Ambulance Background PowerPoint Presentation

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Resilience:Coping with the Stress of Trauma Mike McEvoy, PhD, REMT-P, RN, CCRN EMS Coordinator – Saratoga County Medical Editor – Fire Engineering magazine Sr. RN – Cardiothoracic Surgery – Albany Med

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Disclosures I am an employee of AMC. I have no other financial relationships to disclose. I am the EMS technical editor for Fire Engineering magazine. I do not intend to discuss any unlabeled or unapproved uses of drugs or products.

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www.mikemcevoy.com

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Define Stress

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Stress The confusion created when one’s mind overrides the body’s basic desire to choke the living shit out of some asshole who desperately needs it.

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A response to a demand for change BOTH: Physical Psychological

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A response to a demand for change Different for different people.

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Study of Arousal Level for Sky Divers

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A response to a demand for change Stress is not the event but our reaction to it.

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Life Events Death of spouse Jail term 20% pay cut Fired from job Death of friend Traffic ticket Car accident

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Life Events Divorce Marriage New home Retirement New baby Vacation Christmas

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Life Events Divorce = Marriage = New home = Retirement = New baby = Vacation = Christmas = Death of spouse Jail term 20% pay cut Fired from job Death of friend Traffic ticket Car accident

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Do we need stress?

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Complete absence of stress =

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Hans Selye Stress Illness Disease Death

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Performance Characteristics of people under stress: Reduced awareness of environmental cues Increased sensitivity to signs of anxiety Decreased tolerance for pain and frustration Increased emphasis on performance error Decreased efficiency in mental processing Increased mistakes and injuries

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PTSD Post Traumatic Stress DisorderandASDAcute Stress Disorder

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ASD and PTSD Reliving the event. Emotional anesthesia. Persistent anxiety.

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Resilience: psych & behavioral lingo People noted for ability to withstand negative pressure are resilient They have experienced negative circumstances associated with poor psychological and social outcomes Despite odds, they end up healthy & productive: Mentally ill or abusive parents Deprived social or economic conditions

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Perceptions of Life Change I can’t imagine how I would… I would not want to live like that… "You're sitting here fighting depression. You're in shock. You look out the window, and you can't believe where you are. And the thought that keeps going through your mind is, 'This can't be my life. There's been a mistake."'

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“You play the hand you’re dealt. I think the game’s worthwhile.”

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Some people lack resilience Vulnerable

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Personal Resilience related to: Biology temperament, emotions, intelligence, creativity, immune resistance, genetics and physical condition Attachment capacity for bonding (forming significant relationships with others), capacity for empathy Control mastery over one’s environment, social competence, self-esteem, personal autonomy and sense of purpose

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People who are resilient are: Sociable (form healthy relationships) Optimistic (positive about the future) Flexible (change easily) Self-confident Competent (good at something and proud of it) Insightful (understand people and situations, able to see other sides) Persevering (don’t give up) Objective (view crises as challenges, not insurmountable obstacles) Self controlling (manage strong feelings and impulses)

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Vulnerable people exhibit: Substance abuse Poor anger management Lack of community integration/social isolation Multiple chronic illnesses (or symptoms with minimal, vague or inadequate organic basis) Chronic dysthymia and/or anxiety Dysfunctional relationships Inadequate school/work/community performance

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What makes some people resilient and others vulnerable to life stressors?

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People who focus on solving their problems are the most resilient.

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Bottom Line: Problem-focused coping increases resiliency while emotion-focused coping impairs resiliency When faced with a setback or challenge focus outward on the things that must be handled, not inward on emotions Emotions cannot become the focus of attention.

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Problem Focused Coping: Examine the situation to see what solutions may be possible Consider various actions Select the best Take action Observe effects of the action Modify for best results

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People bounce back by having: Caring and supportive relationships High expectations for success Opportunities for meaningful participation Positive bonds Clear and consistent boundaries Life skills

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Mental Health Interventions Cognitive Behavioral Therapy(CBT)

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CBT: Cognitive Behavioral Tx No single school – multiple approaches Premise is thoughts cause feelings and behaviors (not external things or situations) Change thinking changes feelings/behavior Brief, time-limited, collaborative, stoic Structured, directive, educational model Includes homework

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Critical Incident Stress DebriefingCISD

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CISD History – 1970’s Jeffrey Mitchell Vol. Arbutus FD (Baltimore, MD) Regional Training Coordinator for State of Maryland Concerned about high attrition 1974 conducts debriefing after drunk driver kills a family

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CISD – 7 Phases: Introduction Facts Thoughts and experiences Reactions (feelings) Symptoms Teaching Re-entry “When disaster strikes… The Critical Incident Stress Debriefing process” Mitchell JT. JEMS 8:36-39, 1983.

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Critical Incident Stress DebriefingCISD Does it help?

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Cochrane Collaboration Worldwide network of centers, based in England Launched 1995 Definitive source for evidence based practice Quarterly publication, several separate databases, position papers define best practices.

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CISD – Summary of Scientific Literature (Peer Reviewed) Mitchell model CISD (not CISM) Emergency Services (vs. general population) Cochrane Library Database (last CISD revision 14 Nov 2005, last substantiative update Dec 2001)

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CISD - Conclusions Value neutral to negative. Not effective compared to all forms of debriefing and no debriefing at all. While perceived as helpful, rescuer satisfaction ≠ effectiveness. Some evidence of harm to certain individuals, often iatrogenic.

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CISD – General Population Unsafe! Adds to trauma Complicates recovery Should not be used Recently banned in some countries US Institute of Mental Health and World Health Organization both recommend AGAINST it

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CISD – Emergency Services Not appropriate for 60% of police, fire, EMS, and medical personnel. 85% talk about critical incidents afterwards (colleagues and peers preferred). 15% prefer not to talk at all.

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CISD – Iatrogenic Harm (Worsen anxiety, depression, PTSD) Mandatory attendance Discussion of event (relive emotional trauma) – MH error “Mixing” groups Peripheral personnel with those directly involved in the incident. People lost loved one with people whose loved one survived.

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CISD Harm – Risk Factors Repeated or accumulated severe unresolved stressors Lack of social supports Injury Preexisting psychological problems Traumatic bereavement Strong negative beliefs about meanings of normal stress reactions People who most seek CISD show poorer long term outcomes

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PFA - Working Definition “Psychological first aid (PFA) refers to a set of skills identified to limit the distress and negative behaviors that can increase fear and arousal.” (National Academy of Sciences, 2003)

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General Principles of PFA The most urgent task is to focus on restoring emotional equilibrium (Protect-Direct-Connect)

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From physical or emotional harm, including gruesome or graphic sights and sounds Immediate physical needs Bathroom, food, fluids, breaks, clothing changes, sleep, time off. Dignity and privacy From media or curious well-wishers From danger to self or others Protect

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Direct Recognition for job well done. Encourage normal routines & roles. Discuss self care strategies to reduce anxiety. Exercise, rest, relaxation Encourage people to support and assist others. Identify resources that promote effective coping. Accurate, simple information about plans, schedules, events. MH follow-up assessment @ 3 months.

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Connect Help connect with family, friends, children, significant others. Talking in homogenous groups (ie: firefighters vs. heterogeneous strangers). Provide information on normal signs and symptoms including suggestions for what to do. Educate significant others on s/s and how they can help. With mental health resources Individuals to information about the event

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Summary People are resilient Friends are important Conversation helps Time is a great healer Look out for others while you look out for yourself Gist, et al., The origins and natural history of debriefing, 1998. www.mikemcevoy.com