Critical Incident Stress Management Team
Montgomery County, Pennsylvania
OPERATIONAL AND TRAINING GUIDE
for the
CRITICAL INCIDENT STRESS MANAGEMENT TEAM
of
Montgomery County, Pennsylvania
Department of Public Safety
Division of Emergency Medical Services
(Co-sponsored by Office of Mental Health)
50 Eagleville Road
Eagleville, PA 19403-1425
(610) 631-6520
Chief/Program Coordinator:
Stephen A. Pulley, D.O., FACOEP, BCETS
This original operations manual is based upon a CISM operational manual originally written by Lynn Kennedy-Ewing from the Delaware County CISM Team. This manual was prepared with her permission and we gratefully acknowledge her assistance. The original copyrights are maintained by her. Later modifications/revisions are principally by Stephen Pulley, D.O. of the Montgomery County CISM Team. Copyright is for the current version. The Montgomery County CISM Team should be contacted before any reproduction of this manual takes place.
TABLE OF CONTENTS
PROBLEM STATEMENT 8
PROGRAM ADMINISTRATION AND MEMBERSHIP 13
LEAD AGENCY 13
LEADERSHIP ORGANIZATIONAL CHART (with responsibilities) 14
TEAM CHIEF / PROGRAM COORDINATOR 15
THE CLINICAL DIRECTOR OR CLINICAL DIRECTION COMMITTEE 16
MENTAL HEALTH PROFESSIONALS 17
PEER SUPPORT PERSONNEL 19
TEAM MEMBERSHIP LEVELS (3Rs) 21
Regular Team Membership 21
Resource Team Membership 21
Referral Level 22
Supplementary Team Membership 23
TEAM SELECTION COMMITTEE 24
TEAM MEMBERSHIP LENGTH OF SERVICE 25
REVOCATION/SUSPENSION OF MEMBERSHIP 26
PEER REVIEW BOARD PROCEDURES 27
Appeals 27
CISM TEAM TRAINING 28
TEAM ACTIVATION 30
CRITICAL INCIDENT STRESS MANAGEMENT SERVICES 31
ON SCENE SUPPORT SERVICES 33
GENERAL INFORMATION AND GUIDELINES FOR ON SCENE ACTIVITIES 34
PSP (Peer Support Member) Engaged at the Scene 34
PSP Dispatched to the Scene 35
On Scene Team Leadership 35
Additional Field Service Protocols 35
GUIDELINES FOR ON SCENE SUPPORT SERVICES AND INTERVENTIONS 37
I. One-on-One Intervention 37
II. Advice and Counsel to Command 40
III. Assisting Victims, Survivors, Families 42
DEMOBILIZATION SERVICES 43
DEFUSINGS 46
FORMAL DEBRIEFING PROCESS 48
Who Will Be Debriefed? 51
Where Will the Debriefing Take Place? 51
When Will the Debriefing Take Place? 51
How Long Will the Debriefing Last? 52
How About Refreshments? 52
Who Will Lead the Debriefing? 52
How Many Participants will there be in a Debriefing? 52
I. Pre-Debriefing Activities/Meeting 53
II. Introductory Phase (1) 55
III. Fact Phase (2) 56
IV. Thought Phase (3) 57
V. Reaction Phase (4) 57
VI. Symptom Phase (5) 58
VII. Teaching Phase (6) 58
VIII. Re-entry Phase (7) 58
IX. Post Debriefing Activities/Meeting 59
Additional Debriefing Considerations 59
FOLLOW-UP SERVICES 62
INDIVIDUAL CONSULTS 62
SPECIALTY DEBRIEFINGS 64
INITIAL DISCUSSIONS 64
DEBRIEFING THE DEBRIEFERS 64
QUALITY ASSURANCE 66
APPENDIX A - Proactive and Educational Programs 67
APPENDIX B - Family/Loved Ones Support and Educational Programs 68
APPENDIX C - Community Programs 69
APPENDIX D - Resource and Referral Guide 70
APPENDIX E - Team Reports 71
APPENDIX F - Memorandum of Understanding 72
APPENDIX G– Standard Operating Procedures 76
ON-SCENE 76
DEFUSINGS 77
DEMOBILIZATION 78
APPENDIX H- Emergency Management/Disaster Planning 80
Organizational Mechanics 80
I. Establish and staff a CISM Operations Center (command center) 80
II. Adopt a mechanism to Identify team members 81
III. Establish/designate a CISM Incident Commander 81
IV. Designate a Team Dispatcher 81
V. Obtain Administrative Support Staff that can assist with 82
VI. Designate a Finance Coordinator who is responsible for records of: 82
VII. General Administrative Principles 83
VIII. Logistics-Assess needs early! 83
IX. Incident Command System (ICS) 84
X. Request assistance from Outside Teams based on need 85
XI. CISM Team Member Disaster Selection Considerations 85
XII. Dealing with Out-Of-Area Teams 86
XIII. Resource considerations 87
XIV. CISM Basics 88
J. Keys to Successful Interventions 88
XV. CISM Interventions 90
A. On-Scene Support 90
B. Decompression 90
C. Demobilization 91
D. Defusings 91
E. Debriefing 92
F. Alternative Interventions 92
G. Referrals 93
H. EMDR for individuals 93
I. Do not mix 93
J. Follow-Up Services 93
K. Debriefing-The-Debriefers 93
XVI. Miscellaneous 93
Public Information Officer 93
XVII. Practical Lessons Learned in Disasters 94
APPENDIX I– On-Call Coordinator Protocol 95
Responsibilities 95
APPENDIX J –Montco Radio Standard Operating Procedure 97
Motorola XTS-2500 Operation 97
CISM 800 Mhz Radio Programming Template 98
Montgomery County EMS Communications Policy 99
Section 2.0 FREQUENCY ALLOCATIONS 99
Section 3.0 CONTROL OF COMMUNICATIONS OPERATIONS 101
Priority Traffic Condition 102
Section 4.0 RULES OF RADIO OPERATION 104
When making transmissions 105
4.3 Emergency Identifiers Buttons: 106
Resetting an Emergency Identifier 106
Section 5.0 COMMUNICATIONS WITH MOBILE UNITS 106
Section 6.0 TELEPHONE PROCEDURES 108
APPENDIX 1 109
Radio Status Changes 109
Montgomery County Fire Stations and Companies 110
Montgomery County EMS Squads and Companies 113
Montgomery County Police Departments 114
North West Police Dispatch 114
South West Police Dispatch 115
North Central Police Dispatch 115
South East Police Dispatch 115
Norristown Police Dispatch 116
North East Police Dispatch 116
Montgomery County Frequency Plan 116
Montgomery County Fire Low Band Frequency Plan 116
Montgomery County Fire VHF Frequency Plan 117
Montgomery County EMS Frequency Plan 117
Helicopter Landing Zone Frequency Plan 117
Montgomery County 800 Mhz Trunked Frequency Plan 117
APPENDIX K–CISM Pager Standard Operating Procedure 118
Obligations/General Information 118
Pager Programming 121
General Team Members 122
On-Call Coordinator 123
Cap Codes 124
Pager Protocol/Receipt 125
PROBLEM STATEMENT
Throughout Montgomery County, and across the nation, emergency service personnel have become aware of the stressors unique to their occupations. These stressors, to which the providers are routinely exposed, often manifest themselves in physical and/or psychological symptoms which the individuals may or may not be able to successfully work through on their own. Even individuals who can resolve problems on their own may experience a delay in resolution without intervention. The end result is a decrease in the quality of the providers' personal life and professional abilities. Assisting emergency service personnel to resolve stress related difficulties requires specialized skills and knowledge.
Factors and events that may cause one provider to suffer the impacts of stress may have little or no effect on another provider. However, research has demonstrated that very few emergency service personnel are not affected by stressors inherent to their professions. Research has also demonstrated that some of those who demonstrate symptoms related to stress can not resolve these issues on their own and continue to be affected.
The stress response may take several forms. It may be an immediate response to a specific incident in which the provider has participated, or the response to this event may be delayed and resurface after a period of time. Also, the stress response may be the product of exposure to too many events resulting in a cumulative effect. How an individual is affected by stress will depend on several factors: the nature of the stressor must be considered as well as the individual's personal attributes, his previous successes or failures with coping, and the resources and support available to him.
The emergency service worker is, by virtue of his profession, faced with certain events that have the potential to create a significant stress reaction. These have been termed "critical incidents" by Dr. Jeffrey Mitchell. Dr. Mitchell defines a critical incident as "Any situation faced by emergency services personnel that causes them to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the scene or late...All that is necessary is that the incident, regardless of type, generates unusually strong feelings in the emergency workers."
Certain events have been demonstrated to be particularly distressing for emergency service personnel. Research has indicated over 1000 emergency service related stressors. The events surfacing most frequently can be divided into two different categories, environmental stressors and clinical stressors.
Environmental stressors would include:
• Working in extremes of weather
• Environmental hazards
• Problems with administration
• Lack of recognition
• Limited ability for career advancement
• Limited resources (personnel, equipment, funding)
Clinical stressors would include:
• Serious injury or death of a co-worker particularly in the line of duty, during training, enroute to serve, or shortly after serving
• Suicide or unexpected death of a co-worker
• Serious injury or death of a civilian
• Death or violence to a child
• Loss of life of a patient (victim) after prolonged rescue attempts
• Incidents that attract unusually strong high media coverage
• Any incident charged with profound emotion
• Personal identification with the victim or his circumstance
• Any incident where the sights, sounds, or smells are so distressing as to produce a high level of immediate or delayed emotional reaction
The stress exposure for emergency service providers is not limited to the mechanism of their vocations. Public and personal expectations of emergency service workers are high. The public assumes the emergency service workers are devoid of normal human emotion as they perform their duties in a calm and cool manner. However, this is certainly not true. The emergency service provider enters this business because of a great empathy for his fellow man and a sincere desire to assist during times of significant need. They also add to their own stress levels by failing to recognize and deal effectively with inherent stressors in the professions. To admit the need to seek mental health support is often viewed as a sign of weakness in these individuals. The individual may fear to seek such relief as it could raise questions as to his abilities in the performance of his duties. Thus, many emergency service workers have elected to cope with the stressors of their vocations by adopting coping mechanisms with emphasis placed on emotion and reaction suppression and by trying to hide the fact that the service may be getting to them. It has also been reported by those emergency service providers who have sought mental health support that the counselors did not want to hear the details of the events that brought them into counseling and that they did not have enough knowledge or background in emergency service operations to fully appreciate or understand the plight of the emergency service provider.
Emergency service providers need specialized programs designed for their specific personality profiles and addressing issues specific to their vocations. Normal therapeutic remedies performed by persons "outside" or unaware of emergency service operations are generally not effectual. Emergency Service Personnel respond favorably to support services where the emphasis is placed on learning and education. Cross training of mental health providers and the incorporation of peer support personnel into the training and therapeutic process has been proven to be most successful.
The bridge to cross this gap will be a multi-dimensional, comprehensive program which will include proactive, educational, reactive, support, and referral components.
The lay public also exhibits stress reactions in relation to critical incidents. These incidents are of a different caliber and type, when compared to the Emergency Services, yet are no less important. Studies have shown that with severe incidents, a significant percentage of people can suffer long-term sequelae including Post Traumatic Stress Disorder. After an event, the stress reactions can be quite distressing in groups that are not used to such levels of stress. Stressed individuals tend to be emotionally charged which interferes with their ability to address the impact of the event on their normal lives. In addition, large groups of stressed laypeople can offer another level of complication for the emergency services whom are already fully invested in the overlying incident. Large numbers of stressed citizen’s can quickly overwhelm vital infrastructure (e.g. 9-1-1, or highways) which are already taxed. For these reasons, the Montgomery County CISM Team has expanded its scope of operations to include community groups in crisis. It should be emphasized that the intent here is an identifiable group of normal individuals who are in crisis. Individuals, especially those with prior or suspected psychiatric disorders, are best managed through other agencies in Montgomery County. The main objectives in the community group are to: decompress the stress, alleviate anxiety, assess for further mental health needs, and referral as required.
Examples of situations where group crisis may be an issue include:
Fatal Fires
Neighborhood murder
Natural Disasters
Technologic Disaster
Hazardous material events
Place of employment related serious injury or death
Allegation of police brutality (particularly if race related)
School violence
Child abuse/molestation (community’s response)
Terrorism
The Montgomery County CISM Team can act as a single point of contact. The intent is to utilize the most appropriate resource available for a specific situation. This may mean referring calls to other agencies rather than the team handling all situations itself.
MISSION STATEMENT
The Montgomery County Critical Incident Stress Management Program will consist of multi-dimensional stress management services for emergency service personnel and lay citizens of Montgomery County.
The program will consist of the following components:
1. Educational and preventive programming: Stress management programs may be incorporated into the Emergency Medical Technician, Paramedic, and Fire Fighter, Emergency Dispatcher, and Police curriculums. Also, programs and presentations on various related topics may be presented upon request to the emergency service, related services, and community organizations.
2. A Critical Incident Stress Management Team will be established to lessen the impact of major events on emergency service personnel and the community at large. As a reactive service, the team will provide support to emergency service personnel at the scene or after an encounter with a critical incident for both the emergency services or the community at large.
3. A resource and referral network will be established to assist those emergency service providers seeking specialty services. This will include, but not be limited to substance abuse organizations, weight loss/fitness sources, family counselors, etc. A similar referral network will be established for the lay community.
4. Family education and support programs to address the needs and concerns of the loved ones of the emergency service provider will be initiated.
5. A plan for the incorporation of Mental Health and Critical Incident Stress (CIS) services during times of large-scale crisis or disaster will be offered to County Emergency Planning Organizations.
PROGRAM ADMINISTRATION AND MEMBERSHIP
LEAD AGENCY
The Montgomery County Department of Public Safety, Division of EMS, has served as the lead agency for the Critical Incident Stress Management Program. With the expansion of the team to include the lay community, The Montgomery County Office of Mental Health has become a co-sponsor of the CISM Team. It will be the responsibility of the lead agencies to provide the resources necessary to allow the program and its participants to provide the required services. It will be the responsibility of the lead agencies to:
• Provide funding for the program
• Provide a team selections committee
• Provide a Program Coordinator
• Train team members
• Support the activities of the CISM Program
• Provide office support to program activities