situation. Consequently, the data reflects the
targeted emergency, the fire, the hurricane, the
mine explosion, the flood, the earthquake, etc.
Many emergency workers are exposed to a
number of emergencies over time. Follow-up
research is needed on these individuals and
groups of workers who have been exposed to a
number of emergencies within a specific
timeframe. In fall, 1999, the eastern United
States experienced a series of hurricanes, which
included loss of life and extensive pre and post
preparation activities and cleanup. In addition, in
the late summer and fall of that year, earthquakes
followed by after-quakes in Turkey and Taiwan
created devastating loss of life and injury.
Research with these workers, exposed to the
reality of numerous hurricanes and earthquakes
could provide information about cumulative
effects on the emergency worker.

Is there a difference in the emergency worker
response to an unintentional (natural) disaster as
opposed to an intentional disaster (terrorism)?
We have developed specific tools for specific
disasters, for example hurricanes. With
sophisticated technology, we can predict the
path of a hurricane, not perfectly, but well
enough to alert potential target areas. There are

reventative activities we can engage in with
Furricanes, such as boarding up windows,
Preparing food and shelters for the population,
and developing plans for evacuating the
population. We have some control of the
outcome.

There are more limited tools in the prediction
of earthquakes. With both earthquakes and
hurricanes, the major activity is clean up and in
some cases rescue. We have studied fire behavior
and developed innovative equipment that can
assist the fireman in planning strategies to help
control the blaze. Fire protective clothing and
special tools help the emergency worker access
victims and save lives. We have developed
certain technologies and strategies that, though
incomplete, help control the emergency environ-
ment and provide the worker with tools.

But, what of emergency environments that are
intentional, terrorist caused emergencies? Do we
have any control in these situations? Do
emergency workers approach a terrorist situation
differently than an earthquake? We presently
have limited tools to support the emergency
worker in these situations. This is an area of need
in exploring issues in the safety and health of
emergency workers.

Finally, the future must provide a forum for
the sharing of information. As emergency
environments, both natural and_ intentional,
appear to be increasing worldwide as the new
millennium begins, a multi-disciplinary, inter-
national, problem solving, information-sharing
approach is warranted.

The Social Environment 4

The social environment is becoming more and
more intertwined with technology. While much
technology is directed toward production, a
significant portion has been developed to meet
increased health and safety demands, The
performance of these technologies will be hardly
tested in the real world, and their impact on
human/machine and human/human interaction !
will probably not be assessed at all.

As emergency technology and_ personal
protective equipment become more. sophisti-
cated, real-world assessment becomes critical.
That is because each innovation, as it is

‘introduced, gets placed in a social system that

has developed a comprehensive set of formal
and informal rules about how to behave in
certain situations. The adoption of new tech-
nology may allow behavior that has heretofore
been prohibited, for good reason. For instance,
members of a mine rescue team are tethered to a
line. Durit explorations of smoke-filled
entryways, they follow a rigid search protocol.
Recently, however, imaging technology that can
allow at least one member (the captain) to see
through smoke has become available. It is now
possible for a member of the team to release
from the line and, ignoring protocol, go directly
to a victim. As might be asamed, rules for the
proper use of an imaging device are currently
tinder debate.

In order to provide guidance in debates like
the one above, scientists will need to employ a
socio-technical systems perspective to focus
upon variables that are relevant to the design
of emergency work systems. This implies the
application of a systematic methodology to
organization/machine interactions before and
after the technology is introduced. This
approach would concentrate not only on how
things function under normal circumstances, but
should also recognize and address dysfunctional
elements in a system.

The Technological Environment

Many accidents attributed to ‘human error’ may
be due to design features that did not adequately
account for ‘how humans respond. In other
words, a given technology can function perfectly
within its design parameters and still xil people.
Automobile air bags are an example. In the
future, more attention should be paid to how
design parameters are set. The place to start with
this investigation is with the design engineer.
Design engineers usually occupy a position in
a departmentalized organization, and may ~
operate on less than complete knowledge of
how a thing is to be used. Essentially the product
interface is decided outside the design engineer's


the Swedish National Police, the Association of
Icelandic Rescue Teams, and the Australian
Navy.

CISM is a multi-factor, integrated crisis
intervention system that spans the entire
temporal spectrum of a crisis. CISM
interventions range from the pre-crisis phase
through the acute phase, and into the post-crisis
phase. CISM interventions may be applied to
individuals, small functional ups, large
groups, families, organizations, and communities.
The seven core components of this program are
presented in Table 1 and can be applied to the
environments in which emergency workers
function. Everly and Mitchell (1996) note that
these interventions are not typical mental health

counseling methods and caution that these
interventions are not to be viewed within the
typical mental health model. Specialized training
is needed to administer the CISM program.

Future Directions

In conclusion, the authors suggest some research
that might be conducted within each of the
defined environments: ‘

The Emergency Environment Itself

Most research on disasters has been conducted
‘on a specific disaster or a specific emergency

Table 1: Critical Incident Stress Management (CISM): the seven core components

(adapted from Everly and Mitchell, 1999)

INTERVENTION __ TIMING ACTIVATION. GOALS FORMAT
1. Pre-crisis Pre-crisis phase Anticipation of Set expectations; Groups;
preparation crisis Improve coping; Organizations
Stress management
Large Groups:
2a. Demobilizations Shift Event-driven To inform and consult; Large groups;
and Staff Consult. disengagement; To allow for Organizations
(rescuers); or psychological
2b. Group Info. Anytime. decompression;
Briefing for schools, _post-crisis Stress management
businesses and
large civilian groups
3. Defusing Post-crisis Usually Symptom mitigation; Small groups
(within 12 hrs) symptom- Possible closure;
driven Triage
4. Critical Incident Stress Post-crisis Usually Facilitate Small groups
Debriefing (CISD) (I to 10 days); symptom- psychological
At least 3-4 driven. Can closure;
weeks for mass _be event driven Stress mitigation
disasters Triage
5. Individual crisis ‘Anytime; Symptom- Symptom mitigation; Individuals
intervention (1:1) Anywhere driven Retum to function,
if possible;
Referral, if needed
Systems:
6a. Family CISM; Anytime Either Foster support, Families;
6b. Organizational symptom- communications; Organizations
Consultation driven or Symptom
event- driven _ mitigation; Closure,
if possible; Referral,
if needed
7. Follow up; referral Anytime Usually Assess mental status; Individual;
symptom- Access higher Family
driven level of care



domain, Production people do not talk to design
people, and neither spend much time with
marketing. In order to produce better designs,
therefore, it seems advisable to develop a social
organization in which all aspects of product
development are interrelated. Thus, a design
engineer would work with ergonomists and
others to develop a product that would not only
meet its predetermined design parameters, but
that would have human-friendly design
parameters to begin with.

In sum, the future is likely to bring increasing
numbers of ‘accidents by design’ unless scientists
develop a greater understanding of the social
organizations from which our technological
environments arise. It is only by restructuring
the design environment that humankind will
experience more human-friendly machinery in
the technological environment.

References

Emery, F.E. and Trist, E.L. (1978), ‘The Causal Texture
of Organizational Environments’, in Pasmore, W.
and Sherwood, J.J. (Eds), Sociotechnical Systems: A
Sourcebook, Sage Publications, San Diego, CA.

Everly, G. and Mitchell, J. (1999), Critical Incident
Stress Management (CISM): A New Era and
Standard of Care in Crisis Intervention (2nd edition),
Chevron Publishing, Ellicott City, MD.

Hart, D.O. (1995), Cultural Attitudes and Change in
High-Stress, High-Speed Teams, Paper presented at
Decision Workshop, Missoula, MT, June 12-16.

Kowalski, K.M. and Vaught, C. (1995), The Behavioral
Science Contribution to Emergency Management and
Engineering, Proceedings of The International
Emergency Management and _ Engineering
Conference, May 9-12, Nice, France, pp. 35-39.

Mitchell, J.T. and Everly, G.S. (1996), Critical Incident
Stress Debriefing: An Operations Manual, Chevron,
Ellicott City, MD.

Mitchell, J.T. and Everly, GS. (1998), ‘Critical
Incident Stress Management: A New Era in Crisis
Intervention’, Traumatic Stress Points, Volume 6,
Number 7, pp. 10-11.

Occupational Safety and Health Administration; .
(OSHA) (1996), Guidelines for Preventing Workplace
Violence for Healthcare and Social Service Workers,
number 1348-1996, U.S. Department of Labor,
Washington D.C.

Occupational Safety and Health Administration,
(OSHA) (1998), Recommendations for Workplace
Violence Prevention Programs in Late-Night Retail
Establishments, number 3153-1998, USS.
Department of Labor, Washington D.C.

Preuss, G. and Schaecke, G, (1998), Firefighters Exposed
to Psycho Mental Stress and Hazardous Work
Situations, Poster Session I: Stress in Different
Occupations, Work, Health and Stress 1999
Conference, Institut fiir Arbeitsmedizin der Freien
Universitat Berlin,

Vaught, C. and Smith, D.L. (1980), ‘Incorporation and
Mechanical Solidarity in an Underground Coal
Mine’, Sociology of Work and Occupations, Volume
7, Number 2, pp. 159-187.

Von Hallmayer, A., Klingbeil, M., Kohn-Seyer, G.
(1981), ‘Physische und Psychische Belastungs-
komponenten in der Tatigkeit des Feuerwehr-
mannes’, Zeitschrift fiir die Gesamte Hygiene und Ihre
Grenzgebiete, Volume 27, Number 3, pp. 191-194.

Weick, K. (1995), South Canyon Revisited 1 Lessons from
High Reliability Organizations, Paper presented at
Decision Workshop, Missoula, MT, June 12-16.

Work, Stress and Health (1999), Organization of Work
in a Global Economy, Conference sponsored by the
American Psychological Association and the
National Institute for Occupational Safety and
Health, March 11-13, Baltimore, MD.


* Pittsburgh Research
Laboratory, National Institute
for Occupational Safety and
Health, Office for Mine Safety
and Health Research, 626
Cochrans Mill Road,
Pittsburgh, PA, 15236-0070,

United States, E-mail:
kek2@edegov.
* Pittsburgh Research

Laboratory, Office for Mine
Safety and Health Research,
‘National Institute for
Occupational Safety and
Health, 626 Cochrans Mill
Road, Pittsburgh, PA, 15236-
0070, United States, E-mail:
cav9@ede.gov.

The Safety and Health of Emergency
Workers

Kathleen M. Kowalski* and Charles Vaught**

Emergency personnel, like all workers, carry out their duties within an environment composed
of a set of discrete elements. First, there is the emergency itself. Whether a forest fire in
France, a tornado in the American Midwest, or a mining. disaster in Russia, the emergency
imposes certain exigencies upon the responders. Second, a social structure exists with specific
social units, rules, and forms of association. An emergency response, therefore, takes place
within a context of prescribed behaviors, expectations, value judgments that are
sometimes in conflict with each other. Third, there is a technology that must be understood in
order to accomplish group goals. If the technology itself is implicated in the emergency, the
entire emergency environment may be impacted. Clearly, a breakdown in any of these
elements could result in worker injury and might heighten responder stress. This paper
discusses how emergency workers not only get injured but may come to experience burn-out,
post-traumatic stress syndrome, or impaired work and family relationships, even though their
normal work setting (the emergency) is expected to be ‘abnormal’. The authors suggest areas

in each of the three environmental elements that, deserve further inquiry.

Introduction

‘A successful emergency management effort
involves many components. Consequently, a
holistic, multi-dimensional model is needed to
identify and inter-relate the various components
of pre-disaster, disaster, and post-disaster
response, The emergency manager and wo!
play strategic roles and hold key positions. They
are also exposed to. potential injury and loss of
life. Equally important, they are sometimes
required to perform arduous physical tasks and
face emotional situations such as rescue work or
body recovery. The nature of these challenges
prompted the authors to examine some
emergency worker safety and health issues
within the context of emergency work
environments.

The authors first offer a discussion of these
environments, Secondly, the human/environment
interface is presented in a brief synopsis of the
human response under stress, which precedes a
brief review of the latest research in this area.
The goal of this paper is to promote thought and
discussion about emergency workers, their
environments, and their safety and health. The
Critical Incident Stress Management (CISM)
model will be presented as an example of a
multi-dimensional intervention focused on the
safety and health of emergency workers. Finally,
the authors will suggest areas in each of the
three environments that warrant further study.

The Disaster Work Environment

A disaster scene, such as the scene of an
underground mine fire, is a dynamic work
setting. As such, it presents workers with a
need to constantly adapt to their physical
environment. Meanwhile, they must adhere to
the formal and informal expectations of their
organization. Their organization, in turn, is an
open system that must be responsive to its
organizational environment.

Emery and Trist (1978) suggest that
circumstances such as those described above
can lead to a gross increase in an organization's
area of relevant uncertainty. In response, values
are instilled and rules promulgated to shore up
this uncertainty. These rule ‘enactments’ to use
Weick’s (1995) term, are likely to be oriented
toward organizational cohesion rather than
toward individual affect. This condition gets
translated into cultural attitudes that emerge in
the form of policy letters, directives, memos,
and other organizational manifestations. From
this chain of events, two primary implications
arise for the safety and health of emergency
workers.

First, official directives may be instrumental in
squelching public concer, but potentially
dangerous to workers when put into practice.
Hart (1995), in referring to the South Canyon
fire near Glenwood Springs, Colorado, noted
that the Grand Junction District Management


Team directive stated that all fires should be
‘initially attacked and suppressed as soon as
ossible’. This directive reflects a highly

\ctional cultural attitude. The firefighters’ roles
are unambiguous, and other organizations in the
environment (such as town councils or timber
companies) automatically see that approach as in
their best interests. Further, from the workers’
perspective, such a cultural attitude reinforces
the sense of ideal solidarity that characterizes
groups in dangerous work settings (Vaught and
Smith, 1980), In other words, the need to
enhance interpersonal predictability can be
achieved through a like-minded sharing of group
core values,

Unfortunately, the attitude described above
can also have deleterious consequences.
Organizations can easily lose sight of individual
needs in pursuit of the organizational mission.
Weick (1995), in referring to the general wild
land firefighters’ guidelines called ‘Watch Outs’,
suggested there should be a separate guideline
compiled for administrators. First on this list
would be ‘Watch Out when the governor is in
town’. In other words, when: high-ranking
officials are present, the organizational mission
is likely to be pursued zealously, possibly at the
expense of individual needs.

A second problem with the response of
emergency organizations is that they, like other
formal organizations in society, are designed to
be instrumental. Because of their basic mission-
oriented structure, there is little provision for
affect. Thus, even when it becomes apparent
that the human factor should be included to
achieve organizational effectiveness, change is
not easy to foster. Perhaps the most basic barrier
to change is that those who inhabit an
organization have internalized the very prin-
ciples that undergird contemporary organiza-
tional forms. These principles, taken from the
industrial era, and mechanical in nature, evoke
such criteria as speed, reliability, and efficiency
of operation. Scant allowance is made for people
in this milieu.

A third barrier, in relation to worker safety
and health is organizations’ interlocking
networks of divisions and functions. Because of
the way they are structured, non-instrumental
activities (or those seen as non-instrumental) can
be shunted into ‘staff’ status. Those who work
outside the line functions have a different
command structure, are valued differently from
an_ organizational perspective, and have a
differential ability to impact the organization.
Thus, many of the affective innovations that
could enhance organizational functioning are
grafted on rather than integrated into the
organization's structure. An example of this is
the role and status given mental health pro-
fessionals during a disaster. These professionals

are given less status and involvement in the
structure than traditional medical personnel.
Although, clearly, sequence of function must
be triaged in an emergency i.e. stop the bleedin,
before addressing the emotional trauma, bot
functions are key to long-term adjustment and
overall health of the victim.

Applying the Social Sciences to
Binergency Situations

The. stress response, sometimes referred to as
‘fight or flight’, is a normal, primitive human
reaction to a stressor. Thus, this response may
be thought of as a survival mechanism. The
stressor may be bio-organic (physical) or
psycho social (emotional). Psychosocial stres-
sors are described as environmental events,
such as the type of exposure emergency
workers face, in which an individual's inter-
pretation plays a key role in triggering the
stress response. Regardless of its source, there is
a physiological response that brings about such
symptoms as dry mouth, sweaty palms, and the
cessation of digestion. Additionally, symptoms
may include increases in heart rate, temperature,
respiration, and visual acuity. Finally, blood
moves to the skeletal muscles. The body
prepares to fight or to run.

A typical scenario would include the decision
to fight or run, execution of that decision,
resolution, and return to a normal baseline until
the next stressor arises. Unfortunately, in today’s
world the stressors often continue, overlap, and
do not provide for a ‘down time’ or return to a
baseline. This is particularly relevant in an
emergency response situation where the stress
is ongoing, even chronic. In fact, the high level
of stress has become a part of the socio-technical
system. This impacts emergency managers,
workers, and victims, not only during the
present disaster but cumulatively.

As the authors suggested in their treatise
presented at the 1995 TIEMES Conference in
France (Kowalski and Vaught, 1995), the
behavioral science disciplines are important to
emergency management planning and
engineering. Knowledge in the social sciences
can provide empirical information, not only on
general human response patterns, but also about
individual and group behavior during
emergencies. This information might mitigate
safety and health factors for emergency workers,
resulting in fewer injuries and fatalities. Such
knowledge could also lessen longer-term
consequences such as burnout or post-traumatic
stress symptoms that can lead to Post Traumatic
Stress Disorder (PTSD).


Recent Research on Stress and
Emergency

An international conference was held during
March, 1999, in Baltimore, Maryland, U.S.
Entitled ‘Work, Stress and Health 99:
Organization of Work in a Global Economy’
(WSH, 1999). This conference presented the
latest global research dealing with exposure to
stressful situations. Thus, we are provided a
current picture of thinking about human
response.

Overall, work stress may increase an
individual's risk of injury, cardiovascular disease,
psychological disorders, and = other health
problems. Stressful working conditions are also
associated with increased disability claims,
absenteeism and tardiness. An overload of stress
can result in burnout, which may manifest itself
in emotional and physical exhaustion, emotional
withdrawal, depersonalization, and aggressive
tendencies. The Japanese even have a term for
brain and heart disease caused by overwork:
karoshi, Overload, fatigue, and varying work
schedules (all relevant to the worker in an
emergency) can lead to unrealistic expectations
and a constant demand for high performance.
Couple this with a lack of resources (not
uncommon in an emergency _ situation,
particularly in the first hours and days of a
disaster) and the risk to the emergency manager
and worker safety increases.

During the Work, Stress and Health
Conference 1999 it was noted that studies
showed 90% of disaster victims exhibit some
of the symptoms of PTSD, most commonly
defined as intense psychological distress upon
exposure to events that symbolize or resemble
some aspect of a traumatic event. These
symptoms include: difficulty in concentrating,
headaches, nervousness, nightmares, difficulty
falling or. staying asleep, loss of appetite,
anxiety, depressions, helplessness/hopelessness,
irritability or outburst of anger, and a feeling of
detachment from others. Studies on emergency
workers indicate these symptoms, but the
percentage of the population of workers
suffering has not been extrapolated.

A study of firefighters in Germany (Preuss and
Schaecke, 1998) suggested that specific activities
resulting in maximum stress included, first of all,
the rescue of children. Other studies of
emergency workers (police, hospital emergency
personnel) suggest that the number one stressor
is disasters in which children have been injured
or killed, In addition, age is a factor in
determining the measurement of stress for
firefighters. Von Hallmeyer found that as
firefighters became older and more experienced,
they perceived the risks differently and more
negatively (Von Hallmayer, A., Klingbeil, M.,

Kohn-Seyer G., 1981). Preuss and Schaecke
found no significant correlation between age,
experience, and level of perceived strain, but did
find that the highest stress for the firefighters in
their study was related to rescue operations. In
other words, emergency operations involving
fatalities or injured people were viewed as most
stressful.

The authors suggest that stress could be |
present in two of the three environments in +
which emergency workers must function: the
circumstances of the emergency itself, and their
social environment.

Another dimension of ° stress concerns
intentional and unintentional _ technological
disaster. Intentionally caused disasters have
increased in the past several years, and
emergency managers and workers have had to
respond to this trend. Intentional disasters
include terrorism, which is on the rise globally.
The subway chemical release in Japan is an
example, as is the Oklahoma City bombing in
the United States. In fact, the Associated Press
recently noted that the 1995 bombing sparked a
wave of right-wing terror in the United States
that has led to an alarming growth in the anti-
government movement. The Southern Poverty
Law Center's Intelligence Project (SPLC)
reported that the FBI was investigating about
100 domestic terrorism cases prior to the April
19, 1995 bombing of the Alfred P. Murrah
Federal Building. According to the SPLC, three
years later the FBI was working on more than
900 such cases. If intentional disasters continue
to escalate, there should be increased evaluation
of different environments with respect to the
safety and health of emergency workers.

Crisis Interventions

Given the complexity of emergency manage-
ment, a comprehensive, multi-component, multi-
discipline intervention is appropriate. The
world’s most widely used crisis intervention
system is the Critical Incident Stress Manage-
ment (CISM) model (Mitchell and Everly, 1998).
This model effectively addresses the many facets
that must be included in an intervention aimed at
ensuring the safety and health of disaster
workers. The US Occupational Safety and |
Health Administration recommends that multi-
component crisis intervention programs be
established in healthcare institutions, social
service agencies, and even in convenience stores
(OSHA, 1996; OSHA, 1998).

CISM has been adopted by diverse
organizations in a wide variety of workplace
settings. These include the Federal Aviation
Administration, the U.S. Secret Service, the FBI,
the Airline Pilots Association, the U.S. Air Force,