Normal or numb: that is the question but what is the answer?
By Carl Betts MCPara, Aspirant Specialist Paramedic and Quality Improvement Advisor at Yorkshire Ambulance Service.
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”. As I arrived on scene I was joined by a fellow RRV responder.
On entering the house it became clear that it was neglected. Proceeding upstairs I was directed to an attic room, where a clearly deceased man was laid prone, surrounded by used needles, syringes and improvised tourniquets. Little could be done other than complete our paperwork and wait for the police to arrive.
As we waited, my colleague and I discussed what we wanted for dinner. Eventually settling for a Chinese takeaway, to be picked up returning to the ambulance station. As I left the residence, I started to feel guilty about discussing our plans for dinner with a deceased 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.
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 mental harm?
These questions returned to me, whilst dealing with a varying patient complaint list over the following couple of days. Any one of the incidents attended would have prompted an emotional response to an untrained person, 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 emotionally like an untrained 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 and the development of resilience through training, there is a real potential for burnout to occur and also a perception that staff are brash, uncaring and unsympathetic individuals.
Our employers, and the patients in our care, demand a high level of service. However we all come with human fallibilities having good and bad days both physically and mentally. Unfortunately, we still have to work despite not being in the best place at times, risking both our professional reputation, as well as the organisation’s.
If asked how your day has been and you un-emotionally reel off a list of incidents you have dealt with, most listeners would be shocked.
So the questions I have asked myself are, am I normal, numb? How is my mental health affected? And does the ambulance service attract people with particular characteristics and mentality whose level of perceived normality is slightly different from the start?
One of the significant issues with crew mental health is the incremental evolution of stress. Over time you may learn to build coping strategies including becoming numb or detached. Becoming numb or detached from the situation may also be the mind’s response, allowing us to deal with the issues we are faced with.
Suffering a decline in our mental health, affects our work and family life. Family life should be our number one priority, but it can become strained or in some cases destroyed. In many instances it is difficult for an ambulance person to open up, unless there is a family member who understands why it is all going wrong. Opening up can be very challenging, being twofold in nature. Firstly to protect the family from hearing about some of the experiences we deal with and secondly they just may not be able to understand or comprehend the issues that need to be discussed.
Mental health is personal. From my own experiences starting work as a newly qualified paramedic, I am aware that my stress level rose very sharply at first. Seven 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, as with all aspects of mental health, I have no idea where my tipping point or cliff edge is. I am aware however 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 in our minds.
I can now visualise my own stress curve. How does yours look? Have you thought about the build-up effect? Not every person in the ambulance service will have a breakdown of course. I am aware, however, that there is a significant chance that we are exposed to enough 'stuff' to cause our personality to change thereby not being the same person as we were when we started our career. Our personal lives can also contribute to a negative mind set. Change is part of the rich tapestry of life, but it is concerning to see close friends and colleagues’ crash and burn as a result of our role. I have been struck by people asking the question “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 and detached from situations, in order to protect ourselves. Following my time of reflection, I believe I am numb to many things, both good and bad feeling, I am looking at the world from behind a glass wall. Numbness and detachment are defensive walls allowing me to be disengaged from the reality of other people’s situations. Currently I feel like I am a long way off falling off a cliff on my current trajectory but it is anyone’s guess as to how much any person can take.
As a leader/manager, I strive to listen and encourage the frontline staff that have decided to disclose their mental health difficulties. I always find it a bizarre, and an incomprehensible concept that an employer will quite happily pay to have a member of their team off work with stress, increasing the isolation and so becoming more and more distant from their colleagues, rather than keeping them in the fold and allowing them to do alternative duties on a flexible personal plan. Staff should not be pressurised to accomplish tasks but should rather be given support to manage what they can do thus phasing in a return to normal duties. 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 or 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.
Thoughts from Health Psychologist, Esther Murray
“This is an excellent piece, Carl has captured the way numbing out is necessary but it numbs out everything - not just the bad... I think it's hard to be as honest and clear eyed as Carl is so I am really grateful to him for sharing here.
We often talk about psychological wellbeing in terms of end points, as if you were either sick or well and that was that, but it isn't. We all have mental health, just like we all have physical health, and over time and for all kinds of reasons the things that we experience affect us. Just as if you ran a lot of marathons and over years of running you developed sore knees, by the time that happened you would have learned a lot of tricks for soothing sore knees. It's not your fault, or your knees' fault or the marathon's fault that your knees are sore, it's just what happens.
I think our mental health is the same, but we haven't really been taught much about how to look after it. If you're into sports you're probably surrounded by a community of fellow enthusiasts who have lots of tips about how to deal with physical injuries and wear and tear, and there are lots of experts you can learn from on the internet and so on. Our mental health ought to be the same, we ought to be surrounded by people who are open about how to look after it, and to have easy access to advice and support.
Things are changing, that's for sure, and the pandemic will make them change faster. There is already a huge community of people who live with all sorts of mental health problems who know exactly how to manage because they have learned it, just like the marathon runners, and I think we will see more openness about it as time goes on. Sharing our experiences and learning to listen to one another knowing that we don't need to fix anything for each other, only be there, is a fantastic start. When more help is needed, there are professionals for us to talk to. There's nothing shameful or unusual in that, we're only bringing it out into the light just now, that's all. And it's about time."