The Psychology of the Shirt

      As our EMS careers progress, we become accustomed to being exposed to images and situations in our everyday working lives that devastate those involved and can deeply affect witnesses and caregivers alike. Through this process of gradual and continuous exposure, we often become inured to such situations and incidents, taking the trauma for granted and letting it wash over us like water off a duck's back. Sometimes we're accused of being impersonal, distant and not invested enough, but such mechanisms serve to shield us and keep us functional.

   It is when we personally identify with a patient that we risk losing the cushion of distance that helps protect our psyches and allows us to perform in high-stress situations. For some providers, calls involving children are especially challenging, for others it might be when responding to victims of a particular crime. However, there is one situation that leaves providers vulnerable to their emotions--responding to line-of-duty incidents. When the patient is one of your own, everything seems to change. Seasoned veterans can lose their focus, while brand-new providers might find emotional reserves they didn't know they had. But why are such calls particularly challenging?

   It has to do with identity. Our badges, patches and uniforms define who we are. They tell the outside world that we will be calling the shots during the next 30 minutes. Our uniforms also represent our fraternity, that we are all brothers and sisters in EMS. Call for help and the cavalry will come. This undercurrent of strength bolsters us and helps us do the jobs that we do, with one exception: caring for each other. So it is no wonder that LOD incidents send us reeling when "one of our own" is ripped out of the line and thrown to the mercy of fate. I know this from personal experience.

   About five years ago, there was an explosion where I work. I remember distinctly hearing a loud boom that sounded relatively close to the building I was in. I shook my head, even saying aloud to the empty room, "They'd better not be screwing around out there," when I heard shouting and someone screaming for "ALS."

   I jumped up to look out of the window, and from behind a rescue truck one of my coworkers staggered into sight. He was being supported by one of the rescue guys as he held up the mangled remains of his right hand. By the time I ran outside, the others were bundling him into the back of one of the ambulances. I clambered in behind them and took stock of what was going on. They had wrapped what was left of his hand in a bulky dressing and were putting him on oxygen, but here's the funny thing--he was sitting on the bench seat. Of course he was, that's where we sit, isn't it? Stretchers are for patients, not EMS providers. It felt like time was stretching out like a strained rubber band; like the situation was getting more frantic, yet nothing was getting done. At that point, the patient became ghost-white and said, "I'm going to pass out."

   With his injury covered it was hard to process what was going on. I ended up saying, "Come on now! We can do this, it's what we do." As a unit, the four of us grabbed him and lifted him onto the stretcher. As we started to realize we were dealing with a blast injury, it became clear what our next steps should be. At that point, I noticed his shirt, really noticed it. He was wearing a summer uniform shirt and looked just like the rest of us. We were trying to check his chest and back without removing the shirt. I grabbed his shirt, looked at the EMT next to me and said, "We have to cut it." Doesn't sound like such a big deal, does it? That's what we do with trauma patients; we cut off their clothes. But in our eyes, he wasn't a patient, he was one of us. We started to cut off his shirt and the rubber band snapped, just like that. Time returned to normal, we started to talk above him and around him, and things got done to the best of our ability. In fact, the surgeons reported that our initial actions contributed to their ability to save and rebuild as much of his hand as they could.

   There is no layer of invulnerability sewn into our uniform shirts, no matter how much we'd like to think otherwise. The reality is that at some point in our careers, we can find ourselves in a situation where a coworker, if not ourself, is on that stretcher. It's hard to predict how someone will respond in a LOD incident. Here's what I tell my students:

• Rely on your training and experience to guide you through those few minutes.
• Know your protocols for LOD incidents--whom do you contact and what's the next step?
• After such an event, do not turn down offers for help. Allow a CISD team to have some access; you cannot predict what your personal aftermath will be.

   Our bravado in EMS is legendary; we may need someone who insists on looking out for us, even for a short time. It may not be pleasant to consider, but you should have an idea about what you would do if the person on the stretcher is dressed just like you.

   This guest editorial is dedicated to Mark Davis, EMT, who was fatally shot by a patient in Cape Vincent, NY, in January.

   Tracey A. Loscar, MICP, is a training supervisor at University Hospital EMS in Newark, NJ. A practicing paramedic for 19 years (and counting), she is very active in multiple facets of prehospital education. At any given time she can be found in ambulances or classrooms throughout northern New Jersey, or you can reach her via e-mail at taloscar@gmail.com.