MD Roundtable – Avoiding PTSD

Avoiding Post Traumatic Stress

Looks like we got a great topic tonight, and it’s a very, very good topic because becoming more prominently known. I remember the days, and I know you do, Dr. Eschelbach, where people looked down on you if you had mental health issues, especially related to the trauma involved in the job. So I’d like to introduce you all to Dr. Matthew Eschelbach.

He’s an Associate Medical Director for us, and Assistant Medical Director, I’m sorry, and he is up on the Northwest Coast. He is in charge of the medical school program there, as well as Indiana’s Medical Director for many years, and teaches on the circuit up there. So, because I have a lot of extra noise here on this end, I’m going to mute myself and turn this over.

All right. Good evening, everybody. Usually, we spend a lot of time and topics and time on things that are going to be on your test and things that are going to be on boards and passing tests, etc.

We’re going to go off-course a little bit and personalize it a little bit tonight, and I hope to get through all of this. If I don’t, we can talk about it at a future time, or you can send me an email, if you’d like, but we’re going to talk about wellness in general and avoiding PTSD, and we’ll go from there. This isn’t Psych 101, and we just want you to leave with an understanding of what post-traumatic stress disorder is, who is susceptible, how to recognize it, and develop a plan in your department to deal with it.

If, for example, you join a agency and they don’t have a plan, you can help construct one, and we’re just going to talk about some SAGE advice for others. So, let’s talk a little bit about PTSD. There’s a condition in combat, most people know about it, it’s when a fighting person’s nervous system has been stressed to its absolute peak and maximum, can’t take any more input.

The nervous system has either snapped or is about to snap. In the First World War, that condition was called shell shock. Simple, honest, direct language, two syllables, shell shock.

Almost sounds like the guns themselves. That was 70 years ago. Then a whole generation went by, and the Second World War came along, and we, the very same combat condition was called battle fatigue.

Four syllables now, takes a little longer to say, doesn’t seem to hurt as much. Fatigue is a nicer word than shock, shell shock, battle fatigue. Then we had the war in Korea, 1950, Madison Avenue was riding high by that time, and the very same combat condition was called operational exhaustion.

Hey, we’re up to eight syllables now, and the humanity has been squeezed completely out of the phrase, it’s totally sterile now, operational exhaustion. Sounds like something that might happen to your car. Then, of course, came the war in Vietnam, which has only been over for about 16 or 17 years, and thanks to the lies and deceit surrounding that war, I guess it’s no surprise that the very same condition was called post-traumatic stress disorder.

Still eight syllables, but we’ve added a hyphen. And the pain is completely buried under jargon. Post-traumatic stress disorder.

I’ll bet you if we’d have still been calling it shell shock, some of those Vietnam veterans might have gotten the attention they needed at the time. All right, so the late great George Carlin, who was very good at pointing out inaccuracies sometimes, but I’m gonna disagree with Mr. Carlin a little bit because they are, I would say those symptoms are a continuum of the same thing and not necessarily distinct. I’d say that we’ve evolved in our understanding over the years.

So what is the sympathy versus empathy? Sympathy is, I feel bad for you because your dog gets hit by a car. I feel sorry for you that you’ve lost your pet. But empathy is, my dog got hit by a car, therefore, I’m not only sorry because of the loss, I feel that loss with you.

And that’s where we have to understand that sympathy and empathy are so important in the wellness of EMS. So I’m going to go over a couple of quick case histories here. I’ll be very quick.

And these are things that I want you to understand that I have empathy for you because I have been through similar states. So all of these next cases are my cases. 17-year-old female, and this is a fourth-year student, medical student who worked at St. Joseph Medical Center in Philadelphia.

And if you wanted to go into emergency medicine, this was a clerk shift that you really wanted to get into because you had really almost total control of your patients as a student, which never happened. So the patient comes in, a complaint of abdominal pain and vaginal bleeding, and she was assigned to me, the fourth-year student, for evaluation. She denied a past medical history of being sexually active, blood pressure of 120 over 65, pulse a little tacky, respirations on the borderline, no fever.

And as I did a vaginal exam on this young lady, I saw a foot protruding from the cervix. And this is essentially what I was seeing, this tiny foot coming out of the bleeding cervix. Well, this woman, young woman, went on to deliver spontaneously a 25-week-old fetus, and the mother at that point in time said, well, you’re not going to save it, are you? And of course, you know, I said, yes, we are.

I mean, this child is breathing. And at that very same time, my attending physician, the person who had an actual license, got pulled away because a gunshot was brought to the ER as this child was being delivered. Now, there’s no OB in-house.

There was no ER resident, no ER attending, and anesthesia had gone to the trauma bay, and I had no intern in the ER. So I called a code and took care of it myself. I started an umbilical line.

I was able to intubate the child, and then I gave the child atropine, did CPR, and eventually Hahnemann neonatal resuscitation unit showed up, but the child by that time had died. Another time, Mountain View Hospital, early in my career, a five-year-old Hispanic male was brought in by EMS after a cattle gate. This is a cattle gate.

They put them together at the fairgrounds, and he climbed on it, and it fell on top of him. He was found pulseless, apneic, and cyanotic, and it was not known how long he was down. EMS began CPR and transported him to the ER.

He had no IV. He was being bag-valved. CPR was in progress.

No discernible blood pressure, heart rate, any of that, so I began a code. Anesthesia showed up and intubated the patient, and we worked on this patient for a long time. I did a cut down for IV access.

I continued for 75 minutes, almost an hour, hour and a half, and we never returned pulses. After, now, nearly two hours after the event, I had to go out and say to his immigrant parents, you know, lo siento. Juan had already died.

A 14-year-old male was brought in a few years later in my career. A 14-year-old male was brought in from Crooked River Ranch after an accidental gunshot to the right chest. They were, they found a gun in dad’s home, and they took it out to shoot it at the cinder pit, and the daughter mistakenly shot her brother in the right chest.

Again, they brought in with no vital signs. I did a cut down by myself, and the surgeon opened the chest in the ER for a direct cardiac massage. Sixty minutes later, the code was called.

We found in doing our own post right there that the bullet had disrupted what’s called the azygous vein, and that patient essentially bled out immediately, and you know, his heart and vessels were just too injured to go on. And then, this was just a few years ago, a 53-year-old man took a gun to his right temple and pulled the trigger. It was unwitnessed, but the girlfriend reported that there was a recent divorce from his wife, and his wife was in child custody dispute, and he had lost his children.

He was intubated by EMS, large-bore IVs. When he came in, he had pretty good vital signs and a good wave form. GCS, of course, was three.

We called a trauma code, and we spent two hours on this gentleman, trying to keep him alive, eventually admitted him to the ICU just long enough for the transplant team to come in and harvest organs. So, paramedics reported to me this case, a 19-year-old girl who hung herself in a tree, crumpled note in her hand that said goodbye. Her mother collapsed when she was told that her daughter died.

The father wept, and the paramedics said a chill crept into your spine, and you go home, and you hug your daughter extra close that evening. Maybe it’s the man whose trachea was crushed in a fight who died from his injury, as you struggled with his airway, or the burns from a high-tension line that covered a teenager who, his arm was blown off from the electricity, or a 23-year-old heroin overdose who worked desperately, but you never regain a pulse, and she looks a lot like your niece. Now, these are all terrible things, things that we are going to see in our career.

I have seen in my career. Jane has seen in her career, and we do the best we can to bury them, put them down, get them out of our mind, do something else, but they are personally disturbing incidents. So, what is PTSD? You say, I’m fine.

I’m okay. When a member of your team comes up to you after a traumatic event, and violent acts or acts of loss, like I have just described, are all part of the stressors called personally disturbing incidents or events, and they can lead to PTSD, which is unrelenting, a recollection of those images that interfere with the normal thinking and sleep. Now, we’re not that far from about two weeks ago, where every image on the television, on the History Channel, on 9-11, was about what happened on the day of 9-11.

We don’t have to watch the news very long before we find out how something’s going on in Gaza or somewhere else, so we wind up with these ticking time bombs. Our compadres may worry about us, but we tend to hold the stiff upper lip and say, I’m fine, and, you know, the EMS here is denial, and what does that lead to? He says, I’m a rock, but is he really a rock? So, a PDI, a personally disturbing incident or a critical incident, is an event that’s overwhelming enough to threaten, to overwhelm your normal coping mechanisms. Findings vary from non-harmful outcomes.

Some people just let it roll off their back, and some people will develop post-traumatic stress disorder. So, what is PTSD? It comes down to bad memories, a withdrawal from the things that you like, and then added stress on top of that. The withdrawal can be from your family.

It can be from your job. It can be from the things that you hold dear to you. The memories could be of that day, of that event, of that face that you saw as you looked up and realized that you were not going to be able to save this person, and the stress that comes in every day as you work.

What’s the criteria? Well, the person has experienced or witnessed or been confronted with something that involves actual or threatened death or serious injury to, you know, themselves or others. The person’s response involved intense fear, helplessness, and horror. Just think about that.

As you roll up to a scene in the middle of the night, you smell alcohol, you see the broken bottles in the back of the car, and you see dead teenagers inside and somebody who’s at the wheel who looks like they’re about to expire. So, it’s susceptibility at its highest when rescue efforts fail for the victims. So, if you save two or three people and one person dies, the PTSD doesn’t come to get you as much as it does for the failed victims.

It’s heightened when these occur in children or among those known by providing medical care. So, if you think back of my episodes, I had a 14-year-old who got shot in the chest, a 25-week-old baby who died because of a negligent mother who, turns out, you know, tried to do her own abortion at home, and people, the hung victim, all of these are children making things even harder. So, there was a study done and they looked at EMS recruits, people like yourselves, over two years, and up to eight percent of them can develop an episode of PTSD, 10.6 percent, some type of major depression.

All but nine cases, about 2.3 percent, showed they were still around after four months. At two years, episodes of PTSD or follow-up was still around. So, they don’t just come and go.

It’s not something that’s gone in a shift or two. Can we predict it? Well, we can show that rumination of memories and stressful events will start with a PTSD. So, participants who are at risk for developing episodes of PTSD or depression could be identified in the very first week of training if once they get out, meaning if you’re a new hire, they can do tests to find out if you’re subject to possibly being a victim of PTSD.

That’s very forward-thinking. Most agencies won’t do that. So, PTSD could also be the result of increased hostility and liability, but there’s a fair amount of denial or masking that goes on.

New events can trigger a learned response from a prior trauma, so you might decide well, I’m not going to go to this call. I’m going to go fight the fire instead, or you might go take, when you get to the scene, you go to the car that you know that the victims are not hurt as badly. ER docs, nurses, EMTs can get what’s called vicarious traumatization when dealing with so much trauma.

Exposed to it every day, we almost become numb, and a trigger or a flashback happens more likely than people will admit. The main symptoms of PTSD are repeated or unwanted re-experiencing of the event, whether it’s when you first show up on the scene and you smell gasoline or maybe you smell beer on the floor. There is some kind of stimuli that will give you some re-experiencing of the event.

Many people who develop PTSD recover without treatment over the next few months, but a substantial subgroup, up to 40 percent, can have symptoms that persist for many years. So, Charlie Brown said, even my anxieties have anxieties. PTSD is strongly associated with recent critical incidents, especially when you have a feeling of helplessness, like there’s nothing you can do to help the person, and it becomes persistent when you process the trauma in a way that leads to some kind of serious threat to your psyche, and the sense of threat arises as a consequence of excessively negative appraisals of the trauma, meaning you keep saying, Oh, I wish I could have done this.

I wish I could have done that, if only this, that, or the other had occurred. Sometimes you can get recurrences by visitations to a geographic location. You might not even realize it, but all of a sudden you realize that, as you’re passing a certain light or underpass, that, Oh my gosh, you get these feelings of dread all over.

You could have visual or audible nightmares and flashbacks, and when flashbacks occur, they can be debilitating. You might avoid aspects associated with the situation, whereas, for example, you come upon a scene, and the next time you don’t go to the big car. You go to the car that shows less trauma, as I said before.

You go take care of the bumps and bruises where you have your compadres and your mates and friends take care of the really hard stuff. People will also wind up with something called psychogenic amnesia. I’m going to talk to you about that in just a little bit, but that’s an inability to recall an important aspect of the trauma.

You wind up almost detached and isolated, and it can lead to mood and sleep pattern problems. It can possibly even lead to alcohol and drug problems, and you’re constantly exposed to things that will remind you of the trauma. Now, psychogenic amnesia.

I’m going to set up the scene. If you do an internet search for the saddest scene in television, you’ll come up with this one. I’ll give you just a setup.

It was the end of the Korean War, the show was M.A.S.H., and Alan Alda played Dr. Hawkeye Pierce, a surgeon in the M.A.S.H. unit. He had an event happen, and he winds up at the very end of the show in a mental institution, and here he is being interviewed by a psychiatrist. You want to tell me what you and BJ were talking about? Same thing he always talks about.

What’s that? Fingers, smiles, teeth, booties. Was there anything about that you found upsetting? No, I’ll tell you what I find upsetting is being in here. I want you to get me out of here.

I don’t care how you do it. You can put me on a plane, on a train, on a bus, on a slow boat to China. I’ll go out on a mouse-drawn chariot.

I don’t care what. A bus, huh? Again with the bus? Why don’t you subscribe to Arizona Highways and leave me alone? It’s more fun with you. Keep that damn chicken quiet.

Then what happened? Then I went back toward the front of the bus. And what happened next? There’s something wrong with it. It stopped making noise.

It just, just stopped. She killed it. She killed it.

She killed the chicken? Oh my god. Oh my god. I didn’t mean for her to kill it.

I just wanted it to be quiet. It was a baby. She smothered her own baby.

You son of a bitch. Why did you make me remember that? You had to get it out in the open. Now we’re halfway home.

So in this scene, they’re in a bus and there are soldiers, North Korean soldiers around the bus. They’re trying to hide and the baby’s crying and this woman killed her own child in order to keep it from crying and Hawkeye turned that into a chicken. So that’s situational amnesia.

Believe it or not, this is much more common in younger care providers who don’t have strong ties or family or are particularly vulnerable, people like yourselves. Older adults who have been through this before have a network of social support that have a more built-in buffer. ER physicians accumulate significant more stress compared with other salaried physicians like internists or perhaps ICU doctors, etc.

because we see things like you just saw. So what doesn’t work is a coping style where you say I’m fine or you say, you know, suck it up, which is maybe the way that they dealt with it in the past. Suck it up and get over it.

There’s a famous scene from a movie about George W. Patton who slapped a patient who had battle fatigue or PTSD or shell shock and he slapped him calling him a coward because he had gone through so much trauma and that’s not going to work. Obviously other people don’t believe that either. Patton almost lost his command.

So how does a PDI convert to PTSD? Well, in cultures that value action over talk where you’re discouraged from seeking emotional support, things like that can happen. If you think back to our recent Olympics four years ago, Simone Biles had a case of I am sorry, I can’t remember, the topsy turvies or something like that and she actually had to leave competition and a lot of people said, you know, just suck it up. You’re an Olympian.

Well, she came back and showed everybody that they were wrong, but that was a culture that values action over talk. Sometimes not sharing what’s going on. You shield your loved ones.

You don’t want them to know just how cruddy your day was and you don’t talk about anything. Maybe you talk about the weather or a baseball game and not sharing damaging experiences is a very bad thing. Or you might have shame or guilt because you feel that you could have done better or should have done better.

More than four percent of 159 positions in rural and remote areas of Canada met criteria for PTSD with over work, lack of resources and relational problems and a personal disturbing incident can happen even in a situation where there’s not the remotest chance of a different outcome, meaning somebody is dead at the scene and they’re impaled by a large pole through their chest. For some people, there’s no way you could have done anything, but there’s no chance for a different outcome, but you still feel guilty. Four percent of EMS personnel in Hawaii in a Hawaiian survey had criteria for PTSD and 83 percent had some symptoms of it.

Analysis shows that serious injury or death of a co-worker, especially those involving children, will help convert a PDI to PTSD. So, left untreated or unaddressed, we tend to form detachment over the reaction to patients and this can begin to occur. It’s the same thing as burnout in a certain way.

When people lack the ability to find fulfillment in their job anymore, you wind up becoming detached from your job. If you downplay the symptoms, like it’s only providing lip service, if you downplay symptoms where you really should be seeking some care, that can be a problem. Some people with PTSD can over-identify with someone seeking medical attention in a way that makes the health care provider seem like a crusader.

Expressing anger at not being able to do enough in a particular patient, you know, railing at the system. You come home from a call and they just go on and on about the terrible things in society. That’s also a contributor.

And then you can wind up getting hostility towards your colleagues and breaking boundaries. What are coping strategies? These are all, you can read them, but you know, talking with colleagues, thinking about the positive benefits of work, you know, sometimes I would come home from a long shift in the ER and as the garage door closed and I all turned off my car, I would sit there with my hands on the wheel and go, I love my job. I love my job, you know, or thinking about happy things like outside interest, your family, what you’re going to do when you get off duty.

We are all guilty of black or dark humor, so much so that rarely, if ever, do people in emergency medicine or EMS ever turn each other in for inappropriate or dark humor. Sometimes people will use mental health services, but look at this, only 50 percent, that’s terribly low, and then talking with the spouse is also pretty low. D, constructive coping strategies, keeping things to yourself, don’t talk about the calls, picking or choosing calls, doing the bare minimum of the work required of the individual, alcohol and risky behaviors are all part of deconstructive coping strategies, things that are bad for you.

What they found is the best thing to do is talk about downtime and that’s the optimal period for downtime was between less than 30 minutes to the end of a shift, meaning very often a proactive thinking captain or a shift provider will say, you know, that was a bad call. I’m going to take you out of service for a little while and I want you to do chart reviews, whether it lasts a day or two days or something like that. The further you get away from the event greater than a day, these things become less effective.

So the best thing to do is if you see a colleague who had a really bad time from something happened on a call, refer it to your shift commander and say, you know what, I’m worried about Hank because Hank really bonded with this gal and then she died. I think he needs help. So bringing that forward, is not snitching on your partner.

It’s helping. Sometimes this downtime you have to look for things with lower depressive symptoms and sometimes people will have a faster recovery from acute stress and since depression is an important long-term outcome of critical incidents in EMTs, paramedics, a brief downtime period may be worthwhile for organizations to adopt. So we can’t give everybody a day off, but those who are involved in the meat of the shift or in the meat of the treatment of that patient, they might need some time off.

They might need a day off. They might need a day out of the rig and a day of, you know, chart review. I want you to study intubations and missed intubations and something like that.

It’s not busy work. It’s something to get you out of harm’s way. How do you prevent it? Well, it can occur even in the most nurturing environment.

When I had a case that went bad, I always tried to get my nurses together with anybody who took care of that patient for a debriefing. What do you think we could have done better? Well, I don’t think we could have done anything different. I think this person was their own worst enemy and there’s nothing we could have done or maybe we could have involved social services a little bit early.

So but even then it can happen. So cognitive behavioral therapy is expensive, but something that departments should consider. So, you know, put your nickel in the can and go talk to somebody about it.

So you might say you have a problem, you talk to your captain about it, or your chief, and the evaluation can vary widely depending on how good the evaluator is. They can help you with the professional evaluation. It can take anywhere from 15 minutes to eight hours to get it done, and sometimes it takes a lot of in-depth questioning to get through it.

More thorough assessments can include interviews, psychological tests, family members might be brought in for discussion, especially if it’s affecting your home life, and you might even just get a physical exam to make sure that everything is okay so you don’t have a condition that’s making things worse. So treatment can be broad, like I said, individual or group support, and that’s very good for chronic PTSD, and some people might need medication, something that helps them sleep for a week or antidepressants even. What’s very important is the debriefing.

Some type of debriefing with your colleagues or other EMTs to talk about the situation. Is there anything that you could have done to avoid this? Stress debriefing, along with medication and psychotherapy, might be helpful. If you develop chronic PTSD, you might need group and individual psychotherapy, and for kids, adolescents, psychotherapy is probably the best treatment.

Exposure therapy is education about common reactions to trauma, learning how to control your breathing, and the goal is for the traumatic event to be remembered without anxiety or panic. Cognitive therapy will separate those thoughts from the anxiety they produce, and stress inoculation training is variants of exposure, of trying to teach the client to relax and think about, when they think about the traumatic event, learning to follow a script, like you did everything you could. There’s nothing you could have done to prevent that death.

Sometimes, they have to reinforce self-monitoring of your thoughts, what you’re thinking and how you act towards those emotions, and identifying the emotions and how to work to get rid of them. These are all things that psychologists can do. I like the fact that you were able to help people in their hour of need.

For 20 years, Wade Walker was a paramedic in regional New South Wales, but now, even after leaving the job, what he saw continues to haunt him. It’s burnt there on that DVD that’s in your brain. It’s there for life.

In 2010, Wade was called to an accident on the Pacific Highway in Almora, north of Coffs Harbour, where a B-double truck had ploughed into a ute driven by a young man. Whilst we were getting him out of the vehicle, I had to go and vomit. I just felt so sick, just to see him struggling for air and, you know, the smell of diesel and fuel and the wreckage.

In the previous six weeks, Wade had been to 11 major accidents that resulted in five deaths. A week later, in hospital, the man in the ute also died. I started not sleeping at night, just having horrific nightmares.

You can’t isolate yourself. You’d see something on the news. Even though you weren’t there, I would relive it that night as if I was there.

People, you know, like ambulance officers or fire officers or policemen, in fact, probably have more traumatic exposures than military personnel do. How can you come home and tell your parents or your wife or whatever that, you know, you’ve just seen a baby die or someone’s limbs have come off during an accident? Paul Hornett was a police officer for 11 years. His beat included some of the country’s most dangerous urban areas.

But after witnessing countless acts of violence and being badly hurt on the job, Paul began falling apart. I started dreaming about, you know, jobs and traumatic things that I’d been to early on in my career that never affected me at the time. But now I’m starting to get night terrors and nightmares and I was having flashbacks during the day.

Post-traumatic stress disorder can develop in anyone who goes through a dangerous event, leading to feelings of intense fear or horror. PTSD sufferers often relive the event in their heads over and over. They also try to avoid reminders or similar situations and may become withdrawn from others.

That it is a condition that can be readily treated as long as you get it early. The problem we have is that often people don’t recognize that they’re unwell and the system in many ways conspires to stopping them getting early treatment. At least six percent of Australians have experienced PTSD, but emergency service workers are particularly at risk.

I did have a senior manager phone me and say that I should take it to heart. I need to just get on with it and and get over it. Wade Walker resigned from the New South Wales Ambulance Service.

I had a passion to treat people in their darkest hour. Would I still like to be there? Yes. Could I be there now? No.

Paul Horner was medically discharged from the force. He’s since written a book and gives talks on PTSD to other police officers. If cops can learn about how to deal with or recognize the signs and symptoms and deal with them, then, you know, they’ll be in a much better place.

I think the essence of an effective society is where people are willing to take on roles despite the risk to themselves. If we don’t understand the psychological cost to those individuals, I think we all suffer. All right, so you can see that it affects all kinds of folks.

Let me see. There’s a couple of questions in the chat. How would I handle us? Okay, let’s see.

Let’s start at the top. Culture, Edward says, speaking of culture and PTSD, it’s been said to us in the military that the culture of specific units have a great impact on their likelihood of its members to develop PTSD. And that’s true.

I mean, you might have naysayers in the group or people who are just too macho to admit that they have feelings. I feel like leadership has really made an effort to change cultures, which is great and address it early on so it doesn’t ruin lives. That’s a fantastic thought.

Would you say the same applies in civilian EMS? Absolutely. As soon as you handle it, grab at it. Just as Mr. Carlin said, it went from shell shock to PTSD.

I think that’s a good thing. Over time, we have embraced it and we’ve given it a name. A culture shifting in a way that PTSD is talked about more and addressed more effectively.

And the answer is, yeah, we got to grab the bull by the horns. Like I said, in the early, early days of my medical training, I remember the day that that 25-week baby died. I just went home and cried.

That’s all I could do. And there was no way to get any sympathy for it. Samuel says, have you found the critical incident stress briefing model to be effective? And I do think it’s effective because you communicate your thoughts to the people on the team and they can communicate back to you why you did certain things and why certain things happen.

Hyperfixating on mistakes? No, I think if done correctly, a critical incident stress debriefing takes blame off of you. So if it’s done correctly, I don’t think you’ll hyperfixate on those mistakes. Connor asks, how would you handle a situation with a friend or co-worker who continually says they don’t need any help or they don’t need to talk about it, but you know they need help? That’s when you bring in your captain, you bring in your shift commander, and you go, you know what? I think it’s affecting them.

Are there people who are quote, so cold that it doesn’t affect them? Well, there are people who are better at compartmentalizing, but I think these things affect all of us. That’s why we go into this profession to help people. And when we, when that doesn’t happen, it hurts us.

Would those who already have had PTS pass go into MS be susceptible to PTSD? Yes, I mean if you, that’s why Victoria it said that they can identify in the first hundred days of some new recruits whether or not they’re susceptible to PTSD. By certain things that they do, there’s certain questionnaires they fill out, etc. And it can be done effectively.

Is there any research, some journaling as a way to do memory dump? You know, I don’t know the answer. This could be a helpful strategy for yourself or someone else by journaling what happened. You got to be careful though, and this is the medical director in me, just be careful in your journaling that you’re not too specific about the case.

If there is a case because you don’t want somebody to get a hold of that journal and find you liable later on. When folks work in rural settings, journaling can be option supplemented by other telehealth and peer support. Yeah, that’s true.

We do have in our own group of physicians. I started a program where people can get telehealth immediately. You can talk to a psychiatrist or psychologist in the state of Oregon.

We have eight psychiatry visits a year, which are free and not on the record, so it doesn’t go into a permanent medical record for people who have had things, symptoms of burnout, etc. Okay, do you see that municipal EAP programs help with mental health and PTSD? Yes, if they’re done correctly. In a lot of options, that’s the only option for mental wellness.

However, the reason I wrote this talk and the reason I’m giving you this talk is I want you to be able to say we need a better system, so I do want all of you to be able to say we can do better. Here’s the research. Let’s not become victims, so rather than just something simple, you should be able to help.

When the video says you can catch it early, you can treat it, what types of early treatment are there? Oh, well, just as I said, there is, you know, talk therapy, critical debriefing, talking out with each other, talking to your shift commander, your shift commander reassigning you and giving you time off when you need it, maybe pulling you from the rig and putting you on a QA, QI of charts. All of these are possible if you do them early on. So my goal is not to bum you out.

You’re going to love your jobs. You’re going to enjoy your jobs, and you’ve all done your jobs or gone into this to become heroes, you know, to become the best that you can be, but don’t let your job kill you. It can.

If you take it too seriously or you take it too personally, it can eat at you, and any other questions? Anybody want to unmute and ask a question? Jane, do you have any comments? I think you missed the one above Tyler Gore’s from Eduardo Contreras. Let’s see. How much of a liability? He’s asking questions about underfunded How much of a liability can personnel with PTSD be? Okay.

Do I think we should screen them before joining? Not necessarily, but can they be a liability? Yeah. There’s in the ER, for example, people might do what we call cherry picking. Avoid the really, really tough cases like, oh my gosh, I just dealt with a homeless man last week who wound up killing himself.

I can’t do it again. I’m not going to go in to the room. I’m going to pick up the laceration of the broken femur and do the other.

Now, in large agencies, you might have a choice what call you respond to, or you might have two cars, like I said at a scene, and go to the easier car. So yeah, there is some liability there. I haven’t heard or seen any initiative to help with this endemic occurrence, and it doesn’t help that mental health in Texas is severely underfunded.

What can we do or advocate? Advocate for yourself. As I said, you’re going to be the new person in town, so you can be the smartest guy in town, meaning talk to your shift commanders early and often and talk to if you could be so bold as to volunteer to help get the program started. The movie Bringing Out the Dead is a prime example.

Yeah, I guess that is true. How does PTSD affect brain function? Well, it can lead to brain fog and worsen your memory, and the nervous system can be fried over time so that you wind up with truly depression or real chronic PTSD. What impact can this have on mental health and physical health? Well, we all know that if your mental health is not good, your physical health is going to suffer, so all of those are tied together.

Edward asks, can you briefly speak to how PTSD affects pediatrics versus adults? Well, it’s been shown in children that they can lead to neuroses, you know, chronic fear, the boogeyman complex, or, you know, some of the PTSD that happens in children is unfortunately the result of sexual assault and things like that that can lead to chronic depression, even in a child, so kids are much more resilient, but they’re much more sensitive. How have we seen PTSD from someone’s personal history or home life affect their work performance? Well, I can tell you that as a former medical director of the ER, I’ve had to counsel lots of physicians and say, hey, what’s going on? Something going on at home? Is there a problem with your marriage? Are your kids okay? That type of thing. We’re going to add because there’s patient complaints.

You know, I don’t like this doctor gets more complaints than others and you find out that you know, their wife asked them for a divorce and that was last week or a month ago or something like that. So yes, mental health will affect your performance at work. Well, I think that’s everything.

This was a great discussion. I think we’re out of time. Yes, and everybody got some questions in, some comments in.

I hope this was helpful for all of you. I know sometimes, like I said at the beginning, it’s stuff that we don’t talk about, but I’m glad after being in EMS for 38 years, I’m glad to see that we’re finally starting to remove the stigma associated with the trauma that people who, like us, see. So I appreciate the lecture tonight, Dr. Eshelbach.

It was great. You’re welcome. Thank you.

All right. Good night, everybody. All right.

Thank you, everybody, and good night. Thank you, guys. All right.

Good night, Gene. Good night, sir.