Exposure to trauma is common in the human experience.1 It is estimated that between 50%–90% of the population is exposed to a traumatic event during their lifetime.2 The average rate of large-scale disaster occurrence in the world is one per day.3 While major trauma events (e.g., earthquakes, war) can affect tens of thousands of people, smaller-scale events happen each day to individuals and families. These include suicides, domestic violence, sexual assaults, motor vehicle and industrial accidents, drownings and various medical emergencies.
A traumatic event may be defined as an event in which a person is exposed to actual or threatened death, serious injury or sexual violation. This can also apply when one learns that such an event occurred to a close family member or friend.4 These types of incidents can be further described as having an extremely threatening, catastrophic or horrific nature.5 They are the types of events that can create exceptional mental and physical stress on the person involved, triggering fear and helplessness.6,7 It is postulated that such events are generally unexpected, infrequent and high in intensity.8
Some of those who partake in or witness a traumatic event go on to develop acute stress disorder (ASD) or post-traumatic stress disorder (PTSD),9 while those not meeting the criteria for a formal diagnosis can still experience highly distressing psychological symptoms. According to the World Health Organization’s 11th revision of the International Classification of Diseases (ICD-11), somebody not yet meeting the formal criteria for a formal diagnosis of ASD or PTSD can still suffer from acute stress reaction.10 This term refers to the development of emotional, somatic, cognitive or behavioral symptoms from exposure to a traumatic event. The symptoms of acute stress reaction can include anxiety, anger, despair, overactivity, inactivity, social withdrawal, stupor and impairment, and physical signs of anxiety such as tachycardia. This type of response can be considered normal and nonpathological immediately following an extremely distressing event; nonetheless it is a difficult and painful experience, worthy of intervention.
In studies done both in the U.S. and abroad, ASD has been recognized in up to 20% of non-interpersonal traumatic events (e.g., motor vehicle accidents). Even higher rates have been found after events that involved interpersonal trauma, such as assault, rape or witnessing a mass shooting, with estimates as high as 20%–50% of those involved.11
ASD as a Predictor of PTSD
Those with acute trauma exposure can suffer from a sequelae of debilitating symptoms that include dissociation, disordered sleep, hyperarousal, inability to experience positive emotion, intrusive distressing trauma memories and more,12 making acute traumatic stress problematic in its own right and deserving of early intervention. Beyond acute trauma, a chronic presentation of psychotrauma can develop into PTSD.
Approximately half of those diagnosed with ASD go on to develop PTSD.13 The presence of an ASD diagnosis is a fair predictor of PTSD if no intervention is made.14 Peritraumatic dissociation and acute distress in the acute phase of a trauma incident are strong predictors of PTSD development.15,16 Dissociation following a critical incident was found to predict PTSD up to 10 months later.17 The correlation between ASD symptoms and later development of PTSD has been observed in a variety of incidents, including fires, mass workplace shootings, motor and industrial accidents and violence.18–26
These findings may suggest the importance of early intervention for patients recently exposed to traumatic incidents. The goals of early intervention are twofold: to reduce a patient’s acute distress following a traumatic event, and to curtail the development of post-traumatic stress through early intervention just minutes after a traumatic event has taken place.
Clear, measurable symptoms of trauma pathology may not develop until weeks after the critical incident,26 requiring a flexible intervention in the immediate phase after a disaster that doesn’t depend on the presence of any particular symptoms. Psychological First Aid (PFA) has been adopted by the disaster behavioral health community as one of the main interventions delivered to disaster survivors and is encouraged by numerous organizations, including the WHO, NATO and the National Center for PTSD.27,28 It has been described as a flexible psychosocial intervention with a goal to “reduce the initial distress caused by traumatic events and foster short- and long-term adaptive functioning and coping.”29
Due to the possible lack of symptoms as a guide for formal clinical work, PFA aims to decrease the distress that follows a trauma event generally and does not claim to focus on treating any specific pathology or symptom. PFA includes a component of practical assistance that helps survivors meet basic physical, medical and financial needs (e.g., obtain food, housing or other services), as well as components that help garner social support, develop tools of resilience and self-regulation, address immediate needs and link to resources for additional services or follow-up care.
Although PFA is popularly known from use in major disasters, it is designed to be used in any emergency. Any of the eight core actions of the PFA model can be easily applied to individuals in smaller-scale trauma events as well.
Risk and Protective Factors
Several factors present in the acute phase of a disaster are thought to exacerbate stress reactions and possibly increase the risk of developing psychotrauma injury. These may include lack of social support, fatigue, cold, hunger, fear, uncertainty, loss, dislocation, lack of information about the event’s nature or origin, treatment given in an authoritarian or impersonal manner, and a lack of follow-up support in the weeks following the exposure.30
Trauma by its nature denotes something disruptive, unexpected and sudden. The predictability of life, safety and comfort becomes challenged. In this vulnerable place, human beings can either be supported and reassured or forgotten and ignored. The empathetic treatment of a responder or provider can communicate that they are still cared for, worthy of attention and deserving of help and assistance. Responders can also practically address survivors’ immediate concerns and consequently mitigate the effects of trauma due to lack of information, dislocation and lack of physical comfort or shelter. It is additionally possible to facilitate healing and resilience by connecting survivors with broader support networks and helping them discover inner resources for coping with disaster.
The United Hatzalah Trauma and Crisis Response Unit
United Hatzalah is a large volunteer organization whose EMTs, paramedics and doctors provide free emergency medical care to anyone in Israel regardless of race, religion or color. Volunteers arrive within a national average of three minutes after an emergency to stabilize the patient until transport. Responders use advanced GPS technology and specially outfitted ambucycles, cars, boats, tractors and traditional ambulances to rapidly arrive and provide prehospital medicine.
In 2016 United Hatzalah assembled a multidisciplinary team of medical professionals with backgrounds in behavioral health to form a Trauma and Crisis Response Unit. Members of the unit include an overseeing psychiatrist and EMTs who are also trained as social workers, psychologists and professional counselors. Unit members’ training in emergency medicine and behavioral health makes them ideal candidates to study and apply disaster behavioral medicine on the scene or in the immediate aftermath of a trauma event.
Prospective candidates for the unit are trained in the National Child Traumatic Stress Network’s PFA and Skills for Psychological Recovery (SPR) models, and the Immediate Stabilization Procedure (ISP) developed by Gary Quinn, MD, the unit’s overseeing psychiatrist. Responders are educated in topics related to acute trauma and disaster behavioral health, such as complicated grief, cultural differences in emotional expression and the skills of providing treatment at mass-casualty incidents.
The trauma unit is integrated into United Hatzalah’s greater framework of prehospital care services and deployed to any traumatic event regardless of its size or number of casualties. When a dispatcher receives information from callers and on-scene medics about a seemingly traumatic event that has occurred, they mobilize traditional resources (ambulance, police, etc.), then contact the Trauma and Crisis Response Unit’s team leader and describe the event. If the Trauma Unit leader affirms the case is a traumatic event congruent with the unit’s skills, the incident details and location are then forwarded to all trauma unit members. Individual members closest to the location respond to the call.
Methods of Intervention
When Trauma Unit members arrive, they receive a handover from on-scene medics and begin an initial assessment and triage of psychotrauma injury among the patients, family members, witnesses or others at the scene. People with acute traumatization are identified visually or by a brief interview and rated on a SUDS (Subjective Units of Distress Scale) of 0–10 to measure their level of distress. A score of 0 represents no distress, 10 represents the highest level of observable agitation possible. Traumatized patients generally present in one of two behavioral typologies: overresponsive or underresponsive. When a patient appears dissociated and unresponsive due to an extreme distress level, this is rated as 10+ and called “silent terror.”
The responder then decides whether basic PFA and a general psychosocial intervention are called for or whether the patient’s distress level is too high, contraindicating PFA. When the patient is deemed too agitated for basic conversational interaction and PFA, the ISP protocol is indicated. Once the ISP method is used and the patient is successfully calmed to a lower level of distress that allows conversation and basic functioning, PFA may be used.
The ISP technique originates from EMDR (eye movement desensitization and reprocessing) psychology. Quinn developed it as a method for first responders not trained in general EMDR to be able to apply bilateral stimulation and related grounding techniques in an acute post-disaster environment. ISP is based on the EMDR principles developed by Francine Shapiro, PhD, which were designed originally for treatment of PTSD. ISP adapted these principles to fit the time frame of minutes to days from the event. The purpose of the procedure is to allow the victim to fully integrate that the traumatic event is over, an understanding often difficult to contemplate in the ASR (acute stress reaction) stage.
Initially the first responder introduces himself to the victim and receives general information about the event. Next a screening is done to differentiate victims with medium- to low-level agitation to be treated with standard PFA from those with high-level agitation or “silent terror,” who will receive ISP. At this point the first responder will normalize the symptoms being experienced and explain that there is a procedure that can help lower the patient’s agitation. The responder then uses a combination of bilateral stimulation and repeated words that help the victim accept that the event is over. At this point the agitation normally decreases dramatically. Patients receive an explanation of common symptoms that may continue over the next two to three days and are given a number to call for further treatment if there is no gradual improvement.
When the Trauma Unit is done working with a patient or a family, they leave contact information that explains how to get in touch with them if further contact is desired. They provide the number of a national trauma help line and encourage patients to call for further assistance if necessary. This intervention alone is invaluable, as it helps people enter treatment months and sometimes decades before they otherwise might have sought help.
Case Study #1
The Trauma and Crisis Response Unit received information about CPR being done on a 40-year-old patient in the presence of the patient’s adult sister, Mary. When Mary saw her sister collapse on the floor, she immediately called for EMS. Although Mary herself was a nurse, she couldn’t recall her medical training and made no attempt to perform CPR. Instead she attempted to secure the patient’s airway with a spoon and simply waited until medics arrived.
When the medical team arrived, they found Mary screaming, crying and psychologically overwhelmed. Aside from the great noise and chaos, which distracted the medical team performing resuscitation on the patient, it was clear that Mary herself needed assistance. The United Hatzalah dispatch center forwarded information about this call to the Trauma and Crisis Response Unit director, who then dispatched members of the Trauma Unit to treat Mary.
When the Trauma Unit members arrived, they received a handover from an on-scene medic explaining the situation. Mary was introduced to the Trauma Unit members and assessed on the SUDS as an 8–9. Besides her agitation, she complained of feeling extremely weak and unable to be present with the scene unfolding in her home. Mary was reacting in such a way that she seemed unable to stop herself.
The trauma team helped relocate Mary to a different room where she couldn’t see her sister or the medical team performing CPR. Mary asked to be helped onto a bed in case she fainted. There a Trauma Unit member performed the ISP protocol, using bilateral stimulation on Mary’s shoulders. At the same time responders called Mary repeatedly by name and asked her to make eye contact.
After a few cycles of ISP and its related components, Mary could engage in the present moment. A paramedic entered the room and informed Mary that her sister had died. Mary was able to hear this information, stand up and return to the kitchen. From this point Trauma Unit members offered Mary practical assistance such as helping her locate the number to a funeral home, contact family members and meet other needs.
Case Study #2
The Psychotrauma Unit was dispatched to CPR being performed on a 2-month-old baby. During the hour-long duration of the CPR, one male and one female unit member worked with the mother and father of the child, being supportive and using Psychological First Aid. It became clearer as time went on that the CPR efforts weren’t going to resuscitate the child. The parents began arguing over who was to blame for the child’s death. One unit member, also an advanced EMT, skillfully explained to the couple about SIDS and how although nobody is necessarily to blame, people look to assign blame as a way of coping with the situation. This brief intervention and normalization of the parents’ reactions helped the parents stop assigning blame and band together.
Ultimately the on-scene paramedic declared the child’s death. The child’s mother began tossing objects violently about the house, then dropped to the floor. Pounding her fists on the ground, she loudly and repeatedly wailed, “Why didn’t God take me with him?” She was no longer communicative with her spouse or anyone present. Our team assessed the mother at 10+ on the SUDS, indicating the ISP protocol was needed to help lower her agitation level.
One of our members got onto the floor to do ISP on the mother and repeated cycles of bilateral stimulation and other components for 10 minutes. Finally the mother calmed to a lower agitation level and began to cry. She became communicative, took a drink of water, lit a cigarette and demonstrated that she was again able to interact with her surroundings.
The mother became retraumatized, however, when a well-meaning medic mistakenly brought her the baby’s blanket to warm her. Again the mother became highly agitated, 10+ on the SUDS, screaming and wishing for her own death. After another few minutes of ISP, the mother again returned to herself. At this point family members had arrived to comfort the parents.
Here the Psychotrauma Unit members inserted some calm into a chaotic situation and were a supportive presence for the parents before their own support networks arrived. They helped the parents support one another and transition from blame to togetherness, and stabilized the grieving mother twice when her agitation exceeded 10 on the SUDS.
Case Study #3
In January 150 Israeli soldiers were disembarking from several buses on a field trip to a park when a terrorist ran through them with a truck, killing four and wounding dozens. Aside from those physically injured, there were numerous traumatized soldiers and citizens who witnessed the attack and were highly agitated or dissociative.
From the perspective of the Trauma and Crisis Response Unit, this was as a mass-casualty event, with scores of traumatized people at the scene. A dozen members arrived on scene and set up a command center next to the location in order to move traumatized people away from difficult sights and create a safe place to receive and stabilize patients. Responders used equipment supplied to them in their kits, such as compact folding stools, pop-up tents, blankets, food, water and other aspects of physical comfort.
After ensuring adequate physical comfort for the patients, team members used PFA to help them connect with family and support networks and identify and address their immediate needs. They treated 50 patients, 12 of whom first needed stabilization with the ISP protocol and grounding techniques.
Social workers from the city welfare department and army psychologists arrived after the Psychotrauma Unit had treated the patients, and a handover was given to these professionals to help them continue care. Psychotrauma Unit responders stayed on scene while the remaining soldiers organized into groups in the park to do a formal debriefing with their commanders and hear words of resilience, remaining available in case any became too agitated. Indeed, several soldiers became markedly upset during the debriefs, and the responders treated them as well with ISP and PFA.
A fully integrated EMS-based psychotrauma response service is a viable and timely modality for providing Psychological First Aid to patients, bystanders and responders in the setting of critical incidents.
By training mental health professionals as first responders, using evidence-informed treatments to stabilize highly agitated and distressed patients, and utilizing the infrastructure provided by a national EMS system to rapidly respond minutes after a critical incident, the prehospital healthcare system can improve how it relates to patients and witnesses to traumatic events.
A special thank you to on-call medical director Adam Ballin, MBBS, of Maccabi Healthcare Services and Hadassah Medical Center in Jerusalem.
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Avi Tenenbaum, BA, EMT, is a board-certified addiction professional and emergency medical technician. He directs JNARS, a nonprofit organization for advancing professional treatment of addiction disorders. Avi is also a liaison officer and first responder for the United Hatzalah Psychotrauma Unit.
Miriam Ballin, MFT, EMT, is a family therapist, emergency medical technician and director of the United Hatzalah Trauma and Crisis Response Unit. Miriam uses her background in psychology, education and medicine to train, lead and dispatch the unit’s responders to emergencies nationwide.
Gary Quinn, MD, is a board-certified psychiatrist and director of the EMDR Institute of Israel. He specializes in the treatment of traumatic stress and authored the ISP-EMDR protocol for use in EMS settings. Dr. Quinn is also a consultant, trainer and responder in the United Hatzalah Psychotrauma Unit.
Rivkah Rabinowitz, MSc, EMT, is a team leader for the United Hatzalah Trauma and Crisis Response Unit, responsible for curriculum development, training, supervision and debriefing. She has a clinical practice in Jerusalem, where she also is known for her successful ladies learning program.
Avi Steinherz, LMSW, CBT, AEMT, is a team leader for the United Hatzalah Trauma and Crisis Response Unit. He trains, supervises and manages the medic support unit. He’s an Advanced EMT in United Hatzalah's ambucycle unit and a clinical social worker with a private practice in Jerusalem.
Debby Zucker, MSW, ACSW, AEMT, is a clinician, consultant and facilitator for the EMDR Institute of Israel. She also lectures in the school of social work at Hebrew University. Debby is an ISP consultant for the Trauma and Crisis Response Unit. She has been a medic and ambulance provider for 20 years.