Dealing with Chronic Stress

Basic Training

My first encounter with real death was on my EMT internship. The ten hours I spent at an inner city hospital in Brooklyn, New York set the stage of my life to come.

I sat in the busy ER, ignored and bored, as most EMT interns. The permanent ER staff went about their business and avoided me whenever possible. It was not that they were rude, as I would later learn from experience, it was just that they had little time to deal with some inexperienced and non-certified healthcare provider. It was an interruption of their routine. It was an intrusion on their lives. It was a slow night and the last thing they needed was to make small talk with a complete stranger. I was there for one shift and chances were that our paths would never cross again. They wanted me to sit there, not play with the patients, not hurt myself and at the end of the 10 hours say, "if I don't see you again, have a good life."

Since I picked a particularly slow night, a knack that I have never been able to duplicate, there was very little staff. As I sat in a large chair meant for ambulatory asthmatics reading my prep test manual, my eyes closing for the hundredth time, the room started to get noisy.

What I later found out was a very green crew brought in an elderly woman in cardiac arrest. They were doing CPR and bagging her with a BVM, both crew members drenched in sweat. The ER doc looked over at me and yelled, "take over."

Take over what, I thought? Somehow, my body made its way to the gurney and started to do chest compressions, just as I learned on the manikin. After a few thrusts, I heard the crunch of bones snapping. "Oh Lord," I thought. "What did I do?"

The ER nurse sensing my distress and my inexperience consoled me, stating that broken bones are quite common, especially in the elderly. After what seemed like an hour or so, about 30 seconds later, the ER doc noticed that this particular human being had dependent lividity. I even noticed that she was purple on one side. The doc proceeded to pronounce the patient and mumbled a few unkind epithets at the crew.

Not fully understanding why we stopped doing CPR other than that was what the doctor said to do, I looked at the patient's open eyes. With my hands slightly shaking, I closed them as gently as I could. The ER nurse, recognizing that I was green around the gills, insisted that I go out and get some fresh air.

It was at that moment that I decided that EMS was probably not the job for me. I did not want to lose the battle of life and death again. It was for someone else to fight and win or lose.

Advanced Training

Somehow, I became an EMT and helped fight other battles with life and death. I think what helped was that the battles were not fought alone. I had great partners. However, I had been lulled into a false sense of security.

Anytime we think we got it figured out, God or the fates smack us in the back of our heads. The minute you say, "I never miss an IV line," you are going to blow the next vein. The minute you say, "I'm a great driver," you are going to bang up your vehicle, etc., etc. The long and short of it is God, the fates, reality and life humble us.

I, like many other EMTs had the stubbornness to continue because of our teachers. All good men and women, none perfect, some better than others, each and every one, people doing God's work, helping to ease the suffering of humanity. Each dedicated on some level to make the world a better place.

Much later, as a paramedic student once again on my internship and anticipating taking state, local and national exams, the bottom fell out. I questioned my choice of professions.

A young woman, walking out of her office, collapsed and died. We brought her back for a while but despite the efforts of a team of doctors, nurses, medics and EMTs, she never came back from the dead. I just didn't get it! She was in relatively good health, in her twenties and had her whole life ahead of her. Why in God's name couldn't we get her back? What made her different from any other patient who I helped treat before? Why did she matter more to me than the other patients that came before her?

Aside from her age and her lost potential, she was "my" patient. I was fully in charge and was calling all the shots with the help of others. I decided what drugs to push, what treatment modalities, what to ask medical control for. I guess I made right decisions, because my experienced preceptors did not pull the plug from me. The doctors did not question my choices and the nurses did not look at me with scorn or doubt. I was right on the mark and still did not save her. I watched her die as if I were a bystander with no medical training or skills. Why did the force of her life leave her body, when everything possible was done for her?

Real Life

The largest problem in EMS is that no matter how well we train, the concept that is never fully realized is how to deal with death. People die and sometimes there is nothing we can do about it.

Because EMS is relatively a new emergency service, there is no uniform way to deal with death and other stresses in our job. Are we healthcare providers? Yes we are. So if we address critical stress, we have to be approached with the same critical stress as physicians and nurses. However, our particular brand of stress differs from nurses and docs.

Are we in stressful situations similar to police officers? Yes we are. How many times are we shot at, threatened, and assaulted? How many times do we enter the homes of our patients, not knowing what we will encounter in these strange surroundings? Therefore, our particular brand of stress must incorporate debriefing designed in part for law enforcement professionals.

Are we often in harm's way similar to firefighters? Again, the answer is yes. Whether it is riding towards a motor vehicle with lights and sirens, crawling into confined spaces to help a patient in need or treating the helpless while debris falls around us, our profession has a fair amount of risk involved.

It is a useful concept to say scene safety first. It is a great rule of thumb, but if we are not willing to accept risks, then we do not fully understand the magnitude of responsibility entrusted to us by our partners, brothers in other public service professions and those who rely on us to do the right thing. Our job is not to fight fires, do surgery, or treat the wounded in the middle of a firefight. However, the rules of the street sometimes mandate that we do all of these things. Sometimes scene safety is not possible to help save a life. Scene safety is a rule, but sometimes rules need to be broken. Many of our brother EMTs have gone above and beyond the call of duty. That does not mean those who do not take great risks are without bravery, but it does point out the enormity of responsibility and related stress that we encounter on a daily basis.

With all these different types of risk factors, there has to be a development of a new modality to treat "ambulance stress." It will take more than research studies, none of which I have found that adequately address the treatment of EMS professionals.

Once a treatment of "ambulance stress" is developed, it has to be implemented uniformly by social workers, psychiatrists and other mental health professionals who have some clue of what we do everyday.

The second part of a new treatment modality is how we are educated to deal with this unique stress. Crews need to be put out of service until they are cleared medically to return to work. Every significant event needs to be monitored by a designated health officer who is actively involved in EMS. It will not work with a nurse practitioner who works in employee health, who has been designated as the EMS health liaison and has never been on an ambulance a day in his life. We have a public information officer, why don't we have a health officer or morale officer dedicated to the mental health of our crews? I am sure that there are some systems that have these protocols in place, but they are rare.

We have to get out of the habit of sending a crew back out to the street after an event that would put the everyday person into therapy for life.

In order for us to be able to function in our jobs, we must be able to build a sense of callousness to the loss of life; otherwise, we would be proverbial basket cases. Nevertheless, know it or not, it affects us the same exact way it affects the average Joe or Jane. The only difference is that we can put it into the recesses of our minds and not fall apart at the seams. What happens is that we have the potential to fall apart internally long before we manifest it into our daily lives.

Finally, there must be a balance between what we are able to do to serve the public and what needs to be done to keep co-workers and ourselves on an even keel. The obvious answer is resources. Time, money, personnel are needed to keep our profession healthy and happy. The time is now to plan. Our state and local councils, in addition to meeting the needs of the patient, have to address the long-term effects of "ambulance stress" on its members. It will be decades before the physical and psychological effects are known for those of us who put on a uniform every day and make house calls. It would be ironic if the pre-hospital professionals of today would be the in-hospital patients of tomorrow.

Stay safe and please feel free to direct any questions or comments to my website at www.francisrella.com.

Francis Rella worked as a teacher on the high school and college level for 13 years before changing to a career as a paramedic and registered nurse.

He has served in the Armed Forces with the United States Marines, the US Navy Reserve and the 11th Special Forces Group (Green Berets).

As a member of Actor's Equity, AGMA, AFTRA and Screen Actors Guild, he has worked as an actor for PBS, National Public Radio, New York City Opera and stage companies in New York and throughout the United States.

His first book, "Manhattan Medics," (Princeton Book Publishers, 2003) has received outstanding reviews and he has also received national awards for his Screenplay and television scripts. He has just completed his first novel entitled "Lullaby of Broadway."

Francis grew up in Brooklyn, New York and attended Cathedral Preparatory Seminary, where his studied for the Roman Catholic Priesthood. He went on to study at St. Vladimir's Orthodox Theological Seminary after college for the Priesthood.

He holds a Master's Degree in Music, a Nursing Degree, and is pursing a second Master's Degree as an Acute/Critical Care Nurse Practitioner at Seton Hall University.

In addition to writing projects, he continues to work as a paramedic, emergency room and mobile intensive care nurse in New York City and New Jersey. He is also a Special Law Enforcement Officer in his hometown of Old Bridge, New Jersey.

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