I was 11 when 15-year-old Jane Creba was shot to death on Boxing Day of 2005, just outside the Eaton Centre mega-mall in downtown Toronto. I remember watching the flood of TV broadcasts about her death in the days that followed, but what stuck with me wasn't the black-and-white photo of the high school student used by every news station. Instead, what's clear in my mind is a brief, maybe 15-second interview with one of the paramedics who first responded to the call. She was talking about how the experience of trying to take care of the dying young girl was haunting her. And while most of the city was mourning Jane Creba’s tragic death, I was left wondering why the paramedic wasn't being taken care of too.
Recently, I spoke with Toronto paramedic Vince Savoia who entered 25-year-old Tema Conter's apartment back in 1988. Tema, who had moved to Toronto three years earlier and worked in fashion management, had been raped, beaten and stabbed 11 times. She was already dead when he arrived. The sight of Tema’s naked body, still bound and gagged on her bed, would haunt Vince for over a decade.
Vince, who was 27 at the time of the murder, told me, “It just hit too close to home. You go to a homicide where a young lady has been brutally raped and murdered for no apparent reason other than some guy wanting to get his rocks off. That’s not morally right.”
Despite suffering from symptoms of post-traumatic stress disorder, it was years before Vince would be diagnosed and get help. His story isn't an isolated one – according to him and other paramedics, it's likely that thousands of paramedics across the country are dealing with some form of mental distress, but aren't admitting it or getting help. And right now, no one knows how this could be affecting the quality of care paramedics are expected to provide.
Along with depression and anxiety, one of the most common mental issues paramedics develop is critical incident stress (CIS), often described as a normal reaction to an abnormal event. It encompasses both immediate reactions to a traumatic situation, like nausea, anxiety and hyperventilating, as well as delayed reactions, like having trouble sleeping, flashbacks, panic attacks and emotional numbness. The symptoms can become so severe that they prevent sufferers from functioning normally.
If a paramedic is still experiencing symptoms of CIS 30 days after the initial traumatising event, they can then be diagnosed with PTSD. According to the Canadian Mental Health Association, about eight percent of Canadians have PTSD. That number rises to ten percent when you factor in soldiers returning from combat. However, in emergency service workers, like paramedics, fire fighters, nurses and doctors, the number jumps even higher: they're two times more likely than the average citizen to be affected. A 2012 study on Ottawa emergency service workers found that paramedics were at the highest risk of developing PTSD.
After his experience, Vince founded the Tema Conter Memorial Trust, a foundation that advocates better mental-health support for emergency service workers. Tema estimates that 16 to 24 percent of Canadian paramedics will be diagnosed with PTSD at some point in their careers. However, exact numbers on who's suffering from what are hard to come by. According to Vince, services tend to resist attempts by organisations to get statistics on paramedic mental health.
It takes months of treatment before a PTSD sufferer is back to a healthy mental state. But for treatment to begin, the condition needs to be reported and diagnosed, which is where another problem arises – paramedics don't like admitting they need help.
“It’s a very male-dominated, Type-A, macho sort of environment that you’re working with,” Vince said. “Any sign of mental distress is perceived to be a weakness for most of these individuals – men or women. And the expectation is: ‘This is your job; you should be tough and you should be able to handle it.’”
David Whitley, a paramedic with York Region EMS since 1982, gave another reason for the stigma.
“If you get to the scene of a horrific call, you have to repress your feelings to get the job done,” he said, explaining that some paramedics forget to stop pushing their emotions to the side when they're not working. “You end up losing yourself,” David said. “You become a robo-medic.”
Being exposed to traumatic events is ingrained into a paramedic's profession. They play a crucial role in any city's emergency medical services and carry a heavy responsibility – they must assess the raw scene in order to think and act quickly enough to save lives. Paramedics see the most gruesome injuries, accidents involving multiple fatalities and the results of murders and suicides every day.
Centennial College paramedicine instructor Doug Kunihiro said that the school tries to prepare students for the high-stress nature of the job by gradually building up the intensity of class activities. Students start off with simulated medical emergency scenarios and work their way up to riding in an ambulance with paramedics so they can respond to real calls. However, training doesn’t make them immune to stress.
“No one can prepare them for everything because none of us have seen everything,” Doug said.
Doug, who's also been a part-time paramedic for York Region since 2000, said he's seen five colleagues develop PTSD, but that there could have been more. “A lot of people will go on leave, but no one ever really says why,” Doug said. “For all we know, a bunch of them could have been taking time out because they got PTSD.”
Toronto EMS is the only unit in Canada with an in-house psychologist, Dr Lori Gray. Gray said the unit closely monitors its paramedics for signs of mental distress, and that she and a peer-support team are available by phone 24 hours a day. Last year, Gray took just under 430 calls about previously unreported problems. The peer-support team took over 1,200.
“Our strength is our early-intervention programme, so we're not just waiting for people to have a hard time,” Gray said. Toronto EMS focuses on treating symptoms of mental distress before they escalate. Paramedics who are still distressed after 30 days are referred to out-of-house therapists. Workers can also request help anonymously. Gray said the response has been positive.
“When we surveyed our staff, well over 97 percent of our front line paramedics and dispatchers supported what we were doing,” Gray said. She could not provide any statistics on how many paramedics in Toronto EMS suffer from PTSD or any other mental distress issues.
Toronto's system, though, is an exception. Most paramedic services in Canada depend on peer-support teams, where paramedics are encouraged to check in with each other after handling traumatic cases to see how their colleagues are coping. Paramedics also have access to the Employee Assistance Program (EAP), a hotline they can call if they're in mental distress. But David says that isn't enough.
“EAP workers aren't trained to do trauma work,” David said, nor can they relate to paramedics since they've never worked in the field. “They're a good front line, but not what we need... We need better education about mental health and a better work environment. The whole culture needs to change.”
This situation worsens outside of Canada’s major cities, especially on First Nations reserves, land belonging to Canada's indigenous peoples. Mike Seth, the current fire chief of Six Nations of the Grand River and a former paramedic supervisor and manager for the Six Nations EMS, said that the small size of its response team and limited funding means that paramedics have to deal with more cases and have fewer resources than units in big cities.
Six Nations’ population of about 12,000 makes it the biggest First Nations reserve in Canada, but its EMS team is made up of just over 30 people, one EMS station, one 24-hour transport car and one emergency response vehicle. On average, emergency personnel on reserves respond to two and a half times more cases per worker than their counterparts in municipal or provincial units. The nature of the cases is also different on reserves, with higher rates of drunk driving accidents and youth suicides.
“We've seen numerous multi-fatalities; we've seen numerous children dead; numerous teens that are committing suicide or attempting to commit suicide; we've seen a lot of housing despair and how people are unable to cope. And it's just all of that stuff starts to get at you, [along with] the high volumes of calls and the inability to take the time to relax,” Mike said.
The Six Nations EMS depends heavily on peer-based debriefings to help its paramedics cope with mental stress, and they have also launched an EAP hotline. On top of all that, Six Nations has a Tragic Events Response Team (TERT) that is made up of 700 people from the community. The team is available 24-hours a day and was originally developed to help residents deal with traumatic events in the community, such as drunk driving-related deaths. It now also responds to emergency service workers who have just responded to tough cases and is so popular that its services are being requested by other First Nations reserves.
Currently, according to Mike, fire, paramedic and police services are working together to try to launch a training programme for its workers to recognise CIS and PTSD in their colleagues. Over the past four years, managers at Six Nations emergency services have also been making more of an effort to check in with their employees after particularly stressful calls, encouraging them to talk about how they're feeling and offering paid time off if needed.
Although the developments are a big improvement from two decades ago, when the stigma against mental distress made it almost impossible to talk about, there's still a long way to go. EAP services are expensive, costing Six Nations $1,000 (£620) to $2,000 (£1,240) per session, and so are training programs, which is why none of the emergency workers on the reserve have received any yet. Mike said that no mental health statistics have ever been collected, but, anecdotally, it's obvious that the mental stress of the job is taking a toll.
“We're seeing a lot of our personnel turn to alcohol, sometimes drugs – and many have family or marital problems,” said Mike.
With no hard numbers coming from any EMS units in Canada, it's impossible to say exactly how many paramedics are dealing with mental distress issues, or how that's impacting emergency health care. Studies by organisations like Tema and research papers like the one on Ottawa emergency service workers suggest that it's a bigger problem than anyone's willing to admit. Vince said that the fact there are no internal statistics on paramedic mental health issues, or at least no one who's willing to give them up, shows that not enough is being done to make sure paramedics are mentally OK.
“No one keeps track. Nobody wants to keep track,” he said, laughing.
Previously on PTSD: