“Many people have the wrong idea of what constitutes true happiness. It is not obtained through self-gratification but through fidelity to a worthy purpose.” Hellen Keller

There are approximately 266,300 professional (paid) fire fighters in the U.S. and 815,500 volunteers, and the number of volunteers is declining.  Fire fighters and paramedics1 are continually exposed to high levels of job-related trauma.  In 2001, 438 fire fighters and paramedics died on the scene of fire incidents (344 responding to the attack of the World Trade Center on 9-11).  Of those who died, 83% were professional fire fighters, 71 deaths were of volunteers, part-time or wild land fire fighters.  In 2005 there were 115 line-of-duty deaths and 41, 950 injuries.  Surprisingly, in the past 20 years, heart attacks have accounted for about 50% of on-the-job fire fighter fatalities.  Motor vehicle crashes have accounted for about 21% of deaths; gunshot wounds for 5.3% (www.usfa.dhs.gov/fireservice/fatalities/statistics/casualties.shtm.; Fire Headquarters; 2002)

Although the high rate of on-the-job deaths of fire fighters as a result of heart attacks may initially be interpreted as being the result of the combination of the exertion involved in the use and wearing of heavy equipment and poor physical condition of some fire fighters, recent research is suggesting that the response of a body and brain to threatening and traumatic experiences and how this impacts on heart rate, blood pressure and immune reactions is also a contributing factor.

In a study by Corneil, Beaton, Murphy, Johnson & Pike (1999), which compared 203 U.S. fire fighters in urban departments with 625 Canadian fire fighters, 22% of the U.S. fire fighters and 17% of the Canadians were found to be in PTSD.  (The U.S. sample had 9% women and 13% paramedics, not found in the Canadian sample).  Other researchers have found 33-41 % of fire fighters were experiencing emotional distress; 21% of ambulance service workers were found to have PTSD (Clohessy & Ehlers, 1999).  Rates of PTSD in U.S. fire fighters are similar to those found in a study of German fire fighters, 18.2% (Wagner, Heinrichs & Ehlert, 1998) and are higher than those generally found in wounded combat veterans, i.e., 20%.  These researchers concluded that the high level of PTSD Asuggests that this is a serious mental health problem of epidemic proportions in urban professional firefighters in the U.S”.

U.S. fire fighters were found more likely to be injured on-the-job and to have multiple exposures to traumatic job-related incidents than their Canadian counterparts.  Furthermore, high levels of social support from both family and the job were associated with a significantly lower odds ratio of developing PTSD.  In fact, being married (regardless of previous divorce) was a protective factor in U.S. fire fighters.  The social support that develops in the firehouse as a result of the significant periods of time where fire fighters live together can help to insulate fire fighters from the impact of traumatic experiences, particularly if the fire fighter fits into and is accepted by his/her peers.  However, withdrawal from social relationships is common in fire fighters who develop PTSD.  High levels of work stress (problems with supervisors, and other work-related problems) was associated with a 3 to 4 fold increase in the odds of a fire fighter developing PTSD (Corneil, Beaton, Murphy, Johnson & Pike, 1999).

Fire fighters, paramedics and EMT’s are routinely exposed to horrific scenes involving death and injury.  Traumatic incidents occur not only in burning buildings, but also from traffic accidents, chemical explosions, bomb incidents and other situations.  The death of a child in an incident can be quite traumatizing, particularly to fire fighters who have children of their own.  Exposure to the intense grief reactions of citizens who have lost a loved one is also a routine aspect of the job.  Paramedics and EMT’s have the added responsibility of treating critically injured victims, which can be a source of further trauma.  Furthermore, line-of-duty deaths and injuries are a common occurrence in the fire service.  In contrast to law enforcement officers and combat soldiers, whose jobs involve intentional conflict with perpetrators or the enemy and the use of weapons, fire fighters, paramedics and EMT’s lose their lives while seeking only to protect life and property.

Incidents most likely to traumatize Emergency Service Workers/Fire Fighters/Paramedics

• Witnessing the death of a fire fighter or EMT/paramedic or viewing their body at the scene, especially a friend or partner.  Trauma is often increased if the fire fighter or EMT/paramedic believed he or she should have protected the person who died, trained the dead peer or if the dead fire fighter or EMT/paramedic was temporarily serving in their place.  Trauma is increased when a fire fighter or EMT/paramedic imagines him or herself as the one who died, then visualizes the impact that their death would have on those they love.  Survivor guilt increases the impact of the traumatic experience.
• A reasonable belief that their death or critical injury is imminent and certain, such as being in the middle of a burning building as the structure collapses.

• Viewing the body of a child, particularly if the fire fighter or EMT/paramedic is a parent and even more so if their child is the same age and sex of the dead victim or if the child victim is similar in some other way to their child, through appearance, clothing, toys, or school.
• The death of a child due to irresponsible adults, such as drunk drivers or careless parents.  (For example, drowning in a swimming pool after being rescued from the same pool in a prior call).  The impact can be greater if the body of the child body has been burned or dismembered.
• Hearing a citizen (particularly if the citizen is a child) scream for help from inside a burning house or trailer and, because the fire is too involved, being unable to save the child.
• A fire fighter or EMT/paramedic is blamed or told he or she is responsible for the death of a citizen, particularly a child victim, by his or her department, family members of the victim, or the media.
• Guilt, such as feeling responsible for violence or death, whether irrational or based on fact, usually intensifies symptoms of PTSD.  Two events which seem to lead a fire fighter or EMT/paramedic to blame themselves for a death or injury with accompanying guilt are: the deaths of a peer during a shift that they would have been working had they not taken leave, been sick, been on vacation, etc. and or responding to a call minutes after a fire fighter or EMT/paramedic has lost their life. (“It’s my fault he/she is dead; I should not have taken sick leave.” or “If I had been there, he would not have gotten killed.”)
• When a dead victim becomes personalized, rather than just an unknown body, through interaction with grieving family members or friends, or from information gained in numerous ways from the scene, news reports, and so on.  Continued association with the pain of survivors through investigations (and often long after) also can personalize the dead victims.  When a victim dies in the arms of a fire fighter or EMT/paramedic, or on route to the hospital, particularly when the victim is a child or adolescent.
• The terror of being caught in a violent riot and feeling trapped, particularly when the crowd is focused on killing or injuring the fire fighter or EMT/paramedic.
• Particularly bloody or gruesome scenes and the length of exposure to these scenes.  Viewing victims with severe burns, the suffering and/or grief of victims or their loved ones.
• Observing an event involving violence or murder, but not being able to intervene (i.e., “I watched him kill her.  She was screaming for my help but there was nothing I could do.”)
• Feeling personally responsible for someone’s life, such as those administered by an EMT/paramedic at the scene or on route.  When a victim dies on route to the hospital.  Symptoms may occur even when victims are rescued or survive, as a result of the stress hormones released during long rescue operations.
• When citizens at the scene threaten to kill or critically injure a fire fighter or EMT/paramedic unless some condition is met (For example; “If my father dies, you die.  You had better save him.”)
• Lack of support by management following their involvement in a very traumatic incident.
• Being referred to as a “Hero” after being involved in an incident where other fire and rescue service professionals died or were critically wounded; their sense of guilt at living or not saving their peer and/or friend can dramatically increase PTSD symptoms.

These incidents were compiled by combining research with the numerous stories of fire fighters and emergency service personnel  treated by Dr. Davis.

© 2003; 2007; Dr. Davis gives permission for this article to be duplicated and used for training and/or educational purposes provided she is acknowledged as the author.