This annual report summarizes the history and activities of the Critical Incident Stress Management (CISM) Program at American Medical Response from 2005 to 2015. It provides an overview of the program's origins in 2005 in response to a contract requirement. While initial training was provided to staff, the program became dormant after 2010. In 2012-2013 discussions began about restarting the program. In 2014, the current program was launched with a coordinator appointed to develop the program and provide CISM services to staff in 4 counties. The report acknowledges those instrumental in developing the current program.

1. American Medical Response
Critical Incident Stress Management Program
2014-2015 Annual Report
Serving Clark, Cowlitz, Clackamas, and Multnomah County Operations, Communications, Special
Services Division, and Special Teams
June 1, 2015
Prepared by:
Bill Lang, B.A., Paramedic, CISM Coordinator

2. Introduction
This First Annual Report of the Critical Incident Stress Management Program which has been in
service since March 17, 2014, provides a history of the CISM Program activities which began in 2005,
a statement of the mission, goals, and objectives of the program, a description of the current program,
a Mock CISM Activation Scenario, an Action Log spreadsheet documenting the actions taken by
those involved in the Program accompanied by a Glossary of terms and abbreviations, and a summary,
as well as components for future development within the program. Pertinent guiding documents
and photos are included with the report as an aid to understanding how the program functions.
Please note that any mention within this report of American Medical Response (AMR) is in reference
to the Company's Operations located in Multnomah and Clackamas Counties in Oregon as well as
Clark and Cowlitz Counties in Washington State. This Program currently has no formal function in any
other operation within American Medical Response.
Acknowledgements
Recognizing that CISM is a community effort, developing and maintaining a meaningful program is dependent
upon the support of everyone in an organization. Along the journey to this first anniversary a number of folks
have been generous with their time, effort, personal skills, and moral support. Therefore, I would like to
acknowledge and thank the following people: Pontine Rosteck, former Clinical and Educational Services (CES)
Manager, who had the vision to include all four counties in the bargaining unit in the original CISM Program
back in 2005; Randy Lauer, General Manager for AMR NW Oregon and SW Washington, who took the risk of
allowing a street medic to function as coordinator of the program and secured the funds necessary to get the
project off the ground; Paul Priest, Director of Operations in Multnomah and Clackamas Counties, who gave
approval for providing catered lunches at team meetings, shift coverage for team meetings and pre-incident
education presentations, and office work days for the coordinator; Liz Upton, Administrative Assistant for
Multnomah and Clackamas County Operations, who instigated and arranged to have meals provided for the
CISM Team during meetings and reserved meeting space; The folks at the International Critical Incident Stess
Foundation (ICISF), who, having weathered misunderstanding of and opposition to their mission as well as a
recent economic downturn, have provided a template for this program and helped locate our course instructor;
Tim Dietz, Licenced Professional Counselor (LPC) and Recognized ICISF Instructor, who skillfully got the
CISM Team off to a strong start with his steller course on crisis intervention and peer support, and his pointing
Drew Prochniak in our direction; Drew Prochniak, LPC, who has been generous with his time and moral support
of the program without which the program would not exist. Drew has ridden with crews on his own time and
even shaved his beard in order to be fit tested; Tifphany Hofstetter, Paramedic, who endured long hours sitting in
the ambulance listening to my half baked ideas and rantings, edited several defining documents for the program,
and provided valuable feedback throughout the months leading up to the lauch of the program; Melody Lang,
my wife and best friend, who has endured my ranting, mood swings, and interruptions and continues to believe
in this project. Ultimately, the back bone and worker bees of this program are the members of the CISM Team:
Jeff Beck, Lori Moorison, Nicole Beaulaurier, Alice' Hall, Julie Bolt, Mark Jones, Ed Palmer, Gary Laurent,
Aaron Botteron, Mary Watson, Derek Stekhuizen, Jody Caprino, and Lewis Coleman. These are the people who
face the same perplexing situations in the performance of their duties as the peers they seek to support. The peer
counselors are exposed to all of the same critical incident stress, cumulative stress, and the stresses of their
personal lives all the while making themselves available to their peers when the chips are down. The program
exists because they said 'yes' to providing this service. These team members are among my favorite people
in the whole world. Thank you..... and be safe.

3. A History of CISM at AMR
In March of 2005 Pontine Rosteck, Clinical and Educational Services (CES) Manager, was
given the responsibility for establisihing a CISM Program at AMR. The motivation for this
was a stipulation in the renewed Clark County, WA Ambulance Service Area (ASA) contract
which required AMR to have a CISM Program in place for the Clark County Operation. Ms.
Rosteck decided to establish a CISM program which would serve all Operations in the
collective bargainng unit: Clark and Cowlitz Counties in Washington State, Clackamas and
Multnomah Counties in Oregon.
Ms. Rosteck recruited a number of employees to take a two day course in crisis intervention
and to serve as peer counselors in the program. Employees volunteered their time spent in the
class as no funding was made availiable for compensation. The course was held on April 21-22,
2005. A group of field employees and supervisors attended a two day course on CISM, crisis
intervention, and peer support. Sam Bradley and Leslie Simmons, EMS Supervisors from AMR
Operations in California served as co-instructors using curriculum developed by the
International Critical Incident Stress Foundation (ICISF). Those in attendance included Dale
Courson, Ken Garrett, Gary Laurent, Lindsi Huff, Bill Lang, Dusty Nichols, Lori Paoli,
Heather Tucker, Pontine Rostek, and Alice' Hall.
After this training event little organization or activity took place that the peer counselors were
aware of. The peer counselors saw little to no utilization of their newly acquired crisis
intervention skills.
On September 23, 2005 a CISM Team Meeting commenced and a Dispatch Activation Protocol
was presented as a means to provide service to the workforce. Deployment and scheduling of
peer counselors was also discussed with no tangible plan resulting from the discussion.
Ms. Rosteck convened two additional team meetings to re-establish the CISM program on July
21, 2009 and January 22, 2010. Both of these meetings focused on how to best develop and
maintain the CISM program as it continued to struggle to become a viable resource for the
workforce. Ms. Rosteck indicated that to have an employee from the field coordinate the
program may be a better option as she was finding that being in the role of both CES Manager
and CISM Program Coordinator had created a perceived conflict of interest as well as an
unmanageable work load. Additional discussion took place regarding the need to identify a
Mental Health Professional (MHP) to partner with the program for the purposes of referral and
oversight. During this time Requests For Proposals (RFP) were solicited from the Mental
Health Network (MHN), the Employee Assistance Program (EAP) vendor for most of AMR
operations across the country and from Public Safety EAP, the EAP Vendor for several AMR
operations on the East Coast. MHN submitted a proposal for full time employees (excluding
part time employees) at a cost of $12,000 to $18,750 in the first year. Public Safety EAP
submitted a proposal for all employees at a cost of $6,350 to $9,150 in the first year. It was
determined that neither proposal was feasible because neither vendor had a physical presence in
the local service area.

4. In November, 2010 Pontine Rosteck, CES Manager was laid off without notice to the CISM
Team and her position was eliminated. The leadership of the program was not transferred to
anyone else in the company. No information regarding the future of the CISM Program was
made available and the program went into dormancy.
The CISM Program ceased to function after the CES Manager was laid off. Between 2010 and
2013 this writer was asked by management, on occasion, to meet with field personnel for CISM
defusing after exposure to various critical incidents. This writer attempted to make it clear to
management that this approach was not a CISM Program and that liability was increased by
not having a partnership with a culturally competent MHP for the purpose of providing
program oversight and to receive referrals.
In 2011 and 2012, casual conversations between this writer and Randy Lauer, General Manager
for AMR in NW Oregon and SW Washington, took place in which the possibility of appointing
a field employee for the position of coordinator of the CISM program was discussed.
On June 25, 2012 a meeting was held as a 'CISM Program Development Focus Group.' Several
members of the management team including, Phil Moyer, David Barker, Dave Fuller, (Randy
Lauer was unable to attend), Frank Hiltebrand, Teamsters Shop Steward and this writer were in
attendance. A discussion took place regarding whether or not the Company would compensate
peer counselors for performance of duties while off duty. A few members of the management
team stated that this work should be perfomed on a volunteer basis with no financial
compensation. This writer maintained that peer counselors should be compensated for their
time if performing peer counselor duties while off duty for the benefit of employees and the
Company. No agreement was reached at that time. There was also renewed discussion
regarding RFPs from Public Safety EAP and MHN to design and administer a program. Neither
RFP submission appeared to be promising as neither agency had personnel physically located
in the region to effectively facilitate a program.
No further action was taken until November 29, 2012, when Randy Lauer recruited this writer
to serve as coordinator with the mission of restaring the program. This writer began writing a
program mission statement and goals, job descriptions for the position of coordinator and peer
counselor, and began a search for possible therapists in the local community to partner with the
program for MHP referral and oversight.
The ICISF provided assistance with identifying a Recognized ICISF Instructor to teach the
course entiled 'Individual Crisis Intervention and Peer Support.' Tim Dietz, Licensed
Professional Counselor (LPC), was contacted and plans were made for him to teach the course
at AMR once the CISM Team Members were identified. Mr. Dietz suggested that peer
counselors be recruited through a nomination process. Nomination forms were distributed to
the work force asking each employee to name up to three coworkers whom they would want by
their side if they were in crisis. From these nominations the top fifteen were identified. There
was a commitment to having a number of peer counselors from each county Operation and
Communications based roughly on the size of the Operation. Managers in each Operation and
Communications were contacted and endorsements of peer counselor candidates were obtained.

5. This would mean that the peer counselors on the CISM Team would be nominated by peers and
endorsed by management.
This writer spoke with numerous people from the mental health community in hopes of
identifying a therapist who would be willing to partner with the program and be (or be willing
to become) culturally competent in the realm of Emergency Medical Services (EMS). In
January, 2013 Drew Prochniak, LPC, contacted this writer stating that he was new to the area
and was setting up a practice specializing in first responder issues. Mr. Dietz had conveyed to
Mr. Prochniak of the need for a therapist to partner with the program. After several
conversations with Mr. Prochniak, an interview with Mr. Lauer, and reference checks, Mr.
Prochniak agreed to serve as the MHP resource for oversight and referral for the program.
Because there was no funding provided for retaining the services of a MHP, it was decided that
the therapist would be reimbursed through the current EAP vendor. At this time AMR had a
national contract for EAP services with MHN (Mental Health Network). The process for
establishing Mr. Prochniak on the provider network proved to be long and arduous. After six
months of lengthy telephone and email conversations with representatives from MHN, Mr.
Prochniak was finally added to the provider network. The program was one step closer to
launch with the infrastructure in place connecting employees to professional therapy. Mr.
Prochniak volunteered his time obtaining the required immunizations, fit tests, and OSHA
course work in order to ride with ambulance crews in the field. Mr. Prochniak was hosted by
crews in Clark, Clackamas, and Multnomah Counties for a first hand experience of a typical
work day in the EMS field.
The original activation procedure, written in 2005, had been adopted as a company policy. It
called for the on duty Controller and Communications Supervisor to be an integral part of the
activation procedure. Several meetings were held with this writer and Kim Earls,
Communications Supervisor, who was appointed for this task by Kevin Anderson, Director of
the Communications Center, for the purpose of updating the policy to fit current needs. At a
meeting to finalize the revised policy with Kevin Anderson, Paul Priest, Director of Multnomah
and Clackamas County Operations, Chad Heidt, Chief Operations Supervisor, and this writer
(Kim Earls was unavailable), Mr. Anderson stated that it would not be feasible for the
Communications Center to be involved in the activation of the CISM peer counselors, after all.
An alternative activation procedure was written by Chad Heidt which called for the on duty
supervisor to locate and activate an on duty peer counselor. The supervisor would contact
neighboring county Operations if no peer counselors were available in the county where the
activation was needed. If no peer counselors were on duty anywhere in the service area, off
duty peer counselors would be contacted by the supervisor.
Nominations for peer counselor were solicited from the workforce. Approximately one hundred
seventy names were submitted, tabulated and ranked, based on the number of nominations each
nominee received. Supervisors of nominees were consulted for the purpose of endorsement.
The top nominees were contacted and recruited to serve as peer counselors. The original goal
was to assemble a team of fifteen peer counselors including the Coordinator. But one nominee
withdrew from participation too close to the course date to allow for recruitment of an

6. additional nominee. The charter members of the CISM Team include: (Paramedics) Jeff Beck,
Cowlitz; Alice'Hall, Clark; Lori Moorison, Clark; Julie Bolt, Clark; Niccole Beaulaurier, Clark;
Gary Laurent, EMS Supervisor; Aaron Botteron, Multnomah; Ed Palmer, Multnomah; Mark
Jones, Multnomah; Bill Lang, Coordinator; Jody Caprino, Clackamas; Lewis Coleman,
Clackamas; Derek Stekhuizen, Clackamas; (Emergency Medical Dispatcher) Mary Watson,
Communications; and (MHP) Drew Prochniak, LPC.
Once the CISM Team members were identified the 'Individual Crisis Intervention and Peer
Support' course was scheduled. This writer spoke with Tim Dietz, LPC, Recognized ICISF
Instructor, about the uniqueness of EMS personnel employed by a private sector ambulance
service. Mr. Dietz designed a course which was received with great enthusiasm by those in
attendance. The two day course was held in the training room at the AMR Multnomah County
Operations Center on March 10-11, 2014. A catered lunch was provided by Paul Priest,
Director of Multnomah and Clackamas Operations. Drew Prochniak, LPC was present for part
of the course and made a presentation on the nature of his practice and his role within the
program.
The program went live on March 17, 2014. During the first year of operation the program has
enjoyed anectdotal wide spread acceptance. Peer Counselors have been activated by
supervisors, have self activated when indicated, and have been contacted directly by coworkers.
Peer counselors have addressed critical incident stress, cumulative job stress, and have assisted
coworkers with personal problems.
Drew Prochniak, LPC obtained the required OSHA training and fit testing of personal
protective equipment in order to ride with on duty crews. Mr. Prochniak rode with crews on
four occasions in Clark, Clackamas, and Multnomah Counties during the first year of service. A
number of employees have benefited from professional counseling offered by Mr. Prochniak
via peer counselor referral.
Pre-incident education was provided during the first year of service in several ways.
Presentations on CISM were made to new employees during New Employee Orientation and to
the River Rescue Academy by Aaron Botteron and this writer. Lucie Drum, Community
Education Director and Public Information Officer for AMR, wrote articles introducing the
program to the workforce. These articles were published in “The Parascope,” AMR's monthly
newsletter.
In October of 2014, this writer received the 'EMS Commitment to Quality Award' from the
EMS and Trauma Systems Section of the Oregon Health Authority at the Oregon EMS
Conference in Salem.
In December of 2014, it was discovered that AMR had discontinued its' national contract with
MHN and established a new contract with Public Safety EAP to administer the Company's
EAP. This created an unexpected challenge as the process of having Mr. Prochniak accepted on
the new provider network needed to be expedited so as to not have an interruption of benefits to
employees. The situation also created additional work communicating the changes in access to

7. EAP services to the workforce.
In January of 2015, the 'EMS10 Innovation in EMS Award' was received from the Journal of
Emergency Medical Services/Physio Control at the EMS Today Conference in Baltimore, MD.
An article about the program was published in JEMS magazine in March, 2015. Since then,
several collegues in EMS from other regions of the U. S. have contacted this writer expressing
interest in the program.
On January 27, 2015, this writer made a presentation on the CISM Program and participated on
a Q and A panel at the Peer Support Conference in Salem which was sponsored by the Oregon
Patient Safety Commisssion.
Two team meetings were held during the first year providing continuing education, program
development, and team building. This writer occasionally publishes the 'Hug Squad News,' a
newsletter for the CISM Team. It is limited to one page and is distributed to the CISM team as
an email attachment. It's purpose is to communicate with team members in a way which is
tangible yet brief. It's byline is: 'News and continuing education for the AMR CISM Team.' A
joke is included in each issue to remind team members that humor is an important part of
maintaining good mental health.
The Program continues to evolve through the experience of trial and error as efforts are made to
develop, maintain, and make accessible the primary components of CISM to a large,
geographically dispersed workforce functioning within several distinct operational units.
Program Mission
The mission of the CISM Program is to provide crisis intervention and peer support, access to
culturally competent Professional Mental health services, and critical incident and cumulative stress
education for Emergency Medical Services (EMS) field, communications, and management personnel,
as well as their family members/significant others.
Program Goals
The program shall assist employees in the management and reduction of the negative effects of acute
psychological stress due to exposure to critical incidents and cumulative stress due to chronic exposure
to generally stressful situations encountered in the EMS work environment.
The program shall provide education for EMS field employees, Communications employees,
Management, and their family members/significant others on the subject of critical incident stress,
cumulative stress, symptomology of stress, and strategies to manage stress.
The program shall provide barrier free access to culturally competent professional mental health
services.

8. Program Objectives
The program shall develop and maintain a CISM Team which includes representatives from
Operations, Management, and Communications, a Program Coordinator, and a Mental Health
Professional. This team shall be trained in crisis intervention and peer support using curriculum
developed by the International Critical Incident Stress Foundation. Team members shall be identified
by soliciting nominations from the field, communications, and management followed by endorsement
from management. Team members shall be available while on duty to offer peer support and defusing
of critical incidents. The CISM Team shall meet at least semiannually for the purposes of professional
mental health oversight, continuing education, and mutual support.
The program shall be led by a coordinator who will provide program development and administration
as well as moral and educational support for the CISM Team.
The program shall develop and maintain a formal relationship with a Licensed Mental Health
Professional (MHP) in the community of service who shall be (or become) culturally competent and
shall be identified as a provider in the Company's EAP for the purposes of reimbursement. The MHP
shall be given the opportunity to participate in ride alongs in the field and shall have access to
Company facilities.
The program shall develop and present Pre-incident Educational opportunities for employees via New
Employee Orientation and other continuing education venues offered by the Company.
The program shall develop specialized support services for employees who are veterans of the military
in conjunction with the Veterans Administration.
The program shall develop specialized support services and educational opportunities for family
members/significant others of employees in the understanding and management of critical incident and
cumulative stress.

9. Program Design and Features
Critical Incident Stress Management (CISM) is a program which enables EMS personnel to effectively
manage acute stress and cumulative stress associated with the EMS work environment. EMS personnel
encounter incidents which are out of the ordinary and generate an unusually high level of stress. How
one responds may affect how well one functions as an EMS professional and in one's personal life.
Historically, EMS personnel have experienced a high incidence of failed relationships, early career
burnout, and changes in personality which correlates with the experience of having one's coping
mechanisms overwhelmed by critical incident stress and cumulative stress. While CISM is not a cure
all, it is hoped that by establishing a functioning program, EMS personnel can assist each other. Critical
incident stress and cumulative stress can be considered the byproduct of the EMS environment. It is a
normal response to an abnormal circumstance. What does one do with this byproduct of managing
other peoples' crisis? It is similar to the process of manufacturing which produces a toxic derivative. If
the byproduct of manufacturing is not neutralized the manufacturer will end up with a hazmat incident.
The same could be true of the EMS profession. Without neutralization one's coping mechanisms
become overwhelmed and eventually demand one's full attention to the detriment of one's overall
mental and physical health.
The following features of the CISM Program:
 It is overseen by a Mental Health Professional (MHP). The MHP will participate in ride a
longs, be educated in the unique environment of the EMS field and be available for further
individual counseling through AMR's Employee Assistance Program. The MHP will also be
present to oversee any formal critical incident stress debriefing (CISD) meetings which involve
a group of responders. Drew Prochniak, Licensed Professional Counselor (LPC), has agreed to
serve in this capacity. Drew specializes in treating First Responder stress and comes from a
public safety family (his father is a retired police officer and his brother is a paramedic). Drew
is a Wilderness First Responder and also has a background in Search and Rescue. He was a
member with, and CISM resource for, the Southern Arizona Search and Rescue Association
before relocating to Portland.
 It is peer based. Peer Counselors (PC) are nominated by their coworkers. After completing a
16 hour training course PCs will provide initial defusing with individuals lasting approximately
30 minutes. A defusing is a more informal meeting than a debriefing which is a longer event
usually involving larger groups of responders. PCs provide emotional first aid to their
coworkers and may refer individuals to a MHP.
 It is emotional first aid. CISM is to psychotherapy what EMS is to surgery. It is not
psychotherapy and does not replace psychotherapy provided by a MHP.
 It is confidential. All CISM services are confidential and are regulated by the Healthcare
Information Portability and Accountability Act (HIPAA).
 It is credentialed. The program model and curriculum is drawn from the International Critical
Incident Stress Foundation. Related training qualifies for Continuing Medical Educational
(CME) credit.
 It is voluntary. There is no requirement to participate in the program in any way.

10.  It is accessible. Peer Counselors will be available for defusing within hours of activation.
During defusing, issues generated by the critical incident can be identified and information and
resources can be provided by the PC. Anyone can activate CISM services by calling the on duty
supervisor or by contacting a PC directly. PCs will be utilized primarily while on duty. If no PC
is on duty then an off duty PC will be contacted. Additionally, PCs can respond across county
and state boundaries. This program will serve AMR personnel in Clackamas, Clark, Cowlitz,
and Multnomah Counties as well as the Communications Center, Special Services Division, and
Special Teams.
Mock CISM Activation Scenario
Medic 51 responds to a Murder/Suicide involving a child. The on duty supervisor hears the call
dispatched (or is notified by an astute dispatcher or other personnel). The Supervisor instructs the
dispatcher to keep Medic 51 out of service after the call. The supervisor contacts Medic 51 after the call
to offer CISM services or simply keeps the crew out of service if critical incident exposure is obvious.
If a CISM Activation is indicated the supervisor refers to the CISM Team Roster to identify a peer
counselor who is on duty. The Supervisor then puts the peer counselor's unit out of service, contacts the
peer counselor and offers as much information about the incident as is available. The supervisor then
arranges for private meeting space for a Defusing. The peer counselor meets with the crew and follows
(as much as possible) the SAFER-R Model of Crisis Intervention (See the International Critical
Incident Stress Foundation for an explanation of the SAFER-R Model, icisf.org) and assists the crew
with understanding stress symptoms, making a self care plan, and referral to the MHP if indicated. The
PC provides the crew with Critical Incident Stress Information Sheet (handout) and contact information
for the MHP. The PC then offers to make a follow up call within one week. The crew and the PC decide
if the crew will be relieved of duty for the remainder of the shift or go back in service. (AMR pays out
the entire shift if the crew remains out of service after a critical incident so the crew does not suffer a
loss in pay). The PC reports the work status of the crew to the activating supervisor and reports a CISM
activation to the CISM Program Coordinator. The coordinator documents the action in the CISM
Action Log. The identities of those served are not documented in order to maintain confidentiality.

11. Summary of Action Log
March 17, 2014 to March 16, 2015
Offers of Peer Support made by Supervisor: 7
Peer Counselor Contacts with Employees: 37
Defusings conducted: 46
Follow-Up Calls made by Peer Counselors: 19
Referrals to MHP by Peer Counselors: 2 (Without additional services)
MHP Ride Along: 4
Team Meetings held: 2
Pre-incident Education provided-
New Employee Orientation Classes: 2 Classes
River Rescue Academy: 1

12. Glossary of Terms
for
CISM Action Log
Shaded fields-
Actions in Brown: MHP ride along
Actions in Grey: Actions performed before the official launch of the current Program.
Actions in Blue: Team development such as Team meetings for the purpose of mutual
support, continuing education, interaction with the MHP.
Actions in Green: Actions having to do with Pre-incident Education. Includes presentations on
CISM at New Employee Orientation, Continuing Education Inservices, and other
venues where education on crisis intervention, peer support, mental health
therapy and information about the CISM Program are presented.
Abbreviations-
LPC: Licensed Professional Counselor. One of several credentialed Mental Health
Professionals.
MHP: Mental Health Professional. Can be a LPC or other Mental Health Professional
such as a Licensed Clinical Social Worker.
MVC: Motor Vehicle Crash
MCI: Mass Casualty Incident
NEO: New Employee Orientation
Sup: Supervisor. In this case, EMS Supervisor.
PC: CISM Team Peer Counselor. EMS personnel and EMS supervisors trained in
crisis intervention. PCs provide psychological first aid to coworkers.
Ld: Lead. In this case Lead Paramedic
Code/ Ped Code: Cardiac arrest/ cardiac arrest involving a child
FF: Fire Fighter
+ symbol Indicates an additional, unrelated issue issue
TBGJ: Testify Before Grand Jury

13. Glossary of Terms
for
Action Log
Continued
SERT: Special Emergency Responce Team (Law Enforcement)
Xport: Transport by ambulance.
Terms-
Contact: When a peer counselor contacts an employee in person, telephonically, via text
or email, offering peer support.
Defusing: An informal meeting between a peer counselor and 1-4 employees for the
purpose of providing peer support, stablization, acknowledgment of a critical
incident, facilitation of understanding of stress symptoms, management of stress,
and referral to a mental health professional, if indicated.
Follow Up: Contact made by a peer counselor with an employee withing one week after a
defusing with a three part question; 'How are you doing? Better, worse, or
about the same?' Assessment for the need of additional services is made at this
time.
MHP Ride Along: When the mental health professional rides with an ambulance crew in the field
for the purpose of getting to know employees and gaining first hand knowledge
of the EMS work environment. This is an opportunity for the MHP to develop
cultural competency and for EMS personnel to understand the work and role of
the MHP in CISM.
Offer: Offers to activate a peer counselor for defusing/peer support made by a
Supervisor but the employee declines.

19. Job Description
Job Title: Peer Counselor Reports To: Operations Supervisor
Department: Operations Location: Multnomah County
Position Status: Volunteer
POSITION SUMMARY:
The mission of the CISM Program is to provide emotional and psychological support to field and dispatch
personnel as they deal with the unique critical incident and cumulative stress encountered in the Emergency
Medical Services (EMS) work environment. The foundation of the program is peer based with the guidance
and oversight of a Mental Health Professional (MHP). Peer Counselors (PC) are the first line providers of
support to employees. PCs assess, provide emotional first aid, and referral to a MHP when appropriate, and
follow up contact.
Essential Duties and Responsibilities:
1. Attend an initial company sponsored Peer Counselor Training Course (approximately 16 hours).
Employees attending the course during their regularly shift will have their shift covered by the company.
Employees taking the course while off duty will be paid at their applicable training pay rate. Training
hours for the course are included within the 24 CE hour afforded to employees through the collective
bargaining agreement.
 Attend quarterly CISM Team meetings in order to address program issues, interact with the
MHP, offer and receive moral support with other PCs, and obtain continuing education for PC skills
development.
 Adhere to the AMR confidentiality agreement understanding that any interaction with
employees in the context of a CISM activation or speaking with an employee while in the role of a
PC is protected by HIPAA confidentiality laws.
 Be available for CISM activations while on duty. This may involve making contact with
the employees in person or by phone at the PCs earliest convenience to assess the need for a
Defusing. The PC may be taken out of service from regular duties by the on duty supervisor in
order to meet with employees at a location identified by the on duty supervisor to provide a
CISM Defusing. The Defusing gives the personnel an opportunity to explore the incident and
identify stress symptoms they may be experiencing, The PC will offer emotional support, provide
information regarding the nature of critical incident stress, information on self care while
experiencing stress, and contact information for the MHP if therapy is desired.

20.  Make contact by phone or in person with employees within one week after a Defusing
for follow up.
 Make a report of the CISM contact and/or Defusing and forward the report to the CISM
Coordinator.
Minimum Qualifications:
Education/Licensing/Certification: Current EMT-Basic, EMT-Intermediate, EMT-IV/Airway, or EMT-
Paramedic License.
Experience: Minimum 3 years experience working in the EMS field or communications center.
Knowledge and Skills: Respected among peers and and in good standing with the Company. An understanding
of the unique emotional and psychological stress among EMS Personnel. Previous experience working with a CISM
program desired.

21. DATE: October 24, 2013
TO: Communications and Operations Personnel
FROM: Bill Lang
RE: CISM Peer Counselor Nominations
Nomination Form
for
Peer Counselor
Critical Incident Stress Management Program (CISM)
AMR Communications and Operations
As an AMR operations or communications employee you are invited to nominate those persons from
among your co-workers to serve as peer counselors in the developing CISM Program. The peer
counselor (PC) will be deployed generally while on duty to provide a defusing with personnel after
encountering a critical incident. A defusing is a short, informal meeting lasting approximately 30
minutes during which personnel may talk about the incident, explore its' effects, and identify symptoms
of stress. The PC may then provide information on coping skills, provide peer to peer support, and
make a referral to a Mental Health Professional (MHP) if appropriate. Keep in mind, the best person
for this role may not be your best friend or the most popular coworker. When making your nominations
consider the attributes which are needed to function effectively as a peer counselor. The persons you
nominate will be considered for the position of Peer Counselor based on the following skills and
attributes:
- Effective listening skills - Respected among coworkers
- Trustworthiness - Maintains confidentiality
- Dependability - Respects privacy
You are encouraged to nominate up to 3 individuals.
My nomination for CISM Peer Counselor: 1.__________________________________
2.__________________________________
3.__________________________________
My county of employment:___________________________________
Hard copies of nominations can be sent via interoffice mail to Bill Lang at Multnomah County AMR
Operations or sent via email to william.lang@amr.net by November 25, 2013.
MEMORANDUM

22. CISM Program
Peer Counselor Activation Procedure
The purpose of the CISM Program is to provide peer support and professional mental health follow up
for employees experiencing critical incident and cumulative stress. The goal of the program is to
restore employees to full functioning both personally and professionally.
Please utilize the following procedure when you encounter employees who are experiencing critical
incident stress or cumulative stress. This procedure facilitates a private, confidential meeting with a
peer counselor away from work responsibilities for the purpose of defusing critical incident and
cumulative stress symptoms experienced by employees.
 Place affected crew out of service.
 Review your county system status level and peer counselor list to determine if you will be able
to utilize an in County peer counselor.
◦ If you are able to spare the resources and have a peer counselor on duty, notify the peer
counselor and give as much of the call information as you can. Determine if a follow up
phone conversation is needed or if both crews need to be placed 10-7 for a defusing.
◦ If you are unable to spare a peer counselor resource or do not have one on duty, please
contact the duty supervisor or your sister operations to locate an available peer counselor.
◦ In the event there are no on-duty peer counselors available, please contact off duty
members to see if they are available to assist.
 If a face to face defusing is required, please arrange for a safe and private place for this to
occur.
 Please e-mail your supervisor team, including Operations Chief and Manager as well as the
CISM Coordinator. This e-mail should include the following.
◦ Incident classification, IE: Ped Code, Homicide, MCI, etc.
◦ The affected employees.
◦ The peer counselor assigned.
◦ Time you were notified.
Additional Guidelines:
These matters are confidential and our crew members should be effectively treated as patients as it
pertains to their protected health information.
Often those affected will not be able to return to work. You should make appropriate staffing
accommodations accordingly.
Only those directly involved in the incident and the Peer Counselor are to be present during the
Defusing.

23. Hug Squad NewsNews and Continuing Education for the AMR CISM Team
March 2015 Vol. 1, No.6 Bill Lang, Editor
[The following is part 2 of a study researched and written by Aaron
Botteron, PC, FTO Paramedic, Scholar in Residence :-) with the CISM
Team. He posted the following article this past Fall and I am just now
getting around to publishing the newsletter]
Part 2: First Responder Stress by Aaron Botteron
I need to apologize for my long hiatus. I have been on deployment
to multiple wildfires and just recently got home. Okay, we left off
on activation of the HPA axis.
As the initial surge of adrenaline and noradrenaline
subsides, the hypothalamus activates the second component of the
stress response – known as the HPA axis. This network consists of:
hypothalamus, pituitary and adrenal glands. The HPA axis relies on
a series of hormonal signals to keep the sympathetic nervous
system activated. The hypothalamus releases CRH (corticotropin-
releasing Hormone), which travels to the pituitary gland, triggering
the release of ACTH (Adrenocorticotrophic Hormone), which
travels to the adrenal glands, prompting the release of cortisol. This
is a complicated process, but the main theme involves the release of
cortisol (nicknamed the “death hormone”).
One distinctive feature of a hormone is that they
regulate their own secretion through negative feedback inhibition.
After enough cortisol is released, and the threat is no longer
perceived, cortisol binds to the glucocorticoid receptor (GC) in the
pituitary and hypothalamus, essentially turning off the HPA axis.
Now in moderation cortisol is essential to the maintenance of
homeostasis, but with prolonged exposure we see negative affects.
Essential maintenance of: Negative prolonged
exposure:
2. Regulates blood
sugar
3. Impaired cognitive
function
4. Gluconeogenesis
(metabolism)
5. Dampened thyroid
function
6. Immune function 7. Decreased bone
density
8. Anti-
inflammatory
9. Sleep disruption
10. Regulates blood
sugar
11. Decreased muscle
mass
12. Heart and blood
vessel tone and
contraction
13. Elevated blood
pressure
14. Central nervous
system
activation
15. Lowered immune
function
16. Slow wound
healing
17. Increased risk of
MI and CVA
18. Worsening
depression and high
risk behavior
*These two columns are pivotal to understanding first responder
stress and the long-term consequences of the stress response.
Remember when Tim Dietz discussed “stealth mental health” and
screening for the 2% of our peers…these are the symptoms we need
to educate ourselves on as PCs (peer counselors) “mental health
exposure”.
Cortisol (glucocorticoid (GC)) is liposoluble and easily
cross the blood-brain barrier. Three of the most important brain
areas containing GC receptors are the: hippocampus, amygdala and
frontal lobes. One of many problems with prolonged cortisol
involves the over-stimulation of neurons. When over-stimulated,
calcium is released through channels in their cell membrane. This
over-firing is seen as a dangerous malfunction, therefore the cells
shutdown to avoid death due to over-stimulation.
In the next column we will discuss how cortisol affects
PTSD, anxiety, depression, long-term potentiation (LTP) and
flash-bulb memories (FM).
Spotlight On The SAFER-R Model
Previously, we highlighted the first step in the SAFER-R Model of
Crisis Intervention- Stabilize: 'Introduce defusing, meet basic needs.' In
June we looked at the second step which is Acknowledge: This is where
the PC acknowledges the event with the effected personnel and
encourages the personnel to talk. Then we explored what is meant by
Facilitation of Understanding: Normaliziation. In this phase we may
actually do some talking as a PC. We can speak about how what they are
experiencing is a normal reaction to an abnormal circumstance
In this issue we will examine the fourth step: E: for Encourage
Effective Coping (Mechanisms of Action). If you can't think of anything
to say refer to the 'Things To Try' section of the Critical Incident Stress
Info Sheet. Examples are: rest, exercise, healthy diet, talk, etc. Encourage
folks to not make any big decisions until their stress symptoms subside.
Remind them that healing does not take place rapidly and patience with
themselves and their situation is important.
Team Meeting
We are working on a Team Meeting for March. March 17 is the 1
year anniversary of the program being in service. We look
forward to celebrating this momentous milestone on or near to
that day....appropriately, of course...with case review, a
presentation from Drew Prochniak, LPC, and.....lunch.
A Joke For the Road: What did the Minnesotan say to the
Pillsbury Doughboy? “Hey, man—nice tan.”

25. “Happy Birthday Peer Support”
Drew Prochniak, LPC, presents a cake to the CISM Team at the team meeting on
April 22, 2015 celebrating the first year of service.

27. This photo was taken on the second day of the Individual Crisis Intervention
and Peer Support Class held at Multnomah County Operations on April 11,
2014. The term 'Hug Squad' was originally coined by Carl Lemmon,
Paramedic, during a light hearted conversation about the Program. Can EMS
personnel more comfortably 'embrace' CISM/Peer Support using a humorous
term such as 'EMS Hug Squad?' Time will tell.