Andrew Rose talks to Courtney Moreno about her new novel, the specter of PTSD, and hazing in medicine.
Photo by Lydia Daniller
Courtney Moreno’s début novel, In Case of Emergency, depicts two women suffering in varying degrees from unfathomable pain and stress. The book opens with Piper, a newly minted emergency medical technician, trying to learn the ropes at an ambulance company. Piper is confused and distraught and suffering from a long-ignored wound. When she falls in love with Ayla, a veteran coping with severe post-traumatic stress disorder, Piper begins to understand what it means to work through and truly experience her own pain rather than attempting to will it out of existence. The acute stressors of being an EMT grow more and more insistent as Piper must learn to confront her past and herself. Piper’s first job as an EMT is navigating for the ambulance; her steadily improving grasp of the topography of Los Angeles is countered by her steadily deteriorating ability to function in the city.
Moreno was an EMT herself and the book’s graphic but clinical descriptions make for a taut frame around which the irregular and unpredictable sinews of a woman’s life can be delimited. In Case of Emergency uses the lives of EMTs and soldiers to show how trauma can break us apart, and how it can also bind us.
—Andrew Rose for Guernica
Guernica: I read your piece about being an EMT in the LA Weekly. Could you tell me about how you first started as an EMT? A lot of the experience you describe is also in the book, this kind of optimism followed by a high rate of burnout.
Courtney Moreno: I think that observation comes from being an EMT and also from being a field-training officer. At some point I got really curious about if there was a certain personality type that was more suited to that type of work. Because especially after I had gone through my first cycle of burnout and then come back out again I started to wonder if it’s just me, am I not able to do this kind of work? Am I not cut out for this and other people would be? But then as I started to train people and watched them go through that experience. I saw the same thing over and over again no matter who they were, no matter how old they were or where they’d come from—that’s when I started to realize that, no, this is actually part of the job. And it’s part of the job that no one talks about, which I think is really kind of terrifying.
Guernica: Trauma and what happens to you as an EMT are obviously really big themes in your book. I was wondering, because you have the two protagonists, Piper and her girlfriend Ayla—Ayla is recovering from PTSD—and it was interesting to me because they’re both dealing with trauma but at kind of different points on the continuum; they’re kind of sliding next to each other.
Courtney Moreno: The idea was that Ayla is much more recovered—or at least has kind of made peace with where she was—so she was sort of dealing with her trauma and the aftershocks of her trauma head-on and is very blunt about it and realistic about it and she knows that it’s like a daily thing that she’s struggling with, whereas Piper is more in denial and more trying to escape the reality of it, so that was some of the tension between those two characters.
There are some really subtle, haunting, weird ways in which EMTs work that can be so compelling and disturbing and heart wrenching.
Guernica: It seems like you learn so much from the people that you treat on the scene. Especially in the book, the one patient who can’t function—that’s his chief complaint.
Courtney Moreno: That was also a real call and one that I found particularly haunting. I remember the lead medic being just really bewildered about what to do with this patient, and people at the hospital also not knowing what the next step should be. And I felt like it was this really fundamental thing—who hasn’t felt like that before—where you just hit a total wall and you just say, I can’t do it. But again, if someone makes all these assumptions about what it’s like to be an EMT, it’s just like trauma, trauma, trauma all the time or something like that—it’s like, no, there are some really subtle, haunting, weird ways in which we work that can be so compelling and disturbing and heart wrenching.
Guernica: It’s not just the two principal characters: all the other EMTs, or at least most of them, seem like they’re also in a kind of transitional or a liminal state. Was that your experience: that most of the people you worked with wanted to be somewhere else?
Courtney Moreno: It’s definitely thought of as being a stepping-stone sort of job. There are a couple of people I know who are in it for life; they don’t have an interest in working in a hospital or fighting fire, so they decide that’s just what they’re going to do, but they’re very few. Generally people are looking to get some experience and put it on their résumé and say, Hey I did this thing, before going police, fire or medicine—those are the three most obvious. And military, too; sometimes people go right from there to the military.
This isn’t just show up and do what you can. It’s this other way of thinking; it’s the medical way of thinking of who can you save? Who’s going to take the most resources? What’s going to make the most sense?
Guernica: One of the things that really stuck with me is when Piper discovers a car wreck and she goes out to the victims and starts putting black and green dots on their heads for triage. I think this idea of triage is really interesting in terms of trying to deal with trauma, trying to prioritize.
Courtney Moreno: That was one of the first things that we learned in EMT school. I remember feeling this really abrupt shift in myself of, like, Oh, wow—this is gonna be the new way to think about things and it was very unfamiliar at the time. And triage is an extreme example, which is what I wanted to use just to set a precedent. But this idea, that someone could basically still be alive and you would say, No, this person’s basically dead, considering that we don’t have enough resources and there are people who have a better shot making it and so they’re going to be the priority right now, which, in a normal circumstance, even if someone’s dead you do CPR; you would try to bring them back unless—there are a few really obvious markers. So that idea on the first day of EMT school, of triage [laughs] it’s like, Oh, OK, it’s a whole new world. This isn’t just show up and do what you can. It’s this other way of thinking; it’s the medical way of thinking: who can you save? Who’s going to take the most resources? What’s going to make the most sense?
Guernica: Absolutely, a medical way of thinking, because the book also has a lot of precise medical terminology, you know, sinus rhythm, things like that, and I thought it was interesting to contrast that with the real trauma and what Piper’s going through in the novel. How did you feel about putting such specifics in there and how that works to contrast with her experience; it was just very interesting what you said that anyone who comes into this is going to come out traumatized or having to deal with it in a really serious way as you do.
Courtney Moreno: I think there’s this way in which medicine can be very comforting. It can also be a promise that we’re going to be able to name it and we’re going to be able to cure it and we’re going to be able to treat it—that once something is known then everything’s going to fall into place. And definitely with the EMT mentality when you’re trying to do everything you can in basically 20 minutes or less and then get them to the hospital immediately, you just have this very tight window and these very tight corners in your decision-making. I think that was something, too, about working as an EMT where you want this world to offer us a certain kind of comfort or believe that it can and then you realize it’s got its limitations.
Guernica: It’s too bad, but I’m pretty sure every medical practitioner has to deal with this where you get into the job and you feel these ideals—you really want to help people—but it seems to me that the first thing you learn as an EMT is that you can’t help everyone.
Courtney Moreno: Right, exactly.
Guernica: You can’t even save many lives; it’s mostly just stabilizing them.
Courtney Moreno: Yes.
Guernica: So you trained other EMTs? What was that experience like? You said that everyone pretty much down the line ended up where you were.
Courtney Moreno: Or their own version of it somehow. It was really interesting to be a field-training officer because there’s something so raw about the people coming in—and I know I was like this—but you sort of get to see everybody’s take on it and it’s a real quick evolution. Either they adapt or they don’t. I’ve seen people who started to go through training and pretty quickly realized they’re not going to be able to do this. And then there were other people. One of my favorite trainees—he just seemed like he was going to be the biggest mess; he was so scattered and it seemed like he had trouble holding focus. And he just seemed so young—he looked like he was sixteen and I think he had a full set of braces. He just had every stereotype of being this total blank-faced rookie. [Laughs.] And then we would get on scene and he would just jump in. He would just grab things that were needed and do it right away. My partner and I couldn’t believe it. It was like, Who is this person?
Guernica: I guess people can really surprise you.
Courtney Moreno: Yeah, it was fun to get surprised and one thing that was actually really nice about doing the training was getting a break to calm down afterwards. You get into a rhythm and you don’t do that anymore unless it’s a particularly bad one or funny one or something like that. It was kind of nice to have a trainee for that reason, too: to go over what happened and what could have gone a little smoother—what did you first think was wrong with this patient and what did you realize later was actually wrong with them and how did you figure that out? There was something satisfying about that.
Guernica: In the book you write about Ayla and her PTSD. I was wondering what you felt were the connections or commonalities or lack of commonalities between the kind of PTSD or trauma that an EMT might exhibit or get from being on the job and what you might see from a soldier returning home?
Courtney Moreno: I did a lot of research on PTSD and PTS and traumatic brain injury because all of those things literally affect how the brain functions and the brain chemistry. I interviewed a couple of specialists, like I interviewed a woman who specializes in PTSD and she explained it really well, it just gave me such a clear sense in my own life and what I’ve seen, which was lovely. She said generally speaking if there’s a single traumatic event, there’s sort of a two-week period where, whether the person realizes it or not, they make the decision to step towards and through it or, because the situation’s so bad or because they can’t for whatever reason, they get stuck in it or hold onto it in some way. So if in that two-week period—it may not have been exactly two weeks but it was a surprisingly short window of acute post-traumatic stress. And then if you don’t get help or if you don’t have a way to release or digest any of this thing you’ve experienced then you’re that much more likely to get pulled into a more chronic problem. It’s not that it can’t be cured, it’s not that you will never recover—I think that sometimes people think that it’s a permanent disorder and it actually doesn’t have to be a permanent disorder. But it lasts longer; it’s harder to break up the neurological patterns that are solidifying that and then creating these triggers. With soldiers, what is so hard is that you don’t get a day off when you’re in an active war-zone and it can be hard for them to even try to separate out, is there even a single traumatic event or are there five? When you start having that accumulation of trauma without any kind of release valve, how do you get home and try to separate any of that out into something tangible?
Guernica: Could you talk a bit about your own experiences as an EMT and this PTSD/PTS issue? How much of that did you take home?
You get so used to being really capable so then to have a hard time feels like a weakness or maybe there’s something wrong with you.
Courtney Moreno: Part of what I was trying to do with Piper was have her go through acute post-traumatic stress. There was this idea that Ayla would be this old trauma and Piper would be this new, fresh explosion. I never had anything that extreme in the field. I think for me, basically the way EMTs and firefighters and ER docs talk about burnout is this idea that, I would say about every four or five or six months people go through it, and certainly that was true for me. So in my two-and-a-half year period there was at least three distinct cycles of burnout that I can remember. And the symptoms of burnout are things like irritability and mood changes and loss of appetite or not being able to sleep as well, not being able to have connections with people the same way. And people talk about this really casually, and I remember talking about it really casually, “Oh, I’m just really burned out right now,” if something happened or if I blew up about something that I had no reason to be so upset about. You just kind of wave it off. So there was something really astonishing for me personally to start doing this research for these characters and okay, the symptoms of post-traumatic stress are irritability, mood changes, loss of sleep, loss of appetite. So there was this kind of bizarre shift in my awareness that I think is even still hard to talk about because, similar to the military you get into this habit of, you know there’s a machismo that comes with the work of “I can handle it. I can handle anything.” You get so used to being really capable so then to have a hard time feels like a weakness or maybe there’s something wrong with you. There’s this constant affirmation that’s like, I can do this job and I think even while I was doing it I tried to question it a bit; is this actually the healthiest way to handle this job? And is it the best for the patient? Which is sort of the bottom line.
Guernica: I was surprised, but I guess I shouldn’t have been, that you pull 72-hour shifts—that just seems so bad for the patient.
Courtney Moreno: Right, yeah, well and if you think about it, it’s worse with doctors. When they’re going through residencies and fellowships and stuff sometimes they’re expected to be on their feet for 80 hours in a week. It’s like, how is that good for anybody? It shouldn’t just be this automatic rite of passage that because you want to do this thing you have to do what all of your ancestors in that line of work did before you. At what point do you say, maybe this ritual isn’t a good idea.
Guernica: I would never ask you what your worst case was, but can I ask if you have a case that we haven’t discussed that was really good, that made you feel good about your work and what you’re doing?
Courtney Moreno: There’s a ton of those. [Pauses.] You know, delivering a baby can be pretty amazing. That one was a tough one because I helped deliver, I think, four babies while I was an EMT and three out of the four were sort of problematic: the baby almost didn’t make it or just really gnarly home situations or something like that. But there was one where it was just sort of, mom’s in labor, dad’s just over-the-moon excited, she’s over-the-moon excited when she’s not screaming [laughs] and sometimes it’s bad for us but on this occasion it was great. The firefighters were like, “Oh, look, we’ve got a female here so why don’t you be the one to deliver the baby?” It was amazing to get to, it is kind of rare to be a joyous call when you’re an EMT. That was pretty incredible to get to catch this thing and the baby was fine, the mom was fine and the dad was thrilled and everyone was smiling and happy and it was really cool.
Guernica: It does sound like a very male profession from the book and what you’ve said. What was that like and how did that impact everything else?
Courtney Moreno: It was an extra layer to navigate. I spent, I would say the first three months, just really proving myself over and over and over again. Always making sure to do the heavy lifting, be the quickest and as good as I could possibly be and it took a while but when it started to land… It’s sort of a double-edged sword where you want people to be like “You’re good at your job,” but you don’t want to be one of the good girls. [Laughs.] You don’t want this distinction of, “Oh, girl EMTs are going to suck” and sort of be surprised and delighted when you don’t suck. On the one hand it’s nice, but on the other hand, why did you assume that in the first place?
One thing that was fun about it is that during the time that I was there, there started to be a lot of women who came through and there started to be a lot more women candidates for the fire department. So even in that short time period—less than three years—there was a big growth in people taking women seriously and it was really fun to find them. It started to be a little bit more normal as opposed to people being like “whoa” and being surprised by you or something.
Guernica: What would you say the ratio of men to women was when you started?
Courtney Moreno: One way to do this would be to say that in my initial training group with the ambulance company there were maybe thirty of us, and I think I was one of two women. So that’s just one training group, who knows what it was like for the whole month or the whole year. There’s a physical test that’s part of getting the job where you have to drag a 180 lb dummy, I think. You’ve got a time limit; you’ve got to be able to drag it in a loop around the room. I forget what the time limit is. And I remember the person interviewing me was kind of shocked [laughs]. So again it’s like, Have you not been interviewing women or have they not been passing this part? And then to see a year later there were probably at least three times as many women.
Guernica: Wow, in just a year?
Courtney Moreno: Maybe not a year. By the time I left there were probably three times as many women.
Guernica: That’s really impressive.
Courtney Moreno: Yeah, I don’t know how that happened. I think the fire department, too, might have been getting quite a bit of push to have a more even distribution. That’s probably part of it.
Courtney Moreno’s award-winning writing has been published in LA Weekly and The Best American Nonrequired Reading. She received a BS in Molecular Biology at UC Berkeley and an MFA in Creative Writing at the University of San Francisco. During the ten years in between, she worked as an entomologist’s assistant, lab technician, clinical research coordinator, stagehand, set carpenter, modern and aerial dancer, EMT, and field-training officer.
Andrew Rose is an editorial assistant at Guernica Daily and a student in NYU’s Cultural Reporting and Criticism program. His work has also been featured in Words Without Borders and The Weeklings, and he tweets @signandsight.