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In your darkest days, know you can weather the storm

Grounding techniques, peer support and your physician can help manage a mental health crisis – a real danger for EMS providers


Coping strategies are essential to managing the stress inherent in EMS.

Photo/courtesy Sean Hulsman

By Sean P. Hulsman, M.Ed, EMT-P

Mar. 14, 1994, was a typical spring day in Lancaster, New York, until about 2 p.m. It was then that a car carrying a father and his four sons, aged 6 months to 8 years, inexplicably crossed into oncoming traffic and struck a tractor-trailer head-on.

The man and two of the children died instantly. The other two boys met their ends in the hospital later that day. That a woman lost her entire family in less than the time it takes to watch a football game was an unimaginable tragedy both for her and for everyone who responded to that scene.

While I was penning this article about mental health, I serendipitously happened to speak with one of the paramedics who was on that call 24 years ago. “You know, it sounds weird,” he shared, “but I know where they’re buried and I go visit them every year on the anniversary of the accident.”

I didn’t think it sounded weird at all. This medic had found a coping strategy. During all of my EMS training and experience, I was repeatedly told that I wasn’t allowed to be emotionally affected by the things I saw, so I didn’t visit any graves. I didn’t share any grief. I didn’t open up about those rough calls. Gallows humor and forced indifference were my only coping skills, and after two decades in the field, I found myself in the midst of a full-blown nervous breakdown.

My personal experience with PTSD is unfortunately not unique. In 2017, more law enforcement officers, firefighters and EMS workers died by suicide than in the line of duty. Approximately 45% of first responders in a recent study reported symptoms of mental health disorders including PTSD, depression and panic disorder.

Researchers investigating the cumulative effects of stress on the people who come when 911 is called are reaching one conclusion; mental health is a serious problem for our industry. This is not really news anymore. The problem is clearly understood. The focus is now this: what should you do when gallows humor fails and “it won’t happen to me” becomes a lie?

Depression and PTSD are very real in EMS

As emergency medical providers, we all know that there is an acute phase of a patient’s pathology which is followed by a long-term management phase. The acute phase is the time with the most chaos and uncertainty. Your own mental health issue can be very similar. The presentation of a problem might be rapid and terrifying, like a panic attack. It can also be slower, like a gradual slide into depression.

In either case, it’s important to identify the problem quickly and own it. You need help and that’s OK. You’re certainly not alone; industry leaders and even politicians have begun to understand that depression and PTSD are very real in the lives of responders, and the stigma is slowly fading. A call to your primary doctor is generally all it takes to get you on the road to recovery. Otherwise, what you’ll need is patience and some support.

How to manage the crisis phase of a mental health issue

In the crisis phase of a mental health problem, the best approach is to turn your focus on your own wellbeing, while simultaneously reaching out for assistance. You cannot help patients or be an effective friend or family member if your internal plane is spiraling toward the ground. Take a step back from duty and contact your doctor as soon as you realize you’re having a problem.

Some agencies contract with EAP services that can provide initial counseling. You may even be able to receive services through a faith leader if you are a member of a religious congregation. The important thing is to get help as soon as possible. As someone who has been through it, here is my advice for managing your acute phase:

  • Suicidal thoughts are obviously an emergency, and if you’re having them, calling 911 or getting a ride to the ER from a trusted person is immediately indicated. The people in your life need you – probably more than you know.
  • Contact your primary physician as soon as you can. He or she may be able to prescribe medicines to get you through the early stages and can direct you to a mental health specialist.
  • Let family and trusted friends know what’s happening. They can be your best allies and supporters during this difficult time.
  • Lose the shame. If you broke your arm on a call or wrenched your back lifting a patient, you’d be out of work getting medical attention. Mental health is no different. You need to be well physically and mentally in order to be a good clinician. EMS will be there when you’re well enough to continue.
  • Do not try to hide your struggles by working increased hours or by turning to alcohol or other substances. Self-medicating may temporarily relieve the pain, but it won’t fix the underlying problem, and indeed may make it worse.
  • Believe that you will persevere. In the darkest days, it may be hard to imagine the sun rising on your personal night, but that hope can and will pull you through.

Anxiety, panic attacks and PTSD

Panic attacks are a common symptom of PTSD. There’s no danger to you but your smart brain shuts down in deference to your lizard brain, which fools your body into a sympathetic adrenalin dump. You may experience symptoms including shortness of breath, racing heart, perspiration, chest pain and a sense of “going crazy.” Panic attacks can be initiated by a trigger or can simply arise from nowhere. They’re no picnic. You’ve probably treated patients who were having panic attacks, and you may have been skeptical about or even annoyed by their complaints, but I promise, when you’re the one having the panic attack, your worldview changes.

Should you find yourself in the midst of such an attack, take slow, deep breaths into your belly. Your abdomen should expand outward with each inhalation. Try to breathe out longer than you breathe in – five seconds in/seven seconds out. This is a variation on the very popular 4-7-8 breathing technique which includes a four-second breath in, a seven-second hold, and an eight-second breath out. This type of breathing signals your brain and body to relax.

Work through grounding techniques. Grounding basically calls your attention to the things immediately around you. There are numerous techniques for grounding that therapists can teach you (e.g., counting backward from 100 by sevens and naming things that you see or hear in your immediate surroundings). These exercises literally ground you in the present moment and work to stop racing thoughts.

If possible, get yourself out of the situation you are in. Deep breaths and a minute to step away can sometimes be all you need to quell a panic attack.

Finally, understand that every emotion you feel is fleeting – it will eventually pass. Knowing that you’ll get through the current moment can help you to calm yourself. A wise therapist once told me: “Emotions are like weather. They arise due to certain conditions and fade when those conditions change. Weather never stays the same.” You will get through the storm.

EMS self-care

EMS is a rewarding field. It’s also physically and mentally challenging. By keeping yourself fit, you can avoid or lessen the negative effects of cumulative stress. Just because you’re not experiencing any psychological disturbances now does not mean you shouldn’t work to remain healthy. Here are some ways to increase your resilience:

  • Get regular exercise. Exercise is universally considered to be good not only for physical health, but for mental wellbeing. Most psychiatric practitioners will prescribe it for their patients with anxiety and depression.
  • Learn meditation. You do not have to be a Buddhist monk to practice mindfulness meditation, nor do you even need to be religious. Mindfulness meditation is a discipline which teaches you to be present in the moment. It can have tremendous benefits for those suffering with PTSD. There are many apps that teach and facilitate mindfulness meditation, and there are plenty of people out there from whom you can learn the practice.
  • Get to sleep. Sleep deprivation, including poor sleep, has been associated with disorders including depression, anxiety and bipolar disorder. Expert opinions vary to some degree, but seven to nine hours of sleep per day seems to be the general recommendation for adults.
  • Eat well. The benefits of healthy eating are now so unquestionable that mentioning diet seems superfluous. Still many of us fail to eat right and it thus bears repetition. Caffeine is a tool, not a food group.

Exercise, meditation, sleep and a good diet all promote a healthy lifestyle, and can be the difference between a long rewarding career and an abbreviated stay fraught with emotional or physical pain.

Still, the slings and arrows of EMS may yet land you in the midst of a psychiatric crisis, and when that happens, you must deal with the problem as soon as possible. Remember that many of us have been there, face your fears and ask for help. The people in your life – and your patients – will be glad that you did.

About the author

Sean P. Hulsman, M.Ed, EMT-P, is director of education, Twin City Ambulance Corporation, Amherst, New York.