Time for action on psychological injuries (part one)
Psychological injury prevention is the next steps as we see understanding and treatment for those who have been injured start to improve. It has been a long road from stigmatized recognition of psychological injuries to a place where we can feel more comfortable in being open about Paramedic psychological health… well maybe for some of us. The acceptance and destigmatization of these injuries are inconsistent across Canada’s Paramedic Services. Awareness has yet most likely improved from any previous level that your Service was at, but this process is not one with a goal line. Continual improvements and assessments are needed to make our work as safe as possible.
Post injury care has also improved but not all of Canada provides psychological injury presumptive coverage for Paramedics and with varied levels of coverage and accepted injuries (some have even gone backwards including Alberta who has reversed presumptive PTSD legislation for Paramedics). Why are we waiting until a Paramedic is injured to the point of not being able to perform their duties at work, having significant personal life changes and for some the terminal result of their psychological injuries – suicide. Our health and safety committees, management and ourselves must do more to prevent and recognize psychological injuries. These psychological injuries can be likened to back injuries. Most often it not one incident that causes the resulting pathology and outcome. It is repeated incidents that lead to a more significant injury. This is why many service have made changes to prevent back injuries.
It is time to focus on prevention so we have less injuries and those who are injured are less serious. Health and safety injury prevention always start with the Hierarchy of Controls: elimination, substitution, engineering controls, administrative controls and personal protective equipment. All of these are possible. It can seem like they are not possible which is how we can be conditioned to think. Finding reasons to not act on these important controls for psychological harm may seem like the only possible option. When we take a step back we can see how many aspects within our work can be positively effected by measuring them against these controls. These are changes that can be difficult to see and adopt, but there are some that are easier to implement. We also avoid change and look for stability as we work in a world of inconsistency, instability and risk. We try to control what we think we can as so much is out of our control, but nothing will change until we change.
One recent change is a focus on resiliency of employees – defined as the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress—such as family and relationship problems, serious health problems, or workplace and financial stressors. We can see how this falls into the engineering, administrative and PPE sections of the controls but ignores the first two steps. It also largely places the responsibility on the employee to just get stronger and more resilient to the assaults to their psychological health. Earlier interjections to prevent injury rather than waiting for the incident to occur and cause injury should be a priority. This is not meant to diminish the importance of resiliency and its ability to assist in injury prevention and recovery. It is meant to realize that relying on resiliency can be a limited to many factors and avoiding the incident causing injury should be the focus when possible.
What can we control? We can do our part in health and safety to follow the hierarchy of controls. A simple example of elimination/substitution is when we talk about our “war stories”. These are an important outlet as well they help our peers with calls they may see in the future and can assist us as we decompress from these calls. Can we tell the details of the calls in a way that is more responsible? Yes, we can eliminate many of the details that are so descriptive as they are seared into our minds, we do not have to sear them into our peers. Share but with consideration that they do not need to carry what we carry. Another important factor is to check in with the peer you are speaking with. Are they the right person to share with at this moment? Please consider where their resiliency and ability to deal with the information is at. Likewise consider where you are at when a peer starts to share with you. Please set your own psychological harm boundaries when possible.
We can go through our day and look at the controls and apply them when we can to do our part. We are only one variable in the equations that leads to psychological injuries and harm. What are our services doing to prevent injuries? The challenges can seem impossible to overcome but our services will need to help create a safer workplace. Paramedics do this job because they care deeply. Deeply enough to be put in harms way to help those in need. If there is someone who needs help, we answer the call. This is also our downfall and where our management needs to step in with checklists assessing our return to readiness. They will have to be the ones to step in when we can not see that we are being injured. The operational and organizational stressors are just as important as the calls we experience. This is not to blame the services or the employees but to see the issues around the system and work together to solve them in our share responsibility for our health and safety.
How do we get from here to a safer workplace? The road map to where to go next has been laid out for you, your health and safety committee and your service to follow.
CSA Z1003.1 – 18 Psychological health and safety in the paramedic service organization
This standard details how and what to do next and is built from the same standard for other workplaces. The CSA saw how psychologically dangerous being a Paramedic is in the organizations we work for, they saw how specifically we needed our own standard to address our safety needs. This standard provides the framework to build a psychologically safe workplace. They even built a process to help implement it called guarding minds at work. This extensive process is not specific for the Paramedic version of the CSA standard but has all the pieces needed to start evaluating prioritizing and moving forward.
Maybe you are thinking; I want to make my workplace safer and not see myself and my peers injured, but how? If you are thinking this is to big for me to take on by myself, you are right. There is good news. There are mechanisms for change already built. Here is a list of places to start.
Ask your Health and Safety committee what is being done to prevent psychological injuries and harm at work? Ask for the stats on injuries and types to assess if psychological injuries are being reported? Ask the Health and Safety Committee to consider forming a Sub Committee as referenced in the CSA standard. Request the Health and Safety Committee adopt the CSA Standard z1003.1 – 18. Speak to your Supervisor, share your concerns for the psychological injuries and harm being caused by the work we do. Ask them what training they have to prevent these injuries and request the process for reporting these injuries or risks to your supervisor? Start reporting any psychological injuries and near misses using the process within your service and provincial legislation. Take some time to consider what could be a psychological harm or injury incident to you. This will be different for everyone and there will be many daily activities within our work that could be harmful.
So what can you do? Start… No one is coming to save us we will need to do it ourselves using the tools that have been provided. Check in for part two as we look at what happens next and what to do if you receive the no answer we are worried will come.
Psychological health advocate for Paramedics
Chair of the OPA Wellness committee
Vice-President of the PPAO
Strategy to combat violence against Paramedics launches in Peel
When a dispatch call rustles over the radio, paramedics are told what to expect at an emergency scene. For many, experience also tells them to prepare for violence. The women and men racing through our streets in ambulances to save lives and treat the injured are often confronted with a range of abusive behaviour.
Ontario paramedics are kicked, punched, spat on, yelled at, seriously injured, groped and sexually harassed on the job. Violence against paramedics is well-documented by studies which have, for at least a decade, demonstrated an urgent need to enhance workplace protections for first responders.
Now, a new reporting tool developed by Peel Paramedics, a first-of-its-kind in Ontario, is slated to help steer the service away from a compliant culture that has allowed abuse on duty to become normalized. It is one of several initiatives led by Peel’s External Violence Against Paramedics Working Group that will make it easier for first responders to log abuse when it happens, and generate comprehensive data about these occurrences.
With the support of Peel Regional Council, paramedics are also advocating to the provincial and federal governments for legislative changes that would criminalize assaults on emergency response personnel in the same way the law currently protects police officers.
The moves come after a disturbing 2019 study by Peel paramedics Mandy Johnston and Justin Mausz, who found 80 percent of their peers experienced physical violence at work. The study surveyed 196 paramedics – about half of them had over 11 years on the job – who offered their retrospective take on experiences of abuse.
The new reporting tool will allow violent occurrences to be documented in the same software, by Interdev Technologies, which tracks patient calls. It promises to create a more accurate picture of how pervasive these incidents are in Peel, where it will be launched, while other jurisdictions running Interdev can also opt-in to use the tool via the software company.
“The existence of a mechanism for them to report violence is really solidifying this new idea that we’re trying to instill in the culture, in which we don’t accept violence as part of the job anymore,” Johnston said.
A big part of that culture encourages brushing off and making light of these situations, she said. In the aftermath of attending a traumatic scene as a paramedic, many are also confronted with the heavy emotional toll of recovering from a personal attack, and are sometimes shamed for it. In Peel’s 2019 study, one paramedic reported being mocked by superiors for not coping. “The two (supervisors) on that night found me hiding in the ambulance crying. In a nutshell, I was told I’m probably not cut out for this job and should start looking for a new career,” the survey respondent said.
A study published in 2016 done by Drexel University’s Dornsife School of Public Health in Philadelphia examined why first responders are so often assaulted on the job. It found that paramedics in one U.S. city, where the department served a population of more than a million residents, were 14 times more likely to be victims of a violent attack than firefighters. The study found the higher rate of violence against paramedics was linked to several factors, including a lack of information about the emergency situation they were sent into, a lack of training to deal with combative individuals and extremely close contact required to medically assist patients. Some female paramedics who participated in the study also reported being seen as “easy targets” by some men, including those who become violent under the influence of alcohol or certain drugs.
Johnston’s research into Peel’s paramedics included similar findings.
“As a woman, having men think it is their right to comment on a female’s look, or put their hand up a medic’s thigh, or ‘accidentally’ grab a breast, all regardless of the paramedic’s verbal warnings,” was common, one anonymous paramedic said in the report.
The Peel study found that many paramedics did not bother to report abuse because there was no recourse available to them, or consequences for the perpetrator, who is often the very patient they are trying to help. Paramedics expressed feeling dejected, with comments such as: “What’s the point?”, “Nothing is going to get done” and “It’s part of the job.”
According to the research, 97.9 percent of paramedics were exposed to verbal abuse, 86.1 percent reported intimidation and 80 percent said they experienced physical assault. Additionally, 61.5 percent reported sexual harassment and 13.8 percent said they had been sexually assaulted.
Johnston is encouraged by feedback she has received since her study in Peel, which was presented to Council last November.
“It’s really impressive to see, in a one-year period, that paramedics are now willing to start coming forward and speaking about their experience, and that they actually believe change is happening,” Johnston said, adding that more of her colleagues say they feel supported by management when raising these issues. Johnston’s team will also be releasing a new violence policy for paramedics, educational materials about the reporting system, and a public awareness campaign that will roll out in the new year.
“I am very excited about the project that Peel is undertaking, as it represents the first prospective data collection on violence in Canadian paramedics,” said Elizabeth Donnelly, an associate professor at the University of Windsor School of Social Work, who has over a decade of experience as an emergency medical technician. Her research interests include investigating the effects of occupational stress on paramedics. In an email to The Pointer, she said the institutional response to Peel’s initiative would be just as important in reinforcing to paramedics that there is value in reporting abuse.
“If we can create a base of empirical evidence that links work-related violence with workforce health issues, that could be a useful tool for advocating legislative change,” she said.
A November 12 Peel Region staff report from Nancy Polsinelli, Commissioner of Health Services, called on Regional Chair Nando Iannicca to submit a letter to the federal Minister of Justice requesting criminal code amendments through Bill C-211, the Post-Traumatic Stress Disorder Act, to include protections for paramedics. It was introduced as a private member’s bill in 2017 by Conservative MP Todd Doherty. (Doherty did not respond to an interview request from The Pointer.) Similar legal reforms to protect paramedics were made in 2018 in Australia and the U.K. The latter country introduced tougher sentencing guidelines earlier this year for those convicted under its Assaults on Emergency Workers (Offences) Act.
But legal amendments alone are not effective to promote paramedic safety, and neither are the varying standards across jurisdictions, said Dr. Blair Bigham, an emergency physician at St. Michael’s Hospital and anesthesia critical care fellow at Stanford University. He previously worked as a paramedic in downtown Toronto, and is also a health and science writer.
“What we need is a national strategy to address this. What we have instead are piecemeal bits and pieces that pop up here and there, and ultimately end up either fading away or not being acted upon,” he said.
Bigham began his career as a paramedic in 2006 and led a peer-reviewed study about workplace violence, published in 2014, that surveyed 1,676 paramedics in Nova Scotia and Ontario. Similar to Peel’s 2019 study, Bigham’s research found that 75 percent of respondents were victims of violence in the workplace at least once in the year prior to the survey.
He has also experienced violence, and said one of his former colleagues was injured so badly on the job that she could not return to work. Bigham said the success of Peel’s program will depend on the transparency and follow-up from management to signal that paramedics are being heard.
Greater buy-in to tracking offences could create “really strong longitudinal data – almost epidemiological quality data – to follow this [issue],” he said. “But you can’t just put the buttons into the software. The paramedics actually need to feel empowered and enabled to complete that documentation.”
Covid Offload Challenges
The nightmare scenario governments face in their battle against COVID-19 is the possibility hospital beds could run out. During the first wave of the pandemic, New York and northern Italy provided cautionary examples of the impossible choices faced by healthcare workers when acute and critical care spaces dry up.
This danger was one of the main motivators in March when Ontario Premier Doug Ford ordered the vast majority of businesses to shut down.
Eight months later, despite images of COVID-19’s ghastly toll seared into the minds of those who worked on the frontlines, serious concern about hospital capacity has been largely ignored by many politicians, as debate around economic impacts has dominated the discourse. Record breaking case numbers have led to a rise in deaths, but so far infection has been more common in younger people with lower mortality rates.
As an increasingly bitter debate over the economy and healthcare priorities plays out, physicians have warned the government COVID-19 cases will rise among all age groups. Hospitalizations, we have been repeatedly told, are a lagging indicator.
After a Wednesday report from Ontario’s Auditor General that slammed the Province’s pandemic response, Health Minister Christine Elliott hit back. “Thanks to the leadership of public health experts and hospitals, Ontario never reached the point seen in New York and Italy,” she said in a statement.
But, in Mississauga, overwhelmed hospital capacity is creating scenes eerily similar. Stretched hospitals in the city have been forced to reassign spaces to care for increasingly ill COVID-19 patients and, as a result, paramedics are unloading people from ambulances outside in the cold, rain and snow.
In the spring, Trillium Health Partners (THP), which operates two hospitals in Mississauga, turned its indoor paramedic bays (used to unload patients from ambulances) into extended emergency areas.
“THP has been vigilantly following all public health guidelines and has required the ambulance bay space for three reasons: we do not have internal adjacent space in which to expand; physical distancing between patients and staff remains an important infection prevention and control measure; and separate space is required to assess potential non-admit COVID-19 patients,” THP spokesperson Keeley Rogers said in a statement to The Pointer. “The bays are currently being used for triage and rapid assessments. The safety of our patients, staff, and community partners is our top priority and such decisions are made with this in mind.”
For paramedics, rushing through Peel’s streets to emergency calls, this decision has caused significant concern. In the summer, unloading patients outside was far from ideal, but in the winter months, it increases the risks patients and paramedics face. Without bays inside Mississauga hospitals where patients are transitioned to hospital beds, those who are seriously ill are being unloaded in public and then shifted into hospitals. Paramedics must guide their stretchers across an open space and into the hospital.
“Short term: fine; warm weather: fine,” Dave Wakely, paramedic union boss in Peel, said to The Pointer. “We’ve been bringing it up since August, concerned about the snow. It’s a risk to patients in terms of exposure to the elements, but also in terms of tipping the stretcher over. We want to get back inside so we can provide as safe care as possible to patients.”
Currently, paramedics find themselves splitting their attention between life saving treatment and navigating blasts of snow or the hazards of icy asphalt.
“We have the need to offload our patients somewhere safe and, ideally, private. These patients are sick, they’re coming in and having the worst day of their life,” Wakely added. “It’s not great to have to walk past the public when you’re doing CPR on someone.”
Despite “raising the issue repeatedly” with THP, paramedics are still unloading their ambulances outside. Spaces have been negotiated inside the hospital to clean stretchers and equipment. THP says it has created a “dedicated area” at Mississauga Hospital to transition patients, while there is a covered entrance at Credit Valley Hospital.
For now, ambulances will continue to remove patients outside.
“THP’s overall capacity continues to be around 100 percent or above on any given day,” Rogers added. She said the number of COVID-19 positive patients at THP hospitals had increased 160 percent in the past three weeks.
“The rise in COVID-19 prevalence coupled with the growing impact of patient admissions requires us to continue the current use of our ambulance bays. We continue to assess our infrastructure and evaluate all our options as we prepare for the winter season and the rising cases of COVID-19 in our community.”
The COVID-19 pressure on hospitals, pushed by a case count in Peel that continues to spiral upward, means some impossible choices are already being made. To guarantee space for patients, and in anticipation of a growing surge, THP has had to freeze paramedics out. The decision increases space inside hospitals, but adds risk to emergency workers and marks the beginning of difficult choices between the needs of first responders in the critical moments of early intervention and the longer term needs of hospitals.
These are signs that our system has reached its breaking point.
“We all want to work together with the hospitals, we understand this is a time of unprecedented demand. But we talk a lot about partnership and it’s time for it to actually look like a partnership,” Wakely added. “We’ve sort of been paying second fiddle the whole time.”
Peel Newest Addition to our Fleet
The PPA is proud to announce the newest vehicle to the PRPS Fleet.
In partnership with Mattel and Peel Regional Paramedic Services, we entered into a licensing agreement for a line of PRPS branded toys. This 1963 Cadillac Ambulance was launched November 1st as part of their 2021 Matchbox Toy line up.
At this time the plan is to add additional PRPS to the line up in the later part of 2021.
A special thanks to the Mattel Team for their great work and support .
The PPA would also like to thank Chief Peter Dundas for his support on this initiative and all PRPS projects.