Post-Traumatic Stress Disorder and the Firefighter

Post-Traumatic Stress Disorder and the Firefighter

HEALTH

Dost-Traumatic Stress Disorder (PTSD) was only recently (1980) recognized by the medical profession as a bona fide diagnosis. This was acknowledged when large numbers of Viet Nam combat veterans began to display common symptoms indicative of the disorder. Veterans from previous wars who displayed these symptoms were treated only for shell shock or traumatic war neurosis.

One of the criteria for diagnosing PTSD is the presence of stressors that would evoke symptoms of distress in almost anyone. It is understandable, therefore, that Viet Nam veterans would suffer from this disorder because of extremely stressful combat conditions.

PTSD AND THE FIRE SERVICE Stress factor

This kind of “combat” stress, that could conceivably lead to PTSD, is common in the daily working lives of fire service members. Training reduces much of the physical and psychological stress associated with firefighting. Smokehouses and training towers, for instance, can alter the firefighter’s expectations and actions in extreme situations by giving him an increased familiarity with darkened, enclosed, smoke-filled areas; or with ladders and heights.

Studying the burn and draft characteristics of certain occupancies and materials also helps to replace stress with confidence. In addition, exercises involving the repetition known only to the firefighter also prepares him to function well in circumstances that would elicit panic from the average person.

Despite all this training and experience, the firefighter is likely to encounter some emergency incident for which nothing can prepare him psychologically. Reading about collapses, studying the physics and chemistry of backdrafts, talking to men who have lost co-workers, is not the same as the experience. And the experience can be a life-changing ordeal.

Reliving the trauma

In addition to the presence of stressors, another criteria for determining if an individual is suffering from PTSD is if he relives the trauma. This can take any of three forms:

• Repeated and intrusive memories of the event. A firefighter in a busy truck company remembers a close call that happened six years ago:

“Sometimes I’ll be sitting on house watch at two in the morning—just looking at an old movie or something—or we’ll be out on hydrant inspection; and, for no reason at all, I’ll think of that damned beer distributor.

“I don’t know why. I just suddenly remember the roof feeling spongy. I was at the corner of the parapet and I dove over the side as the place went down. I must think about it once a month. For six years now, I keep thinking ‘Suppose it was a six-story apartment house instead of a one-story beer distributor?'”

• Recurrent dreams of the event. More than recollections and intrusive memories, dreams are often a terrifying replay of a traumatic experience. Sometimes they are exaggerated in their focus on one detail in a pattern of events, or they contain a distortion of time or other circumstances surrounding the trauma. An engineman recounts his dreams of going through a hole in the third floor of a vacant building four years ago:

“I’ll be going into the room with the knob. I can remember thinking ‘We got it now’ because the main body of fire was in a hall just beyond this room. Then the bottom went out and I wound up straddling a beam on the second floor. They say they got me out in less than five minutes, but in the dream I just hang there calling for help.

“There’s a lot of fire below the beam, which there wasn’t in the actual fire—the only fire was on the third floor—and I’m, like, on a spit. Nobody comes to get me. Nobody comes to extinguish the fire. There’s nobody there but me, and I’m scared. I wake up soaked with sweat.”

• Suddenly acting or feeling as if the trauma was happening again because of something “triggering” the traumatic memory.

An engine officer, first-due at a major plane crash over five years ago, says he’s glad the crash didn’t occur on a sunny day because every time the weather approximates what it was the day of the crash, he reacts as if he were once again pulling up to a smoky landscape dotted with wreckage and parts of bodies:

“A gray drizzly day still gives me the creeps. I get nauseous all over again. Pouring rain, thunder, and lightning, that’s okay. It’s just that constant gray drizzle that sets me off. It can depress me for days.”

The triggering mechanism can be the time of the year, a certain intersection or box number, or any other thing that has become associated with the event in the mind of the person who lived through it.

These three types of reliving a traumatic event are known as flashbacks. The person experiencing flashbacks is most often frightened by them and thinks they are the result of some personal inadequacy. (“This stuff shouldn’t bother me—it’s part of the job.”) The person often tries to deny that they are happening at all.

Sometimes that denial is not simply a psychological defense mechanism, but is for good practical reasons: “If I told anybody in this department that I get ‘bad dreams,’ I’d be finished. No promotion. Maybe an early retirement. With three kids, I keep my dreams to myself and keep drawing my salary.”

Very few departments provide a supportive atmosphere that would address these concerns. However, if the problem is not tackled, it will not go away by itself.

Emotional withdrawal

Frequently, the person suffering with PTSD will start to display another telltale sign for diagnosis. It is best described as “emotional numbness.” The following symptoms can occur sometime after the trauma:

• Withdrawal from the external world;
• A diminished interest in one or more significant activities;
• A feeling of detachment or estrangement from others;
• An apparent narrowing of emotional range. (“I don’t laugh.I don’t cry. I just don’t care about anything.”)

By themselves, these signs of isolation can indicate many diagnostic possibilities. But, combined with the other criteria of a recognizable stressor and reliving the trauma, these symptoms hint at the presence of PTSD.

Additional symptoms

For additional confirmation that a person is suffering from the disorder, look for at least two of the following signs that were not present before the trauma:

• Hyperalertness or exaggerated startle response. “When the bells go off, I’m bolt upright in bed. It used to take until the second round before I would get going.”
• Difficulty sleeping.
• Guilt. This can occur if one has survived an incident in which others have perished; or if one saves his own life at the expense of one of his co-workers. “The room lit up and I actually knocked the lieutenant down getting out of there. I stepped on him.”
• Impaired memory or difficulty concentrating. “I find myself easily distracted now. I couldn’t study for the captain’s test the last time around because I couldn’t look at a book for more than five minutes.”
• Avoiding activities that stimulate recall of the traumatic event. “Since Chuck died, I’ve never taken the ‘roof man’ position again. The other guys know about it. I don’t feel right, but I just can’t do it.”
• Intensification of symptoms by exposure to events that are similar to the traumatic event. “Whenever we go to a mobile home fire, I remember those kids and my legs turn to jelly. I can’t do anything. I’m useless on the fireground.”

These are all examples of the kinds of PTSD that could affect you or your fellow firefighters now or sometime in the future. PTSD is categorized as “acute” if the onset of related problems occurs within six months after the trauma and lasts less than six months. When symptoms persist more than six months, the PTSD is called “chronic.” When the onset occurs six or more months after the trauma, PTSD is known as “delayed.”

DEALING WITH PTSD PATIENTS

PTSD is usually accompanied by decreased self-esteem. A firefighter can feel worthless because of something he did (knockingdown a lieutenant to escape a burning building) or because of something he failed to do (being unable to function at a fire scene). But he must realize that, under the conditions, his actions can be considered as normal human behavior.

The person experiencing flashbacks is most often frightened by them and thinks they are the result of some personal inadequacy. The person often tries to deny that they are happening at all.

Nevertheless, many of the initial symptoms of PTSD are related to this poor self-image and can be mistakenly attributed to other causes. Fatigue, drinking, or drug use are the most frequent explanations offered for the withdrawal and social estrangement associated with PTSD. Unless you are aware that a fellow firefighter could be suffering from this disorder, it is understandable that drug or alcohol abuse would be suspected because the symptoms are similar.

Officers should be alert for firefighters who display “atonement heroics.” These individuals feel that they have failed in some way and must overcompensate in order to redeem themselves. They will often take unnecessary risks that cause injuries. This action is sometimes a form of self-punishment for what the individual perceives as a poor performance.

Medical treatment

There are various treatments for PTSD. The patient can be hospitalized and given medication to ease his anxieties. Another method is for the patient to attend meetings with people also suffering from the disorder. These can be informal “rap” sessions or therapeutic groups led by a clinician. In some cases of delayed stress, hypnosis is effective in helping the victim recall the cause of his trauma and deal with his pain.

Supportive atmosphere

In addition to hospitalization and medication, fire departments should make an investment in the continued mental health and overall performance efficiency of all their members by creating an accepting climate for PTSD. Firefighters would undoubtedly function much more effectively if they and their departments were prepared not only to accept the occurrence of PTSD, but to expect it.

Just as departments have an obligation to train the firefighters intheir operational skills, they also have a duty to prepare their members for the emotional rigors of their profession.

One irony of PTSD victims is that their dedication is often the very characteristic that renders them vulnerable to feelings of worthlessness. The very intensity of their distress is in itself a sign that they are responsible and conscientious workers.

One way to create a supportive atmosphere to deal with these difficulties is to offer lectures on the warning signs of stress and PTSD. This often improves members’ attendance records and leads to increased efficiency and safety.

Education also results in awareness and prevention. This is very important, since the average firefighter is unlikely to acknowledge PTSD symptoms. It has been ingrained in his mind that this stress is an ordinary part of the job—part of the old “take it like a man” philosophy. PTSD can be present for years before it is recognized.

Referral system

In addition to initial training and ongoing education, fire departments should try to develop a mental health resource referral system, and attach no stigma to its use.

One irony of PTSD victims is that their dedication is often the very characteristic that renders them vulnerable to these feelings of worthlessness.

“I’m useless. I should have made that room. If only I could have gotten in there a minute earlier.” It is the good firefighters who expect the most of themselves. Your best people will be most critical of their own performance.

The very intensity of the distress exhibited by PTSD victims is in itself a sign that they are responsible and conscientious workers. The understanding that PTSD tends to affect “quality” personnel should help remove the stigma that is often unfairly attached to an individual seeking assistance.

Officers and other fire service managers should be aware that PTSD has the potential to affect any firefighter at any time. It can sneak up on him very quietly. He need not respond to a plane crash in order to be at risk. Years of repeated exposure to lesser tragedies and human indignities add up to a cumulative stress. There are some who argue that all firefighters experience it to some degree.

The firefighter requesting help for PTSD should not have to fear that he is jeopardizing a promotion, or even his job. Rather, he should be commended for his insight, honesty, and dedication to service.

If it is possible, the chief officer of the department should establish and participate in firefighter stress groups. This will be the best example that participation in such groups is a part of the firefighter’s professional growth.

SUMMARY

Neglecting the mental health concerns of the firefighter can be just as dangerous as ignoring the physical problems associated with the job. A firefighter suffering from PTSD can be considered as handicapped as a firefighter with a broken leg or malfunctioning mask.

Firefighter stress must be dealt with intelligently, professionally, and with concern for the people who do a job that would evoke significant symptoms of distress in almost anyone.