Helping first responders deal with on the job trauma

'I wish my brain could forget what my eyes have seen.' New RCSI programme aims to support emergency workers

When Michelle O'Toole went out on her first call as a newly-trained recruit with the Dublin Fire Brigade she wasn't expecting the "horrific scene" that greeted the crew.

It was what turned out to be a fatal road traffic accident, in which a car and van had collided, and a young man had suffered “fairly gruesome injuries”.

“When we’re trained for road traffic collisions, we’re trained to stabilise the vehicle and cut the vehicle away from the person. All the procedures went out the window and it was just get in, get him out as best you can and start CPR [cardiopulmonary resuscitation].

“I was completely flummoxed. I was wearing my fire gear; I didn’t expect to have to do that kind of work that day and I didn’t expect the kind of reaction I had.”

She froze to the spot.

“I remember thinking about what I was supposed to be doing but I couldn’t get my feet to actually move in the direction I needed to move.”

One of her colleagues – she didn’t know all their names at that stage – noticed her reaction, put his arm around her, guided her across to the vehicle and said “this is what we need to do”.

“I was lucky to experience that peer support straight away on that day,” O’Toole recalls. She also considers herself fortunate that the station manager organised for the brigade’s Critical Incident Stress Management (Cism) team to come into the station and chat to them all about what had been a traumatic call-out.

“I was new, didn’t really have a clue what was going on and I was kind of struggling to be honest.” But the “lovely” Cism team leader, the late Adrian O’Grady, “talked us through the incident and normalised all the reactions we were having”. He also advised them on signs and symptoms that might come later.

She found it really helpful and decided, there and then, she wanted to become part of the Cism team, which she did after getting a few years’ service under her belt. It was later, when as a mentor to the team, that a seed was sown for what is now a new research project at the Royal College of Surgeons Ireland (RSCI) for supporting the mental health of first responders.

Global studies have long shown the psychological distress that working in the emergency services can cause, with post-traumatic stress disorder (PTSD) known as a “silent killer” among first responders. In the US, firefighters are three times more likely to die by suicide than in the line of duty, according to the National Fallen Firefighters Foundation.

“It’s a real privilege to be helping people at their worst time but if we don’t look after ourselves, that can take its toll,” says O’Toole. She was involved in a research project in 2016/17 to see how Dublin Fire Brigade staff, who are trained as both firefighters and paramedics, could be better supported. “We know that male-orientated professions don’t put their hands up and say ‘I need help’. It is getting better but, at that time in particular, it wasn’t good.”

The survey showed that family members were the most likely first port of call for recruits when troubled after an incident. “We were absolutely shocked because we thought, and all the research says, that firefighters and paramedics talk to their colleagues – some of them do, but a lot of them, particularly the recruits, were telling us they were talking to their family members, spouses, people that they live with. We realised we had to do something about that.”

The “something” started with the development of a family support night as recruits came through their training. Key family members were given information about the signs and symptoms of stress and what their loved one would be going through, during training and beyond.

The initiative, which attracted international attention, has now evolved into the Safer Families/Friends research project, due to start early next year at the RCSI's SIM Centre for Simulation Education and Research, where O'Toole started working last January, after 12 years service with Dublin Fire Brigade. She is co-leading the project with Prof Walter Eppich, RCSI chair of stimulation, and they recently secured €267,000 in funding from the international charity Movember, as part of a global €5 million veterans' and first responders' mental health grant programme.

Hear the word “simulation centre” and you might think of a mocked-up airplane cockpit. “It has come from that,” says O’Toole, “but nowadays people are using simulation for the non-technical skills, like communication, conversation and mental health.”

They create the same environment – say a sitting room for these family members – making the setting as realistic as possible, in which participants learn to say the words they should use if the situation they’re training for arises. It brings role-play to a whole new level. “It really does help people to feel prepared for when it happens in real life and there is a lot of research behind that too.”

This project will build on the family nights idea. The aim is to not only train family members of first responders to recognise stress, but also teach them basic, psychological first-aid techniques, while being mindful of self-care too. They can support loved ones by knowing what are the appropriate questions to ask and where they should go for professional help.

Mental Health Ireland (MHI) is one of the partners on the research project. It brings “co-production” expertise to the development of the programme.

The line "nothing about us without us" is thrown around a lot, says Sonia Rennicks of MHI, but it does sum up the co-production approach. It involves the collaboration of a representative group of the target audience – in this case first responders and family members of first responders.

MHI is recruiting those collaborators to work alongside professionals and she envisages they may include retired first responders and and/or family members of retired emergency workers, who have years of lived experience. (Anyone interested can email sonia@mentalhealthireland.ie).

The organisation, which promotes positive mental health, wellbeing and recovery, will also set up “connect cafes” to enable family members of first responders to support each other.

It is “exciting to work with the RCSI and their simulation experience”, Rennicks adds. “When people get the opportunity to say out loud the things that might be difficult to say, they get the practice and it really embeds in them.”

Dublin Civil Defence (DCD) is also going to be involved in the research, initially supplying volunteers with authentic experience to play the part of first responders in the simulations. However, after the pilot phase of the project, covering family and friends of 100 firefighters and paramedics, it is hoped some of DCD volunteers' family members will be able to avail of the programme as it evolves.

Assistant civil defence officer Fergus Byrne, one of six staff who work with 300-400 volunteers at DCD, explains how their members can face potentially traumatic situations. "They will have encountered very ill people who might have passed away in their care. Or, out searching, find a person who has taken their own life. That can have an adverse effect on the volunteers."

Even pre-search briefings can hit a chord. For instance: “You’re looking for a 31-year-old male, he has left three notes, he has two young children.”

“Just that sort of background we have to give them, they can make an association with their own family and it makes it more personal and more likely it will have an impact on them,” says Byrne.

Through the Department of Defence, the civil defence has a Cism programme and full-time people such as himself are trained as debriefers, taking the “first aid” approach of chatting to individuals or a group who could potentially be in crisis. If they need further psychological support, he says, they are referred to a company that the Department of Health has available to DCD 365 days a year.

“That works fine in as far is it goes but what Michelle has identified and I agree with her, is that the ‘I don’t need help’ stand-off can still occur,” says Byrne, who worked with Dublin Fire Brigade before joining DCD nine years ago. If first responders fail to recognise they need support, the first people who might see changes indicating they’re in crisis is a family member.

At least in the full-time emergency services, the crews are in every day and signs could be picked up by the professionals, he points out. But with DCD, volunteers do their duty and go home and may not be seen for a week or two weeks “particularly during Covid”.

Byrne reckons he is lucky that nothing from his Dublin Fire Brigade days still keeps him awake at night; but that is not to say he hasn’t been affected by what he’s seen. He recalls the often-quoted remark of a Detroit firefighting veteran: “I wish my brain could forget what my eyes have seen.”

“If somebody says to me ‘do you remember the fire at….’ I will remember it vividly,” says Byrne. “But they don’t haunt me.”

However, he doesn’t hesitate when asked what was his worst experience. He wasn’t long in the service and was in the ambulance when they were called to a building fire in the city centre.

“When I got there, one fire engine had arrived at the same time as us and there were loads of people out in the street screaming. Three children trapped in a bedroom, two adults hanging out of a balcony and, even though we were in the ambulance, we were taking down ladders to try to get access to the building.

“One of the children survived and two died. The parents survived. I had young children myself at that time and that is one of those ones that I can literally tell you every single thing we did” – from the moment the call came over the radio when they were in O’Connell Street.

“Most of the time we’re lucky, we get people out,” he says, and they’ll likely be suffering just from smoke inhalation. “We take them to hospital and they do fine but this particular one didn’t work out that way.”

O’Toole believes the fact that she had a number of very challenging scenarios early on in her career helped her get used to it and figure out coping strategies for herself.

“One of the most difficult ones would have been a child who died in a fire. Other ones were murders, suicides; those kinds of things really do stick with you, especially if you have an experience in your own family where you can relate.

“I really tried to leave my work at work but sometimes that wasn’t possible and I really leaned on my family members and my support people.”

You never know what might trigger you, she says. Maybe it’s hearing a reference to a previous incident in the media, such as a subsequent court case, “and it brings it back up for you”.

There were plenty of uplifting experiences too. A mother of two boys herself,  Liam (9) and Harry (5), she treasured the maternity cases. Obviously people don’t want to have their babies outside hospital, she acknowledges, “but sometimes it just happens and it’s lovely to be part of that”.

There’s no doubting O’Toole’s passion for the RCSI project, which is both professional and personal for her. Her husband, Paul O’Toole, who she followed into the Dublin Fire Brigade when she was 26, continues to serve with the emergency services, as does her brother, Stephen Cleary, who, in turn, took her lead.

Although first responders are more at risk for post-traumatic stress, anxiety, depression, alcohol use, and marital breakdown, there is a plus side, O’Toole says, which has only been looked at in research relatively recently.

“Because we are dealing with all those incidents, there is also a much higher rate of post-traumatic growth” ie, positive psychological changes. Emergency workers can “come out the other side better than before”, she adds, “and have a greater appreciation of life in general”.

O’Toole, for one, sounds as if she has done just that.

Participants for this RCSI research will be recruited from January; for more information, email michelleotoole@rcsi.ie.