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Post Incident Response, an Organizational Approach

Discussion in 'EMS Talk' started by John B, Jul 10, 2018.

  1. John B

    John B Forum Ride Along

    Critical Care EMT-P
    Hello all,

    My name is John and I am looking for advice, input or general suggestions concerning a project myself and a colleague are currently trying to get off of the ground at our service. I apologize in advance if this initial post is a little wordy, but I want to provide as much background as I can to elicit a good discussion. I also want to thank you in advance for any assistance with this project.

    A little background about myself and the service I work for. I am a critical care paramedic (FP-C, CCEMTP), Field Training Officer and SWAT medic for a large metropolitan service. Our service area is approximately 300 square miles, servicing the gamut of urban, suburban and rural communities. We average approximately 60,000 calls for service per year, not including wheelchair, BLS and critical care transfers. We primarily operate in a medic-medic capacity due to legislative mandates in the county we serve. Our ground critical care units are staffed with an RN and CC medic. These numbers only represent our metro division; we also have out state divisions that service more rural outlying communities throughout the state, as well as a 7 ship rotor wing division that performs both scene flights and inter-facility transports that services a large portion of the state. Our metro division (where I work) currently employs approximately 150 wheelchair drivers, EMT's medics and nurses. We are a hospital-owned system, and that hospital is Level 1 trauma center, comprehensive stroke center and has multiple other Level 1 designations.

    The project we are working on is based in one question: how do we care for our own after they take care of others? Since I have been a medic, I have witnessed many of my coworkers deal with job related, or more specifically duty-induced PTSD, stress, anxiety and depression. These issues don't have a singular cause, but as you may know are often a result of burnout, high acuity calls (pediatric arrests, line-of-duty deaths, significant trauma, etc.) and other stressors. These events can often have a far reaching impact, not only professionally, but personally. Marital and family issues, drug and alcohol dependence and suicide are all possible outcomes. These events can also lead to poor work performance, lack of focus and poor patient care. I have personally witnessed high acuity events affect my friends and coworkers this way, and have experienced it to a degree myself. I assume that those of you reading this have some experience in this as well.

    The response to these sort of events, in my experience, has been lacking. The typical process of a CISD, while helpful to some, may not be enough, and may be actually harmful. I personally am not a fan of the traditional CISD approach, and I'll explain why. When I am a part of a high acuity call or event, I have my own perspective of the event that I have to reconcile. When I am a part of a CISD, I now add on the collective perspectives of everyone else involved. These may not have been feelings or sides of the story that I considered before, and I typically end up feeling worse for the patient and everyone involved (even if I logically understand that there may have not been anything else I could have done). I usually chose to recuse myself from these gatherings, unless I feel that my input with help others deal with the trauma. Again, these are my feelings alone; I understand that this process may be helpful to others.

    We also feel that in EMS we have a "it's just part of the job, shut up and deal with it" mentality when it comes to these events. This is often followed by "if you can't deal with it, you're obviously not tough enough and this job isn't for you" sentiment. I absolutely agree that a successful paramedic, EMT or first responder requires a significant degree of mental, physical and emotional resolve. However, the dismissive nature of the aforementioned sentiments provides no benefit to ourselves or our coworkers.

    So, the questions we asked ourselves are: how do we respond proactively, instead of reactively? How can we get ahead of these problems before they manifest into something more sinister? How do we take care of our own? My colleague and I began by doing what every medic/EMT does; get a certification. We went to classes becoming certified in suicide intervention and crisis debriefing. We then started brainstorming how we could make an organizational process. Here is what we have so far:

    • Development of a team of peers who are designated for "emotional first aid". This team will vary by age and experience to reach every social group in our organization.
    • Integration with dispatch, so the team can be automatically notified when a high acuity event occurs (pediatric arrest, line of duty death, etc)
    • Immediate contact with crew following event. This will be done in person ideally, but by phone if possible. No texts or social media communication.
    • Implementation of a mandated time frame after the event where the crew is out of service. This allows time for the team to contact the crew, and for the crew to defuse on their own terms. Get coffee, eat, be alone, etc. That time is theirs.
    • Mandated follow up at predetermined intervals. Currently we do 24 hour, 72 hour, 1 week, 2 week and 1 month check ups with the crew. People are individuals and experience trauma differently and in different time frames.
    • Consistency in follow up. Whoever makes first contact with the individual or crew maintains contact and follow up. This way, the effected crew doesn't have to relive the event and explain themselves to a new person multiple times.
    • Development of relationships with mental health professionals either within or outside the organization if escalation is necessary, and of course with the individuals consent.
    • Time off without repercussion if necessary.
    This project is in its infancy right now. We have been doing it informally for the last 6 months (with our directors and supervisors approval). Thus far we have had nothing but positive feedback, and have a list of people who passionately want to be a part of the team and help their coworkers.

    My question to you all is if you have something similar to this at your organization/company, and if so is it similar? How does your service approach these events and the potential fallout after? Do you have any suggestions or feedback on our approach? Is there anything that we aren't considering or thinking of?

    I would like to thank those of you who made it to the end of this thread, I know it is very long and involved. This is a topic that is important to us, and we want to make it work. I thank you all in advance for participating and providing any suggestions you may have. Stay safe out there.

    John B
  2. mgr22

    mgr22 Forum Asst. Chief

    John, it sounds like you're doing lots of things right. As I was reading your bullet points, my only concern was the extent to which participation in debriefing is mandatory. I'm in favor of making help available to EMS providers, but I'm against forcing anyone to attend CISD sessions. In my experience, involuntary participation sometimes interferes with well-established, personal coping mechanisms, and can lead to worse outcomes.
  3. John B

    John B Forum Ride Along

    Critical Care EMT-P
    Thanks for your response, and I totally agree. Mandatory was probably the wrong word to use. We want to make it accessible and voluntary.
  4. Ouroboros

    Ouroboros Forum Ride Along

    Thank you for articulating what I have always also not liked about CISD, but had trouble succinctly explaining to others! It's tough to deal with your own feelings about what happened, but then also tough to hear how co-workers/responders are struggling in a group environment. It always makes me want to help/fix them too, and as a dispatcher, adds to the feelings of lack of control and guilt over not being at the scene, while still being impacted by the knowledge of what happened.

    I am also trying to implement a similar program at our agency. The document that I am trying to pattern it after is the "NENA [National Emergency Number Association] Standard on Acute/Traumatic and Chronic Stress Management", which specifically covers dispatch, but also has somewhat of a blue print for how to structure the program that might be applicable to other first responders. I've also used this link: xhttps://911wellness.com/building-your-psap-csmp/, which has a helpful link on how to engage with an EAP to possibly make it more effective [take the x out to make the link work]. I've found those resources useful to start a proposal of how I hope to implement this in our agency - right now to supplant our volunteer CISD resources, but eventually to hopefully begin to phase that model out, as we've had a number of issues with our debriefs being more stressful than helpful in the past.

    One other possible consideration for you - you mention getting notifications from dispatch if there is a critical event. Is your dispatch center a primary PSAP that would also be taking the calls you mention? In the cases of, for example, child deaths it is very easy to second guess myself as a dispatcher - whether I truly understood the situation, gave proper instructions to the parents, etc. It can be extremely helpful just to know what responders encountered on-scene - not from a CISD-type feelings perspective, but just a quick 10 minute conversation to understand what actually happened, as I know impressions I get on 911 are often inaccurate or totally wrong and I like to have the best understanding I can. One of the things I would like to add to the NENA program is possibly reaching out to liaisons within our response organizations who may be willing to have those conversations with dispatchers after a tough call (some officers/firefighters have been rude and refused to speak to us in the past - not what someone already dealing with a traumatic situation needs to have happen - so we're trying to identify the individuals who would be more open to a quick operational debriefing in advance). Have you considered somehow including dispatchers who took/dispatched the call or law enforcement who also responded in your program? Maybe even just to be available to speak to one another after the fact in case having a certain piece of information about the incident helps someone with closure? I'm not sure if that fits in with what you're trying to do, but just a possible consideration.

    I think this is an incredibly important topic - one that I've given a lot of thought to recently as well. It's one thing to say CISD isn't an effective or proven model, but it's another to come up with an alternative solution to effectively replace it and convince others that this will work better. Having worked a number of major incidents impacting our entire jurisdiction (active shooter) as well as a number of quieter private tragedies that have still broken the hearts of everyone involved, I know how important it is to have something in place ahead of time to hopefully help people overcome what happened and still be able to work and go on with their lives. I'd definitely like to exchange ideas with you and any others working on similar programs as we try to implement and refining this process within our agencies.

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