EMS World

MAR 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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40 MARCH 2018 | EMSWORLD.com the highest rate of PTSD, even more than firefighters and police. 4 With responsibil- ity, guilt can arise—and stress as a result— especially if clinical mistakes are made or patients die despite our efforts. Apart from workplace stress, our per- sonal lives also have a monumental impact on our overall resilience. If we're experienc- ing relationship issues, going through life transitions or the loss of a family member, or have had other traumas, we are more likely to carry that stress over on our shifts at work. We can attempt to keep our per- sonal and work lives separate, but that can only be protective to a degree; sooner or later our personal life can begin to affect our work life, and vice versa. How could chronic stress affect EMS personnel? One may begin to notice an impaired memory—for example, it may take longer to recall drug calculation dosages— or impaired concentration while initiating a difficult IV or intubation. Mental focus may be fuzzy. One may become irritable and short-tempered with difficult patients or overtime calls. Coordination could even be off, and one may find themselves slipping more on icy surfaces or bumping into cor- ners. These impairments are due to a com- plex interaction of many factors, including increased cortisol levels that can remain in our system for some time. There is no denying that changes in the ability to respond to stressors, such as in chronic states, can lead to disease. What can we do about it? Can we prevent acute stress from manifesting into chronic issues? HPA Axis and the Amygdala Bill is a paramedic new to the industry. One day he responds to his first pediatric ana- phylaxis call. As soon as he receives the dis- patch, Bill begins to perspire. His heart rate increases, his hands begin to tremble, and his stomach feels queasy. While responding with lights and siren, Bill struggles to com- pose himself and has difficulty remember- ing weight-based dosage calculations and advanced airway adjunct sizes. When he and his partner arrive on scene, they find a 2-year-old girl in her mother's arms. She is centrally cyanotic and strug- gling to breathe. Bill freezes and feels a lump rise in his throat. His partner hands him an epinephrine vial; Bill looks at the concentration and dosage on the packag- ing but cannot comprehend what his brain is trying to read. Does any of this sound familiar? Most practitioners experience "tunnel vision" to some extent at least once in their careers. This is when the sympathetic nervous system—our "fight, flight, or freeze" (FFF) response—initiates and autonomic pro- cesses begin. Responses include increased heart and respiration rates, dilated pupils, blood shunting from the core to extremities, and a cessation of digestion. All of this hap- pens instinctively as a survival mechanism in the face of threats or the unknown. The problem with this stress response when it is all-consuming (as happened with Bill) is that it interferes with our prefrontal cortex, or our ability to think rationally. Human biology is powerful. The human brain is the continuous conductor of physi - cal functions. Inside our skulls we have a brain stem (the "reptilian" brain responsible for autonomic responses such as heart rate, respiration, and digestion), limbic system (emotional center), and prefrontal cortex (capable of conscious, rational thought). When a stressor is present, or even the thought of one, information is relayed up through the brain stem and limbic system twice as fast as the time it takes to reach the prefrontal cortex. Before we even have time to consciously respond to the stressor, problem-solve, or decide there is no real threat, our autonomic nervous system and stress response have already kicked in. After that it can become difficult to access the prefrontal cortex until our stress-response symptoms begin to abate. 5 Key components of the stress system are the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous system (ANS). These systems interact with other vital centers in the central nervous system (CNS) and tissues/organs in the periphery to mobilize a successful adaptive response against the imposed stressor(s). 3 When there is a sustained or frequent stress response, or even a perception of stress, the HPA axis is stimulated, which initi- ates physical responses and the release of chemicals that work together to create and condition the pathway. Over time this creates detrimental psychological effects and disease processes in the body. The amygdala connects to the limbic system and is one of two almond-shaped clusters of nerve cells located in the tempo- ral lobe of the brain. It responds to informa- tion from the body's senses and is involved with the development of the fear emotion— it presses the "panic button." The amygdala is connected to all parts of the brain and will send signals to the brain stem to activate the FFF response. As with the HPA axis, the amygdala will respond and even increase in physical size with persistent stressors; its neuropathways can be reinforced with its activation of the fear emotion. This can cause paranoia, an increased startle response, inability to cope, and a generally overtaxed sympa- thetic nervous system—symptoms that can lead to PTSD. 6 Perception and Brain Training As mentioned earlier, perceived stressors can be as important as real ones. One study enrolled 26 participants in an eight-week mindfulness course. 7 (The definition of Table 1: Behavioral and Physical Adaptations During Stress Behavioral adaptations • Increased arousal and alertness • Increased cognition, vigilance, and focused attention • Suppression of feeding behavior • Suppression of reproductive behavior • Inhibition of gastric motility; stimulation of colonic motility • Containment of the stress response Physical adaptations • Adaptive redirection of energy • Oxygen and nutrients directed to the central nervous system and stressed body site(s) • Altered cardiovascular tone; increased blood pressure and heart rate • Increased respiratory rate • Increased gluconeogenesis and lipolysis • Inhibition of reproductive and growth axes • Containment of the stress response • Containment of the inflammatory/immune response — Adapted from Chrousos GP, Gold PW, The concepts of stress and stress system disorders. Over view of physical and behavioral homeostasis. JAMA, 1992 Mar 4; 267(9): 1,244–52.

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