Boston Marathon: A First Person Experience

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Xander Merboo -

Thank you for sharing a truly horrific experience. I hope no one else is ever put in such a terrible setting.

I do take strong issue with the statement in this content that said something like 'we are much better than police or fire at organizing chaotic events'. Nothing could be further from the truth. As someone who has worked in fire and law enforcement for years, I can honestly say that there are few experiences more frustrating or counter-productive than when my well organized firefighters are running a scene and a doctor runs up and tries to take over.

The Incident Command System [ICS] now adopted by FEMA as the National Incident Command System [NIMS] has its origins in the fire service and is now used for most all emergency scenerios here and globally. There are ICS courses for hospital disaster management. We in the fire service are ICS gurus, who use it every day and are incredibly competent at managing multi-patient disaster scenarios.

Should anyone find themselves in a terrible situation such as this one - please help. However, it is best to be a subject matter expert providing medical care and DO NOT try to run the scenario. Leave that to the experts.

In the mean time, anyone interested in learning how to work better as a team in an emergency scenario or disaster setting can take any of the free NIMS course through the FEMA website.

http://training.fema.gov/is/nims.aspx

jonathan b., pa-c -

= limits of the comfort zone.

Wow...thanks for sharing such profound experience. It was very cathartic listening to this podcast.

I have 3 events to share with you which snuck up on me and caused PTSD and eventually chased me out of EMED:

Way back when I was not even a year out of PA school I worked in a very remote clinic and on one day I had a full code with no team support at all; an XR tech. We lost the patient: PEA. We closed the clinic b/c the body recovery by the Coroner's office didn't take place for 3 hours. During that time, while I was suturing a 20 suture lac wound, a 30 year old woman presented with her newly wed husband with slurred speech. I immediately called for air evac, which was delayed due to the air ambulance not taking my report seriously. They finally arrive and found her to be lucid with a non-focal neuron exam and debate me why in the world she needs this. They transfer her, admit her but do not even scan her until the next day. Sadly, she had a massive temporal parietal lobe IC bleed.

And lastly, these two stories =

I've been volunteering essentially since childhood and started volunteering in the medical field for nearly 16 years and have traveled all over the world taking care of poverty stricken people with zero access to care. For years, my safety was never compromised until 3 years ago while in Colombia and Ecuador. I was attacked two times, both incidents were during transit while in major cities, bogota and quito. While taking pictures during a futbol game (the same people I was playing the game with), I was attacked at knife point by two young men which I fended off but I didn't see the third attacker and was struck in the face and knocked silly. They got my camera,but thankfully, I had no stab wounds.

The quito attack was at night while grabbing cash at an ATM (i broke my own rules) b/c the place I was volunteering charged me to stay there and only took cash. 6 men approached me as I left the atm machine (guarded by 2 police officers) and threw popa (popalina...aka dragon's breath) and woke up the next day at 1600 in my hotel room, completely delirious and pretty damn beat up. Ostensibly, a cab driver picked me off the street and drove me to my hotel. Luckily, I had the hotel business card in my jacket pocket for him to see why hotel name/location.

This was not a bombing experience, but felt very similar to a terrorist attack which caused PTSD. It snuck up on me so much I had no idea and then it dawned on me I needed to find a more mellow line of work.

Take care of you. We don't do enough of this. We are not as tough as we think.

Thanks for this awesome session and the aforementioned catharsis.

Christian Menard -

This was a very interesting segment, but the conclusion that stress debriefing is critically important actually contradicts a good body of empiric evidence. While it intuitively sounds beneficial, it has not been proven to benefit survivors, and there is some evidence that it aggravates symptoms. The evidence suggests a screening and long-term treatment approach is more appropriate.

A 2002 Cochrane Review found, "Single session individual debriefing did not prevent the onset of post traumatic stress disorder (PTSD) nor reduce psychological distress, compared to control. At one year, one trial reported a significantly increased risk of PTSD in those receiving debriefing (OR 2.51 (95% CI 1.24 to 5.09). Those receiving the intervention reported no reduction in PTSD severity at 1-4 months (SMD 0.11 (95%CI 0.10 to 0.32)), 6-13 months (SMD 0.26 (95%CI 0.01 to 0.50)), or 3 years (SMD 0.17 (95%CI -0.34 to 0.67)). There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety, or that it was superior to an educational intervention."

Adam -

Agree strongly with the above comment. Having worked in EMS/fire for a while before becoming an ER physician, I've been around CISD for a long time and have had the opportunity to learn some about it.

Whereas an operational debriefing (i.e., what went well, what could we improve next time) is valuable, the majority of the quality evidence actually comes down against acute psychological debriefing for both primary victims and emergency workers, despite it being gospel for decades. Some of the scientific highlights: a Lancet study (van Emmerik 2002), a WHO publication (Mental and Social Aspects of Health of Populations Exposed to Extreme Stressors), and a second Cochrane review on the topic.
From Lancet:
"Despite the intuitive appeal of the technique, our results show that CISD has no efficacy in reducing symptoms of post-traumatic stress disorder and other trauma-related symptoms, and in fact suggest that it has a detrimental effect."
From WHO:
"Because of possible negative effects, it is not advised to organize forms of single-session psychological debriefing that push persons to share their personal experiences beyond what they would naturally share."
From Cochrane:
"There is no evidence that single session individual psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease. A more appropriate response could involve a ’screen and treat’ model (NICE 2005)."
From UpToDate:
"Meta-analyses of numerous clinical trials found no evidence of effectiveness for either the initial, single-session intervention [39] or for subsequent, multiple-session versions [40]."
Here's a well-written plain-language discussion:
http://www.emsworld.com/article/10325074/ems-myth-3-critical-incident-stress-management-cism-is-effective-in-managing-ems-related-stress

Clearly, people are affected by traumatic experiences in different ways. Individuals with abnormal or distressing emotional responses should be referred for individual counseling. One useful tool is simple self-guided writing exercises (Pennebaker, Ayduk, Kross et al), wherein people are more likely to successfully process--and move on from--traumatic experiences in a healthy way.

Jess Mason -

Thank you for sharing your stories and the above references. I think this is why I was so eager to interview Bryan about this. We all have experienced or will experience something that deeply affects us and cope differently. Maybe just sharing stories as a community is helpful in some ways. It at least gets a dialogue going about a reality of our line of work. Thanks again for the comments and lit review.

Constantine P., PA-C -

Jessica and Bryan, thank you for a really nice exerpt on multi-casualty incidence (MCI) response. I appreciate that Bryan's experience may not reflect what is taught in the FEMA ICS model. However, I believe there are many incidences that will be an ad hoc response like that. I teach classes on MCI response at US diplomatic posts overseas. I just returned from 3 weeks in Sudan teach trauma first responder classes and facilitating a MCI exercise and would've loved to have had this story as a way to emphasize why we prioritize mass hemorrhage control using tourniquets.

Paul B., M.D. -

Agree with Xander Merboo's post.

While I felt the Aurora, CO segment was an amazing recollection of an non-EMS trained EP applying her skill set to a unique, horrifying experience, this segment has made generalizations that undermines what EMS Physicians have been trying to formalize for years.

Out-of-hospital events will always happen, and EPs are ideal members to utilize on a team in the field. However, very complicated and intricate systems are in place in every area of this country, and these systems can vary greatly based on location. A wise maxim recently stressed by Dr. Mell is "if you've seen one EMS system, you've seen ONE EMS system".

To imply that EPs are better at running out-of-hospital events when compared to municipal response is unwise. As much as EMS/Fire/Police may have difficulties coordinating their response in the field, it will only complicate things if a higher trained / un-informed medical authority attempts to run the entire scene. Patient care and provider safety will suffer because of expected frustrations and poor communication.

Concepts such as:
--recognized field triage (START, SALT, others)
--scene safety
--Incident Command, specifically unity of command / chain of command
--inter-agency communication

were completely underscored in this segment.

We train our residents on incident command using multiple formats so that they 1) understand greater how the out-of-hospital system works and 2) understand greater how HICS works. Both of these concepts are vital to their roles as future EPs.

EMS Physicians have proudly made a statement to the rest of the house of medicine they have a specific and unique medical practice, as evidenced by the ABEM certification and the ACGME accreditation of fellowships. EMS Medical Directors are the ones who should be making decisions an out-of-hospital scene like this because of our explicit understanding of our system. Making decisions without knowledge of your surroundings leads to poorly informed decisions.

As an EMS Medical Director and fellowship trained EMS Physician, I have been part of many out-of-hospital events, both planned (10 NYC Marathons) and unplanned (from singular arrests to mass casualty incidents). My training has afforded me the ability to make decisions to improve patient care and safety of the providers. An inexperienced / untrained EP might not have the same level of comfort in a similar situation.

My take home point here is not to lambast [rant?] the segment but to highlight the importance of EMS in our academics. I hope all programs train their residents in ICS and furthermore track any interested residents into EMS careers, so that the future generation of EPs have an improved understanding of out-of-hospital coordination. Even those not explicitly interested in EMS will secretly they will take the tenets of ICS / preparedness to the bedside during the resuscitations they run for the duration of their career.

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