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Critical Incident Stress Critical Incident Stress ManagementManagement

Managing the Stress ResponseManaging the Stress ResponseErica Diethorn RNErica Diethorn RNErica Diethorn RN, Erica Diethorn RN,

Psychiatric Emergency Nurse, UPMC Mercy Psychiatric Emergency Nurse, UPMC Mercy

Critical Incident Stress Management Team MemberCritical Incident Stress Management Team Member

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What is a Critical incident?What is a Critical incident? Out of the ordinaryOut of the ordinary Self definedSelf defined Mass casualty incidentMass casualty incident High media interestHigh media interest Death of a coworkerDeath of a coworker Serious on the job injurySerious on the job injury Relatives or a known victimRelatives or a known victim Death involving childrenDeath involving children Acts of TerrorismActs of Terrorism Prolonged incidents especially with a lossProlonged incidents especially with a loss

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What is the Stress Response?What is the Stress Response?

Chemical Surge: Chemical Surge:

Adrenal Medulla: Adrenal Medulla: Epinephrine [heart, blood vessels, sweat glands] Epinephrine [heart, blood vessels, sweat glands] Nor epinephrine [Emotional behavior, Information processing] Nor epinephrine [Emotional behavior, Information processing] Dopamine [Mood states, Fear, pleasure] AcetylcholineDopamine [Mood states, Fear, pleasure] Acetylcholine

Adrenal Cortex: Adrenal Cortex: Corticotrophin releasing factorCorticotrophin releasing factor-- stimulates the stimulates the Anterior Pituitary: ACTH, Endorphins Glucocorticoids Anterior Pituitary: ACTH, Endorphins Glucocorticoids ––Cortisol Cortisol Mineral Corticoids Mineral Corticoids –– Aldosteroine Aldosteroine

Somatotropin Releasing Factor Somatotropin Releasing Factor –– stimulates the Anterior Pituitary : stimulates the Anterior Pituitary : growth Hormone growth Hormone ––increase glucose , decrease free fatty acidsincrease glucose , decrease free fatty acids

Thyrotropin Releasing Factor Thyrotropin Releasing Factor –– effects TSH, T3, T4, prolactineffects TSH, T3, T4, prolactin

Posterior Pituitary releases Vasopressin, Oxytocin, testosterone, Posterior Pituitary releases Vasopressin, Oxytocin, testosterone, luteinizing hormoneluteinizing hormone

Cognitive [Thinking] DistressCognitive [Thinking] Distress

Sensory DistortionSensory Distortion ConfusionConfusion Poor concentrationPoor concentration Difficulty making decisionsDifficulty making decisions

G iltG ilt GuiltGuilt Preoccupation with the eventPreoccupation with the event Inability to understand consequences of your Inability to understand consequences of your

behaviorbehavior Suicidal / homicidal ideationsSuicidal / homicidal ideations PsychosisPsychosis

Emotional DistressEmotional Distress

AnxietyAnxiety IrritabilityIrritability AngerAnger PanicPanic

Vegetati e dep essionVegetati e dep ession Vegetative depressionVegetative depression Fear, phobia’s, phobic avoidanceFear, phobia’s, phobic avoidance Grief vs. pathological griefGrief vs. pathological grief-- severe, impair ability severe, impair ability

to functionto function Elevated state of arousal can lead to PTSD, Elevated state of arousal can lead to PTSD,

Acute Stress Disorder, panic Attacks, depression, Acute Stress Disorder, panic Attacks, depression, Alcohol and other drug abuseAlcohol and other drug abuse

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Behavioral DistressBehavioral Distress ImpulsiveImpulsive Risk takingRisk taking Excessive eatingExcessive eating Alcohol or drug useAlcohol or drug use Hyper startleHyper startle Hyper startleHyper startle Sleep disturbanceSleep disturbance WithdrawalWithdrawal Family discordFamily discord Crying spellsCrying spells 1000 yard stare1000 yard stare ViolenceViolence

Physical DistressPhysical Distress

Tachycardia, BradycardiaTachycardia, Bradycardia HeadachesHeadaches HyperventilationHyperventilation Muscle spasmsMuscle spasmspp SweatingSweating Fatigue, ExhaustionFatigue, Exhaustion Indigestion, nausea, Vomiting, [blood]Indigestion, nausea, Vomiting, [blood] Chest painChest pain Loss of consciousnessLoss of consciousness

Spiritual DistressSpiritual Distress

Anger with GodAnger with God

Withdrawal from faithWithdrawal from faith

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What does it look like???

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FEMA Disaster Recovery PlanFEMA Disaster Recovery Plan

Worrying:Worrying: Event will happen again.Event will happen again.

Someone close will be killedSomeone close will be killed Someone close will be killed.Someone close will be killed.

They will be left alone / Separated from their They will be left alone / Separated from their family.family.

News coverage eliciting fear, anxiety, confusion News coverage eliciting fear, anxiety, confusion with kids with kids

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How do you interveneHow do you intervene

SafetySafety

Emotional SupportEmotional Support

Mobilize ResourcesMobilize Resources ––Supports CISM TeamsSupports CISM Teams Mobilize Resources Mobilize Resources ––Supports. CISM TeamsSupports. CISM Teams

NourishmentNourishment

Help, work reliefHelp, work relief

Long events: resting station away from the Long events: resting station away from the incident, phone available, Mental Health Teamsincident, phone available, Mental Health Teams

After the incident is completedAfter the incident is completed

NourishmentNourishment Job reliefJob relief Support Support Defusing/Briefing: Tell them what to expectDefusing/Briefing: Tell them what to expect Defusing/Briefing: Tell them what to expectDefusing/Briefing: Tell them what to expect Offer informational sheets with crisis support Offer informational sheets with crisis support

numbers.numbers. Do they need any further intervention before Do they need any further intervention before

going home??? going home??? CISM personnel on handCISM personnel on hand

Assess who all has been affected

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Important PointsImportant Points The majority of individuals exposed to a traumatic The majority of individuals exposed to a traumatic

event will not need formal psychological event will not need formal psychological intervention, beyond being provided relevant intervention, beyond being provided relevant information.information.

The focus should be on the individual more so thanThe focus should be on the individual more so than The focus should be on the individual more so than The focus should be on the individual more so than the event. Don’t ask them to relive the event.the event. Don’t ask them to relive the event.

Assessment is essential; an ongoing dynamic Assessment is essential; an ongoing dynamic process. Normalization of the crisis response is to be process. Normalization of the crisis response is to be encouraged. Crisis intervention should be voluntary.encouraged. Crisis intervention should be voluntary.

Try to reduce vicarious traumatization.Try to reduce vicarious traumatization.

CISMCISM

Normalize the response. They are normal people Normalize the response. They are normal people who are having normal reactions to abnormal who are having normal reactions to abnormal eventsevents

Educate the responder on what to expectEducate the responder on what to expectp pp p Restore to adaptive functioningRestore to adaptive functioning Mitigate impact of the event [lower tension]Mitigate impact of the event [lower tension] Most crisis intervention is done by pre hospital Most crisis intervention is done by pre hospital

personnel, nurses, physicians, soldiers, clergy, personnel, nurses, physicians, soldiers, clergy, hospital workers, community members.hospital workers, community members.

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Interventions

Assessment / triageSmall groups: Defusing, CMB, DebriefingOne on oneDemobilizationDemobilizationFollow up and referralPre incident educationStrategic planning in the incident command

structure

Dissipating the Stress ResponseDissipating the Stress Response TimeTime

Avoid numbing alcohol, drugs / stimulantsAvoid numbing alcohol, drugs / stimulants

VentingVenting

On Scene Support / DemobilizationOn Scene Support / Demobilization

DefusingDefusing

BriefingBriefing

DebriefingDebriefing

PrePre--incident educationincident education

Reaction to a critical event.Reaction to a critical event.Variables:Variables: Personality type: Personality type:

AAAANegativeNegativeToo center focusedToo center focusedCatastrophizingCatastrophizingRealistic expectationsRealistic expectationsControllingControllingMistrustfulMistrustful

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PrePre--EmptiveEmptive

Have a personal disaster plan in place.Have a personal disaster plan in place.

Keep a change of clothes at work.Keep a change of clothes at work.

Carry extra personal medicationsCarry extra personal medications Carry extra personal medications.Carry extra personal medications.

Know yourself.Know yourself.

Check your coworkers.Check your coworkers.

Have resources easily available.Have resources easily available.

How do I reduce my stressHow do I reduce my stress

Postpone choresPostpone chores DelegateDelegate Allow yourself to say NOAllow yourself to say NO Increase you knowledge of new hurdles you must Increase you knowledge of new hurdles you must y g yy g y

accomplishaccomplish Try to decrease conflicts, improve relationshipsTry to decrease conflicts, improve relationships

[Those who anger you, conquer you][Those who anger you, conquer you] Keep perspectiveKeep perspective Have a sense of humorHave a sense of humor Better time managementBetter time management Get plenty of sleepGet plenty of sleep

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The Pittsburgh CISM Team412-647-CISD [2473]

Allegheny County Re-Solve Crisis Network: 1-888-796-8226

Beaver County: 724-775-5208Butler County: 1-800-292-3800Fa ette Co nt 724 437 1003Fayette County: 724-437-1003Indiana County: 877-333-2470Lawrence County: 724-652-9000Mercer County: 724-662-2227Washington County: 724-225-6940Westmoreland County: 1-800-836-6010

ReferencesReferences

Molecules and Mental Illness; Samuel H. Molecules and Mental Illness; Samuel H. Barondes; 1993Barondes; 1993

Critical Incident Stress Management [CISM]:Critical Incident Stress Management [CISM]: Critical Incident Stress Management [CISM]: Critical Incident Stress Management [CISM]: Group Crisis Intervention; 4Group Crisis Intervention; 4thth edition Jeffrey T. edition Jeffrey T. Mitchell, Ph.D., C.T.S.; 2006Mitchell, Ph.D., C.T.S.; 2006

FEMA Disaster Recovery PlanFEMA Disaster Recovery Plan