Team Member & Physician Support

How I Heard

Pat, above right:

I’ll never forget the 6:50 am call I got that Sunday from an HR exec who told me our downtown ED had been flooded with dozens of victims from a nearby mass shooting — a disaster beyond anything we’d responded to before. I couldn’t imagine how intensely this was affecting our team members and physicians, and I knew that I wanted to get there ASAP to provide support where needed. Shortly after I arrived on campus and had been briefed on the basics, I made it a priority to head for our ED, surgery and Trauma/ICU departments to find out how those teams were doing and let them know that we were nearby. What I did not expect to see was that the night teams had mostly gone home and things looked unrealistically calm and organized. Knowing that I’d circle back to those departments in the hours and days ahead, I wanted to find out how some of our other departments were doing. It was clear that our Environmental Services team had done a remarkable job of cleaning up a sea of blood in our ED; our Security teams were everywhere, keeping us safe from the next possible wave of threats; and our Guest Services team was helping the growing number of distraught family members looking for wounded or deceased loved ones. It didn’t take long to see that this crisis was sending shock waves through our entire hospital system, and many other departments would be pulled into the collective response to this tragedy.

Then, an even bigger picture began to emerge: Every one of our team members was also part of our Central Florida community, and we were all shaken by the fact that some form of terrorism had crept into our own backyard. How on Earth was our small EAP team going to support dozens of departments and thousands of team members at the same time?

Mary, above left:

My phone went off at 5:00 am and the 10-minute drive to the hospital seemed an eternity. All I was told was, “We need you.” The walk to the incident command center with the HR leader gave me time to gather my thoughts and develop a plan. The request was to support the physicians. Immediately I knew the physicians were in full response mode. They would not need psychological supports yet. As I left the command center and walked through the hospital, my previous training in crisis intervention/PTSD was running through my head. The physicians and residents would not require or accept any kind of support for at least 24-48 hours post trauma. The theme that emerged for me was: Make yourself available when and where possible. I spent the next 12 hours with the families of the victims. As the time past and the traumatized family members waited, I worked alongside the guest service personnel, chaplains and EAP counselors to comfort, console, provide updates and pray. Just around noon, I connected in a back hall with the head of our EAP. We said very little but shared our mutual understanding of the magnitude of this event and that we would partner by end of day. This connection became important as we moved through the next days and weeks.

Synopsis

Pat:

Orlando Health’s internal EAP is a small, quiet department that provides a safe place for team members to discuss personal or job-related concerns with a licensed psychotherapist in complete confidentiality. Most of our work happens in private sessions, but when a traumatic event affects an entire department, we facilitate critical incident debriefings to support the staff’s natural recovery process. We advise HR and leadership on behavioral health matters, deliver presentations when times permits and keep up with community resources. For nearly 30 years, our services have been highly utilized, and our work has always felt very meaningful by knowing that we’re helping those who help others. At the time of the Pulse event, our team consisted of three therapists and a department secretary.

Mary:

The utilization of a physician coach was a new endeavor for Orlando Health. My role was developed only seven months earlier to address physician burnout. All of my work was confidential and most physicians had yet to be exposed to the resource. Up until the time of the Pulse event the purpose of a physician coach/counselor was to provide support and training in such areas as leadership, communication and conflict resolution. My role expanded dramatically after the Pulse tragedy.

Preparation

Pat:

Our EAP counselors were seasoned at working with the symptoms associated with traumatic events including shock, grief, and anxiety, and we knew how to address symptoms of PTSD, albeit within the short-term EAP model. We’d debriefed hospital teams for well over 20 years and had been trained and experienced in the use of psychotherapeutic “power tools” to rapidly ease mental and emotional distress (Energy Psychology and Rapid Resolution Therapy.)  In minor ways, we’d participated in Hospital Incident Command exercises over the years, and we’d already created an EAP Crisis Response Plan for a “grab-and-go” response. But this Pulse shooting was beyond anything we’d ever seen.

Mary:

There was no preparation in the role of physician coach. It was my previous training as a clinical therapist in crisis intervention/PTSD that allowed me to respond. The understanding of long-term effects of trauma and how to mitigate were crucial. I had researched topics such as emotional exhaustion, depression and burnout among physicians in preparation for taking on the role of coach/counselor. This step would prove invaluable even at the one-year anniversary of the Pulse tragedy.     

Response

Pat:

Timing may not actually be everything, but it’s pretty critical when you’re trying to provide effective behavioral health support after a highly traumatic event. Our impulse was to be there for as many team members as possible within the first 24 to 72 hours to help lessen any lasting psychological effects from this MCI.  We knew that people would need witnesses for their emotional distress, support for their recovery process and ideas on how to heal.  However, the realities of scheduling debriefings for a 24/7/365 workforce with its shift changes, varying work schedules and different levels of need was not a simple process -- at least not in the first few days.

Day 2: We started facilitating “open” debriefings called Team Member and Physician Support Groups for anyone who, regardless of role or department, wanted to connect with others to talk about what happened, to share reactions and to express concerns.  Our  hospital’s physician coach, who had decades of clinical experience, instantly allied with our team and helped facilitate these debriefings every two hours, around the clock for a 24-hour period of time.  As debriefing facilitators, our jobs were to hold the space in which people could talk about how stunned they felt, how angry they felt and how scared they felt in a world where massacres were happening more frequently. We fostered conversation about how to regroup psychologically.   

I continued checking in with key department managers to find out how their teams were doing and got responses that fell along a continuum from “Yeah, this really hit us hard and we want to bring you in” to “We’re fine, thanks, this is just what we do.” Really? A hundred people were just shot next to our hospital, half of them died, the other half were in our hospital; we thought there’d been an active shooter inside the hospital; police, FBI, media and family members were crawling all over the place; and helicopters were still hovering overhead. It felt as though the modern understanding that psychological support really can help reduce long-term effects was bumping into the bravado of certain groups. So I knew that I’d have to find another way to offer these particular groups well-deserved support.

Day 3:  Our EAP counselors and some of our HR professionals began calling the managers of our behind-the-scenes departments such as telecommunications, patient transporters, patient access and the blood bank to find out how their teams were doing.  We also checked in with our other hospitals to identify any critical needs that they might be having, and it eased our minds to know there were chaplains at each site to provide some needed up-close-and-personal care.  

Days 3-9: Our debriefing schedule downshifted to four open debriefings a day, including times for those on night shifts, and we began facilitating department-specific debriefings (as opposed to those that could be attended by any team member).   

To reach the thousands of team members who didn’t attend debriefings, we sent out corporate-wide messages that acknowledged what had happened and the different ways that this MCI was likely affecting our Orlando Health work family.  We offered individual sessions at the EAP and sent out educational materials through our intranet on such topics as 1) normal reactions to a traumatic event, 2) the need for self-care in the healing process and 3) tips for managers on helping their teams after a crisis.

It wasn’t until day 5 that our ORMC ED/Nurses were ready to talk. More than 30 members from this team gathered to discharge wave upon wave of shock, sadness and tears. They got real. For two hours, they told stories about what they’d experienced in the ED that night, they comforted one another, they shared such deep respect for one another, and they even allowed for an occasional wave of laughter to dilute the emotional intensity of the conversation. This team’s willingness to connect so profoundly with one another made for a remarkable, perfect debriefing, and I left in awe that such people existed.

Days 10 – 13:  We were still providing 2 debriefings per day, knowing that some folks needed more time before they were ready to talk. Outside counselors, who had been brought in to supplement what our own team could offer, continued to sit in HR offices and classrooms to provide drop-in sessions. They also helped by debriefing outlying areas within our system, and we appreciated their contributions.  

We sent out more system-wide messages that addressed Grief and Loss as well as the subject of PTSD which, though not formally diagnosed until three months after a traumatic event, was a topic that we felt team members should understand. 

Day 14:  By the two-week mark, the statistics that I kept regarding the collective efforts of our EAP, our physician coach and our chaplains showed that we’d provided 44 debriefings and supported nearly 1,200 team members with some form of direct contact (not including individual EAP counseling sessions).

1 Month:  We tried offering weekly support groups for those who had been more directly affected by the MCI — perhaps because they’d been regulars at the Pulse nightclub or because they’d lost someone dear to them, but by this time people really just wanted individual sessions.

6 Months and One Year: On these anniversary dates, we sent out EAP messages reminding people that we were there for them should the dates trigger emotions that were related to June 12, 2016.

Mary:

The first few days following the trauma, I partnered with EAP to provide open debriefings. Knowing that most physicians would not be comfortable in a group setting, I walked the ICU, ED and other locations to “randomly” meet physicians. This allowed for spontaneous conversation and an acknowledgment of what they had just experienced. My overriding question was, How do I minimize the likelihood of PTSD for the physicians and the residents? The six senior emergency medicine residents had all been working the night of June 12. This group was especially vulnerable due to limited experience. My direct communication with the heads of trauma, emergency medicine, surgery and graduate medical education served two purposes. It enabled coordination of individual and group debriefings, and allowed the physician to share his/her own response to the trauma in a confidential and informal setting. I brought each group together to debrief and just be together over the next six days. The initial small group was on day three. The physicians and residents were reticent to share. It was too soon. The physicians were coming off adrenalin. I used this information to set the timing of all future debriefings. 

Physicians are scientists, they are trained to respond to the needs of others and compartmentalize or deny their own emotional wellbeing. At 7:00 am on day five, every resident from trauma, EM, surgery and ICU were gathered together on the insistence of the department leaders following my recommendation. Physicians from all areas of the hospital were also in attendance. The room filled to almost 80 individuals.  The only non-MD present was the CEO of the health system.  I had been in continuous contact with him and the COO as plans developed to support all physicians. He felt it important to show support to this most impacted group and to thank them personally. The debriefing was scheduled for one hour, it lasted for two. The session started slowly. The residents were reluctant to speak in front of the attending staff. Those who spoke described what they did, but not how they felt. I needed to take a different tact.

 This group was not at all similar to the multitude of team member groups I had been facilitating. Then I asked the questions: What about your families? What about leaving them and putting yourself in harm’s way? How do you think they felt? This line of questioning opened up a flood gate. The head of surgery shared first and then one by one each attending opened up. It was the courage and openness of these leaders that allowed the residents and fellows to begin to share. Themes included shock, fear, anger, frustration and guilt. The physicians were overwhelmed with guilt. I didn’t do enough, I couldn’t save my patient because…, I wasn’t allowed to come in and help, I didn’t call my loved one etc. These feelings of guilt resonated for each physician I met subsequent to the group debriefings.  At the conclusion of the gathering, one of the senior trauma surgeons insisted that each resident select a buddy. He charged them with taking care of each other, being available, checking up on each other. I continue to use this model today when working with program directors and chiefs.

As the days and weeks went on, I met with physicians and physicians in training individually, sometimes twice a week. I continued my contact with physician leadership through email, text and phone conversations that lead to continuous referrals. Making my role as coach accessible to all the physicians was important and much less threatening than the hospital providing a therapist or counselor.  

The media presence was overwhelming and permeated the entire physical campus. Physicians, fellows and residents were being hounded for comments, details or just to say anything to media outlets. I knew the local and national media attention could become a hindrance to recovery. My continuous recommendation to administration was to not over expose the doctors. The senior leadership responded well to the recommendations. Specific physician leaders were identified as spokes people to interact with the media, and all others were asked to decline comment. As the weeks went on, requests for speaking engagements nationally did not slow down. The concern expressed by some physicians was somehow they might cry or show emotion. This need to “stay strong” allowed some to express to me what they were feeling and this better prepared them for their presentations. I would talk with physician leaders about how to prepare for talks and encouraged them to never go without a “buddy” to support them. This same strategy was shared with administration as they prepared to share lessons learned with other health systems.

On the six-month anniversary of the Pulse tragedy, I partnered with the chief of the medical staff to provide two sessions open to all physicians and team members. It was important that an identified leader of the medical staff share his story. He was not present the night of the Pulse shooting. His theme for the sessions was “we were all there” because those present couldn’t do what they did if the others didn’t do what they did on a daily basis. This theme of selflessness, compassion and unity went a long way in healing our community and mitigating the feelings of guilt.

The one-year anniversary was themed “resilience.” The hospitals held ceremonies and small gatherings. As physician coach, I reached back out to many of the physicians most affected by the events of June 12, 2016. Most were doing well, but some I was still supporting.

Lessons Learned

Pat:

• Persist in your efforts to provide support for the departments hit the hardest by a mass casualty event such as the ED, Surgery, Trauma/ICU and Security teams. These hardy souls can make it look like they’re OK after the initial wave is over, and varying work schedules may make it hard to pull the teams together, but don’t accept the first “we’re fine.”Sometimes it may simply take time for them to decide they really do want some support. Make repeated efforts to be there when they’re ready, and if a debriefing is provided, follow up with them a few days or a week later.
• Ask managers to help identify those who are suffering the most acute stress. Don’t overlook team members who had to perform in ways outside of their normal job descriptions. What about the ED patient business representative who had to hold pressure on a victim’s wound until a physician or nurse could step in?
• Use both “open” and “department-specific” debriefings. “Open” debriefings can work well for those not directly involved in the crisis response or who may want immediate support.Certain departments, however, really warrant “department-specific” debriefings so they can talk privately about the experiences unique to their group.

  It is imperative to maintain complete confidentiality for all debriefings in order to maximize psychological safety, and we always held that to be sacred. We found, however, that while the groups wanted their individual reactions to be kept confidential, they often wanted their concerns and worries as a group to be shared with leadership.  With the groups’ permission and with the assurance that no individual speaker would ever be identified, we passed along their concerns – such as the desire for enhanced security measures to reduce future vulnerabilities.

• Remember those who work in behind-the-scenes departments.A couple of weeks after the shooting, I was called in to debrief the group that does medical coding. They’d had to read some pretty horrific notes about the wounds sustained by the Pulse victims and about the clinical care that was provided. It’s not hard to see how this kind of exposure could create a form of secondary trauma, so I gladly spent time with this team.

• Include the use of psychotherapeutic “power tools” in your repertoire.I’ve mentioned that ours included Energy Psychology, an evidence-based tool, and Rapid Resolution Therapy. These tools can rapidly deactivate the disturbing emotions connected to specific thoughts, memories or images.On several occasions, when I saw that a team member was physically shaking from the experience, I lightly held neurovascular points on his or her head (an energy psychology technique), with permission, to restore a sense of calm. A female team member told me after I’d gently placed by palms on her head for 5-6 minutes, “I feel normal again.” This was usually done in private settings. EMDR and several other approaches also are effective.
• Find creative ways for team members to express their emotions. We recommended that HR put up poster boards on which team members could stick post-it notes that expressed thoughts and feelings about the event. Emotions carry a vibrational resonance that needs to be released in multiple ways, and this provided yet one more way for people to do just that.
• Use different forms of support for different groups. Not everyone wants to talk with a counselor or attend a debriefing. We get that. Some people want to gather and pray, others want to chat in a hallway and others just want to be left alone. Our security team kept telling us, “We’re OK.” These guys had been front and center in a dangerous crisis, but said they didn’t want a debriefing. So I decided that every time I entered or left one of our hospitals, especially ORMC, I’d introduce myself to the security officer(s) guarding the doors and linger and chat for just a little while. I simply wanted to provide another layer of attention and appreciation for this important team, and I hoped that our chats would offer an informal way to swap stories. They’d been through a lot.
• Advise your HR team. Other than leadership, this is the group that’s most dedicated to hiring, educating and cultivating of your hospital’s most important resource – its workforce. They’re often the first people in contact with department managers, so stay closely connected with them and provide expertise on behavioral health matters.
• Identify outside behavioral health resources in your community, in advance, based on reputation.Look for those with experience and skill in crisis management.
• Be there for the long haul. People heal in phases and the reverberations from a major catastrophe can resonate for weeks or months. Send out periodic messages acknowledging the reality of what happened and remind team members that the EAP will continue to be there when needed. These messages will taper off with time.
• Debrief the de-briefers. Debriefers can soak up a lot of intense emotions from the many groups with whom they spend time. They, too, need a chance to decompress.
• Have educational handouts ready in advance. In my next life, I will be a brilliant writer. Looking back, I can see that the educational handouts I thought I’d polished up reflected signs of sleep-deprivation and split-screen attention.Work on them ahead of time.

Mary:

• Acknowledge that physicians respond to a crisis differently. Be available, accessible and confidential in all contacts.
• Utilize the established physician leaders within the organization, including the residency training program directors, to access physicians at all levels and specialties following a crisis.
• Be patient and allow time for physicians to seek confidential support in a form that works best for them. This may be six months or a year later.
• Be able to provide immediate referrals to an external therapist. Have the referral relationships established and notify those on the list that they need to respond quickly.

What We Changed

Pat:

Our EAP Crisis Response Plan evolved into one with more details and more phone numbers for key people. Though no two critical incidents are ever the same, we’ve got the key elements of our response plan pulled together in one place and can re-order these elements as needed: questions regarding details of the incident, primary goals and the different forms of support we can provide. We have even more contact information for leaders, HR, key managers, chaplains, behavioral health professionals and others (such as who to call to arrange rooms for debriefings). These plans are kept in the trunks of our cars so they’re always at hand.  There’s a deeper partnership between our physician coach and the EAP, and we know that we will work in tandem when there is a need within our healthcare system.

Conclusion

Pat:

Throughout history, when humans strategized about ways to deal with impending danger or how to recover from disaster, they likely focused on things such as improving defenses and stockpiling supplies. While these are critical elements, we now understand that they’re not enough. Our strategies also must include plans for helping the human heart to heal. This is no longer just a poetic notion, but a very real priority if people are to make the best recoveries possible. There are no perfect plans for providing psychological healing, and we still have much to learn about this dimension, but it’s important to elevate its importance within your broad Crisis Response Plan.  Enlightened executives at Orlando Health immediately grasped the psychological fallout from this tragedy and fully supported the allied efforts of our EAP and our Physician Coach. They wanted as much care as possible for the team members who’d responded with such brilliance and heart to this Pulse shooting. May you never have to endure such a painful event, but should one occur, know that your teams will always remember the attention and care that you provided not just for their safety and not just for strategies to carry on in the face of unexpected difficulties, but how you cared for their hearts after the smoke clears.   

Key Takeaways

• You may be called upon to provide behavioral health support for a large, organizationally complex hospital system on a moment’s notice. Make sure your EAP has a “grab-and-go” EAP Crisis Response Plan that’s ready and updated with current contact info for key people in your organization. Your EAP will need to multi-task and connect with a lot of people in a short period of time.
• Influence physician culture to recognize that they will be affected and that they deserve and need support in forms that work for them. Continue to educate and maintain a working relationship with physician leaders, and stress accessibility and confidentiality.
• Be able to toggle back and forth between the big-picture needs of a large organization and the individual and departmental needs of those most acutely affected by the event.