They say sometimes you can’t forget a face. For medical providers and other first responders involved in backcountry rescue, sometimes it’s also a place. Some trails on ski maps are no longer denoted by their official names, but rather by memories: where this patient broke a femur, where that patient became a quadriplegic, or where a twelve-year-old girl with pink dinosaur socks hit a tree and died in front of you from a brain injury. Those damn pink dinosaur socks – no one could ever forget those innocent-looking socks. Or the trail where the confused and agitated head injury patient, who became combative as you were starting his IV, escaped one of his restraints and started punching you in the face before you could get the sedative medication onboard. It goes on, seemingly forever. The average shelf life of a paramedic is five years. The toll is never openly acknowledged and when you can no longer be a hero you sort of just fall by the wayside.

The ski area I worked for as a paramedic for fifteen years averages 5-6 fatalities each year, in addition to many, many critically-injured patients. On a single busy day, about seventy patients come off the hill due to injuries. If you are a full-time paramedic, you will be on-scene for most of the critical calls and fatalities.

Stress injuries incurred by first responders may be due to chronic exposure that causes emotional, cognitive, and even physical depletion over time or just a single trigger event. Even experienced EMS first responders and ER staff are not immune to these, even though for them a cardiac arrest may have become routine. This hardening of perspective is not normal for non-providers, but you must be able to do it to move on to the next patient. But then, suddenly, right when you feel like you have become numb to even the worst cases, you respond to a call that changes everything: a patient is staggering towards you on a ski run after hitting a tree, pleading with desperation and terror in his eyes, and you know he is going to die in the next few minutes- just by the color of his skin. You are alone with only an IV start kit in your pocket; any further gear or help is at least five minutes away. A sense of powerless frustration and anxious helplessness starts to flood through you.

However difficult my job is at times, I still love it. The responsibility of working as a paramedic serving 21,000 guests on the ski mountain each day is a challenge that I find enthralling and rewarding. But this occasion threw me for a loop that I had never experienced before. I felt discombobulated by this man who was collapsing and dying in front of me while I was having a semi-conversation with him. I found myself performing CPR alone while waiting for the rest of the cavalry to arrive. I was still in disbelief while running the call. I was in such a hurry to perform any Advanced Life Support skill that might save him that I couldn’t even wait for a backboard to get him up and out of the ditch. I asked the responding patrollers to haul him up hand-over-hand, which was not a commonsense move. If you’ve ever tried to lift a dead body, you’ll know what I mean. Another paramedic arrived and we quickly performed our protocol for a traumatic cardiac arrest: one of us intubating the patient and performing bilateral chest decompressions while the other performed chest compressions with the EMTs. I knew something was wrong with me when I had a casual conversation with my paramedic partner while traveling down the hill performing CPR on a dead man in the double-rig sled as if this were a perfectly normal thing to do.

My custom after difficult calls is to go for a long run. I ran quite a long time that night, but I couldn’t put away the memory. For a couple weeks, I did not enjoy being a paramedic anymore. It was not that I felt I was going to make a mistake, but I did not feel like being first out the door to a call either. My responsibilities felt like a pressure and an obligation to perform, rather than something I relished. I covered this up because I was supposed to be the go-to person for difficult calls as the senior paramedic and medical staff trainer. I avoided that spot where he died. I could not stop seeing his face. I still see it sometimes, even seven years later. I did not second-guess the call, because there is nothing I could have done for a lacerated aorta. Traumatic cardiac arrest resuscitation attempts are rarely, if ever, successful in a remote care situation except in a couple of unique and rare situations. The work began to feel perfunctory, and I resigned myself to the outcomes that seemed inevitable.

At the time there was no formal stress injury response training or awareness. Fortunately, because of the nature of our responsibilities, there was an informal cultural norm and ethos amongst the paramedics to call staff covering the other peaks and ask for someone to have your back that day if you weren’t feeling 100%. Some of the paramedics and I had worked together for so long that they were like brothers to me. We often went out of our way to help each other when we heard a bad call drop on the other side of the mountain. It wasn’t a formally institutionalized or ritualized process, but it probably should have been.

I recovered from that episode relatively quickly, considering how bad it hit me initially. However, having a tool like the stress injury response continuum scale would have been useful for me to formalize that I was not in the “green”, but in the “yellow.” This scale would have provided me a language to use with my partners to indicate how I was doing, seek support, and normalize the experience. Having a formal back-up system, or at least being able to back-off similar calls for a few days, would have also helped. There is no doubt that judgment and performance are affected when we are even slightly distracted by the stressors of our job.

Fortunately, some of those informal trail maps in our heads are also denoted by places of amazing gifts of life and human resilience. Surprisingly, many of those medical cardiac arrests over the years have been resuscitated with complete neurological recovery, mostly due to exceptional pre-hospital care by our staff. The young man who punched me several times, projectile vomited on my favorite jacket, and became completely unresponsive with difficult airway management? He suffered a brain injury so severe his neurosurgeon told him he was the definition of a miracle when he finally woke up in the hospital. He also showed up in my EMT class at the local college seven months later, aced it, and joined our ski patrol. It is a reward and an amazing thing to be part of saving a life. It is worth the efforts of keeping yourself in the “green zone” to prevent burnout and to keep providing excellent care to others. A physician I know says that “caring for others and relieving suffering is a privilege,” but to be inside that “circle of caring” for others, often you must first heal yourself.

“What else could there be if you have the inclination, and it suits you?” – Anthony Fauci M.D.

The author and long-time patrol paramedic partner, Hunter.