How the Best
The American Institute of Stress https://www.stress.org/how-the-best-handle-s
Commentary, Health & Safety
Commentary by Mark Lamplugh
On June 20 of this year, Fire Department of New York (FDNY) EMS Lieutenant Matthew Keene did not report to work. He was found at home by coworkers with a gunshot wound to the head. Tentatively, his case is being ruled a suicide. In April, John Mondello, another FDNY EMT, had taken his own life. Lieutenant Keene had nine years of field experience. EMT Mondello had three months. Neither had been perceived as being at high risk for behavioral issues, and their colleagues were devastated by these sudden losses (Edelman, 2020).
Some within the FDNY associate these deaths with the impact the COVID-19 (novel coronavirus) pandemic has had on the first responder community, particularly with regard to mental health. Having been a firefighter and captain for seven years, I can attest to how poorly managed stress can spiral out of control. COVID-19 in particular has proven to be particularly exhausting physically, mentally, and spiritually. These cases are sad reminders of the psychological costs many of our fellow brothers and sisters endure and how the current crises is amplifying those issues.
The Stress Tetrahedron: A New Way To Visualize First Responder Stress
Paul Combs Poster: Firefighter PTSD and Suicide
My Journey Out of the ‘Darkness’ of PTSD
Strategies for Preventing Suicides in the Fire Service
A variety of mental health issues can affect first responders, and their effects are wide-ranging. Post-traumatic stress disorder (PTSD), characterized by any combination of anxiety, avoidance, hyper-awareness, changes in mood or beliefs, and anger sustained over a period of several months, is the most commonly associated condition. However, the symptoms can be far more wide ranging. Delayed stress syndromes, where psychological trauma is not recognized until after the event (i.e., following a prolonged search and rescue operation) or resulting from protracted stress without decompression (such as repeated 24-hour shifts) is another common issue. Eating and sleeping disorders, apathy, mood swings, changes in or lack of interests, and substance abuse are other problems plaguing emergency personnel (Lewis-Shroeder et al. 2018). While understood as existing issues, how does the COVID-19 crisis amplify them?
One major stressor is contact precautions. As a first responder, we are used to using exam gloves and masks, but COVID-19 has significantly changed the use of personal protective equipment (PPE). We are now using N95 masks (sometimes reused due to shortages) and recommended protective goggles (which inevitably fog up) on all calls. Treatment approaches to respiratory patients and patients on ventilator support have become more complicated. Equipment is being completely sanitized after every call. This proves a difficult task after repeated requests, particularly at shift’s end. Physically, performing work through an N95 mask can be exhausting and can worsen claustrophobia and axiety. When dealing with sick people, how are you supposed to avoid getting sick when there are national shortages of protective equipment? Fear of catching the virus is high, give the health effects of the virus, and the loss of work due to illness or quarantine looms in the background. An additional stressor for many first responders is passing the virus onto family. We as first responders assume calculated risks, but these are risks we signed up for. What if we become a vector of disease to family members who have underlying health conditions if we go to work? For many, this has led to alternative, detrimental living arrangements. Children are sent to family living away from viral epicenters. Many choose to sleep away from home or self- isolate to a select few rooms (Wang, 2020). Chores are made harder from trying to keep work clothes separated or trying to access a laundry cleaning facility. The cumulative tediousness adds up psychologically.
Workloads have worsened during this crisis. Most apparent is the increased acuity of patients and call volumes. FDNY noted a 50-percent call volume increase in April (Wang, 2020). Even after call volumes decreased (related to public health guidance), FDNY still saw higher numbers of cardiac and respiratory-related 911 dispatches (Winter, 2020). Many first responders work 24-hour shifts, and there is often little time or ability to decompress. Combined with many first responders going home to self-imposed isolation, it is unsurprising to see a significant increase in health and behavioral issues amongst personnel. At one point, 18 percent of the FDNY workforce was off duty due to illness. Twenty-percent-more work had to be performed by the remaining 80 percent of the force, exacerbating the issue further (Wang, 2020).
There are also financial issues. Many EMS working for private EMS services are facing significant hour cuts due to COVID-19. The most straightforward cost-cutting measure is to reduce the number of shifts scheduled when there is no demand. Fire departments with inconsistent call volumes face a similar issue, particularly in rural, underfunded regions. When COVID-19 hit my service area, our non-911 related call volume dropped at least 50 percent, resulting in a commensurate drop in scheduled shifts. Consequently, many EMTs and other service personnel face significant monetary issues or end up using unemployment benefits in some form.
The most poignant, personal issue is that personnel face significant problems with processing their experiences, which is made worse with the current pandemic. First responders are being used for higher acuity and riskier patients and are increasingly involved with managing human remains in possible coronavirus-related deaths in prehospital settings. One paramedic reported being unable to sleep, continually seeing images of cardiac arrest patients or deceased victims found at home (Wang, 2020). In epicenters like New York City, significant numbers of human remains are being seen by first responders, called in by neighbors complaining of foul odors. Repeated events, without the time to process them nor the ability to rest at work or home adequately, are significantly contributing to the “burnout” phenomenon.
Addressing the mental health needs of first responders has always been challenging, and that’s made more difficult in the current environment. There is often an underlying attitude of the need to “be strong” or “not show weakness.” Individuals may deny having symptoms,or not wish to admit their own issues out of fear of ostracization (“Addressing Suicide Amongst First Responders,” 2019). In some cases, problems are brushed under the rug (individually and institutionally), and affected personnel return to work quickly after a traumatic experience. Many first responders fear having changes in their employment due to obtaining mental health services, whether perceived or actual (Lewis-Shroeder, et. al., 2018). Recognizing behavioral problems is another common issue. One police officer reported enduring four years of poor sleep, chronic fatigue, pain, and other issues before being diagnosed with PTSD, never have recognized the culprit previously (Cousins, Helfman, and McCullough, 2018).
Another concern is how many first responders play down their stress levels or find other stress relief outlets. A Harvard study identified down-playing events, stoicism, or depersonalizing themselves or those that were involved in the event that triggered their issues as major obstacles to care. Substance abuse, alcoholism, and other forms of addiction are significant risks to unaddressed mental health problems previously (Cousins, Helfman, and McCullough, 2018).
COVID-19 has significantly worsened some aspects of these issues. Social distancing has affected many systems, isolating personnel within their own stations while on duty. Inability to engage in social activities compounds using positive stress outlets. In-person behavioral health services are not readily accessible in many areas currently, and not all mental health professionals regularly work with first responders; the latter has been identified as one issue in getting first responders to accept help from mental health professionals. Telehealth services are becoming more readily available, including an online responder recovery group I created over a year ago, but not all emergency service systems have embraced them or made them readily accessible to personnel.
The nature of our work is stressful and emotionally costly, and the COVID-19 crisis accentuates this. Even in the best of times, we are not always well equipped to process our experiences; under quarantine and social distancing conditions it’s much more difficult. I must confess that I have struggled at times with processing the increased demands COVID-19 has placed on my patient care.
An internet search will yield a significant number of stress-relieving techniques. Having discovered yoga this way a couple of years ago, I can attest how great a tool and teaching method the Web is. Many techniques are easily compatible with shifting work in the confines of an ambulance, fire truck, or police car. A recent Webinar by Mike Taigman, a former paramedic and stress management and resiliency expert, succinctly outlines our stress response (particularly during this pandemic) and a variety of methods to combat it.
Seeking professional help is not indicative of weakness or failure. As someone who has previously sought help, I can attest to how beneficial that interaction is. There are resources dedicated to first responders either or support available. The National Suicide Helpline is a great, free resource that is underutilized and can direct those seeking help to appropriate providers experienced with first responders. All Clear Foundation, an organization dedicated to assisting first responders, has a phone line and a text line connecting first responders to crisis counselors. Additionally, they cooperate with many behavioral health resources to obtain free or low-cost counseling. Next Rung, a non-profit seeking to stop first responder suicide and provide mental health resources, also has a crisis line available. Share the Load and many other organizations that can be found through the internet provide similar resources as well.
My peer support groups are my greatest mental health resource, and I hope you do, too. There are few people who know and trust me the way they do, and there’s little I do not entrust to them. On difficult shifts and calls, I have found greater comfort in knowing my struggles are understood by one of them; they are people where no filter is needed and no judgment is to be had. The current pandemic has isolated us from many we care about and has worsened many of the negative factors of our profession. However, I have found great strength in embracing the bond I share with my fellow firefighters because I already trust my life to them and we equally share our collective burdens. COVID-19 cannot change that. Lieutenant Keene and EMT Mondello should be painful reminders to all of us that no one is immune to mental health concerns. Our experiences here should remind us of the damage caused to our brethren who have backs in a structure fire, cardiac arrest, or active shooter situation. Every struggle we face, we face together, because so long as you work as a first responder, you have every first responder backing you. That is stronger than the COVID-19 pandemic.
Addressing Suicide among First Responders: How Colleagues, Friends, and Family Can Help. (2019, May 28). Retrieved June 25, 2020, from https://counseling.northwestern.edu/blog/first-responders-suicide-help/
Cousins, R., Helfman, L., & McCullough, D. (2018). The Dialogue: 2018, Volume 14, Issue 1 [PDF]. Rockville: SAMHSA.
Edelman, S. (2020, June 20). FDNY EMS lieutenant dead in apparent suicide may be due to coronavirus PTSD: Union. Retrieved June 25, 2020, from https://nypost.com/2020/06/20/fdny-ems-apparent-suicide-may-be-due-to-coronavirus-ptsd-union/
Faculty, A., Stelter, L., Hanifen, R., & Contributor, I. (2020, May 28). Traumatic Stress from COVID-19 Raises Concerns for Front-Line Responders. Retrieved June 25, 2020, from https://inpublicsafety.com/2020/05/traumatic-stress-from-covid-19-raises-concerns-for-front-line-responders/
Lewis-Schroeder, N., Kieran, K., Murphy, B., Wolff, J., Robinson, M., & Kaufman, M. (2018, July/August). Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Retrieved June 25, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6624844/
Wang, H. (2020, April 23). ‘I Hear The Agony’: Coronavirus Crisis Takes Toll On NYC’s First Responders. Retrieved June 25, 2020, from https://www.npr.org/2020/04/23/842011186/i-hear-the-agony-coronavirus-crisis-takes-toll-on-nyc-s-first-responders
Winter, T. (2020, May 03). Stay-at-home protests held across the country. Retrieved June 25, 2020, from https://www.nbcnews.com/health/health-news/live-blog/2020-05-01-coronavirus-news-n1197431/ncrd1198241
Mark Lamplugh is a fourth-generation former firefighter holding rank of Captain and sits on the executive team as Head of Marketing & Growth for Maryland Oncology Hematology, which operates 11 cancer centers throughout the state of Maryland and falls under the US Oncology network. Mark also owns Influence Media Solutions, which is a Marketing, Branding, Public Relations, Digital Marketing, Website Design, and Social Media firm in two cities with accounts nationwide. Mark serves on the board of One World for Life, National Fire Heritage Center, and the Institute for Responder Wellness and Responder PTSD which is his resource website for first responders. He is also the host of Firefighter Wellness Radio for Fire Engineering.
This commentary reflects the opinion of the author and does not necessarily reflect the opinions of Fire Engineering. It has not undergone Fire Engineering‘s peer-review process.