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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