You are the first responder dispatched to a multi-casualty incident (MCI) for a motor vehicle collision on the interstate, with multiple cars on fire and bodies strewn all over the highway. You arrive in the “controlled” chaos with the roadway barely shut down. You immediately smell smoke, see fire everywhere, and see danger at every step. You are handed the limp body of a three-year-old female child who isn’t breathing, and you note a weak pulse on brachial palpation. You start resuscitation efforts and transport her to the appropriate facility. Once you turn over care to the receiving RN and MDs, you and your partner head back into service and move toward the designated call area. As the adrenaline subsides, you are left alone with your thoughts.
This article’s title and first paragraph were chosen to catch your eye and hopefully pique your interest in a topic you may like. As it piqued your interest, you may have thought the article was about trauma or a cool case review on a new procedure. Contrary to your initial curiosity, it isn’t any of these. This is about First Responder Mental Health.
Throughout the US, there are currently about 25 million first responders. This equates to 7.5% of the total US population. That is 7.5% to help the other 92.5% of the population. That seems reasonable and fair, right? Of the 25 million, it is estimated that approximately 30% (7.5 million) suffer from mental health issues. This is a massive number compared to the 4% (13 million) reported by the general US population. About 50% (3.75 million) of those first responders who suffer from these issues turn to some form of substance abuse. Think about those numbers again but on a more personal scale. Think of 10 of your first responder colleagues that you know. Three suffer from mental health issues, and about two become substance abusers. But worst of all, the suicide rate of first responders is 1.5 times more likely than the general population. Every year hundreds of first responders across the country take their own lives, and even more attempt to do so. In fact, more US die from suicide than in the line of duty. These numbers are horrible and sad, but they are a reality. Sadly, those numbers are almost underestimated based on the stigma attached to these astounding statistics. When you think of these numbers, know they are the bare minimum.
Why is this? The answer is obvious, right? Or is it? We all suffer from PTSD due to the very nature of our profession. But the existential threat is we don’t seek help. We work too much, eat atrociously, don’t sleep, and treat our bodies like garbage. We don’t stay physically, emotionally, mentally, or spiritually fit. We don’t see our families and friends. We work, we suffer, and we die.
Ok, here is where I changed the pronoun from “we, or us” to “me and I.” This is based on what I’ve learned in my recovery. I point the finger at myself first.
I’m a paramedic and have been in the EMS industry for 22 years. I work closely with police, fire, and communication specialists. Some of my closest friends are in the field. The very nature of our business has one common denominator, danger. Currently, I’m a flight paramedic for a community-based helicopter service. I’ve been at this post for almost nine years. Before that, I was an EMT for a convalescent transport service. I then worked as a ground ambulance 911 paramedic, an ED paramedic in a level 1 trauma center, and even a contracted remote duty medic overseas in a war zone. These jobs had a considerable amount of risk and multiple hazards attached to these positions. It is the nature of the business. I’ve responded in austere conditions to people experiencing the worst time of their lives. I’ve jumped into an ambulance or helicopter and sped quickly to the scene, with road conditions and the weather rarely optimal. Half my shift occurs at night, which increases every facet of danger. This factor makes my job substantially more dangerous than the general public’s. I often arrive on scenes of busy highways where people prove on a daily basis that they don’t know how to act when they see an accident or emergency vehicle. Or maybe it’s an active house fire or even a dangerous crime scene. Of course, I would be remiss if I forgot the other side of the coin. Most importantly, my focus is on my patient. They are dead, dying, critically ill, mentally ill, in the act of a crime, or just generally angry when I arrive. Oh, and there’s the “frequent flyer” that I’ve responded to too many times to count, whose chief complaint is just being “lonely” and needing ten minutes of my time to feel like a normal human. Finally, even when I’m not responding to a call, I sit at a base for 12-24 hours. Those hours are spent away from my family and friends. Those hours exacerbate my interpersonal relationship issues with the people I love. The old proverb “absence makes the heart grow fonder” isn’t true. If you don’t believe me look at the divorce rates. Look at the single-parent first responder families. Look at the children who grow up without seeing their mother or father for many of their lives simply because they are gone for 12-24 hours being first responders. And then watch most of those children follow in their parent’s footsteps, repeating the cycle. My story is just 1 of 25 million in this country, but it’s a story that needs to be heard and related 25 million times.
I’ll never forget the first day I responded as an EMT in the summer of 2000. I was going to “save lives.” I worked for a transport service. On my first call, we picked up a large body habitus patient and took her to her dialysis appointment. On the way, she became nauseated and vomited her entire stomach contents on the floor of my ambulance, which, in my professional opinion, was about a gallon of what appeared to be chicken noodle soup. As I saw it then, she was definitely aiming for me. But my spry, young mind and body were able to pull a “Matrix” move and get my legs out of the way just in time, missing me by inches. She looked me dead in the eyes and said: “Now I’m going to be hungry.” I couldn’t believe this woman had just projectile vomited, and all she could think about was that she would be hungry again soon. I told my grisly old paramedic partner thru the tiny window that separated the patient care compartment from the driver’s compartment what happened, and she said, “Ok, well, we have a water hose back at the base,” as she snickered. Of course, she was driving because this was a BLS transfer and not of the caliber of her paramedic expertise. Besides, I had to learn. The truth is it was probably her poor driving that caused the poor woman to vomit in the first place.
The next thing I vividly remember was September 11, 2001. So many people have heroic and daunting stories of that day and the days to follow. And my thoughts of them are of complete reverence and a bit of jealousy. Everyone has a “where were you when 9/11 happened” story. My story…I was asleep at home when the planes hit because I had just gotten off my night shift on September 10, where we’d been up all night running inter-facility transports. My roommate woke me up, and my TV showed the smoldering buildings pre-collapse. I sat there for the next few days, watching the coverage of all the sadness but unbelievable heroism in the face of that tragedy. However, life for me just went on as usual. I wasn’t in NY, Washington D.C., or the countryside of Pennsylvania dead under rubble or digging through it. I was completing another convalescent transport. That repeated itself for the better part of three years.
Fast forward to 2004, when I got my paramedic license and ran my first call as the lone medic on the truck. This was the day when it all changed. I was going to “save lives.” Upon arrival, it was a patient that was beyond dead. He had gotten hit by a train and was almost dissected in half, with his abdominal organs eviscerated. I’ll never forget how large his abdominal cavity contents looked, as I found them spread out on the large rocks you find on railways across the country. Obviously, there was no saving that life. We just called the coroner. When I got back to the base, all the older EMS personnel joked that I would be “the black cloud” since that was my first call as a medic. I thought that was some fairly dark humor, to say the least. But it quickly became normal in my life.
By the time I had been a medic for nearly a decade, I had cared for countless people, some with miraculous outcomes, though many ended in tragedy. I felt like I had dipped my toes in many different roles as a paramedic, including working in the ED and even doing contract work overseas. I then started my flight medic career in June of 2013. I thought that flight medicine was the only thing I lacked from seeing it all. Then just a few days before I headed off to orientation training with my company, Air Evac 109 crashed in Manchester, Kentucky. This was just a few miles from where I lived and worked, tragically killing everyone on board.
The pandemic has loomed in my psyche for the last two years and possibly the foreseeable future. I often reflect on how times have changed and how they will affect the people around me and me in the future.
Any of these events, the thousands of calls and patient transports, might spur the rational person to run in the opposite direction and find another career. So, what is wrong with me? Why did I stick with it for so long? Why do I continue to do this job in the face of all that I’ve seen? Maybe… it’s the enormous paycheck.
In the summer of 2015, I sought psychological counseling. It wasn’t my idea, and I didn’t want to go. The stigma attached to mental health counseling was something I wasn’t prepared to admit or take on seriously. What if my friends, family, colleagues, employer, or even licensure-certification board found out? With reluctance, I went, with my fiancé at the time gently encouraging me to go with the threat of ending the said relationship. I was in the midst of full-blown alcoholism and just starting the spiral to rock bottom. In the end, I was able to find recovery before it was too late. I knew one thing; I didn’t want to lose that relationship. So I went through the motions, with most sessions being spent having a level-1 type conversation about tough subjects like the weather or our favorite sports teams. One day my counselor said something that resonated with me; to this day, I’ve never forgotten it. He hadn’t counseled a lot of first responders in his career, but after hearing some of my stories, he asked this question: “Do you think you suffer from survivor’s guilt mentality?” I remember saying, “what is that?” even though I knew what he was asking. I knew because it was so obvious. It was so obvious, yet I didn’t dare deal with it.
Google dictionary defines survivor’s guilt as “A condition of persistent mental and emotional stress experienced by someone who has survived an incident in which others died.” I contend that every first responder and I suffer from this in some form. If I peeled back every layer from all the years of the hurts, habits, and hang-ups I’ve collected from my childhood, adult life, and years of first response, I would find a heart riddled with survivor’s guilt.
Sound familiar? How many calls have I responded to, then found myself arguing with my partner, family, friend, colleague, or even internally, rationalizing that somehow that person deserved what happened to them? “Oh, they were driving like an idiot, distracted, or drunk.” “They were fat, treated their body like crap with self-caused co-morbidities, and that’s why they have that life-threatening emergency.” How many? If I had to guess, I’d say about 99%. Why not 100%? How often have I responded to a child or baby and said, “they just don’t deserve what happened to them.” Then finding myself not sleeping well for weeks, with constant nightmares and internal comparisons to my child’s life; is that thought process some survivor’s guilt by proxy? I can confidently say 100% of these calls end up just like that. That has to be it. As I said, this job is dangerous, and there must be a reason I survive these dangerous situations, but the “Joe Q” public doesn’t survive. I treat my body with the same amount of disrespect too, but there has to be a reason that I’m sitting on the bench seat taking care of patients and not laying on the stretcher as a patient.
Mental Health Awareness
Why do I do this? The Diagnostic and Statistical Manual of Mental Disorders describes this as its diagnosis. But now, it is described as a symptom of PTSD. I respond to death and dying and can’t understand why that person died and I survived. Surely, they were a bad person or, at least, a worse person than me. Because if they are a good person, why did the universe, or God in my case (because I am a Christian), let this happen? And what about when I respond to a child? I can’t reconcile anything bad happening to a child, the most innocent of them all. This is where I struggle, with the computer in my brain not being able to write 1s and 0s to explain this phenomenon away. So I don’t explain it. I lock the thoughts away for another day, another call, another sleepless night.
So how do I cope? I experience the event. I can’t reconcile the event. I receive the pain. I internalize it. And I cover it with layers of filth and self-harm so that no one, especially me, can see what’s wrong. I created “SUSPECTED INTERNAL INJURIES.” Those being an injured heart, mind, and soul. I say I’m a broken person and can’t be fixed. In reality, I build walls to protect myself from anyone helping, especially myself, in some sick form of psychological homeostasis to said internal insult. What are those layers? I’ll gladly bring them to light so they may not hurt another person again: anger, resentment, grudges, hate, isolation, lack of self-worth, fear of love, and being loved. Addictions to: food, alcohol, drugs, sex, pornography, co-dependency, or just the rush of running another call.
Now that I know what’s wrong, how do I fix it? Look, I’m a paramedic! I’ve been taught my whole career if I find a problem, I don’t move on until I fix it. Well, it has taken my entire adult life to realize I have a problem, and I still don’t have a complete resolution. And that’s ok. I can’t expect it to be fixed overnight. Our lives are not trauma assessments that must be completed in 10 minutes. And I write this because I know I’m not alone. I know this because the statistics say so, and I see it in my and my colleagues’ lives. How many of my preceptors or the men and women I work beside, and respect deeply, have crashed and burned to do the same things as me? How many of my friends and family have fallen to this? How many of my current students and orienteers have all the signs of turning out just like me? Too many to count – that is how many.
I’ll close with this simple statement. If any of this resonates with you, seek help now. Don’t wait another minute. Don’t follow in my footsteps, or worse, be one of the hundreds of first responders that will take their own life this year. Do better than me, be better than me. Fight for yourself. Fight for your family. Fight for your career, better work conditions, better wages, and better treatment from your employer. When you respond to calls, seek counsel afterward. Find a good friend, colleague, counselor, or pastor. Pray if so inclined. Find a support group, study group, or recovery group. But, most importantly, deal with the guilt. Don’t internalize it. Don’t build walls that will take longer than the Berlin Wall to tear down. I guarantee you will be happier, healthier, and live longer, and your patients will have better outcomes.
Suicide Prevention Hotline: 800-273-8255
John Yeary, BS, FP-C, Paramedic
John Yeary, BS, FP-C, Paramedic, is the current flight paramedic in the southeastern US. He has worked in the EMS field for 22 years with the past 9 years spent in the HEMS industry. John is a guest writer, friend, and longtime colleague of FlightBridgeED.