By Joe Poulton, MTI Contributor
After my Uncle Jim’s Suicide in his backyard with a gun, my Aunt joined Out of The Darkness Walks through the American Foundation for Suicide Prevention (AFSP). When I saw the community of support being built through those walks, and noticed the AFSP expanding; I jumped at the opportunity to help build the Portland Chapter. That commitment lasted from December 2008 to March 2009; then AFSP consolidated the PNW Chapters with the Seattle Chapter and moved meetings north. Looking for another way to help those with depression and suicidal thoughts; inspired by my wife Ariel and her work as an RN, my path shifted towards EMS.
In 2010 I tackled an EMT Basic course in Vancouver, WA. It was difficult learning the required aspects of patient care; where to take pulses, how to take blood pressure, how to splint fractures, CPR, and the list goes on for how to manage the patient. There were no skills for the EMT to manage the psychological effect of the work.
After my EMT course, work began with Denver AMR operations and transitioned from there to AMR’s Boulder 911 system. This was when memories of death ramped up, my first suicide call was a hanging in an Open Space Park. When my Medic partner and I went up trail to the tree I remember being more curious than anything. I saw the face and wondered how many dead people Hollywood artists had to see to get it so right. Suicide calls compounded, but none were similar to my uncle’s. All were overdoses and hangings.
When we had our son, we moved back to the PNW and I began working for Clackamas AMR. While I worked through the Reach and Treat (RAT) Academy with AMR; a high school friend after years of trying to manage a TBI and physical challenges died by suicide, but he also took his daughter’s life with him. That was May of 2014 two days before my 35th birthday. I completed the RAT Academy the following October.
A couple years later Eric Pracht, a Denver EMS Brother; became a Paramedic for South Park Ambulance in the years following my move west. He went missing in 2016 and was found in 2020 by hikers within an Open Space Park, a gun nearby. He was 25 years old.
Summer of 2018 was busy with Reach and Treat shifts between fire deployments. One night, a call dropped; knelt on the ground and checked for a pulse, even though there would be none, just cold. A women shot herself the same way my uncle Jim did, there was family and friends experiencing their pain of loss on scene. I remembered my Aunt recalling how grateful she was for the EMS crew talking with her, staying for hours. I wanted to help this family in a similar way. The husband was in heavy grief, unable to talk; I walked over to the friend. Put my hand on his shoulder and in a strange calm spoke, “If you or the family need a network of support, connect with the American Foundation for Suicide Prevention—remember the AFSP if you’re able, just A—F—S—P.” But I didn’t stay for hours, the county has a different crew that comes to assist with grief. Another suicide—this one—a mirror reflection of my uncle’s. Different than all the other suicide calls—no family or friends were present experiencing their grief on previous ones.
Even after the Summer of 2018, I didn’t accept the reality of the damage fully. Engaged in sporadic counseling that was not effective. I’ve seen this before—suicides—not understanding the significant difference at the time. This led me down a road of complacency that maintained a disconnect from myself.
Responded to a call in October of 2019 for a suicidal ideation patient, as I stumbled with my questions the patient responded with aggressive irritability. I was unable to have a conversation and shut down, my partner on the rig took the call and I drove. After we transported and got the patient into an ER bed, I had a full panic attack sitting in the driver’s seat of the rig. This was the first intervention that occurred, a Critical Incident Stress Management co-worker from Multnomah County was at the ER. We sat in the EMS breakroom of Mount Hood Medical Center for some time. That was my last RAT shift call. The patient, an off-duty firefighter.
I was late to the game in understanding this challenge, thankfully I’m here. I’m still learning. Not having a significant relationship with other forms of traumatic death in my personal life; lessened the impact of other traumatic calls. I did maintain RAT status with monthly training for Wildland Fire Deployments. However, anxiety remains over the idea of responding to another suicide.
There is a mechanism of overlap between PTSD and Anxiety, but as noted in the Neuroevolutionary Time-depth Principle article in a segment focused on combat “PTSD may be partly due to it being an overconsolidational fear circuitry overactivity superimposed on a premorbid suboptimal dosage of harm-avoidance-related genes.”
My accumulation of stress specific to suicides through my EMS work; my lost family and friends, has increased my anticipation anxiety. In a perceived protection mechanism through the avoidance of working another suicide call; fearing that it could be similar to the previous, has kept me from a 911 shift. Curiously, on the call itself; I did all I could do.
Joe Poulton has worked in EMS for 12 years with the last 8 being on the Reach and Treat team in Clackamas County OR.
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Critical Incident Stress Management (CISM) is an “umbrella” term for a variety of psychological modalities that encompass preventative care, intervention, and postvention used in a variety of tools to manage psychological stress before, during, and after traumatic events of all shapes and sizes.
How does this compare to our old friend epinephrine?
comes in a number of concentrations
Has many delivery routes
Can be used in a miriad of scenarios
It’s effectiveness in certain scenarios are often in question
If used incorrectly by poorly trained personelle, outcomes can be poor
If used correctly by well trained personelle, it can (and has) saved lives
We’ll go into a deeper dive of CISM/ CISD/ PEER SUPPORT soon. But for my medical providers out there: before you lean all the way in into the LOVE IT or HATE IT camp. Ask yourself how well epi works for anaphylaxis and how we still have a ton of research to do to determine it’s efficacy in cardiac arrests.
Also, to my mental health providers out there:. If the first time you’re meeting a team is to perform a CISD you’re doing it wrong. This failure may be yours, it may be the failure of the providers agency, but if it all possible you should meet the teams you will be asked to care for BEFORE you’re expected to care for the. [sic]
DanSun Photo Art
PTSD and Anxiety
Human brain evolution and the “Neuroevolutionary Time-depth Principle:” Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder
Based on the first 10 episodes of the Resiliency 1st Podcast I’ve learned some simple techniques.
4×8 inhale 4 exhale 8 seconds
Continuous 7+ hours, naps 20-30 minutes or greater than 90 minutes to avoid waking in a sleep inertia cycle. If you continuously wake with an alarm you are not getting enough sleep.
After a difficult call, do some form of activity. Run or walk fast, even right after the call before you finish the chart. 5 minutes in the ER bay or longer at post if possible. Do it before you nap or go to sleep that is important. Remember to go play when not at work.