Written By Kimberly Webster, HCA/RPN, 4th year BA Student (Psychology major, English minor) and Dr Christopher Montoya, PhD
As a student at the University of Lethbridge I worked as a student counsellor and first aid attendant. In exchange for these services I only had to pay one half the normal rent per semester. Nothing too grave ever happened in the University of Lethbridge residence. Paper cuts, skinned knees, depression after exams, and talking people down after substance use was the norm. However, two weeks after passing my certification, while in the nursing station a call came in that someone had collapsed on the eighth floor of the building. The memory is startlingly clear and vivid, but not all bad. I see myself, first aid kit in hand, running up four flights of stairs and not being tired at the top. I pushed through the double doors at the top of the stairwell and almost ran into half a dozen professors standing in a semi-circle around a fallen colleague. I asked, “Is he breathing?” Half a dozen shoulders shrugged. Falling to my knees next to my patient I asked, “Does he have a heartbeat?” Half a dozen shoulders shrugged again. I put my fingers on his carotid artery. No pulse. His skin was unshaven, cold and clammy. I asked, “How long has he been this way?” Really, again with the shoulders? I went to start mouth-to-mouth before compressions, but my patient had false teeth… A full set and they were not in place. When I removed his dentures, mucous and saliva flowed from his mouth. His jawline had lost its rigidity. I cupped my right hand gently over his mouth before putting my mouth over his nose and administering the first rescue breath. I saw his chest rise. I began compressions. I don’t know how long I did this for, but suddenly a gurney with a respirator arrived along with the resident nurse. I was glad to hand off to a more experienced responder. That was my training. I don’t really know what happened next but I found myself outside my girlfriend’s door on the third floor, D section. I gently knocked. My future wife opened the door and I asked, “Do you have some mouthwash?” This event happened over 40 years ago, yet I had to stop writing this paragraph four times. Suffice it to say I only made it a few more years as a first responder. I don’t know how others continue. The victories are great… the losses hurt. Oh… the patient was pronounced dead later… Oh… I hated writing this. What is wrong with my head? Personal experience: It is really hard to wash off death.
First responders suffer some of the highest rates of posttraumatic stress disorder in the helping professions and, nevertheless, resources for them are scarce. How does society not place more value upon these virtuous souls? Our healers. Our protectors. Individuals who risk their sanity to save the lives of strangers on a daily basis… But also our friends and colleagues, whose jobs take them from the mundane to the neo-liberal and often provocative ethos of modern medicine. We look up to them to fix us when we are stretched out on the ground. We look, hoping to grasp a fleeting glimpse that this is fixable. That we are fixable. When we fall, we fail to understand that they fall too. They have cracks in their armour and holes in their shields, as we do. More often than not we view them as larger than life… but these immortals are Titans not Gods in the Greek sense. In our minds they are the brave, not the broken, yet they are beautifully broken and splendidly shattered. First responders are human. For them to function, they need to put what they have seen behind them. Humans don’t always win, sometimes the answer is “no”, and we learn instead. We need to ensure that our front line workers are psychologically prepared and that when they run out of strength, and they will, that there is an army of brothers and sisters standing behind them, ready to hold them up.
We tried to intervene. Yet we couldn’t. Sometimes we cheat death, but often we are faced with battles greater than ourselves. Sometimes, although the team tried, the team failed. All throughout our careers we are told not to internalize and yet, that is precisely what many of us end up doing. Some of us come to realize it sooner, and blow off little bits of steam as we power along… But some of us shovel it under the proverbial “I am okay” rug. Denial is bliss. Cuckoo birds constantly circle overhead, but don’t let them build their nests on your head. The question remains: Can we continue to dodge those pesky cuckoos when they are overhead every day, when they are multiplying at alarming rates? How do we remove the nests when the branches are the faces of our patients? How do we pluck out the twig that is a baby dying in our arms? How do we clean up our brains and tame a seemingly endless forest of twigs? We are stopped in time, transitioning from the past to the present, while attempting to envision a future worth living. It is impossible to imagine a future when we are stuck in the past, covered in nesting material.
A psych professor of mine once asked a rather probing question. He asked, “How many of you have read a page in a book, and at the bottom of the page, did not know what you had just read?” This got me thinking. How many of us, when performing a procedure that we have done umpteen times, got lost in the procedure because we lost focus? Where was your mind? This professor went on to explain that most people do not live in the now. Most people are trapped in the troubles of their past, or locked onto visions of their twisted future that compromise their present. As an opportunity for pragmatic learning, he posed another query, “Why did the Titanic sink?” From around the class answers were proffered from various perspectives such as, “Well, because it hit an iceberg… Duh.” Perhaps it was going too fast to dodge the iceberg. Or maybe the ship was built in too great a hurry, and safety precautions were ignored. All were offered as various dimensions of imminent disaster, contributors to impending catastrophe. Catastrophes we have all witnessed.
The professor’s pedagogy was infused with the image of the moving ship. “No,” he stated. “Modern ships could hit the iceberg at greater speeds, gouging larger holes in the superstructure, but they would not sink. The Titanic was well designed and compartmentalized. Deconstructing the disaster, we can see that the main problem was that the compartments were not finished. Water could flow from one compartment to the next freely. In modern ships, to avoid such catastrophic failure, the various compartments of the ships must be able to be sealed off completely.”
What does this have to do with reading a book or working as a paramedic? The reason that students could not remember what they had just read was that they were not reading in the present. The reason that paramedics perform rote procedures incorrectly is because they are not performing in the now. We all need, at times, to stop and take a breath… to take a moment to clear away some of the debris of the day, the wreck of the week, the catastrophes of the calendar year.
So, let’s play the professor’s little game. Pretend, just for a moment that you are a ship captain sailing across the Bermuda triangle. You look to the back of the ship and you see storm clouds, troubled waters, a dark portend indeed. Secure in your experience as an old salt sea captain you yell, “Seal off the back of the boat. Batten down the water tight compartments.”
Just for a moment, play with me. Pretend you have no past. All you have is the present and the future. Now, as that old salt sea captain, you look to the front of the boat. You are assaulted by an unambiguous, nasty, oppressive, and murky future. With unparalleled forcefulness, the captain in you liberates himself by shouting, “Seal off the front of the boat. Batten down the water tight compartments.”
Play the game with me for just a little longer. Pretend you have no past. Pretend, just for a minute, that you also have no future as it has been sealed off as well. Pretend that all you have is the now. Psychologically, how does the now feel? Look around. Throw something across the room. Send a flirting email to your significant other. Question: When is the only time that you can fix a past problem? The answer is simply… now. Question: What were you worrying about a year ago? Did worrying help? You can’t go back into the past and fix something that was broken long ago. And you can’t peek into the future to try to steer your ship on a better course. The only time that you can change who you are and where you are heading is… now.
When is the best time to start living in the now? The answer, of course, is now. To be a fully functioning paramedic, lecturer, lawyer, or person one must live and play in the now. Be careful if you start living in the now and do not tell your significant other this fact. You may face the following interrogative, “Who are you and what have you done with __________?”
There are, indeed, many wonderful things you can do in the now. Do them, now, before this particular version of self dissolves to make way for another temporary self. This underscores the self’s transitional quality. In a way, the transition functions as a defence mechanism against the singularity of existential pain generated by loss. Ultimately, living in the now creates the prospect of molding a new better future self and the prospect of liberating yourself and your loved ones from the past’s old and outdated oppressive conditioning. Just a thought: Keep smiling in the now. I find that with a little prayer and a lot of hard work things eventually work out.
If there is joy in living in the now, there is pain in living in the past. This pain is translated into physical brain-based manifestations. People who are trapped in the past carry baggage, as we say, in the form of painful memories and experiences. This pain releases corticosteroids that are brain killers if sustained over long periods of time. Many of us know of the “brain fog” that accumulates over time, and seems to worsen as we face trial after trial. What begins as one error quickly is imagined as many. We allow ourselves to feel guilt and shame, which results in the release of more corticosteroids, ultimately leading to poorer performance and further failure. So why do we do it? Why do we dwell on our mistakes? Will cultivating these unhealthy feelings will somehow motivate us to do better in the future? Will it help or hinder? The best thing we can do for ourselves, and therefore the best we can do for our patients, is to stop and let it go. A simple test to see if you have too many corticosteroids circulating in your bloodstream is to look in the mirror. When you look in a mirror who do you see? If you see an enemy, a failure, a loser or worse… then yes, too many corticosteroids. The person you should see in the mirror is your very best friend. There are enough people in this world waiting to replace you, hurt you, or bury you without you getting in line ahead of them. By not adding more dirt to your grave, you are not burying future patients along with you.
Remember, the brain is competitively plastic. That means that as one part of the brain grows, another part shrinks. In our jobs we all develop coping techniques that help us to manage the onset of grief, but in doing so, other parts of our brain diminish in size, scope, function, and utility. What are we to think then when past ways of coping just don’t cut it anymore? Are we getting worse? Or are we just changing? If we consider that the human brain has over 100 billion neurons, and that each neuron has up to 50,000 connections that can fire up to 1,000 times per second, we know that what we are dealing with is beyond our scope of comprehension. Long-term potentiation (long-term memory) actually alters the physical morphology of our cerebral cortex. In layman’s terms the size, shape, and composition of our grey matter changes with everything we learn and with every trauma we endure.
The brain is also electrochemical, that is chemicals are released that carry charges. However, there are approximately 100 putative neurotransmitters in the human brain, and some of these neurochemicals release in mosaics where one presynaptic button releases a set pattern of combinations of transmitters that interact on a postsynaptic mosaic. Thus restructuring has a profound effect on the brain.
So, even superficially, one can see the complexity. We must assume that we are not doing worse per se, we are simply morphing into different people. We have advanced along the road of life, and we, as travelers, have changed. As such, the strategies that we employ must change to ones that are more utilitarian, nonconventional, and adaptable. Mentally, we need to adapt to our new physical selves (brain) and then our new selves (mind) will be changed for the better. We know that anatomy and physiology are intertwined, form follows function and indeed function follows form.
On a more mundane note, this might mean that previously enjoyable activities become less enjoyable, but it does not mean that no activities will be enjoyable. As we age our tastes change. Yes, cheese and broccoli now tastes okay, and perhaps we do not chew Hubba Bubba bubble gum anymore. As your brain changes, look for more long-term activities that upturn your interests and attitudes. Keep looking. Do not lose faith in yourself simply because you have grown into a different version of yourself. Many physicians consider a loss of enjoyment from previously enjoyable activities to be an indicator of poor mental health, but we propose that with change comes change… and maybe, just maybe, you aren’t as screwed as you, or others, think.
Another strategy employed by people as they age is not to avoid difficulty, but rather to embrace the worst. Chinese philosopher Lin Yutang came up with a philosophy to accept the worst. The following two stories, that we lifted from “How to Stop Worrying and Start Living,” by Dale Carnegie, will highlight the point of this philosopher’s discourse.
The first of the stories concerns a multimillionaire in the early 1900s who, because of worry, was dying of ulcers. Back in the day, the best practitioners could do was to provide him with a small bottle of mineral oil and an IV drip. One day, after reading Yutang’s philosophical position, he began to rethink his life. Soon after, his physician came in and announced that there was nothing further Western medicine could do for him, and that he had less than six months to live. He was advised to prepare his will and get his estate in order. The multimillionaire decided to act on the philosophy of Lin Yutang. He said to himself, “Okay, I’m going to die. What do I want to do with the remainder of my life?” The multimillionaire had always wanted to travel to China, so he booked an entire suite on a steamship and ordered a refrigerated coffin. As he got up to leave the hospital, mineral oil bottle in hand, and still hooked to the IV drip his doctor asked him incredulously, “What are you doing? You can’t leave the hospital. You’re dying!” The multimillionaire replied, “I realize that I am dying, however, I have always wanted to see China.” He was no longer stressed over his company, and was no longer stressed over dying. The long and short of it is by the time he reached China his ulcers had healed. By accepting the worst, and not stressing over things he could not control, he was able to manipulate things in his life that he could control.
The second story concerns a Texas oil millionaire in the year of 1942. The story was set in the time of World War II. It was a time of rationing, and tight government control. While in his office one day, the millionaire was approached by a card-carrying member of the FBI. The agent explained that someone in his company was selling oil on the black market. According to the law, as he was the CEO of the company, he would be charged with treason. Treason in times of war carried a mandatory life sentence. The agent then stated, “I know that you are not the person who engineered this plot. However, the law is blind to that fact. I am not heartless. If you pay me $20,000 I will look the other way until you clean this matter up. I’ll give you 24 hours to decide: jail or money.” As it happened, the oil millionaire had just finished reading Lin Yutang’s philosophy. So he said to himself, “Okay, I’m in a lot of trouble. I’m going to go to jail for a long time.” He accepted the worst. “I’m going to need a really, really good lawyer.” He called up the most expensive lawyer in Texas, and explained the situation. The lawyer said, “I’m glad you called me. The person you are talking to is not an FBI agent, but a con man. He has defrauded over 10 other companies in Texas already. Have the police arrest him when he comes to see you for the money.”
In each case accepting the worst allowed individuals to let go of what they could not control, and gain control of what they could control. These types of psychological strategies tend to work for young adults and seasoned veterans of life, but of course they do not work for everyone all the time.
If you happen to find yourself in a position where you are feeling as though you have exhausted every avenue, with very little success, I would like to ask you a question. Do you believe in providing holistic health care for your patients? Do you look at them as though they are simply a slab of meat on your stretcher (purely physical)? Or do you know that each patient is a unique being, with individualized mental processes and emotional states? All the pieces are melded together as a mass of atoms, capable of possessing spiritual beliefs and requiring certain social elements in order to function fully as a human. Humans are complex beings. You are a complex being. Each of us functions best on our own personal radio frequency, and trauma is the ultimate station changer. George Engel and John Romano of The University of Rochester acknowledged, decades ago, that a new medical model was needed, and brought forth the concept of a biopsychosocial approach. However, with current staffing shortages, funding cuts and patient load increases, many practitioners are feeling the crunch, rushing patients through their offices as quickly as they can without taking the time to explain that there is no “easy” fix. Truly holistic care encompasses all of the dimensions of health (physical, mental, emotional, spiritual, and social). Our current system does not support such care… So, I want to bring this concept to your attention: Have you provided yourself with holistic care before throwing in the towel? Have you swallowed a handful of pills and expected to be cured… That handful of pills in combination with therapy, positive social interactions, and spiritual reflection may leave you feeling a lot better than any of these things would alone. Working through each area as though it is separate from the others rarely works… I recommend combining these things for the ultimate self-care during tough times. You’ll need to treat yourself how you treat your patients: As more than a slab of meat on a stretcher. Don’t stick a bandage on one small section of your body, ignore your soul, and walk away. You deserve a chance.
Regardless, this treatise is a love letter to our first responders. When you need help, seek help. We have only touched on a small portion of the techniques employed by psychologists, therapists, and others in the helping professions. These healers of the mind are in place to help those who risk their lives to help others. They see your pain, and they stand with you. We stand with you. Seek help, keep going, and stay the course. Thank you for your service!