Talking Green

Code Green Campaign logo

There’s a secret behind this job.

You go to work. You run the calls: the boring, the exciting, the obnoxious, the weird. Occasionally, the terrible. You see, you do, you move on. Like everything else, it runs off our backs. Like rain off a tin roof.

At least, that’s what we tell ourselves. But there’s a secret.

The secret is that hidden beneath the uniformed cowboy swagger of no-problem, we-got-this, no-big-deal, a thick vein of psychological stress is flowing. You don’t see it in your coworkers, because they hide it away. When it reaches you, you do the same, because it’s not okay to show it. Our professional image is unflappability, and you can’t be unflappable if you let things get to you. So we push it under the rug.

Until one of us takes their own life.

PTSD, depression, anxiety, substance abuse, and yes, suicide, are a fact of life in EMS. But we never talked about it. At least, not until a few of our colleagues were brave enough to start shining light upon the problem, in an effort called the Code Green Campaign.

Code Green collects anonymous confessions from our brothers and sisters who can’t speak them out loud, reports the (all too frequent) suicides, collates the research exploring first responder mental health, and performs outreach to build awareness.

Explore their website for more information about their basic mission. After that, come back, because I asked them to unpack a few of the subtleties behind this problem and how they’re trying to solve it.

Question: While most first responders agree with the need for the Code Green Campaign, most of us haven’t actually done anything about it. You did. How and why did it first come about? What was the impetus and how did the early days take shape?

Answer: In March of 2014 one of my co-workers died of suicide. After his death I was talking about it with a group of friends, and we realized that even though we worked for different agencies in different states, we all knew someone that had died of suicide or had a serious attempt. We knew that this couldn’t be a coincidence, so I started looking into it further. I couldn’t find a lot of data, but what I did find told me that this was a much bigger problem than anyone realized.

Once we established that there was, in fact, a mental health problem, as well as a stigma problem, we started discussing what could be done — particularly about the stigma. It occurred to us that if there was one thing first responders like doing, it is sitting around telling stories. We thought that if we could come up with a way for first responders to share the stories of their own mental health problems, other people could read them and realize they weren’t the only ones struggling. We started collecting the stories and posting them on social media every Monday, Wednesday, and Friday. Things blew up from there.

In the early days things moved fast. My co-worker died on March 12th, and on March 16th we came up with the story sharing idea. We came up with our name a couple days later, and I think it was by March 23rd that we had our Facebook page up and running and stories being shared.

Q: Let’s get down to the elephant in the room. Why is this a problem for us? Why do EMS providers seem to be at higher risk for mental health issues in general, and for suicide in particular, compared to bakers, librarians, and schoolteachers?

A: I’m going to preface this answer with the warning that this is a lot of supposition, extrapolation, and educated guesswork. PTSD has most extensively been studied in the military population, so that is the best info we have. This is also a simplified answer, since the long answer would probably beat a doctoral dissertation in length.

  1. We are frequently exposed to known risk factors for PTSD, such as seeing people hurt or dead, feeling helplessness or fear, having poor social support after a traumatic event, and having extra stress outside of work (marital, financial, etc).
  2. We are poorly prepared for the realities of the job. Yes, we’re warned that we’ll see blood and guts and gore, but we’re not told that we are going to feel helpless on a regular basis, or that we’ll be scared we hurt a patient or made them worse. We’re not taught about how different this job can be from normal jobs, and how hard it can be for spouses and other family members to understand what we go through.
  3. Aside from stressful calls, we’re exposed to higher rates of assault, vehicle crashes, and workplace injuries than many fields, which can add to the trauma.
  4. We seem to have higher rates of depression, anxiety, and substance abuse, although it is unclear why.
  5. We work in a very macho field and we’re supposed to be the helpers, not the ones that need help. There have also been reports of people being suspended or fired after admitting they have a problem. That combination helps create a huge stigma against admitting any sort psychological problem and asking for help.
  6. We have more knowledge about lethal means of suicide.

Q: Okay, so let’s contrast EMS against some similar fields. Other first responders like fire and police, or medical personnel like doctors and nurses, all seem share most of the qualities you listed. Are they in the same boat? Or is there anything that puts us at greater risk compared to them?

A: Other first responders like fire and police are in the same boat. In fact, we don’t separate EMS numbers from fire service numbers because the employee base is so entwined.  There are almost no fire departments out there who don’t do any EMS at all, so it is tough for us to draw a line as to who counts as EMS and who doesn’t. Just because an agency doesn’t transport doesn’t mean their employees/volunteers aren’t exposed to the same trauma. If you can’t draw the line at transport versus non-transport, where do you draw it? In the long run, it becomes almost impossible to separate people out. With police officers it is easier, but their suicide rate is on par with Fire/EMS. I believe that in 2014 there were over 140 reported police suicides.

As far as other medical professionals go, we do know that doctors do have a high rate of suicide, to the tune of 46 per every 100,000 (for first responders we’re looking at about 30 per 100,000). We don’t know what the suicide rate is for nurses, PAs, or NPs, but we wouldn’t be surprised to learn it is also high.

This is purely supposition on my part, but I do think we are particularly susceptible, because EMS is less developed than other medical fields. Nurses and doctors have well-established professional organizations representing them at the state and national levels. EMS is much more fragmented. The one big difference we’ve especially noticed with nurses and doctors compared to EMS is that many states have license preservation programs in place for RNs and physicians, but not for first responders. That is, if they have a mental health or addiction issue, their state may have an official program in place to help them keep their license while getting help. Few (if any) states have a similar program for first responders. EMS doesn’t have that kind of well-organized advocacy yet.

Q: I expect many of our readers aren’t familiar with license preservation programs. What are they and what are the possible ramifications when we lack one?

A: My answer is based on the states I’ve lived in. From what I understand, most states have such a program set up for either doctors and/or nurses. Basically, the state has recognized that nurses and doctors spend considerable time and money to obtain their licenses, and that it is in everyone’s best interest to keep them on the job, rather than automatically revoking their license. Here is an example of how it would work: say a nurse starts diverting narcotics. She self-reports her behavior to her employer and to her state licensing agency. She will likely be suspended or fired from work, but if the state has a license preservation program her license will only be suspended. The licensing board will then review the case and outline what the nurse has to do to get her license reinstated. They may require her to complete a treatment program, attend weekly counseling sessions, and submit to monthly drug tests. As long as she meets those requirements, she can keep her license.

The issue with lacking a license preservation program is that it creates an atmosphere of fear. People will avoid seeking help for anything they think could possibly cause their license to be suspended, since they have no way of knowing the outcome of that. No license means no job, and unless you want to move to another state, you’d have to come up with a new career fast.

Q: In the absence of such programs, is there a real possibility that EMS providers can lose their jobs or even their certifications merely for reporting mental health issues? In other words, no diversion or actual violations, just the typical paramedic suffering from depression, anxiety, or PTSD?

A: This question is difficult to answer because it is based on the idea that people are routinely reporting their mental health issues to the employer or the state. Unless someone is seeking to use Worker’s Comp or other employment benefits for a mental health issue, there is no reason to be reporting routine treatment to anyone (unless it is required, like with some communicable diseases). Someone wouldn’t report that they’re being treated for asthma or hypertension to their employer or state licensing board, so why would they report depression or PTSD? Employment benefit issues aside, in absence of diversion or actual violation it really doesn’t make sense for anyone but the person and their treatment team to know anything. 

Such programs are generally more reactive than proactive, although in the ones I’ve looked at it is strongly encouraged to self-report issues/violations before they are caught by an employer. In fact, at my employer you’re much more protected if you self-report to the EAP than you are if you get caught.

I think that no matter what the reality is, having programs like these make it so that people don’t feel like they are backed into a corner once they develop an issue. We don’t want people feeling like a situation is hopeless, we want them to be able to see there are options.

Q: I imagine that in most cases, “reporting” occurs in the circumstances of a worker’s compensation claim (i.e. asking the employer to pay for mental health services), or perhaps when an employee needs to take time off work.

In the real world, I expect some employers are inclined to be less than supportive about these types of requests. Are they sometimes refused? Are employees sometimes asked to “prove” that their condition is work-related? Is there a legal framework mandating employers to provide these services and accommodations?

A: We answered earlier that Worker’s Comp claims or using other employment benefits are the instances an employer is most likely to learn that someone is having issues.  It is difficult to answer a straight “yes” or “no” to any part of this question. No one has sat down and studied how often requests like the above are made, how often they are granted, how often they are refused, and if the response to such a request is affected by the type of employer or the state the employee is located in. We don’t know how often time off requests for mental health conditions are granted or refused, or how often they are granted or refused compared to other time off requests at that same employer. We could come up with anecdotes of both positive and negative outcomes, but there is no data.

What is and what isn’t covered by Worker’s Comp will vary from state to state and employer to employer. We do know that there are states where psychological conditions are not covered for anyone, or are only covered for certain jobs, and the employer has no control over that. It’s not uncommon for Worker’s Comp claims to be investigated no matter what kind of claim it is, so we would not be surprised if people filing a claim related to a psychological issue would be subjected to some questioning. Just ask anyone who has filed Worker’s Comp for a back injury or knee injury. Worker’s Comp tends to be difficult no matter what. 

Furthermore, people who have had to take time off for physical injuries will tell you that on top of their injury being investigated and questioned, they likely also had to jump through hoops in order to return to work. Fitness for duty evaluations, physical agility tests, etc. Because of the differences between state laws and agency policies it is very difficult to know if mental health conditions are being treated differently at a significant rate.

As for accommodations, that is even more complicated. Under the Americans With Disabilities Act (ADA) employers are mandated to provide reasonable accommodations for employees that have disabilities. Now, how many first responders do you know that are willing go through that process, and then admit to their employer that they have a disability that needs to be accommodated? Additionally, first responder agencies are in a tough spot when it comes to accommodations because this field is so unpredictable. Agencies can’t ensure that you’ll never run another pediatric cardiac arrest, or never have to respond to a certain address again. If someone has an anxiety attack while responding to a call, or on scene of a call, is taking them out of service going to be considered reasonable? Probably not. Accommodations get very complicated very quickly.

Q: Interesting. So despite these challenges, the problem is clearly an urgent one. What steps can field staff take to prevent and manage mental health issues, whether for themselves or for their colleagues?

A: Resiliency, and building resiliency factors, seems to be a key to helping prevent mental health issues from arising, so everyone should review what resiliency factors they have and work on building upon them. People also need to be able to recognize signs of decline in themselves, such as worsening sleep, increased drinking, and anger issues. For co-workers, the biggest thing is not to be afraid to say something to someone if you think there is a problem. Asking someone, “Are you thinking of suicide?” is not going to put the idea into their head — so if you’re concerned, ask.

Something else that is important is reducing the stigma around mental health in general. Don’t make jokes about “BS psych patients” or complain that psych calls are a waste of time. This contributes to the stigma and makes it harder for people to admit they have their own problem.

Q: What other points do you want do make on this important topic?

A: We need to keep talking about this and keep the conversation going. Changing how mental health is addressed is going to involve changing the culture, which is going to take time and effort.

For people who want to get involved there are several things you can do. Speak up if you hear someone speaking negatively about mental health, whether in the context of our peers or our patients. If you hear about a suicide, please report it to either Code Green or to the Firefighter Behavioral Health Alliance. All reports are confidential and we do not disclose information without permission.

If you know of a first responder–friendly mental health professional in your area, let us know so we can add them to our resource database. It may not seem like much, but this kind of stuff is incredibly helpful to us and to the cause.

Visit the website of the Code Green Campaign to learn more, read personal accounts, and see else what you can do to help.

A Saga of Spurious Spines

Journal cover

There’s a story we’ve all been told. It goes like this:

A person suffers a traumatic injury, usually a minor one, like bumping their head or crunching their fender in traffic. Afterwards, they appear fine, without deficits or any great pain. Ambulance and hospital personnel are unimpressed. But all of a sudden, our seemingly-well patient makes some slight movement — maybe he turns his head — and instantly collapses to the floor, unable to move. He is paralyzed forever, and it’s all because of the unstable spinal injury that you missed.

You heard this cautionary fable in EMT or paramedic class. They tell it in medical school, in the emergency department, and on the trauma wards. It goes back decades. And it makes sense, right? Even a layperson would agree that if the structure of the spine is damaged, the cord it protects will become vulnerable, just like how you’re not supposed to poke the soft spot on a baby’s head.

In fear of this event, we go to great lengths to prevent it. We wrap collars around our patients’ necks, we tie them onto boards, we strap and tape and secure. If their spine can’t protect the cord, by golly we’ll protect it instead, at least until somebody definitively proves that there’s no injury. Which there usually isn’t. But still.

Here’s the trouble: practically nobody has actually seen this phenomenon of mechanical instability occur. For real; the next time somebody mentions it, ask if it’s happened to them. No, they’ll say; but my partner’s cousin’s babysitter saw it a few years back. And if you bother to track that person down, invariably you find that the case either never occurred or has become terribly dramatized through the telling. Steve Whitehead calls it the “Sasquatch event.”

So does this happen at all? After all, many things in medicine that make sense aren’t real. Indeed, doubt has grown lately as to whether our spinal immobilization precautions are effective, and we’ve become more aware of the harms associated with them; as a result, backboards have become increasingly vilified in recent years, and “selective immobilization” algorithms have been accepted in some areas. But there’s been less attention to the question of whether the disease itself is real or a myth, and I wanted to know.

So we went and looked. With the help of four folks smarter than me — Domenic Corey, NREMT-P; James Oswald, B.Emerg Health (Paramedic); Derek Sifford, FP-C; and Brooks Walsh, MD, NREMT-P — we canvassed the literature as far back as possible to dig up any actual, confirmed, peer-reviewed reports of this event. And we just published our findings in the journal Academic Emergency Medicine. Check it out. (And also check out the accompanying editorial by spine connoisseur Mark Hauswald, who you know from “that Malaysia study.”)

I won’t spoil the results, but let me put it this way:

  1. Despite looking across 50+ years, we found few examples.
  2. Most of them weren’t very impressive.
  3. Even fewer occurred in the EMS setting, and none of those were the classic, sudden event you’ve heard about.

So the next time your buddy mentions this unicorn, tell him you don’t doubt him, but that he should write it up for the journals — because it’ll be the first one, and that’s publishable.

This has been an exciting project for another reason. From start to finish, this paper was the child of two parents: the FOAM and EMS communities. Of my four co-authors, I knew three of them exclusively through the web, and have only met two, yet we share interests and passions enough to collaborate on a project that took us over a year. Moreover, every one of us is either an EMT or paramedic, most of us still working actively in the field (although in a few cases we’ve accumulated some other titles too). In fact, had this reached print a few months sooner, the fanciest initials of the lead author would be EMT-B, and that should tickle you.

So never let it be said that the nonsense in this profession is invincible, or that we can’t be the ones to exorcise it. We can fix our own problems, and if we spent more of our energy on moving forward rather than complaining, it just might happen sooner than you think.

Murder by Checklist

Reader Steve Carroll passed along this recent case report from the Annals of Emergency Medicine.

It’s behind a paywall, so let’s summarize.


What happened

A young adult male was shot three times — right lower quadrant, left flank, and proximal right thigh. Both internal and external bleeding were severe. A physician bystander* tried to control it with direct pressure, to no avail.

With two hands and a lot of force, however (he weighed over 200 pounds), he was able to hold continuous, direct pressure to the upper abdomen, tamponading the aorta proximal to all three wounds.


Manual aortic pressure


Bleeding was arrested and the patient regained consciousness as long as compression was held. The bystander tried to pass the job off to another, smaller person, who was unable to provide adequate pressure.

When the scene was secured and paramedics arrived, they took over the task of aortic compression. But every time they interrupted pressure to move him to the stretcher or into the ambulance, the patient lost consciousness again. Finally en route, “it was abandoned to obtain vital signs, intravenous access, and a cervical collar.”

The result?

Within minutes, the patient again bled externally and became unresponsive. Four minutes into the 9-minute transfer, he had a pulseless electrical activity cardiac arrest, presumed a result of severe hypovolemia. Advanced cardiac life support resuscitation was initiated and continued for the remaining 5-minute transfer to the ED.

The patient did not survive.


When the cookbook goes bad

The idea of aortic compression is fascinating, but I don’t think it’s the most important lesson to this story.

Much has been said about the drawbacks of rigidly prescriptive protocol-based practice in EMS. But one could argue that our standard teachings allow for you to defer interventions like IV access if you’re caught up preventing hemorrhage. Like they say, sometimes you never get past the ABCs.

The problem here is not necessarily the protocols or the training. It’s the culture. And it’s not just us, because you see similar behavior in the hospital and in other domains.

It’s the idea that certain things just need to be done, regardless of their appropriateness for the patient. It’s the idea that certain patients come with a checklist of actions that need to be dealt with before you arrive at the ED. Doesn’t matter when. Doesn’t matter if they matter.

It’s this reasoning: “If I deliver a trauma patient without a collar, vital signs, and two large-bore IVs, the ER is going to tear me a new one.”

In other words, if you don’t get through the checklist, that’s your fault. But if the patient dies, that’s nobody’s fault.

From the outside, this doesn’t make much sense, because it has nothing to do with the patient’s pathology and what might help them. It has everything to do with the relationship between the paramedic and the ER, or the paramedic and the CQI staff, or the paramedic and the regional medical direction.

Because we work alone out there, without anybody directly overseeing our practice, the only time our actions are judged is when we drop off the patient. Which has led many of us to prioritize the appearance of “the package.” Not the care we deliver on scene or en route. Just the way things look when we arrive.

That’s why crews have idled in ED ambulance bays trying over and over to “get the tube” before unloading. That’s why we’ve had patients walk to the ambulance, climb inside, and sit down, only to be strapped down to a board.

And that’s why we’ve let people bleed to death while we record their blood pressure and needle a vein.

It’s okay to do our ritual checklist-driven dance for the routine patients, because that’s what checklists are for; all the little things that seem like a good idea when there’s time and resources to achieve them. But there’s something deeply wrong when you turn away from something critical — something lifesaving — something that actually helps — in order to achieve some bullshit that doesn’t matter one bit.

If you stop tamponading a wound to place a cervical collar, that cervical collar killed the patient. If you stop chest compressions to intubate, that tube killed the patient. If you delay transport in penetrating trauma to find an IV, that IV killed the patient.

No, let’s be honest. If you do those things, you killed the patient.

Do what actually matters for the patient in front of you. Nobody will ever criticize you for it, and if they do, they are not someone whose criticism should bother you. The only thing that should bother you is killing people while you finish your checklist.


* Correction: the bystander who intervened was not a physician, but “MD” (Matthew Douma), the lead author, who is an RN. — Editor, 7/22/14

Glass Houses: Suicide in Both Seats



Of all the skills we’re called upon to wield without adequate training, care for psychiatric complaints tops the list. In particular, it’s a rare shift when you don’t handle a person — whether on the initial emergency response or a subsequent interfacility transfer — who has thought about, or even attempted to commit suicide.

Probably because these patients aren’t very medically exciting and can be challenging to deal with (due to varying degrees of cooperativeness), many of us aren’t big fans. We also tend to have a cynically individualistic sort of streak, which says that deep down, patients are responsible for themselves. If someone wants to be healthy and they get unlucky, we’ll help out. But if they can’t be bothered to try, we can’t be bothered either, and if they’re actively trying to hurt themselves, surely we have better things to do than interfere with natural selection.

But before we throw stones, we should probably understand the disease we’re discussing. Just like you can’t treat CHF without grasping its pathophysiology, properly treating the suicidal patient — or even deciding not to care — demands knowledge before judgment.

Depression itself is hard to grasp from the outside. This easy walkthrough may shed some light, but if you haven’t been there, you probably shouldn’t pretend you understand it. Nevertheless, it’s one of those conditions that invites amateur opinions, because it seems like the sort of thing we all know something about.

Maybe depression is too loosey-goosey; maybe it’s better if we stick to concrete facts, yeah? And there’s nothing more concrete than suicide. Let’s talk about suicide.

Start by reading through this article at the Daily Beast. It’s long, but it’s real good, and you may start to change your mind about a few things by the end.

For instance, in 2010, in the developed world where we have good statistics, suicide killed more people in the prime of their life (ages 15–49) than anything else. Read that again. Of all the terrible insults we study and treat, from gunshots to heart attacks, car crashes to cancer, suicide was more deadly than every single one. Over a hundred thousand suicide deaths that year. Almost a million across all age ranges. Every murder, every war, every natural disaster you read about in 2010 — throw them all together, and they still don’t equal the number of suicides. There were probably even more that weren’t reported, and even that’s just the successful suicides, of course; those that were attempted but didn’t quite succeed make up a much larger group, perhaps twenty-five times larger. (Yes, 25 times.) And there are more and more every year.

When we talk about CPR, we often talk about quality of life. When a 98-year-old bed-bound dementia patient dies, we might ask whether we should jump through hoops to save them; even in the best possible case, they’re not going to return to a very long or very fruitful existence. But when the 20-year-old college student drops dead on the lacrosse court, we want very badly to bring him back, because if we can he might live another 70 wonderful years.

Well, the people committing suicide are the second kind. They’re often middle-aged, middle-class folks who could be happy and live long — if they can get past their illness. But dead people won’t get past anything.

Of course, we see a lot of depressed people, and most of them won’t kill themselves even if they’ve thought about it. Figuring out who’s most at risk of taking that step is a worthwhile goal, and the Daily Beast article describes three risk categories that you may find useful:

  1. Those who feel alone, that they don’t belong anywhere
  2. Those who feel like a burden to others
  3. Those who have the willingness and capacity to go through with self-annihilation

Who feels alone? Everybody, at times. We need connection. Married people kill themselves less often than the unmarried, twins less often than only children, mothers raising small children almost never. Sometimes those who seem to have everything in life may have the weakest connections, which is why they say that money doesn’t equal happiness.

The life-saving power of belonging may help explain why, in America, blacks and Hispanics have long had much lower suicide rates than white people. They are more likely to be lashed together by poverty, and more enduringly tied by the bonds of faith and family. In the last decade, as suicide rates have surged among middle-aged whites, the risk for blacks and Hispanics of the same age has increased less than a point — although they suffer worse health by almost every other measure. There’s an old joke in the black community, a nod to the curious powers of poverty and oppression to keep suicide rates low. It’s simple, really: you can’t die by jumping from a basement window.

When nothing ties you down, when nobody cares what happens to you, what’s stopping you from shuffling off into the abyss? “I’m walking to the bridge,” one note said. “If one person smiles at me on the way, I will not jump.” Did you smile at your last psych patient?

Who’s a burden? Anyone who’s not achieving, contributing, responsible for something or someone. The unemployed, the chronically cared-for, those with debilitating diseases or intractable poverty. We do this job because we like taking care of people, but that means there’s always someone being taken care of, and nobody loves being on that side of the equation. Some people will go to their graves rather than add to the work or worry of those around them. A few will send themselves there.

Finally, who’s actually willing to end their own lives? It takes something special to close the deal, a particular resolve; no living creature’s natural instinct is to die. Even if you have the desire, it’s not easy to pull the trigger. It’s those with the gift or the learned ability to follow through with difficult deeds, the “athletes, doctors, prostitutes, and bulimics . . . All have a history of tamping down the instinct to scream.”

Think about those categories. None of those are particularly insane thoughts to have. All it takes is their juxtaposition, and suddenly, something unthinkable becomes a very real possibility. Honest. It happens hundreds of thousands of times every year.


Suicide in EMS

“Well, what the heck,” you’re thinking. “That’s nice, but I’m not going to fix them, so why do I care? I’ll bring ’em where they’re going and say good luck; God and the doctor can take care of the rest.”

Fair enough. But I have a homework assignment for you.

Find that guy at work. You know the one. His nickname is “Doc” or “Papa.” He’s been doing this for twenty-plus years, since the days when ambulances were dinosaur-drawn wooden wagons. Ask about the other old-timers, the endless sea of faces he’s worked with over the years.

He’ll have good stories. Tons of them. Partners and coworkers and crazy SOBs. Hijinks were had, shenanigans performed, laughs all around.

But then ask what happened to those guys.

Because a lot of the time, they’re not running around on the ambulance anymore. Ol’ Doc is the exception. They’re not semi-retired, spending their afternoons fly-fishing and golfing. They didn’t jump careers to become bankers or meteorologists.

They’re dead. Or maybe in jail. Or shot robbing a 7-11 for $13. Or they were committed to a psych hospital so many times nobody knows what happened to him. Maybe they overdosed. Living on the street. Living who knows where.

And yes, some of them committed suicide.

Seems a little rich to judge your psych patients when, the way the odds go, you’re probably going to be the next one.

I suppose you could argue that EMS was different back then. Russ Reina talks about the time when most “ambulance drivers” were people who couldn’t find a job anywhere else, drifters and ex-cons. Not like now. Now we’re all as well-adjusted as Mr. Rogers. Right?

Yeah, sure.

Let’s be real. A lot of the people doing this job can’t stay employed even in our own dysfunctional field, and would never stand a chance anywhere else. Drug abuse and PTSD are common. And our social support networks often don’t extend past a partner or two.

Do we belong anywhere? Maybe you do in the police or fire service. But those of us who enter private EMS usually don’t last long before being sucked into a loop of working more and more overtime until we no longer have hobbies, no longer spend time with friends, no longer travel or expand our horizons. If we have spouses, significant others, or family, we neglect them. If we don’t have those relationships, we sure as hell don’t develop them from the driver’s seat of an ambulance. The last step — which doesn’t take more than a few years — is when we start to view every one of our patients as a nuisance. Burnout takes away the last string tying us to other people; if patients aren’t worth helping, aren’t hardly people at all, then the circle of humans in our life may become no larger than our uniform belt.

Are we a burden? In many cases, that shoe drops when we find ourselves off the clock. If our life has become the ambulance, what happens when we lose the ambulance? Your company goes belly-up. We piss off the wrong boss and get tossed out on our ass. Or, inevitably, we get injured. Suddenly, the only reason to get out of bed in the morning is gone. Sounds nice at first, but you realize quickly that having nothing to do actually means you’ve got no reason to be alive.

And are we afraid of dying? Who could be less afraid? We spend every day minimizing death, trivializing the human condition, ingraining a culture that teaches we should be able to order nachos after bandaging a burn victim. We drive fast; we laugh at seatbelts. Sometimes we snort cocaine and have sex in ambulances. (No, not you. But you know who.) There’s nothing beyond the pale for an EMT. Including pulling the trigger.

So is suicide a big deal? Yes. Should we try to understand it? Yes. Does it matter for us? Yes.

But more importantly: do we get to judge it? Do we get to pretend we’re above it? Are the kind of people who attempt it so bizarrely pathological that we’re nothing like them?

You can decide. But you only get to say that if you’re willing to say you don’t care about a disease that kills more healthy patients than anything else. Willing to write off hundreds of thousands of people every year.

And willing to say you don’t care that your partner could be next. Or your boss. Or yourself.


Check out The Code Green Campaign for mental health support for EMS. — ed. 1/17/15

Further reading

Preparation vs. Improvisation

Everything in its place

I have a new partner who called me obsessive once.

“Eh?” I asked.

“Everything has to be just so. When you come in you make sure the collars are organized and facing the same direction, you fold over the ends of the tape and stack it in a certain order, you make sure the handles on the bags are easy to grab…”

“I’m not obsessive… have you seen my car?”

“Well, you are here.”

And it’s true. When I show up in the morning, I do my damnedest to ensure that all of our equipment is as stocked, ready, and prepared as possible. I’m the guy who checks the integrity of the air-filled gaskets on the BVM masks, and considers two spare O2 tanks one and one none. If my blood pressure cuffs aren’t labeled, I label them, and I ensure my map book is turned to the correct page.

And all of that may sound funny, because everybody knows that one of the hallmarks of EMS is improvisation, the ability to adapt to unusual situations and “make do.” If you’re juking around at a chaotic scene and discover that you haven’t got any splints, or your stretcher strap is broken, or your patient is dangling over the side of a balcony and needs to be boarded, you see what you have and use your noodle and make it work. Not long ago I saw somebody apply pressure to a laceration on top of a patient’s head by tying a bandage to both stretcher rails and rubber-banding it over their skull like a bow-and-arrow. Why not?

We find a way. So why am I so anal about being prepared while we’re still standing on solid ground?

The fact is, in this job, things are going to go wrong. They just are. And you’re going to handle them the best you can. But if too many things go wrong, the situation may reach a breaking point — your capacity to “adapt and overcome” is not infinite.

Have you ever read a book or watched a show about a major disaster? Plane crashes, reactor meltdowns, bridge collapses. What they have in common is that numerous intelligent people usually foresaw the possibility of such an event, and so they designed systems and safeguards to prevent it from happening. When disaster happens nonetheless, it isn’t because one thing went wrong. It’s because five, six, twelve things went wrong. The backups to the backups to the backups failed. More problems occurred simultaneously than anybody expected..

In this job, too, the only time when feces hit fans is when problems accumulate. It’s not that the patient was sicker than you expected. Or that the stairs were rickety and covered in snow. Those are a nuisance. It goes from whoopsie to trainwreck when you didn’t bring your stairchair and your suction. Then when you go back, the chair falls open while you’re walking, and as you try to fold it you trip over your untied laces, and when you finally get inside you realize the suction canister is missing a cap and won’t hold pressure. And then once you get the patient extricated they’re already unconscious, but you can’t find any Yankauer tips in the truck, and by the time you do they’ve stopped breathing…

See? With this job, even at the best of times, the line between well-in-hand and circling-the-drain can be pretty slim, and once you’re on that slope it’s hard to recover. The only way to stay safely in control is to create a buffer, and that means doing everything you can to prepare yourself when you have the chance, because you won’t always have a chance. If you don’t bother dotting your I’s and crossing your T’s before you enter the mix, then when things inevitably go wrong, the sum of those unhingings may be too much to handle.

Consider your emergency responses. It’s a safe bet that you’re going to drive past the address, or turn the wrong way, or get caught behind the world’s slowest schoolbus. Something is going to cause problems, whether it’s your dyslexic partner who confuses Gable Street with Bagel Street, or you forgetting the apartment number three times in a row. But that’s just a small delay. It won’t be a real problem unless you also stopped to pee before leaving the base, or forgot where your boots were, or had to spend five minutes backing out of where you parked. In that case, you already burned through your margin for error, and now when the unexpected (but inevitable) comes along, you’ve got no slack left.

In short, you can be the best in the world at rolling with the punches, and in this job, you ought to be. But that doesn’t mean you shouldn’t also try to be prepared to the point of obsessiveness. One lays a foundation for the other, and when you habitually have both to work with, you can handle whatever comes your way; if you’ve only got one, you’ll be lucky to get through your shift.