‘Normal’ job-related stress and the additional psychological burden of COVID-19

Existing research shows that paramedics face significantly higher rates of depression, anxiety, fatigue, sleep disorders, post-traumatic stress disorder (PTSD), suicidality and suicide than the general population.^{Reference Bentley, Crawford, Wilkins, Fernandez and Studnek1,Reference Vigil, Grant, Perez, Blust, Chikani and Vadeboncoeur2} These are a grim result of several job-related stressors, including regular exposure to human suffering and death, being faced by situations that threaten their own health, the unpredictable nature of their job and a poor work–life balance. The shift-work pattern has a large impact on their sleep and circadian rhythms. Additionally, the nature of their work involves dealing with crises and medical emergencies, which demands vigilance, focused attention and performance under psychological pressure. Moreover, paramedics may also suffer from moral injury (perpetrating, failing to prevent or witnessing morally conflicting acts), manifesting as guilt, shame and emotional numbing.^{Reference Murray3}

During the ongoing COVID-19 pandemic, paramedics are at an even higher vulnerability to mental health problems. While paramedics realise their pivotal role in responding to emergencies and saving lives, they may also face major ethical and moral dilemmas, which can add to the psychological burden of care provision, especially in under-resourced settings. They might have to decide, for example, whether they should treat patients despite the risk of contracting and propagating COVID-19, and how to distribute life-saving medical resources in resource-constrained settings. Faced with the choice of prioritising public service over personal safety and well-being, a growing number of paramedics are quitting their jobs and fewer are applying for training and practice as paramedics.^{Reference Cerullo4,Reference Dopelt, Wacht, Strugo, Miller and Kushnir5} Moreover, owing to the worrying lack of personal protective equipment (PPE), paramedics also face a very realistic reactive anxiety or fear of contracting COVID-19 themselves, which itself leads to a reduced workforce. This loss of workforce amplifies the burden on the remaining workers, demanding of them increased working hours and greater workloads. Problems may be greater in low-resource countries, owing to factors such as a greater deficiency of PPE, a chronic shortage of trained healthcare workers, and widespread community and public distrust of healthcare workers.

What can be done?

The harsh reality is that, despite having to face regular challenges to their mental health, paramedics are inadequately trained to protect and care for their mental well-being. The current situation highlights the lack of protective psychosocial interventions for paramedics, which stems from the lack of resource allocation and the stigma surrounding mental illness. This stigma may be ingrained within the culture of some societies, institutions and individuals, and could overtly or covertly discourage discussions about the mental well-being of paramedics.

Dealing with a crisis of such a magnitude requires an emotionally intelligent, proactive and responsive model of leadership. Leadership that is both task-focused and able to sense and respond to the anxieties of staff would help maintain harmony and collegiality in front-line groups during this time of crisis. It is therefore extremely important for interventions to be taken now with timely effect:

1. (a) appreciation, acknowledgement, professional validation and ready access to mental health services (including mental health screening, including screening for suicidality, and subsequent counselling) will play a pivotal role in reducing the risk of mental distress in this vulnerable group of healthcare professionals;

2. (b) paramedics should be given complete transparency concerning updates and facts regarding COVID-19, so that they can make informed decisions about subsequent steps when dealing with novel and challenging situations on the front line;

3. (c) best-practice protocols and guidelines should be devised and employed, to ensure that paramedics face the least possible risk of contracting and spreading COVID-19;

4. (d) self-care practices should be encouraged by providing subsidised gym memberships or yoga classes for paramedics and other front-line healthcare workers;

5. (e) peer support programmes and online support forums should be developed to decrease paramedic burnout and maintain motivation during these challenging times;

6. (f) in low-resource countries, international support may be essential to ensure that PPE is provided to all front-line healthcare workers; moreover, initiatives such as the World Health Organization's COVID-19 Emergency Medical Teams (EMT) may be implemented for international redistribution of paramedics to reinforce the emergency medical services of low-resource countries;

7. (g) trauma-focused PTSD treatment including cognitive processing therapy (CPT) can be used effectively to treat those suffering from moral injury, reducing the associated guilt and shame;

8. (h) organisations should implement paramedic retention and recruitment strategies that emphasise institutional commitment to mental health support, workplace safety and protection, adequate compensation and incentives packages for paramedics.