Suspected Internal Injuries by John Yeary

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 and see fire everywhere, seeing 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.

The title and first paragraph of this article 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 something about trauma, or maybe a cool case review on a cool 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. Of those first responders that suffer these issues, about 50% (3.75 million) 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 of those people suffer from mental health issues and about two of those turn to substance abuse. 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 first responders die from suicide than in the line of duty. These numbers are horrible and sad but are, unfortunately, reality. The sad fact is those numbers are almost all under-estimated, simply because of the stigma attached to these astounding statistics. When you think of these numbers, just know they are the bare minimum.  

The question then is WHY? The answer is obvious, right? Or is it? We all suffer from some type of PTSD due to the very nature of our profession. But the existential threat is that we don’t seek help. We work too much, we eat atrociously, we don’t sleep, and we 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 change the pronoun from “we, or us”, to “me and I” based on what I’ve learned through my own experience and recovery.

My Experience 

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. Prior to that, I was an EMT for a convalescent transport service, 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. All of these jobs had a considerable amount of risk, and hazards associated with them; It is the nature of the business. I’ve responded in austere conditions, to people who are 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 weather rarely optimal. Half my shift occurs at night, which increases every facet of risk. These factors alone make my job substantially more dangerous than most other careers. I often arrive on emergency scenes in the middle 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. Sometimes I am called to active house fires or even unstable crime scenes. Of course, I would be remiss if I failed to mention that I also respond to facilities that should change their names to "Bless Their Hearts* Memorial Hospital" because of the lack of good patient care found there. 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 an acute inflammation of their need for attention related to chronic loneliness and urgently in need of 10 minutes of my time to feel like a normal human. Finally, even when I’m not responding on a call, I’m sitting at a field base for 12-24 hours. Those hours are spent away from my family and friends. Those hours away can exacerbate any type of interpersonal relationship issues I may have with the people I love and I have found that the old proverb - "absence makes the heart grow fonder" - just isn’t true. If you don’t believe me look at the divorce rates for first responders, the single parent first responder families, the children who grow up without seeing their mother or father because their job makes them completely unavailable for 12-24 hours at a time. Furthermore, a good majority 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. 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 - in my estimation, this had to have been about a gallon of what appeared to be chicken noodle soup - and I was absolutely sure that she was intentionally directing her vomit at me. My spry, young mind and body was able to pull a “Matrix” move and get my legs out of the way just in time, missing me by inches. She looked me right 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 the fact 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". I had to learn and this was the quality on-the-job training that I had come to expect from such a professional, experienced mentor like my old partner - it was probably her lousy driving that made the patient nauseated now that I think about it.

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. My thoughts of those days are of hallowed reverence and a bit of jealously as well. Everyone has a “where were you when 9/11 happened” story. Where was I you ask? I was asleep at home when the planes hit because I had just gotten off my night shift on September 10 and I had 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 and unbelievable heroism in the face of that tragedy. Life for me, however, just went on as usual. I wasn’t in New York, Washington D.C., or the countryside of Pennsylvania dead under rubble or digging through it. I was just completing another convalescent transport which was the endless loop of my professional life for the better part of three years.

Now, fast forward to 2004, when I got my paramedic license and ran my first call as the lone paramedic medic on the truck. This was the day when it all changed and I was FINALLY going to “save lives.” Upon arrival at the scene of that first call, I found that my patient was waaaaay beyond salvageable. He had gotten hit by a train and was almost dissected in half. His abdominal organs were scattered around everywhere in a twisted, bloody mess. I’ll never forget how large his abdominal cavity contents looked, as I found them spread out on the large rocks that you find on railways across the country. Obviously, there was no saving that life and we immediately called the coroner. When I got back to the base, all the older EMS personnel joked that I was going to 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 the norm in my life.   

By the time I had been a medic for nearly a decade I had cared for countless patients. Some of the people I cared for experienced miraculous outcomes, but many cases ended in tragedy. I felt like I had gained a lot of experience and knowledge as a paramedic which included putting my skills to good use in the ED and even doing contract work overseas. In June of 2013, I started my flight paramedic medic career. 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.

Current Day

For the last two years, and possibly for the foreseeable future, the pandemic has loomed in my psyche. I often reflect on how times have changed and how it is going to affect me and the people around me in the future.

Any one 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 I ask myself, "what is wrong with me and why have I stuck with this career path so long and in the face of all that I’ve seen?" I know what you're thinking... it’s probably the enormous paycheck, right?  

In the summer of 2015, I sought out psychological counseling. To be completely transparent it wasn’t my idea and I sure 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. Let me explain the circumstances a little bit so you can understand what was happening in my life around that time. I was in the midst of full-blown alcoholism and scheduled for an all-expenses-owed trip down to rock bottom. I am happy to report that 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, and 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 asking him what that was even though I kind of knew what he was asking because it was so obvious. It was so obvious and yet I didn’t dare deal with it.  

Google dictionary defines survivor’s guilt as this: A condition of persistent mental and emotional stress experienced by someone who has survived an incident in which others died.” My contention is that I and every first responder suffer from this in some form. When 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 being a first response, I found a heart riddled with survivor’s guilt.

Sound familiar? How many calls have I responded to, then afterward found myself arguing with my partner, my family, a friend, a 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 are having that life-threatening emergency.”

How many you ask? I’d say about 99%.

Why not 100%? When responding to treat a child or an infant I often thought that they just don’t deserve what happened to them and then find myself not sleeping well for weeks; my nights filled with nightmares and internal comparisons to my own child’s life. I can confidently say 100% of these calls end up being processed as some type of survivor’s guilt by proxy.

As I said, this job is dangerous and there must be a reason why I survive these dangerous situations, but "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 these patients and not laying on the stretcher as the patient being treated.  

Mental Health Awareness 

Why do I do this? The Diagnostic and Statistical Manual of Mental Disorders use to describe this as its own 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. In my mind, I reason that they must have been 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 why do bad things happen to children who are so pure and innocent? This is where I struggle, with the computer in my brain not being able to logically rationalize these circumstances and come up with any sensible answer. Since I can't explain it I just lock the thoughts away for another day, another call, another sleepless night.

I experience the event. I can’t reconcile the event. I receive the pain. I internalize it and I cover it up with layers upon layers of filth and self-harm so that no one, especially me, can see what’s wrong. I create “SUSPECTED INTERNAL INJURIES” of my heart, mind, and soul. I just say I’m a broken person and I can’t be fixed. I build walls up inside myself to "protect" myself from anyone actually helping.

What are those layers that are building and building? They are anger, resentment, grudges, hate, isolation, lack of self-worth, fear of love, and being loved. They are addictions to food, alcohol, drugs, sex, pornography, co-dependency, or just feeling 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 that if I find a problem, I don’t move on until I fix it. It has taken my entire adult life to realize I have a problem and I still don’t have a complete resolution to it and that’s ok because I can’t expect it to be fixed overnight. Our lives are not trauma assessments that have to be completed in 10 minutes.

I know I’m not alone. I know this because the statistics say so, but also because what I see in my own life is also what I see in many of my colleagues’ lives. So many of my mentors and co-workers that I love and deeply respect have crashed and burned doing the same things as me. How many of my friends and family have fallen to this? How many of my current students and orientees have all the signs of turning out just like me? Too many.

If any of this resonates with you then please don't stay layered under all that pain. 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 and fight for yourself and for your family. Fight for your career, better work conditions, better wages, and better treatment from your employer. When you respond to calls that leave you with unanswered questions or twisted up inside mentally and emotionally give yourself permission to seek counsel. Find someone you trust and talk to them; a good friend, colleague, counselor, or pastor. Pray if you are 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. From my own experience I can say that you will be happier, you will be healthier, you will live longer, and your patients will have better outcomes.  

Suicide Prevention Hotline: 800-273-8255



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.



* For those readers who are not from the Southern United States, "Bless Their/Your Heart" typically is not used in conjunction with an expression of actual sympathy (although it can be). What a Southerner means when they say this is... "they/you are an idiot and they/you can't really help it." 


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