When Johnny Met Rosie--Women in EMS Part 9: Divas & Dead Babies

"My life before children I don't really remember. I've heard references to it, but I really don't remember." --John Malkovich

There is a medic in our department named Kris who is not so much a woman as a force of nature. Neither time nor experience has done much to develop her filters, but has instead tempered her wit to something akin to concertina wire. She is likened to a volcano in terms of temper, and the lava that is her opinion of your poor performance would sear the strongest of egos. She is an excellent clinician and certainly someone you would want around when you or your loved one need help. She is not, however, someone you want to be around if you cut a corner or engage in poor behavior at work. So how does one deal with this formidable lioness without risking bloodshed or a fast track to therapy?

Ask about her son.

A sincere inquiry about her little piece of immortality will cause the clouds to part and a genuine smile to cross her face. In the space of a few breaths you find that she is beset by the same fears and worries of any other parent: recurrent ear infections, daycare concerns, being depressed if he's asleep before she makes it home from her night shift. In short, she's a mother.

Time may be the great equalizer, but it is children who put the parent back into the paramedic.

Parenthood is like being in a secret society, similar to home ownership. If you put a bunch of home owners in a room, they will always have something to talk about, even if it's just the cost of window treatments. For you single renters, nobody cares about your generic beige carpeting or that you now have to pay utilities. Parents are the same way.

I was the last in my circle to have children. Don't get me wrong. I love children and have cared for other people's children for years. Wasn't the same; they didn't care. Women would hear my inane anecdotes and just exchange glances that said, "Let her pretend; she's harmless." I simply did not speak the language. I didn't comprehend the amount of overhead needed to keep a baby in diapers, or the soul-draining exhaustion that comes with a child with colic. I was an amateur, a poser. I wasn't in the club.

When my time came and I was finally pregnant, of course the requisite horror stories were offered in the form of helpful advice from women recounting their most intimate moments in exquisite and gory detail. And, without fail, they would say two things: "Sleep now, for it's the last you're going to get," and "This will change everything." The latter is what I heard most often from EMS parents.

That's an ambiguous statement. Of course everything is going to change! Duh! I am fully aware that having a baby means my schedule, lifestyle and relationships all around will undergo significant changes. You aren't telling me anything I don't already know. Problem is, they weren't referring to my lifestyle--they were referring to my perspective on the world and my role in it. Both were about to change.

I didn't know. I could not begin to know.

Ten years ago, after almost 40 hours of labor (there, a gratuitous plug at my personal horror story), my son was born. Precisely 20 days, 6 hours and 8 minutes later the first [World Trade Center] tower fell while I watched. As I watched the goliath structure collapse in a surreal cascade of shrieking metal, I said out loud, "Oh my god, they're all dead." I wasn't referring to the civilians. I was thinking instead of all those police, fire and EMS personnel I knew were there and who were now lost. Because I knew, as surely as I draw breath each day, that they went into those buildings when everyone else was running out. I know this because I would have done the same. It's who we are; it's what we do.

In the stunned silence and glare of the TV, as my brain worked feverishly to process what it was seeing, I turned and looked down on my couch at the tiny pink bundle with a shock of blonde hair on his head, clenching his tiny fist at the world and regarding me with that infant gaze that said, "You are all I have. I am your responsibility. Without you I will die." And in that moment, for the first time in my career, I felt my resolve crumble. My thoughts reeled, stumbling around and trying to process this new role. There it was--that change in perspective that would alter how I viewed so many things about my job. That epiphany of purpose that is ultimately only possible once you enter that all-important secret society and learn the code phrase to get in: It's not about me anymore, is it?

I went back to work. The job did not change, nor did the clientele. What did change was my tolerance and reaction to certain situations. I spoke the language now, and when it came to pediatric calls, I was more empathetic in some situations and much harder and less tolerant in others. I took additional safety precautions that I had not given much priority to before. I was more conscious of anything that might prevent me from going home to my son. Even germs were the enemy; the thought of bringing home something attached to my uniform that might hurt the baby came to mind, unbidden, like a stranger had invaded my brain and forced it out of my comfort zone.

Pediatric calls consistently rank among the most highly charged and distressing calls any provider will face. There is no big mystery as to why. Infants and children represent innocence, happiness and all that should be right with the world. In general, what happens to them is unfair or undeserved. They haven't had time enough on this earth to abuse their bodies, ignore the advice of their doctors or engage in any of the sundry activities that riddle the bodies of our typical patients with a host of injuries or comorbidities. They look to us to keep them safe and make them happy; anything else is confusing and often heartbreaking. When you add that to the fact that most providers are uncomfortable with pediatric calls due to lower volume and unique presentations, you have a recipe for emotional disaster.

The International Critical Incident Stress Foundation (ICISF) estimates that more than 90% of critical incident stress debriefings (CISDs) conducted throughout the U.S. and Canada during the last 15 years were for incidents in which children were the primary victims.

It's important to understand just what defines a "critical incident" versus going on a "bad call." Every provider goes on any number of "bad" calls in their career, but that does not mean each one results in a stress reaction. As we progress in our field, each of us develops a number of coping skills to help us process the complex and often negative emotional experiences that we are subjected to each time we go out. What turns it into a "critical incident" is when the event has sufficient emotional impact to overwhelm normal coping abilities. Because each person processes these things differently, it is impossible to categorize just which event will become a critical incident for someone. It is individual and unique to a provider.

When a critical incident arises, it can result in intense feelings of guilt, remorse, anger and grief. These emotions are defined as a stress reaction and represent normal feelings of someone placed in an abnormal situation. They often resolve quickly, with minimal to no additional support; however, they can be very disruptive to a person's life, affecting them emotionally and physically. If they are not managed correctly, they can negatively impact someone personally and professionally, affecting their relationships on all levels.

We can predict types of calls that will place us at risk for a stress reaction, but it does not mean we are guaranteed to have one that we cannot resolve for ourselves. Therefore, it is important to remember that just because you weathered an incident emotionally unscathed does not mean that everyone in the same circumstance will be able to do the same.

My partner, a father and 25-year veteran, recalls one such incident. As a member of the flight team, he was sent to a scene where the cold-water drowning patient was a young child who was successfully resuscitated. During transfer of care, the BLS crew made some obvious errors, and he found himself yelling at them in frustration, even using profanity. This was completely out of character for him, and it caught everyone off-guard. He'd been on plenty of bad pediatric cases by this point and had never lost it like this. What was so different this time?

Well, this incident was just one month after the stillbirth of his first child. When he stepped back and looked at it objectively, he realized that the two events were related in his mind. He later found the crews from that call and apologized.

The death or serious illness/injury of a child can easily result in an overwhelming critical incident. The low frequency of pediatric calls can result in confidence being shaken and abilities questioned. Were there alternatives? What could have been done differently? If the circumstances were dictated by carelessness or deliberate cause, feelings of frustration, sadness or even rage may come up.

If the child is close in age or appearance to your own, it is not unusual to suddenly picture them in place of your patient. Perhaps the patient is wearing a similar article of clothing or shares a physical feature with your child. It is always disturbing to see a child in pain or distress. It is exponentially so if you are superimposing your own child onto that situation. This can result in marked confusion, sudden terror and increased fear that your own children may end up in the same situation. These are high-pressure calls to begin with; compounded with these factors, you may feel painful after-effects long after the call, even if it went as well as could be expected and had a positive outcome. Any combination of these factors can overwhelm a provider's psyche and turn a "bad" call into a critical incident. Let's revisit Kris and see what happened when she came back from her maternity leave.

"My first dead baby after coming back from maternity leave was my second shift back. I was a mess to begin with, having spent the entire hour ride to work crying after having to leave my son at daycare." Like most of us, Kris is not given to bouts of crying…and certainly not in public at work. Straight up Boston Irish, she was already having a difficult time going from tough-as-nails to crying at stoplights. A decade's worth of EMS experience played every possible scenario in her head on a loop reel as she drove in. She's a bit of a black cloud when it comes to dead babies; been that way her entire career. In fact, her last call before going out on leave was a pediatric arrest. But they never traveled with her: "It sucked, but that's it--it just sucked. It didn't profoundly affect me."

Now she was back at work, second day in, and it's a two-year-old in cardiac arrest--one with a long history of underlying medical problems. While the call was uneventful, she found herself very upset afterward, and when she tried to explain her feelings to her husband, he didn't understand. "That kid was sick; our son isn't." What happened is that she just experienced every parent's worst nightmare and now understood on a visceral level what that meant.

In the year following her return, she had five dead babies, the majority in the first few months back. We have a high SIDS incidence in our area, but none of these were from that. One was an outside delivery at 25 weeks that they managed to resuscitate. That one played on all the fears she'd had while she was pregnant. She followed up on them weekly for over six months, until someone pointed out that it was probably not emotionally healthy to keep doing it. "I just needed one to be OK," she said.

The last of the five dead babies for Kris was not so very long ago. It was a four-month-old boy whose mother shot him twice in the chest during a domestic dispute and barricade situation.

Kris's vehicle was staged almost two blocks away when she was suddenly thrown a dead baby with two holes in his chest. She took him to the truck, "doing compressions while he bled his entire blood volume all over my chest." Her starkest memory is of his hand. While intubating him, she looked at his hand just after she passed the tube. "He must have put his hand to his chest just as she shot him, because she shot off a few of his fingers," she said. "They were just hanging off. All I could see was my son's perfect little hand."

When they got to the hospital, she crawled with the stretcher as it was being removed, hanging onto the tube before handing it off as the stretcher was whisked into the trauma center. "I was left on my knees in the back of the truck, and all I could do was hang my head and cry." Now that all of her tasks were done, she didn't know what to do next. As she headed in to try and clean some of the blood off, she recalls wandering in a daze, unsure of what to do next and wanting to get out of there, out of public view.

That call represented a culmination of everything--all the anxiety and fear and pain that comes with the loss of a child incorporated with the parent being the perpetrator. "I got through it, but it will stay with me forever," she said. "My entire being has changed since having my son. I have had people at work tell me having a kid has made me soft. I have always had a big heart; I just kept it hidden and protected. After having a child, that's much harder to do."

The maternal bond is strong and timeless, but let's not forget that it takes two to tango. New fathers are also exposed to this radical shift in perspective and are often subjected to the same emotional upheaval that we naturally expect from mothers. My own husband, father of four, cites it as an advantage. "Having children increases your comfort level on pediatric calls. They are no longer little, fragile alien beings." Learning the basic care and feeding of an alien is tricky work, but it does allow you to build confidence in handling them, which improves your ability to assess them as well.

There is also a whole flavor of guilt to contend with. People in EMS traditionally work more than other professions, out of necessity more often than other reasons. This takes them from their children and makes them unavailable to share the burdens or joys of those fleeting moments and milestones so important to every parent. It does not have to be any one particular call that generates this new stress, but just the act of having to be present when you'd rather be somewhere else.

Beyond having horrific luck, Kris's experiences are an excellent representation of what happens to all career EMS people once they become parents. How we each build up our defenses, carefully erecting emotional fences to compartmentalize what we deal with each and every day until we go to that one that hits so close to home and a little piece of us breaks off. The veneer chips, then cracks and suddenly the full tragedy of every call we've ever been on tumbles in on us in a flood of emotion we have deliberately made ourselves unprepared for. Is there anything we can do besides "suck it up?"

Practice, practice, practice: Any skill that you don't use, you will eventually lose. Critical pediatric calls are low frequency even in high-volume departments. There is little that will make you feel worse on a call than being helpless because you are floundering with protocols, skills or equipment. Practice them by developing muscle memory and knowing things by heart so you are able to turn your mechanical skills on autopilot while your brain sorts through everything else. If you are confident and comfortable in your skill set, that will be one less stressor.

Acknowledge your feelings: I know as well as anyone that big girls don't cry (or at least that's the perception). The reality is that without an outlet, you will do nothing but hurt yourself. Bad things happen on this job. We do not have to take everything in stride. There is horror and tragedy and heartbreak every day that we go to work--it's just not usually ours to deal with. Go off and have a good cry, scream it out somewhere privately, engage in (healthy) behaviors that help you release pressure. It is not a sign of weakness to be affected by a bad call. Failure comes when you know you're affected and do nothing about it.

Ask for help: We do not do this. We should.

Not everyone needs or wants a full or formal debriefing or intervention. When asked, the responses most commonly are essentially to have a sympathetic listener--someone who can see there is a problem, understand where it is coming from and not try to judge or dissect it.

When Kris arrived at the emergency department with the baby who had been shot, one of our coordinators was there waiting. He's not in her normal chain of command, but he heard the call go out and knew the gravity of it. He also knew (like the rest of us) about her run of bad luck with pediatric calls. He did not hound her or make her feel weak or embarrassed. When she felt lost, he led her out of the ED and removed her from the situation, giving her the privacy she desperately needed. I asked her if she felt uncomfortable that he came there for just that purpose. She said it felt more like she was being looked after and welcomed the guidance so she could take a break from thinking and just let him help her. We are so task-oriented that once we are out of tasks, it can be a confusing circumstance that just makes things worse.

In the first few hours after an incident we are more receptive to interventions like peer-defusing. After that, we try to handle it ourselves. It is important for departments to do just like the coordinator did: be present, be aware, be willing to intercede, but do not force. If you try to choke us into a debriefing, we will put up a wall strong enough to keep the barbarians out, even if we wither slowly behind it.

Remember that not every "bad" call is a critical incident, especially once your frame of reference changes. Mine was not dramatic or even close to dead. I once picked up a seven-month-old boy for a mild respiratory complaint. He had a bad cleft palate that split his cheery little face in two. His mother was barely 19 years old, and they lived in a clean, but very spartan apartment. It quickly became obvious that she was doing this all by herself. The baby was fine, and on the way to the hospital, he suddenly laughed. With his cleft palate, that laugh sounded like a goose honking, and it startled all of us. I looked down at his smiling, disfigured face and saw my son. My beautiful little boy, with his normal laugh and perfect smile, and thought, "There, but for the grace of God and a few chromosomes…"

At the hospital, they secured his carrier to a hospital bed. When all the preliminaries were done, this mother, who was still mostly a child, thanked us for helping her. Then, without any drama, she quietly climbed onto the hospital bed, curled herself around the base of the carrier holding her son and immediately fell into an exhausted sleep. Now that he was safely being cared for, she could rest, even if only for a little while.

I went out to my truck, climbed in the back and cried.

Tracey A. Loscar, NREMT-P, is the training supervisor in charge of QA at University Hospital EMS in Newark, NJ. 

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