In this article I will discuss Post Tramtic Stress Disorder and Critical Incident Stress Management (Debriefing). In the 80's and early 90's when we as EMS directors along with our medical directors began paying more attention to this disorder, I feel we took it lightly, I know I was guilty of this at first as an EMS director.

After taking a few classes about PTSD however, I began paying more attention and researching PTSD more closely. I was convinced at this point this was truely a disorder I needed to incoporate into my services training program. I also began developing my services Critical Incident Stress Debriefing program at this point.

This is quite a long article so please bear with me. I am covering two topics in this article as I feel the two walk hand in hand.

Post Traumatic Stress Disorder (PTSD) is an anxiety disorder that can develop after exposure to one or more terrifying events in which grave physical harm occurred or was threatened. It is a severe and ongoing emotional reaction to an extreme psychological trauma. This stressor may involve someone's actual death or a threat to the patient's or someone else's life, serious physical injury, or threat to physical and/or psychological integrity, to a degree that usual psychological defenses are incapable of coping. In some cases it can also be from profound psychological and emotional trauma, apart from any actual physical harm. Often, however, the two are combined.

Fast Glance at Post Tramatic Stress Disorder
• An estimated 70 percent of adults in the United States have experienced a traumatic event at least once in their lives and up to 20 percent of these people go on to develop posttraumatic stress disorder, or PTSD.
• An estimated 5 percent of Americans -- more than 13 million people -- have PTSD at any given time.
• Approximately 8 percent of all adults -- 1 of 13 people in this country -- will develop PTSD during their lifetime.
• An estimated 1 out of 10 women will get PTSD at some time in their lives. Women are about twice as likely as men to develop PTSD.

Extreme Trauma Associated with PTSD
• PTSD may develop following exposure to extreme trauma. (such as emerency services professionals frequently encounter)
• Extreme trauma is a terrifying event or ordeal that a person has experienced, witnessed, or learned about, especially one that is life-threatening or causes physical harm. (often witnessed aby emergency services professionals)
• The experience causes that person to feel intense fear, horror or a sense of helplessness.
• The stress caused by trauma can affect all aspects of a person's life including mental, emotional and physical well-being.
• Research suggests that prolonged trauma may disrupt and alter brain chemistry. For some people, this may lead to the development of PTSD.

Recognizing and Diagnosing PTSD
    1. A specific number of symptoms from each of the three clusters have lasted for one month or longer.
    2. The symptoms cause severe problems or distress in personal life, at work, or in general affect daily life.

Clusters
• Re-living the event through recurring nightmares or other intrusive images that occur at any time. People who suffer from PTSD also have extreme emotional or physical reactions, such as chills, heart palpitations or panic when faced with reminders of the event. One or more of these symptoms must be present for diagnosis.
• Avoiding reminders of the event including places, people, thoughts or other activities associated with the trauma. PTSD sufferers may feel emotionally detached, withdraw from friends and family and lose interest in everyday activities. Three or more of these symptoms must be present for diagnosis.
• Being on guard or hyper-aroused at all times, including feeling irritable or sudden anger, having difficulty sleeping or a lack of concentration, being overly alert or easily startled. Two or more of these symptoms must be present for diagnosis.
• People with PTSD may have low self-esteem or relationship problems, or may seem disconnected from their lives.

Other problems that may mask or intensify symptoms include:

• Psychological problems such as depression or other anxiety disorders, including panic disorder.
• Physical complaints such as chronic pain, fatigue, stomach pains, respiratory problems, headaches, muscle cramps or aches, low back pain or cardiovascular problems.
• Self-destructive behavior, including alcohol or drug abuse, as well as suicidal tendencies.
• Responses to trauma vary widely and many people who experience extreme trauma do not develop PTSD. However, for those who do, PTSD symptoms usually appear within several weeks of the trauma, but some people don't experience symptoms until months or even years later.

Common signs and symptoms of excessive stress

Critical Incident Stress Management (Debriefing)
Critical Incident Stress Management (Debriefing) (CISD) in a very important aspect of any emergency services agency. EMS, fire, police and other emergency services should adopt a good CISD program and stick with it. There should be no delay in using the CISD program when the need arises, it should be next to immediate after a bad call. It is the responsibility of the service director, training officers and medical director to assure the CISD is accomplished in a timely and professional manner.

In 1991, I wrote my first CISD protocol for the EMS service I ran. I continually updated and worked hard at implementing this new policy for my EMS responders. We stuck to our CISD program as outlined and I do feel this helped my EMS responders greatly. I became a firm beliver in CISD and always assured there was no delay in calling my CISD team to action. This was a mandatory part of my services protocols.

Below is a short description of CISD and what's it's all about. I'll keep it short as I am just getting my point across of how important a good CISD team is to have with your emergency service.

Critical Incident Stress Management is designed to help people deal with their trauma one incident at a time by allowing the individual to talk about the incident when it happens without judgment or criticism. This includes emergency services responders as there are on the front line of all trauma related incidents in one way or another. The program is peer-driven and the people giving the treatment may come from all walks of life, but most are emergency services responders or work in the mental health field. All interventions are strictly confidential, the only caveat to this is if the person doing the intervention determines that the person being helped is a danger to themself or to others. The emphasis is always on keeping people safe and returning them quickly to more normal levels of functioning.

Normal is different for everyone, and it is not easy to quantify. Critical incidents raise stress levels dramatically in a short period of time and after treatment a new normal is established, however, it is always higher than the old level. The purpose of the intervention process is to establish and set the new normal stress levels as low as possible .

Critical incidents are traumatic events that cause powerful emotional reactions in people who are exposed to those events such as emergency services responders. Every profession can list their own worst case scenarios that can be categorized as critical incidents. Emergency services organizations, for example, usually list the Terrible Ten.

They are:
• 1. Line of duty deaths
• 2. Suicide of a colleague
• 3. Serious work related injury
• 4. Multi-casualty / disaster / terrorism incidents
• 5. Events with a high degree of threat to the personnel
• 6. Significant events involving children
• 7. Events in which the victim is known to the personnel
• 8. Events with excessive media interest
• 9. Events that are prolonged and end with a negative outcome
• 10. Any significantly powerful, overwhelming distressing event.

Types of Intervention
There are different types of interventions for various situations. The most stressful being line of duty deaths, co-worker suicide, multiple event incidents, delayed intervention and multi-casualty incidents. The type of intervention used depends on the situation, the number of people involved, and their proximity to the event. The optimum is a three-step approach that addresses the trauma at various stages of progression. A defusing is done the day of the incident before the person(s) has a chance to sleep. The defusing is designed to assure the person/people involved that their feelings are normal, tells them what symptoms to watch for over the short term and to offer them a lifeline in the form of a telephone number where they can reach someone who they can talk to. A debriefing is normally done within 72 hours of the incident and gives the individual or group the opportunity to talk about their experience, how it has affected them, brainstorm coping mechanisms, identify individuals at risk, inform the individual or group about services available to them in their community. The final step is to follow up with them the day after the debriefing to ensure that they are safe and coping well or to refer the individual for professional counselling.

Methodology
Debriefing or Defusings are limited only to individuals directly involved in the incident and are often done informally, sometimes at the scene. They are designed to assist individuals in coping in the short term and address immediate needs. Although I state sometimes done at the scene, this is reserved for those emergency responder who break down on scene. My programs were completed behind closed doors with my CISD team present.

Debriefings are usually the second level of intervention for those directly affected by the incident and often the first for those not directly involved.

There are a variety of methodologies currently in use for debriefing. The most common process used is a seven step program, although some emergency services utilize a three step program.

The seven steps are:
• introduction of intervenor and establishment of guidelines
• details of the event given from individual perspectives
• emotional responses given subjectively
• personal reaction and actions
• symptoms
exhibited since the event
• instruction phase where the intervenor assures individuals that their responses to the event are normal
• resumption of duty where individuals are returned to their normal tasks.
The intervenor is always watching for individuals who are not coping well and additional assistance is offered at the conclusion of the process. All of the methodologies currently in use have follow-up as the final step. This is always done after the intervention, optimally within twenty-four hours.

CISD Criticism
A number of studies have shown that CISD has little effect, or that it actually worsens the trauma symptoms. On the other hand, Jacobs, Horne-Moyer and Jones argue that CISM has beneficial effects when conducted with emergency services personnel, but does not work or does more harm than good with accident victims.

Summary
I feel PTSD and CISD walk hand in hand together. I further believe that all emergency services agencies need to have policies and procedures in place to deal with each. This is especially true for rural EMS services where the emergency responders may know the person affected or run very few calls that involve severe trauma etc.

Please feel free to post your comments, thoughts or suggestions about this article.

Phillip Sampson
EMS Prime
http://emsprime.com