Written by Kate Dernocoeur, this article appeared as a feature article in the August, 1995 issue of JEMS (Journal of Emergency Medical Services).

THE OKLAHOMA CITY BOMBING was a made-for-TV catastrophe. The images thrust on the EMS community after the devastation of the Alfred P. Murrah Federal Building last April are imprinted on our minds with awful clarity. And to see images of other disasters often causes memories of other awful scenes to arise unbidden: Sioux City's airline disaster, the New York City World Trade Center bombing, hurricanes, earthquakes and other devastation. Each takes its toll on emergency care providers.

In 1983, former firefighter and paramedic Jeffrey Mitchell, PhD, introduced critical incident stress debriefing (CISD) to the emergency care world. Since then, Mitchell's initial template has evolved into a more comprehensive system known as critical incident stress management. CISM is one of the few things we, who give so much to others, can give ourselves.

But two questions remain: Is it enough? And, are we doing it right?

The "Mitchell model" has spread far and wide. There are now more than 300 CISD teams in the United States, up from only three in 1984. The International Critical Incident Stress Foundation, with 32,000 members, is dedicated to helping people "get it right." Yet many of the basic principles of CISM are commonly misunderstood and misapplied. For example, several cardinal rules—no media in a debriefing, no recordings and nothing shared outside the group—were knowingly shattered in the May 16 airing of "Rescue 911," which covered the Oklahoma City bombing.

Two Points of View

The issue of whether emergency providers are getting the help they need is perhaps an individual matter. Some report feeling very good about their roles and the emotional aftermath of being involved in Oklahoma City.

"It was an adrenaline-packed 40 minutes," said William Lindsay, a paramedic with the EMS Authority (EMSA), which contracts with American Medical Response (AMR) of Oklahoma to provide 9-1-1 service there. "The truth is, we transported 58 critical patients in 20 minutes and over 100 in the first hour," he explained. Lindsay and his partner moved eight patients in four quick trips; one of their patients who was in respiratory arrest has now gone home.

According to Bill Kenney, training supervisor and program coordinator for the Peer Support and CISD Program for AMR of Oklahoma, AMR "made a real effort to contact everybody." He claims defusing began almost immediately and was available for the first several days. By noon the first day, two local psychologists—with no Mitchell-model CISD training—were at company headquarters. However, according to Chaplain Mike McElroy, who worked for EMSA until January and who is a member of the company's new CISD team, the field providers were reluctant to talk to anybody who hadn't "been there, done that." Fortunately, a Mitchell-trained AMR-based CISD team from the San Francisco Bay area was summoned immediately after the bombing and arrived by I p.m. that day. By 5 p.m., the team was facilitating group defusing. That team stayed three and a half days.

Yet some involved in the bombing's aftermath report intense frustration and anger—and no safe place to deal with it. A lot of the anger stems from the handling of the incident. "Most of us felt we were not allowed to do our job," reported one EMSA paramedic, a five-year veteran who requested anonymity. "We were very angry because doctors and nurses were in the building doing triage. They wanted to be heroes. People were in there doing our work."

This same paramedic was not impressed by EMSA's CISD efforts. "CISD was scheduled on days that I worked. They wouldn't pull you off the streets," the paramedic said. "I asked for relief, but they said they needed the coverage."

That frustration and anger was directed at company management. "The company doesn't look to see what's going on with their own employees," the paramedic said. "They're doing nothing to support us. They're treating us terribly." This person later reported contemplating suicide and even got out the gun. Then came a lifesaving thought: "I wasn't going to let the bomber take one more life."

So whether help for the helpers is there and whether that help is adequate seems to be in the eye of the beholder. The impact of such an event varies from soul to soul, depending on previous life experiences, personalities and individual circumstances beyond the reach of even the most comprehensive tool.

Will It Work?

"I've been in this business nearly 35 years," said Chief James Roberts of the Midland (Texas) Fire Department. "Over that time, a person comes up with some mechanism to cope with [hard calls] . . . . I can see for young kids these days, when they're starting and haven't come up with a coping mechanism, I guess it would help. I don't see a problem with doing [CISM] at all. You see, we don't know what's going to happen to people 10 or 15 years after these incidents. There will be people who sail right through and others who have tremendous, big problems."

Chief Roberts knows. In October 1987, 18-month-old Jessica McClure fell down a narrow abandoned well in Midland. For 58 hours, the world watched until she was pulled from the hole strapped to the chest of Firefighter/Paramedic Steve Forbes. Today, Forbes, a family man, is a captain in the Midland Fire Department.

Down in the hole, another paramedic, Robert O'Donnell, had strapped Jessica to Forbes' chest. One week after the Oklahoma City bombing, O'Donnell was found in a pasture north of Midland, dead of a selfinflicted gunshot wound. It's natural to wonder whether there is a relationship between the two critical incidents.

In 1987, CISM hadn't reached the dry flats of western Texas. A regional team was formed in 1992 to educate, defuse, debrief and otherwise manage critical incidents, the same year O'Donnell resigned from the fire department. Would a debriefing in 1987 have helped O'Donnell? It's possible, according to Vaughn Donaldson, a driver/paramedic for Midland Fire Department and a member of its CISD team. "I won't say whether it would have prevented Robert's suicide, but I do believe the [Jessica McClure] event severely impacted Robert," he said. After the suicide, O'Donnell's brother told media representatives that "ever since that Jessica deal, his life fell apart."

So, the answer to the question of whether CISM is working depends on a few things. "The caveat is that if applied properly by trained teams, CISM has a substantial chance of working very well," said Mitchell. "There needs to be a reorientation on the emphasis [of doing it properlyl so people don't see CISD as the be-all and end-all. It takes hard work to make this stuff work. CISM is not an accident; it's a planned activity. It works best when it is carefully planned out and done with proper training."

In New York City, critical incidents happen every day, enough to support professional debriefings under the auspices of the New York City EMS Employee Assistance and Trauma Intervention programs. Program Director Susan Sabor agrees there is considerable confusion about whether CISM is working.

"Anecdotally, people have told us [CISDI works," she said. "It offers a cognitive framework, often a reframing of the event, as well as an opportunity to process some of the troublesome reactions. I do believe it helps. But it depends on where you're looking. Programs set up with good intentions but without ongoing support are often over-, under- or inappropriately used."

"[CISD] is not a miracle and will not eliminate all the pain for all the people in all the circumstances, said Mitchell. "You can't expect too much of it. It is one step in a whole series of steps designed to mitigate the impact of traumatic stress."

In western Texas, CISM is still struggling for acceptance.

"A lot of people out here—more than 50 percent—are still hanging on to the John Wayne image," said Donaldson. Asked if the emergency services welcomed their efforts in regard to CISM, Donaldson said, "They're not accepting it yet. So we have been doing as much preincident education as we possibly can."

Ironically, the more people "buy into" CISM, the more help they will receive. Through the process of defusing or debriefing critical incident stress, a certain amount of healing occurs. Workers learn that the physical, emotional and cognitive signs and symptoms are normal reactions to abnormal events (see "Symptoms of Stress" on page 35). They are given suggestions on how to take care of themselves. Often, at the conclusion of a debriefing, a palpable sense of relief floods the room.

In Oklahoma City, "we've done it by the book," said Oklahoma City Fire Department Chief Alan Benson. The fire department's CISM team, in conjunction with numerous outside teams, tended to the 1,025 fire department personnel, plus mutual aid agencies, spouses and families. Each of the basic steps of CISM laid out by Mitchell were followed. (1,2)

• Pre-lncident Education— According to Chaplain Ted Wilson, a member of the Oklahoma City Fire Department CISM team, for the past five years an inhouse team has provided education about critical incident stress and its management to fire department personnel.

• On-Scene Support, Including Initial Discussion, Defusing and Demobilization— Chaplain Wilson was providing a "presence of ministry" at the bombing site within 15 minutes of the blast. A defusing area was staffed 24 hours a day by people from the Oklahoma State CISM team, CISM teams from other states and chaplain/firefighters from at least four other states from April 19 until rescue efforts ended May 5. Firefighters were required to pass through that area before going off duty. The fire department also conducted predeployment briefings in which an off-going officer gave updates to crews coming on duty to get them mentally prepared before they faced the sights in reality.

• Formal Critical Incident Stress Debriefing— By protocol, debriefing is mandatory for Oklahoma City Fire Department personnel. According to Benson, "We take away the judgment call for the individual, of whether or not they feel like they need it. Everyone goes." Debriefings for the fire department and mutual aid agencies were ongoing in May and were conducted by the Texas State CISM team, which had been held in reserve for that purpose. Other formal debriefings were scheduled by the Oklahoma State team for more distant mutual aid agencies.

• Spouse Support— Spouses and families of fire department personnel were invited to a defusing one week after the bombing. According to Wilson, 450 people showed up.

• Follow Up— lndividual consultation and specialty debriefings will be conducted on an as-needed basis.

To specifically measure the benefits of debriefings is difficult. "I think you couldn't measure it, but once those macho guys get involved, they come out thinking, 'That wasn't too bad,"' said Benson. "The benefits will show up in the amount of long-term problems we have."

Oklahoma City Fire Department anticipates a low rate of attrition due to the bombing because CISM was such a priority from the outset. "In fact," said District Chief Jim Conner, "a lot of them feel like we overdid it."

Properly conducted studies are beginning to show the powerful, positive impact of CISM when it is done right. (3,4) It appears, however, that some people perceive it doesn't help.

According to Mitchell, "Some people feel a little worse during debriefing because they're bringing up issues and situations that were uncomfortable the first time around, and they become more aware of symptoms because of the information and knowledge given. Because they can identify more symptoms, there's a sense that [CISM] is harmful, but don't misinterpret the data," he cautions. "Managed properly, those signs and symptoms go down fairly rapidly."

Mitchell has found that 75 percent of people who go through proper, formal debriefings have a marked decrease in symptom patterns within 48 to 72 hours. Healing for others takes longer, but is complete. Only a few are permanently affected negatively, he says.

Oklahoma City—Weeks Later

McElroy, the self-described "keeper of the soul" of EMSA/AMR, said stress arose in the weeks after the bombing because of a sense of abandonment.

"The medics have essentially been forgotten," he said. "I'm battling constantly to get these people some recognition."

On emotional fallout from the bombing, paramedic Lindsay reported good support from his employer (EMSA/AMR)—an essential ingredient to proper CISM—but admits feeling blackballed by the media. "Everyone's keyed up on the firemen being the 'heroes of the heartland,” he commented. "They aren't putting credit where credit is due."

Kenney, too, expressed frustration at the media's lack of EMS coverage. "Our [field providers] have interpreted that we have become largely invisible," he said. This is despite the fact that EMSA maintained a bomb-site presence 24 hours a day throughout the rescue efforts. The management dilemma then becomes, Kenney explained, either dealing with it vocally to the media, which can sound like sour grapes, or ignoring it, which hurts the field providers. It's a question, he said, of trust and respect.

What It All Means

Are we getting the help we need?

As the saying goes, the situation may not be perfect, but parts of it are excellent. As such, the CISM process does have a lot to offer, but it works best in an environment of multilevel respect and openness in which the personnel do not have to wonder, "Who can I trust?" It works best when pre-incident education is farreaching and of good quality. Research shows that with appropriate critical incident stress intervention, nearly all workers regain their career confidence in a shorter time frame and with less residual devastation than those who do not receive intervention.

We all share, to some extent, the horror of all the disasters that invade our lives, both in direct witnessing and through the media. But in the end, how one handles the challenges of life boils down to an individual story. In spite of all the help, each person has ultimate responsibility toward his or her life. One of Jessica McClure's réscuers made a choice that highlights the bottom line.

As Vaughn Donaldson said, "In the long term, [the memory of a critical incident event] doesn't stay so acute. But without proper help, it never heals. It kinda scabs over, and if you bump it up against something, well, let me put it this way: How many days after the Oklahoma City bombing did Robert die? Do I think an event like that knocks the scab off? Yes, I do."

References

1. Mitchell J, Bray G: Emergency Services Stress. Englewood Cliffs, N.J.: Brady, 1990.

2. Dernocoeur KB: Streetsense: Communication, Safety and Control. Second Ed. Englewood Cliffs, N.J.: Brady, 1990.

3. Robinson R, Mitchell J T: "Evaluation of psychological debriefing." Journal of Traumatic Stress. 6(3):367—382, 1993.

4. Leeman-Connelly M: "After a Violent Robbery." Criminology Australia. April-May:4—6, 1990.

What Are We Talking About?

Some Terms You Should Know

CISM, CISD, debriefing, defusing. It may seem these terms are thrown about willy-nilly and each can be used in place of the other. In fact, each has a specific meaning that is helpful in understanding the nature of critical incident stress management.

Critical Incident Stress Management (CISM)

This term is for the overall process, or the entire series of steps, undertaken from pre-incident to post-incident. In this article, we also call this the "Mitchell model," after Jeff Mitchell, PhD, who originated the concept.

A CISM program should have the following components: extensive basic and continuing education programs, a critical incident stress team and other support programs, family support projects, an administrator and supervisor of education and support programs, peer support programs, mutual aid and community outreach programs, various intervention techniques, chaplain services, professional counseling services, mutual aid programs with other organizations and community education programs. (1) The Oklahoma City Fire Department describes their CISM program that closely fits the Mitchell model in the text of the accompanying article.

Critical Incident Stress Debriefing (CISD), often simply called a debriefing

A debriefing is just one step in the formal CISM process. It occurs after an incident and is conducted by a specially trained team of other emergency services personnel and mental health workers, who have been educated to lead debriefings in an organized, productive manner. A debriefing has clear procedures and is conducted in complete confidentiality as a way to provide a safe forum for rescuers to respond emotionally to their experiences. It is not a critique of operations, and no one is allowed to attend who wasn't at the scene. Debriefings do not take place immediately after an incident; rather, they ideally take place 24 to 72 hours after the event. However, they can take place later than that, when the people involved are ready to accept the help.

Defusing

A defusing is a gathering of people to talk in a less formal setting than a debriefing and takes place shortly (within 8 hours) after an event with two-person CISM-trained teams consisting of peers. Defusings typically last less than an hour, and the people involved can go home or go back on duty afterward. Sometimes, a defusing is all that is needed, but in other cases, the people involved may arrange for a formal debriefing a few days after the defusing.

1. Mitchell J T: "Critical incident stress management. " In Kuehl A (Ed.): Prehospital Systems and Medical Oversight. Hanover, Md.: Mosby Lifeline, 1994.

First In! Twice!

What is it like to be on the first-arriving ambulance at the "Big One?" Many people understand that a certain expletive would be the very first response. But after that, what do you do?

Alina Badia, a veteran New York City EMS paramedic, was "first in" on not one, but two major disasters: the World Trade Center bombing March 26, 1993, an-cl the New York subway fire Dec. 21-, 1994 (also, ironically, the seventh anniversary of Badia's start in EMS).

At the World Trade Center, so many ambulances were within seconds of arriving that Badia elected to immediately transport a man with glass embedded in his thigh that threatened to cut an artery. Thus, she avoided the onslaught of victims. But at the subway fire, other ambulances were caught in traffic, and she and her partner had to cope with floods of burned and bleeding people emerging in a panic from the subway entrance. In all, the two were inundated by almost 40 people.

"That," she said, "was a mob scene. We got out, went to open the side doors, and 10 to 15 people piled into the ambulance—all with second- or third-degree burns. Some had 50 percent to 60 percent burns [over their bodies]. Others weren't so bad, and we had to tell them to get out.

"It hit me later. I broke down and cried," Badia admitted. "While you're doing your job, you just take care of the patient, but once you are in a more controlled environment, then you start thinking about what you saw, and it hits you—the burning flesh coming off their bodies, people asking for help. . . .”

Although stress affects different people differently, Badia advises colleagues to take some time off after a critical incident and talk about it.

"The best thing is to talk about it with co-workers who know what it's all about," she said. "We do a lot with humor. That's how a lot of medical professionals deal with the stress. It also helps to have the support of your family and a loving relationship. If you have a life besides work—a social life—that helps. Some people really live the EMS life. I have other things, other hobbies. Even though I like this job, it's not my whole life." Still, she said, if the stress is so overwhelming that it prevents someone from doing his or her job, it's time to go to another field.

Badia, currently on leave because of an injury, plans to continue her work in EMS. And she's not necessarily thrilled with the saying that "things happen in threes."