I recently participated in a complicated scene call in a Southeast Idaho community. We were part of a 4-agency response team, working together on a tragic event, which had an emotional effect on most of the first responders. A few days later, the EMS medical director invited all the responding agencies to come together to debrief. I have worked in the air ambulance industry for the last 9 years. The debrief I attended was only the second time I have been part of an organized breakdown of what happened during a scene call.
I have had multiple calls that I have dealt with on my own. It is not often that Life Flight pilots or crew get involved in a formal debrief. Throughout my career I have often found myself thinking about the traumatic and mentally taxing calls. A couple of these calls I dwelt on for quite a while and felt quite emotional thinking back to the things I dealt with or saw on scene. I have never had any formal training on how to debrief after a scene; and I have worked for 4 different large air medical companies. Typically, the patients are critically injured and so the emotions can be high.
I felt that being a part of an organized debrief was very uplifting and reassuring. I left the debrief feeling I had received direction on how to deal with what we all see as air medical personnel on just about every flight. The local EMS medical director used a format that needs to be shared. Before we have him share the organized debriefing, I want to talk about some signs to look for in yourself or in your coworkers that would signal a need to seek out some help.
Signs to look for:
Being withdrawn or not involved
Annoyed about small things
Emotional on next call
Inability to focus on task at hand
It’s time to act and change your path.
Tools you can start with:
Humor—if you let the fear consume you, you are not able to manage that fear
Talk with your peers
Talk to your family
Reach out to peer support provided by company
Participate in an organized critical incident stress debrief (CISD)
What is CISD?
CISD stands for critical incident stress debrief. I was able to sit down and talk with EMS Medical Director Lance Bryce, MD, the team lead that held the debrief that night. I asked him to summarize his process of the CISD. The following text is from him.
The CISD is a very organized debrief for any incident that causes stress to the members of any agency that responds to an incident. CISD teams can be full-time employees of large metropolitan agencies and have formal training to become team leaders and team members. The rural and smaller agencies rarely have budgets for full-time CISD teams, so they must rely on assistance from large agencies or find local medical professionals willing to try and learn the steps to a formal debrief. A CISD is conducted by a team leader in charge of the introduction phase, which is essentially setting the “rules.” The debrief is then conducted in phases.
Introduction Phase. Introduce yourself as the team leader. If you have other members of the lead team, introduce them and their role. It may be obvious but state the reason/event that is bringing everyone together—literally identify the event.
The following is a list of MANDATORY TOPICS that must be covered. The team leader CANNOT leave anything out. I choose to read these so that all personnel understand the ideas we are trying to establish in the debrief.
Everyone reacts to critical incidents differently.
The debrief is to help everyone involved identify and understand how they may be feeling or reacting to the incident.
THE DEBRIEF IS NOT THERAPY. It will not prevent serious complications like post-traumatic stress disorder.
The debrief is NOT to be a CRITIQUE of the event nor is it a JUDGMENT of others.
Participation is voluntary; those present do not need to participate.
CONFIDENTIALITY. Nothing leaves the room. (This is the only way to keep the discussion legally protected; otherwise, the discussion can be opened for investigation by legal teams.)
Only emergency personnel INVOLVED IN THE INCIDENT should be at the debrief. (I personally do not abide by this rule as our agencies are so small. I like the peer support across multiple agencies for the team members who were involved in the incident. Literally, knowing a colleague in your agency who was not there is present in the debrief to support you and pledges to do so for the foreseeable future. I also think the discussion helps limit the FACTS shared by those who actually lived the scene to the FACTS and we avoid the rumors and hearsay that can occur from these very traumatic events. Simply put, it kills the lies and misconceptions of what actually occurred in the incident.
Fact Phase. Not everyone that responds to a critical incident will know everyone who was there, so this is where the team leader will go around one by one and ask what job/role the person completed during the incident. We also ask, “What happened from your point of view?” Thought Phase. When you had a chance to settle in and come off of autopilot from your assigned duty, what were your first thoughts? Can you identify any thoughts you cannot seem to get rid of or shake off at this point? This is the critical moment of the debrief when signs and symptoms are expressed verbally by the participants. I feel it is very important to try to take mental notes and to keep eye contact with each participant so as to not interrupt their thought process wondering what I might be writing down. In fact, as an added layer of protection, I choose not to take any notes at all. The debrief is a verbal exercise and decompression of emotions, thoughts, reactions, and points of view. If agency leadership wants to take notes to help them follow up on personnel or processes, I am not opposed to this, but as the team leader, I need the participants to see and feel my genuine interest in THEIR experience.
Reaction Phase. What was the worst part of the incident for you personally? Do you have a part of the incident that really bothers you or that you cannot let go of?
Symptoms Phase. The team leader should have been listening through the debrief for symptoms that might be manifesting in a physical manner. If not, the team leader should go through a list such as difficulty sleeping, headaches, stomachaches, desire to fall back into drinking, consideration of using an illegal drug, consideration of using a legal drug not for its intended prescription use. The team leader should find out if anyone felt this way on scene, afterwards, or even now at the debrief. Has anyone had their life changed in any way? One example I can give is from an aviation incident: one member of the team can no longer use fluorescent green marking tape for hunting because that color was used to mark pieces of the wreckage/bodies at the crash site.
Teaching Phase. Here is where the team leader addresses the reactions described by the group and addresses reactions that may still come. It is important to identify and “normalize” the reactions. “You are not going crazy if you are having trouble sleeping over what you saw.”
Now, concerning grief and survivor issues. (Here is where I give my personal input.) DO NOT MAKE THIS INCIDENT ABOUT YOU! It was not your family member that died. Do not put yourself in the position of a surviving family member, and make sure you do not project these emotions or thoughts onto your own family. It is natural to want to imagine how the victims might have felt or their survivors. For example, if we were to experience an auto accident where a child is killed, we need to remember it is NOT our child that died. We should also not put ourselves in the position of the parents or the surviving victims. Here is where the team leader may find out that some members of the response team may have experienced a similar tragedy in their own life and the incident has opened old wounds.
The team leader should provide some ideas on how to handle the stress as it comes up. Exercise, talking with a peer, talking with the chief/commander/supervisors, etc. TALKING WITH OTHERS IS NOT A SIGN OF WEAKNESS AND SHOULD NOT HAVE A NEGATIVE IMPACT ON YOUR FUTURE PARTICIPATION ON THE RESPONSE TEAM. Here is where you might have the agency leaders jump in and back up that statement!
Reentry Phase. This is where the team leader makes sure that nobody has any other comments or points of view. This is where the team leader can go back to any of the phases. The team leader should MAKE SURE TO REITERATE the confidentiality of the meeting. This is the point where the team leader should emphasize the positive learning aspects of the discussion. [For example, “I hope that we all could see that many of us are feeling the same things, and you are not alone in how you are dealing with this incident. We have multiple participants who are having trouble sleeping...or there are multiple participants that are very angry about the drunk driver killing the victim. However, what I can see is that you all are finding your way forward. You are not alone, as can be seen by the number of participants here tonight, and everyone here is now linked for life. Collectively, there are enough resources here to overcome anything this incident has thrown at us. We all walk out of here better prepared for the next incident. We make up a certain genome of the population. Not everyone can do what we are tasked to do. Only those in this room and others like us truly know the cost of being a first responder to incidents like what we discussed in this debrief.”] Lance Bryce, MD
How to apply this in the air medical environment?
A lot of time you leave the scene, drop off the patient, return to base, and don’t have a chance to debrief. Medical members are normally more aware of the traumatic stress and emotional toll of what they see and deal with, but sometimes tend to ignore it and push it aside. Not too many of us think about ourselves, the pilot, the dispatcher, or even the mechanic and how it can affect them.
Focus on the tools above, go through the CISD yourself or with your crew. Involve your dispatch/comm center or anyone that you think may benefit. You could take notes on scene and call the agencies you worked with after to debrief. If your company doesn’t have a peer support [group], start one. It is also important to take care of yourself physically and mentally. This includes getting enough sleep, eating healthy foods, and exercising regularly. You should also make time for activities that you enjoy and that help you to relax. It is a good reminder to take care of yourself, not only physically but also emotionally and mentally. Know the 9-8-8 number that is like a 9-1-1 for suicide prevention. Use the tools to take care of you and watch out for your crewmembers that may be struggling. If you are struggling to cope with the effects of a critical incident, please reach out for help. There are many resources available to you, and you don’t have to go through this alone. Enjoy your job, enjoy life, enjoy those around you. You are a badass, and life is good!
(Reference: Nebraska Critical Incident Stress Management Program Outline)
Brett Reeder, NEMSPA President, and Lance Bryce, MD, EMS Medical Director