Are we working EMS providers to death?

By Michael Ward

There appears to be three factors in the EMS caregiver environment that contribute to the troubling increase in caregiver deaths by suicide.

1. Too many hours on the job
In Japan, researchers found that some workers who were putting in 100-hour work weeks were suffering from Karoshi, translated as "death by overwork." More Japanese died of Karoshi-induced cardiovascular failure, stroke or suicide than in motor vehicle accidents. According to the Japanese Health, Labour and Welfare Ministry’s 2013 statistics, 8.8 percent of full-time employees at Japanese firms, or an estimated 4.74 million, worked more than 60 hours per week.

Many EMS caregivers are working the equivalent of two full-time jobs, caring for patients on an EMS unit for 72 to 90 hours a week. Including travel time from job A to job B, these caregivers are often putting in hours that approach the 100 hours a week linked to Karoshi. Even when assigned to EMS units with low workload, the caregiver is not off-duty and does not have the ability to decompress, rest or recover.

Peter Bungate, writing about his 2013 experience as a foreign attorney in Tokyo, shared this experience:

"Once at an 8:00 a.m. conference call, I was joined by a colleague who rushed into the room, apologized for not arriving earlier, and promptly opened a large can of Red Bull, which he placed on the table next to his laptop. From his briefcase he procured yet another can of Red Bull and two cans of coffee."

Most of us can probably recall a similar scene playing out at the station kitchen table or in the cab of the ambulance.

Caregivers are working these hours to obtain a middle class level of income. The EMS1.com, Fitch & Associates and NEMSMA 2016 EMS Trend Report shows that most EMTs annually earn between $25,001 and $30,000 (median of $13.22/hour) and paramedics earn between $35,001 and $40,000 a year (median of $18.03/hour). Using the Pew Research Center "Are you in the American middle class"" calculator, many EMS caregivers will determine they are part of the 29 percent of Americans in the lower-class income tier.

2. Compassion fatigue
Compassion fatigue is the emotional and physical exhaustion affecting health care providers, usually as a consequence of caring. It can be seen in those who repeatedly witness the emotional or physical suffering of others [1]. Compassion fatigue is linked to "vicarious traumatization," where the trauma or distress is witnessed but not actually experienced [2].

When compassion fatigue hits critical mass in the workplace, the organization itself suffers. Chronic absenteeism, spiraling workers’ compensation costs, high turnover rates, friction between employees and friction between staff and management are among organizational symptoms that surface, creating additional stress on workers.

Often, the mistrust that caregivers feel towards management is justified. Most EMS caregivers have additional challenges such as low wages, lack of space, high management turnover rate and constantly shifting priorities. EMS leaders should consider organizational compassion fatigue when considering the root causes of [3]:

• Inability for teams to work well together.
• Desire among staff members to break company rules.
• Outbreaks of aggressive behaviors among staff.
• Inability of staff to respect and meet deadlines.
• Lack of flexibility among staff members.
• Inability of staff to believe improvement is possible.
• Lack of a vision for the future.

EMS agencies tend to be rule-driven and overly routinized. These organizational characteristics increase the risk of developing institutional compassion fatigue. EMS leaders need to examine how the organization operates to reduce the conditions leading to caregiver suicide and early disability or death. Recommended activities to reduce organizational compassion fatigue include [4]:

• Provide adequate training about caregiver stress.
• Encourage peer support, both formal and informal.
• Provide workplaces that allow for privacy, confidentiality and a calm and pleasant work environment.
• Offer employee assistance programs.
• Monitor caregiver workloads.
• Have an open-door policy and encourage feedback.
• Address and resolve staff conflict.

3. War in the streets
Caregivers are confronted with more challenging and demanding situations than earlier generations:

• Deaths from opioid overdoses have quadrupled since 1999, creating an epidemic of overdoses.
• The number of morbidly obese individuals (100 or more pounds over their ideal weight) increased by 70 percent [5].
• Lone-wolf terrorist attacks are becoming more common and the number of fatalities per attack has increased.
• Patient-initiated violence against EMS caregivers is becoming an area of significant concern and research.
• Distracted drivers account for almost 40 percent of vehicle collisions.

EMS leaders should consider the following organizational activities [4]:

• Regularly check in with first-line supervisors and caregivers — do not wait for them to approach you.
• Track significant incidents and follow-up with the involved caregivers.
• Engage in your own self-care program.
• Avoid stigmatizing staff who suffer from compassion fatigue or other stress-related issues.

Few other professions see the confluence of these three factors as often or as significantly as EMS. Failing to address them in individuals will lead to entire organizations suffering, which will only make it more difficult for individuals to escape the cycle. EMS leaders can no longer ignore or write-off these factors as inevitable, and must work with each other, with their employees and with other experts who can help agencies address these problems. If we don’t, then we are failing ourselves, our colleagues and our profession — and the patients and communities that rely on us to be compassionate, caring and competent during their time of need.

About the author
Michael Ward, a senior associate with Fitch & Associates, has more than 40 years of experience in the emergency care industry. He retired as the acting EMS chief from a large fire and rescue department, has served as executive director of a hospital-based 911 paramedic and medical transportation service and was an assistant professor and program director at a university medical center. He lives in the Washington, D.C. suburbs.

References

1. 6. Compassion fatigue in emergency medicine. http://ift.tt/2gJ0kTI
2. What is Compassion Fatigue. http://ift.tt/2gvoZbs
3. Symptoms - Compassion Fatigue Awareness Project http://ift.tt/2gJ69R7
4. Teater, M. and Ludgate, J. (2014) Overcoming Compassion Fatigue: A Practical Workbook. Eau Claire, WI: PESI Publishing and Media. ISBN 978-937661-44-1
5. Strum, R. and Hattori A. "Morbid obesity rates continue to rise rapidly in the United States." International Journal of Obesity (London). 2013 Jun;37(6):889-91.

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