The ABCs of First Responding: How Disciplined Thinking Can Reduce Stress

By Hersch Wilson

“I let her die,” I said to myself over and over again.

The Mechanism of Injury seemed so minor. Everyone had been conscious and alert. We brought the mom into the back of the rig. She had been sitting in the back of the car when it went off the road into the river and collided with the opposite bank. She had been wearing a seatbelt. In the rig, we talked. She seemed fine, worried about her kids. I told her they were okay. I had also told her kids that they would see their mom at the hospital. Then, she closed her eyes and slipped away while she was holding my hand. We lost her pulse. We started CPR, intubated and shocked her. But to no avail. Later we found out that the seatbelt (no shoulder strap) had dissected her descending aortic artery and she had bled out into her belly.

At the CSID meeting, the facilitator told us there was nothing we could have done short of having a surgeon on scene. (There had been many other factors: the crash was in a flooded river and pouring rain, the helicopter couldn’t land because of weather, the nearest ER was closed due to patient overload).

But by then, the thought, “I let her die” was firmly fixed in my brain. I felt shame and overwhelming guilt. Without the support of my department over the next few weeks, I would have quit.

Looking back on that call from a separation of 25 years, there are a couple things that I take away from it. First, it was a tragic death, and it was natural to grieve. Second, again from the perspective of a couple of decades, I understand that my thinking was out of control; my thinking was not disciplined. Thus, besides grieving, I was stressed and “lost” for months.

What do I mean by disciplined? Think about it this way. Firefighting is a discipline. Whether on the fire side or the EMS side, we’ve learned and we follow a set of procedures and rules that govern what we do in order to produce the best outcome. We may quibble about details, but we use the ABCs on every patient (unless it’s CPR, and then its CAB). Every fire starts with a 360 and answering the question, “Is rescue needed?”

In the same way, we can learn how to be disciplined thinkers.

We can understand and practice a way of thinking that can help us produce less stressful outcomes for ourselves.

To begin, we need to think about what we think about.

“One of the problems with mental health is that we don’t often think about what we think about and that causes all kinds of problems.” –Dr. Maxie Maultsby, psychiatrist and writer

The ABCs of First Responder Thinking

The ABCs of how we think are just as essential for us to understand and practice as the ABCs of patient care.

An example. Three EMTs respond to a cardiac arrest. Our first individual, Stacy, is an experienced paramedic. She has attended multiple arrests. A few had good outcomes, but most were fatalities. Her partner, Bill, is a brand new EMT. This is his first cardiac arrest. Then there is Julio, a veteran volunteer chief. He has been to hundreds of these kinds of calls over his 30 years.

Twenty minutes into the call, Stacy calls it. She is calm and comforts the family. She’s thinking, “We did our best.” Bill, the new EMT, is upset but goes through the motions of cleaning up — he’s thinking, “This is not how it worked in CPR class.” Julio, saying he’s stepping out to contact dispatch, walks out the door. He is thinking to himself, “CPR never works,” and he is feeling anger and hopelessness.

In this example, it is easy to understand that it was the individual’s beliefs (based on their individual experiences) about working a cardiac arrest and death itself that caused the different reactions.

Here is a graphic version of what happened.

The Activating Event: In this graphic, the death of the patient is the “activating event” (the “A”). For our purposes, an activating event is any event that “activates” an emotional reaction. In our work, some calls don’t rise to the activating event level while others grab us by the throat.

Beliefs: Our past experiences and assumptions construct our “beliefs” (the “B”).

Consequences: How we respond in emotions and ultimately actions are the “consequences” (The “C”).

There are two important takeaways. First, we are not in control of the A’s, the activating events. Stuff happens.

Second, it’s not the A’s that cause how we respond. Instead, it is our beliefs (The B’s) about activating events that cause how we respond. The death doesn’t cause Bill to question his skills, Julio to think of resigning, or Stacy to handle it matter-of-factly. It was their beliefs about the call that caused the different responses.

“Your thoughts often have much more to do with how you feel than what it is actually happening in your life.” –David Burns, Feeling Good. The New Mood Therapy

The key is that although we can’t control the activating events in our vocation, we can influence the B’s, our thinking and beliefs. And in doing so, we can also influence how we feel and how we act.

Here is an example that we are all familiar with. On an overdose call, if we believe that opiate addiction is a “character flaw” we are going to feel and act differently than if we understand that addiction is a disease. One decision can lead us to anger and resentment, the other to compassion and care. It is all about what we choose to think.

Disciplined Thinking

“Mental health is an ongoing process of dedication to reality at all costs.” –Scott Peck, The Road Less Traveled

There are two fundamental rules for choosing disciplined thinking.

The first is that when you feel like you are spinning out of control, ask, “Is my thinking based on reality, on the facts?” In my case, with the death of the mom, my thinking skipped right over the facts (there was nothing we could do) and jumped to, “It was my fault.” That was irrational, and that thinking caused the consequences of elevated stress that lasted for months.

In the case of Julio, the department chief, his belief that “CPR never works” is also not based on the facts (CPR has a 10% to 15% survival rate if the chain of survival is followed). His thinking led to feelings of futility and hopelessness.

The second rule is to ask, “Is my thinking (the B in the ABC model) in my best short- and long-term interest?”

Ramos Tsosie, a 25-year veteran firefighter-paramedic, explained to me his “thinking discipline” that illustrates this rule. He works in an area with lots of frequent flyers and substance abuse. After running on those calls, he told me, he has a choice in how he thinks. He can get frustrated and angry, or he can “think” that all these people have problems and are suffering, and his job is to help. That second choice makes him feel better and reduces his stress. His thinking is in his best short- and long-term interest.

The Two-Minute Drill

Here is a skill that we can use to help discipline our thinking. It takes about two minutes, about the same amount of time it takes to put on bunkers and an SCBA. It’s called Stop, Challenge, and Choose.

STOP: Anytime you feel negatively (say after a call — an activating event), or your thoughts begin to spin out of control: Stop. Take six deep breaths. Slow your thinking down. Notice how you’re feeling. Are you tense, stressed, angry, sad? Take a moment to “think about your thinking.” Ask, “What is it about the call that is upsetting me?” “What is the activating event?”

CHALLENGE: Challenge your thinking. Is your reasoning based on reality, on the facts? Is there more than one interpretation of the activating event? What is the information that supports or negates your thinking?

CHOOSE: Choose thinking that:

  1. Aligns with the facts.
  2. Is in your best short- and long-term interest.

This is a simple skill. But like every skill, it takes practice and repetition. It is much like the ABCs of patient care. We do it the same way every time whether it is our first patient or our 500th. It is a habit. Being disciplined about our thinking, using Stop, Challenge, and Choose, and making it a habit can go a long way to helping reduce the stress that comes with the profession.

Final Notes

In sum, if you are a first responder, you’ve chosen a path of fulfillment but one strewn with challenges. There is the joy of helping others, but there is also the constant exposure to some of the worst moments of the human condition.

In other articles I’ve written about the ways we can stay emotionally healthy throughout our careers. Sleep, being physically active, having a plan to deal with stress, staying optimistic, being in a community, and having a purpose in your life are all tools we can use to help us manage stress. But number one, in my view, is the ability to discipline our thinking.

That we can choose our thinking and thus choose how we respond is probably one of the most profound lessons we can learn. Veterans who have been in the field for a long time have learned this wisdom — often the hard way. But it is wisdom that we need to pass on to future generations of first responders — volunteer and career — so that they can enjoy this amazing vocation.

Hersch Wilson is the assistant chief with Hondo Volunteer Fire and Rescue in Santa Fe County, NM. He has been with the department since 1987. In his “other life” he is a writer and a soccer coach. Visit him at Herschwilson.com or on Facebook at ‘Hersch Wilson-Firefighter.’