Have you ever wondered why you can deal with a cardiac arrest, a structure fire or a right old horrific wreck without any problem at all and yet lose your mind when someone gets your food order wrong? That's something I hear quite regularly from first responders. We can cope with the most stressful situations at work and then come home and have absolutely zero patience with things that aren't really that important.
Why is that? Part of the answer may be that we've become very adept at coping with a certain type of stress. The stress we experience at work is very different to a lot of the frustrations we encounter when we're not at work.
We Are Good at Handling Emergencies
First responders get loads of practice in dealing with emergencies. Having run calls for years you learn how to get on with it when everyone else is having the absolute worst day of their lives. There's always going to be a problem in front of you and there's always going to be something you can do about it.
Someone isn't breathing. Something's on fire. A vehicle is piled up against a tree. Someone has to be found, treated, moved, contained, extracted or in some cases just calmed. We've got the training, the kit, the protocols and we usually have other people to work with us.
Even on a terrible call there's invariably some next thing that needs to be done. We don't have to be wondering what we're going to do with ourselves. We look at the problem and we get on with it.
Now compare that to being stuck in traffic when you're already late. There's nothing you can do. You can't get the cars in front of you to move and there's no protocol that's going to make it any better. You just sit there.
For someone used to identifying a problem and then doing something about it, that sort of situation can be absolutely infuriating. The same is true of the problems you encounter at home. Relationships, kids, broken appliances, money and all the rest of the normal stuff of life rarely have the clear-cut solutions that you're used to at work.
Being Good at Your Job Doesn't Mean You Aren't Stressed
There's a difference between not experiencing stress and being able to function in the face of stress. First responders get very good at the latter. You can have a very high heart rate, your sympathetic nervous system can be fully switched on and your body can be spewing adrenaline around the place and you can still carry on with the job.
You can still start an IV, pull a hose line, manage a scene or talk to someone who is absolutely losing it. After a bit of experience it can start to feel quite normal. That doesn't in any way mean the stress isn't there.
The issue is that our bodies don't necessarily "reset" the instant the call is over. We might clear the call, put the truck back together and go available again, whilst our nervous system is still responding to what just occurred. On a busy shift you can do that multiple times. Allostatic load has been proposed as one useful concept for understanding the cumulative impact of repeated physiological and psychosocial demands over time (Igboanugo & Mielke, 2023).
Think about being woken up at 2:00 a.m. for a call. You get back to the station, get back in bed and as you're just about to go back to sleep the alarm goes off again. You may well run all night or you may have a few hours of fragmented sleep before shift change.
Then you go home. Your spouse wants to have a chat about something, the kids are up and about, the dog needs to be let out and there's a whole host of errands to run. Someone asks you what you'd like to have for dinner and you're instantly irritated by everyone.
Research with firefighters and their spouses has shown that sleep loss doesn't stay at the firehouse. It follows us home. Firefighters and their spouses have described the difficulty of recovering from accumulated sleep debt and spouses have reported their firefighters becoming irritable at the most trivial of things when sleep deprived (Watkins et al., 2021). That's probably not at all surprising to anyone who's come home from a bad night at the station.
Why Is It Always the Stupid Little Thing?
Perhaps you made it through the whole shift without losing your temper at all. You'd had a difficult patient, you'd been woken up several times, you'd listened to admin moan about something and you'd run a call at 3:00 a.m. for a problem that had started three days previously. None of that did it.
Then the drive-thru gives you the wrong coffee and you're pissed. Why is it the coffee that gets you when everything else had seemed so manageable?
It's probably not down to the coffee. Our ability to cope with stress is finite and successfully coping with a stressor doesn't mean it didn't take something out of you. There is a well-documented association between repeated occupational stress and mental health symptoms in first responders and the area continues to be researched with respect to the impact of coping, emotional regulation, social support and recovery (Kshtriya et al., 2020; Popok et al., 2022).
This in no way absolves you of treating other people badly. If you're shouting at your spouse or your kids that's still something you need to take ownership of. The point about understanding why it's happening is that it gives you a far better chance of actually doing something about it.
Sleep is obviously part of this. Sleeping at the station is no substitute for sleeping at home, even if we technically do get several hours. Part of us is always in the state of "waiting for the alarm to go off" and over time we become quite good at waking up when it does.
Unfortunately, being really good at waking up is the very antithesis of what we're trying to achieve when we're sleeping. Sleep loss has been shown to lead to reduced patience, increased irritability, reduced attention and problems with recovery after shifts (Watkins et al., 2021). It makes you tired and tired people are just in general less patient.
Then we go home to the people who have their own legitimate needs. Your spouse didn't run your calls and your kids didn't keep you up all night. They're just happy you're home. They may well be getting the version of you that has the least to give.
We Learn to Put Things Away
Compartmentalisation is talked about as if it's always a bad thing, but in EMS it can be absolutely necessary at times. There are times when we just can't possibly deal with what we're feeling because we've got a job to do. The patient still needs looking after, the fire still needs putting out and the scene still needs to be dealt with.
McElheran and Stelnicki (2021) use the term "functional disconnection" to describe the ability to temporarily disconnect from emotional reactions in order to function effectively in the face of stress. They don't see this as an inherently bad thing at all and actually stress the importance of having the ability to reconnect as well.
That's very much something that would be familiar to anyone in the emergency services. There are times when the very thing you need to do the job is to put it away for later.
You finish the bad call, put the truck back together, write the report and get ready for the next call. Someone might make a really bad joke about what just occurred. The tones drop again and you're off to the next thing.
On a busy shift, there may not even be time to come down from one call before the next one drops. Talking with the crew on the way back to the station or around the kitchen table can be one of the first opportunities we have to begin processing a difficult call (Jahnke et al., 2014). When you're running from one call to the next, that opportunity may simply not be there.
The key thing isn't whether we disconnect. The key thing is whether we can reconnect afterwards. Something that's perfect for twelve or twenty-four hours at work may be quite a different proposition when you get home.
Research into emotion regulation in first responders does indeed point to the importance of that distinction. In a study of 895 first responders, higher levels of occupational stress and greater use of expressive suppression were both associated with symptoms of PTSD, depression and generalised anxiety (Popok et al., 2022). That doesn't mean that emotion regulation on the scene is in any way a bad thing. What it does suggest is that if you're relying on suppression as your primary mechanism for managing your emotions then there are likely to be negative consequences beyond the immediate context of the incident.
I've written before about how first responders can end up being in a state of "always on". We look for exits as we walk into a building, we don't like having our backs to the door and we'll wake up to noises that other people would just go right through. All of that is completely sensible given what we do for a living.
Going home means we have to shift gears. The skills that are so effective in an emergency aren't necessarily the skills we need when we're having a conversation with our partner or when we're dealing with a frustrated child. We may simply not have made that gear change yet.
Have you ever just sat in your car for a few minutes after you've got home from shift? You may be doing absolutely nothing at all. You may just not be ready to go in yet. There might be a reason for that.
Sometimes One Call Is Different
There is another version of this that I hear from first responders. Most calls don't bother them much anymore, but there is one call they can't seem to let go of. It may not even have been the worst call of their career.
Maybe you keep thinking about something you did or wonder if you could have done something differently. Maybe you know you did everything right and still can't get comfortable with how the call ended. Sometimes the calls that stay with us aren't necessarily the most graphic or dangerous ones.
Some calls bother us because something about what happened conflicts with how we believe things should have happened. Maybe the outcome seemed unfair or preventable. Maybe you couldn't give someone the help they needed, or maybe every available choice seemed wrong.
This is where moral injury can sometimes be useful in understanding what is happening. Litz et al. (2009) described moral injury as resulting from perpetrating, failing to prevent, witnessing, or learning about events that violate deeply held moral beliefs and expectations. While much of the early research focused on military populations, moral injury is increasingly being studied in firefighters, paramedics and other public safety personnel (Smith-MacDonald et al., 2021).
Most first responders aren't going to search for "moral injury" when something like this is happening. We are much more likely to say, "Why can't I let go of this call?" or "Why does this one bother me?" Sometimes it is simply, "I don't feel like myself anymore."
Those questions are worth paying attention to.
Being Able to Work Doesn't Mean Everything Is Fine
First responders are very good at using work performance as an indicator of how we're getting on. We tell ourselves that we're still going to work, still running calls and still doing our jobs. If I can do all of that, then I must be OK.
But work may actually be the place where you function at your best as it is the environment you've spent years learning to deal with. The changes may be apparent in all sorts of other areas. You may be absolutely fine on shift and yet be increasingly irritable, withdrawn or exhausted at home.
Perhaps you just don't want to do anything on your days off. Perhaps your partner tells you that you're always angry. Perhaps you've started drinking more than you used to. Perhaps you're not sleeping well or you just don't enjoy the things you used to enjoy.
Or perhaps you can't point to anything in particular. You just don't feel like you.
If you can cope with the chaos at work but the little problems at home are increasingly difficult to deal with then you need to pay attention to that. Look at your sleep, look at how much overtime you're working and whether you're actually doing anything to allow your body to come down from being "on" all the time.
Also think about whether there's a particular call, a particular patient or a particular event that keeps coming back to you. You don't have to be completely unable to work before you've got something that's worth addressing. Sometimes the first sign that you're carrying too much isn't what happens in the emergency itself, but what starts to happen once you get home.
Therapy for First Responders in Orlando
If some of this sounds familiar, you don't have to wait until it starts affecting your ability to do the job. I work with firefighters, paramedics, law enforcement officers, dispatchers, and other first responders dealing with stress, difficult calls, moral injury, and the effects the job can have outside of work.
Learn more about Therapy for First Responders in Orlando →
References
Igboanugo, S., & Mielke, J. (2023). The allostatic load model: A framework to understand the cumulative multi-system impact of work-related psychosocial stress exposure among firefighters. Health Psychology and Behavioral Medicine, 11(1), 2255026. https://doi.org/10.1080/21642850.2023.2255026
Jahnke, S. A., Gist, R., Poston, W. S. C., & Haddock, C. K. (2014). Behavioral health interventions in the fire service: Stories from the firehouse. Journal of Workplace Behavioral Health, 29(2), 113–126. https://doi.org/10.1080/15555240.2014.898568
Kshtriya, S., Kobezak, H. M., Popok, P., Lawrence, J., & Lowe, S. R. (2020). Social support as a mediator of occupational stressors and mental health outcomes in first responders. Journal of Community Psychology, 48(7), 2252–2263. https://doi.org/10.1002/jcop.22403
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
McElheran, M., & Stelnicki, A. M. (2021). Functional disconnection and reconnection: An alternative strategy to stoicism in public safety personnel. European Journal of Psychotraumatology, 12(1), 1869399. https://doi.org/10.1080/20008198.2020.1869399
Popok, P. J., Kshtriya, S., Lawrence, J., Alfano, A. R., SantaMaria, D., & Lowe, S. R. (2022). Investigating strategies of emotion regulation as mediators of occupational stressors and mental health outcomes in first responders. International Journal of Environmental Research and Public Health, 19(12), 7009. https://doi.org/10.3390/ijerph19127009
Smith-MacDonald, L., Lentz, L., Malloy, D., Brémault-Phillips, S., & Carleton, R. N. (2021). Meat in a seat: A grounded theory study exploring moral injury in Canadian public safety communicators, firefighters, and paramedics. International Journal of Environmental Research and Public Health, 18(22), 12145. https://doi.org/10.3390/ijerph182212145
Watkins, S. L., Shannon, M. A., Hurtado, D. A., Shea, S. A., & Bowles, N. P. (2021). Interactions between home, work, and sleep among firefighters. American Journal of Industrial Medicine, 64(2), 137–148. https://doi.org/10.1002/ajim.23203
