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Critical Incident Stress Management

Some situations that health care workers face are similar to to situations that may represent a critical incident for emergency medical services, police and fire fighters. These situations may include large-scale disasters, tragedies, serious injuries or deaths, known victims and life or limb threatening situations. A reaction can occur whether people are involved in the situation or are witnesses to the situation.

Some of the most frequently occuring events in health care that can result in a critical incident stress reaction include:

  • Deaths and/or tragic loss, which may involve patients or coworkers. This may include:
    • Unexpected emergencies resulting in death
    • Prolonged unsuccessful resuscitation
    • Suicide
    • Serious accident or injury that prevents return to work
    • Homicide
  • Violence in the workplace, which may be verbal, physical or sexual. The combinations are many as both the aggressor and victim may be a patient, family, visitor or coworker.
  • Incidents involving children: eg. deaths, abuse or neglect resulting in injury to a child
  • Incidents involving high media exposure
  • Ethical/moral issues, or professional conflict over care
  • Personal relatedness or connectedness: eg. patient is known to caregiver or resembles someone they know. Caregiver over-identifies with patient.
  • A real or perceived error while providing care resulting in harm/death of patient; unsafe situation or care issues.

Almost any situation has the potential to become a critical incident if the individual is vulnerable and the situation is “right.” Because everyone has unqiue life experiences and events, what may be significant to one person may not mean the same to others involved in the incident. What may be a critical incident for one person may not be an incident for others in a group.

What is Critical Incident Stress?

Even though a traumatic event is over, individuals or a group may experience strong physical and emotional reactions, or “emotional aftershocks,” in response to the event. This reaction, which follows a critical incident, is called Critical Incident Stress (CIS).

  • The reaction may be immediate, or appear a few hours or days later. Sometimes, even weeks or months may pass before the stress reaction appears.
  • The extent of a reaction may range from mild to intense.
  • The duration of a reaction may be a few days to weeks, months or longer, depending on the severity of the traumatic event. Most people will start to feel better within a few weeks.
  • Sometimes the event is so painful that it does not pass, and professional help may be needed. This does not mean the person is crazy or weak. It just means this event was too powerful for them to manage by themselves.
  • Remember, this is a NORMAL reaction of a NORMAL person to an ABNORMAL event.

So, how do I know this time is different?

The Critical Incident Stress reaction may include cognitive, emotional, physical, behavioural and spiritual signs and symptoms, which are listed below.


Common Types of Signs and Symptoms: Chills, thirst, fatigue, nausea, fainting, twitches, vomiting, dizziness, weakness, chest pain, headache, elevated blood pressure, rapid heart rate, muscle tremors, shock symptoms, grinding of teeth, visual difficulties, profuse sweating, difficulty breathing, etc. (Any of these may indicate a need for medical evaluation. When in doubt, contact a physician.)


Common Types of Signs and Symptoms: Confusion, nightmares, uncertainty, hypervigilance, suspiciousness, intrusive images, blaming someone or self, poor problem solving, poor abstract thinking, poor attention / decision making, poor concentration / memory, disorientation of time, place or person, difficulty identifying objects or people, heightened or lowered alertness, increased or decreased awareness of surroundings, etc.


Common Types of Signs and Symptoms: Fear, guilt, grief, panic, denial, anxiety, agitation, irritability, depression, intense anger, apprehension, emotional shock, emotional outbursts, crying easily, feeling overwhelmed, loss of emotional control, inappropriate emotional responses, etc.


Common Types of Signs and Symptoms: Withdrawal, antisocial acts, unable to rest, intensified pacing, erratic movements, change in social activity, change in speech patterns, increase or decrease in appetite, hyperalert to environment, increased use of alcohol or drugs, change in usual communication, etc.


Common Types of Signs and Symptoms: Anger at God, questioning beliefs, withdrawal from place of worship, faith practices and rituals seem empty, loss of meaning and purpose, uncharacteristic religious involvement, sense of isolation from God, anger and clergy.

Reference: Taken from International Critical Incident Stress Foundation Inc. website 2003 pamphlet

Suggestions for Self Care After a Critical Incident

Basic Self Care

  • Within the first 24-48 hours, alternating periods of appropriate exercise with period of relaxation will help to alleviate some of the physical reactions. During times of stress, your body produces stress hormones (catecholamines) which can make you feel jittery and on edge. Exercise helps the body clear these hormones, and releases endorphins which should help you feel better.
  • Get plenty of rest. Your energy may feel depleted just trying to cope with stress.
  • Eat well-balanced and regular meals, even if you don’t feel like it. Coffee, tea and sweet food may create a temporary burst, but will throw your body out of balance.
  • Be aware of numbing the pain with overuse of alcohol or drugs. These only provide temporary escape and slow down the healing process. You don’t want to complicate this incident further with a substance abuse problem.

Regain Some Order in Your Life

  • Maintain as normal a schedule as possible. It helps to add some order to the chaos you are feeling right now.
  • Structure your time; try to keep busy.
  • Make as many decisions as possible that will give you a feeling of control over your life, ie: If someone asks what you want to eat, answer them even if you are not sure.
  • This is not the time to make big life changes. You may see the situation differently in the future.
  • Do things that feel good for you. Put some positive energy back into your life.
  • Some people find it helpful to keep a journal. Write down your thoughts to get you through those sleepless nights.

Connect With Your Social Supports

  • Reach out, people do care.
  • Continue to spend time with others. Isolating yourself from family, friends, or coworkers may make you feel worse.
  • Talk is the most healing medicine. Talk to someone you trust and who supports you. You will probably find that each time you are able to talk about the event, thes easier it becomes.
  • Help your coworkers as much as possible by sharing your feelings and checking out how they are doing.
  • Realize that those around you may be under stress as well.

Remember, This is a Normal Reaction!

  • Expect that the event may affect you. Educate yourself about Critical Incident Stress and how it may impact on you.
  • Remember that you are normal and are having normal reactions. You don’t have to label yourself as “crazy.”
  • Give yourself permission to feel rotten for a while and share your feelings with others.
  • Realize that the reoccuring thoughts, dreams or flashbacks are normal and should begin to decrease and become less painful over time.
  • Most reaction symptoms are exoected to settle down within three to four weeks after an incident. Give yourself time to heal.
  • Get help if necessary. If the incident is staying with you longer than you think it should, call the contact person at your facility.

Some signs and symptoms are more time-related, as described in the table below.

Normal reactions in first few hours after event

Mainly physical and perceptual. Related to “fight or flight” autonomic nervous system activation.

  • Mild reactions: fixating on the scene, not aware of things around them, gagging, lump in throat, heavy feeling in stomach, feel like crying
  • Intense reactions: time warping (time goes more quickly or slowly), distortions in hearing (increased or decreased), visual disturbances (greater sense of detail or tunnel vision), tremors or “the shakes.”

Normal reactions in the first few days after event

Initially numb, but start to feel impact as we start to process the event. Reaction related to higher levels of stress.

  • Heart palpitations, stomach aches, heart burn, change in bowel function (diarrhea or constipation), muscle aches, difficulty sleeping (this one is common), decreased sex drive
  • Feeling numb, disbelief, function on “auto-pilot,” inattentiveness, memory gaps, loss of perspective on life events, tense, irritable, feel isolated, feel no one cares or understands, preoccupied with the event, greater sensitivity.

Normal reactions 3-7 days after event

Less physical reactions, but psychological and emotional continue.

  • Reactions seem abnormal outside of context of event; start to have negative impact on their family / work life and relationships
  • May have ongoing difficulty sleeping – Insomnia or sudden awakening, sexual difficulties, increased use of alcohol or drug use to cope.
  • Flashbacks, nightmares, increased sense of danger, increased startle response, anger, blaming, guilt, isolation and social withdrawal, alienation from people, avoidance of things associated with event, fear / anxiety about the future, feeling numb, depression, feeling of being out of control, fear of the event happening again, increased family problems and misunderstandings