I remember the first time I cried over the death of a patient. It still seems odd—I didn’t know him before our paths crossed, and I never expected to hear about him again after that day. For the longest time I remembered his name, and even though enough time has passed that I can’t anymore, what’s difficult to forget is everything else that surrounded his death and the context that framed it.
At the time I was a relatively new EMT, and I can still remember several details about that day, such as my partner and what shift we were working, the fire crew that responded with us, and which parking lot the patient’s parents called 9-1-1 from. I recall the chief complaint being generalized illness with a working diagnosis of febrile seizures and no history of epilepsy. The parents said he hadn’t been feeling well that day, appeared lethargic at times, and was running a fever.
In hindsight the fact that he would seize for a couple of seconds and then return to a normal baseline mental status almost immediately was a red flag that something was seriously wrong. We eventually discovered that what we witnessed were “cardiac seizures,” occurring briefly when his heart would go into a dysrhythmia, suddenly depriving the brain of oxygen, then resolve on its own before we could notice it on the monitor.
I remember dropping him off at the hospital, alive and in stable condition, only to get a phone call later that day from a fellow medic who advised us he’d crashed and was now being worked up. We immediately drove back to the ER to find he was now in the resuscitation room, intubated and unconscious with a team running around frantically to stabilize him for transport to a pediatric specialty center.
It was still daylight when we arrived back at the hospital, and it was dark by the time I snuck out to the ambulance bay, unable to watch any longer, and broke down in tears. I felt so stupid for crying. The narrative in my head that repeated was: Why am I upset over this? I should know how to handle these types of calls. I’ve done this before. It isn’t my kid dying; I I have no right to feel this way. I remember feeling confused about my reaction and wanting to shrink up and disappear so nobody else would see me like that.
Looking back, this might have been the moment I began to condition myself into suppressing the emotions evoked from experiences like this at work. My MO became avoiding the family at all costs, even if it meant depriving them of the closure only we could offer. I know better now but was completely unaware for the better part of my career.
I might have forgotten his name, but it was nearly impossible to ignore the look on his mother’s face as she watched her son’s health decline right before her eyes. The team worked hard to keep him alive. The scene stored most vividly in my mind was seeing the exhausted look of defeat on the attending physician as she collapsed into a gray chair just outside his room, tears streaming down her face, arms crossed over her distended belly. She was nearly full term with her first child, and this was her last shift before going out on maternity leave.
I can’t remember his name anymore, but I remember that he was only 4 years old and died on Easter Sunday.
Grief: The Healing Process
Several years later I now understand that my response to that call was quite normal and even predominant in our field, but ironically it’s something we rarely talk about. To better understand the dynamics of this experience, we have to start by deconstructing a process we all go through but sometimes fail to recognize: grief.
Grief is considered a natural response to loss. However, it is essential to clarify that grief is the healing process, not the injury. The significant loss (which can range from termination from a job to death) is the injury, and grief is the process that must take place for that wound to heal. Many are familiar with the typical grieving process in which the bereaved make their way through the five stages of denial, anger, bargaining, depression, and acceptance. However, these do not occur in any specific order, and we may experience more than one of these stages at a time over a period that lasts six months on average.
Complicated grief is when we get stuck in those stages and are unable to adapt to life following our loss. This type of grief is especially common with survivors of suicide, homicide, and unexpected/freak accidents. Part of the grieving process is being able to find closure in the circumstances that led to the death. In the case of suicide, the one we mourn is also the one responsible for the loss. When a homicide occurs it can be months or years before the perpetrator is caught, if ever. When a freak accident leads to an unexpected death, we often turn our anger toward spiritual deities, angry our god would allow this to happen. Many times the conflict lies with an inability to identify and direct our blame (i.e., pain). It is not uncommon for complicated grief to be associated with guilt and for the bereaved to eventually turn that emotion inward and ultimately blame themselves for the death.
Disenfranchised grief, although considered a type, is closely related to complicated grief in that one often precedes or follows the other. This type of grief is the inability to grieve publicly or acknowledge the loss socially. It is common with women who suffer the loss of an unborn child or those involved in a relationship that ends in death but must be kept secret (e.g., extramarital affairs, same-sex relationships in some cases). It is often tied to suicides and overdoses due to their stigma. Ultimately the bereaved is either not recognized or unable to open up to others about the circumstances of their loss. Most of these examples have two things in common: shame and a lack of communal support.
Community plays a significant role in how we heal. It’s instinctual for us to reach out to others for support when we are in crisis. Many understand the hormone oxytocin to be the “hug drug” or “cuddle hormone” because it most notably spikes when bonding between two individuals occurs, especially just after birth. However, many would be surprised to learn that oxytocin, while accurately considered a feel-good hormone, is also a stress hormone. Just like cortisol, oxytocin increases when we are in crisis. The purpose of this is to encourage us to reach out to others when we go through something traumatic because we are not intended to go through these experiences alone. It is in our biology, and it’s instinct, so you can imagine how conflicting this might feel when we isolate ourselves through the grieving process.
The Weight of Expectation
Now, here’s why all the above is important: Disenfranchised and complicated grief has been linked to mental stressors, occupational burnout, and compassion fatigue in physicians, nurses, and, yes, even first responders. Why? Because the persona and uniform we wear carry the weight of expectation. We are supposed to be more capable than the average person and expected to remain unscathed by the chaotic environments of 9-1-1 calls. We are supposed to be the ones who can handle the blood, guts, and death. We are the ones who can transport a traumatic cardiac arrest to the hospital, spend an hour deconning the back of a bloody ambulance, and still have enough of an appetite to ask, “What’s for dinner?” So you can understand how unnatural it feels on those occasions when our emotions escape the containers in which we’ve strategically placed them and suddenly we, too, are grieving the death of someone we don’t even know.
One discernable link that seems to increase the likelihood of a call getting to you is when we can identify with the patient and/or family in some way. The most straightforward example is kids. I’ve asked a classroom full of first responders and nurses, “What changed for you when responding to and treating children after you became a parent?” The answer is always the same: “Everything!”
Everything changes because there’s an instinct within us all that remains dormant until we become parents. Suddenly that toddler in cardiac arrest approaching his second birthday is your little guy at home, and you can’t help but imagine what it would be like for a freak accident like this to impact your family, your spouse, and their siblings. You put yourself in the mom’s or dad’s shoes, and you can’t seem to stop the thought process that unfolds. Now you’re the one holding back tears because you can’t help but empathize with the emotional response of his parents.
But why does the same call manage to affect us all differently? Imagine responding with your crew to that scene where the toddler in cardiac arrest was worked up and ultimately pronounced in the ER—and afterward you feel like you’re the only one who’s feeling a strong emotional reaction, whereas everyone else appears to have compensated without any issues.
This is an all-too-familiar scenario, and it’s difficult to pinpoint precisely why. We all have different backgrounds, risk factors, levels of resilience, and adverse experiences in our lives that subconsciously accompany us on every 9-1-1 call. What significantly impacts one person will roll off the back of their partner. This is because it’s the call plus everything else: That tough call plus a nasty divorce, a career-compromising injury, a parent’s declining health, a bankruptcy or substance abuse. Often it’s the call that is simply the trigger to the underlying risk factors we carry with us on any given day.
How do we respond to those daily adversities we all experience on top of the anticipated stressors of the job? We compensate by coping. Coping is a natural way that all people respond to stressful events, and most of us don’t realize we’re doing it, much less the difference between healthy and unhealthy mechanisms. The most natural and subconscious way first responders cope is by compartmentalizing. Simply put, compartmentalizing is how we manage to go on a scavenger hunt for missing body parts without triggering our gag reflex, or how we function on that cardiac arrest in the living room on Christmas morning. It’s how we manage to help stabilize multiple shooting victims while the gunman is still unidentified: We shift our focus to the task in front of us and repress any natural emotions that might divert us from completing it.
Researchers have found first responders are exceptionally good at this. That’s great—until those containers into which we separated and organized these emotional responses ultimately spill over. The reason is simply that we all potentially compensate until we can’t. The tricky part is not being able to predict and recognize when that happens for each person because it is all relative to his or her own life experiences and compensatory abilities.
Other ways we cope include using substances like alcohol to numb the feelings these stressors evoke. I’m not going to tell you not to drink—you know the effects already, and I’d be lying if I said I’d never made the same choice. Mind-numbing substances are, in fact, effective at helping us circumvent the painful emotions we experience. But what I wish I understood earlier in my life is that when we numb out the sadness, we inadvertently numb out the joy. When we numb out the grief, we numb out the hope. When we numb out the depression, we numb out our ability to feel happy. We can’t select what we repress, and the negative emotions are just as normal and a part of life as are the positive ones. So while I won’t tell you it’s a bad idea to call a friend and ask them to meet you for a beer after your latest rough call, I will at least ask that you be mindful of all the positive things our vices block us from experiencing when we overdo them.
Closing the Loop
Positive coping mechanisms include working out and finding ways to discharge the stress that gets built up over time. The simplest but sometimes most challenging is opening up to someone you trust to hear your story. This is the fundamental purpose of peer support programs within organizations: to simply give one another a safe and familiar place to be heard and understood. This is also why it is important to have strong support systems off duty.
An often-overlooked but effective way to cope is by seeking out closure and requesting a follow-up on a patient’s hospital outcome. After my department experienced a rash of pediatric drownings, two colleagues and I developed a process called an “integrated conclusion of care” to provide a timeline of calls in their entirety. This includes objective notes from the dispatcher’s engagement with the reporting party, the events that occurred on scene, and detailed information as to what occurred after the patient was transported to the hospital. This report is sent to every person who responded, as well as the dispatcher who took the call. Nothing about it is clinical, punitive, or developed for any purpose other than the mental well-being of the providers. While this is a new idea for us, it has already been welcomed with positive reviews from our field personnel, and we encourage other agencies to adopt it.
To say our mental health in EMS is in crisis would be a significant understatement. We now belong to a profession where more of us die by our own hands than by the hazards of the job. While I believe the way we grieve is a contributing factor, it is just one piece of what sometimes feels like an endless puzzle we’re still trying to decipher.
What I do know is that it is beneficial to understand how the survivors of the patients we cannot save respond with grief, because it allows us to be better patient advocates when there’s nothing more that can be done for the patient. As a result it helps us recognize this response in ourselves when it’s our turn to do the healing. Because at the end of our shift, there is still an ordinary person under the uniform, and we are not hardwired to go through these hard times alone.
Alexandra Jabr holds a master’s in mental health, specializing in death, grief, and bereavement. She works for Riverside County (Calif.) Fire Department as a paramedic/EMS specialist and is an adjunct faculty member at the Victor Valley College Paramedic Academy.