Stories from the point of care: Carl
It is 9pm on a cold winter’s evening. I am at my local Emergency Department (ED) restocking some supplies for the Rapid Response Vehicle (RRV), when I receive a message from my control room to attend a Category 1 incident. It simply reads, “?deceased, no bystander CPR in progress”. Being so close by meant I was unable to find out any more pertinent information. As I arrived I was joined by a fellow RRV responder.
Upon entering the house, it was soon clear that it was in a neglected state. Proceeding upstairs, I was pointed in the direction of an attic room, where a man laid prone, surrounded by used needles, syringes and improvised tourniquets.
He was clearly dead and had been for several hours. There was little for us to do but complete our paperwork and wait for the police to arrive.
As time passed, we found ourselves talking about what we wanted to have for dinner. Options were discussed and we eventually settled upon a Chinese takeaway. Too which I agreed to pick up on the way back to the ambulance station. As I left the house, I started to feel guilty about discussing our plans for dinner with a dead person in the room. To us it had become a simple incident to manage – walk in, assess patient, confirm death, inform police and complete paperwork. Job done!
A series of questions started to cross my mind. How could I be so unaffected? As a member of the public just a few years ago, I would have been appalled at the sight of a dead person. Now I was able to continue as if nothing had happened. What had happened to me? Was it a healthy response or something that could in time lead to harm?
These thoughts kept returning to me over the next couple of days, as more patients followed. I managed a dying patient in respiratory failure and another with urinary sepsis combined with complications of diabetes. Lastly, there was someone choking in front of me, who required a succession of back slaps and abdominal manoeuvres in an attempt to dislodge the obstruction. As we made the blue light run to the ED, all I could think about was how to set up a needle cricothyroidotomy system if we didn’t make it through the doors in time.
For the average person, any one of these incidences would have prompted an emotional response, yet for me and other ambulance service staff, these scenes are commonplace. The longer I work in this field, the further I seem to move away from responding like the average person. This then poses the question of whether this is healthy.
Of course, the answer isn’t cut and dried.
Without some form of coping strategy, there is a large potential for burnout. This could risk staff coming across as brash, uncaring and unsympathetic individuals
Within our role, the organisation who employs us, and the patients in our care, demand a high level of service. But we are all humans and come with the fallibilities. Humans are not robots, we have good and bad days both physically and mentally. Sadly, we still have to work despite not being in the best place, and this risks both our professional reputation, as well as the organisations.
When a family member asks how your day has been and you un-emotionally reel off a list of incidents you have dealt with, most listening would be shocked.
So the question I have asked myself is, am I normal or numb. How much does either of the above impact our mental health and does the ambulance service as a role, attract a certain mentality of person whose level of normality is slightly wayward from the start!
One of the huge issues with crew mental health, is that it is a slow, gradually evolving situation. Where over time you may learn to build coping strategies. Becoming numb, may well be one of those strategies, but the longer the situation evolves, the bigger the snow ball becomes and eventually the faster the snow ball roles down the hill. Sadly, the snowball only comes to a stop when it runs out of energy, either by a sudden crash or it loses its speed on the flat and just melts away into obscurity.
When we have a decline in our mental health, not only is our work affected but more importantly our family lives. This should be our number one priority, but it can become strained or in some cases, destroyed. In many instances, unless there is a family member who understands why it is all going wrong, (then the ambulance person won’t open up) opening up can become vey challenging. This may be two fold in nature. One is to protect the family from hearing about some of the experiences we deal with and the other is that they just may not be able to understand or comprehend the things that need to be discussed.
Our mental health is a very personal thing. From my own experiences, I have noted that upon starting work as a newly qualified paramedic, my stress level rose very sharply. 7 years in, I know that my stress level trajectory has eased off, but I am now becoming aware that the upward curve has still been progressing. Sadly with all aspects of mental health, I have no idea where my tipping point or cliff edge is. But I am aware that we all need to manage our stress curve as the upward motion of compounded post incident stress and pre incident anxiety continues to gnaw.
Our stress curve are all very personal and I can now visualise my own curve. How does yours look? Have you thought about the build-up affect? I am by no means suggesting that every person in the ambulance service will have a break down. However, I am aware that there is a significant chance that we will be exposed to enough “stuff”, we will not be the same person as we were when we started our career. I am also aware that it is not only our work history that affects our mental health. Our personal lives may be the main contributor to the negative mind set. We all change, it is part of the rich tapestry of life, but it is concerning seeing close friends and colleagues’ crash and burn as a result of our role. This piece is not written with a plethora of academic reading behind it, but is written following a lot of reflection and listening to colleagues who have had problems. One thing that has struck me is people questioning “when did it all start going wrong?”
This is a poignant question and one of the reasons why I have chosen to share my thoughts. As ambulance service staff, we still wait too long before we acknowledge or act on a deterioration of our mental health state.
I truly believe the world of ambulance work is bad for all of our long term mental health and I do believe that we do become numb to many things, in order to protect ourselves. Sadly I am now realising that becoming numb to experiences and having numbing strategies as a main part of our armoury to many aspects of our work, only causes the issues to be pushed into a box that can only hold so much. At some point we stop being able to close the lid and as such our coping strategy falls apart. By this time we may already be a long way down the line of becoming mentally unwell.
So, to answer my question, am I normal or numb? Following my time of reflection, I believe I am numb to many things, both good and bad and this can make you feel like you’re looking at the world from behind a glass wall. This defensive wall allows me to be disengaged from the reality of other people’s situations. Currently I feel like I am a long way off, at my current trajectory, of falling off a cliff. However, I am aware that my box is filling up, but as this box is invisible and there is no gauge on it, then it is anyone’s guess how much space is left.
If you are a leader/manager, strive to and encourage frontline staff, who have noted and made the decision to disclose their mental health difficulties, to have adjusted duties facilitated. I always find it a bizarre, strange and a somewhat stupid concept that an employer will quite happily pay to have a member of their team off work with stress, being isolated and getting more and more distant from their colleagues. Rather than keep them in the fold by, allowing them to do alternative duties on a flexible personal agreement. With this, the staff member should not be pressurized to accomplish any tasks and should just be given support to manage what they can. This has the potential to keep that person protected by their colleagues and be surrounded by people who understand and can empathise with the situations they find themselves in.
So what can we do to make things better? In very simplistic terms, watch out for your friends and ask them to watch out for you, and as a friend please speak up if you are concerned. The last person to notice/accept things going wrong is often the person themselves. I strongly believe that we are all potentially, only one incident away from never working on the frontline again. It is imperative to keep a check on yourself and be honest. Sometimes acceptance is the hardest realisation, but with acceptance comes hope, and with hope comes positivity, and with positivity comes a willingness to open up and strive for personal change.
I hope this little article is thought provoking and opens up positive conversation for you and your colleagues.
Carl Betts is an Aspirant Specialist Paramedic and Quality Improvement advisor.
This article was previously published as ‘Normal or numb – that is the question but what is the answer!’ in the College of Paramedics’ INSIGHT magazine.