Rule Number Two
"Look, all I know is what they taught me at command school. There are certain rules about a war and rule number one is young men die. And rule number two is doctors can't change rule number one."
--Henry Blake, "M*A*S*H"
In our line of work, there are things you can’t change. While Dr. Blake was talking about wounded soldiers during the Korean War, his statement still holds true today. And it isn’t just in the military. It’s the fire service as well. Young men and women die. It is a fact of life. There is nothing that you or I can do, as medics or firefighters, to change that fact. The one thing that we can change is the way that we deal with rule number one.
The highest rates of Post-Traumatic Stress Disorder (PTSD) during Operations ENDURING FREEDOM, IRAQI FREEDOM, and NEW DAWN (OEF, OIF, OND, respectively) are among those that are considered “outside the wire,” i.e. battlefield personnel, and medical personnel. For medical personnel, it is not just embedded medics and corpsmen. An alarming high rate of PTSD occurs in those that work in ERs, ORs, ICUs, aeromedical staging flights, and aeromedical evacuation personnel. I know, because I am one of them.
From the beginning of my Air Force career, I wanted to be an Aeromedical Evacuation Technician. One of my instructors at Medical Readiness Field Training was a prior AE tech, and I thought the wings on his uniform were pretty cool. After I did my time in a traditional Medical Group, I applied for AE, and subsequently got orders to go to flight school and survival school.
During flight school, the instructors told stories of their experiences “in the system,” taking care of sick and injured members of the military, and their dependents. Some of them were good, some of them bad, some funny, some sad. But it in no way prepared me for what I would see during my first deployment as an AE tech. More on that later.
As a requirement to be an Aircrew member in the US Air Force, you must attend Combat Survival Training. CST is a 19 day, nonstop course in Survival, Evasion, Resistance, and Escape, or SERE. It teaches you just about everything you need to know in order to do those four things, should your plane get shot down, or you otherwise become an isolated person. They make the training as realistic as they can. Including, for those of us that are unfortunate, PTSD.
For about six months after SERE school, I would wake up in the middle of the night from nightmares related to my experience. Cold sweats. Not being able to sleep. Depression. Mood swings. All considered normal. With portions of the course being classified, it’s hard to talk about. The nice thing about being on flying status is that you are seen by a flight surgeon for your routine care. And all flight surgeons are required to go through the course. So I did have the opportunity to share my experiences in order to deal with them.
Once that I completed all of my required training, I moved to Ramstein Air Base, Rheinland-Pfalz, Germany. A beautiful base, on the edge of the largest forest in all of Europe. The flying is good. So is the food. And lets not forget about the beer!
The job of the Aeromedical Evacuation Technician, and the Flight Nurses that we work with, is simple. Provide en route patient care to sick and injured Department of Defense beneficiaries, while they are being transported to the appropriate level of care. We are not alone in our mission, though. AE crews can, and often are, augmented by medical attendants or specialized care teams. These teams include Critical Care Air Transport, Neonatal Intensive Care, and burn teams. Critical Care Air Transport Teams, also referred to as CCATT, consist of a doctor, critical care nurse, and a respiratory therapist. They care for patients that require constant attention that cannot be provided by an AE crew due to other responsibilities or complexity of injuries.
It is the interaction with the CCATTs, and the patients that they care for, that has been the hardest thing about this job for me.
The first time you step foot onto a plane for a mission carrying wounded warriors, you realized that you have to numb your emotions. Seeing kids with one, two, or three limbs blown off. Gun shot wounds to just about ever different body part. Mild Traumatic Brain Injuries. PTSD. The list goes on and on.
When I say kids, I don’t mean children. I call these patients kids because they are either lower ranking than I am, or younger than I am. I’m 24, and an E-5 in the Air Force. I would venture to guess that I am either older than or outrank 90% of the patients I care for. Usually both.
I am required to talk to my patients about their injuries. If I didn’t, how else would I do my job? But I have to limit it, and filter what I ask, and how I ask it. Partly because I don’t want my patient to have to relive what caused their injury. But mostly because I must remain numb and distant to the emotions that it will bring about in me.
One patient I will never forget is a 22 year old Soldier that was shot in the head. He was completely brain dead, and on a ventilator to sustain life. Talking with the CCATT doctor that was caring for him, I learned that the young soldier’s parents were also onboard an airplane. While we were taking this young man from Afghanistan to Germany, his parents were on a plane from America to Germany, so they could be with their son as he took his last few breaths.
It isn’t all that sad, though. Some of the amputees will actually have fun with their situation. A fellow AE Tech was talking with a patient, when he asked her to help him put his shoes on. When she pulled back the sheets, she was pleasantly surprised to find that he had bilateral below knee amputations. He, along with his buddies on the flight, were laughing.
Resilience is the capability to cope with stress and adversity. It’s the ability to bounce back, if you will. There are many ways to go about this, and we each must find out what works best for us. The American Psychological Association has suggest 10 ways to build resilience. They are listed here:
1) Maintaing good relationships with family, friends, and others.
2) Avoid seen crises or stressful events as unbearable problems.
3) Accept circumstances that cannot be changed.
4) Develop realistic goals and move towards them.
5) Take decisive actions in adverse situations.
6) Look for opportunities of self-discovery after a struggle with loss.
7) Developing self-confidence.
8) Keep a long-term perspective and consider the stressful event in a broader context.
9) Maintain a hopeful outlook, expecting good things and visualizing what is wished.
10) To take care of one’s mind and body, exercising regularly, paying attention to one’s own needs and feelings and engaging in relaxing activities that one enjoys.
One of the best things you can do to cope with stress is to talk about your experiences with someone that you can confide in. It doesn’t have to be in the format of a Critical Incident Stress Debriefing. It can be a friend that wasn’t involved in the situation. It can be a spouse. It can be a chaplain or mental health professional. It can be your dog.
Rule Number Two
The APA has something similar to rule number two in their list. To accept circumstances that cannot be changed. Young men die. This is a fact of life. You must accept the fact that you cannot do anything about this, no matter how hard you try. We can only make the world so safe. We can only do so much with medicine and surgery. Young men and women are going to die.
This rule is harder to accept when it is a brother or sister firefighter. A family friend. Someone from your town. Someone your age. Knowing that that young soldier was going to die less than 72 hours from the time we landed in Germany sucked. It still sucks. But, I have come to terms with this talking with my friends, family, and coworkers.
Not many men will admit the fact that they cry. Many brush it off with a phrase like, “I must have some dust in my eye.” I cry. I can admit that. I cry for the young men and women that I care for. I cry for the young men and women that I didn’t get the chance to care for, who paid the ultimate sacrifice. But then I remember Rule Number Two.
Healthy and Fit Force
In order to maintain a healthy and fit force, we must be not only physically fit, but mentally and emotionally fit as well. Understanding the stressors in your life, and knowing how to deal with them, is a large portion of this. Recognizing the signs and symptoms of depression or PTSD in yourself and your coworkers should be at the forefront of your mind. Take action before it becomes a problem. We must be open to receiving help, and we must encourage others to seek help.
One of my good friends was showing increasing signs of depression, and starting to drink heavily. Flying every other day with wounded warriors for four months took its toll. In addition to talking with him about his experiences, and sharing mine with him, I emphasized the fact that he should seek professional help. And he did.
While we will never know if he would have spiraled into deeper depression and worse symptoms of PTSD, I do know that today he is flying again, doing the job that he loved.
Always remember to look out for yourself and your coworkers.
This thing we do, that others may live.