Resilience starts with you.
Emergency medical response…a challenging and fulfilling career, an integral part of our public health and healthcare system. But let’s face it, there are risks…risks to the mind, body, and spirit of those who dedicate themselves to this and related professions. It is imperative that we find ways to mitigate these risks for these selfless professionals with whom our communities cannot do without.
For those who enter into harm’s way to rescue and care for others, we must commit to providing the highest level of education, training, tools, resources, and support possible to perform their duties well and get home safe as well as sound. It is also our indisputable duty to be there for them and their families when things go wrong. This requires awareness, understanding, and significant preparation for these very complex situations. Who better to help us understand these complexities than those who know like none other?
These resources are brought to you by survivors of careers in emergency medical response, of incidents and accidents, and of grief and loss. Survivors make the unforeseeable seeable, the unpredictable predictable, and the unthinkable thinkable, so that others may know.
The most essential key to managing the complexities of life as an emergency medical responder is clear: Prepare, prepare, prepare. Understand these issues exist, learn about them and how to manage them as you progress in your career, and plan ahead of time for the “unthinkable”: loss of career, incidents, accidents, and line of duty deaths. Though all of the above are extremely difficult to contend with, it is exponentially more difficult if you are unprepared.
This document is not intended to replace professional help. These resources are by no means comprehensive, rather they are designed to give you a place to start as you pursue resilience and safety for yourself and your organization.
While it is difficult to envision your life without you in it, it is essential to do so in order to adequately prepare, should you be injured or killed in the line of duty. It is equally as essential that you are thoroughly familiar with the financial coverage your organization provides in the event of your death or disability on the job. While some organizations are well prepared to assist employees in the event of an accident, many are not. In either case, it is advisable to plan as if you will have little assistance.
Important things to complete:
Develop a “plan B”—what will you do if you are unable to return to your chosen profession because of an accident, or maybe because you’re burned out?
Savings—we recommend you have at least enough savings to last a year, should you be unable to work for whatever reason
Beneficiary status up to date for any financial assets you may hold
Life Insurance— Many policies do not cover you if you were engaging in high-risk activity, like flying in a helicopter, at the time of your death, so make sure you are clear on this and have your coverage in writing.
Disability Insurance: short-term/long-term
Will/Guardians for children and pets
Family Emergency/Disaster plan
Letter of instruction/Funeral wishes
Instructions for digital assets
Make sure your personal information sheet/emergency contact info is always up to date at work. If you are in transport, make certain your communication specialists or dispatchers are clear as to who is on the rig or in the aircraft at all times.
While incidents and accidents are life-altering events, the stress of living through the aftermath will be significantly decreased if you have made these types of preparations ahead of time.
Recommended Resources: FINANCIAL
Family Preparedness Guide: Courtesy of Todd Denison, Boston MedFlight
There is good stress and bad stress. Good stress motivates us and helps us to do our jobs well. Bad stress, however, can be detrimental to our job performance and our health. The day-to-day grind, tough calls, and constantly witnessing tragedy and human suffering can, if unmitigated, set us up for secondary trauma, cumulative stress or burnout, and post-traumatic stress and related issues.
There are also increasing issues of violence towards emergency medical responders, adding to our stress. Further, situations which create the feeling that one’s integrity or ethics are being compromised may lead to “moral distress.”
Add to all of this an incident or accident, and the trauma can be overwhelming and seemingly unmanageable as the ripple effect expands exponentially.
The anatomy and physiology of stress
In order to effectively manage stress, it is important to understand the anatomy and physiology of the stress response. An acute stress reaction results from a complex series of physiologic events mediated by the neurological and endocrine systems. While we don’t need to memorize this process, it is important to have a general understanding so that we can learn to manage stress, as well as identify when stress is getting the better of us.
Understanding the stress response:
Once you have an understanding of the stress response it’s easier to understand why the following are proven methods for helping to manage stress, as many of them have direct physiologic benefits and offset the body’s stress response.
Recommended Resources: Stress Management Tools
Healing at the Speed of Sound: How What We Hear Transforms Our Brains and Our Lives by Don Campbell and Alex Doman
Other Stress Management Strategies:
*Decrease exposure—to trauma, to triggers. Take a break or vacation.
*Engage in resilience training
*Find a comfortable balance between work & non-work life
*Find hobbies that offset the intensity or stress of work
*Practice mindfulness, meditation, yoga, martial arts
*Peers—talk it out with those who “get it”
*Professional help—seek appropriate professional help when you need it. Ideally, seek out a clinician who is
experienced with first responders and potentially utilizes EMDR (see below), a powerful and well-researched
method of mitigating and treating post-traumatic stress.
*Remember you're human...and you're not alone
Recommended Resources: Stress, Trauma, and Resilience
Eye movement desensitization and reprocessing (EMDR)
Beyond the Cliff--Laura van Dernoot Lipsky
Why we all need to practice emotional first aid—Guy Winch
Restoring the body: Yoga, EMDR, and Treating Trauma--Bessel van der Kolk
Secondary trauma Resource Center
Doctors and nurses working with critically ill patients suffer moral distress, research finds
SHARON KIRKEY, POSTMEDIA NEWS 12.15.2014
The Risky Business of Nursing, Laura A. Stokowski, RN, MS
The Road to Resilience
Bulletproof Spirit: The First Responder’s Essential Resource for Protecting and Healing Mind and Heart
by Captain Dan Willis
Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others
by Laura Van Dernoot Lipsky and Connie Burk
The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma
by Bessel van der Kolk MD
Scenes Of Compassion: A Responder’s Guide For Dealing With Emergency Scene Emotional Crisis
by Timothy Dietz
Surviving Survival: The Art and Science of Resilience
by Laurence Gonzales
The Survivors Club: The Secrets and Science that Could Save Your Life
by Ben Sherwood
In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness
by Peter A. Levine and Gabor Mate
Waking the Tiger: Healing Trauma
by Peter A. Levine and Ann Frederick
“Prolonged exposure to violence, trauma, death, and suffering can scar a first responder’s spirit and take a terrible toll; substance abuse, depression, post-traumatic stress disorder, emotional suffering, suicide, and lost careers plague these honored professions…losing a first responder to emotional and psychological trauma should never be a side effect of the job.”
― Captain Dan Willis, Bulletproof Spirit: The First Responder’s Essential Resource of Protecting and Healing Mind and Heart
“While each individual is impacted differently by exposure to another’s suffering, whoever is exposed is always situated in the middle of a ripple effect…the initial impact creates repercussions and resonances that expand almost infinitely, reaching and having an effect on everyone involved.”
― Laura van Dernoot Lipsky, Trauma Stewardship
“The good news is that stress levels rest largely on our own behavior and decisions and that we can optimize our bodies’ responses to stress based on how we live our daily lives.”
“The healing process may require a continuous effort to realize and re-realize that our trauma exposure response is not going away unless we give it proper attention. The sooner the better for this realization, since we are hoping to consider this from a preventative standpoint when possible, and, as those who are savvy in the ways of the human body will tell you, ‘By the time you are thirsty, you’re already dehydrated.’”
― Laura van Dernoot Lipsky, Trauma Stewardship
“We shall draw from the heart of suffering itself the means of inspiration and survival.” ― Winston Churchill
Post-Traumatic Stress Disorder
While PTSD has historically been poorly understood, recent research has clearly demonstrated much of the physiology of PTSD and powerful tools, such as Eye Movement Desensitization and Reprocessing (EMDR) have been developed, making a tremendous difference in outcomes for people with PTSD.
Some of the risk factors for developing PTSD include:
Living through dangerous events and traumas
Seeing people hurt or killed
Feeling horror helplessness or extreme fear
Having little or no social support after the event
Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home. http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
While not everyone who experiences these risk factors will develop PTSD, emergency medical responders certainly are exposed to many of these risk factors--nearly all of them if they’re involved in an accident. They should be familiar with the symptoms of PTSD and seek professional help if they find themselves experiencing these symptoms. The prognosis for PTSD can be very good with appropriate help and effective treatment. It is advisable to find professional clinicians who specialize in trauma, utilize EMDR, and who are experienced with treating emergency medical responders or similar professionals.
“While we all want to move beyond trauma, the part of our brain that is devoted to ensuring our survival (deep below our rational brain) is not very good at denial. Long after a traumatic experience is over, it may be reactivated at the slightest hint of danger and mobilize disturbed brain circuits and secrete massive amounts of stress hormones. These posttraumatic reactions feel incomprehensible and overwhelming. Feeling out of control, survivors of trauma often begin to fear that they are damaged to the core and beyond redemption.” –Bessel Van der Kolk, MD, The Body Keeps the Score
PTSD and Addiction
“The symptoms or PTSD can be extremely distressing. Because there is such a great amount of stress on the individual, many with PTSD will be unable to cope and turn to drugs or alcohol as a means of escape. This self-medication has led to very high percentages of PTSD suffers with alcohol dependence (over 50 percent) and drug dependence (over 30 percent).” http://www.dualdiagnosis.org/post-traumatic-stress-disorder-and-addiction/
If you find yourself needing to use alcohol or drugs regularly to cope with your stress, you would probably benefit from professional help sooner than later. There are organizations that treat people with PTSD and addiction issues that your health care provider may refer you to.
“You and I employ a lot of denial to get through the world. For instance, when we are driving down the freeway weaving in and out of traffic at 75 mph and we actually believe we are safe. But if I have been exposed repetitively to death and I know I can die at any moment, it changes my world view. You can’t employ that kind of denial. It’s actually one of the reasons I really enjoy and appreciate and feel honored being able to work with people with PTSD because to be honest with you, they have a more realistic view of the world, in my opinion.”
—Dr. Steven Southwick, Professor of Psychiatry at Yale, Director of Clinical Neuroscience Division of the National Center for PTSD in Boston
Code 4 Northwest
"One Call, A Community of Support"
Code 4 Northwest is an entirely volunteer-run, free and confidential crisis response and referral network for Washington State active and retired first responders, EMS, corrections, civilian support personnel, and their families.
Addiction Center 24/7 Treatment Help: 888-988-9185
Drug Rehab Connections
Resources on PTSD
A review of PTSD including symptoms, causes, complications, treatment, coping, and prevention
Post-traumatic stress disorder: the neurobiological impact of psychological trauma
National Center for PTSD
National Institute on Mental Health
When Should a First Responder Reach Out for Help? --Mark Lamplugh
Grief, loss, & traumatic grief
Recommended resources on grief and loss
Beyond Closure: Nancy Berns at TEDxDesMoines
How to go on after sudden loss of a loved one—CNN.com
Getting Grief Right—Patrick O’Malley
Resources on Grief
Trauma, Loss, and Traumatic Grief
Traumatic Grief and Children
Family Lives On
Traumatic Grief and Post-Traumatic Stress
“The reality is that you will grieve forever. You will not ‘get over’ the loss of a loved one; you will learn to live with it. You will heal and you will rebuild yourself around the loss you have suffered. You will be whole again but you will never be the same. Nor should you be the same nor would you want to.”
― Elisabeth Kübler-Ross
“The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths. These persons have an appreciation, a sensitivity, and an understanding of life that fills them with compassion, gentleness, and a deep loving concern. Beautiful people do not just happen.”
― Elisabeth Kübler-Ross
“If you are looking for a sign NOT to kill yourself, this is it.” – Unknown
If you are feeling suicidal, reach out…GET HELP. Call a friend or family member.
Call 9-1-1, go to an ER. Do whatever it takes to get to a safe place. There are people who understand and want to help you. They may not know you’re struggling unless you tell them. Caregivers and rescuers are masters of the poker face and pretending they’re okay. If you don’t know how to ask for help, here’s a start: 1) Find somebody you trust, 2) Say, “I feel_____________ (depressed, anxious, suicidal, like Hell)…I need help.” Suicide is not the answer.
1 (800) 273-8255
National Suicide Prevention Lifeline
Hours: 24 hours, 7 days a week
Languages: English, Spanish
Suicide Prevention Guide
You are not alone: Code Green Campaign
Mission: To bring awareness to the high rates of mental health issues in first responders and reduce them.
To eliminate the stigma that prevents people from admitting these issues and asking for help. To educate first responders on self and
peer care and to lobby for systemic change in how mental health issues are addressed by first responder agencies.
Eating Disorders Resource
Addiction, PTSD, and Eating Disorders Resources
“The person who completes suicide dies once. Those left behind die a thousand deaths, trying to relive those terrible moments and understand … why?”
– Clark (2001)
“Anyone desperate enough for suicide should be desperate enough to go to creative extremes to solve problems: elope at midnight, stow away on the boat to New Zealand and start over, do what they always wanted to do but were afraid to try.”
– Richard Bach
“Suicide is a permanent solution to a temporary problem.”
"Our mission statement about treating people with respect and dignity is not just words but a creed we live by every day. You can't expect your employees to exceed the expectations of your customers if you don't exceed the employees' expectations of management. That's the contract." --Howard Schultz
Tips for managing emergency responders
-Understand your employees and what they do
-Provide resilience training/stress education
-Utilize trained peer support with professional clinical oversight and streamline access to qualified professional clinicians as needed.
-Create a comprehensive plan to manage incidents and accidents
-Create a comprehensive plan to ensure employees are financially supported after incidents and accidents
-Provide high level education, training, tools, and support. Excellent training = less stress
Proven business benefits of having a proven comprehensive plan addressing accidents
-Decreased costs related to incidents/accidents
-Reduced negative impact to business related to accidents
-Improved public perception and customer satisfaction
-Increased resilience, longevity, sustainability of people and organizations
Incident and accident survivors have a unique perspective that can be invaluable to your organization. Give them an opportunity to share their observations about what went right and what went wrong. Survivors want to prevent what they experienced from happening to others.
Recommended Resources: Management
Unless you’ve been there, you wouldn’t understand: A Paramedics farewell to the job. https://dimcmath.wordpress.com/2015/02/10/unless-youve-been-there-you-wouldnt-understand-a-paramedics-farewell-to-the-job/
Safety and Quality in Medical Transport Systems: Creating an Effective Culture
by John W., Jr. Overton (Editor), Eileen Frazer (Editor)
Just Culture: Balancing Safety and Accountability
by Sidney Dekker
Second Victim: Error, Guilt, Trauma, and Resilience
by Sidney Dekker
Outliers: The Story of Success
by Malcolm Gladwell
by Ori Brafman and Rom Brafman
Whack-a-Mole: The Price We Pay For Expecting Perfection
by JD Marx
Drive: The Surprising Truth About What Motivates Us
by Daniel H. Pink
In the Wake of the Storm: Living Beyond the Tragedy of Flight 4184
by Theresa Severin
Willful Blindness: Why We Ignore the Obvious at Our Peril
by Margaret Heffernan
98.6 Degrees: The Art of Keeping Your Ass Alive
by Cody Lundin and Russ Miller
by Jocko Willink and Leif Babin
How helicopter accident reports can save lives
Dan Doepker, Chief Helicopter Instructor for Hillsboro Aero Academy
Commission on Accreditation of Medical Transport Systems (CAMTS)
Federal Aviation Administration (FAA)
National Transportation Safety Board (NTSB)
Blue Threat: Why to Err is Inhuman
by Tony Kern
When it comes to accidents, operate under the assumption of when, not if.
“Organizational culture is another factor influencing trauma stewardship. Golie Jansen, an associate professor at Eastern Washington University recently concluded a study in which she found ‘that when people perceive their organizations to be supportive, they experience lower levels of vicarious trauma.’”
--Laura van Dernoot Lipsky, Trauma Stewardship
Incidents and Accidents
“No matter how self-assured we are, in a fraction of a second, our lives can be utterly devastated.”
–Peter Levine, In An Unspoken Voice
Risk and Preparedness in Emergency Medical Services:
According to the National EMS Advisory Council:
“Risk of Harm to EMS Personnel: Regardless of their location or the type of system in which they work, EMS personnel are expected (and often expect themselves) to do their work under difficult, unpredictable and rapidly changing circumstances. They may work long hours, in harsh environments, with limited information, assistance, supervision and resources to accomplish their mission. In the course of their work, they may be exposed to risks such as infectious organisms, emotional stress, fatigue, physical violence, occupational injury, vehicle crashes, and personal liability. They are more than 2-1/2 times likelier than the average worker to be killed on the job,3 and their transportation-related injury rate is five times higher than average.”4
“When it comes to preparing for a line of duty death, a recent EMS1 poll found that the majority of EMS agencies – 84 percent to be precise – have no policies, activities, or research in place. Only 9 percent of those who responded said their agency has written its own or adopted an LODD protocol.”
EMS tips for creating an LODD policy, EMS1, Feb. 3, 2015
A recent study with survivors of air medical transport accidents demonstrated the following:
“Conclusion: Planning for AMT post-accident response was identified to be lacking in scope and quality. More focused efforts are needed to assist and support the survivors as they regain both their personal and professional lives following the accident. This planning should include all stakeholders in safe transport; the individual crew member, air medical transport companies, and the industry at large.”
Survivors Perceptions of Recovery Following Air Medical Transport Accidents. Jaynes, et al. http://www.ncbi.nlm.nih.gov/pubmed/24932568
The Survivors Network for the Air Medical Community strongly recommends that air medical transport and EMS agencies research and adopt appropriate policies to enable them not only to prevent accidents, but also to respond effectively to incidents, accidents, and line of duty death (LODD.)
“In recent years, concern for persons who have suffered distress and loss as the result of aircraft accidents has led to increased efforts within the aviation industry to establish means by which the anguish can best be mitigated.” ICAO Circular 285-AN/166 (i)
ICAO News Release: Montreal, 4 March 2013—“International Civil Aviation Organization (ICAO) has approved a new policy document that calls on its 191 Member States to reaffirm their commitment to support aviation accident victims and their families.
A resolution of the UN aviation body’s 32nd Assembly led to the publication of an earlier document on Guidance on Assistance to Aircraft Accident Victims and their Families (ICAO Circular 285, 2001). The Circular stressed that assistance to persons involved in aircraft accidents was an indisputable humanitarian duty.”
“Irrespective of the scale of an accident, the victims and their families should receive appropriate assistance. Because of variations in the size and circumstances of aircraft accidents, the extent of the resources required to provide family assistance will vary considerably.” ICAO Circular 285-AN/166 (ii)
In light of the risks of emergency medical response professions, it is imperative that air medical transport organizations, EMS agencies, and related organizations plan ahead for incidents, accidents, and line of duty death.
“A proven plan is critical to the provision of family assistance because the need to provide such assistance will occur with little or no warning, will require an immediate response and will involve large numbers of trained personnel, significant expense and the use of specific resources.” ICAO Circular 285-AN/166 (17)
Along with comprehensive planning, it is highly recommended that relationships are established proactively with professional clinicians who specialize in trauma in this population of professionals. The development of trained peer support and critical incident response teams can be helpful for day-to-day stress, as well as for some incidents and accidents. It is helpful if peer support teams are trained at regular intervals and operate with oversight from a professional clinician who can step in when people need professional assistance.
Air Medical Accident/Incident Preparation, Response, and Recovery: Lessons from Crash Survivors
Connections: A Disaster Resources Consortium
EMS tips for creating an LODD policy: An EMS1 poll revealed the majority of EMS agencies have no policy in place; here’s how better prepare for such a tragic event
Air Medical Memorial
National EMS Memorial Service
Line of Duty Death Handbook for EMS
Association of Professional Flight Chaplains
Public Safety Officers’ Benefits Program (PSOB)
HOPE Animal-Assisted Crisis Response
National Transportation Safety Board (NTSB)
NTSB Transportation Disaster Assistance Division (TDA)
Survivors Perceptions Of Recovery Following Air Medical Transport Accidents
Aviation Disaster Family Assistance Act of 1996
Passenger Rail Disaster Family Assistance Act
International Civil Aviation Organization (ICAO)
Policy on Assistance to Aircraft Accident Victims and their Families
The MedEvac Foundation has a Children’s Scholarship that is offered to children who have lost a parent or had a parent seriously injured in an air medical or critical care ground transport accident.
Preventing incidents & accidents: a place for survivors
“Human beings, who are almost unique in having the ability to learn from the experience of others,
are also remarkable for their apparent disinclination to do so.” —Douglas Adams
Despite the hundreds of emergency medical response professionals that have died in the line of duty and even more hundreds of survivors, it is only recently that the value of the perspectives of survivors and surviving family members has been acknowledged. The experiences of survivors have brought forth important lessons relevant to a variety of topics including personal and professional preparation, safety culture, Just Culture, Crew Resource Management/Air Medical Resource Management, survival training and gear, accident prevention, and accident survivability.
The experiences of “survivors,” in the broadest sense, are invaluable in helping the emergency medical response professions understand how to survive a career in these professions, from the day-today to the “unthinkable.” It is essential that we give survivors a voice…and that we listen.
Call to Action
Safety and survivorship are not proprietary. If you know of best practices or resources that would be helpful to this community, please let us know.
“Although firsthand experience with trauma leads to personal suffering, it can be sublimated into social or artistic action and thus can serve as a powerful agent for social change.”
--Bessel van der Kolk, The Body Keeps the Score
“We can't practice compassion with other people if we don't treat ourselves kindly."
― Brene Brown