Getting to the Roots of Resilience

Getting to the Roots of Resilience

This is the last of a three-part series on stress and resilience in EMS. Find the first part at www.emsworld.com/article/219949 and the second at www.emsworld.com/article/220171

When one enters the EMS profession, there is a strong chance they will feel—at least initially—they are immune to the effects of accumulative stress. This is a natural feeling at first, when you have yet to witness the insidious effects of long-term stress and have not yet accumulated the experiences to know how you’ll respond in such situations. 

Thankfully, the old EMS mentality of “bucking up” and the notion that “if you can’t handle this, then the job is wrong for you” is beginning to unravel as evidence mounts on the effects of stress on first responders. In one study 16% of paramedics were found to meet PTSD criteria.1

We are not robots. We bring prior life experiences with us when we begin working in EMS. Human beings are a complicated matrix of thoughts, emotions, associations, and physiological responses. It is virtually impossible to not have certain calls that affect us more acutely than others, or to not have some that linger for an extended time. In fact, we may think we’ve forgotten about a traumatizing call, though it may still manifest itself subconsciously in seemingly unrelated ways such as poor sleep, irritability, or avoidance.2

So how can practitioners be better prepared to recognize where our personal triggers lie? And what can we do to minimize the harmful effects of prolonged stress in the face of triggering events?

Our History Tells a Story 

Understanding our internal processes paves the way to insight and liberation. As humans, our life perspective is a collection of past experiences as well as emotional responses, fragments of memory, instinct, and sensory awareness. Our brains store memory, as do our bodies.3 As well, chronic stress and negative emotions influence the rate of secretory immunoglobin A (SIgA), which can cause immunosuppression.4

In some instances we may not have had much choice with prior life experiences, but these experiences still aid in shaping us. They can affect us negatively, as one study on the origins of addiction quotes: “The compulsive use of nicotine, alcohol, and injected street drugs increases proportionally in a strong, graded, dose-response manner that closely parallels the intensity of adverse life experiences during childhood.”5

How does this information serve us? Contrary to how it may seem, our prior life events do not have to chain us or predict our future behavior. Devastating events can offer a doorway into profound insight, if reconciled both mentally and physically.6 By digging into our past experiences, we can begin to piece together why we might be sensitive to certain situations or why a certain genre of call bothers us more than others. By its nature this type of personal investigation consists of deep work; therefore, depending on the magnitude of association, it may be appropriate to work with a registered psychologist. 

Our timeline in our lives is like a tree branching out, beginning from the trunk and splitting off into more and more branches moving upward. This analogy illustrates how trauma, or accumulated stress-related responses, affect us. One initial traumatic event is the trunk of the tree, and subsequent events make up the branches splitting from it.

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The key to managing these subsequent stress events is to trace back the origin of their branches to the trunk. Recognizing where these associations originate can help one better understand their own fears, biases, limitations, and beliefs, as well as help process the initial event completely. This then sows the ground for liberation in the future. Processing the trauma is an act of reconciliation that accepts and digests the past event while simultaneously practicing present-moment awareness.

The Color of Your Lens

When we start work in EMS, we likely begin to realize our career is more than high-acuity, fast-paced action. We encounter situations of all varieties, from a sliver in the foot to an unresponsive drowning victim. Interactions also come in the form of someone needing emergent housing, an elderly patient requesting additional home care resources, or someone suffering a mental health crisis.

We may begin to learn that some situations don’t have easy answers. A lot of our job consists of actively listening to people, gaining rapport in a short period of time, and attempting to grasp the nature of their crisis. 

As we begin to interact with people from all walks of life, we may also recognize where our own strengths and weaknesses lie with certain patient populations. As we all have lifetimes of experiences in our pockets before beginning the journey of the work world, we all perceive the world in different ways. When recognized this awareness can be a tremendous instrument for personal growth; conversely, when unrecognized it can be detrimental to our patients and our own self-care.

To minimize the barrier of recognizing our biases, we must eliminate the shame and stigma of having them in the first place. Everyone has negative thoughts and can be judgmental, but the key is to recognize that these thoughts don’t have to define who we are, and we can choose to accept or dismiss them.

When we begin to dismiss these biases as they come up, they will appear less frequently over time. Consciously distancing the negative or judgmental thought from personal connotation eliminates the shame associated with it, thus helping one realize where this bias may have originated.

Reconciling with our prior experiences and understanding the roots of our biases is a jump start to connecting with those around us in a more meaningful way, including our patients. The EMS profession is a gold mine of potential for understanding humanity better—interaction occurs on every imaginable patient’s doorstep.

Matrix of Protective Factors

Of course there are many other internal and environmental factors that contribute to resilience. Some of these include the degree of stressful stimuli, frequency of stress responses, community or family support, societal perception, and spiritual, cognitive, social, physical, and emotional capabilities and reintegration habits.7 Evaluation of each category can be assessed personally or with the assistance of a trained professional.

The environmental context in which an individual operates is very influential on resilience processes. In the EMS realm practitioners are less likely to suffer from symptoms of depression when services allow for brief periods of downtime following critical incidents.8 CISM (critical incident stress management) peer groups in organizations can decrease feelings of isolation and extend support. External resources such as psychological sessions can greatly assist practitioners with working through stress-related symptoms. Following a leave of absence, work reintegration programs are immensely valuable for instilling confidence in moving back into one’s career. 

Sleep, Exercise, Nutrition

These three foundational aspects to well-being are reinforced time and time again, and with good reason. As biological creatures, our bodies are amazing at sustaining homeostasis without conscious intervention, but they still require basic elements to sustain function. Once these basic demands are met, we can focus our energy and cognitive powers onto higher-level tasks. A balanced body is the bedrock for developing resilience. 

Sleep is essential for our bodies to rest and for our brains to categorize and process the events of the day. When sleep is consistently disrupted, this will impair our daytime function, cause daytime sleepiness and fatigue, and lead to a decreased quality of life. Persistent sleep disturbances create the risk of developing mental conditions (e.g., depression, anxiety) and even chronic pain conditions such as arthritis, migraines, and musculoskeletal pain. Furthermore, research indicates that inadequate sleep quality negatively affects resilience.9 

As shift workers, how does this sleep dilemma tie into managing our personal resilience? It can certainly be challenging to implement a routine when work hours change from one week to the next. “Sleep hygiene” consists of implementing routine schedules involving sleep (as best as one can), ensuring the bedroom is dark and quiet, silencing cell phones or television screens in the vicinity, and limiting caffeine.

With varying shift schedules, napping strategically can also be a useful tool to bolster energy levels throughout the day and realign the circadian rhythm. Preparing yourself with a presleep routine—e.g., showering before sleep or using breathing relaxation techniques—can cue the body that it’s time for bed. 

Exercise not only conditions our muscles and releases feel-good endorphins but also regulates anxiety by increasing the activity of neurons that inhibit excitement in the ventral hippocampus.10 Thirty minutes of exercise daily can be enough to regulate both body and mind; it can include anything from vigorous running to taking a stroll in the park. Establishing an active routine can ensure that a physical lifestyle is normalized, and long-term benefits follow. 

The food we eat is associated with our mood, behavior, and cognition. Eating highly processed food over a prolonged period has been linked to mental health conditions such as depression; conversely, long-term stress can impact nutrition absorption or even influence brain development.11 There is also a strong link between immune function and proper nutrition. Ensuring a well-balanced diet rich with whole foods, protein, and leafy greens is vital in the journey of resilience. 

These factors may sound like basic knowledge, but with the pressures of everyday life, combined with shift work and the challenges of stress in the EMS profession, they truly represent a balancing act that requires special attention. 

Conclusion

Resilience can be thought of as a matrix between our present and our past, as well as internal and external factors. The one commonality that ties all these aspects together is the part that makes us human: our prefrontal cortex, with its ability to make conscious choices. 

We can choose to understand ourselves at a deep level and explore how our perception relates to the world around us. With this understanding we can begin the task of building a life in which we can bounce back from adversity and adapt to both professional and personal stressors.  

References

1. Fjeldheim CB, Nothling J, Pretorius K, et al. Trauma exposure, posttraumatic stress disorder and the effect of explanatory variables in paramedic trainees. BMC Emerg Med, 2014 Apr 23; 14: 11.

2. Babson KA, Feldner MT. Temporal relations between sleep problems and both traumatic event exposure and PTSD: a critical review of the empirical literature. J Anxiety Disord, 2010 Jan; 24(1): 1–15.

3. Mate G. When the Body Says No: The Cost of Hidden Stress. Vintage Canada, 2004.

4. Jones and Bartlett. Managing Stress in Emergency Medical Services, http://stress.emszone.com/instructor/mindbody.html.

5. Felitti VJ. [Origins of addictive behavior: evidence from a study of stressful childhood experiences.] Prax Kinderpsychol Kinderpsychiatr, 2003 Oct; 52(8): 547–59.

6. Levine PA, Frederick A. Waking the Tiger: Healing Trauma. North Atlantic Books, 1997.

7. Kumpfer KL. “Factors and Processes Contributing to Resilience: The Resilience Framework.” In: Glantz MD, Johnson JL (eds.), Longitudinal Research in the Social and Behavioral Sciences. Resilience and Development: Positive Life Adaptations. Kluwer Academic Publishers, 1999.

8. Halpern J, Maunder RG, Schwartz B, Gurevich M. Downtime after critical incidents in emergency medical technicians/paramedics. Biomed Res Int, 2014; 2014: 483140.

9. McCuistion TS. The Relationship Between Resilience and Sleep Quality. Digital Commons @ACU, https://digitalcommons.acu.edu/cgi/viewcontent.cgi?article=1008&context=etd.

10. Schoenfeld TJ, Rada P, Pieruzzini PR, et al. Physical exercise prevents stress-induced activation of granule neurons and enhances local inhibitory mechanisms in the dentate gyrus. J Neuroscience, 2013 May 1; 33(18): 7,770–7. 

11. Dietitians of Canada. The Role of Nutrition in Mental Health Promotion and Prevention, https://www.dietitians.ca/Downloads/Public/Nutrition-and-Mental-Health-1.aspx.

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.

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