More than two decades ago, William “Bill” Lang, BA, EMT-P, left a career in pastoral ministry to pursue his interest in emergency medicine. The draw to EMS started as far back as high school when he volunteered as a firefighter and first responder for the local volunteer ambulance company. Still, his desire to serve people stayed with him and he began to focus on those who struggle professionally in emergency medicine.
“Over the years I’ve watched a number of EMS personnel disintegrate in the field,” said Lang, who’s lead paramedic and critical incident stress management (CISM) coordinator for American Medical Response (AMR) in northwest Oregon and southwest Washington. “I’ve seen several people die pretty young, and I’ve seen them break down psychologically and emotionally. Others developed a pattern of behaviors and made decisions that were career ending.”
These incidents left a mark on Lang, but it wasn’t until 1998 that he came up close and personal with his own critical incident–one that would change his life forever. He and his partner had been called to the shooting of two police officers. They quickly found themselves in the hot zone of potential gunfire.
“We declared one officer dead on scene and treated and transported the other. In the process we were brought under threat of fire, although no gunfire happened while we were there,” said Lang. “That incident ended my partner’s career, and it almost ended mine.”
Lang developed some of the classic symptoms of critical incident stress, including the dread and fear of going to work. With help he recovered, and then he developed a keen interest in understanding how to survive critical incidents and CISM.
“Looking after people and making sure they have the resources and the internal skill set to do what they need to do in critical incidents has always been on my mind,” he said.
In 2005, his chance to do something about CISM became a reality when AMR entered a contractual obligation that required the company to have a CISM program in place. The company already had a few pieces, but it was far from a working program. “I was getting requests at times to talk with coworkers after a bad call, but I realized that wasn’t really a program,” Lang said. He talked to his general manager about restarting the program. Lang was appointed the coordinator two years ago.
Lang started his quest to rebuild the program with reading and research, and is indebted to the International Critical Incident Stress Foundation (ICISF) for their support. “They have a lot of great information and ideas and have really tried to hone in on what works and what doesn’t work,” he said.
The whole idea of addressing critical incident stress is a controversial one, as the mental health community has pushed back some about having these programs in emergency service environments. Lang recognized that he would have to keep this in mind if the program was to be successful.
“It’s a specialty in mental health to work with people affected by traumatic incidents,” he said. “So what the ICISF came up with is the need to have a multicomponent program in place. That involves, among other things, pre-incident education.”
To achieve this education, Lang would need to build a program that would educate his providers in the signs, symptoms and treatments of critical incident stress. He also would need to develop peer-to-peer support resources. “We needed to train selected field personnel in psychological and emotional first aid,” he said. “That’s the first line of intervention for people who have been exposed to critical incident stress.”
Once trained, these peers would support their fellow coworkers in addressing CISM, but they wouldn’t be engaging in actual professional mental health treatment. “When they see an individual with what looks like symptoms of critical incident stress that are deeper than their training, they can refer them to a licensed mental health professional or counselor,” said Lang.
The more Lang researched the material from the ICISF, the more he realized he could design a CISM program based on an EMS system. “EMTs and paramedics are very used to coming in, identifying a chief complaint, coming up with a treatment plan, and then transporting that person to someone with an equal or higher level of medical training,” he said. “So if you use that as a model for CIS management, EMS providers already understand that process.”
With his research completed, Lang outlined for his superiors how the program could effectively work. “CISM is to psychotherapy what first aid is to surgery. It’s seen as part of a continuum of care,” he said. “That’s how I decided we would present the idea.”
It worked. From there, Lang put out the word that he needed peer counselors for the program. He did it by asking the workforce whom they would want at their side if they were having a crisis. He received more than enough nominations for the program and selected 14.
“The peer counselors are doing critical incident stress diffusing, not debriefing. It’s a scaled-down, more casual and shorter duration form of debriefing,” Lang said. “The peer counselors do a follow-up contact with the people they’ve seen to find out if there’s more discussion needed, or if there’s a need to get the person connected with a therapist.”
To run such a program, Lang discovered that a licensed therapist had to be formally associated with them, one who would act as a professional partner. They found such a therapist in Drew Prochniak.
“We were so fortunate in finding a fellow who specializes in first responder stress that was setting up a practice as a therapist in our community,” Lang said. “He jumped on the bandwagon. This couldn’t happen without his involvement because the model wouldn’t work.”
Prochniak has adapted to his new role with gusto, riding with paramedics and EMTs and becoming known on a first-name basis. Lang couldn’t be happier with the results. “Historically, getting paramedics and EMTs to go and see a counselor has not been something that was popular,” said Lang. “It’s seen as weakness and we’ve had to overcome all that silliness.”
There’s also the logistical challenges with which Lang contends. AMR’s workforce spans 500 people across four metropolitan counties. “They all work different schedules, have different operations, and different management teams,” he said. “It’s like herding cats.”
Despite some of the initial hurdles, the program is a success. Lang is pleased and grateful for this because he recognizes the importance of having such a program in an industry where jobs are getting harder to execute. The squeeze on resources, the complexity of challenges facing many patient populations, more violent and mentally ill patients, and more gun violence and drug abuse all contribute to the difficult hazards prehospital providers face every day. New threats, such as terrorism and Ebola, only add to the mix.
“We really weren’t facing this stuff 20 years ago to the degree that we are now,” said Lang. “More accountants and attorneys have gotten into the leadership of healthcare, and that has changed the environment significantly. So we are doing more work with fewer resources.”
More advanced technology also has added to prehospital provider stress. Twenty years ago, an ambulance might have had a radio, pager and map book.
Today, that same ambulance has two radios, computers, pagers, monitoring equipment and GPS. Ultrasound is expected to be added to ambulances in the next few years. “So we are expected to know more and do more than we did previously, and we’re expected to do it faster, with more volume, in a shorter period of time,” Lang said. “There’s a personal price providers pay for being out there and attempting to do all this work.”
As such, the need for CISM programs has never been greater. It’s a challenge Lang is uniquely suited to, given his background and outlook on life. “One of my old partners said, “˜You can love EMS, but it will never love you back.’ But I’m thinking that maybe there is a way that we can look after each other,” he said.
And Lang has proceeded to do just that with his much-needed program. “I think that we find the goodness of life in our efforts to make someone else’s bad day survivable,” he said. “I’ve been very gratified with the reception we’ve gotten.”