Trending Topics

A good night’s sleep

The FIRST approach to provider resilience focuses on removing the stigma and supporting emotional intelligence


We are reactive to the world around us, on an evolutionary level, so the expectation that we are going to walk into any call that involves a modicum of human suffering and walk away unscathed is unrealistic.

Photo/Getty Images

I wake up drenched in sweat. It takes me a few minutes to breathe through the panic, quiet the screaming in my head from the nightmare that had jolted me awake. I lay in bed, scared to close my eyes again, breathing in a rectangle like they told me I should when I get stressed. The screaming in my head quiets with each long exhale, but I can still see the scene in my head. I stare into the dark and I know that when my alarm goes off in the morning, I am going to be tired and low, dark as the jolt that moved me to reluctant consciousness. I could try to sleep again, hopefully avoid the grey cloud and risk returning to the underworld I had banished that screaming human to, or I could give up and order extra shots in my coffee. I roll over and start tapping apps on my phone, insomnia being the better option.

I’ve been on ambulances for a good chunk of my life. I’ve seen my fair share of joy, I’ve sighed relief over patients who have turned around with my treatments, I’ve prayed to whatever God was listening and been answered with life returned. Good stress, rewarding stress, is something we all keep coming back for. You know what else I’ve seen? Horror. Gore. Tragedy.

We’ve all seen these things; been told to consider it part of the job and that sentiment is not wrong. We take the miracles we see and balance them out with the worst days of people’s lives. The scales tip one way or another and at the end of the day, we get a paycheck and go home.

You know what that is? Unfair. Why? Because we didn’t ask for either and were never taught how to manage the feelings we would have in response to the contact: the reluctant hero, who isn’t supposed to be affected by the onslaught and so isn’t supported through it.

Human nature

Let’s talk human nature. We are reactive to the world around us, on an evolutionary level, so the expectation that we are going to walk into any call that involves a modicum of human suffering and walk away unscathed is unrealistic. We can’t help it. We are also ruled by the standards of a culture, by nature. EMS culture tells us to go against what happens naturally and stifle those reactions. We are the heroes, the warriors, and so, if we feel anything, we are somehow “less.” We invite disorder by the nature of our culture.

Why aren’t we taught this when we first certify? The guy who has worked retail all his life and finds his calling in EMS is not prepared further than, “that’s not your bad day,” so of course he self-medicates, of course he can’t sleep, of course he is overcome by pain. Of course.

How do we stop the stigma in its tracks and empower both new providers and those already in the field?

It takes some insight to understand what emotions are and how they affect you personally. The goal of training is to make actions second nature, but being aware is also a conscious choice. We have to stop considering cognitive intelligence as the only thing we nurture in a certification class and start considering emotional intelligence as an equal priority. This is where FIRST comes in. Another acronym – yes – but make this the first one you work through in your assessment, and you take care of yourself and your partner while you take care of your patient.

FIRST stands for:

  • Feelings
  • Intervention
  • Recovery
  • Safety
  • Talk

The application takes some practice. It’s hard for us as humans, not to mention type A humans, to disengage our frontal cortex where all that critical thinking happens and engage our amygdala where all those emotions happen especially when a situation demands that we think critically. It takes personal understanding and insight, mentally stepping back from the situation in front of you to protect yourself takes just as much grit as laying hands on the sick and injured. This tool helps you to assess yourself constantly, in prescribed steps, so you are finally making yourself a priority.

The conscious choice to acknowledge and address feelings is something that is a little more crunchy than we as providers like to deal with. If I were to put the cultural stigma on a platter in front of you, what you’d see is a steaming heap of anxiety and depression glazed in words like “weak,” “crazy,” “dangerous” or “unhinged.” Our first step is removing the dish. Send it back. It’s not what you ordered. Insist on the special; resilience.

It’s a red-letter word, resilience. It’s tossed around as a necessity and there are any number of theories on how to build it. The bucket theory states that we fill our buckets with experiences, and if we don’t address the contents, they will spill over and cause damage, resilience being found in keeping the contents shallow. FIRST addresses not only the contents of the bucket but also the material the bucket is made of.

By staying vigilant of the impact the world around us has on our emotions as the impact is happening, and then following that up with a focus on emotional recovery and targeted conversations about the experience, we circumvent the stigma and create a new culture of acceptance. Our buckets become deep and made of titanium, built and held together not only by ourselves, but also by the tribe we are unashamed to readily call for help.

Stress is natural, expected and manageable

When it comes to mental health, I wish someone had told me what to expect before I took my certification test. Maybe then I wouldn’t be waking up in the middle of the night sweating through my sheets. Now, with the focus on the effects of stress on providers, we have so much available to us to help those reactions and provide comfort even if the process is slow going.

In the EMT class I head up, we teach the students that this kind of stress is normal, it’s natural, it’s expected and it’s manageable. We introduce this seminar in the very beginning of their training and then practice it in all of their assessments as they progress through the class. We have check-ins before the class starts to see what mindset the students start their day with and we talk about how we are going to improve that mindset openly, which removes the stigma that surrounds their reactions and gets them used to being open about their self-assessments.

As for me or the experienced provider in the field who wasn’t trained in this process, there is still hope to create a healthy mindset. We don’t have to live in our own heads, we can be both exposed and effective in our practice, we are never alone, no matter what the chemicals tell us. The lie that is these conditions, paired with the culture we have become accustomed to, keep us quiet and dying, and it’s time we use effective methods to help ourselves and our peers. F.I.R.S.T employs a systematic approach to emotional intelligence and gives us permission to exist openly and even injured without the stigma. We all deserve a good night’s sleep.

Read next: Self-care is critical for managing stress levels in EMTs and paramedics responding to COVID-19

Anna Ryan is a paramedic in New Jersey who has been participating in EMS for 14 years. Starting her career as a volunteer, she grew up in the field and has held positions throughout the spectrum of emergency services as an EMT, dispatcher, paramedic and, most recently, EMS educator and course coordinator.

She has written articles for EMS World and The Overrun. She is a contributor to The Overrun podcast and co-hosts The GLAM podcast, a show designed for women by women in EMS. She is currently a Bachelor of Psychology candidate at Southern New Hampshire University.

Part 1 — The San Diego Fire-Rescue captain shares the emotional story of how a seemingly “routine call” quickly escalated to a near-fatal stabbing
As “tactical athletes,” responders should focus on whole-body fitness to enhance their job performance
Capt. Jeremy Norton shares that EMS is the majority of work firefighters face
“I consider meditation as a form of elite cognitive training. These positive impacts are especially transformative for first responders.”