Critical Incident Stress Management

Rescuing the rescuer

CarolinaFireJournal - By Dr. Jim Baxendale
By Dr. Jim Baxendale
08/04/2013 -

After more than two decades, firefighter Lieutenant Charlie Robertson still thinks about the holiday fire where eight children died in a three-family structure. He also recalls the accident in which two firemen were killed when their vehicle was hit and cut in half by an Amtrak passenger train while they were responding to a vehicle fire that had already been extinguished.

Former Paramedic Jeff Mitchell vividly remembers the China-doll-like face of a young woman who was hit and killed by a dump truck in Howard County, Maryland. “Her eyes were fixed open, and, for a long time, that was hard for me to shake away,” says Mitchell.


These are perfectly normal reactions to horrific situations. It’s not being able to resolve those feelings that may lead to posttraumatic stress disorder (PTSD). But it’s not just horrors of this magnitude that can cause difficulties later. Traumatic stress in emergency service workers is cumulative, so that a relatively minor incident can literally be “the straw that breaks the camel’s back.” Stress is that normal state of physical and psychological arousal which we all need in order to function.

Without stress we would lack challenges in life and fail to be motivated. But, stress can be difficult to live with when it has built up over time or when it involves a critical incident. Without intervention, the symptoms of a stress response may cause individuals to be physically and emotionally ill; may cause them to lose their jobs or not want to continue in their jobs; may cause them to end their marriages; may, in the extreme, cause them to consider suicide.

A critical incident is an event that causes emotional or psychological trauma in people exposed to the incident directly or even indirectly. It is a sudden, powerful event outside the range of normal experience — and outside an individual’s control. A critical incident will often overwhelm a person’s ability to function in a normal way by causing strong emotional reactions. It is an incident of such magnitude that it results in what psychiatrist Gerald Caplan has termed a “psychological crisis” where our psychological balance has been thrown off kilter and our usual coping mechanisms just aren’t working. That results in emotional and physical distress and a general inability to function in an effective manner.

The possibility of experiencing a critical incident is there every time we answer a call. Most of the time, most of us are able to handle these events pretty well. But there are certain types of critical incidents that take an especially heavy toll on emergency workers:

  • Line of duty death or serious injury
  • The suicide of a co-worker
  • The death of a child
  • Mass casualty incidents
  • A prolonged failed rescue attempt
  • A situation where the victim is known to the responder

These situations should always raise a red flag that a critical incident has occurred.

The public safety subculture holds many myths that can lessen our ability to deal with the situations we face on a daily basis. “Real firefighters/medics can handle it.” “You’re supposed to see the burned bodies, the mangled remains, the dead children. It’s part of the job, so suck it up.” “If you can’t deal with it, find a new line of work.”

No matter what uniform we wear, the truth is that we are all human beings. And no human being is supposed to see burned bodies, mangled remains and dead children. And as human beings, we all experience deep emotional reactions to a critical incident. Attempts to deny these reactions often cause emergency personnel to suffer in silence and not seek help. When this happens, their lives — and the lives of their families — can be totally disrupted.

Emergency services personnel share several personality traits that make them very good at what they do. But these same traits can feed into the stress of a critical incident. These personality traits include:

  • A need to be in control;
  • Obsessive/perfectionistic tendencies;
  • High levels of internal motivation;
  • Action oriented;
  • High need for stimulation and excitement;
  • Easily bored;
  • High need for immediate gratification;
  • Tendency to take risks
  • Highly dedicated
  • High need to be needed; and
  • Strong identification with their role in emergency services — It’s not what we do, it’s who we are

These personality factors not only make emergency services personnel do a good job, but also make them more vulnerable to the effects of critical incidents. The demands of the job, in combination with these personality traits, are reasons why emergency services personnel need to be more aware of stress and the impact that stress has on their everyday functioning.

Obviously, not all people exposed to a critical incident experience critical incident stress. Trauma is truly in the eye of the beholder. In fact, generally speaking one-third of them will experience little or no reaction at all, while another third will experience only moderate reactions. But the final one-third can be expected to experience a severe stress reaction. This does not mean that up to two-thirds of emergency services personnel are immune. In fact, someone who has experienced a number of critical incidents may find that they are terribly affected by a particular call, although it may seem rather benign and routine.

On the other hand, a person who took some time to recover from a critical incident may find that there are few, if any, symptoms after an especially bad call. In fact, the effects of any given potential critical incident are a complicated mixture of the personality characteristics discussed above and the characteristics of the call itself.

Some of the call factors are:

The nature of the event.

How involved was the individual? How much control over the outcome did he/she have? How grotesque was the call? How much did the call disrupt the individual’s beliefs and expectations about the world and about people in general?

Degree of warning.

The less time there is to prepare, the greater the risk of experiencing a severe response. Warning provides time to develop some coping strategies.

Prior mastery of the experience.

Practice makes perfect? Going through a particularly nasty call may make it easier to go through a similar experience.

The amount of stress in one’s personal life outside of the job.

Remember that stress is cumulative, and a seemingly small event can precipitate a severe stress response.

The nature and degree of support available after a critical incident.

Not only is it important that support be readily available, but it is equally important that the emergency services worker be willing to accept that support. If individuals push support away with the “I can handle it” attitude, they place themselves a greater risk.

So, how do you know if critical incident stress has affected you or a co-worker? There are some very predictable signs and signals sent by the brain and the body to alert you. These signals come in four varieties: physical, cognitive, emotional, and behavioral.

The physical signals include:

  • Muscle tension: aches and pains, trembling, poor coordination
  • An increased startle response; jumpiness at sudden sounds or movements
  • Cold sweat, dry mouth, pale skin;
  • Vision changes, hard to focus;
  • Feeling out of breath; hyperventilating until fingers and toes go numb or cramp;
  • Upset stomach, vomiting, diarrhea, constipation, frequent urination;
  • Fatigue: just feel tired, drained; takes a real effort to move;
  • Distant, haunted; show “1000 yard stare”

Cognitively, you may experience:

  • Difficulty making decisions
  • Confusion
  • Disorientation
  • Poor concentration
  • Memory loss
  • Inability to perform routine, even familiar, tasks

Emotionally, you may feel:

  • Grief
  • Guilt
  • Depression
  • Anger
  • Resentment
  • Anxiety/fear
  • Feelings of being overwhelmed
  • Feelings of being detached from reality

And the behaviors that may be associated with critical incident stress include:

  • Decreased job performance
  • Withdrawal from friends and family
  • Irritability and sudden outbursts of anger
  • Loss of sense of humor
  • Risk taking behavior;
  • Increase in alcohol/drug use

Any of these symptoms may show up immediately or very soon after an incident. In that case, this is called an acute stress reaction. In other cases, the symptoms may not appear for several days, weeks, or even many months. This is referred to as a delayed stress reaction. In either case, if not dealt with, the symptoms can become chronic and develop into full-blown post-traumatic stress disorder (PTSD).

A critical incident can obviously be disturbing and even devastating. But swift intervention can minimize the impact on emergency services personnel. An extremely effective intervention is Critical Incident Stress Management.

Critical Incident Stress Management (CISM), as taught by the International Critical Incident Stress Foundation (ICISF), is a comprehensive and multicomponent system which has been widely acclaimed as the standard of care in crisis intervention. It is an adaptive, peer-driven and clinician supported, short-term helping process that focuses on enabling affected individuals to return to their daily routine more quickly and with less likelihood of experiencing PTSD.

There are different types of CISM interventions for various situations. The most commonly used are one-on-one peer support, small group defusings, and the more formal Critical Incident Stress Debriefing. Defusings are limited only to individuals directly involved in the incident and are often done informally, sometimes on the scene, and frequently conducted by trained peers. Defusings are designed to assist individuals in coping in the short term and address immediate needs. Debriefings are usually the second level of intervention for those directly involved and generally take place days to weeks following the event. A mental health clinician typically conducts debriefings with the assistance of specially trained peers.

Why “specially trained peers”?

Just as there are protocols in emergency medicine and the fire service to ensure the highest quality of care, so there are protocols in CISM to ensure the highest quality of service to our peers. Training programs developed and delivered under the auspices of the International Critical Incident Stress Foundation provide a level of training that is recognized internationally and puts everyone “on the same page.” There are two courses that are specifically required to enable peers — as well as chaplains and mental health professionals) to provide CISM services. The first, CISM: Assisting Individuals in Crisis is a two-day program that teaches the basics in intervention in the midst of a psychological crisis. The second, CISM: Group Crisis Intervention is a two-day course covering small group interventions with particular emphasis on defusings and debriefings. These two courses can also be combined into a single three-day class. Peers trained in these interventions form the nucleus of an agency CISM program. And every EMS organization, fire department, and law enforcement agency should have a CISM program.

Of course, a CISM program is more than just training some peers in the basic interventions used following a critical incident. It is a commitment by all personnel, from the top down, to the process. It is recognition of the science that, despite “the way we’ve always done it,” CISM saves careers, families, and relationships. It saves lives. Critical Incident Stress Management rescues the rescuers.

A Certified Trauma Specialist, Dr. Jim Baxendale has over 35 years of experience in the mental health field, 25 of which have been focused on post-traumatic stress disorder and providing Critical Incident Stress Management services to emergency services personnel. As a paramedic, in addition to his mental health credentials, Dr. Baxendale brings added credibility to his consulting practice. For more information visit
Comments & Ratings

  9/18/2013 6:13:17 AM

Great article! 
I think this message needs to get out to all, the EMS family.

Issue 33.4 | Spring 2019

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