR has significant positive results in patients. This study randomized therapy (EMDR and Supportive Counselling) given to 39 first responders (20 male and 19 female) and measured the results for four months. These show that those given EMDR therapies responded faster and more efficiently than the rest. (24)
Burnout Syndrome and PTSD are two very different diagnoses, and each has very specific criteria that must be met. Although the symptoms for these are not the same, there are sufficient bibliographical references to instigate a common thread between the two. Further research is required to delve deeper into this relationship and obtain sufficient evidence to indicate a clear relationship between the two.
That said, the literature referenced in the article leads this author to believe that unchecked Burnout Syndrome can be an important precursor to developing PTSD symptoms.
There are various treatments that continue to evolve with our knowledge and understanding of the human mind in relationship to past trauma and work stress. These also merit further research into how they affect paramedics and first responders who are dealing with any of the previously mentioned diagnoses.
1. Burn-out an “occupational phenomenon”: International Classification of Diseases [Internet]. Who.int. 2019 [cited 4 October 2021]. Available from: https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases
2. Cornelius A, Callahan A, Grey J, Siddiqui D, Cvek U, Kilgore P et al. Occupational Stress and Burnout in EMS Providers [Internet]. Journal of Emergency Medical Services. 2021 [cited 4 October 2021]. Available from: https://www.jems.com/exclusives/occupational-stress-and-burnout-in-ems-providers/
3. Vahia V. Diagnostic and statistical manual of mental disorders 5: A quick glance. Indian Journal of Psychiatry. 2013;55(3):220.
4. Norwood P, Rascati J. Recognizing and Combating Firefighter Stress. Fire Engineering, 87-89. 2012;:87-89.
5. Hall L, Johnson J, Watt I, Tsipa A, O’Connor D. Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLOS ONE [Internet]. 2016 [cited 4 October 2021];11(7):e0159015. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4938539/
6. Ways to Avoid Paramedic, Firefighter, and EMS Burnout | CareerCert [Internet]. CareerCert. 2021 [cited 4 October 2021]. Available from: https://www.careercert.com/blog/fire/ways-to-avoid-paramedic-firefighter-and-ems-burnout/
7. Farina A. EMS burnout: Try this 4-step cure [Internet]. EMS1. 2020 [cited 4 October 2021]. Available from: https://www.ems1.com/mental-health/articles/ems-burnout-try-this-4-step-cure-I4mxGm5dAyVb5q8A/
8. Kvitne O. 5 reasons EMS providers should take yoga seriously [Internet]. EMS1. 2017 [cited 4 October 2021]. Available from: https://www.ems1.com/health-wellness/articles/5-reasons-ems-providers-should-take-yoga-seriously-sbUzt65KtRrGxbon/
9. GUIDE TO BUILDING AN Effective EMS Wellness and Resilience Program [Internet]. NAEMT; 2021 [cited 4 October 2021]. Available from: http://www.naemt.org/docs/default-source/ems-preparedness/naemt-resilience-guide-01-15-2019-final.pdf
10. Meadley B, Caldwell J, Perraton L, Bonham M, Wolkow A, Smith K et al. The health and well-being of paramedics – a professional priority. Occupational Medicine. 2020;70(3):149-151.
11. The Cost of Burnout in Healthcare | symplr [Internet]. Symplr.com. 2021 [cited 4 October 2021]. Available from: https://www.symplr.com/blog/the-cost-of-burnout-in-healthcare
12. Kim W, Bae M, Chang S, Yoon J, Jeong D, Hyun D et al. Effect of Burnout on Post-traumatic Stress Disorder Symptoms Among Firefighters in Korea: Data From the Firefighter Research on Enhancement of Safety & Health (FRESH). Journal of Preventive Medicine and Public Health. 2019;52(6):345-354.
13. Torres F. What Is PTSD? [Internet]. Psychiatry.org. 2020 [cited 5 October 2021]. Available from: https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd
14. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.
15. Schuster B. Burnout, Posttraumatic Stress Disorder, or Both – Listen Carefully!. The American Journal of Medicine [Internet]. 2021 [cited 5 October 2021];134(6):705-706. Available from: https://www.amjmed.com/article/S0002-9343(21)00156-X/fulltext
16. Korczak D, Wastian M, Schneider M. Therapy of the Burnout Syndrome. GMS Health Technol Assess [Internet]. 2012 [cited 5 October 2021];8(5). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3434360/
17. Post-traumatic stress disorder (PTSD) – Diagnosis and treatment – Mayo Clinic [Internet]. Mayoclinic.org. 2018 [cited 5 October 2021]. Available from: https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/diagnosis-treatment/drc-20355973
18. What is Cognitive Behavioral Therapy? [Internet]. https://www.apa.org. 2012 [cited 5 October 2021]. Available from: https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
19. Kar N. Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatric Disease and Treatment. 2011;:167.
20. Skedel R. CBT for PTSD: How It Works, Examples & Effectiveness [Internet]. Choosing Therapy. 2021 [cited 5 October 2021]. Available from: https://www.choosingtherapy.com/cbt-for-ptsd/
21. Shapiro F. The Role of Eye Movement Desensitization and Reprocessing (EMDR) Therapy in Medicine: Addressing the Psychological and Physical Symptoms Stemming from Adverse Life Experience. The Permanente Journal [Internet]. 2014 [cited 5 October 2021];18(1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3951033/
22. Wilson G, Farrell D, Barron I, Hutchins J, Whybrow D, Kiernan M. The Use of Eye-Movement Desensitization Reprocessing (EMDR) Therapy in Treating Post-traumatic Stress Disorder—A Systematic Narrative Review. Frontiers in Psychology [Internet]. 2018 [cited 5 October 2021];9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5997931/
23. Wat is EMDR? – EMDR [Internet]. Emdr.nl. [cited 5 October 2021]. Available from: https://www.emdr.nl/wat-is-emdr/#hoe-werkt-emdr
24. Jarero I, Amaya C, Givaudan M, Miranda A. EMDR Individual Protocol for Paraprofessional Use: A Randomized Controlled Trial With First Responders. Journal of EMDR Practice and Research. 2013;7(2):55-64.
25. Whitfield S, Rengers A. Paramedic Mental Health: You Are What You Sleep. Canadian Paramedicine [Internet]. 2020 [cited 7 October 2021];44(1):6-8. Available from: https://canadianparamedicine.ca/paramedic-mental-health-you-are-what-you-sleep/