Administration and Leadership, Cardiac & Resuscitation, Patient Care, Training

How to Heal after a Tough Call

Issue 5 and Volume 38.

The “fog of war” is the confusion that occurs when soldiers become preoccupied with fighting or rendered lost by the elements of battle. As the battle rages and accurate intelligence deteriorates, the fighting force becomes more and more obscured in this fog.

Scientists are working feverishly to reduce this phenomenon, but so far, they have had little success. Recently, I considered the “fog of EMS.” If you have been in EMS for any length of time, you can relate to some of what I am about to describe.

EMS is very much like the battlefield. We are called up in a moment, no waiting, just a second’s notice, and find ourselves thrust into incredible situations with very little information, or more often, inaccurate battlefield “intelligence gathering.” We try to bring an out-of-control situation into order and save a life by doing the best that we can.

Unfortunately, as we all know, sometimes our best is not good enough.

The emergency services industry as a whole has tried to limit this fog with its own science and intelligence gathering. We send our EMS personnel to continuing medical education classes and offer advanced training. We have developed all sorts of emergency medical dispatch programs to help gather information and relay it to our responders. We drill into our responders the importance of command and control, adherence to protocols, responder safety and many other factors of emergency response .Yet, there is still a significant fog of EMS.

Early Entry into the Fog
Do you remember when you were first certified as a first responder? Whether you were an EMR, EMT or Firefighter 1, you listened to instructors’ stories, got your certifications, and maybe held some vision of your future based what you saw of Johnny, Roy and Squad 51. You were ready to take on the world of emergency response.

The first couple of shifts, you rode with some grizzled old veteran who showed no sign of fear or anxiety. When you went on duty with your new EMS belt kit and clean turnout gear, you were sure you were ready for anything.

I remember those days; but they didn’t last long.

One morning, you woke up to the tones and the grizzled veteran had somehow slipped out of the station. Through your haze, you barely thought, “Gee it’s kind of foggy,” before the dispatcher reported someone not breathing. Off you went with one of the newer guys on the day shift; the one who had only been on the street for four months.

You arrive on the scene, and on the way down the hallway, the police officer passes you to say, “He’s in there.”

You enter the bedroom but what you see is not what the manikin looked like. You go on autopilot and begin a futile resuscitation. The call is a mess; there’s not enough help. Blood is everywhere. Terrible smells won’t leave your nose. All the science of EMS isn’t doing what it should, and someone won’t be saved.

You get to the hospital, and the staff takes over. They end your resuscitation in moments, making you wonder why you even bothered. You do your chart, and you leave. It’s still early in the morning and early in your career, but the fog bank is already present.

Time Moves On
If you continue in your emergency service for more than five years, you become one of the Old Guys. The reality of EMS is, most people don’t last more than five years in EMS; they simply move on to something else. It’s their way of getting out of the fog.
Some are motivated by more money, moving on because of the minimal pay offered in EMS. Some are drawn by the allure of other emergency services or healthcare: firefighting, law enforcement or nursing. They’ll leave the fog of EMS to be caught up in a different fog bank.

If you’ve ever gone out on a boat with a fog present over the ocean’s water, you’ve witnessed what’s referred to as sea smoke. On a boat inside that fog, you know what Columbus felt. You might just fall off the edge of the earth.

That fog dares you to steer your boat into it, just like EMS dares you to enter its fog.

Some of us go on and become full-time EMS providers. Some of us are real gluttons for punishment; we go on to become paramedics. Now we’re well on our way into the really thick fog.

If you’re a veteran of more than five years in EMS, and have seen a number of significant incidents, you are the walking wounded. You’ve been assaulted—physically, emotionally, professionally and spiritually. You thought you were joining EMS to save people, and once in a while you actually do save someone. But all the chaos that occurs in between tugs at your understanding of what the world is supposed to be like, what you learned from your parents, teachers, preachers and instructors. You begin to wonder, “Did everyone lie to me?”

You’ve experienced things that most people don’t see—things they shouldn’t see. For that matter, these are things they shouldn’t hear or smell either. You go on call after call after call. Some of us go from bad call to bad call to bad call. The fog thickens.

As you gather experience past that five-year mark, something else happens. You begin to develop powerful coping skills. The really strange thing is that no one really has studied these coping mechanisms in depth.

Some have people described how EMS people depersonalize their responses. Think about that for a second. We joined EMS to help people, but in order to survive, we need to depersonalize those same people.

Have you ever depersonalized a call? I’ll bet you have. I’ll bet you have done it more than you think.

Thinking back on my own experience, especially the hundreds of debriefings I’ve attended, I’ve sometimes wondered why I was extra stressed that particular day. “Why was I deeper in the fog of EMS this time than before?”

It could be because a patient reminded me of someone I knew, so I personalized the call. We joined EMS to help people, learned some coping skills and developed some immunity from stress. We depersonalize. When we return to being human for a moment, it stresses us out.

In most of our responses, our coping mechanisms have constructed a strong enough barrier to resist the invasion of emotions that exist, and we can keep at our emotional fence line. But every so often, we respond to a call or experience something that puts our resilience to the ultimate test. The fog gets so thick for some EMS personnel that they have to leave the emergency service. They have to get out of the fog.

Jeffrey T. Mitchell, PhD, published an article in August 1983 JEMS, “When disaster strikes. The critical incident stress debriefing process,” on research he and others had conducted that found emergency workers can react very differently after a bad call. The researchers deemed these bad calls “critical incidents,” and they coined the term “critical incident stress.” Mitchell went on to develop a debriefing model that the EMS industry began to use to lead people out when they found themselves in a sudden fog bank.

I’ve been involved in a couple hundred debriefings. If they’re done properly and quickly enough, they help some responders gain a little clarity. The debriefing team doesn’t show up with any magic; they just help the responders reset their own coping switches. I don’t know if they came out of the fog or we just helped them put their fog lights back on, but EMS personnel who come out of these briefings almost always return to duty.

Tests of Time
In the 30 years since CISD was identified, something else happened: The number of debriefing sessions decreased at a time when EMS work has become far more violent and graphic than it’s ever been. Is it because we’re better at coping, or have we learned to depersonalize things even more?

Old timers in EMS have experienced a few cultural, career and life-changing events. Luckily, they don’t come along too often, but it does seem like they are occurring more frequently.

Connecticut had its first really big EMS game changer on April 23, 1987, when the L’Ambiance Plaza building in Bridgeport collapsed during construction. Twenty-eight workers were killed, with a number of others injured. All were trapped under the rubble.

I was one of the paramedics who responded. I spent four 12-hour shifts on that pile. Responders from across Connecticut spent many hours there during the week it took to recover all the victims. It was a big test for Connecticut EMS. We passed that test, but it left scars. There was considerable fog.

Another big test for Connecticut came more than a decade later. Sept. 11, 2001, was an enormous game changer for the emergency services community. It hit Connecticut hard because it was an attack on American soil that happened basically right down the street. (Anyone who lives in western Connecticut almost certainly knows people who commute to New York City for work.) All the years of terrorism talk suddenly became reality. Many Connecticut responders went to New York City to help on the front line.

I lost a good friend. He was one of my Connecticut paramedic partners and a firefighter with the Fire Department of New York. He was killed on that awful day. In addition to him, hundreds of other emergency workers were killed in the attack. No one could have ever even imagined what happened. The fog rolled in, and it was really thick.

It took quite a while for some of us to find our way out of that fog. It helpedthat our country rallied behind emergency responders and supported us like never before. America’s responders were heroes again. We were recipients of a lot of good will and millions of dollars in grant money to buy equipment and hire firefighters. It helped get some people out of the fog.

Unfortunately, most of that goodwill waned at about the 10-year mark.

Now we’re going through the next emergency service game changer, responses to violent incidents. It started with the shootings at Columbine High School in Colorado. There was some serious fog out there, and it resulted in the law enforcement community changing the tactics they used when responding to those types of calls.

The fire service seemed to lag a little behind the law enforcement community in responding to these calls. EMS just didn’t seem to get the memo that police officers were going to storm buildings and then do the best they could against the shooters.

A New Horror
On Dec. 14, 2012, the latest fogbank hit. It happened when emergency responders in western Connecticut arrived at what has become the epicenter of the next paradigm shift for emergency services. That was the day police bravely stormed into Sandy Hook Elementary School and saved lives.

Fire and EMS personnel mobilized. It was very much a fog of war. No one expected this, certainly not in our community. We were trained to respond to emergency calls; to help people. Yet despite hundreds of responders, there was nothing anyone could do. We weren’t really prepared to witness a war crime.

Three paramedics and a physician went into that building with the police. They had no preparation or warning as they entered the school under police cover. It was practically unheard of for EMS personnel to accompany cops into an unsecured scene, but it had to be done. The rules were changing within seconds in front of us. That’s really, really thick fog.

This is the new reality. In some areas, EMS and fire personnel are now going to be running alongside law enforcement into scenes. It’s called a “force protection model,” where police will cover the EMS and fire personnel from the bad guys while our responders rescue victims in hot or warm zones.

We may stop asking if the scene is safe as crazy terms like “acceptable losses” are applied to first responders. Our world is changing once again.

The Sandy Hook incident has caused some of the thickest fog we’ve ever been through. I thought my fog lights were very bright—some of the best around. But it’s hard to see the clarity through this incident.

Out of the Fog
So how do we find our way out of the fog of EMS?

Most of the time, we can use the coping skills we’ve learned and get through it with a little help from our peers. There’s often safety in numbers when it comes to fighting stress. Putting on our uniforms or our turnout gear can be similar to putting on a suit of armor. And, when we stand alongside our comrades, we draw strength from each other.

Everyone must understand it’s OK to ask for help from their friends. But sometimes, when critical incidents affect an entire squad, we have trouble coping with our friends. When the fog gets a little too thick to find a way out, we call the CISD team or our employee assistance program for a debriefing or two. That can help us find a clear spot in all the fog, somewhere we can reset ourselves and get back to our known normal.

Then there are times that go beyond that; the fog gets so thick that we really need some assistance to get out of it. And there is help out there. The fire service and law enforcement are making a big push to make mental healthcare available to their members. EMS has to get on board with these initiatives. We have to take better care of ourselves. We can’t continue to be in the fog of EMS without formal plans to help get us out of it.

This change is up to us. Maybe the next generation of EMS will do better at it than we are doing right now. We really have to take care of ourselves, because no one is going to do it for us.