Evidence-Based EMS: Disaster Scenarios and Psychological First Aid

At 4:30 a.m. you wake to the sound of your telephone ringing. You answer, and your supervisor tells you, “Turn on the news and meet me at the office in 30 minutes.”

Your local news station is reporting that a neighboring town has just been hit by an F5 tornado. The destruction is vast, the emergency response system is in disarray, and utilities are offline. Your team assembles, deploys into the town and starts the hectic work of caring for the wounded, frightened survivors and occasionally finding the dead.

In the evening you pause for coffee, and as you look around you finally notice the spectrum of emotional states among the victims: some silent, some frantic, some angry, others tearful. You think back to your training on how to care for the psychological wounds caused by disasters and remember your Psychological First Aid. By this point you have no energy to waste and want to do whatever will be most helpful for those around you. You begin to wonder, What do we know about the effectiveness of a brief intervention to help disaster victims either suffer less or regain normal function more quickly?

Background

Society has long recognized that victims of traumatic events display a wide array of emotional and functional responses. In Shakespeare’s Henry IV, Hotspur has returned from war but remains hypervigilant and cold in the daytime, only to speak combat orders while asleep.¹ In the American Civil War, “soldier’s heart” was the term for restricted breathing and palpitations thought to be caused by tightly strapped knapsacks during campaigns of unprecedented lethality.² After World War I, “shell shock” referred to a set of neuropsychiatric symptoms thought to be due to brain microtrauma from blast exposures, but later concluded to be the cumulative psychological trauma of surviving relentless mortar shelling.

In the 1950s, to augment Cold War preparedness, the first description of psychological first aid (PFA) was published as a framework by which level-headed responders could triage and assist mentally disturbed victims of a nuclear attack or other disaster.³ While the focus in the Cold War was on immediate stabilization from “hysteria,” the Vietnam era revived old concerns about long-term functional deficits due to emotional trauma. Finally, in 1980 the American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders-III with a revolutionary new line of text: “309.81: Posttraumatic Stress Disorder.”¹ With vast historical experience and the technical definition set, a flurry of research probed emotional wounds, seeking ways to reduce functional deficits that follow traumatic events.

Emergency medical personnel are trained to deliver timely interventions to stabilize people in trouble. Often they are taught that by limiting the severity of the initial insult, one might also limit the chronic effects of an injury. The Cold War PFA model that sprouted in the 1950s grew along these lines, and professional guidelines told responders to offer immediate stress counseling after traumatic events, which grew to be known as critical incident stress debriefing. This well-intended intervention grew in popularity and became the standard of care in many circles through the 1990s, until research found it to be unhelpful and possibly increased the one-year risk of PTSD after a traumatic event.^4,5 Compulsory group debriefing is no longer recommended in humanitarian response, but given the high morbidity of psychosocial wounds after a disaster, responders feel the duty to offer some intervention. With the more structured interventions of the 1990s falling out of favor, humanitarian organizations revived a modified version of the Cold War-era PFA as the standard of care.

Currently leading humanitarian organizations, including the Inter-Agency Standing Committee, World Health Organization and International Federation of Red Cross and Red Crescent Societies (IFRC), recommend applying PFA.^6–8 The IFRC has defined PFA as “a process of facilitating resilience within individuals, families and communities.⁸“ This definition suggests faith in the status quo by stating that the goal of the intervention is not a new fix, but rather ensuring the restoration of the patterns and support mechanisms that sustained the victims prior to the disaster. The WHO, on the other hand, defines it as, “a humane, supportive response to a fellow human being who is suffering and who may need support.⁷“ This definition suggests faith in the power of compassionate interpersonal contact to relieve suffering. In either case, such effects might be delivered by a lay person or a trained responder. While the definitions vary, the recommended steps usually involve engaging individuals with compassion and facilitating community recovery.

Evidence Review:

PubMed contains three high-quality systematic reviews of the literature that describe the evidence behind psychological first aid^9–11. Each of these reviews sought trials with sufficient rigor to demonstrate a treatment effect. Unfortunately, none of the three systematic reviews of the literature were able to identify any trials rigorous enough to establish clear evidence for or against the use of psychological first aid.

Table 1: Recent systematic reviews of psychological first aid.

Discussion:

The lack of experimental data on PFA is remarkable for both its depth and duration. Critical incident debriefing, as a component of Critical Incident Stress Management, was started in the 1980s based on the work of Everly and Mitchell and by 2002 there was sufficient data for the Cochrane database to find an overall increased risk of PTSD in those who received critical incident debriefing.^5,12 Everly and Mitchell argue that their proposed techniques were misconstrued and misapplied without appropriate overall stress management.¹² While their original interventions may have been misapplied, data on the real-world impact of CISD showed a neutral or harmful impact in just 19 years of study. PFA, on the other hand, was conceptualized 62 years ago, widely deployed since the 1990s, and still there are zero fair studies on treatment effects. Despite the lack of evidence concerning efficacy, PFA remains paramount in several prominent guidelines.

The systematic review by Dieltjens et. al neatly compared and contrasted five current PFA guidelines offered by various groups. Of these five guidelines, four were similarly constructed from literature reviews.^13–16 One group, however, took a different approach to building a guideline. An international panel of experts acknowledged up front that there was insufficient evidence for making a guideline up to usual clinical standards, then ignored the weak clinical literature and instead examined common themes among psychosocial needs after disasters and mass violence. After identifying meaningful themes, the panel sought to examine the scientific basis for why each theme would be important for disaster victims. The panel produced the Mid-term Mass Trauma Guidelines, which proposes that any psychosocial interventions in the hours to months after an event should be guided by five key principles: safety, connectedness, self and collective efficacy, calm, and hope.¹⁷ Each of these principles is supported in their guideline not by frail clinical evidence for the PFA’s external validity, but by introducing the scientific rationale for each element and offering the best evidence available for the internal validity of the interventions they recommend. While the Mid-term Mass Trauma Guidelines does not offer a stronger evidence-based solution than the other available guidelines, it focuses the reader not on the vast gap in PFA effectiveness research, but instead on the wealth of psychological and neurobiological science that makes the whole family of PFA guidelines seem reasonable, reality-driven, and worthwhile.

Considering these five elements in the Mid –term Mass Trauma Guidelines, one might reconsider the Civil War era explanation of “soldier’s heart”. Soldiers wore their tightly cinched knapsacks on the way to battles where up to 30% would die in combat, then more still to malaria and infection: no place was safe and few were calm.² Unable to protect themselves and their friends, any sense of efficacy would wither. Their social supports and families were distant and often unreachable. This combination of factors would be enough to strip most people of hope. Perhaps it is no surprise, then, that entire camps would fall languid and weary with a mental affliction they termed “nostalgia”, from the Greek roots nostos (“homecoming”) and algos (“pain”). ¹⁸ The soldiers of the American Civil War were surely victims of the protracted anthropogenic disaster they were living, and the PFA construct is our best understanding of how they might have mitigated one another’s suffering.

Bottom Line:

Despite over sixty years of use, there is no rigorous research on whether PFA is helpful in mitigating the immediate, medium- or long-term psychosocial injuries caused by traumatic events. Until there is more research we cannot support any specific intervention with scientific evidence. Given the difficulty of psychosocial research in disaster settings, it is difficult to develop a scientifically rigorous evidence base for PFA in the near future. More likely, humanitarians, families, and responders will continue to do what they have been doing since long before Dr. Aubrey coined the term “psychological first aid”: we will compassionately approach those in trouble. Given the sound internal validity and the lack of evidence against the use of PFA, there is no sound reason to withhold this intervention in the right setting. Psychological first aid aligns with the best psychological and biological science available and its focus on safety, calm, self and group efficacy, connectedness, and hope are also aligned with our most treasured values.

1.            Trimble MD. Post-traumatic Stress Disorder: history of a Concept. In: Figley CR, ed. Trauma and Its Wake: The Study and Treatment of Post-Traumatic Stress Disorder. New York: Brunner/Mazel; 1984:5-14.

2.            Horwitz T. Did Civil War Soldiers Have PTSD? Smithson Mag. 2015. https://www.smithsonianmag.com/history/ptsd-civil-wars-hidden-legacy-180953652/?no-ist=&page=1. Accessed March 4, 2015.

3.            Drayer CS, Cameron D., Woodward WD, Glass AJ. Psychological First Aid in Community Disasters. JAMA1. 1954;156(1)(September 4):36-41.

4.            Roberts NP, Kitchiner NJ, Kenardy J, Bisson J. Multiple session early psychological interventions for the prevention of post-traumatic stress disorder. Cochrane database Syst Rev. 2009;(3):CD006869. doi:10.1002/14651858.CD006869.pub2.

5.            Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002;(2):CD000560. doi:10.1002/14651858.CD000560.

6.            Interagency Standing Committee (IASC). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. 2007:1-103. doi:10.1037/e518422011-002.

7.            Who. World Health Organization, War Trauma Foundation, and World Vision International: Psychological First Aid - Guide for Field Workers. Geneva: WHO; 2011. doi:10.2307/3416674.

8.            Hansen P. Psychosocial Interventions. (Ager W, ed.). Copenhagen: International Federation Reference Centre for Psychosocial Support; 2010. doi:10.1383/psyt.3.1.36.30294.

9.            Dieltjens T, Moonens I, Van Praet K, De Buck E, Vandekerckhove P. A systematic literature search on psychological first aid: lack of evidence to develop guidelines. PLoS One. 2014;9(12):e114714. doi:10.1371/journal.pone.0114714.

10.          Fox J, Burkle F, Bass J, Pia F, Epstein J, Markenson D. The Effectiveness of Psychological First Aid as a Disaster Intervention Tool: Research Analysis of Peer-Reviewed Literature from 1990-2010. Disaster Med Public Health Prep. 2012;(6):247-252.

11.          Bisson JI, Lewis C. Systematic Review of Psychological First Aid. Cardiff; 2009. https://mhpss.net/wp-content/uploads/group-documents/148/1321872322-PFASystematicReviewBissonCatrin.pdf.

12.          Everly GS, Mitchell JT. A PRIMER ON CRITICAL INCIDENT STRESS MANAGEMENT (CISM) | ICISF, Inc. Int Crit Incid Stress Found. 2011. https://www.icisf.org/a-primer-on-critical-incident-stress-management-cism/. Accessed March 4, 2015.

13.          Kelly C, Jorm A, BA K. Development of mental health first aid guidelines on how a member of the public can support a person affected by a traumatic event: a Delphi study. BMC Psychiatry. 2010;10(49):15. doi:10.1186/1471-244X-10-49.

14.          Bisson J, Tavakoly B, Witteveen A, et al. TENTS guidelines: development of post-disaster psychological care guidelines through a Delphi process. Br J Psychiatry. 2010;196(1):69-74.

15.          Te Brake H, Dückers M, De Vries M, Van Duin D, Rooze M, Spreeuwenberg C. Early psychological interventions after disasters, terrorism, and other shocking events: guideline development. Nurs Heal Sci. 2009;11(4):336-343.

16.          Vymetal S, Deistler A, Bering R, et al. European Commission project: European Guideline for Target Group-Oriented Psychosocial Aftercare-Implementation. Prehosp Disaster Med. 2011;26(3):234-236.

17.          Hobfoll S, Watson P, Bell C, et al. Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry. 2007;70:283-315.

18.          The United States Sanitary Commission. Sanitary Memoirs of the War of Rebellion. (Flint A, ed.). New York: Hurd and Houghton; 1867. https://www.archive.org/details/sanitarymemoirs01unkngoog.

Kurt Eifling, MD, graduated from the Northwestern University Feinberg School of Medicine in 2009 and entered active duty in the US Navy. For three years he served as the General Medical Officer for a Camp Lejeune-based infantry unit, 3d Battalion 8th Marines, including two combat deployments to Afghanistan in support of Operation Enduring Freedom. He is currently a PGY-2 Resident in Emergency Medicine at Barnes-Jewish Hospital, St. Louis Children’s Hospital, and the Washington University School of Medicine in St. Louis, Missouri.

Hawnwan Philip Moy, MD, is an assistant medical director of the Saint Louis City Fire Department, emergency medicine clinical instructor and core faculty of the EMS Section of the Division of Emergency Medicine at Washington University in Saint Louis, MO. He completed his emergency medicine residency at Barnes Jewish Hospital/Washington University in Saint Louis and his EMS fellowship at the University of North Carolina in Chapel Hill.