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