Post Critical Incident Response

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Post Critical Incident Response
America Outdoors Conference
December 6th, 2001
Dennis Kerrigan
Wilderness EMT-Paramedic
Senior Faculty
Wilderness Medical Associates
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Critical Incident
Any situation beyond the realm of a person's
usual experience that overwhelms their sense
of vulnerability and for lack of control of a
situation.
Can involve staff, participants, or guests
Most likely Involve a serious or
fatal injury or illness
Can also involve criminal activity, natural
disasters, lost persons, or any event
likely to attract media attention
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Emergency Action Plan
Guides an organizations response to critical
incidents
Goals of an EAP include:
  • assigning responsibilities during and following an emergency
  • identify resources for responding to emotional, legal liability, and media concerns
  • preplan actions for likely emergencies: i.e. motor vehicle accident vs fatality vs blood borne pathogen exposure
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Incident Command System
Command, Planning, Operations, Logistics, Finance

An organized tiered response system designed to
improve scene management

Can be used in daily operations

Most effective when used to organize complex
incidents and emergencies
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Command & Planning
Person responsible for overall leadership, decision
making, and scene oversight
  • Initially the most senior guide on scene, generally the
    trip leader (TL) becomes the incident commander (IC)
  • should preferably be removed from other operational
  • responsibilities, i.e. medical
  • as situation evolves, command should be transferred
    appropriately to progressively more senior staff, i.e. TL->
    Head guide -> River manager-> Company owner
  • a rapid guide skills assessment by the TL/IC Is critical
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Operations
 L- locate
 A - access
 S - stabilize
 T - transport
  • Initially the 2nd guide on scene, then should generally
    be transferred to the 2nd most senior guide (sweep guide)
  • gold standard" for medical care is Wilderness First
    Responder (WFR)
  • an MD/RN guest may or may not be sour best resource
    (consider an 'Unsolicited Medical Intervention" protocol)
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Permission for Non-solicited Medical Intervention
Thank you for your offer of medical assistance.
Please be advised that these guides are operating under the
regulative authority of (Agency having jurisdiction) and under
protocols approved by (Company Name). These emergency care
providers are also operating under the authority of a Medical
Control physician and standing medical orders designed for
extended-care wilderness contexts under guidelines approved by
the National Association of EMS Physicians.

To avoid confusion and to expedite patient care, no individual
should intervene in the care of this patient unless the individual is:
  • requested by the guide providing primary patient care
  • authorized by the company's Trip Leader/Incident Commander
  • capable of providing more extensive emergency medical care at the scene
 
If you assume patient management, you accept responsibility
for patient care until a responding Emergency Medical Services
EMT or EMS Medical Control physician accepts that
responsibility.
This requires that you accompany the patient to the
emergency department


If you are willing to assume this responsibility, please sign the bottom
of this form, and note this on the patient's incident report/patient run record.
_____________________
(Company Medical Control signature)

________________________   ___________________
(MD name accepting care)     (MD signature accepting care)

_________________________________________________________
(MD license #, state of of license, and field of specialty)
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Rescue vs Recovery
The key operational, emotional, and evacuation
based decision to be made at the scene
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Rescue
Risk/Benefit analysis indicates resuscitation/rapid
evacuation
"Big Three" System involvement or potential to deteriorate
Respiratory mechanisms     
  • cold water near-drowning (< 1 hour submersion)
  • mod to severe asthma attack (75% increased incidence)
  • lighting strike (consider lightning protocol)
Circulatory mechanisms     
  • pre-cardiac arrest heart attack (MI); consider risk factors
Neurologic mechanisms    
  • spine/head injuries; "wilderness protocols" extremely
    beneficial to "rule out" spine injury
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Recovery
Risk/Benefit analysis indicates discontinuing resuscitation efforts ("the outcome is the same")
  • submersion time> 1 hour (PFD's need to be secure)
  • extended CPR (>30 minutes, normothermic body temp)
  • MI's require early defibrillation (survivability decreases
    10% for every minute delay to defibrillation)
  • cardiac arrest from blunt trauma forces (<1% survive in
    urban EMS response/rapid transport)

Significant body fluid exposure and guest or rescuer risk are reasonable justification to DC resuscitation
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Recovery Considerations
  • don't prevent the family from being present during
    resuscitation, but they need to know when they
    have to "say their last good-bys"
  • keep family apprised during resuscitation efforts, using
    direct simple non-medical terminology
  • best situation is to cover the body and secure the
    scene with a guide so the agency having
    jurisdiction (AHJ) can do to their inquiry
  • If the AHJ requests transport of the body, a body bag left
    at equipment stash areas help minimize "vicarious
    traumatization" of guests and bystanders
Goal is a quite, controlled, injury free evacuation
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Logistics
  • Initially responsible for communications, equipment
    and evacuation coordination roles
  • food, facilities, and critical incident stress support become
    important tasks over longer term
  • cell phones and GPS systems are quickly becoming the
    industry standard for activating outside agency
    evacuation resources; requires back-up plans for
    inevitable 'techno-failure
  • requires pre-planned inter-agency and inter-company
    training and protocol sharing to help avoid scene
    "turf battles"
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Field Rescue Team Organization
  Overall Leader  
Medical Leader   Evacuation Coordinator
  Communications  
- triage -extraction/technical team
-scribe/documentation -equipment: medical
 group, technical
 
-patient leaders -scribe
-medical communications -support team
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Finance
Requires an open checkbook" policy
  • trip refunds to all participants of trips involving a fatality
  • trip vouchers for extended evacuations that shorten or
    significantly delay the trip schedule
  • for extended recovery operations, family members should
    have all travel and expenses covered to bring them to
    the scene
  • if the perception of guests is "all they were concerned
    about was taking our money", the company is at significant litigious risk
"You can save your money, or you can save your company"
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Support Liaisons
It is critical to identify one liaison staff member
early in the rescue or recovery operation, chosen
specifically for their interpersonal and
communication skills, for each of the following:
  • trip/guest liaison; requires careful 'politics' to avoid
    implication of blame or fault; witness statements are
    critical in potential litigation/liability
  • family liaison; may involve next-of-kin notification
  • media liaison; require a well-thought out media
    communications pre-plan
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Trip/Guest Liaison
Responsible for supervision and information dissemination
  • organize into a collection/staging area
  • give a brief factual synopsis of what has happened and what
    the plan is for them
  • verbalize evacuation assistance 'disclaimer'
  • utilize other commercial company resources as needed
    to evacuate people and equipment
  • how guests are handled becomes their incident impression
  • carefully preface witness statement collection
  • consider CISM defusing, provided separate from staff
  • refunds or trip vouchers strongly recommended
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Family Liaison
Most difficult and crucial component of immediate incident follow-up
  • most senior staff member of an organization who
    assumes ongoing relations with the family - a
    potentially protracted task
  • inform and involve family in extended body recovery
    operations as evidence 'everything possible is being
    done: solicit rescue AHJ for support
  • be sensitive to over attentiveness, especially in the later
    stages of grief/bereavement process
  • if at all possible avoid next-of-kin notification via sheriff
    or rescue personnel
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Next-of-Kin Notification
Genuine sensitivity and sympathy to family feelings
is foremost concern
"speak from the heart"
  • avoid euphemisms; "passed on', "expired', "deceased"
  • think through what to say, but avoid a "scripted' response
    generated by legal counsel
  • anticipate grief responses; denial, anger, "shock",
    disassociation; often requires follow-up contact
  • n.o.k. have the right to prompt factual information
    pertinent to the accident
  • have facts organized and accurate
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N.O.K. Notification
  • promptness is critical; don't delay notification,
    which can invoke suspicion and fault
  • inquire what immediate support is needed from friends,
    family, clergy, and by to procure it
  • invite family to come to the incident site at company
    expense, consider providing a memorial service at the site
  • consider staff member who was on-scene make a follow-up call
    (coached by legal counsel)
  • consider a personal visit to the family at their home
  • request to participate in the funeral or memorial services
  • avoid implied liability/fault/blame
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Media Communications
Often contrary to public opinion, journalists
generally:
  • share a sense of duty to the public
  • take pride in having accurate information
  • work under tight deadlines
  • are under stress and frequently underpaid
  • are trying to provide a public service
  • don't always let the truth 'get in the way of a good story'
Key is to develop a media relations plan long before a crisis
incident and to use their "power of the pen' to be a friend
to your organization and to your image
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Media Spokesperson
Should be the one person responsible for communicating with the media
  • should be senior staff member, but not the owner or
    CEO, so questions can be referred to the CEO for
    later clarification if needed
  • must be available and willing to take calls at all times
  • must assimilate staff information and respond to media
    inquires at the moment and immediately post-crisis
  • all staff must be aware that all media communications will
    go through only the spokesperson
  • should make personal contact with print editors and local
    TV/radio producers to establish a personal point of
    contact consider offering a free 'media day' raft trip
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Crisis Strategies
  • if feasible, contact the media with a fax press release
    before they contact you
  • be aware of what the media will want to know what
    happened, when and where, have n.o.k. been notified,
    why certain info cant be released, eta
  • do not speculate, and keep answers brief and simple,
    avoiding technical jargon
  • never say "no comment", as that is what will be printed
  • there is no such thing as "off the record"
  • for TV interviews appearance must be serious and
    professional; think and talk in 10 second sound bites
  • be "on guard" as soon as cameras arrive, and assume
    interview isn't over until they drive away
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Media Damage Control
When a situation may not reflect positively on your organization, include the following aspects
  • the response efforts that have been made
  • if a question contains words you dislike, do not repeat
    them even to deny them
  • be aware of sound bites that can be edited from long
    statements
  • state the background and mission of your organization,
    including positive situations from the past
  • tell the truth, goal is a one-day story without repeated
    follow-up story exposure
  • monitor news reports; if a reporter makes an error contact
    them and provide correct information to them rather
    than contacting the editor
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Paradox of Safety and Risk
The overarching message in media interactions
should be that your organization:
  • cares deeply about this tragedy
  • plans an internal and external investigation into the
    causes and ways to prevent future incidents
  • is engaged in providing a value In society that bring life-giving
    recreational experiences, but with that comes
    exposure to inherent risks
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Critical Incident Stress Management
Who Rescues the Rescuers?
  • recent events have focused its adverse impact on
    Emergency Services personnel and the public as well
  • results in an equal if not greater 'burnout" of outdoor
    educators and leaders
  • addresses emotional "aftershocks", despite intellectual
    recognition that the causative events "come with the
    business"
  • is not an operational critique of the accident
  • is not psychotherapy, but rather a peer-based support
    system (requires formal psychotraumatology training)
Goal is to normalize and mitigate stress based responses
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Critical Incident Stress
Has physical, cognitive, emotional, and behavioral effects
  • physical: fatigue/exhaustion, sleep disturbance, hyperarousal,
    gastric disturbance, head aches
  • cognitive: confusion, poor decision making, memory
    problems, distressing dreams, disorientation
  • emotional: fear, anxiety, guilt, depression, anger, apathy,
    denial, relationship problems, panic, irritability
  • behavioral: altered eating habits, withdrawal, increased
    smoking/alcohol use/abuse, excessive humor
These are normal responses to abnormal situations. They do not indicate physical or mental illness, nor do they indicate human weakness. They simply signify a need for simple interventions so that healing can begin.
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Personality Traits
EMS ? or Outdoor educators?
  • action oriented
  • high need for stimulation
  • immediate gratification needs
  • risk taking behavior
  • easily bored
  • control orientation
  • strong need to be needed
  • highly motivated by internal factors
  • "rescue" personality
These are normal, as opposed to pathological, personality traits, but they exacerbate the critical incident stress impacts
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Escalating stress factors
Escalating stress factors unique to outdoor educators:
  • potential for proximate causation; did what a guide do or
    not do contribute to the accident
  • less "image armor", minimal "desensitization" training
  • high level of guide/guest emotional investment, "intimacy
    of connection
  • minimal separation of word/play environments and peer group buffers
  • propensity for substance use/abuse resistance response
  • younger age/maturity profile
"The crisis is always real to the person who is having it"
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De-escalating stress factors
De-escalating factors for outdoor educators
  • generally good peer support structure
  • less secondary and tertiary family-based stressors
  • good verbalization and ventilation skills
  • generally good stress/ambiguity tolerance (needs good
    leadership to achieve this outcome)
  • active physical lifestyle
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CISM models
 
  Defusing Demobilization
     
  Debriefing One-on-one
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Defusing
Defusing: preferred CISM option for stress response mitigation
  • provided within 8 hours, ideally 1-2 hours, post-incident
  • 1-2 peer facilitators in focused impact groups
  • should not be done at the incident scene due to cognitive suppression
  • takes 20-45 minutes, 3 phase process
  • goal is to use the time window of the "numb" Phase prior to
    development of significant resistance responses
Critical time window requires a trained local CISM peer
facilitator network
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Debriefing, One-on-one, Demobilization
Debriefing: used alone or as a follow-up to defusing if needed
  • 24-72 hours post-incident emotional "window" is open again
  • peer facilitated, but requires mental heath provider
    oversight do to onset of resistance/avoidance responses
  • 1-3 hours in length
  • 7 phase process; intro, fact, thought, reaction, symptoms,
    teaching, re-entry
One-on-one: follow-up for individuals needing more re-process

Demobilization: used on multi-day operations/recoveries
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CISM litigation concerns
Peer facilitation, unlike mental health consult, is not privileged,
thus can be potentially "discoverable" by counsel. Safeguards
are designed into the process, and include:
  • targeted impact groups; media, AHJ personnel, trip guests,
    guides would defuse/debrief separately
  • no note taking or record of participation
  • confidentiality "contract"
  • focus is on the reaction from, not the details of, the incident
  • participants encouraged not to disclose serious operational
    problems that may jeopardize participants or any inquiry
Requires facilitator training and discipline to reframe/redirect
discussion away from an operational critique
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CISM training resources
  • International Critical Incident Stress Foundation
    www.lcisf.org
  • American Red Cross Crisis Intervention Teams
    contact your local ARC chapter
  • Local Emergency Services CISM Teams
    over 1,000 active teams in the country
Outdoor Educator models:
  • National Outdoor Leadership School (NOLS)
  • Outward Bound National (OBN)
  • Association of Experiential Education (AEE)
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Pre-planning actions for Emergency response
Determine likely scenarios and pre-plan the probable response
steps to be taken
  • missing person or group
  • fatal accident or illness
  • significant injury or illness
  • motor vehicle accident
  • inter-company accident response
  • blood-borne pathogen exposure
     consider less likely scenarios as well:
  • criminal activity committed or inflicted on staff or participants
  • community mutual aid, i.e. flood response, river rescue, body
    recovery operations
  • staff fatality
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Missing person or group
Response plan model
  • assess and secure the safety of staff and participants
  • establish a base camp/command operations
  • gather all pertinent data to establish search profile: who,
    what, where, when, etc.
  • determine urgency: measured, urgent, emergent
  • determine point last scene (PLS) and direction of travel
    (DOT)
  • establish search confinement/containment points
  • conduct hasty search with available staff
  • notify agency having jurisdiction (AHJ) for SAR functions
  • initiate internal and external communication plan
  • prepare for incident escalation/de-escalation
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Fatal accident or illness
Response plan model:
  • assess and secure safety of staff and participants
  • secure the body and area around fatality site
  • initiate controlled evacuation of trip participants
  • notify law enforcement AHJ
  • initiate internal and external communication plan
  • initiate incident reports from all involved staff
  • obtain witness reports from all involved participants
  • evaluate need for CISM support for participants and staff
  • prepare for internal and external investigation
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Identify resources
External communication Plan
  • sheriff/law enforcement: invite them to mutual aid training
    sessions, determine their resources
  • ambulance/rescue squads: invite them as well to training,
    determine their resources and capabilities
  • land managers/regulative agency
  • insurance/legal advisers: important to get legal advice that
    benefits your organizations long-term interest, not just
    the insurance carriers long term interest
  • PR/media contact
  • CISM resources
  • commercial competitors
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Internal resources
Internal Communication Plan
  • senior trip leaders and staff
  • Head guide
  • River manager
  • Company owner/CEO
  • Board of Directors members
  • PR/media spokesperson
  • other company outposts/operations
  • off-duty staff with particular skills
  • legal counsel
  • insurance underwriter
  • medical control physician
Prioritize a notification/command flow-chart
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Summation
  • models are "a cheap imitation of reality"
  • company EAP models should be "bottom to top' designed
  • every incident is unique - but have predictable and often
    preventable "pitfalls"
  • virtually every documented program critical incident was
    closely preceded by a "near hit"
  • guidelines are an aid, as opposed to a substitute, for a thoughtful well-coordinated incident response
  • no policy or procedure manual can replace the staff qualities
    which need to be developed and nurtured within
    your organization: good judgement, quick and proper
    reaction, and skill
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Future?
How can our industry gain greater control over program
exposures, while still preserving the spirit of outdoor adventure?

By welcoming and demanding opportunities to better analyze
decisions, self-examine our responses, and assess
performance
  • acceptance of peer review
  • accreditation as a replacement for certification and licensure
  • standardized accident data collection and disclosure
  • internal and external safety reviews
  • collective commitment to managing risk as opposed to
    "making the industry safe"