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We were in Basra … close to the ocean, near the oil refineries. A young Iraqi girl was severely injured nearby when she stepped on a landmine. Her father, along with her family, sped toward us in an old pickup truck, hoping we would help his daughter. We thought it was a vehicle-borne IED. We opened fire on them.”
—Nickolas Boone, Firefighter, Golder Ranch (Ariz.)
Fire District, speaking about his service in the 1-7th Marines,
Baker Company during Operation Iraqi Freedom
The conflicts in Afghanistan and Iraq are now the longest in U.S. history. As a result of this prolonged conflict and its associated stress, first responders will undoubtedly be called more frequently for crisis calls involving the 1.8 million active and former military service members who face the long-term physical and emotional scars of war.(1)
Dramatically improved personal protective military gear and significant advances in field trauma medicine have saved more lives in these engagements than ever before. In fact, more than 90% of wounded service members survive their injuries.(2) This does, however, create several secondary effects. These include the skyrocketing increase in wounded service members who face disabling or disfiguring injuries, the estimated 15–20% who may develop traumatic brain injury (TBI) and the 11–20% of these war veterans who are affected by post traumatic stress disorder (PTSD).(1,3)
Crisis calls will escalate and continue over the next 20–40 years as former service members leave military service and return to civilian life, which is why it’s essential EMS responders become familiar with the issues facing our veterans and understand the symptoms of PTSD and TBI.
Because many of our fellow firefighter, EMS and law enforcement co-workers have been deployed, it’s also important for us to understand what they’ve been through and the hardships they’ve endured. This will allow us to be sensitive to their needs once they return home.
Many firefighters and EMS responders have never served in the military; a starting point is to become familiar with military culture, terms, structure and service.
It’s essential for EMS providers to understand military culture when responding to a service member. Knowing how to properly address one who has served in the military, having a basic understanding of the branches of service and recognizing the unique stressors they’ve faced will allow providers to communicate more effectively and empathetically, while assessing the patient’s condition and needs.
When you encounter a service member on an EMS call, ask them how they’d like to be addressed to avoid offending them. For example, calling a Marine a “soldier” will sour the beginning of your patient relationship. The individual may prefer to be called by status, title or rank. If they prefer to be referred to by their branch of service, use the following titles:
>> A service member in the U.S. Army is called a soldier.
>> One serving in the U.S. Air Force is called an airman.
>> A U.S. Navy service member is called a sailor.
>> A service member in the U.S. Marine Corps is called a Marine.
>> U.S. Coast Guard members are called coasties.
Regardless of their military branch, service members face five principal stressors. The first is the life threat that can occur from
direct combat, its aftermath or for operations in which there’s a higher expectancy for injury or death.
In one study of Army soldiers and Marines deployed in Iraq, more than 90% reported being shot at. In addition, 89% reported that they received “incoming artillery, rocket or mortar fire” and 86% reported knowing someone who was seriously injured or killed.(4)
The second is a general sense of loss, which can occur in many ways. For example, it might be grief over the loss of a fellow service member, the feeling of helplessness following a significant injury (e.g., an amputee) or the prolonged absence from friends, family and normal social circles. Other forms of loss include the loss of income (particularly by Reservists) or the loss of one’s possessions during deployment.
The third is inner conflict, which occurs when one’s belief system differs from their military engagement. Witnessing incidents that contradict one’s values—or experiencing the guilt or shame associated with the common task of carrying out orders that contradict these values—can be significant sources of stress.
The fourth stressor is day-to-day wear and tear on service members, which is called operational stress. Sleep deprivation, poor eating habits and prolonged deployments while they’re fully operational can cause enormous stress. Juston Doughtry, a Phoenix Fire Department firefighter who served in the 1st/3rd Infantry and Artillery Division, describes his days in the Iraq desert in 2003: “We were in 130 degrees. It was very dry. We had to wear chemical suits that whole first month. There was no air-conditioning. During the day, it was 105–108° F. At night, it would drop to 50–60° F.”
One top non-combat issue is the length and number of deployments, and separation from family. Recent research shows that these factors affect a service member’s mental health status. In fact, it has been found that suicide risk increases markedly after the third deployment or after a deployment lasting 15 months or more.
The fifth stressor, which is receiving significant attention today, is military sexual trauma (MST), which includes sexual harassment and sexual assault. According to a survey by the Pentagon, one-third of women and 6% of men in the military said they were sexually harrassed.(5)
According to the Department of Veterans Affairs, “MST can result in severe mental health problems and exacerbate adjusting after discharge when compared to sexual trauma in civilian life.”
In addition to the general stressors that could affect any service member, other situational stressors can also be present. For example, National Guard members and Reservists often return from a deployment and go directly back to their rural hometowns. If their rural communities don’t have an adequate support system, their stressors might surface on a behavioral health call. Reassignment of individual augmentees (IAs) may cause additional stress. In fact, an IA may be pulled away from their home unit and reassigned multiple
times, even to a different branch.
Another complicating factor is the lack of time for today’s soldiers to defuse built-up stress. “Today’s service member does not have the ‘fantail time’ like soldiers from World War II or the Korean War,” says Rickey Salyers, a 33-year-old retired Marine chief warrant officer 5 who has served in five combat operations since Desert Storm. “These men faced a ‘slow boat’ home … a four-week ocean trip and were able to bond, talk and debrief before returning home,” he says. “In comparison, today’s service member returning from conflict is back in the United States within 18–20 hours and has no chance to de-stress.
“Soon after,” he says. “We may be called to respond to that individual—with a thousand-yard stare.”
Post Traumatic Stress Disorder
The National Center for PTSD, describes the condition as “an anxiety disorder that can occur following the experience or witnessing of a traumatic event.” For service members, PTSD commonly occurs during or following military combat. The after-effects of combat exposure can last days, weeks or months following a traumatic event, or remain for decades or a lifetime.
More than half of Vietnam vets—both men and women—had “clinically serious stress reaction symptoms, with 30% reporting PTSD.” Up to 20% of Iraq/Afghanistan vets also have reported PTSD symptoms.(1) However, this number is increasing substantially, with previously deployed soldiers being more than three times as likely to develop PTSD as their predecessors.(6)
Not every service member is affected by post-traumatic stress. But risk increases if they have the following experiences:
>> Direct exposure to a traumatic event;
>> Serious injury;
>> Exposure to traumatic events for a long period of time, or
>> Witnessing of a fellow service member’s death or serious injury.
Individuals suffering from PTSD generally experience three types of symptoms. The first is reliving the trauma when confronted with a traumatic reminder. An upsetting memory of a traumatic event, called an “intrusive recollection,” may spontaneously occur or might be triggered, for example, when a service member hears a car backfire, or when one is involved in a vehicle collision.
In a case in Tucson, Ariz., a retired service member caused a police chase when he sped away from an accident he witnessed because he thought it was an improvised explosive device (IED). He floored the accelerator on his vehicle. Another had a flashback by smelling the diesel exhaust while driving on the freeway.
A second type of PTSD response involves symptoms of avoidance and numbing. Avoidance might mean that a service member stays away from places or isolates themselves from people who might prompt a traumatic reminder. Individuals with PTSD might also find it difficult to be in touch with their feelings or be able to express emotions; they may feel emotionally numb.
A third set of PTSD symptoms includes feeling on guard, irritable or startling easily. A veteran may feel constantly on alert, called “increased emotional arousal,” which can lead to difficulty sleeping, sudden outbursts, irritability and concentration problems. A service member who pans the seating area of a restaurant carefully, then sits facing near an exit door would be an example of this response. A severe symptom is agoraphobia, in which a service member may refuse to go out in public.
The National Center for PTSD reports that sufferers also face clear biological changes, such as alterations in central and autonomic nervous system function, and they can have such co-occurring mental health issues as depression, substance abuse, memory or cognition problems, as well as physical health issues.
The prevalence of PTSD also increases if the service member is younger, less educated or had mental health issues prior to the traumatic event or has previously experienced a traumatic event.(1)
Nickolas Boone, a Golder Ranch, Ariz., paramedic/firefighter, says he experienced depression following his discharge from the Marines. “When you’re in the service, you’re around a bunch of folks who’ve been through what you’ve been through. And, you don’t really think about it much until you get home,” he says. “What you’ve done, what’s been done to you, how close you’ve come to dying. Everything replays over and over.”
Treatment for PTSD includes talk therapy, also known as counseling, and prescription medications, such as selective serotonin reuptake inhibitors (e.g., Prozac, Paxil or Zoloft). But one of the most promising treatments is cognitive-behavioral therapy (CBT). This helps the patient understand and change how they think about the trauma and its aftermath by learning to replace stress memories with other thoughts.
Although there’s less shame in seeking help now than in the past, a study of soldiers returning from Iraq found that only 40% said they would get help. Many avoid seeking help due to peer pressure and the fear of what others may think or how it could affect their military careers. Unfortunately, if untreated, PTSD can become a chronic psychiatric disorder and persist for a lifetime.(1)
Traumatic Brain Injury
Traumatic brain injury is the “signature injury” of the wars in Iraq and Afghanistan. The Department of Defense’s Deployment Health Clinical Center defines TBI as a blow or jolt to the head that results in a closed head injury, concussion or penetrating head injury and disrupts the function of the brain. The severity of a TBI may range from mild, such as a brief change in mental status or consciousness, to severe, or an extended period of unconsciousness or amnesia after the injury.
Recent estimates by the Pentagon indicate that up to 360,000 Iraq and Afghanistan veterans may have suffered brain injuries, with 10–20% of troops suffering at least a mild concussion.(7) Many of the war’s TBIs occur when a soldier is inside a vehicle that’s hit by an IED. Although the vast majority recovers, 3–5% face persistent symptoms.(4) This is much higher than in previous conflicts; only 12–14% of all combat casualties during the Vietnam War involved a brain injury. Most—three out of four—died from their brain injury.(4,8)
TBI can cause a wide range of functional changes that affect touch, sensation, movement, language or emotions. These symptoms broadly mirror the effects of a stroke. Headaches, sleep disturbances and sensitivity to light and noise are common symptoms, as well as attention, memory or language disturbances. Often, the most troubling symptoms are behavioral: mood changes, depression, anxiety, impulsiveness, emotional outbursts or inappropriate laughter.
Like PTSD, one of the challenges for veterans facing TBI is getting them the help they need. Often, symptoms of TBI aren’t recognized during or after deployment. For example, a family member might report how moody a spouse has been after deployment. Easily overlooked, this is one of the symptoms of TBI. Many other reasons exist for why they remain untreated.
One reason is that symptoms may develop or worsen after discharge. Even if identified, discharged veterans are forced to negotiate an often complicated process of seeking treatment through various veterans’ assistance programs.
Second, the symptoms of TBI and PTSD can be misdiagnosed. Added to this is that more than 25% of cases of TBI and PTSD are “co-occurring illnesses,” meaning, the soldier faces a brain injury and psychological trauma at the same time. Untreated TBI, when severe, can be debilitating and cause lingering effects.(1)
First responders can greatly assist these patients when they’re experiencing a mental health crisis. Regardless of the type of emergency, use caution. Many service members who have recently returned from deployment experience a period of hyper vigilance and stay armed with a gun, knife, nightstick or other weapon for months after their return.
A threat: If a patient is a threat to themselves or others, first responders should use a standard behavioral health response according to their protocols.
Most EMS systems require first responders to transport a patient experiencing a mental health emergency to the closest emergency department before being transferred to a behavioral health facility. First responders and EMS providers in Maricopa County, Ariz. are allowed to transfer care to a behavioral health team that has been called to the scene. They can do this once they’ve determined a patient is medically stable and does not require transport to an emergency department. It’s essential if that crisis team has also received specialized training on military culture.
A troubled patient: When your patient is a veteran in distress but not dangerous, first responders can refer them to a local “vet center.” These centers, located throughout the country, provide patient privacy and are often staffed by counselors who are seasoned combat veterans. They can assist with issues common to combat veterans, including depression, grief support, substance abuse and family counseling. They can be located by ZIP code at www.va.gov/directory/guide/vetcenter_flsh.asp.
Another option is to refer the individual to the nearest U.S. Department of Veterans Affairs (VA) center, especially if they have an Operation Enduring Freedom and Operation Iraqi Freedom outreach programs.
A troubled family member: Military service can also be difficult on a service member’s family. If you arrive on scene and find a spouse or family in distress, direct them to the family programs office at the nearest military installation or to www.militaryonesource.com. Both have resources that can help with a variety of situations.
Homelessness Among Veterans
Following the Vietnam War, if a homeless man was found on the street by EMS crews, there was a 33% probability that individual had served in Vietnam.(9) These rates have decreased as this population has aged.
Still, we need to understand the link EMS providers are between the patient and available resources. Unfortunately, more than 200,000 Vietnam vets are currently sleeping on the streets. If you encounter a homeless person on the street, there’s a 23% chance they’re a vet.(9) The VA reports that the majority of the nation’s homeless veterans are single males, who come from poor disadvantaged communities; 45% suffer from mental illness; and half have substance abuse problems.
Many resort to substance abuse and begin a downward spiral on the street. Their tough military mind-set can make them less likely to seek help. And that’s where we come in.
Approach to Homeless Vets
So what can we do when we assist a homeless vet? “First, ask them if they were recently discharged. It’s not uncommon for veterans to arrive home, become alienated and isolate themselves from their community. However, if they have been registered through the VA upon their return, they will be eligible for many VA assistance programs,” says Michael Leon, homeless veteran’s coordinator at the VA Medical Center in Phoenix.
“Keep in mind that many homeless vets are very, very angry. Many have spent long, grueling tours overseas, have sacrificed a huge period of life and arrive home to face extreme difficulty,” he says. “They’re disconnected from life and family. They sacrifice everything and come back to nothing.”
Use non-threatening body posture and get to know them by asking questions about the length of their service, whether they were in a war zone and whether they were injured. “Then ask them if they’re using drugs or how they got in their homeless situation,” he says. He suggests helping them contact or get transported to the local VA office for treatment. Another option is to help them locate the nearest Veteran’s Center.
One of Us
Service members and their families are under a significant amount of stress when they return from a deployment and matriculate back into their public safety job. If one of your employees is deploying, your organization should adopt policies to help during this transition. A department’s personnel office can facilitate leave time; while labor organizations, if applicable, can negotiate pay rates so a service member doesn’t see a huge paycheck disparity when they’re activated.
Another helpful option is to ensure the family is provided for during the provider’s active service. This includes arranging for military families to maintain their current work-provided health care and having co-workers offer to help the spouse who stays behind.
A service member returning back to public safety duty has a lot on their mind. They’re going through the cultural shift of leaving the military and readjusting to
One approach used by the Houston Fire Department (HFD) is to check in with a returning service member before they return to the field. Emmanuel Finney, chief clinical psychologist and director of HFDs Firefighter Support Network, says, “We reconnect with service members once they return, see how they’re doing and let them know what employee assistance, peer support and critical incident team support services are through the fire department or the city to help them reintegrate back into station life.”
Of the returning stress he faced, Salyers says, “On Engine 8, I came back to new SCBAs, a different cardiac monitor, new medications in the drug box and additional technical rescue gear on the truck.”
One way individuals can help returning service members is to maintain a log of training, memos, policy changes and new equipment that they may have missed. Another is to be aware that situations will occur that can trigger stressful memories for the service member. Boone says, “Any time we hit a dirt road in the fire truck, go fast, get tossed around, especially at night, I get a little tense. I can’t help but think of Iraq.”
Another service member noted, “When I see the flash of a speed camera, I immediately tense up and wonder how long before I hear the boom.”
If the service member is a new hire, give them the additional respect they deserve, acknowledge their service during their initial training and avoid treating them like they lack significant life experience.
Be aware of other stressors that can occur in the workplace, while on calls, in the station or during training. One firefighter described a flashback during a confined-space drill. “I immediately flashed back to an incident during the invasion of Iraq when Saddam sent a missile our way,” he says.
How does one measure the effectiveness of welcoming home veterans in the workplace? Doughtry says, “Most firefighters were very enthusiastic and asked a lot of questions. Every time I’ve returned home, it’s always been an easy transition. The guys are cool, and the organization takes care of its people—whether it was shift trades, a missed grading, new face piece testing, minimum company standards. And my battalion chief had a really important role in easing my transition.”
EMS providers and firefighters share a common bond with military service members. Both face significant critical incident stress during the course of their normal duties. For first responders, the traumatic death of a group of teens in a car wreck; the sad, unintentional drowning of a child; the near miss or loss of a firefighter in a structure fire; or the violent robbery of an elderly couple are traumatic life experiences.
The emotional numbness of seeing a buddy killed by an IED, the intense stress reaction following an incident or the daily grind of temperature extremes can likewise take a toll on a service member. The risk of TBI for the deployed service member adds to the life stress they face.
Given the shared risk of post-traumatic occupational stress they face, paramedics and firefighters are in a unique position to be in solidarity with our dedicated service members, current and past, who struggle with post-traumatic stress, TBI disabling injuries and forever changed lives.
As first responders, our shared allegiance in protecting the public gives us a tremendous opportunity to listen attentively and treat compassionately these troubled patients and providers who face significant daily life challenges once they return home. JEMS
Author’s note: This article is dedicated to Adam Gibson, who spent 15 months in combat in Iraq. After discharge and suffering from PTSD, Adam took his life in October 2009.
Special thanks: The author is indebted to the Arizona Coalition for Military Families for its support of and assistance with this article.
1. U.S. Department of Veterans Affairs National Center for PTSD. www.ptsd.va.gov/professional.
2. Kudler H. Lecture at Painting a Moving Train Conference. Phoenix. Nov. 17, 2009.
3. Defense and Veterans Brain Injury Center. www.dvbic.org.
4. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. N Engl J Med. 2004;351(1):13–22.
5. MSNBC.com. Pentagon releases sexual harassment data: Survey finds more women feeling harassed, but fewer reports were filed. www.msnbc.msn.com/id/23636487/ns/us_news-military/.
6. Kline A, Falca-Dodson M, Sussner B, et al. Effects of repeated deployment to Iraq and Afghanistan on the health of New Jersey Army National Guard troops: Implications for military readiness. Am J Public Health. 2010;100(2):276–283.
7. Zoroya G. 360,000 veterans may have brain injuries. USA TODAY. March 4, 2009.
8. Okie S. Traumatic brain injury in the war zone. N Engl J Med. 2005;352(20):2043–2047.
9. National Coalition for Homeless Veterans. www.nchv.org.
This article originally appeared in March 2011 JEMS as “Heroes to Hometowns: When veterans come home.”
> Operation Desert Storm (1990–1991): Also known as the Gulf War or Persian Gulf War, this U.S.-led multinational force invaded Iraq following its invasion and annexation of Kuwait in 1990.
> Operation Enduring Freedom (2001–present): Also known as OEF, the War in Afghanistan and Operation Infinite Justice, this started when U.S. and U.N. coalition forces invaded Afghanistan after their refusal to turn over Osama Bin Laden following the Sept. 11, 2001, attacks (aka “OEF,” “War in Afghanistan” or “Operation Infinite Justice”).
> Operation Iraqi Freedom (2003–2010): Also known as OIF, the Iraq War and the Second Gulf War, this began when U.S. and Great Britain forced invasion of Iraq to remove the government of Saddam Hussein.
> Operation New Dawn (2010–present): This reflects reduced U.S. military involvement to support and secure Iraq.
To Learn More …
> Restrepo, Outpost Films, 2010.
> The Soldier’s Heart, Frontline, PBS, 2005.
> Combat Diary: The Marines of Lima Company, A&E Home Video, 2006.
> Lioness, DocuDrama, 2009.
> The Ground Truth, Universal Pictures, 2006.
> Down Range to Iraq and Back, Bridget C. Cantrell, PhD, and Chuck Dean, 2005, Wordsmith Publishing.
> On Killing: The Psychological Cost of Learning to Kill in War and Society, Dave Grossman, 1995.
> Volunteer at Wounded Warriors
> Invite disabled vets to your station for dinner
> The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Click on “For Health Professionals.”
> Every state has a National Guard Joint Family Programs office that can provide resources or training to first responders. Use this resource.
Customer Service Excellence
Thank any service member you encounter on a call for their service to country. This simple but powerful action, accompanied by a firm, ungloved handshake, is an incredible expression of gratitude that may improve the outcome of the call.
Caregiver Tips on a Crisis Call
Once you identify the person as a service member:
> Ask him/her how they would like to be called.
> Use the correct terminology (e.g., soldier, Marine, airman, sailor or guardian).
> Be aware that many veterans may be armed with a loaded gun, knife, nightstick or other weapon.
> Ask what any abbreviations you’re not familiar with mean. This will encourage conversation and promote understanding.
> Ask the following questions in confidence,
away from family members:
• Have you served in overseas conflict?
• Did you have any intense or really difficult experiences during your service?
• Do you think you might have been affected by post-traumatic stress?
• Did you experience any physical trauma, blast concussions or hearing loss that might contribute to traumatic brain injury?
• Are you obtaining any services from the VA or other programs?
• What can we do for you right now to help you?