Not That Kind of Doctor: What a Mass-Casualty Drill Taught Me About First Responders

John Souza, Jr., DMFT

What a mass-casualty drill taught me about first responders, the families who love them, and the cost of going numb

I went into the training thinking the hard part would be the classroom. Three days of FEMA hospital emergency-responder protocols: decontamination sequences, triage categories, and the federal standard of four people per litter. I’m a family therapist. Sitting and listening is the whole job, so a binder of federal regulations looked like the worst I’d face. It wasn’t. What I wasn’t ready for was the field test, where the binder fell away, there were bodies on the ground, and the part of me I lean on in the therapy room was suddenly the wrong tool.

I was there because the work is close to me. My mom was an ER nurse for 30 years, and for the past few years, I’ve been part of Culturally-Based Community Connections for Resilience (CCCR), a University of Hawaiʻi suicide-prevention project for first responders, training mentors to notice the colleagues who are quietly drowning, the ones sliding toward passive suicide, or actively suicidal and saying nothing. I wanted to understand from the inside what we ask these people to survive. I got my wish.

The first thing that undid me was the washing. Non-ambulatory decontamination: a patient who can’t walk, a dirty-bomb scenario, and you wash them down before they move into the hospital. The actors playing casualties were good. Too good. Lying there in simulated agony, they were unmistakably human, and my instinct did what I’ve been trained to do: I talked to them. I reassured them. I was gentle. One patient asked me to stay until I finished, while a colleague told me to clear out: my shift was up, the next volunteer waiting. I had to choose whose claim to honor, the patient’s or the chain of command’s. I chose the patient.

“Wrong answer,” the trainer told me after. The model doesn’t care what the patient wants. It cares about flow, and a break in the chain of command ripples outward. Then he said the thing I keep turning over: this is why so many who work mass casualties start to see a person as a diagnosis, the heart in bed four, the broken leg in the hallway. To see the whole person, the son, the father, the one who wants you to stay, is to risk freezing when the procedure has to happen. The numbing isn’t a character flaw. It’s a load-bearing competency.

Next shift: triage. Much worse, because triage is where you decide who lives.

We were sent in as a team but given no leader. So we did what leaderless helpers do: we scattered, each bent over our own patient, while the standard of four to a litter mocked us: there were never four of us free at once. I’d reach a patient, see he needed moving, and leave him to go hunting for more hands. Along the way, I’d find someone worse off and have to tell them I was helping someone else while walking away. It happened three times, four times, until I could no longer hold the thread.

We tagged patients by color: green for the walking wounded, yellow for serious, red for life-threatening. Gray for the expectant, expected to die. Black for the dead. The colors aren’t a description. They’re a decision about where the resources go.

There was a mother and her son. The boy had a chest wound, a wide one, dark with blood, and she had her hands pressed into it. She looked at me and said, “You have to help him!” I told her I was in the middle of helping another patient. “No!” she said. “You have to help him, now! He’s dying!” I said I couldn’t help him right then. And she said, “But you’re a doctor, aren’t you?”

No. Not that kind of doctor. A volunteer trying to learn how to be useful, not trained for this, not for any of this. I didn’t say it out loud. Instead, I told her to keep pressure on the wound and that I’d come back. Then I went to find hands to move her son. It took an eternity. We got the boy onto a litter and into the decontamination line, but the mom wouldn’t leave him. So I told her she’d see him on the other side, after the ambulatory wash line. It was a lie. I knew it was a lie when I said it. But she believed me and left him, for the last time. I found out later that he had expired. I knew it was acting, but I kept reviewing the tape. If I had reached him sooner. If I had a team instead of a scavenger hunt … maybe he’d have survived.

And then there was the baby.

An infant, not breathing, alone on a stretcher. Forgotten in the churn. I walked over and picked it up. Color: gray. I had no idea what to do, so I carried it to the trainer to ask what was happening. The trainer looked at it and said, “The baby is not breathing. Chuck it.”

Chuck it. That was the phrase for the dead, for the bodies you set aside. And the more the casualties poured in, the more often you said it, because you can’t reach everyone. The arithmetic is brutal and simple: you pour your resources into the ones who can still be saved. Everyone else gets chucked.

My last shift put me back in the washing tent, and my last patient was that baby.

The protocol said five minutes of decontamination, even for the dead. My colleague looked at the small body and asked, “Are we really going to wash this thing for five minutes?” It was only a doll filled with sand. I knew that. I washed it anyway, for the full five minutes, slowly, the way you wash a beloved child. “Yes,” I told him. “Five minutes. The bare minimum we’ll give this child.” Because even though it was sand and rubber, it had become the last reachable vestige of my humanity, after three days of being asked to set that part down.

Here is what I understood, washing a sandbag with more tenderness than it warranted. Do this for real, day after day, year after year, and you can’t keep it from costing you. The work is noble, and the cost is a piece of your soul. Even in three days of pretending, I felt myself pulling back, going quieter and smaller. Over a career, I can see what grows to cover the wound: a sharp gallows humor, then the bar and the banter. There were a lot of jokes, a lot of references to drinking. I don’t think they were incidental.

It fits a pattern the research already points to. First responders die by suicide more often than they die in the line of duty (Ruderman Family Foundation, 2018), and beyond the completed suicides lies a long, quiet territory of passive self-destruction that this work seems to cultivate. We have names for pieces of it: moral injury; secondary traumatic stress; the depersonalization of burnout. And underneath it all, the oldest name for what the work demands. Buber would call it the conversion of every Thou, every person looking back at you, into an It, a thing to be processed. They did it to the patients and to us. The decon suits made us indistinguishable, so each of us became a number, and that was how we called to each other. And in that conversion, grief gets buried. Washing that baby was my chance to refuse to bury mine.

What does any of this have to do with the therapy room? More than I expected.

I expected this training to pull me toward medical family therapy. Instead, it showed me how well what we already do fits: family therapy treats systems and relationships. A first responder’s wall is something the job built, and we’re trained to see that and to meet it with accurate empathy. That is the gift buried in a training this hard: for everything it asked me to amputate, it rounded out my sense of how people survive, and handed me a vocabulary I didn’t have before.

When I work with a couple where one partner is a first responder, my usual instincts are a trap. The models we reach for, emotionally focused and experiential therapy, treat the wall as the problem and connection as the cure (Johnson, 2002). But the responder built that wall on purpose, and it was load-bearing, the same numbing the trainer called the only way to function. Asking them to simply feel more, to be present, can land as asking them to dismantle the one thing that lets them work on Monday. The empathy that makes me good at my job is, in their job, a liability, and over a career a liability at home too. Then they’re in my office, and the easy move is to pathologize the adaptation that kept them alive. What the systemic lens catches, and an individual diagnosis misses, is that the numbing was never only the first responder’s. A whole system trained it into them, and then we treat that competence as the pathology (Sharp et al., 2022). The job cultivated it, and the marriage now lives behind it (Regehr, 2005).

The training also gave me new language. I was working with a couple, the husband a first responder, at a loss for how to reach him. So I reached for the colors. I asked him to sort his relationship the way the drill had taught me to sort patients: what is red, life-threatening to the two of you, what is yellow, what is green and can wait. He lit up. He started handing the colors back, telling me which of his reactions were red, which green, and it finally felt like I had said something he could hear. The concept hadn’t changed, only the frame. This is why I believe family therapists belong inside these worlds, not at the edges of them. More of us should volunteer for a drill like this one before a first responder reaches our couch, as long as we stay honest about what the work can cost us, too.

What it cost is what the training left out. We debriefed, sort of. We ate pizza, talked about what could have gone better. Nobody debriefed the other thing. Nobody asked what it did to us to spend a day deciding who to abandon, to hear “chuck it” said over a baby, to lie to a mother holding her dying son. The closest we came was a shrug and the line I keep hearing: let’s hope we never have to do this for real.

But we did do it for real. Maybe not with real blood, but in our bodies, at least I did in mine. If the training can manufacture the wound this efficiently in three days, that’s where the care should begin. Not only the tactical debrief, but a real one. Room to say out loud that it cost something, before the only coping left is the bottle, the joke, and the slow withdrawal from everyone who loves you.

Where I sit, there is another way to see it. Triage spends the few for the many, a collectivist logic against the individualist grain of the West. Giving yourself to the whole can be where meaning and identity live, the good life itself. The wound is not the sacrifice. It is being made to drown alone.

I went looking for what we ask first responders to survive. I found that we ask them to survive it mostly alone, and then act surprised by what it does to them. The least we can do, in the training tent and in the therapy room, is stop pretending the cost isn’t there. Wash the baby for five minutes. Say the grief part out loud.

John Souza, Jr., DMFT, LMFT, is an AAMFT Professional member holding the Clinical Fellow and Approved Supervisor designations at University of Hawaiʻi at Mānoa.

References

Johnson, S. M. (2002). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. Guilford Press.

Regehr, C. (2005). Bringing the trauma home: Spouses of paramedics. Journal of Loss and Trauma, 10(2), 97–114. https://doi.org/10.1080/15325020590908812

Ruderman Family Foundation. (2018). The Ruderman white paper on mental health and suicide of first responders (M. Heyman, J. Dill, & R. Douglas). https://rudermanfoundation.org/white_papers/police-officers-and-firefighters-are-more-likely-to-die-by-suicide-than-in-line-of-duty/

Sharp, M.-L., Solomon, N., Harrison, V., Gribble, R., Cramm, H., Pike, G., & Fear, N. T. (2022). The mental health and wellbeing of spouses, partners and children of emergency responders: A systematic review. PLOS ONE, 17(6), e0269659. https://doi.org/10.1371/journal.pone.0269659

Not That Kind of Doctor: What a Mass-Casualty Drill Taught Me About First Responders

What a mass-casualty drill taught me about first responders, the families who love them, and the cost of going numb

References

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