CISD Opinion Paper

I was tasked with writing an opinion paper on CISD for my “Well Being of the Paramedic” course that’s part of my medic school’s curriculum.

Names and locations have been redacted.

I’d like to hear your thoughts.

The line of duty death of a coworker, a tragic accident involving a child or a serious mass casualty incident are all critical events that may trigger powerful emotional responses in the parties involved. Due to the nature of the work it would seem that Fire, Rescue and EMS workers would be at the greatest risk for the development of posttraumatic stress from these incidents. Created as a peer driven stress management tool, Critical Incident Stress Debriefing (CISD) was developed to help those exposed to such incidents deal with their emotions. However, since it’s inception, the idea of critical stress management has polarized many EMS workers. The simple idea behind CISD, to prevent or limit the development of posttraumatic stress in individuals exposed to critical incidents, may in some cases exacerbate the stress these individuals experience. After interviewing several individuals that have taken part in the CISD process and recalling my own personal experience with the CISD process, I can argue that while some I spoke with did receive some emotional benefit from the CISD process, each individual’s emotional coping skills are different, and a “one size fits all” CISD counseling session for stress management may do more harm than good in the long term.

In conducting interviews for research, I used a posting on the popular online EMS forum XXXXX.com to solicit responses from EMS professionals who have been in the field for longer than 5 years and had taken part in a CISD event. I received numerous responses and sent standard interview questionnaires to the individuals. I received four complete responses that met my criteria and used these questionnaires, along with specific follow up questions and telephone interviews, to frame my opinion.

I spoke at length with XXXXX, a ten year EMS veteran, who is employed as flight paramedic for XXXXX. She attended her first CISD in 2003 following an incident where an acoustics manufacturing plant sustained a significant explosion and fire, which injured over 40 people and killing 17 in XXXXX XXXXX. After hearing the details of the incident and how the CISD was planned for the team of emergency responders, I asked XXXXX how she felt about the CISD process as a whole. She replied, “I became frustrated during the CISD process because I felt I was pressured to give responses I hadn’t quite come to grips with yet or really had the chance to sort out for a bit myself. I’m a very private person by nature and didn’t appreciate people trying to pry emotions out of me that I wasn’t comfortable expressing to those I didn’t know, which was ultimately the reason I got up and left. I prefer to deal with a few close people I know rather than a large group. I also wasn’t comfortable with the fact it was a forced attendance.” I was surprised to find that this CISD event had a mandatory attendance requirement and XXXXX agreed, stating, “It seemed almost as if they were forcing us to relive the event when we were discussing things … We also felt we would have been better served by a more informal process with simply the offer of additional help if we needed it rather than being thrown in front of a social worker and told ‘Okay, express yourselves’”. XXXXX went on to say that following the formal, mandatory CISD, she took part in several informal gatherings with her crew members and found that in the informal setting, she was better able to evaluate her performance and actions. XXXXX said it took a long time for the memories of that incident to fade and went on to say, “I have very adverse feelings to a formal CISD as I think it actually intensifies the incident and prolongs the recovery period from it.”

I also spoke with XXXXX XXXX, a six year EMT-B from the XXXXX Rescue Squad in XXXX. XXX took part in his first CISD following an unsuccessful pediatric resuscitation. In direct contrast to XXX’s experience, when asked about his experience and why he attended, XXX said, “It was definitely non-mandatory. All of the personnel were invited. I went simply because I felt slightly disturbed by how the family thanked me after I was unable to revive their loved one. I didn’t feel that I should’ve been thanked.” I then asked how he felt about the call and it’s outcome following the CISD event. XXX replied, “I felt more validated and eased in my mind about how I did things.” Even though XXX received some positive feedback and appreciated the opportunity to talk about his feelings following the incident, he was reluctant to recommend the CISD process to other EMS workers, stating, “…simply because what works for me won’t work for everyone else.”

As for my own experience with Critical Incident Stress management, I took part in my first CISD in 1990, following an MVA with multiple fatalities in my hometown in XXXXX. I was the first EMT on the scene and was assigned to triage. It was immediately obvious that two of the patients were DOA and several others would require lengthy extrication. Making this chaotic scene even more emotional was the fact that several of the victims were young adults I knew from High School. The day following the incident, we were all invited to a CISD workshop at the Firehouse. I attended, not because I was having difficulty in dealing with the emotional aftermath, instead I was goaded into attending by the repeated urging of my Chief. During the CISD, I recall being repulsed by several of the other firefighters in my department referring to the trapped occupants as “hamburger” and “DRT” (Dead Right There). The braggadocio and swagger that was on display from my fellow EMS workers upset me more than the actual event. I didn’t say much during the entire event. I recall sitting on my cold metal folding chair, sipping cold coffee from a Styrofoam cup, listening to each member of my crew speak, knowing that it was important for me to listen and my just being there was helping to support the crew. I later spoke with the CISD facilitator about how I was feeling about my crewmembers and he explained that often people covered their shock and emotions with bravado, and that if I had problems I should talk to him. I never did talk to the CISD facilitator again and I continued working in EMS for several years following that incident. After the experience I had, watching my crew, I doubt I would attend a CISD event again. I’d much rather talk it out with my partner, a close friend in EMS or my priest.

As EMS professionals, we will be exposed to critical incidents as a matter of course and it is clear that dealing with Critical Incident Stress is an important part of maintaining the health and well being of the EMS worker. However, I believe that a formal Critical Incident Stress Debriefing, no matter how innocuous or well meaning the intent, may force individuals to attempt to cope with these stressors before they are emotionally ready and willing to face their coworkers. Instead, I feel that department leaders and EMS management should adopt a flexible strategy to deal with traumatic stress situations. A more fluid, less structured and rigid plan, based on the needs of each individual, consisting of informal chats, the freedom to take personal time or the offer of mental health professionals or counselors could be the next step in replacing a regimented, formal, and in some cases mandatory, Critical Incident Stress Debriefing following a traumatic event.