Turtle Treks by a Mindful Medic

I am a 40-year first responder and spent the past 20 years as a paramedic/firefighter with my state’s largest fire department. I have a post-traumatic stress injury (PTSI) related to my job. I succumbed to my demons. There, I said it. In my profession, it is not always wise to admit such things. In fact, I have learned much about stigma, isolation, nightmares, flashbacks, depression, abandonment, and yes … suicide. There, I said that, too. Again, it’s not something we talk about. I have faced some of the deepest pain I could ever imagine.

I survive every day with my diagnosis, continuing my upward battle against the demons. I am living. I am choosing to win by sharing my story, using my experience and research to develop awareness, prevention, and survival outreach programs to begin breaking the silence.

DEFINING PTSI

The Science: What we do know? Post-traumatic stress disorder (PTSD) or PTSI has been most likely around since the beginning of our human consciousness. Looking at the effects of trauma on the brain, we can track throughout history the effects of trauma on the human brain and our most basic survival instincts.

PTSI is a real injury with painful and disabling effects. It is estimated the cost is more than $44 billion annually with $23 billion for direct medical costs. Anyone experiencing this injury, risking this serious injury, or contemplating suicide is emotionally drained and at extreme levels of stress.

Not surprisingly, it is difficult to find accurate data on PTSI and suicide for first responders because of the lack of reporting. There is no clearinghouse or uniform reporting for post-traumatic stress and suicide. Most first responders are reluctant to discuss or report any kind of the symptoms or self-destructive behaviors. Many have simply slipped away, unnoticed in many ways. Studies have shown a wide range of responders who might be experiencing post-traumatic stress, with seven to 37 percent of firefighters meeting the criteria for PTSI.

First responders have more than double the annual fatality rate of the general population. Fire/EMS had 58 documented suicides by the end of September 2014. In Canada, 27 to 28 percent had given thought to suicide by the end of October 2014. In “Post-Traumatic Stress Disorder,” Javidi and Yadollahie cite rates for fire/EMS and police between six and 32 percent with an overall four-percent rate for the general population.1 Most of this is because of our operating environment of weather, violence, and hazardous scenes. Trends can already be seen, and the need for more uniform reporting and research is essential as we move forward in helping with suicide prevention and assisting those surviving with PTSI.

PTSI is described by the medical community as an anxiety-type disorder occurring after a traumatic event. It was first listed in the third revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. DSM-III considered it a disease whose victims strive to prevent thoughts, feelings, situations, and activities that remind them of their painful event(s). Diagnostic criteria for PTSD from the current DSM-5 include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms, the seventh assesses functioning, and the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition. PTSI is a triggering type event that causes a variety of reactions. For fire/EMS, this can be a number of things including violent/hostage scenes, motor vehicle accidents, or any of the calls to which we must respond.

THE BRAIN

More and more studies have shown the physical changes that take place in the brain as a result of trauma. Imaging studies have actually shown physical changes in the brain because of PTSI. During trauma, the amygdala, a little almond size mass deep in the brain that is responsible for emotions and survival instincts, kicks into motion. When threatened, your fear-based arousal and autonomic responses increase. Stress hormones are released, engaging your emotional response. At this time, the brain selects the memories to store and their placement around the cortex. We start to apply feeling, tone, and emotional charge to memory. Flashbulb memory can occur when strong emotional content remains connected to an instinctive fear or threat-based situation.

The amygdala will focus on the dominant experiences. Trauma-induced fear deeply imprints on the amygdala and hypersensitizes it to danger, seeking out threats everywhere. In some PTSI, the amygdala, through imaging, has been shown to increase in size. This may decrease over time in healing.

The hippocampus, located to the side of the amygdala, is responsible for the formation, organization, storage, and retrieval of memories. After conversion from short-term to long-term, it sends them out for storage. Trauma seizes this development. The hippocampus is unable to convert the short-term memory, and it remains active in the short-term memory. Stopping the integration of these memories allows the continued effects of the short-term state. Inversely, the hippocampus has shown to shrink in cases of PTSI and with reversal in healing.

The prefrontal cortex, located in the outmost front part of the brain, has elements for recall. The left frontal lobe handles the individual event memory storage, and the right frontal lobe controls extracting a theme or main point from a series of events.

What happens after trauma? Emotion and instinct win over the inhibitory strength of the cortex. This prevents the control of inappropriate reactions and refocusing of attention. The left prefrontal lobe may have decreased blood flow, causing less ability for language, memory, and other lobe functions. The right side blood flow may actually increase, causing more sadness, sorrow, and anger.

Prolonged, repetitive, or extreme trauma causes the amygdala to stay in a hyperstate, thereby causing the neuron pathways in the amygdala to lose their ability to recover. The body remains in a constant state of fight, flight, freeze, or fawn. The amygdala loses the ability to recover and put things in balance, interrupting the normal flow of memories. The hippocampus is negated by the hyperstate of the amygdala and long-term memory cannot be anchored. The short-term memory will remain and may cause confusion or fear about the safety of a current situation. The brain keeps getting retriggered to the hyper-alert state and may cause flashbacks, strange memories, or other emotional signs.

SIGNS AND SYMPTOMS

Post-traumatic stress symptoms and signs are individualistic; however, there are commonalities. PTSD symptoms are generally grouped into four types: intrusive memories, avoidance, negative changes in thinking and mood, and changes in emotional reactions.

Intrusive memories: Symptoms of intrusive memories may include the following:

  • Recurrent, unwanted, distressing memories of the traumatic event.
  • Reliving the traumatic event as if it were happening again (flashbacks).
  • Upsetting dreams about the traumatic event.
  • Severe emotional distress or physical reactions to something that reminds you of the event.

Avoidance: Symptoms of avoidance may include the following:

  • Trying to avoid thinking or talking about the traumatic event.
  • Avoiding places, activities, or people who remind you of the traumatic event.

Negative changes in thinking and mood: Symptoms of negative changes in thinking and mood may include the following:

  • Negative feelings about yourself or other people.
  • Inability to experience positive emotions.
  • Feeling emotionally numb.
  • Lack of interest in activities you once enjoyed.
  • Hopelessness about the future.
  • Memory problems, including not remembering important aspects of the traumatic event.
  • Difficulty maintaining close relationships.

Changes in emotional reactions: Symptoms of changes in emotional reactions (also called arousal symptoms) may include the following:

  • Irritability, angry outbursts, or aggressive behavior.
  • Always being on guard for danger.
  • Overwhelming guilt or shame.
  • Self-destructive behavior, such as drinking too much or driving too fast.
  • Trouble concentrating.
  • Trouble sleeping.
  • Being easily startled or frightened.2

The symptoms may ebb and flow and can be triggered by reminders of the stressful event.

REMOVE THE STIGMA

This injury is an emotional concussion. It is a traumatic brain injury. Just like any physical concussion, these injuries have long lasting effects. While treatment may differ, the validation that the injuries are real and focused support may decrease the injury, assisting in the healing process. Reducing the stigma through education and awareness would increase the validation for the PTS survivor.

When a person has a stroke, we are concerned with the secondary injury caused by the stroke. The same may be held true with PTS. After the initial injury, if there is not sufficient time to heal, the secondary injury will worsen. This same process appears in the treatment of sports-related concussions. No longer do we see the attitude of “get back in the game.” It is taken seriously when an athlete expresses symptoms of a concussion. This should be the case with PTS as well. It is an injury.

PTS awareness and prevention are severely lacking. Look at what a proper fire prevention program has done to reduce the number of fire fatalities. Awareness, prevention, and support programs could begin to earnestly reduce the stigma.

MY JOURNEY

I am a 40-year first responder. Starting at about age 12, I joined my Dad on calls. I was born to be a paramedic-simple as that. My whole life, my passion, other than family, was being a paramedic, firefighter, nurse, and caregiver. I have been very fortunate to have contributed to my profession at the local, regional, state, and national levels. The passion for the “street” was always primary. I loved creating order from chaos, putting others first, and doing the job to the best of my abilities. Unfortunately for me, the “street” part of my practice is over. It is now medically contraindicated for me to be a paramedic/firefighter at that level because of my PTSI and other physical limitations.

Around February/March 2012, I was on duty with two new guys straight from the academy. Both were very good providers at their levels but were still new to the system. We were dispatched to a pediatric cardiac arrest call, and I was the in the driver’s position. As I was the highest license level, it would be up to me to make order out of the anticipated chaos. I remember at that time having a feeling of total hopelessness as I was working with two new providers, going on their first calls, let alone a pediatric cardiac arrest! What was I to do with these guys? I needed to concentrate on the patient.

On arrival we found a three-year-old girl lying on the floor, with her mother doing cardiopulmonary resuscitation (CPR). We took over, with me at the airway and directing the others to start CPR and get airway equipment. I do remember the haunting feeling as I looked into her eyes that I had been hit in the head with something. The ringing in my ears had increased to where I almost could not hear my coworkers. Luckily, my engine company assist arrived, and we were able to transport the patient, who ultimately succumbed. We had a critical incident stress management session after this incident. This is the first place I think I ever admitted in public that I was questioning my passion and ability to do this job.

After that, I seemed to be angrier at work and at home. I was unhappy with the way life was going and very emotional. I had been on several “difficult” calls and had several personal losses throughout the past few years.

My first “officially reported” injury occurred on August 29, 2012, while at work. Because of a lack of focus, emotions, and after responding to the wrong address, I asked my lieutenant and deputy chief for help. Looking back, there were many events that led up to this point. On this day, the file cabinet overflowed and forever opened. I had been feeling for months that I was out of balance ever since I had responded to that pediatric cardiac arrest call.

I felt like I had been hit in the head after missing the address. I first remember the ringing in my ears and feeling dizzy and off balance with low back and abdominal pain. The next several months, I attempted to heal. Seeing my primary care physician and therapist, however, the pressure to get back to work was dominant so I went back March 1, 2013. I lasted until April, 18, 2013, when I finally realized the symptoms were too much. I had to admit I couldn’t do the job as I was. I had to finally face my demons.

MY STRUGGLES

My symptoms have been, and remain, ringing in the ears, feeling of being under water or in a tube (especially on awakening), dizziness, and difficulties with proprioception/balance. I have flashbacks almost every night of certain calls I have responded to. Many nights are fitful with three to four hours of sleep. There are certain areas where I don’t drive to avoid the memory of being there on a call. Activities are certainly limited. I have tremendous guilt about losing the profession I loved.

The first four months during my first injury I barely got out of bed most days. I was divorced, living by myself, in a newly bought house located in a farm and wooded area. I was lucky enough to have space, but soon the isolation and abandonment pain took over. The world began to spin out of control. I was grasping at anything to try and anchor myself. Calls I had not thought about for years started coming to the surface. Nights were the worst-and still can be-waking up drenched in sweat, never rested, and never remembering my dreams. You begin your journey down the “dark, dark hole” of depression, abandonment, and isolation. There is no longer any validation that your life is worth anything. You are grasping at anything to hold onto, yet no one seems to understand. You feel so ALONE. You are alone in the deepest, darkest, soul-stripping pain that turns your whole being into a world filled with self-doubt, guilt, and depression. You have peeled the onion down to nothing.

You are one click away from ending the pain. It will be okay. No one understands me, so what’s to miss? You’ve got it all set up. What, when, and how are all worked out. The demons have taken over. They will take care of my pain. All will be so much better.

It is at this point, hopefully, before you do act, you remember … you have a choice. To be sure that choice is one of the most difficult you will ever make in your life. It will always be your choice.

From my presence, you can see the choice I made. When I finally realized I had a choice to end my pain or cause more untold pain in others and that this would be a permanent solution to a temporary situation, I decided then and there that surviving with PTSI was far better than the alternative. I began to create better choices by creating a healing environment for myself and someday others.

The support system I was accustomed to did not have the resources or awareness of the far-reaching aspects of this injury and therefore had been largely nonexistent. The two departments I worked for have been silent in any communication or support. I contacted national organizations asking for assistance, yet there were no return responses.

HEALING FROM PTSI

So how does one go about healing from PTSI? Alone at first … on the road to self-discovery, cultivating a positive growth path. I needed to focus on mind, body, and spirit balance. As there were virtually no outside resources or support for me, I created my own using the three cornerstones of mindfulness, intentionality, and emotional connection. I have created my own healing process and setting using these cornerstones with equine, gardening, and woodworking therapy, physical exercise, and organic diet aided by growing my own food.

My first symptoms all had to do with balance, hypersensitivity, and other PTS symptoms. My body, mind, and spirit felt uneasy and unsteady. I found my path to healing via mindfulness, intentionality, and emotional connection. I was lucky enough, after my initial injury, to begin sessions with Terry Fralich, a counselor and author of Cultivating Lasting Happiness: A 7-Step Guide to Mindfulness. He has studied with the Dalai Lama and is an expert in mindfulness practice. I also was able to complete the certified compassion fatigue program through the International Association of Trauma Professionals conducted by Dr. J. Eric Gentry. My third cornerstone of the healing process has been emotional connection and using Raphael Cushnir’s work to become more emotionally connected. Cushnir believes that all emotions, especially those we routinely avoid, dismiss, or resist, need to be accessed and understood to reach full potential.

Mindfulness

Mindfulness is a form of self-awareness training adapted from Buddhist mindfulness meditation. Adaption for use in treatment of depression, especially preventing relapse and for assisting with mood regulation, has been useful. Described as a state of being in the present and accepting things for what they are (i.e., nonjudgmentally), it was originally developed to assist with mood regulation and relapse prevention in depression and has been found to have considerable health benefits. Mindfulness is awareness of what is happening in the present on a moment by moment basis, while not making judgments about whether we like or don’t like what we find.

We all have the capacity to be mindful. By cultivating our ability to pay attention in the present moment and allowing ourselves to disengage from mental “clutter” and have a clear mind, we may be able to respond rather than react to situations, thus improving our decision making and potential for physical and mental relaxation.3

Fralich’s book makes the distinction of being on automatic pilot vs. a more aware state of consciousness and emphasizes that there are many definitions of mindfulness but “that by consciously practicing mindfulness techniques, we gradually become more able to respond to situations with choice, rather than just repeating old patterns and habits.”4

One major aspect of my sessions with Fralich was answering the question” “What am I practicing?” meaning, what do I truly want my growth path to be? By using mindfulness techniques, I found I could make choices. I could either stay mired down or start to cultivate a positive growth path by accentuating the positive moments and transforming the negative to positive experiences by being in the moment.

INTENTIONALITY

Intentionality is basically the capacity to go where you set yourself to go. If we are want to be happy, we have to intend to be happy. The science behind this is that one intentionally uses the prefrontal cortex to control the emotional amygdala. This builds on mindfulness by recognition and acceptance of emotions and their causes. It involves the intent or decision to address and correlate the emotion to what is happening in the moment. The prefrontal cortex then can gain control over the emotions and get them through the hippocampus.

One of the biggest barriers for first responders is overlooking symptoms until they have reached physical and emotional exhaustion. Part of any healing process requires the intent to acknowledge and address the symptoms rather than to avoid the situation.

Once intentionality is activated, the healing process then moves onto connection.

EMOTIONAL CONNECTION

Emotional connection can be both external and internal. Externally, we seek support from our peers. In our business, the symptom of progressive loss, stigma, and ultimately isolation/abandonment leads to further injury. Staying connected to a peer support group would give us the anchoring that our profession needs, providing a healthy support system to reduce the images and emotions associated with secondary traumatic stress that we are exposed to on a daily basis.

Internally, the connection is with our self’s ability to connect with our emotions, particularly those emotions we tend to avoid, attempt to dismiss, or resist.5 This is largely based on Raphael Cushnir’s book, The One Thing Holding You Back: Unleashing the Power of Emotional Connection. While the concepts and teachings are plentiful in the book, the major core discussions hold that emotions are never entirely right or wrong, good or bad, reliable or fallible.

At its beginning, an emotion is a raw, processed feedback. After that, it is our choice on how to respond. Cushnir uses a 2 à— 2 process, where what to do is explained in the first two steps and how to do it in the second two steps.

Step 1: Identify the emotion and place focused attention on to the bodily sensation it produces.

Step 2: Keep your energy focused on the sensation until it either passes or changes.

Step 3: Slow down! As we have grown into an instant gratification culture, the average human attention span has shortened. With sensations, both physical and emotional, there is an expectation that all will be fixed quickly. Instead, sometimes emotions do not expose themselves fully right away. When things are not resolved quickly, we are apt to lose interest, give up, and get down on ourselves.

Step 4: Get microscopic! After slowing down, we can see that initially our internal sensations may seem far off and nebulous as focus is concentrated on a “microview” of exactly how the emotion or sensation is making you feel.

Cushnir writes, “Slowing down and getting microscopic is what allows Steps 1 and 2 to create the emotional connection. Steps 3 and 4, in turn, target the exact location necessary for the slow microattention to achieve maximum results.” “If a physical sensation doesn’t seem emotional after a slow micro-investigation, then it almost always isn’t.”(5)

In some cases, we may need to put some of these on the back burner if we get stuck in the process and cannot slow down enough to get a microview. One of the biggest obstacles to emotional connection is our primitive brain; it cannot distinguish internal or external dangers. The body would respond the same to a gunshot as a painful emotion. The flight-flight-freeze-fawn reaction will be the same to genuine threats as to perceived threats. The protective and instinctive part of the brain wants undesired emotions gone. Understanding the different parts of the system, a difficult emotion may cause the feedback system to want us to feel while another part wants to suppress it assists in the emotional connection. From this, we can see how the symptoms of PTSI can be exacerbated because as first responders we were always taught to “just move on.”

TAKING ACTION

Recently, I read Dan Millman’s book Way of the Peaceful Warrior: A Book That Changes Lives. It is a book based on Millman’s life as a world champion gymnast whose journey takes him to a warrior named Socrates. He is mentored by Socrates into life and the Way of the peaceful warrior. Many messages may be taken from the book but the overall theme is based in mindfulness. There are some core ideas that I found useful in my journey. It gave a perspective that put things together for me.

“A Warrior acts, only fools react.”6 There are many different populations and circumstances and the one thing in our reality we have control over is our response. By mastering your response, you are making the choice and not allowing others to decide for you. Be aware of and rise over your emotions; respond by acting on your choice, not reacting to impulse.

“There is never nothing going on.”(6) There are no ordinary moments in life. The choice is yours to recognize and make them exceptional. The choice is to make the best of it or let it go.

“Take out the Trash.”(6) Our lives are full of clutter. We worry about everything. Living in the moment requires us to clear our minds from everything we don’t need. Past and future thoughts can cause the mind clutter. Focus on the current moment; it’s the only one you’ll have.

“You will never be better, neither be any less.”(6) We are all the same. The differences we may practice in lives we lead, but how we act gives us no better standing compared to others. We all stand on our own mountain. Respect and compassion for all things is the way of the warrior and shows more about a person than anything else.

“Service is the highest Purpose.”(6) As first responders, we know this all too well. Service to others is the highest purpose in life. It means unselfish kindness and not expecting anything in return. It gives meaning to life. We all have a purpose in life. Using that in the service of others will keep our perspective for service to something greater than ourselves.

In times of emotional crisis, I have been able to use the following from Millman’s book:

Where are you? Here.

What time is it? Now.

What are you? This moment. (6)

FLOWING ON THE RIVER OF LIFE

So where to go from here? One could ask, as the onion is peeled down to the last layer, what is left? Most might say nothing, as I did. With choice, you may look at it as having the whole universe in front of you now-no more barriers. My only desire is to live in peace and happiness. I identify with the turtle because of its slow, steady nature and its symbolism for peace. It symbolizes walking our path in peace and sticking to it with determination and serenity. My vision is that of the turtle flowing down the river. There are some eddies and obstacles along the way, and every river has two banks; but I look at the world in a mindful, nonjudgmental, loving manner. Letting the universe happen with the choice of a positive path has given me insight as to how to use my purpose.

Once I realized I had the choice of how to practice and cultivate a positive growth path, I began to create my place of healing at my property. The journey has had daily ups and downs, as this injury affects all aspects of your life. You begin to adapt to what you can and cannot do. Some things take at least twice as long to accomplish as before. Both physical and emotional adaptations are needed throughout the day.

Luckily, the universe had me at a place where I could build on what I thought would assist me in getting the healing process moving forward. My ability to apply my craft as I knew it was gone. I needed a purpose. I needed to create an oasis for acknowledging, healing from, and preventing PTSI in other first responders.

PTS THERAPY

I had never owned many pets or had anything to do with farm and livestock. I had read some articles about equine therapy, and the opportunity to rescue two horses became available. I had the resources of materials and volunteer support, and we built a run-in shed in one day. The horses arrived the next week. My equine therapy began. I have found working with these animals brings a sense of calm and peace like no other.

Since that time, I have added gardening, small farming, and woodworking to my therapy approaches. We now have the two horses, four cats, three dogs, a red-footed tortoise, and two guinea pigs. I established my own support system. I began reading, researching, writing about, and experiencing PTS. Working around my farm has given me the ability to begin the healing and PTS survival process.

My vision for my future is simple: to live in peace and happiness and cultivate a positive growth path by bringing my journey to light. I want to take the lessons I learned over the past three years and end the silence regarding PTS.

Who is the face of PTS? It is mine and all of ours. It has been said in times of crisis to run to the helpers. Who will help the helpers though when they need help? That answer, I have found, cannot rest with reliance on outside organizations to champion our needs. It will be up to us to begin a grassroots effort to assist ourselves in surviving this injury.

I offer my experiences to assist those surviving from PTSI. Outreach assistance is available and other programs are in development. Remember: Safety first and stay cool … and there is always a choice.

REFERENCES

1. Javidi, H., and M. Yadollahie, “Post-Traumatic Stress Disorder,” The International Journal of Occupational and Environmental Medicine, January 2012, Volume 3:2-9.

2. Mayo Clinic Staff. Post-Traumatic Stress Disorder: Diseases and Conditions. www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/basics/symptoms/con-20022540.

3. Black Dog Institute. “Mindfulness in Everyday Life,” (January 2007, http://www.blackdoginstitute.org.au/docs/10.MindfulnessinEverydayLife.pdf.

4. Fralich, Terry, Cultivating Lasting Happiness: A 7-Step Guide to Mindfulness, Eau Claire, WI: Premier Publishing, 2012.

5. Cushnir, Raphael, The One Thing Holding You Back: Unleashing the Power of Emotional Connection. New York, NY: HarperCollins Publishers, 2008.

6. Millman, Dan, Way of the Peaceful Warrior: A Book that Changes Lives. Tiburon, CA: H.J. Kramer, Inc., 1984.

RESOURCES

Gentry, J., Certified Compassion Fatigue Professional Manual. International Association of Trauma Professionals, 2012.

Howard, Sethanne, and Mark Crandall, “Post-Traumatic Stress Disorder: What Happens in the Brain,” Washington Academy of Sciences, Fall 2007, http://www.washacadsci.org/Journal/Journalarticles/V.93-3-Post%20Traumatic%20Stress%20Disorder.%20Sethanne%20Howard%20and%20Mark%20Crandalll.pdf.

Nutt, DJ, and AL Malizia, “Structural and Functional Brain Changes in Posttraumatic Stress Disorder,” Journal of Clinical Psychiatry, 2004: 65 [suppl 1]: 11-17.

PTSD Statistics, http://www.ptsdunited.org/ptsd-statistics-2/, 2013.

PTSD Statistics: If you have PTSD you should know immediately: YOU ARE NOT ALONE. http://healmyptsd.com/education/post-traumatic-stress-disorder-statistics.

Sar, Vedat, “Developmental Trauma, Complex PTSD, and the Current Proposal of DSM-5,” European Journal of Pyschotraumatology, 2011, 2: 5662.

Tull, Matthew, “Rates of PTSD in Firefighters,” 2015, http://ptsd.about.com/od/prevalence/a/Firefighters.htm.

Wilmoth, Janet, “Trouble in Mind,” NFPA Journal, May 2014, http://www.nfpa.org/newsandpublications/nfpa-journal/2014/may-june-2014/features/special-report-firefighter-behavioral-health.

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