Integrating Provider Resilience into EMS System and Community Resilience
A Rural EMS System’s Experience
By Ezekiel Peters, NRP, Esq.
Since 2013, the Colorado Department of Public Health and Environment Office of Emergency Preparedness and Response (OEPR) and Clear Creek EMS have been developing a useful first-responder resiliency program. This article describes the development of the OEPR program and Clear Creek EMS' attempts to use and develop the OEPR resources from my perspective as a paramedic and the deputy chief of a small, rural EMS system. We have reached the point in our experience where we have as many questions as we do answers. We propose two new approaches: One macro, involving how we conceptualize and talk about the problem of provider resilience; and one individual, using auricular acupuncture treatment for chronic stress.
Much of my formative paramedic and field training officer (FTO) experience was at the Denver Health Paramedic Division. As a result, I associate having a successful, healthy and long paramedic career with strong mentoring relationships. As a part of a close-knit community of professional paramedics, I expect to keep an emotional distance between work and "non-work" activities. I don't expect as a matter of course to encounter insurmountable emotional difficulties with or from my work. However, I am able to see that while these and other resiliency techniques and relationships work in many cases, they are also prone to unanticipated and catastrophic failuresâ€”as evidenced by the EMS provider suicide rate. I also suspect there are EMS workforce, cultural and generational changes that make these traditional resiliency approaches less relevant to and effective for newer providers.
The OEPR Responder Resiliency Program stood out from its inception for its different approach. There was an extended scoping period and needs assessment that engaged responders and academics from many different backgrounds before offering any products or services. These included sincere attempts to understand EMS- and agency-specific cultures, with particular efforts to understand the roles of field training and mentoring in agency acculturation, professional identity development and individual resiliency. The responder self-help materials the OEPR ultimately curated and created are unusually relevant, intelligible and available on the CDPHE website.
In late 2014, Clear Creek EMS's entire leadership teamâ€”two chiefs and three shift captains' met several times with the OEPR Resiliency Program manager. As we worked with the OEPR materials, we judged them effective tools for building individual resiliency. However, the leadership agreed there were still unmet needs to, (1) create an agency culture of continuously engaging in resiliency-building activities, and (2) explicitly promote provider psychological resilience as a core agency value and capability. We saw an imminent major hiring with an academy and field training program restructuring as an opportunity to inculcate these values. The OEPR agreed to partner with Clear Creek EMS in creating this agency-specific implementation.
The OEPR, using academic literature from other settings (e.g., U.S. Air Force suicide prevention), helped Clear Creek EMS identify existing strong predictors that we could implement a successful resiliency program, including:
- A culture of physical wellness, including healthy eating and exercising in the stations and a shared interest in physical activities outside of work
- A history of leadership support for employees taking planned and unplanned time off from work
- The entire leadership is open about its concerns with improving provider resilience.
In fact, while we were formulating a longer-term provider resilience plan, individual captains began meeting semi-formally with their paramedics and EMTs at the beginning of each shift to do an exercise from the First Response Resiliency manual or the National Fallen Firefighters Foundation "Stress First Aid" online training.
Despite Clear Creek EMS's understanding and acceptance of the provider resiliency problem and our strong predictors of success for implementing a successful program, we were completely distracted from continuing this work in 2015 by a series of deaths in the Clear Creek community and the Colorado public safety communityâ€”including one of Clear Creek EMS's own paramedics. I took away two major lessons from this 2015 experience which will help guide our next round of provider resilience activities.
- Low provider resilience is an under-prioritized hazard. After the well-publicized February 2015 suicide of my former Denver Paramedic colleague Deb Crawford, Clear Creek EMS had a staff meeting facilitated by OEPR to discuss provider resilience. My staff told me in no uncertain terms that low individual resiliency requires sustained attention and should be more highly ranked in the litany of other risks we chiefs are endlessly trying to mitigate (e.g., roadway, driving, and natural hazards; violence against providers; etc.). While the self-harm examples are becoming more apparent, I assume there is far more individual provider (and therefore EMS system) incapacitation from unrecognized or unacknowledged work-related social and behavioral problems than from most other hazards.
- Low provider resilience is a hazard characterized out of context and at the wrong scale. EMS systems are broadly under-resourced and struggle to address minor shortages or increases in demand. The interdependence of individual resiliency, community resilience and EMS system resilience simply reveals itself more quickly in our rural setting. For example, Chief Johnson and I will often leave the office, get a reserve ambulance and become a paramedic crew to address spikes in demand. But one of the 2015 deaths involved Chief Johnson delivering care, first as a bystander, then as a responder, to a friend and community member. For several weeks after this event, Chief Johnson explicitly decided to remove herself from running ambulance calls as part of her psychological self-care. Having her out of service during what happened to be a particularly busy time of year had clear impacts not only on Clear Creek EMS's short-term ability to scale to meet demand, but also on neighboring systems in the region who supplied us with mutual aid ambulances.
While it might seem far-fetched to extend this rural example to urban EMS systems, we know from Denver metropolitan regional planning activities' Clear Creek is part of the 10-county Denver Urban Areas Security Initiative (UASI) the region's EMS systems have a workforce that is shared to an unknown extent. For example, we know that almost every one of Clear Creek EMS's part-time employees has a full-time clinical job in another agency. And we know that many providers in the region like myself were personally impacted by deaths of former colleagues in other agencies. We simply do not have a good understanding of how impacts on and from individual providers can and do ripple through the region. But if we continue to focus on individual provider (psychological) resiliency apart from its context in the broader community, EMS system and region, we fail to understand both the scale of the risk from and the multiple avenues by which we might address the low provider resilience hazard.
There is also a strategic advantage to discussing the low provider resilience hazard in context EMS chiefs are far more skilled and experienced talking about threats to our workforce if they're not explicitly psychological threats. Years ago, Clear Creek EMS and its neighboring agencies recognized their limited ability to scale in response to physical loss or incapacitation of personnel” a problem exacerbated by the potential for regional incidents with competing demands for "shared" personnel. They agreed that if the chief of an area EMS system declares her system incapacitated due to line-of-duty death, injury or other inability of its personnel to continue operations, the neighboring systems will pool equipment and responders to operate the incapacitated system for 72 hours.
Despite the previous two lessons, we're still struggling to prioritize and operationalize effective mitigation of the low provider resilience hazard, so we're going to try acupuncture. Why do I think we'll get acupuncture implemented when other provider resilience activities have stalled? EMS providers don't have the resources to prioritize self-care. We avoid talking about our feelings, especially if we don't perceive ourselves as having an acute problem. We are doers who need to do something and have something tangible done to and for us. But we can usually keep an appointment. "Normal people" get acupuncture for general wellness, so it's an easy sell to the providers, and it's easy for agency leadership to take the lead in receiving treatment.
We also believe acupuncture will provide significant benefit. Acupuncturist Steven Shomo is experienced in using a widely accepted auricular acupuncture protocol in group settings for PTSD, first-responder stress and secondary trauma. We are fortunate in Colorado to have an acupuncture-based Medical Reserve Corps unit, also affiliated with OEPR, for which Shomo is the training coordinator. The acupuncture MRC was deployed to Colorado Springs in the aftermath of the November 2015 Planned Parenthood shooting. Colorado Springs responders were among those treated using the protocol, in which needles are placed in the ear for 30 minutes while patients sit upright in comfortable chairs. Chief Johnson has received this treatment from Shomo on several occasions. These responders enthusiastically confirm the expected benefits of immediately improved sleep and ability to cope, while commenting about how great it is that "you don't have to talk to anyone."
We are working toward a six-month acupuncture trial using regional treatment centers that are opened weekly to all first responders at the Denver Health Paramedic Division and Clear Creek EMS, including backfill so on-duty personnel can receive the full benefits of treatment. We are taking this approach for several reasons:
- It provides rural and urban treatment locations while acknowledging the reality of our regionally shared workforce;
- It anticipates, if successful, the need for a regional long-term service delivery capability that can be scaled or shifted in response to acute events; and
- It might provide a trusted physical site where complementary services could eventually be offered in addition to acupuncture.
If the initial trial is successful, we hope to attract an academic partner to do more scientifically rigorous and larger scale testing on this approach to improving responder resilience.
Ezekiel Peters, NRP, Esq., is Deputy Chief Paramedic at Clear Creek EMS in Dumont, Colo.
Peters is a licensed attorney and paramedic with an academic background in public health and environmental policy. For over 25 years, he has worked in EMS, with an emphasis on resilience-building activities. Prior to joining Clear Creek EMS three years ago, Peters managed the University of Colorado Natural Hazards Center's national information clearinghouse. He continues to work on initiatives to make academic knowledge more useful and accessible to practitioners and to improve information exchange across hazards disciplines.
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