If I? Moral Injuries

I have spent time writing about Post Traumatic Stress Injuries in first responders. I have tried to educate both responders and the uninformed about my personal struggles in hopes that through recognition, reasonable solutions can be found.

But there is another demon hiding in the closet that is seldom recognized or acknowledged. This demon is Moral Injury. Moral Injury can occur as a result of traumatic event(s) that violates our deep seated moral beliefs or values. It is the intrusive second guessing after the fact, of decisions we made or failed to make during the “heat of battle” when we were forced to make rapid life and death decisions. Decisions that may have been based on training or protocols but are conflicted with our moral beliefs or values.?

Here’s a few of the causes associated with Moral Injuries;

Making decisions or having made decisions that impact survivability of those in our care.

Not being able to care for or comforted those that are injured.

Freezing in a crucial moment or failing to preform duty.

Not reporting an incident that crossed an ethical line.

Feeling that your actions killed or caused further harm.

Being forced to decide who was treated and who died.

Common feelings associated with Moral Injuries;

Guilt that involves feeling remorse and/or distress over traumatic events. Questioning if I did something wrong or could have done more.

Guilt from feeling numbness or indifference from death.

Guilt from feeling excitement in life and death situations.

Shame can develop when an individual generalizes their feelings about an event or events (I’m bad because of what I did or didn’t do)

Disgust often develops as a reaction to memories of participating in traumatic events.

Anger often develops as a reaction to loss or feelings of betrayal.

As responders we respond to life and death situations. Many times at these incidents we must put aside our personal feelings, our moral compass and rely on our training.?

TRIGGER WARNING: An example that quickly comes to mind for me, is the numerous vehicle accidents I have responded to. Where a drunk driver crosses the center line hitting the innocent family. We do our triage, save those that are savable, while the others perish. In some cases we are able to offer comfort to the innocent as they pass. In other cases all our efforts and resources are on the savable even though in our hearts and deep in our morals we know they have killed the innocent. I have been faced with the dilemma and have had to talk through the dilemma with other responders while on scene. Making the argument that while this person caused a catastrophic chain of events that has killed, maimed and changed the lives of many innocent, we must do our job and leave justice up to the courts in the future. I have no doubt that there are many responders that have left the guilty to perish on scene or even saved the guilty, that now second guess that decision. As responders we live in a world where the right thing to do isn’t always the moral thing to do. Or that the legal thing to do is the right thing to do. And no mater what your final decision is when faced with this dilemma, it can have consequences that impact you far into the future.

How many times have you questioned yourself? If I’d just moved a little faster, tried a little harder, noticed that….., it would have changed the outcome. These are the intrusive thoughts that grow into monsters we eventually have to deal with.

While Moral Injuries have been recognized in Combat Veterans, with specific treatments by specifically trained clinicians, it is fairly new to be recognized in the first responder community. We can only hope that clinicians trained in Moral Injuries start to accept and develop treatments for these injuries in first responders. The first step with any injury, whether it is Post Traumatic Stress Injuries, Moral Injuries or physical injuries is to acknowledge you are injured. You won’t find the solution in self medicating the pain away. Seek out programs that you think might be of help. There are more and more grassroots programs with sound medical modalities showing up across the country. Don’t be afraid to try one and if it doesn’t work for you, it’s not defeat. Try something different.

Remember these are injuries that can be healed with the right care.

Steven Schreck (Ret. Batt Chief, Firefighter, EMT)