Wilderness Medicine Updates
The podcast for medical providers at the edges, bringing you digestible updates at the growing edge of Wilderness Medicine, Wilderness EMS, Search and Rescue, and more.
Wilderness Medicine Updates
Ep. 28 - Laura McGladrey, Responder Alliance, and Stress Injury: How to Get Back to Green and Save Living While Saving Lives.
Understanding Stress Injuries in First Line Responders with Laura McGladrey
This episode of Wilderness Medicine Updates, hosted by Patrick Fink, features a conversation with Laura McGladrey, founder of the Responder Alliance. They discuss the critical issue of stress injuries among first line responders, including professional ski patrollers, healthcare workers, and rescue team members. Through personal stories and expert insights, Laura explains the concept of stress injuries, how they develop, and the importance of early detection and mitigation. The episode highlights the need for both individual and organizational strategies to support resilience and manage stress. Listeners are introduced to practical tools, cultural shifts, and personal anecdotes to help maintain a long, healthy, and fulfilling career in high-stress environments.
Links
Responder Alliance Home Page
Access all that the organization has to offer.
Responder Alliance: Resource Hub
Easy access to critical tools and offerings.
The Stress Continuum
See the visual continuum that we discuss on the show.
Scholarships: Responder Alliance Foundation
Apply for aid for an individual or team training.
Make a Donation to Responder Alliance Foundation!
Join me in making a tax-deductible donation to support the valuable work of the Responder Alliance and bring this work to those who need it, regardless of cost.
Chapters
00:00 Introduction and Guest Welcome
02:11 Laura's Background and Work
06:00 Understanding Stress Injuries
10:02 Responder Alliance Mission and Challenges
20:55 Critical Incident Stress Management
30:49 Empowering First Responders
32:13 Daily Investments in Resilience
37:26 Recognizing and Managing Stress
38:14 Organizational Support for Stress Management
39:45 Building Resilient Teams
46:12 Learning from Resilient Leaders
52:42 Resources for Stress Mitigation
57:54 Conclusion and Final Thoughts
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Welcome back to Wilderness Medicine Updates. I'm your host, Patrick Fink. Today I'm very pleased to welcome Laura Mclare on the show. Laura Mclare is the founder of the Responder Alliance, an organization that focuses on reducing stress injuries in first line responders. I first became aware of the Responder Alliance when I was working at Snowbird. I worked as a patrol physician there and unfortunately, in the year prior to my joining their team, the Snowbird folks had actually lost a me, a longstanding member of their patrol to suicide. And because of that, they became closely involved with the Responder Alliance and started to work to develop a system to ensure that no one on their team. Found themselves in that place again, that they lost no more valuable members of their team and their community to stress injuries. Whether you are a professional ski patroller, a volunteer search and rescue member, a member of a healthcare profession, or simply someone who goes frequently into the outdoors, if you frequently manage stressful situations, particularly those in which there is danger to yourself or others, you have the potential to develop lifelong stress injuries as a result of those exposures.
My hope is that this conversation. Tunes your awareness to the fact that we need to prevent these kinds of injuries beginning early in our career and learn how to manage ourselves and the stress continuum so that we can have a long, happy and healthy career working on the front line. Without further ado, here is my conversation with Laura Mclare.
Patrick Fink MD:Hi Laura.
Laura:Hi there.
Patrick Fink MD:Thank you for joining me. I'm sorry for the snafu the first time that we tried to connect. That's okay.
Laura:okay. I think it worked out
Patrick Fink MD:So I know that you work as a clinician in addition to your work in the Responder Alliance. How do you explain to people what your day job is and, and how do you balance the two?
Laura:Thanks for assuming that I balance the two. That's great. Um, and so in my day job, I'm a family and psychiatric nurse practitioner. I work at the Stress Trauma Adversity Research and Treatment Center. It's called the Start Center at University of Colorado. And my day job and background is in really at the interface of occupational stress and traumatic stress and first line responders. So we used to say first responders, but. Really, we're using that terminology now, first line responders to also the people we rely on to protect the things in the places we care about the most. So that's climate responders, forecasters, geo hazards, um, as well as fire law enforcement, EMS, ski patrol, et cetera.
Patrick Fink MD:So how did you come to move from your work as a psychiatric nurse practitioner into your role in the Responder alliance? I know that you have a background in the outdoors in rafting and ski patrolling. What brought you to where you are?
Laura:Well, that's a long story. Let me try and make it concise. So I was, as you said, working for many years as an emergency medicine versus a nurse and a nurse practitioner in level one trauma centers. Um, I did that in part to fund and fuel my. My habit of, um, working in remote places for Knowles wilderness medicine and, um, teaching wilderness medicine, which led to humanitarian aid. And all the while, yes, I was, um, RAF guiding and guiding and working with ski patrol as an a LS or advanced life support provider and. You know, it really was in some ways sort of a fluke that when I got back I was, I spent a year on the north south border, um, South Sudan, and when I got back and I decided to pursue, the psych mental health postmas, so I'd have two certifications, um, as I was graduating it. So happened that the job that fit with my schedule was working, um, with law enforcement and fire and EMS as their prescriber for a prominent, um, uh, police psychologist. And so I, I had been doing that work for a while, and then still, of course, every weekend. I could say I was dirtbagging it with my people and, and what I realized is that as we started to discover the language that the military was using around stress injury and to detect it and the stress continuum and creating some, innovation and scaffolding for folks to really early mitigation and early detection of stress injury, then I would go and work on the mountain on the weekends and realize that this was not getting out to my people. And the time, this has been a while now, but with wilderness responders, I think there was this kind of understanding or maybe a misunderstanding that as long as we got to hang out in cool places and do incredible things, we would never be injured by
Patrick Fink MD:Mm-hmm.
Laura:and particularly traumatic stress. Um, I, you know. People I cared about and spent a lot of time with, you know, and I was at a wilderness responder for many years. I'm like, A pediatric tree strike is a pediatric tree
Patrick Fink MD:Right.
Laura:whether you're in an urban context or remote. And I, I think that misunderstanding that. our jobs are cool. We couldn't get injured by stress was actually, I mean, I was getting phone call after phone call and people tugging on my sleeve and saying, what is this? I was like, well, I'm treating it my day job, but we don't have any language for it in my, in my, on my weekends.
Patrick Fink MD:Let's dive into the language a little bit'cause I think some of our listeners will be familiar with the idea of stress injury, the stress continuum, but for those who aren't, how do you define stress injury?
Laura:Well, thankfully it's not left up to me to define it. I can, I can tell you. Um, it was defined first by the US Military Marine Corps, um, and Navy Combat and Operational Stress First Aid. They and to my knowledge, were the first ones to. To introduce the nomenclature. When I discovered that around 2018, I also learned that Canada had been using the terminology occupational stress injury. Um, but that the idea of stress injury is really, um, the same that we would use in physical injury. It's the amount of exposure, um, over time will equal the severity of the impact. Um, but stress injury is really, uh, kind of a wider. Acknowledgement that we could be injured by stress, um, in our careers. And in fact, my understanding of the literature, it's the most common injury to shorten or end a career, in, in any kind of, um, response. More common than needles take more common than back injury. More common than patient assaults is. Is being injured physically by stress. Um, and it, it is a fatal injury type. And I, unfortunately we've had to come to reckon with that in these last years. But, um, but that's, that's how I would hold the stress, the stress injury language and the. Maybe I would say this too, that after teaching wilderness medicine for so many years, you know, there's a, there's an algorithm or there's a, there's a projection or a progression. When you teach wilderness medicine, it's, if it's a head injury, there's early changing vital signs or late changing vital signs. If it's a sprained ankle, it's a ankle fracture. If it's, you know, diabetes early and then diabetic ketoacidosis, we were missing in my, in my experience, early changing language around. impact. And it wasn't until people were literally coming to see me in what I would affectionately call the psychological ICU, they were finally asking for support. And 20 years of emergency medicine, I'm like, it's the same if you come to me in diabetic ketoacidosis. It's gonna be a lot harder treat this than if we had had a name for it and we could have detected it with a hemoglobin A1C hopefully.
Patrick Fink MD:Yeah.
Laura:show, but some, there were ever even symptoms, we could say, Hey, let's modify with diet and exercise before you develop these really re like, um, difficult and difficult to modify impacts in stress injury, which might involve a loss of a relationship, a loss of a job, loss of a life.
Patrick Fink MD:Yeah. I like that language of the vital signs of stress injury before you show up in the florid shock that is, you know, relationship destroying, substance abuse and suicidal ideation. Maybe we could identify the. The early derangement, the ear derangement is the wrong word, but the, the early tachycardia, the, the slight differences that say, Hey, we're moving outside of, of the realm of what should be our, our normal and safe place to be.
Laura:Like that. You just said derangement. Um, it's funny, when I went from emergency medicine to psych, I had to really start watching my language. But you're talking about electrolyte
Patrick Fink MD:Yeah.
Laura:right? Like the first we see your sodium get low, we should be addressing it. And I, I do think that actually was where Responder Alliance was born because the problem that I was trying to solve is that. Like carbon monoxide, you know, in a high altitude tent, if you don't know that exists, you're not gonna watch for it. if, if you don't know that when you start feeling sick, it means you should get out of the tent. You're gonna, you're gonna take a nap and go to sleep. But without a common language, there is no way for people to actually recognize, oh, what I'm feeling are the early signs of stress impact. I should do something right now. So it really mattered that we had a name for it.
Patrick Fink MD:What now is the mission of Responder Alliance?
Laura:The mission of Responder Alliance is to continue, and it had been for many years to advance the national conversation, on stress, injury and impact. We also now have a foundation, I would say at the heart of the mission is that we want every single. vital responder, meaning anyone who is gonna go put their heart and their life on the line to do something important, have fair warning that stress injuries exist. We want them to, to know about them, what they face, and then we want them to have cutting edge skills to know what to do, and not just for themselves, but for each other.
Patrick Fink MD:How do you persuade the gruff pistachio types who wanna spend all of their learning time on cool things like skiing or learning technical rescue, that investing in education, learning this language, learning the tools that you provide, how do you persuade them that that is worthwhile?
Laura:It really depends on where they are in the arc of their career. And this is candidly why we've really put a focus on FairWarning and a universal right for everyone to know about stress, injury and impact. I spend a lot of time in, say kind of jokingly, snow caves, patrol huts and police departments, hall ski, um, morning meetings. way that I, I talk, I don't think that the, the crusty I'm, I'm assuming we're talking about pistachio men and women.
Patrick Fink MD:Yes. Sorry.
Laura:the, is, um, the folks who are well into their careers, if I start talking about stress injuries, um, they surprisingly, actually sometimes get quite emotional and they're usually the first ones to say, if we'd been having this conversation, if we'd had this conversation at the beginning of my career, I would have my wife. My ski partner, I would, I would have these things back and there's almost a sense of grief for them. It's funny, when I've trained with elite teams, they're always like, oh, watch out for that one Cresty guy'cause he's not gonna believe you. And it helps me that, you know, I have the designation of junior wood check forecaster, um, from the Avalanche folks. Like all I do is pattern
Patrick Fink MD:Mm-hmm.
Laura:So people kind of think I'm way far into their kitchen when I'm not. I've just seen it
Patrick Fink MD:Mm-hmm.
Laura:again, you look at the stress continuum, that there's a progression and it usually goes in a career that you won't feel this or think it could ever happen to you to the, for the first four to six or seven years of
Patrick Fink MD:Mm-hmm.
Laura:It's really difficult about this particular injury. Maybe like a not unlike carbon monoxide is that when it does finally hit you, it usually frequently, you're already very advanced. Right. If we go back to diabetes, you already have microvascular damage. There's already things that are hard to reverse, and so it's tricky. a lot of people who come to me and say, I heard you talk about it. I never thought it would happen to me. I can't believe I'm here, but it happened to me, and so I would say. I have actually never had resistance from the crusty folks because they've lived this injury. Now, they may not feel comfortable. I've had people in a room of ski patrollers like, oh, here comes Laura Mclare again. We're feelers. Uh, I try not to do that, but I, it's not that they were not uncomfortable, but I don't think I've ever had anyone. Deny to me because, I mean, I'm in the trenches. I have, like, I, I can see it from the door that it's not a thing and it's not probably the biggest challenge we face in guiding and wilderness medicine, in climate, in, high angle rescue and the guard, et cetera, et cetera. So I, I don't know. That might be a bit of a take, but I think we always think don't believe it. And I would say. They can almost not afford to believe it. I mean, I think what honestly happens, and this is a shout out to you if you're a mustache C, how, what did you say? A crusty
Patrick Fink MD:Christine Pistachio woman. Yes.
Laura:Yes. But I wanna defend them maybe.'cause I am one to say that we didn't know any better. Like no one ever said to us. Hey, year 4, 5, 6, this is gonna happen. It's gonna impact your relationship. You're gonna put down your kayak and never put it, pick it up again. You're gonna lose. So I think the conversation for them is more painful.
Patrick Fink MD:Mm-hmm.
Laura:why didn't I have this? Um, but. I've never, also can sometimes feel that, um, everyone's looking at them like we talk about the stress continuum, which is that progressive across the arc of the lifespan toward more stress impact. They feel very vulnerable. Like, is everyone looking at me because I actually display these attributes and to which I would be very protective of and be like, yeah, you show me how to get through a 25 year career. You know, if you're in climbing, you've lost half of the people that you started
Patrick Fink MD:Mm-hmm.
Laura:They've doubt the idea that, that they wouldn't be impacted is that I feel very protective of
Patrick Fink MD:So the,
Laura:So you who are listening, um, you came by it honestly,
Patrick Fink MD:you, you mentioned the idea of fair warning. You're, you're saying that that's to bring this idea to those first and second year team members and bring awareness to that, that process, that this is something that can sneak up insidiously through their career. Is that right?
Laura:I use that terminology fair warning. In the same way in public health, we would let people know about crime and monoxide. Like, hey, if you're in a, an enclosed cabin with a, a wonderful chuggy stove, and you start getting a headache and feeling nauseous. You should open the windows, right? Like we do that in wilderness medicine and that is what I'm proposing. And I think particularly, you know, more recently as we've been working on this year one initiative, actually predict that people aren't gonna learn about stress injuries and be like, oh, thank you so much for telling me. Now I know I'll never get a stress injury. I think they'll be like, okay, yeah, got it.
Patrick Fink MD:Mm-hmm.
Laura:to me, but. They hit that year three or four and they get off their, first wild then season, or they get back from a call and they're like, they sit down and they're like, I used to love this, but I don't wanna do it anymore. And I actually have a reaction in my body every time I get on that helicopter. And I don't know what's happening to me. I hope, hope, hope that they'll go, wait, I think I know what this is. I'm gonna take care of this right now. I'm gonna open some windows.
Patrick Fink MD:Let's talk about that. What are, what are the early signs of cumulative stress injury that listeners can recognize in themselves or in others?
Laura:So I think one of the easier ways to think about this and um, happy for you to put this in your show notes. You know, we took the combat and operational Stress First aid, or excuse me, the from combat and operational Stress, first Aid, the
Patrick Fink MD:Mm-hmm. Yeah, I'll put that in the show notes for sure. Yeah.
Laura:Yeah, we'll, we'll talk about that as a capacity continuum too. It's not just about like your stress. You could call it the resilience continuum if you want, but the idea is that. Many of us start our careers or our seasons in this kind of relative green, which I would say is a lot of capacity for complex things to happen. We have maybe a little overage spiritually. Um, we have strong relationships, we have healthy bodies. We feel like we can handle things and, and wem feel mission satisfied. Like, I can't believe I get to patrol all season. I can't believe I get to be an ER doc. I can't believe I get to fly on the helicopter. And then in the yellow, there's usually like a, the earliest of change from your baseline is like, I don't really wanna do this today. Or I'm more short fused than I want to, or I, I care less about to pick up bamboo, or I'm count. I'm starting to kind of count the days till the season ends'cause I'm kind of over it or I'm over my coworkers. It's, it's very subtle, but it tends to be, I would say the best way to look for it is to look for a change from your baseline. Your baseline level of being psyched that you get to do this job, maybe you would do it for free, and then all of a sudden you're like, Hmm. So there's this change that kind of involves that. And I would say energy conservation. Like I don't wanna do this. I'm starting to kind of clock in and clock out. I'm not going out with my friends as much. I'm not engaging in training as much. then there's this other kind of progression into orange, which moves us closer to injury where we actually. what we would, a lot of us describe is that true burnout where you're like, I reached down. I can't find a motivation for this. I'm counting the days till the end of the season or to the end of my career. I'm isolating myself'cause no one would understand. And um, I am maybe using more substances or climbing higher and farther to numb out. it's all happening on the inside. Usually people aren't broadcasting it. They're like, man, I just, not myself. finally, there's this progression that we would put more into the zone where I talked about psychological ICU, which is more recognizable, which we traditionally call like, oh, that's PTSD, or, oh, that's depression or anxiety or substance use. is. feeling trapped and maybe feeling internal reaction every time you go to work and not sleeping well and feeling very isolated. The challenge with getting that far from those early changing the lates is that the farther you are into that state, the less resources are available
Patrick Fink MD:In what sense?
Laura:Right? Well, you know, folks who live in that red zone or who touch down in that red zone. They don't ha feel like they have, um, the energy to get themselves out it from an energy management status, um, kind of standpoint. If you took a battery, like your cell phone battery and flipped it. It would be like that feeling of red is like, I'm running out of time, I'm running out of resources. I don't have that much connection. I don't have enough energy. I can't get myself out. And even the military, when they first defined it, said that state of red, you're probably gonna need someone else to come in and get you. You can't often get yourself out. I think what's most dangerous about that red state is um, most rescuers, until we have this conversation, feel like it's a me problem.
Patrick Fink MD:I, if you're the hero, you're not supposed to show that kind of thing.
Laura:You're there. We actually, we have this resilience myth that heroes don't get injured by stress, and if they do, it's probably a moral failing. so that's where people get really trapped, where it gets kind of dangerous because. only do they feel isolated, they feel down on themselves. They don't feel like themselves is taking everything they have just to go to work or do whatever they're doing. They profoundly feel like they're letting other people down. And the worst part is it's a me problem. so that's why I think this terminology is so important. it gives us a greater perspective to say, no, it is a carbon monoxide problem. It's an, it's an exposure issue. You've been exposed to a lot of stress over time without mitigation, and this is a natural progression.
Patrick Fink MD:In my experience working in both the emergency department and outdoors prior to connecting with the material from the Responder Alliance, I would say that my, my experience has been that the focus on critical incident stress management. Is really for those like four alarm fires where everyone can recognize that something really traumatic happened. Maybe a, a very traumatic episode on the mountain or something that involves a coworker, serious injury or death of a coworker, maybe in the emergency department. A really traumatic patient experience with a pediatric trauma, for example. And I'm interested to hear your thoughts on those critical incident stress debriefings and where that falls into things. But I have always been a person who would rather not participate in that process, and it hasn't been useful to me. So I was very glad to encounter some of the other ideas about how to manage those stress injuries from you. I'll, I'll seed the floor. Let's start with, um, what are your thoughts on those kind of critical incident stress debriefings and where do they they fit into our world?
Laura:Let me say that the critical incidents. Stress debrief was one of the first great innovations of a generation. Think about the generation that started 1973 EMS Act where the the ER and paramedicine was born. You follow that in the late eighties or nineties? I'll try not to be an academic here, but you follow that, and there was a recognition that something needed to be done. Like, um, medics in a small town just pull up on their own family member and everyone was there and they're like, that was bad. We should do something. So that first impulse of, um, debriefing was to bring people together to help them kind of, to reorient and to get people kind of set on a trajectory of healing. a lot of times I work with, still use them frequently and. I think what I would say is maybe in your experience, those aren't helpful for everyone because they're not helpful for everyone. And that came out at least, and I wanna be clear that, um, and stress management are two different
Patrick Fink MD:Mm-hmm.
Laura:the early. Things, um, and in part, you know, early Lancet or articles that, that detail like, Hey, everyone's using these, but some people are actually, are having more difficult outcome work, re-experiencing who go, then don't go. I would say that in my understanding of the literature and kind of what happened next with psychological first aid and some of these next innovations, the problems may be such that If there are moments after something major happens, you definitely need connection. But the thing you probably need the very most, um, is to reorient, like to what happened, to kind of get the ground underneath you and it takes then time to reorient. So um, in my day job, I respond to a lot of officer involved shootings and mass shootings. I unfortunately just responded to one yesterday and. Again, all I did for the first day is said it's okay to be disoriented. leverage those innate, um, those innate capacities of connecting with each other, creating essentially psychological first aid, creating a sense of structure, having you involved in your own rescue, and then let's watch how you do over time. So the challenge for me with debriefing in the old days in ski patrol, for instance, I mentioned that tree strike back in, you know, in the nineties, I hate to say that word, but, um, it, the answer was like, let's go to the
Patrick Fink MD:Mm-hmm.
Laura:And it, we weren't wrong, right? It was like connection. It was trying to reorient before we went home to our families. There was some very good things in there. I think the newer technology says it is not a one size fit all technology. Some of us need to be with others, some of us need to be alone. Some of us, I'm gonna be kind of silly here, but this challenge with occupational health that I learned all through the pandemic was all mitigate stress and. Advance her own resiliency and nourishment in different ways. So where someone, one rescue, I literally work with an elite rescue team where one person needs to go home and pet their cat. The other person needs to be together, the other person needs to wear play Norwegian black metal in their basement. And if you just say, we're all gonna get together and we're. All gonna do this and you all have to be there. Some people are following a very, um, intelligent impulse to go spend some time by themselves and kind of let the state of arousal come down. And the minute you make'em come back in the room and talk about everything again, gets all fired up and they know it. And that might have been your experience. Some people are like, love, debriefing.'cause they're like, I need that connection. I need that reorientation. So what we've done in the last few years is to try and identify what components. be or helpful to kind of everyone structurally, right? 3, 3, 3 protocol that we've worked together to develop says at the three day mark, you're gonna still feel disoriented. By the three week mark, your state of arousal should be coming down. It's a great place for detection. And by three months probably should have really found reorientation. And if you haven't, then those are the points where we wanna stop and intervene. if we went after everyone in the first three days and said, you're displaying signs of P-T-S-D-A, we'd be treating. but B, we would be short cutting people's innate survival responses to come together. So we're more likely to give information and, and inject the skills. Of quote unquote debriefing into the patrol, into the rescue team, into the hospital, and try and get folks a little bit more, um, attuned to what to watch for in each other and who's at the highest risk. So that was a very long answer, but I, I don't wanna criticize debriefing outright because there's a lot of really incredible resources there. And the teams who are using them are using them to great effect. It was not working for everyone. So I think what's, what we're seeing more of now is the need for a wider toolkit so that some people have the skills to, to self deploy on their own stress. And we're seeing that in the military. They want every single operator to have the skills to self deploy on their own stress. then there's kind of a corporate plan for how to, to catch people.
Patrick Fink MD:Let's talk about that self deploying against your own stress. I think, um, the language I've heard before is, is like your green choices. What, what keeps you in the, in the green? How can people identify that toolkit to treat their own stress and. Make it effective. I'm thinking that the, the opposite of effective here to my mind are sometimes the safety plans that I see for some of my psychiatric patients, where it's like when I start to feel suicidal again, I'm going to watch YouTube videos and eat junk food, right? Things that are, that are not necessarily healthy and also don't, um, are hard to deploy in times of, of stress states. So how do people identify effective green choices for them?
Laura:Well, if you don't mind, I would take you back to the why of green Choices, because I think if you're in healthcare, if you're in rescue, if you've been in fire, you've been, if you lived through the pandemic, was a lot of conversation about just. sure you're self-care. Self-care. Take time for yourself self-care, I think we might miss the why, which I think is what actually motivates us to do it. told you about that stress continuum, one of the things I didn't mention is that it's somewhat of a predictive tool for tma traumatic stress. Um, what that means is that, um, when I, as a stress responder show up on scene, I actually am more interested in where people are on the stress continuum what they saw.
Patrick Fink MD:Mm-hmm.
Laura:And the reason for that is that the farther you get in toward the red, remember I said it was kind of a battery. It's like how much can you handle and respond to? So the people who tend more toward green have more capacity. To have hard things happen and not get injured. And this somewhat kind of answers the questions of how you could line up 10 people at the scene of something or in your ER and they could all see the same thing. And some of them are profoundly injured. I've seen this many times at at mass violence events profoundly injured, where some people are like, that was really hard, but I'm okay. Why? And in part it has to do with, you know. the way that stress becomes traumatic stress is essentially when we, whatever's in front of us is more than we can handle. So what might be missing from the conversation isn't just that we make green choices so that we get to be, you know, like go around, like, look at me, I'm glowing in green. It's literally making micronized investments toward your own capacity every single day. And auto correcting. you find that you're getting out of alignment, right? Where green just turned to yellow, you're like, whew, I gotta stop and fix. Because of us who deployed to anything, that could be a wildland deployment, it could be a very busy shift. You know? I know after all those years in the er, I didn't know if I went in the ER if I was gonna be there for three days'cause something happened or I was just working a SZ 12. so that idea that we make green choices as an investment in our own capacity, that's, I think what we need to hold onto because we have really no, no magic wands, and I don't, as a traumatologist particularly right now in this moment, to make the sad things untrue. I can't, there's only two things I can do to prevent PTSD. I can either make all the sad things untrue. Or what we're trying to do, I think, is to try and empower. Everybody, as many, everybody's as we have our hands on or everybody's happen to be first responders and medics and but empower them to live in a space where they have as much capacity as possible to integrate the hard things respond to the hard things when they happen.'cause your brain, something happens. You go, I can't handle this. It's already gonna put you in the trauma pathway. But if something sad happens, you go, this is really hard, but I can handle this at capacity for it, usually you're gonna be okay. So those green choices, a little worried and we're like, you know, people are like, is your whole, is the whole mission just to get people to like, you know, eat more green leafy vegetables and move their bodies and sleep? And I'm like, well, yes, but not for the reasons you think. It's really because we're trying to, essentially my patrol director used to collect carbo loading for the soul. We're trying to preload that people have everything they need. When the hard things come and if the hard things come, like I just said in that first three days, you don't have everything, everything you need, then we're gonna do everything we can in that moment to increase those green choices and decrease stressors to get them to a place of capacity where they can use their innate healing me andry, get themselves through this without getting injured.
Patrick Fink MD:To make this a little bit more concrete, would you be comfortable sharing with us what your investment on a daily basis looks like?
Laura:My investment in.
Patrick Fink MD:Yeah, exactly. You talked about making a continual investment in your capacity to handle these situations. I think it's easy to identify. Severe stress injury. You know, I, I think you've come, you've met Moose Motlow. He was on the podcast and he talked about realizing that he was in the far orange or the red because he was standing in front of his refrigerator door and could not make a very simple decision about what to eat. And it was his wife who recognized in him that he needed to go make that investment and that investment for him was to get back in the water, get back in the river, and, and paddle on the whitewater. What are the smaller things that you do that keep you in, in touch with the, the sources of your resilience? I.
Laura:Well, I feel like full disclosure, just like Moose, who's my dear friend? Um. I think that I don't have a magic wand for this. You would think like, I mean, it feels incredibly important for me to, to stay as close to green as I can because I'm telling other people to do it. But what I've learned coming through a pandemic, administrative changes, some very. stressors. My own cancer journey, like all of these things is that, um, it's not so important that I always in my glowing orb of green, that would be wonderful, but that I have a roadmap. Like moose, that when I get there, I don't think, I don't know what's wrong with me, I'm gonna keep paddling harder. Or like the carbon monoxide example, I'm gonna go to sleep and hope this goes away tomorrow, which we know that will end. So I have a real gentleness with myself, um, that even though this is what I do for a living. Most of us are gonna get to the red in our careers. I have in, you know, after Africa and, and I may again. Um, but what I love is that I know that'cause I, pattern recognition have watched a lot of people who never thought they could get from red to green, get back to green. Um, I think a lot of people right now kind of circle between green and yellow.
Patrick Fink MD:Mm-hmm.
Laura:yellow, yellow, orange. Strange. But, um, so that's important for me. So to me there's this kind of, um, that's sort of the what, what contains my efforts to stay green. I try to, to go with what's in the literature for myself. Um, I know that movement, and particularly running fast and lifting heavy things, stimulates my nervous system. To feel like I can actually discharge my stress and complete the stress cycle. So, so I lift heavy and I am a Nordic racer. I ski as hard as I can. I mountain bike in the summer. Um, I can tell, my friends can tell too, where I am on the stress continuum based on what my lunch looks like, right? And it's like the green with all the, like, you know, you work the shift and people look at your lunch and like pumpkin seeds and like what you like really
Patrick Fink MD:I can relate to that completely. It's the end of the difficult shift when I get garbage food out of the cafeteria.
Laura:Yeah, right. When people are coming to do three days into a shift and they're like, you're eating Trader Joe's Res, like you just. Tore open the lentils and you're just eating it out of the, I mean, all have those metrics and so I often try and pay attention and I want my people to know too, and they're like, Hey, trader Joe's, Emory's. Like I, I just had one of my stress buddies call me this morning, is like, Hey, really? For real? I haven't heard from you. I see some markers, you know, what green choices are you making? And so again, there those, there's exercise, there's nutrition. I mean, sleep is a huge harbinger. Like we, we actually mitigate traumatic stress in our sleep. We clean our, you know, glial cleansing, like we clean our brains when we sleep. We consolidate learning. Uh, it's the first thing I work on with my patients and. You know, I have sort of a stress continuum from my sleep. Like having an eight hour sleep opportunity, I'm gonna sleep or not, is a sign of green for me. So that's kind of how I think about those things. If folks are listening and thinking about green I would also say that because we're living in such a condensed dense time where we've lost so much of the margin we had even before. COVID. We wanna make things count. So you might take that green choice space from the freedom of other minds or space for integration, combine that with movement, combine it with nature or creativity. And to me that's, you know, when I go on a Nordic skier, I'm racing with a friend, I'm like, well, I just hit four green choices in the Venn diagram when I'm, when I'm playing my fiddle. With other people and we're like in creativity and laughter, I'm like, oh, I've got connection. That's a green choice. I've got creativity, I've got joy and kind of learned my own to start checking those things off. And I think you'll know too what it feels like, the version of the Trader Joe's MREs, when you're like, I'm just working. I'm not doing anything that I love. I'm not getting outside. is not sustainable.
Patrick Fink MD:I like, I like all of those. The reaction that I have to, let me, let me start over and rephrase this by saying I like that there are individual tools. I think it's also important for the organizations that we belong to, to help support the individuals that are accruing stress there. Right? Like I, I totally agree with you. Ski patrol is a great example of a setting where people really can accrue. Stress injury. And it can be really written off with that. You know, you get the, the best your, your compensation is to go ski, right? You're, you're poorly paid and poorly supported'cause you get to ski and because
Laura:Two And lunch is what
Patrick Fink MD:Yeah.
Laura:That's you getting paid and two Es and lunch. Yeah.
Patrick Fink MD:So how, how can organizations best support their members? When I think about what I have seen in the past, it's kind of painful. Like when I was in residency, loved my residency, but burnout became a big subject in emergency medicine. And so the, the main response to that was we're gonna have some talks about burnout and then we're gonna have some mandatory fun where we're gonna schedule you and you have to do a fun thing.'cause that's how we prevent burnout.
Laura:It's really
Patrick Fink MD:Oh, I hate mandatory fun. I got in trouble for skipping out on mandatory fun to have real fun and. I know you have a better structure that you can offer. What does, what does that look like for a ski patrol that hasn't worked with your group before to implement a program to help support their members and help prevent severe stress injury?
Laura:So programmatically you're asking or.
Patrick Fink MD:Yes. I think it's great that we give people the tools, but we could fall into that same hero trap, right? If I'm, if I'm not managing my stress effectively myself, I should know all my greens, I should be able to take care of myself. If I'm not, then I'm just failing at one other thing in my life, and that's my personal problem. I think it's important to have a structure also that creates resiliency within the organization so that if, if someone is not able to get themselves back into the green, there's a way to help them back into it.
Laura:Yes. I think there's a few things that I can point to that have been really effective. Um, we also pilot them in healthcare during the pandemic and in ERs of the VA and other set with residents. the first is recognition. Always. I said that before, you have to know what you face before you know what to do about it. we were not working with the stress continuum. I was not for very long before I realized that that teams and organizations. units could be injured by stress, just like individuals. So if you haven't seen it, we actually created the stress continuum for cultural, um, application and organization. So the attributes would be like in, in the organizational green, you would have, um, more of mission cohesion. Um, problems would be faced collectively. There would be a sense of cohesion. And support. And then that would start to fray in yellow where people would start kind of doing their own thing and blaming. And then an orange, maybe we'd see more silos. I'm not gonna call mandatory fun gaslighting, but it is, it's troubling. Um, and then I get the spirit of it though. And then red would be like, don't trust the leadership. Don't trust each other, every
Patrick Fink MD:Mm-hmm.
Laura:themselves and, and drift. And what we learned pretty early on is that. Individual humans like you and I might say, I'm gonna bring my green leafy salads, I'm gonna go to the desert and my time off, I'm gonna do everything I can to leverage my own green. But then they were working in environments. As soon as you got back from the desert, two days in, it's already pulling you into orange because the environment collectively was quite orange. And so we actually created a, a course for the stress stress and your awareness for teams. And what's interesting is that the, that the treatment is in some ways the same if you have a collective understanding. Um, the green choices for teams and rescue, for instance, are, what are you doing? For cohesion and connection. What's your mandatory fun version like when you're at the rescue, you know, you finish a rescue and someone's got chili in the crockpot. Are you gonna stay a kind of a tradition? Are you in the Christmas parade for rescue together? Are you, are there things that you're doing that feel missional to you? Um, how do you relate to each other? And so we actually built and. about programs like the Denali program after the pandemic, like reinstating some of those things that have been lost in the pandemic. Like, Hey, when are we gonna get together? I remember that first year of the pandemic, they went out, um, out on one of the rivers and they're at, at this big, at the end of the season, like a big softball game. And the same happened in Jenny Lake. Um. They used to have a Thursday night softball game, like, where are we playing together? How are we keeping this together? So very tangibly asking teams often, and I just worked with a, an elite team this week and I say that like their high, reliability operators in the military. you know, I asked'em to kind of map that out, like, what does green look like in this environment for you? What does it feel like to be on a team that screen and what are the choices that you could back? And it was really fun. They're like, why are we eating our lunch in front of the computers? Like on Wednesdays we're gonna go outside and here's this amazing humans in uniform, men and women mustache, um, who were like, it's skinny Jean Friday, where wear civvies and let's, we're gonna do this run together. Let's bring play back in. Let's bring, and so those are the green choices of the organization. And what I'll say has been working, you know, responder Alliance actually has supported the formation of resilience teams, embedded teams on a patrol and a rescue team, and an ER whose sole job is to look at from one another and bring those green choices into culture. what I think has been very useful, um, so there's a course on it. There are resilience teams where teams can get memberships and work on these skills. It's been really fun to watch it over time. But what I, I think that's meant over time is that I've started to see leadership actually hire or interview. Like imagine if they'd said in your er, um, Hey, during your interview process, we value, quote unquote green people. Who make our green, our team more green? What do you bring into the table? How do you take care of yourself? How do you take care of your teammates? when you recruit for that, you immediately say, this is what we value. And in the first year, all your residents are like, I better demonstrate my green. I'm gonna say, Hey, I'm making a green choice. Or, Hey, let's make a green choice together. Because you know, that's what leadership values. If you think as I do, when I started, I won't tell you where, but level two trauma center in my twenties, those nurses who could like start IVs on babies in the dark, they were so incredible. They're incredible. They, they were also teaching me how to go out drinking at 9:00 AM in the morning and two marriages in, you know what I mean? Like the culture was. you're gonna be good at this, you're also going to have all these attributes of
Patrick Fink MD:Mm-hmm.
Laura:what we need is to change that cultural relationship to say no. What we actually value is professionalism, cultural competence, and how much you bring green to our team.'cause that's our best shot at surviving. something terrible walks in the door.
Patrick Fink MD:That's interesting. The admirable nurses in your early career who are also modeling bad behavior, that's probably tied back into that generational nature you were just discussing, where that first generation of emergency responders, at least in the US from the seventies to say the nineties, were all figuring it out and figuring out tools that were maybe less effective in the long run. Natural, but less effective. Right. Um.
Laura:I would call them adaptive behaviors rather than bad.
Patrick Fink MD:Sure. Uh,
Laura:they had no guidance and they were and they were coping with their injuries as best they could while trying to teach their young how to get by. And I look back on them and I'm like, I really, I, I could see how they were trying to be like. kid, don't get emotionally involved. If this is getting to you, you should go somewhere else. It sounds really harsh, but they were really trying to say like, this is the best I figured out
Patrick Fink MD:right.
Laura:injured and still take care of other
Patrick Fink MD:Yeah. Those adaptive behaviors that later become maladaptive or no longer serve you. Um, so now we have a, a chance, I guess, to set a, a different culture and have the people that we admire in our organizations model a different form of resiliency. Some of the people that I think of who I admire the most in that respect are, are the most open about their experiences and how they were emotionally impacted by them. And I think 10, let's call it 15, 20 years ago, that might have been seen as a sign of weakness. But someone I'm thinking of off the top of my head is a, a friend of mine, drew Hardesty, who you've, you probably know, who is very open about his, his mind, his experiences and his wisdom, and that vulnerability seems to feed into his resiliency in a stressful profession as an avalanche forecaster who has weathered quite a few accidents in, in Utah and, and his life as a Jenny Lake Ranger. Before that.
Laura:We could spend quite a lot of time on, on talking about what's going right with Drew Hardesty. Um, he's me, my junior wood check forecasting designation. Um. And I will say that he, you're right, the leaders of the industry who've had the courage to say, I mean, I think one of the most helpful things that Drew's ever said to the avalanche forecasters that I support, um, down the line I fucked up that forecast and this is how it felt. And to bring that into avalanche. about the role of shame in forecasting and you know, I think after the Wilson's grade event, we hosted an event together. We're like, you guys, let's talk about the 3, 3, 3 in avalanche. Like he, he's a great example and he, you know, I've been out skiing with him, with his kid on his back. Like we try and play together more than we talk about work. Um, he practices what he preaches and. That's, I think where like we talked about those resilience teams, those teams, we always try and get a few reference leaders who are kind of the ones, the evergreens I'll say, who've somehow managed to stay. They, they either got to there and back again, or they've stayed green in their careers. And I don't mean that they don't leave skin on the pavement, but they still love the job. They have a passion for it. They have a passion for teaching new folks. Um. That's the resilience team idea, right? Like, let's put the city, city on a hill, those bright lights in front of folks and say, this is actually who we want you to grow up to be. And so, um, I think if folks are listening and they, they know those people, first of all let'em know that they're influencing and second of all, you know, follow them home. This sounds like I'm gonna say something creepy, but know. Researcher, like them about their s like ask them what they eat for breakfast. Ask them what you'll find in those people. And I went throughout my dear friend Drew and Moose is another one. Go listen to his podcast. Like what's kept him engaged for all these years. You find out that they actually have very, um, they have a strong commitment to their green choices. off work. Like, I remember Drew going to Japan in the middle of an avalanche season. I was like, can forecasters even do that? And he is like, well, I'm doing it right. They, they go to the woods, they shut off their phones, they spend time with their families. And I can, I can, you know, I'd love to start calling out my friends. I think about, you know, Nick Armitage and the Tetons and the people who we look up to patrol directors who are like, sorry, it's five o'clock. I'm with my band, I'm with my family. I have a life outside of the uniform. I have rituals that I do every year or every day that keep me this way, and I do not falter. And so that's why I would encourage people, and I can think of a lot of them, of the great fortune to work with, some of them who've been out it 30 years and can stay green. It's because of these rituals. So ask them if you're like, how are you staying so green? They're gonna tell you that they made a commitment a long time ago. To take care of themselves and they've stuck with it. And that's when I, when you say green choices, I get a little worried that we're like, get, go to your yoga class and drink your smoothies. It's much grittier than that to me. They're making green choices when they're hard. They're making green choices that work for them, and they're making green choices out of a deep commitment for their family and for themselves.
Patrick Fink MD:I don't have anything to add to that. That's, I love that. Um,
Laura:You ask them, don't say, Laura, I'm glad you asking me and ask you of what you eat for breakfast. You gotta be a little bit
Patrick Fink MD:maybe I'll have him on and I'll just ask him what he eats for breakfast.
Laura:Do it. Yeah, do it. You have him on, have him on and ask him about his green choices. And he wasn't a we, you know, he'll tell you like, I've been there and back again, but this is how I got here. And I think we need more of those conversations and, and more inspiration that you can get all the way red.'cause a lot of us will. And the, the problem with getting to red when you're in others before self person is you can keep operating for a long time
Patrick Fink MD:Mm-hmm.
Laura:red people keep. I kept secrets, like, I'm cool, I'm fine, and all the Y, like I'm not fine, but I don't know what's wrong and. What's happening is they're still serving everyone else, but it's coming at great personal costs. I no longer think of like high reliability responders as like, you get to the red, we should take your badge and a gun. You shouldn't be hoisting, you shouldn't be injecting medication. I just say, this is, you're smoking under the hood. This is gonna have tremendous impact for you or your family and your life. I know you can do it, but please don't.
Patrick Fink MD:Yeah. For me, I find that even when I'm burned out, I can still be very highly functional at work and at least would probably be perceived by the people around me as being highly functional. But where the, the fallout happens and where the warning signs show up is in the rest of my life where I don't have the same energy and capacity to bring home to my family. And so it would be easy enough for some of those around me at work to think, oh, this is going okay. Unless maybe they're picking up on the, the Trader Joe's res or the,
Laura:That's
Patrick Fink MD:the, the chocolate cake. Uh, to be fair, I eat that when I'm green. Um,
Laura:I think chocolate cake's a pretty green
Patrick Fink MD:yeah. Well, I'd like to wrap this up by saying I think there's probably folks out there who are listening to this and they say, I want to be able to work a full and fulfilled career doing the stressful thing that I do. Where should they look to in Responder Alliance to learn more? I.
Laura:So on the Responder Alliance website, there's an opportunity for folks to take their own individual classes. You talked about self deploying your own stress, so maybe you work at an organization that doesn't yet have this kind of a stress mitigation. Program. Um, skill sets there are psychological first response, incident support, and then stress injury awareness for the individual and the team. we'll see, this is kind of exciting, but we'll see a desktop, um, app that will support, um, teams reporting on their own stress levels guiding them through that incident pathway. Um, coming out in the fall, which is pretty exciting. there is an opportunity with responder lines too. You can reach out for team membership, like, Hey, an avalanche center, we're an er, we're a larger organization and we wanna take more steps. To really get my, get those first line, um, change agents trained on this so we can get this into our culture. So would say those are all, those are all great possibilities and all available through responder alliance.com. if you'll let me put in
Patrick Fink MD:Please.
Laura:um. If you just happen to be that person. Uh, well, there's two things. If, if, um, finances are an issue for you, we do have, there is, um, a new 5 0 1 C3, the Responder Alliance Foundation that supports folks going through that process, um, to get funding. Or to enroll in what I shared with you at the year one campaign. So for folks who may be on their own or maybe as a cohort, say, Hey, we wanna train on this from the beginning. And that's a guided, um, skills-based habit science. And program to try and get folks in their first year. But I would say the plug is too, if you also happen to, to have that rich uncle who loves heli ski guiding and really wants to invest in the future of guides, please tell them to donate to the foundation. Because the problem we've been trying to solve there for me for many years is I go to these incredible ski towns and beautiful places all over North America and now in the world, Uh, the folks that I'm supporting who are on the front lines don't have enough money or
Patrick Fink MD:Mm-hmm.
Laura:line in their program, stress mitigation. but yet I'm staying in someone's$4 million house. So we're trying to bridge the people who deeply care the first responders and the ones who actually need that training because unfortunately. You know, unlike some cool, you know, New Zealand, Scottish Mountain Rescue, we don't have a federally funded or a hospital funded program to tell us about this injury type. So we're kind of, doing it from the ground up.
Patrick Fink MD:Uh, thanks for the work you do. I think you guys are really, you, you truly are saving lives, not just those who would be lost to suicide, but. People who otherwise would be torn up by their careers and, and finish wondering why they had spent all that time doing the thing that they used to love. And instead now hopefully are, are learning the tools to stay in that place where they appreciate everything in their lives, including, including their work. And so I, I thank you for that.
Laura:Thanks I, that distinction is really important to me that, um, you know, I remember many years ago, one of the, he was a law enforcement officer. I used to teach wilderness medicine with who I really cared about, who wrote and said. I have everything in my world that I want and love, but I can't find a reason to live. despite going on and being very brave in that and still doing that, I think what we're working on here with this particular problem is saving living.
Patrick Fink MD:Hmm.
Laura:Like really living, not just going through the motions, um, as we unfortunately do sometimes as first responders and healthcare responders. So that distinction may, I do think lives will be saved, but I it's, it's so meaningful that we save living because those of you who are out there doing this work are the climate responders. And the ones protecting the resources and protecting the people and protecting science and protecting our world and our people and our communities. So what is also deeply meaningful is that we could do that with vital vitality and creativity. So thanks. Thanks for your time. And what a great conversation.
Patrick Fink MD:Thank you for coming on. When I'm in the green, I feel grateful to be part of the network of folks who are kind of helping to be the net under society and you are and your organization are the net who are under us, and I appreciate you for that. I.
Laura:Well, thanks so much and, um, make sure to make Drew Hardy tell you all his green choices and, um, think of me the next time you're eating a Trader Joe's Emory at the er. Hope to
Patrick Fink MD:Oh, thank you Laura. I appreciate you taking the time. So that's it for this episode of Wilderness Medicine Updates. I hope that that was valuable to you. I feel like no matter what capacity you are in, whether you're a recreationalists or a professional operator, a rescue team member, or working in healthcare, this is super important information and something that we can all apply to our own lives. Something that became. All the more important after we all learned our maladaptive coping mechanisms during the COVID Pandemic. Please take a look at the resources that are down in the show notes that let you connect with Laura Mc gladly and the Responder Alliance and learn more about this. Learn more about the process to administer psychological first aid to yourself and others. And the steps that your organizations or your teams can take to build a peer support culture that prevents cumulative stress injury. This does, as Laura said, both save lives and save living, and helps support us in long, healthy, enjoyable careers doing the things that we have loved from the very beginning. If you know someone who would benefit from this podcast. Please share it with them. I think that there are a lot of folks out there who would benefit from hearing this material, both the the new folks on your team, as well as the Grizzly Mustachioed ladies out there. And if you have any thoughts on the subject or have any questions, as always, please reach out at Wilderness medicine updates@gmail.com. And until next time, stay fit, stay focused, and have fun.
