The CDC and H1N1: What if We Threw a Panic and Nobody Came?

The Centers for Disease Control is out with its weekly update on the H1N1 pandemic, and that means it's time for another round of alarmist headlines from our friends in the mainstream media:

• Reuters: "Swine Flu Means Worst Flu Season in 12 Years in U.S."
• CNN: "H1N1 death toll estimated at 3,900 in U.S."
• Associated Press: "CDC: Swine flu has sickened 22 million in 6 months"
• CBC News (Canada): "More H1N1 cases, deaths than thought in U.S."
• Wall Street Journal: "CDC Estimates H1N1 Has Killed 3,900"

Here's the headline you are not seeing, but should:

H1N1 on Pace to Kill Far Fewer People Than Typical Seasonal Flu

So, here's what happened today. The CDC reported its statistical estimate of how many people have been infected with novel influenza A H1N1 in the United States in the 6 months since the first cases emerged last spring. Up until now, they have reported confirmed cases, hospitalizations, and deaths. Today they used the very same formulae that they use every year to figure out how many people have the flu, and came up with an estimate of 22 million cases of H1N1 and 3,900 deaths over the last 6 months. They also reported that the percentage of visits to doctors for influenza-like illnesses is now the highest it has been since they started counting back in 1997.

There are two angles from which you can look at these numbers. The first, and the one that the media seems to have jumped at, is that these numbers are significantly higher than what has been reported previously. In fact, this death toll is about quadruple the last death toll number that was announced. That makes it appear that H1N1 is much, much worse than anyone suspected before, and that's news. What's more, more people are going to the doctor than ever before for flu-like illnesses. H1N1 is making quite an impression out there.

The other angle from which you could view today's numbers is to consider exactly what it is that is being reported here, and how it compares to similar numbers we know about. Under this analysis, you are definitely still left with a very large number of doctors' visits for the flu. It isn't clear at all whether that means more people are actually sick or whether when people get sick they are more likely to go to the doctor this time around, but it does seem like the flu is a real problem out there. 22 million people have gotten H1N1. That's less than 10% of the population, which really isn't all that many people as these things go, although I haven't been able to find a decent number on how many people get the flu in an average year.

Furthermore, 3,900 people have died. And while that is 3,900 tragedies, it is also about 11% of the annual death toll from seasonal flu. In order for H1N1 to kill anywhere near the number seasonal flu does each year, more than 5,000 people are going to have to die every month from now through April. Oh, and the death toll didn't triple -- this is a totally different statistic than the previous reports. This is an estimate of the total. The lower numbers were the actual number they had counted.

So yes, you can look at the numbers and say they are much worse than anything we've heard before, or you can look at them and say they are much, much, much better than we feared. In fact, the thing that makes this flu season bad is not any of these numbers at all, but the fact that so many younger people are getting sick and even dying. But while we need to take H1N1 seriously and try to prevent its spread as best we can, I'm kind of wondering at what point the media and, to a lesser extent, the CDC will wake up to the fact that this just isn't the horrible crisis that was predicted. At what point will the evidence outweigh the need to have been right and to continue the high alert? Whenever that point is, it obviously isn't now.

Hostage Situation at Stissing Mountain Middle School: Send in the Peers

This morning, a man walked into Stissing Mountain Middle School in Pine Plains, New York, assembled a gun in the bathroom, and took my colleague, Principal Bob Hess, hostage. The standoff lasted two hours before the suspect surrendered, releasing Mr. Hess. The entire bulding locked down for those two hours, with children hiding in locked classrooms, the school kitchen and even under the desk in the counseling office right next door to where the gunman was.

The fact is, we all know it's a possibility. Any school Principal who has given any detailed thought to an armed intruder coming into the school has already realized that the most likely target is the Principal. An angry parent, a custody dispute that we intervene in, a trespasser we ask to leave, or a disturbed child, if they took out a gun, could all very well be aiming it at us. In places where, as in Michigan, we practice locking down the school, we practice it with the administrator directing the rest of the staff and taking the lead. We try not to think about the possibility that we would be shot or held hostage ourselves.

Counseling will now be offered to the students, staff and families at Stissing Mountain. In the official curriculum I teach on Critical Incident Stress Management, they say that peers may not be necessary in delivering CISM services to schools. If there's anyone from Pine Plains out there listening, I want you to know that I think a peer is absolutely critical in assisting Mr. Hess.

If this were me, I would not want to talk to a counselor or a social worker or a psychologist. I would want to talk to someone else who has lived with the knowledge they walk around with a big target on their head every day. I would want my person to understand that in an emergency I take pride in being able to keep everyone calm and safe, and who can imagine that being the one person least able to do anything in this situation was horrible. I would want someone who has had their own child in the building when something bad happened, and had to worry about the group, not the individual. I would want someone who knew the significance of having something happen "on your watch." I would want to talk to a really well trained Principal.

I hope they have one in Pine Plains. And Principal Hess, I'm glad you're safe.

The Children of Fort Hood

As everyone knows by now, 13 people died and 30 were injured in a mass shooting at Fort Hood last Thursday. There has been a lot of focus, quite appropriately, on the people who died and on their families. There has also been some given to those who were wounded, some quite critically. And of course there has been an inordinate amount of speculation about the alleged shooter, who, reports say, is now awake and talking in the hospital.

It is impossible to predict how any individual person will be affected by Thursday's events. Some who you might expect to be very emotionally impacted will bounce back quickly, and some who seem to be on the periphery of the incident may be profoundly affected. As the CISM personnel work to triage those traumatized by the shooting -- those who lost a loved one, those who were shot, those who knew the shooter, those who witnessed the shooting, etc. -- there is one group that is probably giving them a little pause: the children.

To my knowledge there were no children present when the shooting started on Thursday. That means no children saw the scenes of violence first hand. But that in no way means that the children at Fort Hood aren't impacted, and they are going to need a lot of support. But we all know intuitively that helping children through these moments is different than helping adults, and few early crisis interventionists have any training at all in working with kids.

CNN reports that officials at Fort Hood have called in child psychologists as well as disaster management experts. That means the impact here is big -- bigger than what their town of 60,000 can handle on their own. It is a disaster, just as surely as a building collapse in a large-ish town that killed 13 and injured 30 would be, only probably worse, or at least different, for the families.

So why are the children impacted? There are numerous factors. First, these kids were on lockdown for several hours on Thursday. During that time, they did not know what was going on, where their parents were, if anyone in their family had been injured, or when they would see them again. If they looked out the window they saw what amounted to a live military operation going on outside of their schools, and for all they knew the "bad guy" was coming for them next.

Some of these children, of course, lost a parent in the shooting or have a parent who was injured. If not, they almost certainly have a neighbor or friend who was impacted. They went to school on Thursday morning believing that they were OK in school and their parents were OK at work, and came home knowing that very well might not be true at any given moment.

I've often said that trauma violates our world view. For these kids, that is doubly true. All of us need to believe that the world is generally a safe place, and this incident took away that belief from these children. But it also took away something else. It took away their visceral understanding that soldiers -- parents -- who are stateside are safe, and that danger lies in the war zone. A big part of how they can cope with having parents who put themselves in harm's way for a living is by telling themselves that the fact that they come home means they are OK. Now, 13 people who were stateside, who were home, are not coming home any more.

So what do we do for these kids? That depends, of course, on what they need. I suspect the days, weeks and months ahead will hold a lot of crayons and paper, a lot of tissues, and a lot of nightmares for some of these kids. Watching parents ship out is going to be really hard. Watching them come home is going to be surreal. So while we're honoring the dead and thanking our troops, particularly during Wednesday's Veteran's Day celebration, let's take a moment to remember their kids, and to thank them for all they give up in service to our country, too.

Deer vs. Lion at the National Zoo

Visitors to the National Zoo in Washington, DC today got a little more of an idea of what life in the wild might be like than they were probably expecting. A baby deer wandered out of Rock Creek Park and into the zoo, wandered around for a while and then jumped a fence into the moat of the lion enclosure. After the deer had been captured by the lions three times and escaped them three times, zoo officials removed the lions from the enclosure and rescued the deer. It was too injured to survive, however, and was euthanized.

Reading about this brought me back to my own first experience assisting a person following a critical incident. The social worker at my school and I completed my first Critical Incident Stress Management class on a Wednesday, and the incident occurred on Friday at our building. For those who've never been there, it would help to understand that one whole wing of Ann Arbor Open School is an open library surrounded by a semicircle of classrooms, most of which are linked by internal doors.

On the day in question, one of the teachers had brought her dog in for a piece of classroom instruction. The dog had spent the last couple of hours of the day asleep under the teacher's desk, and in her hurry to get home for the weekend she forgot he was there. She was halfway home when she realized it, and she turned around to go back.

Meanwhile, the dog woke up from his nap and went exploring. He wandered through the internal doors into the 1st and 2nd grade classroom next door, and then through the next set of doors into the Kindergarten next to that. It was there that he met Mr. Wiggles, a long-haired guinea pig who was the class pet.

Shortly thereafter, just before the teacher came to claim her dog, blood curdling screams could be heard through the building. The social worker and I came running and found the kindergarten teacher standing in the door of her classroom, screaming. The sight was truly ghastly -- blood and guinea pig fur was everywhere, and Mr. Wiggles was no more. It truly looked like a crime scene.

The social worker and I found ourselves drawing heavily on what we had learned that week to stabilize the teacher, help her identify resources and coping techniques, and make sure she would be OK when she got home. When it was over, the social worker said to me, "this isn't really what I envisioned when I took that class." It was funny, but it wasn't.

Which brings us back to the National Zoo. We go there to see things that we, in our industrialized society in North America, could not see otherwise. But two lions attacking a baby deer are not really what we have in mind. Undoubtedly many in the crowd found the scene fascinating. To others, it may well have been traumatizing. Living in modern society, the natural course of a predator and prey -- whether it's lions and fawns, or dogs and guinea pigs, or something a little more common -- is not within our experience, and we may not have an emotional framework with which to understand it when we see it. Or we may have one, but only in the wild, so the sight of guinea pig fur in a classroom or a fawn in the moat of the lion enclosure at the zoo is especially upsetting.

All of this goes to prove the wisdom that early crisis intervention is not about responding to incidents, it's about responding to reactions to incidents. Any time an incident overwhelm's someone's usual emotional coping skills, it is critical. One person's fascinating scene is another's critical incident, and violence doesn't have to be criminal to qualify.

Fort Hood: What Compassion Fatigue Is, and Isn't

As we all know by now, the alleged shooter in the Fort Hood massacre is a psychiatrist. There is a lot of speculation in the media right now that he suffered from "compassion fatigue," "vicarious traumatization," "secondary trauma" or "secondary PTSD." In many of these articles these terms are used interchangeably. The basic idea of all of these articles is that the shooter's treatment of people who had been traumatized caused his own traumatization. However, since virtually none of the reporters involved had ever heard of compassion fatigue before Thursday, there is a lot of oversimplification of the facts in the search for answers.

I have no first-hand information about whether this man suffered from compassion fatigue or anything else, and I (unlike both those who think he did and those who think this was religiously-motivated terrorism) am not going to speculate. We have absolutely no facts at all on which to base a diagnosis. What I do have, however, is some information about compassion fatigue that might be helpful at least in understanding what everyone is talking about.

There are two big risks that people who work with trauma victims face: burnout and compassion fatigue. Burnout is just what it sounds like, and just what it is in any line of work. It's the slow and steady deterioration of satisfaction with your job and your willingness and ability to do it well. It's what makes you not want to get up and go to work in the morning. Burnout can be associated with the stressfulness of the job, and listening to people's trauma is stressful. Among trauma interventionists, burnout manifests in not caring much about the stories you hear or the people who tell them, in not doing what you know needs to be done for them, and in quitting your job or volunteer position.

The second risk is compassion fatigue. Compassion fatigue, unlike burnout, usually comes on fast. A single story or a small set of them get to you in a serious way, and you start showing the same symptoms you would if you were exposed to a traumatic event: trouble sleeping, irritability, impaired judgment, appetite changes, nightmares, startling easily, etc. This is not the person who says, "Gee, I really don't feel like going to work today." This is the person who is afraid to get out of bed.

One of the most commonly used screening tools for burnout and compassion fatigue, as well as job satisfaction, in those who work with traumatized people, is the Professional Quality of Life Scale Compassion Satisfaction and Fatigue Subscales—Revision IV (Pro-QOL R-IV). Interestingly enough, when I went looking for a copy for reference for this post, I found it on the website for the Army Behavioral Health Provider Resiliency Training program.

Some of the questions on the Pro-QOL that relate specifically to compassion fatigue can help you understand what exactly it is:

• I jump or am startled by unexpected sounds
• I find it difficult to separate my personal life from my life as a helper
• I feel as though I am experiencing the trauma of someone I have helped
• I avoid certain activities or situations because they remind me of frightening experiences of the people I help
• As a result of my helping, I have intrusive, frightening thoughts
• I can't recall important parts of my work with trauma victims

Clearly, this is serious stuff. And clearly, it needs to be addressed. But just as most people exposed to trauma experience these symptoms and recover, most of us who work with them recover if we show signs of compassion fatigue.

Compassion fatigue and secondary PTSD are not synonymous. Post traumatic stress is a typical reaction of a normal person to an abnormal event. Post traumatic stress disorder is when it lasts, does not resolve, and interferes with functioning. Similarly, compassion fatigue is a normal hazard of the job. The vast majority of people who experience it get some support, back off their work for a while, and return to normal functioning.

So, could the shooter at Fort Hood have had secondary PTSD? Sure. Do we know that he did? No. And is it inevitable that someone in his position would be in that much trouble psychologically? Certainly not. Trauma is contagious, yes, but the contagion is also avoidable, given the right supports. What we don't know is whether this particular psychiatrist had those supports in place.

Quick Aside: You can now follow MMCQuarterback on Twitter!

No Easy Answers: The Why's and Wherefores of Fort Hood and Orlando

He had compassion fatigue. He was a Muslim. He had money problems. He was depressed. He was disgruntled. He didn't want to deploy. He was a terrorist. He was harassed. He faced discrimination. He hated his boss. He was turned down for unemployment. He blamed the company. He blamed the army. He should have been stopped.

Today, as America reels from the second mass shooting in as many days, the blogosphere and the traditional media are lighting up with commentary on why the shooters in the Fort Hood and Orlando killings did what they did. If you google the stories, you find headline after headline with various speculation about motive, interspersed with the occasional article referring to the motives in each shooting as a "mystery."

Human beings don't like uncertainty, as I discussed yesterday. And the media doesn't like to report anything nuanced, and certainly not "we don't know." Where's the human interest in that? So we look for answers, and sometimes the answers we come up with sound good . . . until you think about them.

The shooter at Fort Hood is a psychiatrist. He had treated many people who suffer from Post Traumatic Stress Disorder. Now there is speculation that this experience caused him to be traumatized himself, and in turn caused yesterday's shootings. No sooner had that theory hit the airwaves then we had articles arguing the opposite -- that PTSD is not contagious, and we are just making excuses.

The truth is, PTSD is indeed contagious, in a documented phenomenon called "compassion fatigue" or sometimes secondary or vicarious traumatization. People who work with the traumatized are susceptible to symptoms of trauma themselves -- this is a documented phenomenon and there are documented ways to try to prevent it. But as much as compassion fatigue is a real thing, most people who have it don't shoot people. Saying that is the cause is much too simplistic.

The shooter is also Muslim, true. And yet, most people who are Muslim don't shoot people either. And if mass shootings are caused by being Muslim, how do we account for the Orlando shooter, who certainly wasn't, or the perpetrator in the Pittsburgh gym shootings, or at Virginia Tech, or Columbine? Why is the Fort Hood shooting "terrorism" and those are horrible violent crime?

In Orlando, the shooter almost certainly was a disgruntled former employee with money problems. This is all true. But how many thousands of people fit that description, and never hurt a fly? How many hurt themselves but not others? How do you know who is who and which is which. Unfortunately, you don't.

There is a lot of commentary today suggesting that we as a country are hesitant to admit the "truth" about Fort Hood, and I think they are right. But that truth isn't that the shooter was a Muslim terrorist. That truth is that we just don't know. We may someday, or we may not. And if we don't know, we can't know it won't happen again, and that scares us.

We want to think that if we exclude certain ethnicities or nationalities or religions from our lives, we will prevent the next shooting from happening to us. We want to believe that if we know the Fort Hood shooter was a terrorist, we can protect ourselves by staying away from terrorists. But in Orlando, we discovered that that isn't true either. And that scares us more, so we pretend there's no inconsistency there, no nuance. It seems we'd rather live with our bigotry in this country than with our fear of what is random.

Fort Hood: The Waiting is the Hardest Part

At least 12 people are dead and at least 31 injured in a shooting or shootings at Fort Hood, Texas this afternoon.  One gunman, a soldier, is dead.  Two others are in custody.  By the time you read this -- indeed, by the time I finish writing it -- all of that information may turn out to be wrong.  As the press says, this is a "breaking news story."

The shooting occurred almost two hours ago, but we still don't know what happened.  Fort Hood, is on lockdown, or at least it was within the last half hour.  So are the neighboring schools.  Reports differ on how many gunmen there were and whether they are all accounted for.  News like this, where the details are coming out piecemeal and the information is changing, are both extremely scary and also extremely hard to tear oneself away from. 

This story is compelling for lots of reasons -- a lot of people are dead, the possibility of terrorism is on our minds, the dead are possibly servicemen and women who we presume to be safe before they are stateside.  The fact that it's changing means that we don't want to turn off the news, because we want to know what happened and we aren't sure that we do.  We have one set of facts now, and we might miss the next change if we break away.  We want to understand.

The constantly changing nature of the story also adds to what is so traumatizing about an incident like this.  Instead of hearing the news and reacting to it, we go through a seemingly infinite series of exposures.  We hear the story, we experience the trauma or secondary trauma of it, and then new facts are announced and we experience it again. 

This phenomenon was painfully obvious to me this afternoon as I drove with my daughter.  When we got in the car I explained to her that there had been a shooting at a military base and a lot of people were dead, and that the news would be talking about it.  At that time, the number of known dead was 7 with 20 injured, but I didn't tell her that.  When the headlines came on, they announced that 12 people were dead and 31 injured, and I involuntarily winced.  My daughter, on the other hand, was completely unphased.  I was reacting to the new information, but for her the information hadn't really changed.  I was traumatized again -- she wasn't.

Aside from that increase in the numbers, the most poignant and compelling part of this story thus far for me came in an offhand sentence in coverage by USA Today:

A spokeswoman for the City of Killeen, where the base is located, tells USA TODAY's Donna Leinwand the Army is "asking for EMTs because it's a mass casualty event."

The term "mass casualty event" isn't one you hear in the newspaper a lot.  If you work in emergency services or in crisis response, on the other hand, it is a term that has a lot of emotional charge.  We talk about car accidents as having "multiple fatalities."  Mass casualty events are huge.  9-11 was a mass casualty event, and even though this clearly has none of that scope, the seriousness of that kind of incident is invoked by using that term. 

Another way to look at it is this:  There are roughly 60,000 people at Fort Hood, and they have their own police, fire and ambulance service.  Imagine what would have to happen in a town of 60,000 -- roughly the size of St. Cloud, Minnesota -- to completely overwhelm their ambulance service.  It's bad.

This event will actually become less traumatic for everyone -- people there and people hearing about it on the news -- the minute the information stops changing.  It may even feel anticlimactic.  And then the real work begins.