"Show Me Where It Hurts": Treating the Wouds of Our First Responders
We arrived on scene to find the patient: 92, female, breathing irregularly, making gasping sounds and without a palpable carotid pulse. Her nursing aid presented us with her medical booklet and said “This is the patient’s Do Not Resuscitate order” and we transferred the patient to the floor in the supine position. At this point the patient’s daughter arrived in distress. She pleaded with us to leave her mother alone and to let her die in peace, but we could not do so; the Do Not Resuscitate page was blank. My crew chief ordered me to begin compressions. I was scared, this was the moment I was waiting for, wasn’t it? I placed the heels of my hands on her sternum and pushed. With each successive push I felt and heard pops, like the cracking of very large knuckles, and her chest moved more and more. This was the sound and feeling of her ribs separating from her sternum, as her cartilage was too brittle to survive the compressions. Paramedics were on the scene, and they hooked up and EKG to the patient. With every compression, I could see her hear beat on the monitor. We continued to work on her for half an hour, using an automatic external defibrillator and paramedics pushing drugs to restart her heart, but we could not revive her. When I am not in school, I volunteer as an Emergency Medical Technician. On Thanksgiving morning of 2011 I was working on the ambulance and we received the above call for a cardiac arrest. This moment - my first serious call - was a moment I had anticipated with great excitement. After all of the months training and a dozen or so boring calls, I thought I was ready.
For the first few days after the incident I felt distant from my friends, disconnected from my life, and downright sad. For the next few months, I had a visceral reaction to the memory, which caused further disturbance. Despite my love for the job, like many EMTs, I experienced post-traumatic stress from my first major call. Luckily, I was able to benefit a bit from a wealth of the usual social support (i.e., talking about my experience with colleagues, a therapist, and my family) but surprisingly, I experienced the most relief by expressing this experience and another distressing experiences through creative writing. While trauma and acute stress is a common topic with the military population, this paper explores the role that traumatic experiences play in the Emergency Medical Services profession, including …
In their study, “Identifying, Describing, and Expressing Emotions After Critical Incidents in Paramedics”, Gurevich et al. (2012) studied the role that emotional expression plays in acute stress reactions (ASR) to critical incidents among emergency medical personnel. Critical incidents are defined as “calls that have generated unusually strong feelings, either because of the incident itself, or how it was handled or some other reason”(Gurevich et al., 2012, p.112). In terms of emotional expression, the participants were asked about the types of social contact they had post-incident, the helpfulness of each type of contact, and their degree of emotional expression within the interaction. To gauge effects of the incident, the participants were asked about post-incident ASR, alexithymia, burnout, depressive, posttraumatic, and physical symptoms. Gurevich et al. (2012) states that Alexithymia is the process of identifying and describing emotions (Gurevich et al., 2012). Alexithymia was associated with decreased expression of feelings post-incident and burnout, depressive, physical, and symptoms, but not decreased contact of finding it helpful. The degree to which respondents expressed their emotions was positively correlated with their number of post incident contacts. The results indicate that the ability to identify emotions plays an important role in managing stressful situations for paramedics, but that the actual expression of emotions has no effect either way.
Thus, even though the ability to identify emotions is a strong predictor of post-traumatic symptoms, including burnout, depressive, and somatic symptoms, post-incident expression of emotion is not a good predictor of these symptoms. In other words: identification of the problem is not the same as resolution. It is at this diversion where we I call for more research.
Critical Incident Stress Management (CISM) has become the most common form of response to acute stressors for institutions that employ large at-risk populations, such as police, fire departments, and emergency medical companies. It is the most widely used treatment strategy by large emergency medical institutions, including the FDNY. CISM is effective because it emphasizes pre-incident education, and post-incident emotional expression in the form of group therapy sessions led by peers. It is based on the idea that traumatic experiences can be rewired in the days following the incident through emotional expression and destigmatizing of the incident and the associated emotions. CISM emphasizes the importance of post-incident emotional expression in mitigating post-traumatic symptoms, but, as this study demonstrates, post-incident emotional expression does not have any effect. In many institutions, CISM is compulsory after particularly stressful incidents, such as the death of a coworker.
Stephen A Pulley, D.O. (2005), likens CISM to immunization against ASR, with pre-incident education providing initial resistance, and debriefing boosting that resistance: “Certain animal bites require rabies immunization in an accelerated fashion. Similarly, even after the fact, psychological immunization may help prevent a full-blown reaction” (Pulley, 2005). In certain types of dirty wounds, a tetanus booster is administered to provide a boost to the protective effect of the immunization. Likewise, after a suspected critical incident has occurred, the team interacts with the individuals involved to further boost their resistance. CISM involves pre-incident education, incident support, debriefing, post-debriefing support, and a follow-up. Pre-incident education involves learning tools to deal with stress, how to prepare for stressful situations, and destigmatizing acute reactions to stress. Incident support is caring for the immediate physical and emotional needs of the responders, including nutrition, rest, and immediate post-incident tools for stress reduction. Debriefing occurs within the first two weeks after the incident, is peer-led, and supervised by a trained professional. Debriefing involves discussing the incident, in particular the thoughts and emotions associated with it, and any symptoms the responders are experiencing as a result. Post-incident support is support from family, friends, and coworkers who are assisted by CISM team members to be supportive and manage their own stress as a result of the incident. Follow-up involves ensuring that the responders are recovering well, and if they are not referring them for psychological care (Pulley, 2005).
Dr. Bryan E. Bledsoe has conducted a literature review (2002) of extant studies on the efficacy of CISM. Through an extensive meta-analysis, he has identified two studies (Rose et al., 2002; Van Emmerik et al., 2002) which have found that CISM and single session psychological debriefing had little to no effect on the onset or treatment of PTSD symptoms, and may inhibit normal recovery (Bledsoe, 2003). Most literature supporting CISM is published by the main developer and purveyor of CISM - George Everly. Based on case studies involving psychological debriefing for the treatment of PTSD, it is accepted that CISD intended to treat PTSD, but to prevent its onset (Bledsoe, 2003; Everly, 2002). Although CISD was properly used in these studies, there was no randomization and all of them involved small sample sizes (Bledsoe, 2003). In his review of individual randomized, comparison, and control studies, Bledsoe found that psychological debriefing had no effect on PTSD related symptoms, and some studies found it to have a paradoxical effect. Most of the positive articles on CISM “Are published in the International Journal of Emergency Medical Health, which is edited by Everly and published by Chevron Publishing Corporation” (Bledsoe, 2003, p.276). Everly owns the Chevron Publishing Corporation. The International Critical Incident Stress Foundation was co-founded by Everly, and is the main backer of the Chevron Publishing Corporation (Bledsoe, 2003). Said literature trusted by Bledsoe found that CISM negligible or even paradoxical effects on post-traumatic symptoms. Literature that found that CISM had a positive effect was typically published in the International Journal of Emergency Medical Health, a journal whose legitimacy Bledsoe calls into question due to the conflict of interest that Everly may have. It is problematic that CISM is the most widely used treatment strategy because it has not been proven to be effective and it does not address the most important predictor of PTSD (identification of emotions) and only focuses on emotional expression. Current mental health care for first responders is therefore not based on scientific evidence, but on what has been used for the past thirty years and early biased anecdotal evidence. The effectiveness of CISM needs to be further explored, but preliminary results indicate that it does not achieve its goal of reducing the incidence of PTSD.
On the other hand, in her dissertation “The Change in First Responder’s Trauma Symptoms After Participation in a Residential Recovery Program”, Sally Ann Cantrell assessed police, firemen, and emergency medical personnel’s trauma symptoms before and after participation in a six-day residential treatment program and provides an example of a highly successful treatment program, and the approaches it emphasizes can be extrapolated to treatment on a larger scale. Cantrell found that after involvement in a six-day residential treatment program that incorporated the experience with the patients’ pasts using CBTT and NET, and goal setting in order to help the patients utilize the experience to move forward with their lives, the first responders PTSD symptoms improved markedly. The residential treatment program utilized a varied treatment strategy, using both group therapy and individual therapy with multiple methodologies.
Cantrell’s assessment consisted of an intake interview, the Detailed Assessment of Posttraumatic Stress, and a Trauma Symptom Inventory (TSI) that was used for pre and post comparison. The retreat used a multifaceted approach to treating the first responders, utilizing psychological debriefing, Cognitive Behavioral Trauma Therapy (CBTT), Narrative Exposure Therapy (NET), group therapy, and Eye Movement Desensitization and Reprocessing Therapy (EMDR). The psychological debriefing used by the retreat differs from CISM in that it occurs months after the initial trauma, and the debriefing goes on over the course of several days (Cantrell, 2010). CBTT seeks to reduce the dissonance that occurs in the patient because of the traumatic incident. The CBTT conducted on the retreat is exceptional in that it also seeks to integrate the trauma with the patient’s overall life story. NET seeks to create a life narrative of the patient, habituating emotional reminders to the traumatic event. Group therapy can be particularly effective for groups of first responders, as they have been trained to work in groups. EMDR seeks to alter the way that the traumatic memories are stored in the brain, and in the process alleviate somatic symptoms. Goal setting is also emphasized as important for the participants’ recovery. Goals are important for an individual’s mental well-being, and the significant nature of the participants’ experiences often change aspects of their world views. The study found that all ten TSI subscales were significantly reduced after the retreat (Cantrell, 2010).
The current treatment widely available to first responders is woefully inadequate compared to what is currently available. Effective treatment of traumatic symptoms require not just an expression of the emotions associated with the event, but an integration of the event with the rest of the patient’s life narrative. All too often patients become “stuck” in the traumatic incident, and are unable to move past it. The treatments studied by Cantrell served to integrate the traumatic experience with the patients past, and encouraged the patient to focus on the future. Further research is needed to find a way to make these techniques more readily accessible to first responders and to utilize them on a larger scale. Research should also be done on whether continuous construction of a life narrative and goal setting has any preventative effect on acute stress reactions.
Improved mental health for first responders is essential in the continuing improvement of the emergency response system. Emergency medical technicians experience very high levels of occupational stress, stemming from varying sources (Cydulka et al., 1989). Finding a way to deal the occupational stress that is inherent in the emergency medical field is essential in reducing burnout; improving patient care and the overall stability of the emergency response system. In addition, first responders return home to their friends and families after their jobs are done, oftentimes bringing with them the stress of their jobs. Improving the mental health of first responders improves the lives of everyone they affect, both professionally and socially.
Bledsoe, B. E. (2003). Critical incident stress management: Benefit or risk for emergency services? Prehospital Emergency Care, 7, 272-279.
Cantrell, S. A. (2011). The Change in First Responder’s Trauma Symptoms After
Participation in a Residential Recovery Program. Dissertation Abstracts International: Section B: The Sciences and Engineering, 71, (12-B), 7717.
Cydulka, R. K., Lyons, J., Moy, A., Shay, K., Hammer, J., & Matthews, J. (1989). A follow-up report of occupational stress in urban EMT-paramedics. Annals of Emergency Medicine, 18(11), 1151-1156.
Everly, G. S., Eyler, V. A., & Flannery, R. B. (2002). Critical incident stress management: A statistical review of the literature. Psychiatric Quarterly, 73(2), 171-182.
Gurevich, M., Halpern, J., Maunder, R. G., & Schwartz, B. (2012). Identifying, describing, and expressing emotions after critical incidents in paramedics. Journal of Traumatic Stress, 25, 111-114.
Pulley, S. A. (2005). Critical incident stress management. In EMedicine. Retrieved February 15, 2013 from http://web.archive.org/web/20060811232118/http://www.emedicine.com/emerg/topic826.htm