The word stress has a negative stigma associated with it, as if it were something to avoid. In fact, stress is vital to our performance and strengthens our motivation. Stress is what helps EMS professionals prioritize treatment interventions with critical patients and act quickly with scoop-and-run traumas. Stress also helps first responders focus for regular review of protocols or, with adequate preparation, professional registration exams. As practitioners, what often affects us more even than what we see is our own personal associations—that suicide may remind us of our own child who struggles with mental health issues, or an elderly cancer patient may recall our grandmother battling the same diagnosis.
Psychological trauma can be defined as stress events that present extraordinary challenges to coping and adaptation.1 The definition of what is stressful varies drastically from individual to individual, depending on past experiences, social context, personal perspective, level of threat, belief systems, and current resilience. EMS is a dynamic environment—that may be why you enjoy your career, but it undoubtedly poses a unique challenge to resilience.
There is an optimal stress performance zone in which EMS personnel best perform. It occurs when the sympathetic nervous system is activated—e.g., dilated pupils, increased heart and respiratory rates—but when we still have conscious control of the situation. We can use the surge of epinephrine in our system to work more efficiently and the bump of cortisol to improve memory and increase energy. Without realizing it, this zone is probably where we feel the most confident and comfortable in our abilities. This is the “sweet spot” of performance where we’re most efficient and able to execute our duties at our highest abilities. Ultimately, inhabiting this positive stress zone for extended periods is what keeps us confident and satisfied and may even be one of the reasons we’re drawn to emergency medical services in the first place.
Without conscious control and discipline, however, stress can manifest into sheer anxiety, inability to focus, and lost performance. Over the long term, epinephrine can cause cardiovascular disease,2 and sustained cortisol will impact memory loss.3
How then, do we put the brakes on our stress response?
Resilience as an Art
Resilience can be thought of as a way of living and positively integrating experience with learned wisdom. Resilience does not have to do with wearing a tough “shell” life events can’t penetrate; rather, it is continuous adaptation and reprocessing of events by which we redefine ourselves as the world constantly changes around us. Resilient people do not let adversity devastate them but use it as an instrument for understanding and change. With the extremes EMS practitioners can witness on a daily basis, our experiences can either be a detriment to our coping systems or a tool for us to understand our personal triggers and help build resilience.
Of course, many other factors impact one’s resilience. Most research agrees that positive relationships are vital for resilience capacity, as are a positive psychological mind-set, connectedness to the physical environment, social ties, and a sense of inner wisdom (experiential spirituality).4 And as with any talent, resilience is something to be practiced daily. This comes with understanding our limitations, learning from experiences, relating to others, and cultivating new ways of thinking.
Reacting vs. Responding
Awareness is the first step on the road to resilience. Awareness can mean reflection on our past experiences to better understand what affects us or being fully conscious and immersed in the present moment. When we practice presence, we tune our senses to pick up more sensory information around us, thus helping us process situations in real time and make better-informed split-moment decisions. In this way we can respond to what the present moment needs.
Everyone knows what it’s like to react. Think about the last time you witnessed a practitioner snap with anger at an aggravating patient. When someone is in the reactionary mind-set, they are not fully aware of what is happening in the moment—the amygdala and corresponding “emotional” limbic system are running the show, and the prefrontal cortex “rational” brain is not able to intervene. These individuals are not taking in any new sensory input and cannot formulate new neuropathways of information for decision-making.
When one is aware of what can constitute “trauma,” they can better mitigate these stressors by building up specific coping techniques and being aware when they are affecting capacity. A practitioner in the field may have children of their own and know that when they go to pediatric calls and are hit with a sense of dread, they will feel emotionally unwell afterward.
By knowing this personal trigger, a practitioner can understand where these emotions originate, thus bringing objectivity to help resolve their state. For instance, they can explain their emotions by saying to themselves, “I love my children deeply, and I feel this way because I would be heartbroken if something like this happened to them. I can’t necessarily prevent bad things from happening to my family, but I can choose to love them more in the present, and I can also help others in the meantime.” When we put a name to our emotions and recognize their root cause, we can help loosen their grip on us and our state of stress. Practiced over time, this will strengthen our resilience and deepen our compassion for others.
The Four Pillars
The tones sound for a chest pain call. The responding paramedic, Lila, slept well last night and feels mentally balanced. However, as she has not had a chest pain patient for some time, she notices some anxiety: Her palms are a bit sweaty, and she feels her heart quicken. She takes all of this into account while she and her partner drive to the call.
While taking deep abdominal breaths, Lila mentally reviews her agency’s chest pain protocol and medication dosages and imagines herself palpating intercostal spaces for electrode placement. She tells herself she’s a competent paramedic who is good at her job and sets a goal that will she obtain a 12-lead ECG in less than 10 minutes. While assessing the patient she deliberately focuses on her breath and pays attention to how the patient is presenting and the information offered. Because of her focus and conscious control, she is able to diagnose an acute anterolateral MI in under 8 minutes and administer tenecteplase. Upon arrival at the hospital, Lila witnesses the patient’s ECG convert to a sinus rhythm with no ST elevation. After the call she feels confident that she served her patient efficiently, and upon review she notes that throughout the call she felt a sense of fulfillment and regulation of her senses.
Lars Draeger’s book Navy SEAL Training Guide: Mental Toughness offers a glimpse into the traits Navy SEALs are trained to possess that create mental tenacity.5 Their four “pillars” of mental toughness are goal-setting, visualization, positive self-talk, and breath control.
In the above scenario, Lila practices a bit of each of the four elements to help prepare before, during, and after the cardiac call. She sets a time goal for obtaining the ECG, visualizes electrode placement, reminds herself she’s a competent paramedic, and focuses on deep inhalations. All these methods complement each other to better prepare a practitioner for a potentially stressful situation and help abate an overreactive sympathetic nervous system response.
Goal-setting—Setting both short- and long-term goals helps provide a road map to success. Goals can be anything from completing a two-year paramedic diploma to simply getting to work on time. The key is to break down a larger goal into manageable, bite-size pieces—this allows the mind to focus on one thing at a time without distraction and helps build confidence.
Visualization—Visualization, or mental rehearsal, is common among athletes who will mentally go through the motions of a competition before enacting it in real life. When we “train the brain” by realistically imagining a scenario, the brain gains awareness and responds more smoothly by the time it really happens. EMS examples would be to visually practice a cricothyrotomy before performing it or to envision the steps for piecing together CPAP while responding to a shortness-of-breath call. We probably employ visualization to some extent already in our daily lives, but the more intentional we can be with mental rehearsal, the more we set ourselves up for success.
Positive self-talk—We speak to ourselves many times a day without being fully aware of what we’re saying. If we begin to listen to these words, we may realize a lot of them are filled with negativity and self-doubt. By consciously choosing to replace these negative words with positive ones, we can reaffirm a positive self-image and cultivate confidence in our abilities. By choosing a “mantra”—a positive saying such as “I can do this!”—one can gain motivation and stamina for their task ahead.
Breath control—When we focus on slowing and deepening respirations, there can be a temporary mitigation of the sympathetic nervous system. The parasympathetic nervous system is then activated. Focusing on deep inhalations can cause reductions in heart rate, blood pressure, and overall stress symptoms. This is especially useful to practice going into known stressful situations, such as a cardiac arrest call or a multivehicle highway collision. One method is the “4x4” breathing technique: Begin by inhaling for four seconds, pause for a moment, and then follow with four seconds of slow exhaling.
Awareness and Empathy
There is no question about the link between conscious awareness and stress reduction. How else may providers raise our awareness bar? Some tried-and-true introspective methods include mindfulness and journaling.
Mindfulness is the present-moment awareness of thoughts, feelings, and sensations. When one practices tuning into their mind and body, they can understand their baseline and know when something is amiss. When practiced regularly, mindfulness helps organize thoughts and diminish overwhelming emotions.
Journaling, or simply writing down thoughts, is a great method to understand and organize events and thinking-trap pitfalls. One can jot down how experiences have affected them and may begin to sense relational patterns. Writing also helps writers understand themselves and can lead to solutions.
On a more social level, engagement with others helps one understand their own thoughts, biases, and conclusions. Community is essential for fulfillment, purpose, and motivation. In military studies, unit cohesion and morale are the best predictors of combat resilience.6
By practicing awareness on a continual basis, you begin to understand yourself on a deeper level and thus others in a more profound way. Empathy arises when you can see the connection between a person’s situation and how they’re thinking, feeling, and acting—because even though the context may be different, they too have had similar feelings or endured hardship in their lives.
With the right mind-set and tools, stress in our workplace can be used productively. Practicing awareness and the four pillars of mental toughness can help buffer us against the inevitable difficult situations we face and can assist us with cultivating resilience.
1. Agaibi CE, Wilson JP. Trauma, PTSD, and resilience: A review of the literature. Trauma Violence Abuse, 2005 Jul; 6(3): 195–216.
2. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation, 1999 Apr 27; 99(16): 2,192–217.
3. Tatomir A, Micu C, Crivii C. The impact of stress and glucocorticoids on memory. Clujul Med, 2014; 87(1): 3–6.
4. McAllister M, McKinnon J. The importance of teaching and learning resilience in the health disciplines: A critical review of the literature. Nurse Educ Today, 2009 May; 29(4): 371–9.
5. Draeger L. Navy SEAL Training Guide: Mental Toughness. Special Operations Media, 2013.
6. Williams J, Brown JM, Bray RM, et al. Unit cohesion, resilience, and mental health of soldiers in basic combat training. Military Psychology, 2016; 28(4): 241–50.
Veronica Ryl, EMT-P, CP-C, is a Canadian paramedic who has been in the industry for 11 years. She works for a busy metropolitan 9-1-1 service as a community paramedic and serves on a specialized mental health team. She is also an instructor on mental health readiness.