When I was a young company officer in a combination department, we responded to a townhouse apartment fire in with wee hours of the morning. We encountered heavy fire originating from the kitchen and it was a real chore for the crew protecting the stairwell for the search team that went to the second floor.
Another firefighter and I conducted a search of the smoke-charged living room where we located an elderly woman whom we removed to the outside of the apartment.
The woman was severely burned and charred over her entire body and had obviously been dead long before we found her. The smell of burnt flesh hung heavy in the early morning air.
I’d seen victims like this before. But as I looked around my group of young firefighters (some very young) consisting of both career and volunteer members, I could easily tell that this was a first time for them — the first time seeing and smelling a human being who’d been burned beyond recognition.
When we got back to the station and started cleaning trucks and equipment, I immediately placed a call to activate our CISM Peer Response Team. That two-person team was made up of members of our department who had undergone training with our county CISM Team. That team was made up of mental health professionals from our county’s mental health department as well as members of the fire and EMS department.
Veterans aid debriefing
It was around 3 a.m. when we finally had things back in order and I could assemble our people and the peer team together. I led off the session by explaining that I’d made the decision to call in the team because I remembered what my first badly burned fire victim look and smelled like.
I wanted everyone who’d been on the call to know that it was OK to feel “weird” or not know exactly how they felt about tonight’s call. I wanted everyone to know that the peer team and I were there for them.
Then the peer team took over and initiated a great structured conversation that did the trick; it was a critical incident stress debriefing in sheep’s clothing.
The three career firefighters on my crew did me proud when they took the lead and spoke of what their experience was and how they felt about the call. After about an hour or so, probably 50 percent of the 20 or so firefighters in the room that night talked about what they were feeling.
To the best of my knowledge, we never had anything develop — from a mental health or critical incident stress perspective — among any of our folks who worked that call that night. I like to think that I made the right call by being proactive.
In the previous articles, I’ve approached the company officer’s role in understanding and protecting the mental health of their people from the 35,000-foot level and the 1,500-foot level. Now it’s time to get down to ground level: protecting firefighters who are being exposed to mental trauma while providing emergency services.
It can’t be avoided and currently there’s no personal protective equipment that can protect us. But there is a model of operations that we can effectively use: our response to a hazardous materials incident.
Hazmat response principles
A safe, effective and efficient response to a hazardous materials incident requires following these principles.
- Identity the material and its immediate threats, isolate the surrounding area and deny entry to everyone other than certified personnel working in the appropriate PPE under a defined action plan.
- The incident scene is categorized into hot, warm and cold zones, and zone integrity is strictly enforced.
- Limit the time of exposure, put distance between you and the hazardous material, and use the proper barriers or protective equipment.
- Everyone who works in the hot zone must be properly decontaminated.
That’s not the whole list, but you get the basic premise. Seeing, being in close contact with and caring for traumatically injured patients or those who’ve succumbed to their injuries is the equivalent of a hazardous materials exposure to our brains.
So if we’re going to protect our brains from such an exposure, the incident commander or subordinate tactical leader must learn to apply those hazmat-response principles.
Size up and zones
Here’s what it looks like to convert the hazmat response plan to a mental health response plan.
First, conduct a good scene size-up that includes a characterization of the incident scene. Pay attention to those types of incidents that pose an increased level of mental health exposure.
Some examples of such incidents include a motor vehicle crash with several multi-systems trauma patients, including two children, a house fire where some escaped the blaze, but others did not, and a mass shooting in a shopping mall with multiple casualties including children and teens.
Second, isolate the area and set up operational zones. Get everyone out of the area who can do so on their own power (self-triage) and get them to a common area in the cold zone.
If you started with 20 patients in your field of vision at the mass shooting, but 14 of them can get out of the hot zone on their own, the mental picture that your firefighters and EMS providers will be exposed to has improved greatly just by reducing the size of the problem facing them.
Characterize the scene as the hot zone (firefighters and EMS providers actively providing emergency services), the warm zone (the decontamination unit where personnel will exit the hot zone) and the cold zone (location for staged equipment and personnel and the rehabilitation unit). Ensure that everyone understands the zones and that tactical leaders enforce zone integrity.
Time, distance, rehab
Third, regardless of the patient-to-provider ratio, only deploy the absolute number of necessary personnel into the hot zone. If you’re fortunate to have reserves, use them to rotate with personnel in the hot zone — use the time and distance to limit everyone’s exposure.
Ensure that all personnel operating in the hot zone are wearing the appropriate level of PPE for the job task they are carrying out. The mental exposure is likely bad enough; no need to compound it with an exposure to bodily fluids to an unprotected care provider.
Fourth, everyone who worked in the hot zone goes through the physical and emotional decontamination and rehab units. The physical part is easy — shed contaminated EMS and firefighting PPE, use of waterless hand sanitizer, take fluids and nutrition, and have vital signs checked.
The mental aspect is not so easy. If your department has access to CISM resources or chaplain services, those personnel should coordinate their actions with the rehab unit leader.
This is the time when the incident commander assesses the physical and emotional status of personnel before returning them to the hot zone or releasing them from the scene.
What are your thoughts on how we, as front-line leaders, can help our people protect their brains from the emotional trauma that can come with caring for others on the worst day of their lives?
