Critical Incidents/Death of a Unit Member/Pre-Exposure/Preparation Steps

Critical incidents are events outside the normal experience of people that pose actual or perceived threats of injury or exposure to death that can overwhelm both an individual's and organization's coping resources. Examples of such critical incidents include:

Natural disasters.
Acts of terrorism.
Mass casualty accidents.
Acts of violence (with and without fatalities).
Observed traumatic deaths.
Aircraft accidents/mishaps.

First responders (e.g., medics, fire fighters, law enforcement, or a agency member when the incident occurs at the worksite) are particularly vulnerable to this source of intense distress.

Critical Incident Stress Management (CISM) teams or services exist to help individuals recover from or remain functioning despite the potential negative effects of critical incidents. CISM potentially enables people to understand the normal reactions to traumatic events and to promote use of effective coping skills. This is accomplished through peer counseling, education, group meetings, command consultation, and on-scene supportive services.

Aftermath of a Critical Incident

Providing support and preventing further harm is essential for survivors of critical events. Leaders will need to collaborate with the CISM team and helping agencies to address the needs of survivors. Subsequent to a critical incident, the following are recommended:

Demonstrate concern for members' well-being.
Ensure that the basic needs of survivors are met (i.e., shelter, food, safety, and security).
Let people talk about their experience ("emotional first aid").
Minimize exposure to environmental stressors (e.g., heat, cold, noise, disturbing visual scenes).
Be attentive to the needs of family members.
Provide factual information; prevent the spread of rumors.
Continuously evaluate the environment for additional threats; ensure that needs are continued to be met.
Foster section cohesion.
Foster resilience and recovery through social support mechanisms (e.g., friends, family, and religious organizations).

Body Handling Following a Critical Incident

Individuals who handle human remains following a critical incident may experience a sense of accomplishment and feel they are doing something important. However, the stressors associated with body handling can be overwhelming. These stressors include:

Fear of the unknown.
Fear of their reaction when facing death.
Concerns about the health and safety of loved ones.
Being exposed to bodies of fellow members.
Being exposed to children who have died.
Being exposed to mutilated bodies.

It is not uncommon for individuals to be anxious, sad, and irritable or suffer from restless sleep or nightmares for days after handling human remains.

Training and preparation can significantly reduce the chances that these reactions will persist over time. Prior to handling human remains, educational briefings should be conducted explaining the exact nature of the work. Emphasize that proper handling of remains is highly important to the families of the deceased. Each body handling team should clearly know their tasks and roles with activities broken down into a series of drills and routines.

Team members should be made aware of what symptoms they may experience and they should be encouraged to seek help in coping with their feelings, when needed. Members should be offered opportunities to vent their feelings and share experiences. Regular praise and encouragement should be given emphasizing the importance of their work. Those individuals who are more experienced with body handling should be paired with those less experienced. This buddy system helps protect against feelings of fear and sense of personal isolation.

Alcohol use should be discouraged as a coping mechanism. Fatigue can compromise coping skills, so sufficient rest and regular breaks and shift patterns are recommended.

Other activities that leaders can organize to help prevent and minimize distress from body handling include:

Encourage members to drink plenty of fluids, eat well, and maintain good hygiene.
Assure facilities for washing hands, clothing, and taking showers after each shift.
Plan team activities to help members relax and to stay socially connected.
Keep chaplains and other helping professionals fully informed about what is happening.

II. Relevant Policy

Use of CISM

Not all emergency public safety agencies maintain their own in-house CISM teams. However there are many external sources available. Refer to local policy regarding CISM. Not all members directly benefit from participating in CISM, however every opportunity should be made to provide members with CISM support should they be interested in participating. Many approaches can be used for CISM and your local CISM team will recommend appropriate preventive interventions. Common interventions include the following:

Demobilization. Demobilization is a brief (approximately 10 minute) presentation of information and stress management advice provided over the course of sustained rescue and recovery operations. The goal is to provide a "buffer" between the scene and home life. Demobilizations are applied to each shift prior to being released from duty or when the event is concluded in order to:
- Provide information updates to the scene.
- Allow early screening of individuals who may need further assistance.

Demobilization is not a stand-alone intervention. Generally a full debriefing should be provided following the completion of operations.

Defusing. Defusing is a group intervention usually lasting 20 to 45 minutes designed to help mitigate the impact of exposure to a critical incident:
- It is initiated within 3 to 8 hours following the event or following response operations.
- It is applied to a targeted population that has the potential to be the most traumatized.
- It can enhance the effectiveness or eliminate the need for further CISM interventions.
Debriefing. A structured group intervention employing both educational processes and crisis intervention provided by specially trained personnel. Following a critical incident, the CISM leader will discuss the nature of the event with the commander of the individuals who were exposed. A plan will be developed based on the specifics of the situation and debriefings consisting of 5 to 15 individuals can be scheduled.
- Lasts 1.5 to 2 hours.
- 24 to 72 hours after an event.

2. Death of a Unit Member

I. Overview

General Considerations

When a agency members dies, it is important for the entire organizational community to work together to provide reassurance and a sense of security for those experiencing the loss. Support to help members cope with feelings of loss is very important at this critical time. Common reactions experienced by persons following a sudden death include:

Disbelief--"This can't be true."
Questioning the reasons/justifications for the death.
Anger at being deprived by the death.
Guilt/blame.
Helplessness.
Sleep difficulty.
Nightmares.
Difficulty with concentration.
Numbness and detachment.
Depression.
Anxiety.

In some cases, surviving members may experience distress associated with shock and guilt and the belief that something could have been done to prevent the death. This most commonly occurs following suicides and accidental deaths.

Some agencies have the benefit of an in-house Family Liaison Officer (FLO) while other utilize outside contracted resources. The Family Liaison Officer (FLO), who is designated by the agency to assist the surviving family, may at times encounter a range of reactions from family members who have just lost a loved one, including suicidal behaviors. The distressed family member may not be eligible for care at a local hospital or may be located in a remote area where emergency medical care is not readily available. Under these circumstances, the Family Liaison Officer should:

Consult with the chaplain who is assigned to the family.
Enlist the assistance of a family member they trust.
Approach the family member and express concern.
Encourage the family member to seek help.
Call a local hospital or county community mental health clinic and inquire about local resources for emergency care.
When communicating with officials, be sure to maintain confidentiality.
Ensure the member is accompanied to the emergency care facility.
Keep the commander informed.

Role of Leadership

There is no simple way to deal with the death of a unit member. Leaders should enlist help from a variety of sources such as the chaplain’s office, mental health, Peer Counseling, and Casualty Affairs. Consult with the CISM team chief as to what services may be appropriate.

In the case of a suicide, the grief experienced by people close to the victim can be especially complex. The general goals of post-suicide intervention are to help friends and colleagues understand and begin the grieving process, to help maintain operational readiness, full functioning and morale, and to identify/refer individuals who are at increased risk for distress.

Commanders and supervisors should consider the following actions:

Appoint a FLO to collect the personal effects and to serve as a POC for the family.
Provide basic information to members surrounding the death. Include information such as time, place, method, and how the death was discovered.
Contact appropriate members currently away from the section.
Announce the details for the memorial and funeral arrangements.
Reach out to family members.
- Make personal contact to express condolences.
- Attend the funeral service.
- Visit the bereaved family when appropriate.
Hold a memorial service for members who are unable to attend the funeral. Offer members closest to the deceased key roles in planning and carrying out the memorial service.
Check in periodically with members who were closest to the victim.
Work with Public Affairs to best determine what to say and what not to say in public statements.

Members will look to the commander/supervisor for answers to why the member died. Survivors are especially sensitive to comments or suggestions that imply responsibility. It is important for leaders to avoid passing judgment, providing simplistic explanations of the death or suicide, or publicly placing blame. With this in mind, it is important to keep rumors from spreading by keeping people informed while protecting privacy.

Survivor Support Groups

Contact mental health, EAP, or chaplain for assistance with locating survivor support groups in the community.

3. Pre-Exposure

General Principles Training Handout

PEP can be useful to individuals for whom exposure to a potentially traumatic event is anticipated. Examples include personnel in career fields that are first responders to major incidents and all personnel responding into potential conflict (i.e.: riots, terrorism). The CISM team can provide this training. Additionally, all command and supervisory personnel should be provided a copy of the "Pre-Exposure Preparation Training" brochure. The purpose of this information is to emphasize the basics associated with understanding and coping effectively with the stress of traumatic events.

All members may potentially experience distress and can benefit from preventive self-care.

4. Suggested Resources

Handling Traumatic Events, A Manager's Handbook United States Office of Personnel Management http://www.opm.gov/ehs/htlm/toc.asp
Disaster Mental Health Institute: http://www.usd.edu/dmhi/
US Dept of Health and Human Services Disaster Mental Health: http://www.mentalhealth.org/cmhs/EmergencyServices/
A Manager's Handbook: Handling Traumatic Events: http://www.opm.gov/ehs/html/toc.asp

5. References

Ayers, J. Leading Through a Loss Air Force News Archives (Jun 02 ).
Joyce, J. (2002). Leadership in a time of disaster: Being prepared for new age threats. Journal of Nursing Administration, 32, 455-460.
Keller, R. (2002). Handling human remains following the terrorist attack on the Pentagon: experiences of 10 uniformed health care workers. Military Medicine, 167, 8-11.
Mental Health and Mass Violence, Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence. (2001). Bethesda, MD: National Institute of Mental Health.
Mitchell, J. T., & Everly, G. S. (1996). Critical Incident Stress Management: The basic course workbook. Ellicott City, MD: International Critical Incident Stress Foundation.
Raphael, B., & Bobson, M. (2001). Treating psychological trauma & PTSD. J. Wilson, M. Friedman, & Lindy editors. NY: The Guilford Press.
Reeves, J. (2002). Perspective on disaster mental health intervention from the USNS comfort. Military Medicine, 167, 90-92.
Schwerin, M. (2002). Counseling support within the Navy mass casualty assistance team post-September 11. Military Medicine, 167, 776-778.