Friday, October 5, 2001
Rescuing the rescuers
In the days and weeks since September 11, we have all gratefully applauded the efforts of the rescue teams in Washington, D.C. and New York. All the professionals involved have been constant in their efforts to bring hope and closure to the families of victims, and to us all. They see and handle indescribable horrors, work long shifts, and take life-threatening risks. We know they are trained for these jobs, but what does it cost them to do these things?
These brave people are as human as we all are. After high-impact work such as this, they can experience physical, cognitive, and emotional stress symptoms which, left untreated, can permanently damage their mental health. Who takes care of them while they take care of us?
Carlisle does. As early as 1989, our own Deputy Fire Chief David Flannery and Chief Robert Koning saw the necessity for some kind of treatment to "lessen the impact and accelerate the recovery of involvement" of first response personnel in certain types of calls. They hooked up with Dr. Jeffrey Mitchell of the University of Maryland, himself an EMT coordinator, who had been researching stress responses to emergency calls involving casualties, children, suicide, coworkers, victims known by the first response teams, and the like. Dr. Mitchell termed these calls "critical incidents." He found that after working in these situations, first response team members were subject to a variety of physical stress symptoms including chills, nausea, muscle tremors, chest pain, weakness, elevated blood pressure, and shock. In addition, they suffered cognitive misfires such as confusion, disorientation, difficulty identifying objects or people, and heightened or lowered alertness. Finally fear, guilt, panic, anxiety, depression, and a variety of other emotional responses became apparent.
Koning and Flannery, trained by Dr. Mitchell to identify stress responses, worked to establish the Concord area program using the "Mitchell model." This is a seven-step program carried out by a team of trained peers and other crisis management professionals to treat the people in our first response networks.
Carlisle sent three firefighters, including residents David Ziehler and George Middleton, with a team including a clergyman, an Emerson Hospital chaplain, and a clinician to Ground Zero at the World Trade Center, where they spent five days implementing the CISD (Critical Incident Stress Debriefing) plan to firefighters and rescue workers. Their activities began with an initial period of "demobilization," in which they observed the work of the New York first response teams, assessed safety, physical and mental issues, and advised command centers as to appropriate treatment.
Responders came off duty and were processed through the CISD team, beginning with offers of food and drink, handouts, and short talks with team members. In these talks, team members assured the responders of confidentiality and the protection of their privacy. To secure these protections and ensure the success of this and all CISD programs, members of the team do not discuss their work or their experiences with the press. As David Flannery says, "We need to cherish and take care of our emergency service people and the people who do this job as well."
After this first step, the program addresses the cognitive, physical, and emotional distress of the responders. Team members ask responders to describe the facts: in this case, their particular roles at Ground Zero. In order to focus on their jobs without interference, most people perform, Flannery says, "on autopilot," without taking time to reflect on what is happening, so the third step of the program asks the responders to articulate their first thoughts when they come off duty.
Voicing their thoughts leads directly to step four, as many responders might now begin to speak freely about their physical and emotional reactions to the incident. Team members then ask them to try to focus on the one part of the incident that elicited the harshest reaction, and to identify it. This is typically the part they would like to erase. Trained peers like Ziehler and Middleton support responders through this difficult phase by offering understanding of critical events and common experience. Peers help to create an atmosphere of mutual trust and comfort. Next, responders focus on the reactions of their bodies and minds. Very often, responders experience reactions which frighten them and make them feel as if they have "lost it" and "gone crazy." In this phase responders try to see their reactions, no matter how unsettling or violent, as normal results of this particular incident, and not of any other cause. This step is particularly important: responders need to see the reason for their reactions as specific, understandable, and therefore temporary. Most importantly they need to understand that they are normal people having normal reactions to an abnormal event.
Defusing effects of stress
Once they grasp the idea that their reactions are normal, talks and handouts teach responders how people react to stress, preparing them to understand both the reactions they have suffered, and those they might still experience. The first 24 to 48 hours are crucial to diffusing the effects of stress, so responders learn how to take immediate action: engage in physical, especially aerobic exercise; eat well; talk to family members and others; actively seek support; keep a journal; give themselves permission to feel terrible and share these feelings with others; maintain as normal a schedule as possible. Clinicians and clergy then assist them in understanding the critical incident by explaining grief; in this event, talking with them about terrorism and its goals, and examining the "whys" of the tragedy.
Tying up loose ends
Step seven, or "re-entry," is designed to tie up loose ends. Team members run a question-answer period, peer team members make summary comments, and responders are assured that their symptoms should lessen with time and should have no long-lasting effect.
This particular crisis, however, has far-reaching effects of its own. In a disaster of this magnitude, protection and debriefing are provided for the CISD teams as well as for the first response workers on site. What CISD personnel see and hear while carrying out the programs can cause stress reactions every bit as serious as those they treat. Now that they have returned from New York, Ziehler, Middleton and the other four team members will also be debriefed, putting the program to work for them as well.
Carlisleans Ziehler and Middleton have just participated in the latest in a long history of team deployments. In 1990, the Carlisle critical incident stress management group expanded to include the 26 communities in the Emerson Hospital area now in its jurisdiction. Fire Chief Robert Koning serves as the lead agency administrator for our area. Deputy Fire Chief Flannery was a founder of the program and has been the program director and team coordinator since its beginning. The small program begun by Mitchell in 1989 has expanded to an international operation. Today the nonprofit International Critical Incident Stress Foundation (ICISF) trains fire, police, EMTs, rescue companies, airline pilots, religious organizations and the United States Military. It sponsors a World Congress every two years where membership meets to update and improve educational courses and technology. Much of the work of the CISD teams is done voluntarily, with team members often donating their time and skill. The ICISF relies on dues and fundraising to maintain its operations. This foundation contacted our area group to request the services of Ziehler's and Middleton's CISD team at the World Trade Center.
David Flannery describes the deployment of CISD teams as hugely successful in preventing the long-term effects of stress: "I've seen it work. It's a beautiful process to see happen. Before this, you would certainly lose people, but it doesn't need to be that way now. The mission of the team is to work toward preserving the health, lives and careers of emergency service professionals."
For any of us who have ever wondered what it must be like to relieve the disaster at the World Trade Center, the answer is clear. It's a job that tests the human body and mind beyond its limits, and we are fortunate to have a way to rescue those who rescue others.
© 2001 The Carlisle Mosquito