The Importance of CISM

Here is a part of a paper I had to write for the classes I'm taking. I'm posting here to help promote the idea of critical incident stress management for all first responders and healthcare providers. We can teach physical skills all day long, but as a profession, we haven't really focused much time on caring for the caregiver. It has gotten better, but we're not there yet. Enjoy:

Since becoming a nurse in 1993 this writer has had the honor of working with some of the sickest patients in the region. Couple that with the Emergency Medical Services (EMS) experience which started in 1989, there have been hundreds, maybe thousands of cases that have changed not only the practice of care delivery but has also changed this writer’s view of life itself. How can it not?

Every day in the emergency departments and on the streets of the United States, first responders and nurses alike are on the front lines of dealing with the best and the worst of humanity. From complex medical issues to homicide, these caregivers are subjected to battleground- like environments. If the reader believes this is an over-exaggeration, just consider what it might have looked like, sounded like, smelled like on the night of the Route 91 Harvest Music Festival in Las Vegas in 2017. Caregivers are exposed to, even on a normal day, things that are seemingly nothing that another human should see or try to sort out. Yet, we do it for a living and it takes a toll.

Of all the cases over the past thirty years that have left indelible marks on the writer’s memory, one case, in particular, demonstrates the triumph of saving a life and the regret of losing one, and how delicate life is. On this particular night just before Christmas in 2013, this writer was working for a rotor and ground hospital-based medical transport company. We were manning a mobile intensive care unit along with another advanced life support ambulance. We were both dispatched to a scene of a motor vehicle crash south of our city in a rural area. It was around 2300 hours, dark, cold, and icy. We arrived on the scene to find a compact car that had tried to pass another vehicle on the icy road, slid off the right side of the road, overcorrected onto the pavement to only slide off the left side of the road, glance off a barn and strike headlong into a large tree. Bystanders guessed the speed of travel was around 80 miles per hour. The amount of destruction was unbelievable. Passenger compartment intrusion was some of the worst we had seen in all the years in the business. The tree had pushed to almost the rear seat of the vehicle, the engine was displaced onto the driver, and both the driver and passenger were entrapped. All we could see of the sixteen-year-old driver was his wrist. He had a pulse but the wrist demonstrated a posturing type of rhythmic movement. Initially, we thought the fifteen-year-old passenger was impaled by the A-post of the vehicle, but on closer inspection, we discovered that he was just incredibly trapped. All we could see of him was a small section of his neck. He had a pulse as well.

The fire department worked feverishly to relieve the entrapment. It took over an hour to gain access to the patients. In the meantime, the driver died. The passenger was pulled out of the vehicle and placed in our ambulance. He was unresponsive and barely breathing. His heart rate was 140 and blood pressure was 70mmHg systolic. As a team, we placed intravenous and intraosseous lines, decompressed his chest bilaterally, and worked hard to ventilate him. He had subcutaneous emphysema from mid-chest to his face. When trying to intubate him, he had what looked like ground up, bloody hamburger in his airway. He suffered a severe tracheal tear and other major structural damage. Somehow, we were able to intubate him using a combination of a video laryngoscope and a digital feel. We transported him to the local small hospital. There, he received bilateral chest tubes, a cursory exam, and a chest x-ray. It confirmed severe lung contusions, bilateral pneumothoraces, and a pneumomediastinum. Since it was still precipitating out, the rotor wing ambulances were not available, so we loaded the patient back up and transported him to a level one trauma center about fifty miles away. En route, we worked to maintain adequate ventilation and perfusion. We gave IV fluid and packed red blood cells. But his blood pressure continued to dwindle. We started a norepinephrine drip to try to help. On follow-up, we found that the patient indeed survived this horrific crash. He has diffuse axonal brain injury but was able to walk across the stage to get his high school diploma a few years later. That night, we lost one life but saved another.

In the process, my uniform coat had gotten the patient’s blood on the sleeves and the front of it. Of course, it was laundered. Many times. But in my mind, the smell never left the coat. That is what it was like many times in dealing with tragedy. In this case, it was a young driver who lost control on an icy road, a young driver who made bad decisions. In other cases, it is the smell of gun smoke, the smell of still smoking gunshot wounds when we arrive on scene or when the patient comes into the Emergency Department, and the smell of alcohol in blood mixed with leaking fuel and engine coolant. It is the idea of working so close to pure evil that makes this caregiver feel dirty. After dealing so closely with trauma (emotional and physical), we are left with dealing with those emotions. No matter how many times the coat is washed or how many showers one takes, the smell never leaves. It may be repressed for a while, but one thought, one sound, one smell will bring that feeling back to the forefront.

In a physical sense, we learned a lot about physical trauma and how to handle situations like this going forward. Like anything in medicine, you learn as you go. There is not much we would have changed about our physical care that night. We did what we were trained to.

So, how do we deal with it and continue in the profession? In years gone by, our co-workers and supervisors would just say “suck it up” and “deal with it”. But, thankfully, over the years the stigma of silent strength is waning. Caregivers of all types are now encouraged to talk about their feelings with each other, with professionals, with anyone. Just talk about it. If not dealt with, these profession-related stresses can cause increased attrition through burnout, increased substance abuse, and divorce (Hammond and Brooks, 2001). Worse, more first responders die from suicide than in the line of duty (Ruderman Foundation, 2018). Effective Critical Incident Stress Debriefing (CISM) is essential after a traumatic situation. CISM allows responders time to vent their feelings and share camaraderie with their co-workers. Doing so can help build a sense of team in the process.

For me, I have run the gamut of dealing with exposure to trauma. From alcohol to food. But nothing ever seems to “wash the coat clean”. Being so close to such acute trauma always left me with a sense of being dirty. I found that nothing cleanses like the love of our Savior, Jesus Christ. No matter how many times the coat is washed with soap, it never gets clean, but one visit with our Father who is the best soul cleanser available makes my soul clean. To help give back, I became a licensed minister in 2014 and started a chaplaincy at the local sheriff’s office. Since then, my pastor-partner and I became certified police chaplains, and have taken group therapy classes through the International Critical Incident Stress Foundation. I have also become the chaplain of record for two other fire/ EMS agencies and volunteer with the University of Toledo Center for Mass Violence and Suicide and their regional CISM team and my employer’s Employee Assistance Program as a CISM member. Helping others in their time of grief post-trauma has become a passion but remains in its infancy. We can do more to help those who are exposed to job-related trauma and we must.

Where I work now, there is a robust employee assistance program. This is run by mental health professionals with the assistance of CISM team members who are aligned with the subjects’ clinical focus. If a group of nurses requests a CISM, then the mental health folks contact members like myself who are trained in CISM but are also nurses. Being able to identify with the subject is important. Many times someone who is suffering trauma finds comfort that someone of the same job description can relate to their grief.

Conclusion

As nurses and first responders, we put ourselves out there. We get in the business to help people on their worst day. We can study and train for the worst-case scenario and even perform well under the stress. But how the caregiver is cared for after will only help them moving forward in their career and their life. And we need to continue to do a better job at it.