A Closer Look at the Problem of Post Traumatic Stress Disorder and Emergency Medical Services. (Written circa 2010)

There is no question that Posttraumatic Stress Disorder (PTSD) has been of increasing interest of late.  With soldiers returning from combat operations overseas, the literature on the issue has expanded a great deal.  However, little work has been done on issues related to PTSD regarding Emergency Medical Services (EMS).  What little work there is on the subject is uniform in the assessment that rates in the profession are at twenty percent or more (Bennett, et al., 2005; Berger, et al., 2007; Grevin, 1996). This paper looks into the limited work on PTSD in EMS and attempts to evaluate the broader work in the context of EMS.  An overview of the disorder is offered along with who is effected, to what degree, and a glimpse into possible mechanisms of acquiring the disorder.  Additionally, common treatments are discussed including an evaluation of Critical Incident Stress Debrief (CISD), the most common treatment and identification modality for the disorder in EMS.  Ultimately, it is asserted here that, regardless of the homogeny of symptoms, the disorder is a deeply personal reaction that requires an individually tailored response.  In the context of EMS, a great deal more work must be done to identify commonalities in the development of the disorder without over generalizing to the group.



A Closer Look at the Problem of Post Traumatic Stress Disorder and Emergency Medical Services.
     On Thanksgiving Day, 2001, a colleague and friend died from injuries sustained when his ambulance flipped on its side.  The effects rippled throughout the company where I worked.  The grief and anger had detrimental effects on the workforce leaving some people unable to proceed in a profession they had previously considered a life’s mission.  More recently, another colleague and good friend struggled with problems resulting from a crash she had 2007.  She died the following winter under very odd circumstances and it is difficult to shake the feeling that Post Traumatic Stress Disorder (PTSD) in her life and her husband’s resulted, in part, in her untimely death.  I always knew that stress was part of the job, but I had never really considered how much.  For my own part, stress has been both a companion and a nemesis.  Like many EMTs and paramedics, I work best when stress levels are through the roof, but this has sometimes led to unhealthy behavior, on my part, outside of work.  Recently, I have changed professions and my overall stress has significantly lessened.  Still, I wonder about my own susceptibility to acute stress reactions and what I can do to limit my own risk to PTSD.  What I have found is PTSD, is a stress reaction which is personal in nature; as a result, treatment must be specialized to the individual and may not always be effective.  Moreover, only small measures may be taken to limit susceptibility and the intrinsically personal nature prevents the possibility of entirely removing risk.
    It is important to first get a cursory understanding of the disorder.  In short, PTSD is an acute stress reaction to a traumatic event that has fairly long lasting effects.  The American Psychiatric Association’s Diagnostic and Statistical Manual, or DSM, is generally the first source any study of psychiatric disorders uses to define the diagnostic criteria.  The DSM basically defines PTSD as a reaction to a traumatic incident involving serious moral or mortal implications.  Diagnosis must also include five critical criteria: extreme fear, flashbacks, avoidance, increased arousal, impairment in social or occupational functioning, and symptoms present for one month or more (American Psychiatric Association, 1994).  This definition identifies key characteristics and diagnostic criteria.  While some features are similar to other disorders, the definition is specific enough to be differential.  The important thing to take away from this is that the disorder, by definition, is lasting.  Unfortunately, this definition lacks an inherent understanding of what the disorder means to those who suffer from it.  In an interview by Fire Chief magazine, Paul Antonellis Jr., an author of Post Traumatic Stress Disorder in Firefighters: The Cases that Stick with You and retired Fire Chief form Salisbury, Massachusetts, equates PTSD with the fight or flight response one gets from intense fear but that those who have the disorder never really come off this mechanism (“Stress Reliever”, 2007).  This example illustrates that PTSD is ultimately a stress reaction like any other.  Fight or flight response is a typical reaction to fear that results in heightened arousal.  The fundamental difference is the duration of symptoms.  Typically the symptoms of PTSD last more than a month.
    While the DSM-IV is the principle tool in diagnosis for most disorders, it is not without critics.  Periodically, the American Psychological Association releases a new version of the DSM.  The new edition, the DSM-V, is expected to be released in May of 2013 (American Psychiatric Association, 2010).  There is some concern about how PTSD is defined and characterized in the DSM-IV.  Patricia Resick and Mark Miller (2009) recently proposed that PTSD should be categorized in a new set of diagnoses, apart from anxiety disorders.  As stated above, among the diagnostic criteria are feelings of fear, helplessness, or horror (American Psychiatric Association, 1994).  However, these characteristics are not the sole identifiers of potential development of the disorder.  As Resick and Miller write, “This diathesis-stress interaction results in extensive population heterogeneity in the clinical expression of posttraumatic psychopathology, psychological anxiety being just one manifestation of this interaction” (Resick & Miller, 2009).  Simply put, PTSD is not an anxiety disorder, but rather anxiety may be a symptom.  In this light, PTSD, like other acute stress disorders, should be placed in their own category whose definition is contingent on the triggering traumatic event.  In many cases, shame, guilt, anger, and numbing may be the most significant factors in the development of PTSD (Resick & Miller, 2009).  Similarly, Adler et al. (2008) found that anger and factors related to training were significant toward rates of PTSD.  The Alder study noted that police were linked to subjective assessments of traumatic events of others.  Typically, the problem is akin to helplessness regardless of their extensive professional training.  These may manifest in a variety of ways from shame to guilt as well as other possible pathways.  For Emergency Medical Services personnel, there is no doubt that no matter how extensive the training, there will always be events beyond one’s control.  As a result, the individual response may run the gambit of the DSMs A2 criterion, or a variety of other possible pathways. 
    While it is true that anyone can get PTSD, medical professionals are particularly susceptible.  War is an inherently traumatic event, so it is no surprise that combat veterans experience some degree of PTSD.  Tonya Kolkow, M.D., asserts that military medical personnel suffer PTSD at the same rate or higher than combat personnel.  According to her studies, conducted as a member of the Naval Medical Center in San Diego, their combat experience tends to be less than combat personnel, but their exposure to illness and injury is higher and more concentrated (Mahoney, 2005).  This can be carried over to civilian life in that medical personnel in general have a higher and more concentrated contact with illness and injury than the general population.  EMTs and paramedics deal with life and death issues every tour at work, while the general population is less likely to see the same quantity of these issues.  As observed by a study in the New England Journal of Medicine, soldiers in combat displayed a linear correlation between the amount of exposure to traumatic events and incidence of PTSD (Hoge, et al., 2004).  One way to examine the idea of who gets PTSD is to determine rates across the country.  According to a study by the Institute of Medicine, done at the bequest of the Department of Veterans Affairs, PTSD affects twelve to twenty million Americans.  The study goes on to break down the statistics by stating that 3.6% of the general population is affected while veterans of Iraq experience the problem at rates of 13% and veterans of Afghanistan are at 6% (Institute of Medicine, 2008).  According to these studies and those done by Kolkow, medical personnel returning from Iraq are likely to experience rates of PTSD greater than thirteen percent.  This may seem like a lot, but as it turns out, rates of PTSD in pre-hospital healthcare providers are in fact higher than that.  In a study of Emergency Services in the United Kingdom, the authors conclude that high exposure to traumatic incidents lead EMTs and paramedics to be more prone to PTSD than the general population (Bennett, et al., 2005).  This statement is in keeping with what would be expected from the military studies.  What is surprising is that this study found that rates in EMTs and paramedics were in the range of twenty to twenty-one percent.  They found that comparable studies of firefighters showed rates of seventeen to eighteen percent while American studies of EMTs and paramedics also showed rates just over twenty percent (Bennett, et al., 2005).  Over one fifth of emergency medical services, EMS, personnel suffer from PTSD and this value does not include the wide variety of other severe stress reactions they are likely to suffer.
    There are many reasons why PTSD is a problem that must be addressed.  The two most important reasons that PTSD poses a problem are that PTSD causes prolonged behavioral changes in those it affects which limits people’s ability to interact with others, and the sheer number of those affected.  There is plenty of evidence to support the idea of lasting effects of PTSD.  One report by Susan Blumenthal, a retired Rear Admiral in the U.S. Public Health service and former assistant surgeon general, and her colleague Elise Schlissel states that studies show forty to sixty percent of those affected show successful recovery with treatment, but one in three will have symptoms for the rest of their lives.  They go on to say that once symptoms become chronic, treatment becomes increasingly less effective (Blumenthal and Schlissel, 2008).  This shows that early treatment reduces the number of people with chronic symptoms but some people will always carry the burden of this disorder.  Pair this report with the American Psychiatric Association’s critical criteria requiring impairment in social or occupational functioning and one can clearly see that chronic PTSD will have serious, detrimental effects in many people’s lives.  Moreover, PTSD is the extreme case.  A study of pre-hospital care providers in Brazil asserts that symptoms below the threshold for PTSD, as laid out by the DSM, also have severe consequences (Berger et al., 2007).  Alcoholism, anxiety, depression and other acute stress reactions do not quite meet the DSM’s criteria for PTSD, but many people require treatment regardless (Hoge, et al., 2004; Berger, et al., 2007).  These symptoms are all aspects of PTSD.  If the aspects that make up the disorder are serious problems, then the actual disorder must also be a serious problem.  The volume of people who suffer from the disorder accentuates the severity of PTSD.  A 2004 report in the New England Journal of Medicine established that nearly 13% of soldiers operating in Iraq qualified, by strict definition, for a diagnosis of PTSD and 11 to 17% were at risk three to four months out from deployment (Hoge, et al., 2004).  A broad definition of the disorder showed much higher results on the order of 18 to 20% (Hoge, et al., 2004).  This is an enormous portion of the veterans returning from Iraq.  But this is not simply a problem limited to combat veterans.  The United Kingdom’s National Institute for Health and Clinical Excellence published a report in March of 2005 estimating that nearly thirty percent of people exposed to a disaster will develop PTSD.  The report admits that many mild cases should self-resolve in approximately four weeks (Allen, 2008).  Even with a portion of the effected population self-resolving, the scope of the number is staggering.  Nearly a third of people exposed to a disaster like a major earthquake or terrorist attack will develop PTSD.  These people will spend more than a month living in a state of fear and panic.  The scope of the problem becomes staggering when one attempts to account for sub-threshold disorders and co-morbid factors that will typically exceed the numbers for the full-blown disorder.
    In EMS, there are more possible causes of PTSD than the obviously frequent exposure to traumatic incidents.  The most common causes are directly linked to common defense mechanisms.  In a 1996 study of San Francisco Bay Area paramedics and paramedic students, it was cautioned that the frequent nature of critical incidents, paired with anxiety suppressing coping mechanisms would likely lead to disturbingly high incidents of stress disorders and unhealthy behavior (Grevin, 1996).  Of interest is that anxiety suppression could lead to PTSD.  It is admitted by the author that suppressing anxiety may be necessary at the time of incident to allow personnel to render the necessary care to the sick and injured.  Without these coping mechanisms, panic may keep EMS personnel from performing their duties effectively.  One type of common defense mechanism is dissociation.  Bennett et al.’s (2005) study points out that dissociation prevents people from developing appropriate responses to the event and therefore increases the likelihood of emotional disorders like PTSD.  This precursor is intimately linked to the causative incident.  In my opinion, one reason that EMS personnel are so likely to dissociate from the event is that they are asked to take a clinical approach and not get attached to the people they are treating.  As noted in the Adler et al. (2008) criticism of the DSMs A2 criteria, training plays a significant role in susceptibility for PTSD in combat veterans.  Similarly, how EMS personnel are trained to deal with stressful situations will likely have significant effect on susceptibility.  Furthermore, successful dissociation at critical events early in a career without adverse side effects will obviously lead to increased occurrence of this behavior.  The statistical analysis of the Bennett et al.’s (2005) study shows that in fact dissociative behavior is directly linked to PTSD and that both of these increase as ones career progresses.  The study is clear; the longer people stay in the field, the more likely they are to experience PTSD.  What would be interesting to study is if turnover rates of employees have some correlation to stress disorders.  In other words, do people leave the job because of stress reaction like PTSD and does that artificially lower the observed rates?  This seems a likely possibility.  Perhaps actual rates are higher than those reported by studies of EMS for this reason.  Of equal importance is the fact that current screening methods may under identify incidence of PTSD.  According to a study done by Peirce, et al. (2009), questionnaires currently used to screen for PTSD are not sufficiently comprehensive to effectively identify all cases.
    There are background stressors that may contribute to PTSD as well.  There is a sense in which existing stress plays a contributing role in increasing susceptibility.  Doctor Roger Pitman, a professor of psychology at Harvard Medical School, has said that people of high intelligence and self-confidence may have some innate protection (Barry, 2003).  It is my opinion that people of high intelligence and self-confidence are less prone to background stress.  For the small stressors in everyday life, these people are generally not troubled by small problems.  Their self-confidence results in a self-assured view of stressors that limits their effects.  Their high intelligence allows them to easily think their way through the simple problems that present themselves.  In Bennett et al.’s study, it was found that there are routine work stresses that significantly contribute to the development of stress disorders.  Among these stressors are things such as a dysfunctional work environment, conflict with coworkers, responding to false calls, and conflicts between work and home (Bennett et al., 2005).  In any profession, these sorts of issues act as agents of stress and can have adverse effects.  A poorly organized workforce made up people who do not get along doing work that does not seem to matter to the mission statement of the job seems like the kind of place that no one would want to work and would probably lead to some degree of stress.  In this light, it is easy to think of PTSD as having a break point and our background stressors bring us closer and closer to that point.  As a result, high stress and often chaotic jobs like EMS often lead to a workforce that is increasingly close to the threshold for PTSD.  Additionally, frequent traumatic incidents leave a group that will routinely be on the precipice.  One interesting thing about the Bennett et al. (2005) study is that it looked at organizational stressors and compared them with similar studies of American police departments and found that they were more than six times higher in EMTs and paramedics than in police officers.  There are a number of possible explanations for this finding.  The most obvious is that police departments in the U.S. are generally civil service jobs that offer a certain degree of job security not readily available in private EMS services.  The second is that the fundamental principles of police work do not change very often, while medicine is perpetually changing.  As a result EMS services have a much more flexible and fluid structure and set of rules which requires EMS personnel to routinely relearn primary understanding of treatment modalities.  While these are speculative offerings as to why EMS may have higher levels of organizational stress, the fact remains that these types of stressors play a significant factor in the development of stress disorders in general.
    Among the effects of PTSD are intense fear, flashbacks, avoidance, and arousal.  As stated before, Paul Antonellis Jr. equates PTSD with the fight or flight response one gets from an intense fear (“Stress Reliever”, 2007).  The fight or flight response is an automatic one which is difficult to control.  While this may not be an absolute indicator of actual fear, the response is the same.  Thus it can be said that PTSD is, in part, a fear reaction.  Antonellis goes on to say that, “One of the hallmarks of PTSD is avoidance.  [Sufferers] avoid talking about the incident or symptoms” (“Stress Reliever”, 2007).  This avoidance has a number of ramifications.  The first is that treatment becomes difficult because those affected will not want to talk about the problem.  Second, in an effort to avoid talking about the subject, those with the disorder may avoid those people who care most about them, including family and coworkers.  Flashbacks or troubling memories also play a role.  According to the Bennett et al. (2005) study, up to two thirds of EMS personnel studied had experienced precursors such as troubling memories.  This precursor is in fact a characteristic of PTSD that ties directly into the issues of avoidance and fear.  Talking about the incident may very well trigger a bad memory.  Furthermore, these troubling memories, or flashbacks, can generate a fear reaction in and of themselves.  Arousal is a common effect associated with PTSD that can take many forms.  The Bennett et al. (2005) study indicates that background stressors play a significant role in predicting overall anxiety, a common type of arousal, which is also tied to PTSD.  This illustrates that common, normal stress reactions can be an integral part of PTSD.  All people experience some degree of anxiety as a result of their jobs or life circumstances.  PTSD is different from general anxiety because inappropriate arousal is only a part of the disorder as a whole. 
    Critical Incident Stress Debrief, CISD, is the most common treatment of PTSD in EMS.  Jeffrey Mitchell, a psychologist who started out as a paramedic, developed CISD.  The system works by gathering those involved in facilitated group session within a few days of the incident.  Participants are encouraged to talk about what happened and the facilitator offers explanations of normal reactions and coping strategies (Everly Jr., 1995).  The advantages of this process are clear.  The facilitator can quickly identify and refer individuals who need more specialized treatment.  Also, it affords people the opportunity to discuss the issues they have in an environment that is composed of people who shared the same causative agent.  One concern with police fire and EMS is that these are close knit communities that may be closed off from outside sources of help.  An article in American City & County, this issue was addressed by pointing to the number of CISD teams deployed to areas attacks of September 11, 2001.  Among those mentioned were CHAPPS (Cops Helping to Alleviate Police Problems); a program set up by the Oklahoma City Police Department, and regional CISD teams of southern Pennsylvania (O’Connell, 2003).  This shows the breadth of coverage of CISD services.  In the case of CHAPPS, the team is service specific to police.  In Pennsylvania, CISD teams are set up regionally and have more general applications.  There are examples of EMS specific CISD service.  According to Avril Hardy, Organization Development Advisor to the London Ambulance Service, the LAS designed peer support system was designed to help employees to get the help they need (Allen, 2005).  There are many advocates of this type of treatment modality.  A critical utility of CISD is that it is helpful because it allows a person to get their thoughts out in the open and helps develop connectivity to other people who were there and part of something important (Everly Jr., 1995).  One implication is that those people who respond to and deal with emergency situations can feel good as a result of CISD because they are part of a group which does valuable and important work.  It seems that by feeling good about their role in a terrible situation, people may be able limit their stress reaction.  Another implication is that simply talking about the incident, which people are likely to want to avoid, will make people feel better and limit stress reactions.
    While CISD is arguably the most commonly used tool to limit PTSD, the process has its detractors.  There is considerable concern that the process may in fact be harmful.  While evaluating preferences of firefighters regarding peritraumatic debrief, James Jeannette and Alan Scoboria (2008) outlined several possible problems with CISD.  Among these are that (i) CISD may unintentionally give participants a false idea of what is the proper emotional response; that (ii) since PTSD is not an inevitable outcome of a traumatic event, CISD creates a faulty impression that individuals may have underlying psychological issues that do not exist; and (iii), for firefighters at least, CISD presents an affront the understanding of social norms associated with the job  (Jeannette & Scoboria, 2008).  The underlying issue is that these problems can create larger problems than CISD is likely to solve.  For the first two issues, CISD teams run the risk of exacerbating stress reactions by creating psychological problems where none previously existed.  A recent study of combat veterans indicated that some adverse effects of acute stress disorders, notably increased alcohol use, may actually increase with CISD as the primary means of addressing potential PTSD.  It should also be noted that there is little actual evidence that has shown particular efficacy of CISD.  However, while the Adler et al. (2008) study suggested that there might be a slight increase in alcohol use related to CISD, the study also conceded that another study came to a significantly different conclusion and there was little evidence to support the idea that CISD was particularly harmful.   For the last issue identified by Jeannette and Scoboria, it is clear that social interaction has a role to play in appropriate recovery from any stress or anxiety disorder.  By undercutting the social systems that exist in a group like firefighters, and arguably emergency medical personnel, CISD harms the natural ability of a social group to effectively deal with the problem at hand.  What is particularly of interest in the study on firefighter preference is that firefighters tended to prefer alternative means of debrief for most traumatic events (Jeannette & Scoboria, 2008).  As Jeannette and Scoboria (2008) point out, “Self-report from consumers of psychological interventions is known as a powerful and accepted tool in counseling”.  In this regard, it can only be concluded that we are possibly overusing a counseling technique that may be doing more harm than good.  The common thinking is that the CISD process limits possible development of the disorder and may prevent other stress reactions.  Obviously PTSD is by definition a stress reaction that persists for over a month, so CISD in the first few days of an incident cannot treat what is not yet a problem.  Moreover by treating what is not there, there is strong possibility that people might ask why they do not have the symptoms and, as a result, begin to develop the symptoms.  Finally, CISD is a treatment to stress reaction that assumes that participants are in need of treatment.  Stress usually self-resolves, and when it does not, those affected are not inherently ill, but rather are normal people dealing with more stress than they can handle.  In this respect care should be primarily supportive.
    Other treatments for PTSD are tailored to the individual.  This is because different people deal with stress in very different ways.  Anthony Marsella, an editor of the book Ethnocultural Aspects of Post-Traumatic Stress Disorders, says that therapies in the U.S. reflect our over-emphasis of personal responsibility for our failures; whereas other cultures take a more pragmatic view that some things are simply beyond our control (Wen, 2001).  Likewise, and article by Ethan Watters (2007) indicates, “If we’re unaware of the local idioms of suffering, Miller [a professor of psychology at Pomona College] and other researchers argue, out assistance is likely to be ineffective at best”.  Two things are apparent from these statements.  First, culture and upbringing effect how people deal with stress and as a result will necessitate personalized treatment based on these differences.  Second, cultural factors and local idioms may have more specific connotations vis a vis emergency response personnel like fire, police, and EMS.  How these services, as a group, deal with stress has consequences regarding how individuals in these groups deal with stress.  Supporting the idea that culture plays a role in susceptibility, Jobson and O’Kearney (2008) published a report examining differences between independent cultures and interdependent cultures.  They argue that a change in perceived self-identity centering on the traumatic event is a strong indicator of the development of PTSD.  This is to say that some people change their view of themselves and their views on their social roles based on a traumatic event as a turning point in their life.  In some ways, the trauma redefines who they are.  Of particular interest to EMS is that independent cultures tend to experience this phenomenon to a greater degree (Jobson & O'Kearney, 2008).  EMS personnel place a high value on characteristics typically associated with independent cultures.  As cited from Green, Deschags, and Paez, “independence, autonomy, agency, self-reliance, uniqueness and achievement orientation” are among the hallmark characteristics of an independent centered culture (Jobson & O'Kearney, 2008).  From the very first day of training, EMTs are reminded that they work alone in the back of the ambulance.  Among the central appeals of EMS as a profession are self-reliance, autonomy, and independence.  It is hard to imagine an EMT that stays in the profession without a significant degree of achievement drive.  Mark Shelhorse, head of the Veterans Affairs Mental-Health Program, indicates that the Vietnam War has taught that most cases, if caught early, resolve with minimal support and therapy (Brant, 2005).  Early identification is crucial in that it limits care to minor efforts.  These minor efforts will depend on individual needs even if the general treatment pathways are similar across groups. 
    More specifically, some types of treatment show particular promise.  Arieh Shalev, M.D., and Michael Miller, M.D. (2004), wrote in their article “To Heal a Shattered Soul: Treatment for PTSD”, “Talk therapy, especially cognitive behavioral therapy, also has a role.  A Psychotherapist may cautiously encourage the trauma victim to confront ideas and situations, both real and imagined, that trigger symptoms”.  This is a common treatment that has shown a great deal of efficacy.  Unfortunately, there are some drawbacks with this type of therapy, especially as it pertains to emergency services.  For people who experience PTSD as a result of a car crash, a therapist may walk the person around a car eventually getting them to go in and drive in a safe setting.  For EMS personnel, it can be far more difficult to make associations to traumatic events in a safe manner.  This is obvious when one considers combat veterans; how do you get a combat veteran to relive a combat situation in a safe manner?  Even when treatment is available, a major concern is that, for most treatments, there is often little or no evidence to support the idea of effectiveness.  In an Institute of Medicine report, Dr. Alphred O. Berg, a professor of family medicine at the University of Washington at Seattle and chair of the committee issuing the report, stated in a press conference that most therapies pertaining to PTSD lacked substantive evidence.  Among those identified were cognitive restructuring, individual psychotherapy, group therapy, and all drugs currently in use (Institute of Medicine, 2008).  This is not to say that the treatments are or are not effective per se, but rather there is no substantive evidence to support them.  From this it is clear that any treatment modality must be approached with a certain degree of flexibility.  Perhaps the most telling aspect of how to treat PTSD lies in understanding it as not simply a clinical term.  Arthur Kleinman, professor of anthropology and psychiatry at Harvard University, asserts that people who have a profound moral and emotional experience are not inherently ill as a diagnosis of PTSD suggests (Wen, 2001).  If the problem is approached in this way, it is clear that treatment cannot be overly generalized.  Moral and emotional experiences are generally deeply personal and individual reactions.  In this light, treatment must also be individualized.
    There are some other aspects to treatment that have wide degree of use or growing acceptance.  Among the principles to which there is some degree of advocacy are education, drug therapy, and virtual reality reenactments.  In his interview with Fire Chief magazine, Paul Antonellis said, in regards to prevention, “It is more about education than prevention.  It’s making people aware that they are not the only ones and there is help.  Just because you receive a diagnosis of PTSD doesn’t mean it has to end your career” (“Stress Reliever”, 2008).  In all medical treatments, prevention is an integral part of treating a disease, but PTSD, in some ways, defies prevention, so education becomes paramount.  People in stressful professions must be made aware of the problem so that they can identify it when it happens to them or others.  This appears to be the key to limiting the potentially devastating effects of the disorder.  In addition to education, some drug therapy has been found to be potentially of use.  In an article in Newsweek by Arieh Shalev, M.D., and Michael Miller, M.D. (2004), the authors write, “Stress can exacerbate almost any mental disorder, so a psychiatrist may also prescribe a mood stabilizer such as Lithium or an antipsychotic such as Risperidone.  Anxiety-muting benzodiazepines such as Lorazepam and Clonazepam may actually raise the risk of chronic PTSD if taken continuously”.  This indicates that in some cases, some drug therapy has had some usefulness, while others can have a negative effect.  In general, pharmaceutical therapy, as it relates to psychological disorders, is only beneficial in conjunction with other treatment pathways, so theses drugs are only to be used as an adjunct.  Benzodiazepines are fairly common drugs with many uses, but as this article points out, they can adverse effects.  The ones mentioned here are more commonly known as Ativan and Clonopine, but Valium, also a benzodiazepine, is frequently given for a variety of symptoms that relate to any number of disorders.  Unfortunately, some of these symptoms are also associated with PTSD and a missed diagnosis may result in adverse effects.  Doctors Shalev and Miller also point to a more cutting edge treatment that is gaining acceptance.  In their article, Doctors Shalev and Miller (2004) write that, “Treatments may even include virtual-reality devices that recreate the experience of combat”.  This shows promise in that it plays into cognitive behavioral therapy (not to be confused with cognitive restructuring), the only type of therapy to have conclusive evidence of efficacy according to the Institute of Medicine (2008) report.  There is still some research to be conducted, but this type of therapy will eventually allow combat personnel, and hopefully emergency services providers, with a means of confronting their PTSD indexing event in a safe and controlled manner.  It should be noted that while exposure therapy has been found effective in randomized controlled studies, few clinical practitioners use such methods; this is primarily due to the fact that the carefully controlled conditions in such studies are typically too difficult to maintain in the setting of private clinical practice (vanIngen, Freiheit, & Vye, 2009). 
    There are many studies regarding PTSD.  Most studies center on who is likely to succumb to the effects of PTSD or the pharmacological treatment of the disorder while studies on EMS personnel specifically are notably sparse.  Demographic research is often the most obvious type of research conducted.  The National Center for Post Traumatic Stress Disorder conducted a study in 2004 which indicated that twelve to twenty percent of returning soldiers from Iraq, compared with five percent of the general population, is likely to suffer from PTSD (Blumenthal and Schlissel, 2007).  This is a typical type of citation seen in newspapers and magazines.  It is this sort of demographic study that is often conducted by agencies like the National Center for Post Traumatic Stress Disorder, the U.S. Department of Public health, or the Department of Veterans Affairs.  This sort of study generally provides insight into how well or poorly the issue is addressed on a national level.  There is also a great drive for research into pharmaceutical treatments.  Recently, three studies of note were started: the use of Propanolol, a β-blocker which operates on the sympathetic nervous system, as a possible preventative treatment immediately following a traumatic event, the use of selective serotonin reuptake inhibitors, drugs which act on a particular aspect of brain chemistry, in weeks after a traumatic event as an agent which may stave off chronic effects of PTSD, and d-cyclosterine as an agent which can result in fear extinction (Kilgore, 2005).  While the first two are directly related to PTSD, the third is more generally related to fear reactions in general but will probably be applicable.  Unlike the demographic studies, which are often done by government agencies or non-profits, drug studies are usually the result of interest by the manufacturer.  As long as there is profit in pharmaceuticals, there will continue to be a wide variety of this type of study.  On the other hand, there are relatively few studies concerning EMS in particular.  The Bennett study, which has already been mentioned, was conducted in 2004 prior to that, only a handful of research has been conducted, and most of those were conducted overseas.  Of particular interest was a study cited by William Berger et al., Grevin’s 1996 study in which U.S. EMTs and paramedics were studied from the San Francisco Bay Area had results nearly identical to Bennett’s, while the results from Berger’s own study varied drastically.  The Berger et al. study states that for a variety of reasons, this study of Brazilian pre-hospital care providers is not readily comparable to Bennett and Grevin’s for a variety of organizational and social reasons (Berger et al., 2007).  Berger et al.’s study, published in 2007, illustrates the fact that as a group, EMS is highly understudied.  What is particularly distressing about this fact is that studies consistently show rates of PTSD in EMS to be higher than both the general population and other high stress vocations.  Part of the problem may be that most ambulance work, especially in the United States, is done by private, for-profit companies and there is no particular fiscal incentive to deal with the issue.  Another problem may be that EMS, like fire and police services, yields a close-knit community that shuns help from perceived outsiders.  Ultimately, the issue of a lack of research regarding PTSD in EMS personnel leaves more questions than answers.
    There are many reasons why the issues surrounding PTSD are not always clear.  Even thorough studies of PTSD lead to questions not foreseen by the researchers.  Bennett et al.’s (2005) study found that women in EMS tended to have lower incidence of PTSD and anxiety than men and notes that women report less background stressors.  The study does not provide definitive answers why, but offers the speculation that women may have better access to social support or that the probable self-selection process that brings women to the field may provide less susceptible women in the field of EMS (Bennett et al., 2005).  These speculations show the need for further study.  While data may indicate that women are probably self-selective when deciding whether or not to become EMTs, the study does not offer any hard evidence of this.  Also there is no real indication that women have any better access to social support.  Studying this may provide valuable insight into how to limit PTSD by indicating methods of increasing access to social support.  Another question that this brings up, which Bennett et al. addresses generally to men and women, but Burger et al. addresses more specifically to women, is the question of differences in length of service between men and women as it relates to PTSD.  One of the results that Berger et al. found was that women, in the service they studied, had even lower rates of PTSD in relation to men than the Bennett et al. study found.  Berger et al. (2007) also noted that women had less than half the length of service as their male counterparts.  This demands that we ask, and Berger et al. does ask but does not answer, do people leave the service as a result of PTSD, thus lowering the rates observed by the studies?  Careful study of research always leads to some questions.  Even so, the scarcity of research regarding EMS leaves far more unanswered questions than answers.  Ultimately, there is something inherently unanswerable in the very nature of PTSD.  Patricia Resick of the National Center for PTSD has been quoted as saying, “PTSD doesn’t just come from having a near-death experience, but how personalized it is” (Brant, 2005).  This illustrates that our personal reactions are the primary causes of PTSD.  We can never truly understand what goes on inside a person’s mind because each person’s perceptions are uniquely derived from two sources; these are people’s infinitely diverse biology and equally infinite diversity of experience.  In truth each person has his or her own way of dealing with stress which means that PTSD will be a personal experience whose treatment requires it be individually tailored.

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