3

Aftermath: Survival and Self-Rescue

First responders go to work knowing that by shift’s end, they will probably have gone mano a mano with life and death. Trained as professionals to rush into danger, and seasoned by years of experience to stay clear headed during a call, does not prevent them from feeling shocked and disturbed by what they see, hear, feel, smell, and taste at the scene. As civilians living in unstable times, we have opportunities now to learn from these masters of stress how to rescue ourselves so that we can get back on our feet.

Unless you personally know someone who trusts you sufficiently to reveal emotions in the aftermath of a disaster, it’s natural to default to a stereotype of someone who can function at a high level under extreme stress without becoming temporarily ungrounded.

Such events, called “critical incidents” by police, fire, and rescue personnel, are acknowledged as packing an intense emotional punch. The International Critical Incident Stress Foundation (ICISF), founded in 1989 by doctors George Everly and Jeffrey Mitchell, gives first responders a suite of pragmatic and cognitive tools to cope with the emotional impact of a dangerous event in which there is usually loss of life and a threat to the safety of others.

“Critical incident stress management is a toolbox to help you develop a coherent way of thinking after an event,” explains Dr. Everly, who is considered one of the fathers of disaster mental health. Although the first critical incident stress management workshop drew only two attendees, there are now 1,800 CISM teams and more than 7,500 members around the world.

CISM sessions are confidential and closed to outsiders. The peer support model provides first responders with nonjudgmental support, acceptance, and the emotional safety needed to open up. A crisis management information briefing spells out the signs of acute stress and gives tools for self-care: healthy nutrition, sleep, physical exercise, and hydration for physical health; coping skills to lower stress levels; and communicating with peers, family, and friends instead of withdrawing into isolation.

Although the instinct to go into a cave and hibernate may feel like the only thing to do after a traumatic event, pulling away from others can become habitual. In isolation, the mind tends to wander into the Land of “Could’a, Should’a, Would’a,” prompting guilt and depression, which, in turn, can lead to addiction and ruined relationships. Emotional well-being after a critical incident requires social support, much as the body needs water to regenerate and thrive.

To be clear, critical incident stress management is not psychotherapy nor can sessions be considered group therapy. It is psychological first aid that can stop the emotional bleeding and mitigate the disturbing and painful aftermath of a tragic event.

The system and structure of CISM sessions help people put life in perspective after a critical incident. Paul Schweinler, CISM clinical director for Broward County, Florida, worked with airport personnel after the Fort Lauderdale airport shooting. On Friday, January 6, 2017, Esteban Santiago-Ruiz opened fire at Terminal Two’s baggage claim area, killing five and wounding six. Thirty-one additional people were injured when the crowd panicked after false reports of a second shooter.

“There was no direction. It was chaos,” Schweinler says. “People found themselves on the edge of the airport on the railroad tracks. They were more exposed than had they stayed in the airport.” Food service workers who were closest to the scene locked themselves in the kitchen. Travelers and other airport employees tried to hide behind food counters. “They thought that was the safest place to be. It’s a good example of how something as banal as air travel can suddenly go . . . .” With a sad shake of his head, Schweinler’s voice trails off. His face shows concern for the safety of those who got caught in the wrong place at the wrong time.

Schweinler notes that the October 1, 2017, Las Vegas shooting brought up issues of survivor guilt for many who were working at the venue. “As the event unfolded before their eyes, having planned and developed this series of concerts to be a wonderful and fun experience, they felt that their life’s work was now ruined.”

“There is a profound significance in watching the affect on people’s faces as they are getting to the end of a CISM process,” says Schweinler. “They are catching their emotional breath and thankful they got through it safely. They leave, aware it could happen at any time . . . and with the strength that they are now more prepared.”

An Empathic Movement

ICISF co-founder Dr. Jeffrey Mitchell is a former paramedic and firefighter. After witnessing an auto accident in which a passenger died, he recognized that he was not alone in having problems processing what he had seen and experienced. Other firemen, police, and rescue workers struggled with reactions similar to his, which inspired him to bring about positive change.

“I felt we had to do something to help our people so they wouldn’t be holding on to these images,” he says. “I was a volunteer firefighter, and I was not on duty when there was an auto accident in front of my vehicle.”

Reaching into the passenger side to feel for a woman’s pulse, he saw that the car had crashed into a low truck carrying pipes.

“One of the pipes went through the vehicle and through her chest. That was why she was dead,” he says. “That stuck with me for a long time. It was a very gruesome image.”

He told himself, “There has to be a better way.”

When he asked himself who he would talk to about a similar incident, he realized that the most natural person would be someone in a similar line of work.

Because the groups are confidential and homogeneous, run by peers instead of mental health professionals, the critical incident stress incident model destigmatizes potential fears about appearing vulnerable.

“It’s reassuring to know that others are going through the same thing,” he says. “You hear someone else say something similar to what you yourself are thinking, and then you can tell yourself, ‘I must not be crazy because others are saying the same thing.’ ”

Brooklyn Girl Meets Georgia SWAT Team

During critical incident stress management training on suicide prevention and aftermath, I was assigned to a breakout group with some special weapons and tactics (SWAT) team members from a town in Georgia. For this Brooklyn girl, it was a once-in-a-lifetime experience. With exaggerated eye rolls at each other when I spoke, it didn’t take much to figure out that they considered me a Yankee civilian with nothing to offer. But, to their credit, they let me speak before ignoring my ideas, which, come to think of it, were probably not as useful as theirs because yes, I am a civilian.

Not only did members of that group look like they worked closely together, there was a sincere concern for those they knew who were struggling with suicidal depression. They had designed an ingenious one-page handout to help their colleagues cope with extreme emotions after a difficult call. (I have adapted the SWAT team handout to make it relevant, helpful, and easy to use. See Dr. Laurie’s Pocket Guide to Self-Care for Acute Stress in the Appendix, page 247).

A Guide to Regaining Your Balance

While the CISM model was not designed for a general population, following the sequence of thoughts and questions here will help you reach a calmer state of mind. The first and last points show you how to take better care of yourself in acute stress conditions.

Information: Acute stress affects most people who are directly or indirectly exposed to a sudden, violent event. Become aware of the signs and symptoms so that you can take better care of yourself and help those around you, as well. ICISF co-founder Dr. Everly says, “Most people do not want you to cure them. They want information.”

Facts: This element works well in a dialogue format with another person. You can keep notes in a journal as well. Focus on two questions: “What was your exposure during the event?” and “What happened from your point of view?”

Thoughts: “What were your first thoughts as the event began?” and “What were the most important thoughts that stayed with you during the event?”

Reactions: “From where you are now, what stands out as the worst part of the event?”

Symptoms: Physically, mentally, and emotionally, what did you feel during and after the event? Immediately after the event? Within the first 48 hours? After a week?

Self-Care: Although you probably do not feel normal, it cannot be overemphasized that acute stress reactions are normal in the wake of an abnormal event. This is a good time to read or review the information about self-care in this chapter and the appendices.

Find Support: Reach out to someone in a similar situation to yours. Texting is great but there is nothing like the comfort of hearing someone’s voice. Research into communications shows that 93 percent of our messages are nonverbal; 55 percent of what we mean gets expressed through our facial expression, posture, breathing, and other physiological indicators; 38 percent is communicated through tone of voice, and only 7 percent of our message comes through verbally. With this in mind, my preference is voicemail over text when reaching out to offer or receive support.

Fear + Ignorance = Greater Pain

In his memoir FBI and an Ordinary Guy: The Private Price of Public Service, Mark Johnston writes that failing to address your own reactions in the wake of a critical incident can make them worse. He did not know this early in his career when he and his partner responded to an eviction in which agents used tear gas to subdue a homeowner who had started firing his gun. After several hours of bar hopping, they got home drunk at 1 am.

“That’s what we thought ‘critical incident stress management’ was forty years ago,” he writes.

Johnson defines a critical incident as “any sudden event outside the usual realm of human experience that . . . evokes intense fear, helplessness, horror or dread,” and states, “such events have the power to overwhelm an individual’s or a group’s coping abilities.”

He called trauma “the actual hurt/harm or injury to the mind and body.”8

Eventually, Johnston moved from being an agent in the field to the FBI’s Northeastern Employee (EAP) manager, offering support and stress management tools to agents in the field. “Experience demonstrates that often the worst part of a critical incident is not the incident itself, but what happens afterwards,” he writes, as he cautions: “Fear and/or ignorance about critical incidents and their aftermath can also contribute to the pain.”9

He wrote his memoir to educate us about the emotional price of exposure to traumatic events and what we can do to recognize the symptoms and take care of ourselves.

Reframing Loss

In my interviews with first responders and CISM debriefers, I have seen and heard how their firsthand encounters with tragedy have strengthened their motivation to serve others. They are able to reframe their loss into motivation so that over time, exposure to multiple traumas serves to nurture a continuum of concern for people’s needs.

An EMT/paramedic with the Miami-Dade Fire Department for thirty-two years, Vern Oster is dedicating his retirement to campaigning for safer medications in rescue vehicles.

“I have been dealing with mental trauma because of what I have been through,” he says.

The gift of empathy drives him to continue fighting to replace the drug Versed (midazolam), a controversial medication used for sedation before a tube is inserted to aid the patient’s breathing. Working helicopter rescue, Oster found that due to the medication’s side effects, he was unable to properly intubate patients with head injuries, which he believes resulted in deaths.

“If you are sick or weak,” he says, “you have a 94 percent chance it will make you worse or take your life.”

Oster’s worldview was irreparably altered by continual exposure to deaths that he was unable to prevent. One in particular continues to haunt him.

“It started off early at a wedding. The maid of honor collapsed as they were marching down the aisle,” he says. “We were coming from another territory. Took us about seven minutes to get there. When we arrived, three physicians were standing over this twenty-one-year-old woman. Her color was off. She wasn’t breathing. As soon as I looked at her, I knew she was in cardiac arrest. We yanked her out to the truck and worked and worked and worked her, but she was dead. The autopsy report showed that stress had caused an arrhythmia, which caused her heart to go into fibrillation and finally stop.”

In another call toward the end of the same shift, Oster responded to a case involving another twenty-one-year-old woman.

“This girl’s parents bought her a brand-new Corvette and she got into a drag race on Biscayne Boulevard, hitting a concrete pole going 100 miles an hour,” he says, shaking his head, and inhaling deeply. “We didn’t have to pry her out of the car, but this accident split her right open and she was conscious.”

Recalling how he held her hand as the ambulance rushed her to the hospital, he can still hear her voice: “I’m going to die, I’m going to die.” In response, he kept telling her to hold on. In the end, despite the ER doctors doing everything they could for her, Oster’s patient bled to death on the surgical table.

Here’s the takeaway: Even the most experienced responders are emotionally wounded in the aftermath of certain incidents in which circumstances rendered them helpless. In time, the depth of pain over those losses can serve as a focal point for even greater empathy in the future.

You Are Not Going Crazy

Sometimes, the initial stages of acute stress—shock, numbness, difficulty concentrating, and fear—resolve on their own. When they persist, they can lead to impaired decision-making, anxiety, intrusive flashbacks in which you relive the most horrifying moments, difficulty eating or sleeping, and flashes of irritability. Let’s not forget hypervigilance—being flooded with dread—and feeling like your body is hotwired, making you want to jump out of your skin.

These are all normal reactions to an abnormal situation.

Since the early 1990s, when I started working with people dealing with acute stress and post-traumatic issues, the most frequently asked question I hear is, “Hey, Doc, am I crazy?” In reassuring someone that his or her responses are appropriate for having survived or witnessed an accident, shooting, or disaster, I am often asked, “How do you know for sure?” This may sound facetious, but in my clinical experience I have found it to be true: Crazy people never ask this question. They tend to believe that their model of the world is accurate and that they are only disturbed because another person or the rest of the world has done something “wrong.” There is no formal research to back this up. It is an anecdotal observation based on nearly three decades of clinical work with hundreds of individuals.

The stigma of appearing crazy or vulnerable scares people from being honest about their reactions. It cannot be overemphasized that acute stress reactions are not indicators of mental illness. In developing the critical incident stress management protocols, Drs. Everly and Mitchell opened the way for the first responder community to recognize the need to talk about these issues in a safe setting.

Destigmatization is a work in progress on both sides of the pond.

In London, the British Fire Brigades’ Union (FBU) has been encouraging its 33,000 active firefighters to open up about mental health issues connected to their jobs. When Sean Starbuck, public information officer for the FBU, started his twenty-one-year career as a firefighter, such issues were not discussed.

“It’s always been firefighters are tough guys and don’t suffer from mental health issues, but they do. It’s a taboo subject, but over the past ten years, people realized we have to talk about these things,” he says.

A recent survey of FBU members showed that 36 percent of firefighters reported that they would not speak up about their own issues because, Starbuck says, “They thought they would get undue negative attention.”

The FBU offers training courses for management and union members.

“We have gone to management. We want to work on this together,” says Starbuck. “We want to be proactive. We don’t want a situation where people develop PTSD.”

After Sky TV reported in 2016 that 41,000 firefighters’ shifts were lost that year due to mental health issues, Starbuck said, “If there were 41,000 firefighters off with a broken leg, you would address it and you would be putting it right.”

Acute Stress Disorder

When acute stress persists for more than three months it is called acute stress disorder (ASD).

In “After Hurricane, Signs Point to a Mental Health Crisis in Puerto Rico,” New York Times’ reporter Caitlin Dickerson wrote, “There are warning signs of a full-fledged mental health crisis on the island, public health officials say, with much of the population showing symptoms of post-traumatic stress.”

Hurricane Maria struck Puerto Rico on September 20th, 2017. The Times published Dickerson’s article on November 13, 2017, too soon for a diagnosis of post-traumatic stress disorder, which is now part of our everyday vocabulary.

It is easy to confuse the two, but one key difference between PTSD and acute stress disorder is that PTSD tends to be chronic, with symptoms that can surface spontaneously years later. For example, a recent study of the psychological impact of flooding in the United Kingdom during the 2013–14 season showed that 36 percent of people whose homes flooded reported symptoms of PTSD; 28.3 percent with different anxiety symptoms; and 20 percent with depression. Among those in flood zones whose homes were spared, 15 percent reported PTSD symptoms and 10 percent had depression. In comparison, only eight percent of people who were outside the high water areas reported PTSD and six percent with depression.10

Acute Stress Disorder by the Numbers

As reported in Medscape.com, both within and outside the United States, ASD tends to occur at the following rates:

Information Is the Best Defense

The best defense against ASD is information. When you know what you’ve got, you can take better care of yourself. Sometimes, a critical incident can be a wake-up call for us to start doing that. On a daily basis, first responders and emergency medical personnel put their patients’ needs first. From time to time, it takes a critical incident to make them aware that they need to manage their acute stress so that they can continue to excel at what they do.

Expecting the Unexpected

“Everyone is going to face at least one traumatic event,” says Paul Schweinler, clinical director of CISM in Broward County, Florida, who won a Lifetime Achievement Award for CISM. “I’ve lost count of how many.”

His first accident, at the age of three, happened when he fell out of a three-story window. He has also been hit twice by cars.

“This has helped me to understand and describe how the body shuts down and why we often don’t remember,” he says.

Fewer than five percent of people remember the moment when the airbag deploys.

“The brain says, ‘You don’t need to remember,’ ” says Schweinler, who emphasizes the importance of this cognitive distortion during his critical incident briefings. Whether you are directly or indirectly affected, you and those around you will present with memory loss, confusion, and disorientation.

Whether you are trying to help someone in need, or you yourself are in shock, the gift of patience will prove invaluable. While we cannot know specifics ahead of time, understanding how we are likely to be impacted at some point in the future will lessen the shock. In the immediate aftermath, we can expect changes in sleep patterns, appetite, and breathing. There may be dizziness, headaches, muscle tension, digestive issues, and rapid heartbeat. Internal emotional responses may range from a “deer in the headlights” paralysis to numbness, shock, fear, depression, and guilt. We may feel sorrowful, lonely, vulnerable, frustrated, or angry.

Or all of the above.

Our behaviors—how feelings get expressed—can range from crying, outbursts of anger, irritability, substance abuse, loss of self-worth, a sense of hopelessness, and withdrawal from others. These patterns are usually short-lived and resolve naturally.

(See Keys to Emotional First Aid on page 63.) Please note: If Emotional First Aid, social support, and stress management tools are insufficient and these patterns persist, it is important to seek professional help.

Stress Inoculations

Knowing how to deal with probable reactions ahead of time can help you conserve your energy, although none of us can predict exactly how we are going to feel in the moment. Schweinler advocates thinking ahead of the curve about unplanned special events.

“What’s important is to anticipate what could happen. Let’s say a plane crashes in your neighborhood at night. What are you going to do? If you aren’t dead, you need to get out of there, like now. But since the area could become a crime scene, you might not get home for a long time.”

A plane crash in your neighborhood is highly unlikely, but think of it as a metaphor for catastrophe in general.

One month after writing this, a woman who escaped from the World Trade Center on September 11, 2001, witnessed American Airlines flight 587 crash into the bay near her home in Rockaway, New York, just four weeks after 9/11. “Will planes please stop crashing near me?” she joked during our initial phone call. Her contacting me as I was working on this chapter reminded me once again that life is by its very nature unpredictable and terrifying.

“Parallel things could happen. You will do better if you are prepared,” says Schweinler.

Questioning Answers

What would you do if you had to leave home in a hurry? Where would you go? What would you do if you had to stay indoors for weeks at a time? What supplies would you need? What would you do if electricity and communications were knocked out for more than a few days? Who could you count on for a ride? A place to stay? Basic first aid? Most important, who can you trust to understand and support you during and after the event?

While you might be tempted to think this line of thinking is “negative,” in this case, negative equals a dangerous level of denial. Make a task list and switch each item on the list into a question that cannot be answered as yes or no.

Stress Inoculation Questions

INSTEAD OF:

“Can I live without electricity?”

ASK:

“How long can I hold out without electricity?”

INSTEAD OF:

“Does climate impact my emergency plans?”

ASK:

“How does climate impact my emergency plans?”

INSTEAD OF:

“Do I need to store fuel?”

ASK:

“How would I store fuel if needed?”

INSTEAD OF:

“What if I can’t sleep?”

ASK:

“How many hours of sleep do I need to function?”

Open-ended questions, known as the Socratic Method, strengthen critical thinking skills, which can help you zero in on missing pieces of information or potential solutions. The practice of questioning answers stands alone as a “stress inoculation” to prepare you for situations in which you will need to make effective decisions quickly.

From Denial to Hope

Disaster scenarios help prepare us for huge events that are outside our control, but it would be unrealistic to expect a fool-proof strategy for not losing it when the world around you becomes chaotic. You are not alone. Even seasoned professionals suffer distress because of a heartbreaking loss while trying to save someone.

With regard to becoming proactive in mapping out potential responses to dangerous situations, we have much to learn from ICISF’s groundbreaking work with the first responder community. They have opened the way for us to develop informed responses to critical incidents so that we can take care of ourselves and those we love.

“Denial costs lives,” says ICISF co-founder Dr. Mitchell. “Every year, hundreds and even thousands of people die in misadventures because they spent time denying it could happen in their backyards. It is natural and normal for us to deny that bad things are going to happen, but if you want to be prepared, you need to work against your own natural denial.”

Rescuers are often forgotten heroes. So are those survivors and witnesses who emerged from destruction saying, “Although we have had significant losses, we did not lose our most important things: our health, our children, and those we love.”

ICISF co-founder Dr. Everly observes: “This can turn a lot of negatives around and give us a lot to live for. It goes a long way to helping people recover.”

Staying Safe

If you ever bear witness to a shooting or some other mass attack, first responders recommend the following12 :

Keys to Finding Safety

Critical incident specialist Paul Schweinler recommends asking these five questions after a dangerous event:

Paul Schweinler’s Guide to Emotional First Aid

Go to places that feel safe, comfortable, and familiar.