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The need for ER protocol in the treatment of public
manifesting ASR symptoms following disaster.

The Australasian Journal of Disaster
and Trauma Studies
ISSN:  1174-4707
Volume : 2004-2

The need for ER protocol in the treatment of public
manifesting ASR symptoms following disaster.

Prof. Mooli Lahad, Community Stress Prevention Centre, Tel-Hai College, Kiryat Shmona, Israel. Email: lahadm@netvision.net.il
Ruvie Rogel, Community Stress Prevention Centre, Tel-Hai College, Kiryat Shmona, Israel. Email: cspc@telhai.ac.il
Keywords: ASR-Acute Stress Disorder , Surge capacity phenomena , ER- Emergency Room, Trauma, ASR-site,ASR -protocol

Prof. Mooli Lahad

Community Stress Prevention Centre,
Tel-Hai College,
Kiryat Shmona,

Ruvie Rogel

Community Stress Prevention Centre,
Tel-Hai College,
Kiryat Shmona,



This article will address the problem of Hospital Emergency Rooms (ER) treatment of acute stress response ASR clients, and will review some of the main recommended treatments found in the literature. The findings of our survey will be followed by recommendations on admitting, accommodating and treating ASR clients in ER.

The need for ER protocol in the treatment of public
manifesting ASR symptoms following disaster.


In recent years the amount of acute stress response clients coming to General Hospital Emergency Rooms in Israel following critical incidents has risen steadily. Whereas until the mid-80s the prediction was that the ratio between the physically injured and those with emotional reactions individual would be 1:3 respectively, the reality of the past 48 months in Israel since October 2000 and reports from NY following the 9/11 WTC attack is that the ratio has risen to 1:10 and in some cases 1:12.

The amount of emotional reactions, some of which are accompanied by minor wounds too, puts almost impossible pressure on ER personnel making it very difficult to operate an ER due to this sudden influx of patients, known as the Surge capacity phenomena. There is therefore a need to develop a solution for at least three issues. The first need is for an organisational solution as to where to address the needs of these tens of people; the second is, what is the best procedure of admission and the third, the need for a treatment protocol.

We conducted an extensive survey of 9 ERs in general hospitals in Israel which treated thousands of ASR clients since the outbreak of the second uprising starting on 29th September 2000, “Intifada El Aksa". The in-depth interview was carried out with at least the senior psychiatrist of that hospital and the chief social worker, usually the two disciplines that handle the ASR clients. We used a structured interview asking the senior psychiatrist and head social worker to describe to us a flow chart of admission of ASR clients and the kind of treatment they receive.

What is ASR?

ASR is a transient disorder of significant severity which develops in an individual without any other apparent mental disorder in response to exceptional physical and/or mental stress and which usually subsides within hours or days. The stressor may be an overwhelming traumatic experience involving serious threat to the security or physical integrity of the individual or of a loved person(s).

The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within 2-3 days (often within hours). Partial or complete amnesia for the episode may be present.
There must be an immediate and clear temporal connection between the impact of an exceptional stressor and the onset of symptoms; onset is usually within a few minutes, if not immediate. In addition, the symptoms:

(a) show a mixed and usually changing picture; in addition to the initial state of "daze", depression, anxiety, anger, despair, overactivity, and withdrawal may all be seen, but no one type of symptom predominates for long;

(b) resolve rapidly (within a few hours at the most) in those cases where removal from the stressful environment is possible; in cases where the stress continues or cannot by its nature be reversed, the symptoms usually begin to diminish after 24-48 hours and are usually minimal after about 3 days. (The ICD-10 Classification of Mental and Behavioural Disorders is copyright of the World Health Organisation 1992).

If the recovery from ASR is within three days to week, then why should we be so concerned about it?

Acute Stress Disorder as a Predictor of Posttraumatic Stress Symptoms

Classen et al (1998) studied the effect of being "just" a bystander exposed to shooting of office mates. They found that 33% of the employees met criteria for the diagnosis of acute stress disorder. Acute stress symptoms were found to be an excellent predictor of the subjects' posttraumatic stress symptoms 7-10 months after the traumatic event. They concluded that these results suggest not only that being a bystander to violence is highly stressful in the short run, but that acute stress reactions to such an event further predict later posttraumatic stress symptoms.

Birmes et al (2001) studied peritraumatic dissociation, acute stress, and early posttraumatic stress disorder in victims of general crime with 48 subjects, victims of violent assault. All were admitted to an emergency department, and 9 (18.8%) were hospitalised in surgical units. This study is useful in that it is the only one of general crime victims in which peritraumatic dissociation was measured within 24 hours of the assault and its implication that ASR clients may develop PTSD. They conclude that high levels of peritraumatic dissociation and acute stress following violent assault are risk factors for early PTSD. Identifying acute re-experiencing can help the clinician identify subjects at highest risk.

Thus it is obvious that treating ASR clients in ERs is crucial. Pre-disaster factors that influence who is most likely to experience serious and lasting psychological distress as a result of a disaster are listed by Norris et al (2001):

Gender: Women or girls were affected more adversely by disasters than were men or boys for which women's rates often exceeded men's by a ratio of 2:1

Age and Experience : Middle-aged adults were most adversely affected in every American sample where they were differentiated from older and younger adults. Professionalism and training increase the resilience of recovery workers, although past trauma per se does not.

Culture and Ethnicity: The effects of the disaster were greater in developing countries than in the United States. Majority groups fared better than ethnic minority groups. There are culturally specific attitudes and beliefs that may prevent individuals from seeking help.

Socioeconomic Status (SES). Lower SES was consistently associated with greater post-disaster distress. The effect of SES has been found to grow stronger as the severity of exposure increases.

Family Factors : Married status was a risk factor for women. Being a parent also added to the stress of disaster recovery, mothers were especially at risk for substantial distress. Children were highly sensitive to post-disaster distress and conflict in the family. When measured, parental psychopathology was typically the best predictor of child psychopathology.

Pre-disaster Functioning and Personality : Regardless of the data collection method, pre-disaster symptoms were almost always among the best predictors (if not the best predictor) of post-disaster symptoms. Persons with pre-disaster psychiatric histories were disproportionately likely to develop disaster-specific PTSD and to be diagnosed with some type of post-disaster disorder.

Within-disaster Factors

The presence of all of the following during a disaster has been found, at least in some studies, to predict adverse outcomes among survivors: Bereavement during the disaster, Injury to oneself or a family member, Life threat, panic or similar emotions during the disaster, Horror, Separation from family (especially among young people) Extensive loss of property, relocation or displacement.

As the number of these stressors increased, the likelihood of psychological impairment increased.

Post-disaster Factors

What sort of treatment is suggested?

The treatment of the public following a terror incident can be compared to that of soldiers in battle conditions. The principles of PIE (Proximity – to ensure attachment to the unit, Immediacy – to prevent the onset of post-traumatic reactions and Expectations – a clear message that he will return to full functioning and will assume routines and responsibilities) are relevant for civilians as well.

On an individual level ER provides the closest possible and most immediate treatment. Here too, the emphasis should be on functioning rather than pathology. It is this message at the very early stages which can determine the continuation of the symptoms or their disappearance and return to functioning. On a community level, maintaining community services and keeping the schools running as much as is possible will make sure that people are expected to continue with their day to day life as much as is possible.

However, considering that we are talking about civilians and not soldiers, is treatment of ASR a choice? Some might argue that it is not. Foa says "People should be encouraged to use natural supports and to talk with those they are comfortable with — friends, family, co-workers — at their own pace". In the guidelines for mental health professionals' response to the recent tragic events in the US (post September 11 2001) Foa wrote:

If someone wants to speak with a professional in this immediate aftermath period, a helpful response will be to:

  1. Listen actively and supportively, but do not probe for details and emotional responses. Let the person say what they feel comfortable saying without pushing for more.
  2. Validate and normal natural recovery.
  3. If people do present to clinics or counsellors requesting help, single-session contact should be avoided. In these instances people should be scheduled for 2-3 more visits over 2-6 weeks time.
  4. Traumatic experiences may stir up memories and/or exacerbate symptoms related to previous traumatic events. Thus some people will feel like this is "opening old wounds". These symptoms should also be normalised and are likely to abate with time. It may be helpful to ask people what strategies they have successfully used in the past to deal with this, and to encourage them to continue to use them.

The ER Survey

The aims of this survey were threefold:

  1. To screen ERs where hundreds of ASR victims were admitted and treated in the first 28 months of the Intifada Ak Aksa, hoping to learn about the procedures of handling and/or treatment of these clients.
  2. To look for common procedures across institutes.
  3. To obtain organisational recommendations and a minimum treatment protocol for handling ASR clients.

The survey was initiated by the Community Stress Prevention Centre (CSPC), in collaboration with the hospitals. It was conducted in nine hospitals, using a structured interview covering the process in which ASR clients are treated from the moment of arrival to the time of discharge from the hospital and follow up. It is important to mention the level of cooperation we found among the interviewees, the senior psychiatrist of that hospital and the chief social worker. They all showed enthusiastic and full co-operation and a strong will and commitment to develop a model and a method for the treatment of ASR clients in emergency rooms.

The following are the main findings:

Alerting the psychosocial team
There are variations in staff emergency-call systems i.e.; outside the psycho-social hospital team, who else will be called to ER and how? Some hospitals call both psychiatrists and social workers. In some places, co-operation between the psychiatric departments (PD), and the social services is not yet fully organised and so sometimes both are called upon and at other times just one of the professions

Staff positions and placement – usually staff positions are pre-determined or there is a clear knowledge as to who is the authority to place workers at their positions.

Psychiatric hospitals backup system was designated few months after the outbreak of the Intifada in October 2000. This back up system provides psychiatrists and mental health teams for the general hospitals without psychiatric departments. Most hospitals report that the system is generally working satisfactorily but there is a further need for training in collaborative work so that the local and the backup teams will use the same terminology and methods.

The hospitals' information centres work more or less uniformly, mainly operated by social workers. The structure and organisation is quite clear and so is their method of operation. In some places a psychiatrist or a member of the mental health team joins the social service staff in screening ASR symptoms of severe nature and or support waiting family members or the mildly injured until admission to ER or to the ASR treatment area. At times the psychiatric department will join upon being called.

Examination and initial diagnosis procedures - upon admission every ASR client first undergoes a physical examination by a senior physician, usually a surgeon. That means that according to the "triage" procedure these clients will wait quite a while before they will be seen or referred to the ASR site. There is no agreement as to who makes the psychological- psychiatric diagnosis. In some places police investigations take priority over psychiatry.

ASR assessment and records - There is no clear indication to the number of ASR admissions as all "mild or minor injuries" are recorded as such with no specific indication to the fact that these patients manifested ASR symptoms. However, there is a unanimous feeling that the numbers of ASR clients are increasing with the continuation of terror incidents.

ASR site – There are a number of variations regarding the ASR site. At some places a site exists and operates automatically. At other places it is a professional and /or administrative decision. In some hospitals, the criterion to open a site is the number of patients, despite the fact that ASR patients usually arrive in at least two waves: immediately after the incident and few hours later.

Usually patients do not receive any explanation when being referred to the ASR site as to why they are sent there and what will be done with them. Location of the sites also varies. Sometimes it is within the ER area, at other places it is outside the ER and even within considerable walking distance.

Diagnosis and treatment at the ASR There is no uniformity or agreed protocol of assessment between hospitals, no consensus about who is doing the patient evaluation, treatment approach- individual or group, use of medications and inclination towards hospitalisation. Most places do not tend towards hospitalisation and medications. When a need for hospitalisation is evident – the patients would not be admitted to the psychiatric department. Preferably they would stay in ER. Hearing tests and eye examinations are sometimes held at the site or on referral back to the ER.

In-patient treatment and follow up - is conducted in some places during stay in hospitals, in others the inclination is not to hospitalise at all.

Discharge - in most cases is through ER, however discharge does not always include a mental health professional nor, as stated before, is an ASR assessment registered in the discharge form. Thus GPs are not able to follow up on ASR patients on emotional or behavioural issues as these were not indicated at discharge.

Follow up after discharge - varies. In general no structured follow up is done however there are some variations here. When staff at the ASR site decide that a patient needs special attention this patient is called for additional treatment. In some cases patients come back on their own initiative. The three hospitals with trauma units are more inclined towards inviting patients with severe symptoms for follow up treatment, the other hospitals sometimes refer the ASR patients to community mental health clinics and have no follow up programs and records. The children’s hospital in Jerusalem keeps a documented follow up of hospitalised children. Some places hold follow-up groups for patients with severe symptomatology, but there is no clarity as to the nature and focus of those groups.

Treatment of second wave of ASR patients - that usually arrive at the ERs, some hours or a day after the traumatic event is over, there is no special place for their admission or treatment.

Treatment of accompanied families – despite the lack of a uniform attitude towards families, most places tend to allow a family member to participate in the process. Usually, attitudes to family members do not vary with physical injuries and ASR patients. Families waiting at the information centre or "holding" areas are supported by Social Services staff.

Outside agencies - Social security services are contacted within 24 hours as a regular procedure, as they are obliged by law to follow every injured person after "an act of hostility".

Media coverage in ERs - there are variations and at times conflicting attitudes amongst hospitals as to permitting media access and the range of coverage. All hospitals are aware of the media role as a PR instrument, thus allow them in to advance hospital PR. Some places insist on patients' consent, others, in a few instances tend to allow media coverage as a therapeutic instrument, as a "recall procedure".

Other organisations - police and army units are usually apparent at the ER. They are there for intelligence and information gathering, an activity that sometimes interferes with the psycho-social interview. In some incidents different voluntary organisations, embassies, political organisations and a host of other organisations are present at the ER adding to the chaos and a further source of burden on staff.

Contact with local authorities - An important task of the psychosocial team is to connect victims with their relatives and to make sure that social continuity is functioning. This is not always possible, although in the main cities there are representatives of the local municipality working with the psychosocial team in the ER to help ASR patients connect with their next of kin and to make sure that upon discharge they are not left alone.

Helping the staff - usually there is some consideration of help for staff members, however there are no set rules or a protocol. In some places staff are debriefed, at others it is a process of evaluation and conclusions, and at certain hospitals it is a multi faceted process. There is a very big gap between the level of burn-out and fatigue of certain teams, and the amount of help given to them. Medical staff in general are reluctant to get help, however more and more paramedical (nurses, support staff etc.) indicated a need for such attention.

The paradox of Trauma Centres. Complex injuries are referred to the specialist hospitals which are university or large regional medical centres . It is the smaller local general hospitals that usually receive the Trauma (ASR) patients as they are diagnosed as "minor injuries". However, these hospitals have a very small psychiatric unit and usually no psychologists. As a result the trauma centres get less opportunity to work and study the phenomena of ASR and are therefore less experienced with it and they will receive the patients only as ASD or more often as PTSD.

Areas of specific needs. The interviewees mentioned two places in the hospital apart from the ASR site where they feel there is a need for special attention. The unidentified persons site and the mortuary. In these two places psychosocial team assist the families and individual next of kin who wait to discover the fate of their loved ones.

The issue of mixed teams of Jewish and Arab staff members was mentioned both as a source of intra-staff concern, with a few of the victims (the majority of them were Jews) being aggressive toward the non-Jewish staff.

ASR Protocol
On the whole there was not a clear protocol, that means:

Even the psychiatric assessment is not always very clear. In most places there is some kind of procedure, what is apparent is that most cannot support it with research based validity.


Administration & logistics

In view of the predicted influx of ASR patients to ERs there is a definite need to allocate a specific site for ASR patients and their next of kin. The long wait of ASR patients in the general ER is adding pressure to the ER staff and resources, not to mention the exposure of ASR patients to the sights and sounds of the ER which may affect their mental well being.

ER ASR Protocol

Based on the protocol developed by the CSPC in the 90s to handle ASR clients in the town of Kiryat Shmona, and with adaptations in the past months CSPC came up with an ASR preliminary protocol.

The protocol combines the following elements: Screening and assessment of ASR; Screening and swift assessment of coping resources- according to our Integrative Model of Coping and resiliency – BASIC Ph

For the individual

The use of our modified "triage" model of continuities and re-organising continuities to screen between those at risk and those in danger of deterioration.

Using Milton Erikson’s “Pacing and Leading” method for the dissociative/detached patients.
Use of relaxation both action (Jacobson method) and Focusing (Gendlin)
In special cases: EMDR; TIR; EFT.

For groups

CIPR- our revised and controlled method of debriefing called “Critical Incident Processing and Recovery”, NEVER before 72 hours. We have had success with a version of Mitchell's Diffusion in the immediate stage. Noy (2001) recommends Marshall’s version of debriefing used by commanders with their soldiers after an incident. Here the emphasis is on what happened and although emotions and thoughts experienced during the incident may arise, they are not actively solicited.

The use of Non-verbal Expressive Methods – mostly for children and immigrants who have problems to be fluent in Hebrew, a set of methods and thechniques were developed to allow free and non threatening communication about the incident and its impact.


Despite the fact that the Surge capacity phenomena is clear threat to General hospitals functioning durning mass casualty incident, there is no agreed upon "best practice protocol" world wide . An attempt to develop such a tool is now under way by CSPC in conjunction with Israeli General Hospital MH units sponsored by United Jewish Appeal NY . around the world very little has been done so far to study the ASR in the immediate post critical incident phase where hundreds may arrive at the ERs. The few studies that exist were all made on adults, based on very small samples and it seems as if they were made on an "opportunity- basis" that is reacting to the situation rather than planning in advance.

It is clear from our survey that a structured and well-controlled study of ASR treatment in ERs is needed, as there are differences that may result in negative outcome.

Whenever there is a protocol, it is based on experience and "what looks likely to give good results". It is therefore our recommendation that an international task group will design a research studying existing protocols and validating effective methods in order to have an agreed "minimum–protocol" for individuals (adults and children) for groups (families and other groups) taking into consideration ethnic differences and developmental needs.


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Noy, S. (2001). Prevalence of psychological, somatic, and conduct, casualties in war. Military Medicine, 166 (12) A Supplement devoted to The International Conference on the Operational Impact of Psychological Casualties from Weapons of Mass Destruction. pp 31-33.

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The ICD-10 Classification of Mental and Behavioural Disorders, World Health Organization 1992


Prof. Mooli Lahad & Ruvie Rogel © 2004. The authors assign to the Australasian Journal of Disaster and Trauma Studies at Massey University a non-exclusive licence to use this document for personal use and in courses of instruction provided that the article is used in full and this copyright statement is reproduced. The authors also grant a non-exclusive licence to Massey University to publish this document in full on the World Wide Web and for the document to be published on mirrors on the World Wide Web. Any other usage is prohibited without the express permission of the authors.

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