When you are working a medical incident, does your team take care of all the patients or just those with visible wounds, obvious symptoms, and the loudest complaints? Do you take a moment to look around? What about that loving spouse peering over your shoulder? What about that the less than obvious survivor hanging back just beyond the edge of the action? Over the years our volunteer EMTs have become proficient at comforting loved ones. We have individuals who know just when to counsel the elderly woman who just watched us unsuccessfully perform CPR on her husband of sixty years. Even though this is not a popular duty, it is one that is undertaken with compassion and professionalism.

Earlier this year, after reading Ray Giunta's God @ Ground Zero which chronicles the activities of "Chaplain Ray" working at Ground Zero following the 911 terrorist attacks, my eyes were opened to other victims. Chaplain Ray worked with numerous firefighters and police officers who experienced survivor's guilt as they witnessed hundreds of their comrades dying in service to their fellow man.

"Why am I alive?" was the question that haunted many of these heroes. Tragically, these walking wounded were not counted among the victims of those barbarous attacks. Like the physical victims of the terrorist attacks, these emotional casualties were not limited to rescuers; many every day citizens felt the same remorse. These were office workers who survived. Some were rescued, some got out on their own, some were just out of the office for the day, and some were just casual bystanders witnessing horrific events. I was moved by the immense emotional pain these people bore and how the author and others were able to bring peace and serenity to many shattered souls.

I began to ask myself how this might apply in our small rural volunteer fire district. We have a pretty good support system for our members including a regional Critical Incident Stress Debriefing, but there is little support for those suffering from collateral damage.

Ready or not, the answer was less than 24 hours away. I was home early from work the next day when my pager sounded. The call was an amputation at the boat launch on our local lake. Since the patient was about a mile from my house I preceded directly to the scene. While en route I asked our dispatcher to launch the medevac helicopter since we were more than 20 miles from the trauma center and it was rush hour. I was distressed to discover that the air ambulance was grounded as a result of an impending storm which was due to arrive at our location within the hour. Let's take stock: I am arriving on scene as the sole EMT, the most rapid means of transportation has been taken away, a major thunderstorm was looming over the horizon and I had a patient with a missing limb. I thought I would be the one needing comforting.

As I arrived, a very anxious deputy directed me toward a ski boat. His demeanor was my first clue that the situation was dire; usually these deputies are cool as a cucumber. Climbing into the boat I discovered a twenty-five year old woman sitting in a pool of blood with her arm severed at the elbow. Needless to say, she and everyone around her were very traumatized. This vibrant young woman had taken on the appearance of a small, wet, and bedraggled child. Although I have been witness to numerous traumas, this was my first amputation.

I worked quickly to stem the bleeding and reassure the patient. As I would later realize the role of comforter was just as crucial as the medical care I rendered. She was a young mother whose life had changed forever. Would she ever be able to cradle her children? Would her marriage survive? As we later discovered her husband was apparently at fault for this terrible accident.

As I sat holding the remaining part of my patient's arm in hopes of controlling the blood flow, additional firefighters and EMTs arrived and immediately took action. I soon realized that their response was quite rapid even though the minutes crept slowly by as help seemed to inch toward our location. Anyone who has to wait on scene alone can certainly empathize with patients who claim it took us forever to respond.

Once we had a full crew on scene our volunteers worked like a well oiled machine. Without instruction everyone recognized a need and filled it. Anyone who believes volunteer firefighters are not professional has never seen our team in action. Moments later the ambulance arrived and our patient was quickly loaded and off to the trauma center.

As the ambulance sped away, the events of this heart wrenching afternoon became painfully clear. After completing a home improvement project for John, Barry and his wife Amy were invited out for an afternoon of fun in the sun on John's boat as thank you for a job well done. As the day progressed the sun baked and the beer flowed. Since John was also trying to tempt Barry into purchasing the boat, he let Barry take the helm. As Amy sat on the bow taking in the sun and the spray Barry pulled a quick turn and in the blink of an eye Amy was under the boat and their lives would never be the same. Somehow the boat ran over Amy and her arm was severed by the propeller.

At that tragic moment John sprang into action swooping Amy into the boat and wrapping her damaged limb. As Barry sat by in shock, Johns' measures saved Amy's life. Calling 911 they raced to shore where they were met by the Sherriff's marine patrol and later by me.

What we hadn't noticed as we were caring for Amy was that Barry sat powerlessly in the back of a patrol car painfully observing a group of strangers huddled around his wife. Barry was under arrest for assault with a watercraft. The deputies determined that Barry was intoxicated and thus criminally responsible for the injuries to his bride. Looking back I am not sure which was a more terrible sight, the feeble rung out young mother or her helpless husband longing to somehow turn back time while not even able to offer comfort to the one he loved.

This was when the news crews started arriving. As volunteer firefighters we generally do our best to avoid camera time, and today was no exception. Since this was a crime scene, we were able to let the deputy do all the talking. However, I was not off the hook for talking, for forgotten and alone was another victim, who was trying to avoid the press with even great fervor; John the owner of the boat.

John had also consumed a few beers but since he hadn't been in control of the boat he was not under arrest. Because John had been drinking the deputies would not allow him to drive home. Consequently he was alone with his thoughts as he waited for his wife to pick him up. Understand, it was John's boat and John had purchased the beer, so John sat hunched over with the weight of the world crushing down upon his shoulders. For in his mind, these shoulders bore the responsibility for this tragedy. That is why I knew it was my time as the deputy chief asked if there was anyone who felt comfortable speaking to John. Did I feel comfortable? No way, but I felt prepared, because I knew I was not alone.

John was a collateral victim, wounded with survivor's guilt. As EMTs we are trained to recognize the outward signs of internal bleeding; pale skin, rapid pulse, distention of the abdomen, life threatening conditions that we cannot treat in the field. Our only hope is to protect the "core" and get the patient to advanced life support as soon as possible. John was suffering from another kind of internal bleeding, from open wounds of guilt. I knew all I could do was protect the core and try to stop further harm. By protecting the core I hoped to lessen the formation of permanent scars of guilt, which may never heal completely.

As I approached John I recalled the words Chaplain Giunta first said to the survivors of 911. I simply asked that same question asked hundreds of times in the shadow of the ruins of the Twin Towers, "Where were you when it happened?" That simple question opened the floodgates of emotion, and that's when I saw the signs of those ugly red ulcers of guilt, still seeping vile poison into the soul. I was treading on foreign soil, I had no training, I did not speak the language of a counselor, all I did was say a prayer as I approach John. I was much more comfortable stemming the blood loss from a severed limb than mending a fractured soul. But it was not about my comfort. I don't really remember everything that I said, so if you are looking for pat lines borne of human wisdom to use in times of heartache, you won't find them here.

John bore the yoke of responsibility for the events of the day. My goal was let John know that he did not have to shoulder that weight alone. At first, John just wanted my promise to keep him away from the news cameras. I told him that he was my patient and that it was my job to protect his confidentiality. That was the emotional release that John needed and he just talked. On occasion I was led to inject a comment, trying to lighten the blame he felt.

When I discovered that immediately following the incident John took total charge of the situation, I stopped him; it was my turn to speak. What struck me was that John had saved Amy's life. Barry was certainly not able to help; Amy's future had rested on Johns' broad shoulders. When I verbalized my thoughts to John, he looked at me in stunned silence, as until that point his vision had been clouded by black clouds of guilt. Finally, his face lightened just slightly as a ray a hope pierced the darkness. He responded that he used to be a firefighter and that he was just doing what he was trained to do. The next break in the clouds came as I pointed out that this event may have been the purpose for all those years of training; causing him to respond as a professional rescuer rather than react as paralyzed amateur. As Johns' wife arrived with her comforting touch I could see that even though the skies were still overcast there was sunshine in the forecast.

Later that evening I received a call from one of our EMTs who had accompanied Amy to the hospital where she immediately went into surgery. Waiting outside surgery John saw our EMT and gave her a big hug thanking her for that guy who took the time to help.

With all the trauma I have witnessed in my career, all the wounds dressed, all bones set, all the lives saved, this experience was by far the most rewarding. Not that I am ready to venture into a career in the chaplaincy or grief counseling, I am happy just being a simple firefighter/EMT.

What I learned through this experience was that we need to search out these collateral victims. Most likely they will not come to us. It is like Hazmat Awareness training; you are not expected to go in with a bucket and squeegee and clean up the mess; you just need to recognize the problem, keep the press from stepping in it, and find someone better equipped to alleviate the issue. Just like hazardous materials, grief and guilt will spread causing permanent damage if not properly mitigated.

Bob Kolva is a volunteer firefighter and EMT with Newman Lake Fire & Rescue in Newman Lake, WA. Since joining the department in 1991 he has served in various positions including captain, training officer and chief, and has authored articles for several fire-rescue publications.